Intensive care unit organisation and its impact on patient and nurse outcomes : a cross-sectional study of two models

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Aim: To explore the organisational effectiveness and impact on patient and nurse outcomes of two alternative closed Intensive Care Unit (ICU) models in Australia. Background: Internationally the demand for critical care is increasing. Solely increasing bed capacity is not feasible due to high resource requirements and burgeoning costs. Consolidation of conventional ‘stand-alone’ ICUs into large multi-specialty integrated service models, the ICU ‘hot-floor’, is a preferred organisational strategy. Assumed benefits include improved patient throughput and resource utilisation, concentrated expertise and enhanced operational flexibility. The effect on patient and nurse outcomes however, is not well understood. Balancing efficiency and effectiveness is fundamental to high organisational reliability and sustainability. Design and method: This study compared a general ICU within a hot-floor service and a conventional general ICU with similar service level and workforce characteristics. Patient throughput measures and outcomes were retrospectively investigated in a sample of 1000 randomly selected patient records during 2013. In 2014, a sample of 145 clinical nurses, split between both units, completed a structured questionnaire that incorporated validated instruments to examine the work environment, satisfaction and burnout. Outcome measures: Patient mortality, unplanned extubation, catheter associated blood stream infections, pressure injury, venous thrombosis prophylaxis, length of stay, after-hours discharge and unplanned readmission, and unit level access, occupancy and volume were collected. The Practice Environment Scale-Nursing Work Index and Maslach’s Burnout Inventory, along with supplementary questions on work perceptions, were used to collect nurse outcomes. Results: The hot-floor model achieved higher patient throughput and a lower after-hours discharge rate, with no significant differences in patient outcomes. Patients were however more exposed to the risk of an adverse event such as deep vein thrombosis due to lower compliance with routine clinical prophylaxis protocols. Front-line nursing management, education, clinical support and senior medical staff were shared across the hot-floor service, resulting in less dedicated resources allocated to the general ICU. Nurse manager support was less effective and nurses expressed lower personal accomplishment. High patient turnover and paid overtime compounded nurse workload, though greater internal hot-floor operational flexibility reduced nurse redeployment to external wards. Conclusion: Improved demand management achieved through greater operational flexibility is a key driver for the hot-floor model. Efficiency gains need to account for the work environment to optimise nurse outcomes, reduce turnover and mitigate patient risks. Adequately resourced front-line nursing management and education are required for high organisational reliability and long-term sustainability.
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