ICU is a clinical micro-system and share similarities with other clinical frontline micro-systems in healthcare organizations. Clinical micro-systems are living and complex systems that have some structures, some patterns of relationships, and some processes to create work and output (9). There are some dissimilarities but many similarities between the industrial mode of production of goods and the mode of work in intensive care units. Dissimilarities are in many cases about the exact description and performing of the work process in industrial production and the existing plans for adverse events. One important similarity is the complexity of work, which necessitates multi-disciplinary way of work organization, cross specialty cooperation, evidence based decision-making and the use of standardized procedures to avoid variability. Intensive care medicine (ICM) or critical care medicine (CCM) is usually defined as the crossroads between science, advanced technology, practical medicine and ethics. The first function of ICM is taking care of acutely ill patients who have life-threatening and potentially reversible organs dysfunction. The second function of ICM is providing intensive monitoring and organ support for elective patients who undergo complex interventional procedures and are at the risk of developing organ dysfunction. ICM is by nature multispecialty and multidisciplinary. Multispecialty in the sense that multiple medical specialties are involved in their specialty’s critically ill patients (medicine, surgery, neurosurgery, pediatrics) and multidisciplinary in the sense that multiple categories of caregivers (critical care nurses, pharmacists, nutritionists, social workers, physical therapists –respiratory therapists in North America) are involved in caring for these patients.
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ICM is practiced in an ICU, which is a specially equipped hospital ward with specially trained personnel prepared to take care of critically ill patients. The origin of ICUs may be traced back to the postoperative recovery room established in Massachusetts General Hospital in 1873. However, it was poliomyelitis epidemic and the need of long term ventilation of patients in the early 1950s that triggered the development of ICUs in both Europe and the US.
The benefits of ICUs were gradually realized and resulted in increased interest in ICUs in the 1970s and early 1980s. During this period the annual usage of ICUs increased 8% in USA and nearly 5% in Canada. The ICUs in different hospitals (university hospitals, regional hospitals, and local hospitals) have different functions offering various types of services with different levels of complexity.
The most complex ICUs are university hospital ICUs which should offer all required aspects of intensive care. Hospitals may organize their ICU beds as multiple units divided according to different areas of expertise and managed by a single discipline specialty (medical, surgical, neonatal, neurosurgery, burn, cardiac surgery, or trauma). However, there are good economic and operational arguments for multispecialty ICUs against single specialty ones. The number of ICU beds in a hospital usually ranges from 1 to 4 per 100 hospital beds (10). Multispecialty ICUs, especially if high dependency beds (intermediary beds) are not available in the hospital, would require more beds than single specialty ones. ICUs with less than 4 beds are considered not to be cost-effective, whereas those with 20 beds may be difficult to manage. ICU is an expensive unit in hospital and uses 8% of total hospital budget (14-20% in USA).
In the last four decades the knowledge of ICM has been developed along with the development of ICUs. Intensive care physicians must be experts on this knowledge that includes among others pathophysiology, special management techniques, professionalism, and ethics. The diagnosis and management of critically ill patients in practice is different from other patients and usually require a rapid initial assessment and rapid initiation of treatment before establishing a diagnosis. There is a need for frequent assessment of the patient since the disease process may be rapidly changing. The treatment plans often consist of therapeutic trials with predetermined treatment goals and predetermined responses to possible complications. Critical ill patients are at
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higher risk of iatrogenic complications and assessment of developing or potential iatrogenic complications is an important part of the management plan. However, we have made advances to understand the nature of iatrogenic complications better and learned how to avoid them. The best example of this is probably the introduction of lung-protective mechanical ventilation.
Advances in ICM have resulted in increased survival for critically ill patients.
Other medical and interventional treatment modalities (malignancies, surgical and other interventional techniques) have also developed and led to increased survival. Additionally, there is also an increasing rate of aging population in the society. These factors have accordingly changed the demographics of the ICU patient population and created new changes like sepsis and multi-organ failure.
The prevalence of these serious conditions is increasing while there are only supportive therapies and no causal therapies for them.
There is always a need for improvement of performance and ICUs are no exceptions. There are several process improvement measures and organizational improvement measures, both within and outside ICUs, creating a great potential for improving patient outcomes. These improvement measures which are at least of the same importance as many novel therapeutic interventions, need to be systematically implemented to achieve their potential of improving patient safety. Some of these measures are as follow:
the presence of a medical director with specialist training in intensive care medicine, continuous day and night access to intensivist physician (physician with the subspecialty of intensive care medicine or critical care medicine), daily treatment plan, protocolized delivery of mechanical ventilation, sedation protocols, and daily stop of sedation. Success in process optimization requires great leadership, communication, and organizational skills. Quality control and continuous process improvement must be integrated in the daily practice of ICU (10;11).
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