Terminology \200\224ethics Any discussion of rationing must inevitably involve ethical prin ciples. Deciding what ought to be done involves using principles of ethics or moral philoso phy. Allocating resources may involve the use of utilitarian principles as mentioned in CEA analysis above, where resources are used to maximize the bene \201 t for the greatest num ber of patients. Utilitarianism in this context articulates an important concept, that of c onsequentialism. That it is the consequences of actions that matter. When looking at ration ing decisions using consequentialism, everybody counts equally. However, a pure utilitarian system may not necessarily produce a \200\230fair \200\231 result for an individual, inde ed a rigid utilitarian might argue that it is right to harvest organs from one living perso n to save the lives of many others. This would clearly be unacceptable and to most people m orally wrong. Alternatively, resources may be allocated equally to all regardless of expres sed need as in an egalitarian system, or the resources may be allocated in response to expr essed health needs or capacity to bene \201 t. De \201 ning need, how- ever, is complex; a critically sick patient with a very poor prognosis will still have healthcare needs. Usin g a concept of capacity to bene \201 t raises the issue of unmeetable needs. If a healthca re need cannot be met,then it may be argued that there is no moral obligation to provide he althcare. This has particular resonance for critical care; using resources to attempt to me et an unmeetable need might be unethical. Of particular recent popularity is the concept of the four principles of medical ethics: \200 Terminology \200\224economics In all but a perfect situation of unlimited supply of health- care goods, every healthcare decision involves an eco- nomic trade-off. If supply of healt h goods is limited and demand (i.e. health needs) is not, then any decision of resource all ocation is one of rationing. This maxim is true of any economic decision; an allocation of health dollars to one area inevitably involves a reduction in expenditure, current or futur e, in another area. As well as the cost of treating patient X, such allocation involves a c ost of not treating patient Y or perhaps restricting the treatment of patient Y; this is th e opportunity cost of treating patient X, or building hospital X. Decisions made about reso urce allocation may be related to hospitals or Primary Care Trusts, regionally or nationall y; these may be considered as Macro economic decisions. Decisions may also be made about in dividual patients or patient groups when they can be described as Micro economic decisions. Rationing for a speci \201 c patient has also been described as bedside rationing. It has been suggested that for bedside rationing to occur three conditions are met; doctors shoul d have control over the use a beneficial service which they withdraw or withhold and that i n so doing they act in the interests of someone other than the patient. Decisions made abou t rationing healthcare often use cost-effective analysis (CEA). CEA is a methodology of max imizing health bene \201 ts within a given budget. At its sim- plest, it examines how a mo derately expensive treatment bringing large bene \201 ts compares with a moderately expen- sive treatment bringing moderate bene \201 ts. Such analysis also uses concepts such as t he quality-adjusted life year, the QALY approach looks at cost-effectiveness aggregated ove r time to produce an integer \200\224a quality-adjusted life Autonomy (self-rule) \200\224in the critical care setting most patients \200\231 autonomy i s signi \201 cantly impaired if not absent. Bene \201 cence or doing good implies promoti ng what is best for the patient. Non-maleficence \200\224not doing harm, seems fairly strai ghtforward as in the clinical setting most doctors strive to avoid harm. Avoiding harm at a ll costs, the old adage primum non-nocere, is impossible in practically all healthcare sett ings as all treatments have some associ- ated risk. In the critical care setting, the conce pt of harm vs bene \201 t may be more \201 nely balanced. Justice or fairness forms the fourth principle. In critical care we are concerned both with fairness, which man- dates th at similar patients get equal access to healthcare, but also more with distributive justice , i.e. fair allocation of resources. In the latter context, we are concerned with the effec t of resource usage on other or future patients. 