Introduction Commented [a1]:

This volume covers a number of different aspects of organization and management oi iniénsive care.
It is inevitable that overlaps occur. ln this chapter focusing upon the role of the lCU in the modern
hospital it has been necessary to elaborate over what the modern hospital will be or develop into in
different health care systems. That is perhaps the unique task of this chapter, but besides that the
distinction between the lCU and the high dependency unit, or perhaps the grey zone be tween the
two as well as the relation between the ICU and different outreach activities will also be covered
with the risk of overlap of other entries in this volume.

Relation between lCU, hospital and health care system

Starting up with the role of the individual hospital within different health care systems it is easy to
see differences. Any hospital with an emergency unit would need an intensive care facility. Related
to the size of the emergency unit and/or the availability of alternative emergency units in the same
area. the intensive care facility will be different. There is a suong tendency towards in

creasing the size or emergency units in the westem world in order to reach a critical mass for
handling complicated emergency cases [I]. This is best illustrated by the level one trauma units which
may or may not at the same time handle non trauma emergencies. In other parts of the world the
need of intensive care facilities may be different. Sometimes intensive care facilities are totally out
of the economic possibilities. Here the type of health care system in use will be a strong determinant
of the intensive care facility. In most hospitals dealing with emergency cases or major surgery within
a health care system where patients (families) pay directly or via private insurance there will be an
intensive care facility as a part of the business plan also in countries with a low BNP per capita on the
average.

In countries with a general health care system. public or private, but accessible to all inhabitants, the
situation is different and decision making is different [2.]. Again the roles of the ICU in the hospital
are related to whether there is a uniform public insurance system or of insurances are individualized
on different levels. Expensive parts of hospital care, as in this case a stay in the ICU, may differ in
availability in an individualized insurance system. This may then also be a concepts.

part of the local business plan. It may be attractive for some individuals to sign up for a health
insurance that covers for ICU care on broad indications. The cost for such insurance mav not be
feasible and/or amactive for everybody.

ICU and high dependency care

It seems important to differentiate between the role of an intensive care unit which serves its
purpose ii'om strictly medial indications and when the purpose is a combination of medical
indication and a business plan In any public health care system. whether financed by the tax bill or
by public insurance systems, where admissions to the ICU rest solidly on medical grounds this will be
a limiting resource. The role of the ICU and the ICU physician will be to make use of the resource as
efficiently as possible. The patients that have the best need of these resources at any time point will
ideally be the ones in the ICU. The size of the ICU resource parallel to outpatient activities. ordinary
wards and high dependency unit must be properly analysed. Again. depending upon the size and
prolile of the hospital. the optimal solution may be very different [3].

the ICU registry as a tool

Other chapters in this volume will try to deiine what intensive care medicine is and what the ICU is.
Still. as a reflection of the hospital profile the optimal solution may be a combined intensive

true in sparsely populated areas where transport Iogish’cs will favour comparatively small hospitals
with comparatively broad medical responsibility. The same situation may occur in hospitals confined
to elective admittance or major surgery only. where the optimal solution may be a cornbined
recovery room high dependency and ICU.

A major achievement during the last ten years is the use of computerized information systems and
the develoPment of databases reflecting ICU care. Characterization of patients. activities and
outcome can be studied with an epidemiological perspective (4|. For the first time. systematic
information from clinical practice becomes available for decision making. As with any data

base, a lot of flaws and pitfalls are unavoidable in databases, and these may disguise important
information. Inevitable comparisons between the use of resource and the performance within given
resources come up to discussion in economical as well as in political perspectives. Although these
epidemiological data are still far from perfect, they add new dimensions into the discussion of the
role of the ICU in the modern hospital. As ICU physicians and nurses, we should embrace this
possibility and engage ourselves and make the registration and follow up as accurately and detailed
as we can.

Beside obvious limitations in databases, such as low quality input in terms of imperfect registrations.
there are system-related limitations. These limitations may be that a certain ICU facility is not
accessible to everybody or that the decision of admittance is made only partly on medical grounds,
or there may be other selection criteria that limit the generalizability of data.

