Health Services Research applied in the ICU as experimental model

1. The EURICUS project EUROPEAN ICU STUDIES The Effectiveness and Efficiency of Health Care Health Services Research applied in the ICU as experimental model

2. European ICUstudies = Project-Model INPUT THROUGHPUT OUTPUT Objectives ICU Management case-mix, etc. Process of Care Budgeting Effectiveness Costs Efficiency intermediateoutput

3. University Centers Department Leaders Groningen, NL University Hospital School of Management Epidemiology Health Services Research Org. Techn. & Innovation Statistics & Methodology Prof. Dr. D. Reis Miranda Prof. Dr. W. van Rossum and Prof. Dr. G. Sanders Dr. V. Fidler Utrecht, NL Psychology Social and Organizational Psychology Prof. Dr. W. Schaufeli FU Brussels, B Economics Micro Economics Work organization and Economic psychology Prof. Dr. M. Jegers Prof. Dr. R. Pepermans

4. EURICUS-I The effect of variables of (non-clinical) organization and management on performance SURVEY • 89 ICUs - 12 European countries • 2,200 Nurses • 750 Physicians • 16,000 Patients • 76,000 nursing days • Site Visits 4 Sub-studies: Patients & facilities Organization Personnel Culture Finances

5. EURICUS-II The effect of collaborative practice on performance R.C.T. • 44 ICUs - 10 European countries • 1,200 Nurses • 450 Physicians • 20,000 Patients • 100,000 nursing days • Site Visits + Filming -Randomisation -Training -Use of Protocols -Outcomes of Care -Out. of Human Resources

6. Collaborative practice - Adverse events + + + OSF Mortality

7. INTERVENTION for improving collaborative practice TRAINING to nursing and physicians • How do we communicate? • Conversation techniques • Cooperation as a team 2 PROTOCOLS • Process awareness: • hourly check of monitoring, and decision-tree • to consult physician • Building mutual respect: • nurses and physicians discuss professionally Collaborative Practice was assessed with questionnaires (3X)

8. QUESTIONNAIRES SCALESVARIABLES Quality of communicationPerceived openness Accuracy Timeliness Problem solving Co-operation Collaborative practiceTrust Equality Participation Giving opinion Role clarification Satisfaction with communicationNurses and others Physicians and others Nurses and physicians Job demandsJob demands Decision latitudeDecision latitude

9. EURICUS-III Budgeting and Costing R.C.T. • 45 ICUs - 10 European countries • 89 ICU leaders • 9,300 patients • 54,000 nursing days - Case Mix - Use of Guidelines & Protocols, for - Budgeting & - Direct Costing - Economic Environment ICU managers

10. EURICUS-III INTERVENTION • One day training on Budgeting and Costing • Software for calculations and ‘scenarios’ • Daily collection of costing data

11. Annual Budget Direct costing Real-time measurement of activities at patient level

12. RESULTS

13. Insufficient OM EURICUS-I WASTE OF RESOURCES • Mismatch in 75% of ICU • 30% of resources not used • - beds (Occupancy Rate) • - nurses (WUR)

14. Hidden misuse of resources Due to predominant surgical activities: daily and weekly unfavourable patterns of turnover

15. ICU NURSING STAFF examples # FTE’s/bed Belgium 2.4 France 2.6 Italy 3.2 Spain 3.4 The Netherlands 4.1 United Kingdom 5.0 Norway 8-10 All countries reported shortage of nurses, beds closed, unnecessary death of patients

16. EURICUS Database – ICU vs. ‘HDU’

17. EURICUS studies has shown Among ICUs, the chance of dying could vary up to a factor 6 There are no “standardized” standards of care among ICUs In the ICUs, the processes of work never have been analyzed The way of work lacks structure

18. EURICUS studies has shown Budgeting and costing procedures are systematically lacking or underdeveloped At least 50% of the costs correspond to activities of care that are registered daily for clinical purposes The same medical interventions may cost significantly different across ICUs, with the same clinical outcome If we don’t know what we are doing, how shall we know how to improve it?

19. EURICUS studies has shown • Simple and limited interventions for improving • Collaborative Practice in the ICU • Budgeting and costing skills in the ICU had a significantly positive effect upon • Patient Outcome • Perceived Collaborative Practice • Motivation to Manage Less mortality Less complications

20. EURICUS studies has shown Burnout and Job-dissatisfaction are more dependent of work uncertainty and less of workload Organisational Commitment Results-oriented Culture Decision latitude of nurses Predictability of work-flow Organisational framework improve significantly ICU performance (patient- as well as human resource outcomes)

21. IMPLICATIONS

22. Focus on multidisciplinary care The non-clinical Organization and Management of Hospital Departments Disciplines such as: Decision Theory Economics Management Organization Psychology Statistics and Methodology Should take active responsibility in the organization and management of Health Care in the Hospital

23. Focus on multidisciplinary care Two recommended actions: Implement the multidisciplinary exposure of students in the University Use the multidisciplinary expertise available in the Hospital In the Hospital of the future, non-clinical departments (e.g. finances, organization and management, etc.) will parallel clinical departments (cardiology, surgery, etc.)

24. Need for central Initiative & coordination The changes to be introduced in the organization and management of Health Care shall be commissioned to the macro level of policy making in each country The European Commission shall take a leading role

26. Only 30% of the nursing time is used in direct relation to the High Technology in the Unit The urgent revision of the actual policies of Nursing Careers is recommended

28. THE EURICUS PROJECTS Medicine and Nursing Occupational Psychology Organisation & Manag. Economics Culture Epidemiology • EURICUS-I (Survey) • The effect of OM • EURICUS-II (RCT) • The effect of standardising nursing tasks • and of training collaborative practice • EURICUS-III (RCT) • The effect of use of guidelines Medicine and Nursing Occupational Psychology Training Consultants Epidemiology, Dec. Theory Medicine and Nursing Economics Org. Psychology Epidemiology