545 CHAPTER 33.2 Rationing in critical care \200 there should be a mechanism for appeal there should be some enforcement procedure to ensure such conditions are met. The American Thoracic Society has articulated this concept well, \200\230Marginally bene \201 cial intensive care may be justi \201 ably limited on the basis of societal consensus that its cost is too high in relation to the value of its outcome \200 extraordinary exp enditures of resources for marginal gains unfairly compromise the availability of a basic m inimum level of health care services for all \200\231. None of these conditions is easy to meet, not least in the charged atmosphere of a critical care unit. However, it seems reasonable to ask that clinicians consider rationing services that bring marginal bene \201 t at great cost. CEA may guide us in concert with ethical t heories to making good decisions, but there may be an innate tension between concepts of be ne \201 cence and cost-effectiveness values. Our shared normative values determine the sor t of healthcare we provide and to whom we provide it. Doing well, albeit at times inef \201 ciently in cost terms, may have a signi \201 cant societal value. Rationing decisions Making dif \201 cult decisions that affect patients \200\231 lives is a day-to-day activity in critical care. Decisions as to triage, and withholding and withdra wing active treatment all involve some degree of resource allocation whether directly or in directly. Interestingly critical care providers seem reticent to allocate resources purely on the basis of maximizing bene \201 t. This may be in part due to the rule of rescue. Wit hin Western societies there is a powerful sense of a \200\230rule of rescue \200\231, whic h obliges us to throw a rope to a drowning man for example. Rescuing a lone sailor from the Southern Ocean at immense expense would go against a utilitarian calculus but would certai nly fit in with concepts of virtue, solidarity and duty. There is enormous symbolic and rhe torical force from rescuing identi \201 ed persons or treating named patients in peril, bu t allocating resources to the sickest patient may not maximize outcomes. How can such decis ions be made when none of the theories will give us an answer? Daniels has speci \201 ed f our conditions to implement what is described as \200\230 accountability for reasonablenes s \200\230 in resource allocation; \200 \200 Further reading ATS Bioethics Task Force. Fair allocation of intensive care unit resources. Am J Respir Crit Care Med 1997; 156: 1282 \200\223301. Daniels N. Accountability for reasonableness in private and public health insurance. In: Co ulter A, Ham C, eds. The global challenge of health care rationing. Buckingham: Oxford Univ ersity Press, 2000: 89 \200\223106. Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985 \200\2232000: an analysis of bed numbers, use, and costs. Crit Care Med 2004; 32: 1254 \200 \2239. Sinuff T, Kahnamoui K, Cook DJ, et al. Rationing critical care beds: a systematic review. Crit Care Med 2004; 32: 1588 \200\22397. Society of Critical Care Medicine. Attitudes of critical care medi- cine professionals conc erning distribution of intensive care resources Crit Care Med 1994; 22: 358 \200\22362. decisions should be publicly accessible the rationales should aim to provide a reasonable c on- strual of how the organization should provide healthcare in terms of value for money Tengs TO, Adams ME, Pliskin JS, et al. Five hundred life saving inter- ventions and their c ost effectiveness. Risk Analysis 1995; 15: 1-30 Ubel P. Pricing life. Cambridge, MA, MIT Press, 2001. 546 B TAYLOR & J KNIGHTON ICU layout In the UK, critically ill patients are now regarded as Level 2 (HDU) or Level 3 (ICU) in th e critical illness dependency spectrum. It is recognized that levels of dependency change r apidly, requiring facilities to be \202 exible and cope with changing demand. Most hospit als operate critical care facil- ities that admit both Level 2 and 3 patients, and the layo ut of the unit must re \202 ect this. Design has become more patient focused, with attenti on to environmental aspects such as light, noise and space. The needs of relatives and fami lies are incorporated to a greater extent. washing, and gloving and gowning, which functions as an airlock. The ventilation system to allow isolation may be switchable positive or negative pressure ventilation, or a balanced supply and extract ventilation system that provides a \200\230constant \200\230 system of ventilation without the requirement to switch between pressure systems. Ventilation should be \201 ltered by HEPA \201 lters to prevent the spread of airborne pathogens Bed space layout Bed space layout, whether in multi-bed areas or single rooms, is designed to allow bed areas to \200\230 \202 ex \200\231 and accom- modate any patient, from the l owest to the highest level of acuity. Patients may then be cared for in any bed space. With this in mind, most critical care bed space layouts now follow a generic template, replicat ed in each bed space General principles Core requirements in the design of quality critical care facilities incl ude: \200 \200 \200 \200 \200 \200 \200 Fitness for purpose Preserving patient privacy and dignity Good infection control practices Security