Furthermore. when discussing performance. ICU outcome is far from being one-dimensional [5}. In
additicn to mortality and morbidity, quality oflife must be considered. As a part of the epidemiology.
the long term outcome after intensive care is an important part of the basis for decision making
concerning the role of the ICU in the modern hospital: The long term outcome is an important
perspective when admittance criteria are discussed. It is covered by other chapters in this volume:
which patients should be admitted to the ICU, particularly when there are restraining levels of care
and treatments.
Transporting ICU patients

Another issue to consider is how and when to transport or transfer patients in need of intensive care
facilities [6]. Knowledge about the safety of transport of critical ill patients is rapidly increasing. but
still the risks involved are not sufficiently characterized. It is possible to transport patients on ECMO
with a higher level of safety as compared to a transport of the same patients on artificial ventilation
With me % oxygen and a borderline oxygenation. There are reports that any transport canies the risk
of adding to morbidity and to prolonging the ICU stay. Here it is often difficult to separate the
transport itself from the indication

for the transport [7]. In some areas, transports between hospitals are carried out for no other reason
than shortage of ICU beds. The triage behind the choice for such a patient transport has, to our
knowledge, not yet been sufficiently studied. This is in particular the case when such bedside
decisions must often be made under the pressure of time and where only limited information is
available. These are often decisions of triage which are dependent on several levels.

There are also situations when decisions are merely about the availability of competence and
resources on one hand and the risk of transport on the other hand. Techniques involved and
competence during transport have increased rapidly. Transport between units and hospitals will
probably be more common in the future. This involves a number of problems. where safety is just
one. The acceptance inside the ICU. inside the hospital. as well as among patient relatives and
people in general represented by politicians must all be considered in this process. The need for
these transports comes out of an urge to optimize the use of medical resources as well as that of
economical resources. From a patient and relative perspective any transport that is not motivated by
access to a. higher level of resources and competences, is questioned and poorly accepted. In this
regard. an ICU organizan‘on that 1m olves an increased need of transports must constantly seek
support from taxpayers and politicians.

Flexibility as a success factor

When the role of the ICU in the hospital in the future is discussed it is important to remember that
flexibility historically has been a success factor. There is no reason to believe that the future will be
any different. Hospitals with an ICU organization and an ICU resource that can adapt to new
situations are usually successful [8]. Rigid systems in terms of organization. staffing. localities and
use of technique have usually been less successful. General statements like this may be interpreted
very differently and therefore such a statement must be developed a little bit further. For a
successful ICU management. medical competence is essential. Management and leadership in
general may be organized in multiple ways but it is the involvement and medical corn:

petence in the decision making which remains most essential.

The flexibility may be dependent on the level of number of patients and on the level of care. Today.
scoring systems to differentiate between categories of patients are operational to allow lCUs to
optimize the number of patients in relation to resources. The obvious problem is the non-linearity of
the scoring and the fact that nurse-to-patient ratios can only involve whole number such as 1:1, 1:2,
1:3 etc.~[9]. Flexibility may also be in terms of single-patient rooms and multiple-patient rooms and
the different need for staffing related to that.

Flexibility on another level may be how to handle a change in demand. How can we {ind the optimal
critical mass in a new situation? Here, the ability to analyse ICU need on the hospital level is a critical
success factor. The number of holy grails and hidden agendas in a given hospital will increase the
painfulness-delay rational solutions. Very often no effective solution will achieved at all. Strong
professional organizations of doctors as well as nurses are necessary to guaranty quality. Besrdes
that, the Structure how to use the resource in an optimal way is the key to success.

Health economy

In a health care system where > 70 % of the total costs refers to payment for nurses and doctors,
optimal staffing competes over any other factor in calculations of cost-effectiveness [to]. The role of
ICU in the hospital will then be to care for the patients in need of its full resources and to always
have a high occupancy of its beds. However this equation is not complete without introduction of a
proper time axis. The term optimal care refers to a level of care. but in addition also to a length of
care. lCUs that are understaffed with doctors and nurses tend to have a longer length of stay (L05).
Optimal care also refers to a correct level of care in terms of restrains meaning withholding and
sometimes even withdrawing treatment

It IS obvious that defining the correct level of care will be a critical success factor in the future. To
make this process meaningful in economical terms. the corresponding levels of care must be
available. A proper analysis of the demand for ICU beds. high dependency beds and perhaps

also units for ventilated single organ failure patients. With good planning, such units may provide
care for patients with need of mechanical ventilation, but with no other organ failure demanding
approximately the same staffing as a high dependency unit. These patients often have
neuromuscular diseases and they may be candidates for home ventilator treatment.

