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Book Details
Abstract
The global trend of increasingly ageing societies and long term illnesses has meant a growth in demand for intensive care resources. This book advises on leadership and organizational development of intensive care units, in order to give best practices for governance, performance, emergency response and safety. Written by international experts in the field, each chapter allows researchers, clinicians and service providers worldwide to be able to refer to this single reference book. In seven parts, the volume will tackle aspects of intensive care management in both global and local contexts, and interrogate the key concerns that service providers face. It works as an informative guide for the practical administration of intensive care, as well as being international in its design and information.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Contents | v | ||
| About the Editor | ix | ||
| Preface | xi | ||
| Part I Organization, Structure, and Governance | 1 | ||
| Leadership and Management | 3 | ||
| Key Points | 3 | ||
| Introduction | 4 | ||
| What is Leadership? | 4 | ||
| Leadership qualities | 5 | ||
| Leadership Styles and Theories | 6 | ||
| Behaviour or style theory | 6 | ||
| Blake–Mouton managerial model | 7 | ||
| Situational theory | 7 | ||
| Primal leadership | 8 | ||
| Transactional and transformational leadership | 8 | ||
| Collective leadership approach | 8 | ||
| Management versus leadership | 9 | ||
| The role of the manager | 11 | ||
| The role of the leader | 11 | ||
| Leadership and Management Roles in the ICU | 14 | ||
| Role of the ICU Clinical Director | 15 | ||
| Financial management | 17 | ||
| Clinical governance | 17 | ||
| Human resources | 17 | ||
| Strategic planning | 18 | ||
| ICU Clinical Director Job Description | 18 | ||
| Role of the ICU Educational Lead | 18 | ||
| Role of ICU Research Lead | 19 | ||
| Role of ICU Clinical Governance Lead | 19 | ||
| Does Good Leadership Impact on Unit Performance? | 19 | ||
| The Art of Delegation | 20 | ||
| Institutional Leadership/Management Support | 22 | ||
| Leadership training | 23 | ||
| Choice of leader | 23 | ||
| Succession planning | 23 | ||
| The career beyond unit leadership | 24 | ||
| References | 24 | ||
| Governance | 27 | ||
| Key Points | 27 | ||
| Introduction | 28 | ||
| Evolution of CC as a Stand-Alone Department | 28 | ||
| What Needs to be Governed? | 30 | ||
| New CC medicine models | 30 | ||
| CC policies and rules | 33 | ||
| CC audit and reporting | 34 | ||
| Conclusions | 36 | ||
| References | 37 | ||
| Design and Role of the Intensive Care Unit | 41 | ||
| Key Points | 41 | ||
| Concept to Occupancy | 42 | ||
| ICU as a hospital resource | 42 | ||
| Principles of ICU design | 43 | ||
| Building the ICU design team | 43 | ||
| Design timeline | 44 | ||
| The Vision | 45 | ||
| Renovation or New Construction | 45 | ||
| ICU Technologies | 46 | ||
| Ramifications and Expectations of the New ICU | 46 | ||
| Construction | 47 | ||
| Occupancy, Post Occupancy Evaluation, and Issue Correction | 47 | ||
| ICU Design | 47 | ||
| The ICU patient room | 49 | ||
| Infrastructure | 49 | ||
| Bedside medical technologies | 49 | ||
| Zones | 51 | ||
| Room logistics and waste management systems | 52 | ||
| Room environment | 52 | ||
| Front of ICU room | 53 | ||
| Central areas | 54 | ||
| Central (nursing) stations | 54 | ||