Health and safety requirements A quality patient environment A welcoming environm ent for visitors Bed space size With increased acuity, bed spaces have increased in size. Current recommenda tions are that each bed space should have a \202 oor area of at least 26m2 to allow suf \201 cient space for equipment and clinical activity around the patient \200\231s bed and a dequate space between each patient. In multi-bed areas, there should be a further unobstruc ted 2.5m of corridor space beyond the clinical area. ICU location The location of the critical care unit in proximity to certain services is vit al. Key adjacencies are the A&E department, operating theaters, diagnostic imaging (especia lly CT scan- ning) and acute wards. Patient \200\230journeys \200\231 from these loca- tio ns should be as short as possible. Only some services can be co-located on the same floor, but other key adjacencies should be planned such that vertical transfers, via a lift, are a s direct as possible. Routes between key areas should not involve more than one lift transf er. This may be avoided by detailed planning of patient journeys through the hospital, and location of services accordingly. Bedside medical services Traditionally, medical services such as piped gasses, electric- it y, suction, etc. have been supplied at the patient \200\231s bed head via wall-mounted outl ets. This restricts access to the patient \200\231s head, limits the \202 exibility to tu rn beds (e.g. to allow a conscious patient to face a window) and reduces available window a rea. Most ICUs are now adopting ceil- ing-mounted pendant service delivery. The most versat ile solutions are double-articulated twin pendant systems that allow for separation of \200\230wet \200\231 and \200\230dry \200\231 services if required, and offer the \202 e xibility to turn a patient \200\231s bed through 90 \200\223180 without compromising acce ss or the delivery of care. While local requirements may differ, as a rule, each bed space will require the provision of at least: \200 How many beds? The UK critical care beds make up 1 \200\2231.5% of the total bed numbers i n most hospitals, or <1 bed/10 000 population. This proportion has increased in recent year s and is likely to continue doing so with increased levels of acuity and demand. In the USA and many European countries, a far greater proportion of hospital beds are provided in cri tical care facilities (USA >4 beds/10 000 population). 28 power points, protected by a UPS (uninterruptable power system) Multi-parameter monitori ng Infusion and syringe pumps At least two vacuum points At least two 4-bar oxygen outlets Two 4-bar air outlets Ventilation and humidi \201 cation equipment Examination lamp \200 \200 \200 \200 \200 \200 Multi-bed areas or single rooms? Ideally, every patient should be cared for in a single roo m to help maintain the patient \200\231s privacy and dignity and reduce risks of cross-infe ction. This is seldom a realistic option with the numbers of staff required to care safely for patients in such facilities. Most published guidance recommends increasing the proporti on of single rooms, which are often in short supply. Current guidance in the UK recommends that 30 \200\22350% of bed space allocation in general critical care units should be single rooms, though many do not yet meet this standard. All single rooms should have a lobby, al lowing them to function as isolation facilities. Pediatric patients admitted to adult ICU r equire single rooms. Additional services, such as a gas-scavenging system as well as sockets for television, tel ephone and nurse call, may be required at all bed spaces. Bed areas should be rectangular i n shape to maximize the utility of the clinical space provided. Each bed space must have a clinical hand wash basin sited at the foot of the bed and provision for the storage of drug s and supplies locally (see below). The layout of each bed area should follow a generic tem plate that is designed to facilitate clinical care, patient comfort and good infection cont rol practice. Published guidance has suggested generic layouts that are tried and tested. Isolation facilities All single rooms should be able to function as true isola- tion facili ties, for either source or protective isolation. Single rooms should be provided with a lob by for hand 547 CHAPTER 33.3 ICU layout and noisy, and consideration should be given to reducing noise transmission, e.g. by glazed screening. At each bed space, there needs to be provision for chart- ing and notes, which will be via a computer terminal access- ing the electronic patient record. Clean utility Provides for preparation of trolleys for clinical procedures and for storage of sterile supplies. It should be readily accessible from all bed spaces and the central co mmunica- tions base. It may function as the drug storage and prepara- tion area, or this ma y be provided