Optimal level of care as soon as possible

lf priority and effort are directed to optimizing the level of treatment for each individual patient. we
now come to the problem of how this decision is to be reached. lt is highly likely that patients and
relatives will demand the highest possible level of care. at least initially. This is also reasonable until
a thorough evaluation of each individual patient has been performed and a subsequent decisxon of
the optimal level of care is made. It will then not be possible to immediately house every patient
inside the ICU at every time point. For the availability of various outreach services. or an ICU so to
say without walls you can and must offer the solution yourself. Patients should not be admitted to
high dependency care unless having been fully evaluated in a setting with full lCU resources
available, not necessarily utilizing all technical resources in all cases. Sometimes such an evaluation
process may be facilitated if the patient is well known to the hospital or to the referring doctor.

lt will come naturally that a system as described above will need full medical competence around
the clock. Senior intensivist competence will be needed for doing the correct priorities. A
competence on a similar level will also be needed to evaluate the underlying pathology, in particular
the chronic health evaluation is critical. Again the type of health care system will favour different
solutions of this problem. The cost and availability for senior doctors will make the difference.

Conclusions

lhe modem hospital will serve a defined purpose and that will also define the intensive care facility
needed. Economy will necessitate that patients are transferred to the optimal level of care as soon
as possible. Initial observation

servation, diagnosis and treatment should be offered with access to full resources. but thereafter a
different level of care may be optimal for the individual patient. Various kinds of out-reach facilities
may be needed to fulfil the task of initial handling with access to full resources. Consequently,
median iCU stay will be short. which calls for a high medical competence around the clock and a
highly flexible organization of care. As early intensive treatment has the potential to shorten the
need for iCU stay, this will be a priority. Related to the mission of the hospital the iCU may be
organized as a specialized unit or a combined intensive care and high dependency unit. the size of
the unit is probably not critical as long as it tits the defined purpose of the hospital.

The author

Jan Wernerman, MD. PhD Professor of intensive Care Medicine Department of Anaesthesiology and
intensive Care Medicine Karolinska University Hospital Huddinge

Stockholm, Sweden E-mail: ian.wernerman@karolinska.se

References

1. Ala~Kokko ii, at al. lmproved outcome after trauma care in university-level intensive care units.
Acta Anaesthesiol Scand, 2009;53llo):1251-6.

2. Angus DC, et al. international comparisons of critical care outcome and resource consumption.
Crit Care Clin, 1997;13l2):389-407.
3. Wunsch H, et al. Variation in critical care services across North America and Western Europe. Crit
Care Med, 2008;36l10):2787-93, ere. ‘

4. Fakhry SM. Kercher KW, and Rutledge R. Survival, quality of life, and charges in critically ill surgical
patients requiring prolonged lCU stays. 1 Trauma, 1996;41l6i1999-1907.

5. Carson SS. Outcomes research: methods and implications. Semin Respir Crit Care Med,
2010;31l1):3-'12.

6. Beckmann U, et al. Incidents relating to the intraohospital transfer of critically ill patients. An
analysis of the

reports submitted to the Australian Incident Monitoring Study in intensive Care. Intensive Care Med,
2004;30(8):1579-85.

7. Belway D, et al. the role of transport intervals in outcomes tor critically ill patients who are
transferred to referral centers. 1 Crit Care, 2008;23l3):287*94.

8. Sprung Cl, et al. Recommendations for intensive care

unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the
European Society of Intensive Care Medicine's Task Force for intensive care unit triage during an
influenza epidemic or mass disaster. intensive Care Med, 2010;36(3):428--43.

9.Pirret AM. Utilizing TlSS to differentiate between intensive care and high-dependency patients and
to identify nursing skill requirements. Intensive Crit Care Nurs, 2002:18(1):19-26.

10. Kahn jM. Understanding economic outcomes in critical care. Curr Opin Crit Care, 2006;12fslz399-
404.