| Corridors | 55 | ||
| ICU Logistics Spaces, Supplies, and Medical Devices | 55 | ||
| Pharmacy | 56 | ||
| ICU Laboratory Testing and POCT | 56 | ||
| Staff Lounge and On-Call Suites | 56 | ||
| Family Lounge (Visitor Waiting Room) | 57 | ||
| Conference Rooms | 57 | ||
| Universal Support Services | 58 | ||
| Infection Prevention and Control | 58 | ||
| Staff Communications | 58 | ||
| Signage and Wayfinding | 59 | ||
| Security, Fire, and Safety | 59 | ||
| Advanced Informatics | 60 | ||
| Creating the Smart ICU | 60 | ||
| Advanced ICU Informatics Concepts | 62 | ||
| Medical Devices are Informatics Platforms | 62 | ||
| ICU Applications | 62 | ||
| Alarm systems | 62 | ||
| Virtual device communities | 63 | ||
| Real-Time Locating Systems | 63 | ||
| Data integration, smart displays, and decision support | 63 | ||
| Telemedicine | 64 | ||
| References | 64 | ||
| Part II Staffing and Staff Development | 67 | ||
| Staffing Models | 69 | ||
| Key Points | 69 | ||
| Introduction | 70 | ||
| History | 70 | ||
| Challenges of Staffing Critical Care | 73 | ||
| Nurses | 76 | ||
| Physicians | 78 | ||
| Standards of intensivist availability | 79 | ||
| Advanced Practice Providers | 81 | ||
| Tele-ICU | 82 | ||
| Leadership staffing | 83 | ||
| References | 84 | ||
| Staff Training and Development | 87 | ||
| Key Points | 87 | ||
| Introduction | 88 | ||
| A Pedagogy of CC Training | 89 | ||
| The curriculum house model | 89 | ||
| Ways of Learning | 92 | ||
| Learning from experience and practice | 93 | ||
| Learning from feedback | 93 | ||
| Training with peers | 93 | ||
| Learning in formal situation | 93 | ||
| Personal study | 93 | ||
| Teachers and Trainers | 94 | ||
| Educational contracts | 94 | ||
| Learning using clinical skills training | 94 | ||
| Learning using simulation training | 94 | ||
| Continuing professional development | 99 | ||
| Assessment | 100 | ||
| Workplace based assessments | 100 | ||
| Directly Observed Procedural Skills | 102 | ||
| Acute Care Assessment Tool | 102 | ||
| The Clinical Evaluation Exercise | 102 | ||
| Case-based Discussion | 102 | ||
| Choosing Appropriate Assessment Instruments | 103 | ||
| How many WPBAs and how do they fit into a training program? | 103 | ||
| A note on observational assessments | 103 | ||
| Summary | 104 | ||
| References | 104 | ||
| Leadership and Organizational Development | 107 | ||
| Key Points | 107 | ||
| Introduction | 108 | ||
| The Challenge | 109 | ||
| The Vision | 111 | ||
| Department of CC | 112 | ||
| Mission statement | 112 | ||
| Implementation of the Vision: The Interventions | 113 | ||
| Technical processes | 113 | ||
| Consultant meeting | 113 | ||
| Revised workflows | 114 | ||
| People Processes | 115 | ||
| Performance focus | 115 | ||
| Professional development | 116 | ||
| Leadership development | 119 | ||
| Continuing education | 120 | ||
| Recruitment | 120 | ||
| Stakeholder Strategies | 121 | ||
| Knowledge dissemination: education and courses | 121 | ||
| Organizational engagement | 122 | ||
| Financial responsibility and independence | 123 | ||
| Monitoring processes | 124 | ||
| The Future | 127 | ||
| References | 127 | ||
| Part III Decision-Making and Communication | 129 | ||
| Ethics | 131 | ||
| Key Points | 131 | ||
| Making Difficult Choices | 131 | ||
| Moral reasoning | 132 | ||
| Principlism: A Dominant Approach in Western Moral Philosophy | 132 | ||
| Pluralism | 133 | ||