separately. Clinical hand wash facilities are required. Infection control Good infection control practices are facilitated by good clinical design. Hospital infection control teams should be represented on project teams planning new facil ities. Adequate bed space separation (see above) is critical, as is the provision of clinic al hand wash basins, gloves, aprons, etc. at the foot of the bed (on entry to the clinical area). Air conditioning should be zonal. Furnishings and \201 ttings must be easy to clea n. Horizontal surfaces in the bed area should be kept to a minimum as they harbor dust cont aining resistant organisms. While recognizing the need to keep equipment at the bedside, la rge quantities of disposables may hamper adequate cleaning. Small regularly re-stocked trol leys are a better solution than large quantities of bed- side storage. Screening between be ds may be better achieved by portable screens that can be wiped clean, rather than curtains and curtain rails which attract dust and are dif \201 cult to keep clean. Computer keyboa rds should be protected with plastic covers that are cleaned daily and disposed of when a p atient is discharged. Dirty utility Provides for disposal of bedpans and other waste \202 uids and consumables. It should be sited near the clinical area. Clean disposables should not be stored here. Un it design and operational policy should ensure one-way \202 ow from clean utility, to pat ient, to dirty utility. Contaminated equip- ment may also be held, pending cleaning. Laboratory Blood gas analysis and an increasing array of near-patient testing equipment is required and best sited in a dedicated area with a clinical hand wash basin and adequate st orage space for reagents, specimens and gas cylinders. Space is required for use of compute r equipment. Other support areas required are equipment servicing/ technicians room; clinic al equipment store (haemodialysis, ventilators, monitoring, etc.); linen storage; disposal hold; and medical gas cylinder storage. The volume of consuma- bles stored within a critica l care area may be reduced by ef \201 cient \200\230just in time \200\231 material supply systems. There is rarely enough storage space for clinical equipment! Well planned support accommodation enhances the opera- tional ef \201 ciency of the critical care unit and imp roves the working environment for staff. Environmental conditions It is accepted that a pleasant and appealing environment is of ben e \201 t to staff and patients alike. Critically ill patients benefit from the provision o f natural light and the opportunities for views of nature. Full-length windows should be pr ovided wherever possible, with due consider- ation given to the problems of glare and solar gain as well as privacy. Consideration must be given to noise reduction strategies. Ventilation All clinical areas should be fully air conditioned and pro- vided with temperat ure and humidity control, the former being adjustable locally between the ranges of 16 and 27 C. Humidity should be controlled within the range 40 \200\22360% relative humidity. The frequency of air changes required to achieve environmental control will vary depending on unit design and size. Single rooms should comply with published standards for isolation fac ilities in this regard (usually a minimum of 12 air changes per hour). Facilities for visitors Sitting rooms should be comfortable and welcoming. They must be of suf \201 cient size to accommodate groups of fami- lies who may spend many hours there. Se curity controls should prevent unauthorized access to any clinical area, but there should b e means of communication with the clinical area. Separate interview rooms should be provide d for breaking bad news and private discussions. In surveys, the poor quality of relatives \200\231 facilities is frequently noted and is unacceptable. Lighting Bed spaces should be illuminated by luminaires above the bed. Luminaires should be individually controllable by dim- mer switches to adjust illumination from low level night lighting to at least 400 \200\223600lux for clinical procedures. Additional lighting shoul d be provided in the general circu- lation space and support accommodation, which should al so be dimmable, such that safe low level lighting can be provided at night. Facilities for staff There should be provision of staff changing facilities, includ- ing sh owers. Staff rest rooms should allow space for staff to relax, prepare food and eat, and sh ould receive natural daylight. On-call facilities may be required. Of \201 ce accom- modat ion and supporting interview space are best pro- vided in an area adjacent to, but separate from, the clinical area. Some education and training facilities should be pro- vided withi n the critical care complex, though larger groups may require the use of central facilities elsewhere within the hospital. Clinical support accommodation Staff base A central staff communications base should have a n unob- structed view of the clinical area. The base ful \201 ls many functions and needs provision for computer terminals, radiology image viewing and telecommunications. It is bus y Further reading HBN 57. Facilities for critical care. London: NHS Estates, The Stationary Of \201 ce, 2003. 