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

Management Process of Care Effectiveness Efficiency INPUTTHROUGHPUT OUTPUT European ICU studies = Project-Model Budgeting Objectives ICU case-mix, etc. Costs intermediate output

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

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

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

Collaborative practice ++ OSFMortality + - Adverse events

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)

QUESTIONNAIRES SCALESVARIABLES SCALES VARIABLES Quality of communication Perceived openness Accuracy Timeliness Problem solving Co-operation Collaborative practice Trust Equality Participation Giving opinion Role clarification Satisfaction with communication Nurses and others Physicians and others Nurses and physicians Job demands Decision latitude

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

One day training on Budgeting and Costing Software for calculations and ‘scenarios’ Software for calculations and ‘scenarios’ Daily collection of costing data Daily collection of costing data EURICUS-IIIINTERVENTION

Category - Labour - Med Equipment - Blood products - Clinical Services Laboratory Radiology - Disposables -Non-clinical Serv. Administration, etc - Non-med. Equip. - Pharmaceuticals - Total cost Annual Budget Direct costing Real-timemeasurement of activities at patient level

RESULTS

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

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

ICU NURSING STAFF examples # FTE’s/bed Belgium2.4 France2.6 Italy3.2 Spain3.4 The Netherlands4.1 United Kingdom5.0 Norway 8-10 All countries reported shortage of nurses, beds closed, unnecessary death of patients

P/N<1.5P/N>1.5 p Number 6648 P/N ratio Case-mix SAPS II NS Outcome of Care Mortality NS SMR NS SOFA NS Outcome of OM OR NS WUR LOS NS EURICUS Database – ICU vs. ‘HDU’

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

EURICUS studies 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?

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

EURICUS studies 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)

IMPLICATIONS

The non-clinical Organization and Management of Hospital Departments Focus on multidisciplinary care 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

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.)

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

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

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