| Structuring the Problem; Quadrants | 134 | ||
| Keeping the Dialogue Open | 134 | ||
| Teaching ethical practice | 135 | ||
| Issues of Consent | 135 | ||
| Non-voluntary treatment in an emergency; necessity to treat | 135 | ||
| Refusal of treatment | 136 | ||
| Decision-making capacity | 136 | ||
| Involuntary treatment | 136 | ||
| Advance directives (living wills) | 137 | ||
| Non-voluntary treatment for the adult who lacks decision-making capacity | 137 | ||
| Decision-making; children | 138 | ||
| The unborn child; treating a pregnant woman | 138 | ||
| Clinical Research | 139 | ||
| Goals of Treatment at the End of Life\r | 141 | ||
| Preserving life\r | 141 | ||
| Futility; the appropriateness and advisability of treatment | 141 | ||
| Optimal care; to treat for survival or to treat for comfort? | 142 | ||
| Withhold versus withdraw | 143 | ||
| Withholding attempts at cardiopulmonary resuscitation | 143 | ||
| Withdrawal of mechanical ventilation | 143 | ||
| Acts and omissions at the end of life; the doctrine of double effect | 144 | ||
| Institutional Admission and Discharge Policies | 144 | ||
| Brain Death | 146 | ||
| Donors after Circulatory Death (DCD) | 147 | ||
| References | 148 | ||
| Communication | 151 | ||
| Key Points | 151 | ||
| Introduction | 151 | ||
| Background | 153 | ||
| Communication Models | 153 | ||
| Improving communication during medical crises | 156 | ||
| Improving communication during handover | 160 | ||
| Improving communication with patients and families | 163 | ||
| Conclusion | 166 | ||
| References | 166 | ||
| Part IV Performance | 169 | ||
| Performance Standards and Measurement | 171 | ||
| Key Points | 171 | ||
| What is a Performance Standard? | 171 | ||
| Why measure performance standards? | 172 | ||
| Characteristics of an Ideal Metric | 173 | ||
| Relevance | 173 | ||
| Reliability | 174 | ||
| Actionable | 175 | ||
| Relevant Epidemiological Concepts | 176 | ||
| Chance | 176 | ||
| Bias | 177 | ||
| Regression to the mean | 177 | ||
| Confounding | 178 | ||
| Secular trends | 178 | ||
| Performance Standards to Improve Healthcare | 179 | ||
| Local performance standards | 179 | ||
| Systems reporting of performance standards | 179 | ||
| References | 181 | ||
| Methods of Control | 183 | ||
| Key Points | 183 | ||
| Introduction | 184 | ||
| What is Quality? | 185 | ||
| Quality Control and Quality Assurance | 186 | ||
| Process Control | 188 | ||
| Prerequisites for process control | 188 | ||
| What are some useful tools to guide process control? | 190 | ||
| Factors to consider in developing effective process control | 192 | ||
| Human factors | 192 | ||
| Prevalence/consequence framework | 193 | ||
| ICU organization and integration as the foundation for control of performance | 195 | ||
| Phases of Care as a Framework for Achieving Control of Performance | 196 | ||
| Process control: resuscitative phase | 196 | ||
| Process control: support phase | 197 | ||
| Process control: liberation phase | 198 | ||
| The Future, and CC as a “State of Mind” | 198 | ||
| References | 200 | ||
| Human Factors | 203 | ||
| Key Points | 203 | ||
| Introduction | 204 | ||
| The ICU: Yesterday and Today | 204 | ||
| A Socio-Technical Perspective of the ICU | 204 | ||
| People | 205 | ||
| Physicians | 205 | ||
| Nurses | 205 | ||
| Other staff | 205 | ||
| The Organization of the ICU | 205 | ||
| Human Skills and Human Error | 206 | ||