548 B TAYLOR & J KNIGHTON Medical staf \201 ng in critical care Background Over the last 3 decades, ICUs have worked through an evolutionary process that h as transformed their role in hospital services. Once regarded as enigmatic, isolated, and i ntimidating \200\230end of corridor \200\231 areas into which many patients were perceived to be admitted on a \200\230one-way \200\231 journey, ICU services have become an establi shed core of acute patient care infrastructures, with quality patient care now being increa singly dependent on critical care support. In many units that have driven this change in st atus, high levels of consultant presence and supervision have played a key role in developi ng cohesive working relationships with other specialities, as well as in improving patient outcomes. Strong commitments to education and training programs, many of which have been de veloped locally to enhance trainee recruitment, have also been very signi \201 cant. Consu ltant input to patient care has evolved considerably. On-call rotas of \200\230one in two \200\231 or \200\230one in three \200\231 were accepted as an inevitable consequence of si gning up to intensive care as a consultant specialist, often with insist- ence that they mu st be informed of all admissions irrespec- tive of whether they were \200\230on-call \200 \231 or not! With hindsight such dedicated attention to continuity may be viewed as borderi ng on the \200\230obsessive compulsive \200\231, but the reality is that the establishment of high standards in critical care was a crucial part of an essential development pathway; once these became accepted as the \200\230norm \200\231, even the most reluc- tant employ ers could not escape the fact that it was unrea- sonable to expect them to be maintained by a small number of consultants working excessively long hours. Consequently, consultant sta f \201 ng has steadily increased to more acceptable levels in many units, with the Europea n Working Time Directive and the New Consultant Contract having added strength to the case for this trend. Despite this progress, there is undoubtedly still a wide range of variation in staf \201 ng structures and medical pres- ence on ICUs. Anecdotal reports still sugges t that in some units supervision of care of the critically ill patients is still shared wit h other responsibilities such as anesthesia on-call, and that middle grade trainees may als o be required to provide concurrent cover for both critical care and anaes- thesia services . Such systems are likely to increase the risks to patients and also increase vulnerability of staff to profes- sional criticism or even litigation if an adverse event occurs because of lack of immediate medical expertise when required. Although the NCEPOD report into emer gency admissions to critical care led to an erroneous perception that delayed referrals ten ded to occur as a result of failures of intensive care systems, the time intervals to consu ltant review of patients admitted to ICUs also led to a number of relevant questions being raised about consultant staf \201 ng and availability. The developing new pathways for com mon stem training in acute care are also dependent on high lev- els of consultant input to critical care components. The inevitable conclusion therefore reached by many was that form alized standards for ICU medical staf \201 ng were over- due, leading to their joint produ ction by the Intensive Care Society (ICS) and the Intercollegiate Board for Training in Int ensive Care Medicine (IBTICM). \201 rst UK document, but its recommendations were neces- sarily limited by many organiza tional issues and the wide range of differing clinical practices throughout the country. Th e Faculty of Intensive Care of the Australasian and New Zealand College of Anesthetists als o produced standards for medical staf \201 ng, but these were limited to a degree by the n eed to incorporate both large centralized units (where full-time intensivists were an incre asingly estab- lished normality) and small, rural-sited ones which were predominantly depen dent on anesthetic services. The Medical Staf \201 ng Standards document is based upon the principle that critical care services should be delivered by appropriately and fully train ed staff, but recognizes that de \201 ciencies in consultant numbers will limit the time s cale. It also recognizes that differing levels of consultant exper- tise and availability h ave to be supported depending on the size of the unit and the proportion of their clinical work