A critical care pandemic staffing framework in Australia.

BACKGROUND: Pandemics and the large-scale outbreak of infectious disease can significantly impact morbidity and mortality worldwide. The impact on intensive care resources can be significant and often require modification of service delivery, a key element which includes rapid expansion of the critical care workforce. Pandemics are also unpredictable, which necessitates rapid decision-making and action which, in the lack of experience and guidance, may be extremely challenging. Recognising the potential strain on intensive care units (ICUs), particularly on staffing, a working group was formed for the purpose of developing recommendations to support decision-making during rapid service expansion. METHODS: The Critical Care Pandemic Staffing Working Party (n = 21), representing nursing, allied health, and medical disciplines, has used a modified consensus approach to provide recommendations to inform multidisciplinary workforce capacity expansion planning in critical care. RESULTS: A total of 60 recommendations have been proposed which reflect general recommendations as well as those specific to maintaining the critical care workforce, expanding the critical care workforce, rostering and allocation of the critical care workforce, nurse-specific recommendations for staffing the ICU, education support and training during ICU surge situations, workforce support, models of care, and de-escalation. CONCLUSION: These recommendations are provided with the intent that they be used to guide interdisciplinary decision-making, and we suggest that careful consideration is given to the local context to determine which recommendations are most appropriate to implement and how they are prioritised. Ongoing evaluation of recommendation implementation and impact will be necessary, particularly in rapidly changing clinical contexts.

Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: a literature review.

BACKGROUND: Studies have shown that nurse staffing levels, among many other factors in the hospital setting, contribute to adverse patient outcomes. Concerns about patient safety and quality of care have resulted in numerous studies being conducted to examine the relationship between nurse staffing levels and the incidence of adverse patient events in both general wards and intensive care units. AIM: The aim of this paper is to review literature published in the previous 10 years which examines the relationship between nurse staffing levels and the incidence of mortality and morbidity in adult intensive care unit patients. METHODS: A literature search from 2002 to 2011 using the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Australian digital thesis databases was undertaken. The keywords used were: intensive care; critical care; staffing; nurse staffing; understaffing; nurse-patient ratios; adverse outcomes; mortality; ventilator-associated pneumonia; ventilator-acquired pneumonia; infection; length of stay; pressure ulcer/injury; unplanned extubation; medication error; readmission; myocardial infarction; and renal failure. A total of 19 articles were included in the review. Outcomes of interest are patient mortality and morbidity, particularly infection and pressure ulcers. RESULTS: Most of the studies were observational in nature with variables obtained retrospectively from large hospital databases. Nurse staffing measures and patient outcomes varied widely across the studies. While an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found in this review, most studies concluded that a trend exists between increased nurse staffing levels and decreased adverse events. CONCLUSION: While an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found in this review, most studies demonstrated a trend between increased nurse staffing levels and decreased adverse patient outcomes in the intensive care unit which is consistent with previous literature. While further more robust research methodologies need to be tested in order to more confidently demonstrate this association and decrease the influence of the many other confounders to patient outcomes; this would be difficult to achieve in this field of research.

Do burn patients cost more? The intensive care unit costs of burn patients compared with controls matched for length of stay and acuity.

Modern intensive care management of burn patients is resource intensive with important ramifications for funding of regional burn services. The aim of this retrospective cohort study was to determine the intensive care unit costs for burn patients compared with nonburn patients matched for length of stay and severity of illness. The patient record was reviewed to compare costs associated with expendables (medications and fluids), investigations (laboratory and radiological tests), and physiotherapy sessions in 13 burn patients and 13 nonburn controls. Medical and nursing staff costs could not be differentially determined between groups. The cost of wound dressings were estimated for burn patients. The mean daily cost of burn patients was Australian dollars (AUD) 700.74 and AUD 697.99 for nonburn controls (P = .97), with an additional AUD 1411 estimated for nursing and medical staffing. There was no significant difference in the cost of expendables or laboratory tests between the groups. The largest drug and laboratory costs in both cases and controls were attributed to the use of meropenem and intravenous antifungals (25% and 30%, respectively) and arterial blood gas analysis (31% and 27%, respectively). Analgesics, anxiolytics, and sedatives costed AUD 21.58 more per day in burn patients than in controls (P = .054). Physiotherapy costs were AUD 18.62 higher per day in burn patients (P = .028), whereas radiology costs were AUD 108.10 higher in the control group (P = .001). Burn dressings costed AUD 120.77 per day. The authors found no significant difference in the mean daily intensive care unit cost of burn patients compared with controls matched for length of stay and acuity. However, physiotherapy and dressing costs were higher in burn patients, and there was a trend to increase costs associated with analgesic/anxiolytic/sedative medications. Antimicrobials accounted for a significant proportion of pharmacy costs in both groups.