| Acquisition of technical skills | 206 | ||
| Non-technical skills | 206 | ||
| ICU non-technical skills | 207 | ||
| Leadership and team skills | 207 | ||
| Human error in CC | 209 | ||
| Coordination and Variability of Care in the ICU | 210 | ||
| Coordination of care | 210 | ||
| Reducing variability: checklists and protocols | 212 | ||
| Technology in the ICU | 213 | ||
| Clinical information systems: patient monitors | 213 | ||
| Electronic Health Record Systems | 216 | ||
| Device alarms in the ICU | 217 | ||
| Methods to Enhance Safety in the ICU | 217 | ||
| Root cause analysis | 217 | ||
| Failure mode and effect analysis | 218 | ||
| Conclusions | 219 | ||
| References | 221 | ||
| Part V Quality and Safety | 223 | ||
| Quality Improvement | 225 | ||
| Key Points | 225 | ||
| Background to Quality Improvement | 226 | ||
| What is quality? | 226 | ||
| Deming and Improvement Science | 226 | ||
| Profound knowledge | 227 | ||
| The Gap between What We Know and What We Do, and Getting to High Reliability in the ICU | 228 | ||
| Bundles | 230 | ||
| Checklists | 232 | ||
| The Model for Improvement | 233 | ||
| Background | 233 | ||
| Measurement for improvement | 235 | ||
| Plan to Study Act | 235 | ||
| Data for improvement | 237 | ||
| Statistical Process Control charts | 237 | ||
| Audit and QI in the ICU | 240 | ||
| Principles of audit | 240 | ||
| Linking audit to QI | 241 | ||
| Morbidity and mortality meetings | 242 | ||
| Pro-actively search for harm | 242 | ||
| Psychology of Change and Sustaining Change | 243 | ||
| Conclusion | 244 | ||
| References | 245 | ||
| Patient and Staff Safety | 247 | ||
| Key Points | 247 | ||
| What is Patient Safety? | 248 | ||
| The scale of the problem | 248 | ||
| Patient safety — the context | 249 | ||
| Why Do Things Go Wrong? | 250 | ||
| Active failures | 251 | ||
| Latent failures | 251 | ||
| Violations | 252 | ||
| Reporting systems | 253 | ||
| Patient Safety Incidents | 256 | ||
| Patient safety incident without harm — near miss | 257 | ||
| Patient safety incident with harm — adverse incident | 258 | ||
| Blame and Just Culture | 258 | ||
| Frameworks in Patient Safety | 260 | ||
| Frameworks to facilitate reporting and analysis | 261 | ||
| Frameworks to facilitate cultural change, measurement, and monitoring safety | 261 | ||
| Staff safety and fulfillment | 264 | ||
| References | 266 | ||
| Policies and Procedures | 269 | ||
| Key Points | 269 | ||
| Introduction | 269 | ||
| Admission and Discharge Policies | 270 | ||
| Admission criteria | 270 | ||
| Discharge criteria | 271 | ||
| Ethical issues | 272 | ||
| Triage | 271 | ||
| Tools to Implement ICU Policies and Procedures | 272 | ||
| Overview of Policy Development and Establishing a Quality Improvement Program | 274 | ||
| Implementation of Policies | 275 | ||
| Measurement of Performance | 276 | ||
| Compliance with Physician Reporting | 278 | ||
| Conclusion | 281 | ||
| References | 281 | ||
| Evidence-Based Medicine | 285 | ||
| Key Points | 285 | ||
| Introduction | 285 | ||
| Principles of Evidence-Based Medicine | 286 | ||
| Summary of the evidence | 287 | ||
| Quality of the evidence | 287 | ||
| Moving from evidence to decision | 288 | ||
| Practice Guideline Development | 290 | ||
| Application of GRADE to Assess Quality of Evidence | 292 | ||
| Risk of bias | 293 | ||
| Imprecision of estimates of effect | 293 | ||
| Inconsistency (heterogeneity) | 294 | ||