that is committed to critical care, and de \201 nes training requirements on this bas is. Table 33.4.1 Summary of staf \201 ng standards All newly appointed consultants with programmed activities (PAs) in intensive care medicine (ICM) should have acquired Step 1 competences, or an equivalent level of training. All new ly appointed consultants with >50% commitment to ICM should have acquired Step 2 competence s, a CCT in ICM, or an equivalent. All units must have a minimum of 15 PAs of consultant ti me committed to ICM each week per 8 Level 3 beds. All consultants providing an \200\230on- call \200\231 service to the ICU must have PAs committed to ICM. Consultants should not hav e any other clinical commitment when covering the ICU during daytime hours. During working hours, the consultant in charge of the ICU should spend the majority of his or her time on the ICU and must always be immediately available on the ICU. There must be 24h ICU cover by a named consultant with appropriate experience and competences. A consultant in ICM must s ee all admissions to the ICU within 12h. The document sets out standards for consultant staf \201 ng structure of critical care uni ts, based on recommendations learned from the evolutionary process and from those who have worked through different methods of medical input. Although these may be viewed as challeng ing (or even unrealistic) by some units, it is recommended that for those that fall signi \201 cantly short of achieving them they should be regarded as a lever that will assist in the process of increasing consultant staf \201 ng and improving quality of care. They will also help units to work towards supporting many of the other quality and patient safety in itiatives currently being developed by organizations such as NICE, the National Patient Saf ety Agency, the ICS and the Pediatric Intensive Care Society. Clinical management Information from a number of sources, including the ICS, the Intensive Care National Audit and Research Center (ICNARC), the Critical Care Patient Liaison Group ( CritPal) and NCEPOD support anecdotal reports of wide variations in clinical practice and s upervision of patient Setting the standards Previous attempts have been made to develop standards for medical sta f \201 ng in ICUs. In 1984, the ICS produced the 549 CHAPTER 33.4 Medical staf \201 ng in critical care care throughout the UK. To improve consistency and upgrade quality of care where deficienci es exist, the Standards document logically outlines minimum recom- mendations for clinical management and care infrastruc- tures that are based on existing best practice. These inclu de requirements that: \200 The role of trainees in critical care units is also evolving; historically, many ICUs were dependent on the presence of an anesthetic middle grade trainee for \200\230round the cloc k \200\231 cover; such individuals often shared responsibility for intensive care patients with other commitments such as being \200\230second on-call \200\231 for anesthesia or obs tetric anaes- thetics. In recent years many larger units have overcome the associated con \202 icts of such systems by creating dedi- cated critical care \200\230fellow \200\231 or \200\230middle grade \200\231 posts \200\224often integrated with anesthesia, Emergency D epartment or acute medicine training programs \200\224to ensure that there is 24h presence and support of individuals with appropri- ate skill levels. For such trainees, a careful ba lance between clinical responsibilities, training provision and consultant supervision/avai lability has been essential, and will become even more important as the skill mix of middle grade trainees from differing clinical backgrounds evolve. Variations in local preferences may see a trend towards developing critical care practitioners or nurse-specialists who ma y undertake greater clinical responsibilities. There are also some who advocate that consul tant staf \201 ng levels and rotas should be developed to provide 24h resident consultant cover. Although there may be theoretical bene- \201 ts of such systems, the implications for the development of trainee independence and for future specialty recruit- ment also hav e to be taken into consideration, and there is no current consensus on the wider bene \201 ts of a resident consultant program. The role of clinical academics who specialize in crit ical care medicine is also changing, with re \201 nements in job planning being required t o ensure that valuable contributions made to both clinical and research activities are not eroded by specialty evolution. The importance of maintaining clinical academic posts within critical care units and training pro- grammes is highlighted in the Medical Staf \201 ng Standards document. The document also recognizes that however sensible and desirable the re commended standards may be, in the continuously changing environment of