The Ideal Intensive Care Unit

A culture of safety is not a casual or an inevitable outcome for an intensive care unit, but rather it requires focused and constant attention and directed efforts. To improve safety and quality, hospitals should focus on three key areas: 9

• Creating a culture of safety
• Reducing complexity
• Establishing independent redundancies for key processes

More specifically, successful ICUs commonly share three main features.

1. Using a systems approach. Successful ICUs modify the conditions that contribute to errors. 10 A system is a set of interdependent elements interacting to achieve a common aim. The elements may be both human and non-human (equipment, technologies, etc.). 11 According to the Institute for Healthcare Improvement, such a system includes:

• A leadership system that assures organized systematic care
• An ICU care team and executive leadership that assure continuous improvement
• Efficient and timely delivery of services within a system of care
• Shared decision making between family and staff
• A safe and orderly environment for patients, families and staff
• A skilled, coordinated and collaborative care team

2. Creating a specific environment. Successful ICUs work to establish work environments that embody specific characteristics. 12 The ICU characteristics create an environment that:

• Is patient focused
• Is trusting and open
• Is comfortable, compassionate and caring
• Has strong leadership
• Has everyone on the team involved in rapid cycle improvements
• Has excellent communications
• Has a scientific process of improvement

3. Basing changes on scientific evidence. The impetus to make changes in staff-related structures and processes of care are based on the literature. In particular, successful ICUs recognize that: 13

• Single largest affect arises from having an intensivist-led team 14
• Nurse staffing levels affect health and cost outcomes 15 16
• Pharmacists on rounds are associated with a large reduction in adverse drug events 17
  

9 Pronovost, 2003 IHI Audio Conference

10 To Err is Human, pg 49

11 Reason, James, Human Error Cambridge: Cambridge University Press, 1990.

12 Clemmer, Terry P. and Spuhler, Vicky J. 2003 IHI Audio Conference

13 Lindsay, Mark MD, IHI Audioconference 2003

14 Pronovost PJ, Jencks M, Dorman T, et al. (1999). Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 281(17):1310-1312.

15 Aiken LH, Clarke SP, Sloane DM et al. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 288(16):1987-1993.

16 Needleman J, Buerhaus P, Matke S, et al. (2002). Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 346(22):1715-1766.

17 Leape LL, Cullen DJ, Demspey CM, et al. (1999)/ Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 282:267-270.

© 2004 Michigan Health and Safety Coalition