| Publication bias | 294 | ||
| Indirectness of evidence | 295 | ||
| Enhancing the Rating of Quality of Evidence | 295 | ||
| Actionable Recommendations | 295 | ||
| References | 297 | ||
| Part VI Financial Management | 299 | ||
| Funding systems | 301 | ||
| Key Points | 301 | ||
| Introduction | 302 | ||
| Costs of CC | 302 | ||
| Variability in Funding Systems | 303 | ||
| DRG Funding | 304 | ||
| Pay-for-Performance | 307 | ||
| CC Reimbursement Practices | 309 | ||
| Austria | 310 | ||
| Denmark | 311 | ||
| Germany | 311 | ||
| France | 312 | ||
| Ireland | 312 | ||
| Netherlands | 313 | ||
| Spain | 314 | ||
| United Kingdom | 314 | ||
| ICU funding in emerging countries | 314 | ||
| Appreciation of ICU funding by healthcare providers | 315 | ||
| Reimbursement imbalances related to actual ICU costs | 315 | ||
| Reimbursement and ICU regionalization | 316 | ||
| Reimbursement and ICU telemedicine | 316 | ||
| Reimbursement systems and palliative care | 316 | ||
| Reimbursement and optimization of source documentation | 317 | ||
| Research Funding in the ICU | 317 | ||
| References | 318 | ||
| Cost and Cost-Effectiveness | 321 | ||
| Key Points | 321 | ||
| Introduction | 321 | ||
| Costs | 322 | ||
| Type of Cost Studies | 326 | ||
| Cost-minimization analysis | 326 | ||
| Cost-benefit analysis | 329 | ||
| Cost-effectiveness analysis | 330 | ||
| Cost-utility analysis | 332 | ||
| Conclusions | 336 | ||
| References | 337 | ||
| Budget Management | 339 | ||
| Key Points | 339 | ||
| Introduction | 340 | ||
| The budgeting context for CC | 340 | ||
| For-profit | 340 | ||
| Not-for-profit | 341 | ||
| Government-funded | 341 | ||
| Defining the Budget | 341 | ||
| Types of budgets | 342 | ||
| Capital budget | 344 | ||
| Costing Models | 344 | ||
| CC costing methodology | 344 | ||
| Assigning costs | 345 | ||
| Managing the Budget | 346 | ||
| Assessing resource requirement | 346 | ||
| Budget monitoring | 348 | ||
| The fixed budget model | 349 | ||
| The variable budget model | 352 | ||
| Managing Cost Efficiency | 353 | ||
| Capital Expenditure Budgets | 355 | ||
| Capital assets | 355 | ||
| Alternative funding of capital equipment | 355 | ||
| References | 357 | ||
| Part VII Emergency Preparedness | 359 | ||
| Disaster Response | 361 | ||
| Key Points | 361 | ||
| Introduction | 362 | ||
| What is a Disaster? | 362 | ||
| When should a “Disaster” be declared? | 363 | ||
| Expectations after a disaster | 363 | ||
| Simple versus Compound | 363 | ||
| Size | 364 | ||
| Compensated versus uncompensated | 364 | ||
| Resource Management | 364 | ||
| All hazard approach | 364 | ||
| Resource capability and limitations | 365 | ||
| Infrastructure limitations | 365 | ||
| Medical limitations | 365 | ||
| The Disaster Response | 366 | ||
| Triage | 370 | ||
| Triage algorithm | 370 | ||
| 30-second sieve | 371 | ||
| Chaos theory and Disaster Response | 375 | ||
| The Role of Critical Care in Disaster Management | 376 | ||
| The role of telemedicine | 378 | ||
| Post- Disaster Effects on Healthcare Staff | 379 | ||
| References | 380 | ||
| Pandemic Planning | 383 | ||
| Key Points | 383 | ||
| Introduction | 383 | ||
| Definitions and Descriptions of Pandemics | 385 | ||
| Surge Capacity | 388 | ||
| Surge Capability | 395 | ||
| Ethics of Pandemic Planning | 398 | ||
| Research in pandemics | 399 | ||
| Summary | 399 | ||
| References | 400 | ||
| Index | 403 |