the NHS it is unrea listic to expect these all to be achieved in the immediate future. Accordingly, a timetable for the imple- mentation of these standards, which should be applicable to all units which provide care for Level 2 and Level 3 critical care patients, has been included. The full v ersion of the ICS/IBTICM Standards for Medical Staf \201 ng document is available on the I ntensive Care Society website. A medical practitioner of appropriate experience and training must normally be present on t he unit at all times. There should be a minimum of two, and preferably three, ICU rounds ev ery day at which a consultant is present (except if the round has been speci \201 cally de legated to a senior trainee for training purposes) There must be continuity of care in the consultant cover of the ICU, best achieved by a consultant managing the unit for a period o f several days at a time. Suf \201 cient time must be allowed in consultant job plans for effective handover of unit responsibilities. The number of beds managed by one consultant m ust be carefully considered and will depend on the number of other partly quali \201 ed st aff available. All admissions/refused admissions must be discussed with the duty ICU consul tant and management plans agreed. Trainee staf \201 ng and training recommendations Training in critical care medicine is un dergoing a period of relatively rapid change as a result of the recommendations of the IBTI CM, minimum critical care training requirements for anesthesia and the recommendations for the Postgraduate Medical Education and Training Board (PMETB). Trainee staff numbers will v ary according to the size of units, rotational arrangements, the availability of \201 xed -term specialist training attachments (FTSTAs) and the preservation (and longer term viabil ity) of independent \200\230fellow \200\231 or \200\230middle grade \200\231 posts locall y. However, there is increasing recognition that in addition to the competency- based asses sments that are a key component of training requirements, there are other basic requirement s for all staff working in critical care. These include; \200 A documented induction program for all new staff (medical, nursing and allied health profes sionals) Incremental training programs for all staff Allocated time for training and assess ments for specialty- speci \201 c and generic mandatory training programs Access to online resources and appropriate e-learning packages \200 Further reading FFANZCA. Minimum standards for intensive care units. http:// www.anzca.edu. au/jficm/resources/policy/ic1_ 2003.pdf The evolution of the acute care common stem (ACCS) training programs should lead to more co nsistent and better organized training for future trainees in critical care, and the associ ated rotational training programs are likely to increase the numbers of trainees working in ICUs which have training approval. Trainee presence will also be dependent on the proporti on of those wishing to under- take specialist training in critical care medicine to either Step 1 or Step 2 levels and the number of posts that can be supported by the unit levels of activity. ICS. Standards for consultant staffing of intensive care units http://www.ics.ac.uk/icmprof/ Kmietowicz Z. Many trusts fail to monitor whether complaints have any effect, says watchdog. BMJ 2007; 335: 738 \200\2239. National Con \201 dential Enquiry into Patient Outcome and Death NCEPOD paper. http://www. ncepod.org.uk and http://www. ncepod.org.uk/2005.htm and http://www.ncepod. org.uk/2007.htm 550 G BRADBURY ICU staf \201 ng: nursing attention to the growing number of ICUs where nurses work 12h shifts. Comprehensive critica l care suggests appropriate levels of care based on patient requirement for organ support. The report also recommends that critical care be considered a process rather than a place, and that care is provided as a continuum. Interpretation of this report has led to many org anizations equating Level 3 care with intensive care, Level 2 care with high dependency car e, and then a further assumption that Level 3 care should be based on 1:1 nursing ratios an d Level 2 care based on 1:1.6 or 1:2 care. These assumptions become very problematic for cl inical staff when patients require increased supervision when show- ing signs of agitation or delirium, or are recovering from acute head injury, and require high levels of expert nu rsing supervision. It should be noted that there are variations in staf \201 ng skill mix when comparing urban and rural hospital/critical care settings. The nursing workforce tends to move to large cities early on in their clinical careers, for training and experience. L ater there is a tendency to move away from large urban centers, and they often become more estab- lished in smaller centers as \200\230career staff nurses \200\231. They comprise a stable workforce with differing impact on recruitment, retention and training needs. Nursin g estab- lishments may therefore be constructed to re \202 ect this stable workforce. Volumes have been written about the provision of nursing care to the critically ill over th e years. Nursing Managers have experienced \201 nancial glut, belt-tightening, the intro- duction of workload measurement systems, shortages of nurses, foreign recruitment and, mos t recently, Payment By Results. Hospital beds have decreased in numbers and patient LOS has shortened, compressing the acute/high intervention period of patients \200\231 hospitaliza tion. Tensions have been created within critical care as the staffing expenditure comes und er ever-increasing scrutiny. Table 33.5.1 Competing factors affecting the provision and cost of critical care nursing st af \201 ng Forces opposing current staf \201 ng patterns Forces driving increased need for critical care beds and nursing Technology Increased ageing population Payment by Results Caps on spending/reduction of critical care budgets Nursing shortage Diagnostic-related groups and shortened LOS Rapid interventions and improved pre-hospital c are Compressed acuity Increased complexity of patient care Rising health care costs Litigious society International perspective Critical care nursing varies from country to country, and this, t oo, must be taken into account when establishing nurse:patient ratios. In North America, sk illed practitioners such as Respiratory Therapists add to the total comple- ment of carers. In some European countries, nurse patient ratios of 1:2 exist, but the complement of medic al practi- tioners is higher than in the UK. In the UK, nursing roles have expanded over ti me, taking on expert roles in communication, management and organization of patient care. S uch national variations also mandate caution when comparing nursing establishments directly with other countries. There is also variation in the de \201 nition and staff- ing of ICU s. The UK had the smallest percentage of critical care beds (2.6%) per total hospital beds of any country in Europe, but also has the highest number of nurses per bed, the third high est use of mechanical ventilation (55%) during the \201 rst 24h, and a higher mean SAPS I I score than other countries. Driving forces vary. In the state of California, public and n ursing concern about safe care in acute hospitals resulted in the California Department of Health Services being directed to establish nurse-to-patient staff- ing ratios by January 2 002. Workload and acuity measurement systems Current research A large number of different system s have been set up to assess the amount and type of care required by the criti- cally ill. Some quantify the amount of care required as a result of required medical interventions: AP ACHE II, TISS, SAPSII, GRASP, SOPRA and the recent AUKUH Adult Acuity and Dependency Measur ement Tool. The patient classi \201 cation systems ICU nurses are currently using lack pre cision and do not accurately quantify the amount and type of care required by patients. The y fail to include indi- rect nursing activity, skill mix, the knowledge and skill required for competent and expert practice, and unit geography. Nonetheless, some investigators are examining the rela- tionships between nursing workload and clinical severity. Clinical seve rity as measured by APACHE II was found to explain 25.6% of the daily variability of nursin g workload measured by PRN Rea. In a study of 99 ICUs in 15 countries, investigators were a ble to add 5 new items and 15 subitems describing nursing activities in the ICU. This new s ystem is the Nursing Activity Score (NAS) and explains 81% of nursing time as compared with 43% with TISS-28. Another study attempted to validate a new Intensive Care Nursing Scoring System (ICNSS) by comparing it with TISS-28 as a predictor of mortality. The ICNSS demonst rated higher scores for patients undergoing emergency treat- ment than electively operated patients. Encouragingly, the ICNSS included care of relatives in the 16 variables. This sin gle-center study requires replication, paying particular Future directions for the establishment of appropriate nursing staf \201 ng levels In a ma jor departure from validation of nursing workload measure, Ball and McElligot conducted a s tudy to make evident the complexity of issues associated with the delivery of care by nurse s to the critically ill. Their analysis demon- strated that an effective nursing resource w as dependent on knowledge, experience and exposure. The unit geo- graphy, case mix, activit y level and skill mix also had a sig- ni \201 cant effect on the ability of the nurses to contribute to 551 CHAPTER 33.5 ICU staf \201 ng: nursing Making the best use of current establishments ICUs vary greatly in size, complexity and cas e mix. It is logi- cal, therefore, to expect that staff roles and work patterns will also v