What Does It Take To Run An ICU or Perioperative Medicine Service

What Does it Take to Run an ICU
and Perioperative Medicine

Service?
Mark E. Nunnally, MD, FCCM

Departments of Anesthesiology, Perioperative Care & Pain Medicine, NYU Langone
Health, New York, New York
Departments of Neurology, Surgery and Medicine, NYU Langone Health, New York,
New York
Michael Nurok, MBChB, PhD, FCCM

Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
’ Service Branding
Promoting an intensive care unit (ICU) or perioperative “brand”

helps establish the needs and the goals for the service. Critical care does
not have the same tangible outputs that define many medical specialties.
Service lines are based on expected throughput from clinical services.
ICU goals, such as meeting extubation milestones and following fluid
protocols, support these outputs, but are distinct. It is a mistake to view
critical care as a simple extension of service lines. Administrators and
clinicians who are not involved directly in critical care practice can
underestimate the mission and operations of a highly functioning critical
care service. Absent a clear mission, an ICU will struggle to define itself
against misaligned expectations and misguided efficiency accountabil-
ities. It is easy to convey the need for an ICU to a medical center, but a
challenge to articulate the nature of that need and the benefits to be
gained in the context of other hospital operations.
ICU care is essential to the provision of complex care, and
understanding the fragile physiology of critically ill patients and their
susceptibility to complications requires special training and ongoing
experience. Sick patients require adequate levels of staffing, monitoring,
coordination, and collaboration. These are the defining criteria of ICU
level of care. However, this narrow definition draws no distinction
ADDRESS CORRESPONDENCE TO: MARK E. NUNNALLY, MD, FCCM, 550 FIRST AVENUE, TH-530, NEW YORK, NY
10016. E-MAIL: MARK.NUNNALLY@NYUMC.ORG
INTERNATIONAL ANESTHESIOLOGY CLINICS

Volume 57, Number 2, 144–162, DOI:10.1097/AIA.0000000000000229
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
144 | www.anesthesiaclinics.com
Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.
This paper can be cited using the date of access and the unique DOI number which can be found in the footnotes.
Running an ICU and Perioperative Medicine Service ’ 145
between an ICU, an advanced specialty (eg, coronary or respiratory

support) ward, or a procedural recovery room.1 Temporarily supporting
the recovery of patients requiring support after myocardial infarction,
acute-on-chronic respiratory failure or major surgery, monitoring for
common complications during periods of high risk, and managing
recovery after the effects of anesthesia are important functions that can
be managed in an ICU or a perioperative ward in what may be called a
specialty/recovery model. In distinction, a fully integrated, interdiscipli-
nary critical care service can provide more robust care and coordination,
including optimization of coexisting disease, diagnostic and therapeutic
planning, and proactive therapeutic adjustment. Coordinating the
collaboration of many services in the care of a single patient is its own
skill, best practiced by highly functional critical care teams.2 Contrasting
the specialty/recovery with the integrated models, the former is
efficiently aligned to manage throughput and expected recovery; the
latter is an intentionally under-simplified, individualized, coordinated
management structure that seeks to align goals and mental models of
patient care. Although both models can improve the processes of care,
the integrated critical care service model is unique to the highly
functional ICU service and perhaps the only viable model capable of
caring for patients requiring hypercomplex interventions such as
extracorporeal life support.
Articulating a complex vision to hospital leadership is a prerequisite
to all requests for resources and for setting accountabilities. Speeding
recovery times after routine cardiac surgery, for example, can be
achieved with a simpler model, but as patients and procedures become
more complex, the integrated model becomes essential. As the former is
lean and the latter is resource intensive, one has to make the argument to
leadership for a loss leader. Creating new services and programs requires
adaptively complex, rather than simple, infrastructure. A preoperative
clinic, perioperative ward, or highly functional ICU are such infra-
structure and should be considered a supportive component of hospital
programs, in the same way anesthesiology, pathology, and radiology
services support medical and surgical specialties in a medical center.
Choosing Models of Care

Efforts to define and establish models for a complex, integrated,
highly functional ICU are reflected in guidelines from the Society of
Critical Care Medicine (SCCM)3 and various studies espousing the role of
interdisciplinary rounding4–6 and independent ICU services.7 Simpler
models gain traction in settings where there is predictability or where
there are conflicts or control concerns. It is essential to define the role
of the service to justify institutional investment. In branding an
ICU, leadership should not be confused about the separate roles of
www.anesthesiaclinics.com
146 ’ Nunnally and Nurok
simplification and control. The ICU should respond to needs for

collaboration and complex care when care is complex, whereas a leaner
throughput model should be based on efficiencies and standardized
approaches for more simple interventions.
Expectations about care processes and outcomes are integral to any
model. Standardization and protocol-driven care initiatives reflect
collaborative or coercive efforts to standardize care around an acceptable
standard. This is evident in debates about sepsis resuscitation,8 optimal
condition-specific care pathways,9 therapeutic approaches,10 and varied
discussions about optimal care models.11 Many authors of these debates
attempt to reconcile process simplification and standardization with
patient complexities.12 It is important to ensure that guidelines,
protocols, or checklists adopted from other institutions are locally
relevant.13
Protocols, when built along interdisciplinary terms and when written
with enough flexibility to promote, rather than just constrain practice,
can be valuable social and clinical tools. Instituting standardized care
pathways and operating procedures ensures common expectations
around treatment, only requiring communication if patients deviate
from the pathway. One study in a busy cardiac surgery center estimated
that up to 75% of patients could be treated in a standardized manner.14
Coordination Through Collaboration

Collaboration is an important element in any model of perioperative
care, especially in the ICU.15 Harnessing the capabilities of teams and
specialists requires organizational savvy and diplomacy. Often this entails
defining, sourcing, and remediating preexisting institutional tensions.
Trust is fundamental to the approach. Services must be comfortable
working with one another to improve processes of care. This is an
opportunity for the perioperative care team, but a challenge that, if not
met, can exacerbate problems. Open communications with leadership and
between practitioners, during routine care and after success and failure,
help build relationships. In surgical critical care, the relationship between
specialist anesthesiologists and surgeons, as seen in liver transplantation
and cardiac surgery, translates into greater trust in the ICUs.
Intensive care is a service, not a location. In highly functional ICU
models, outreach may be an important part of the practice. It extends a
collaborative model outside the physical space of the ICU. Keeping
patients out of the ICUs, or preplanning their passage through the ICU
system, are functions that can be managed by members of the ICU team
and are seen as a part of the value proposition for an ICU service.
Medical and surgical response teams,16 ICUs “without walls,”17–19 and
intensivist participation in presurgical evaluation and optimization20 are
examples.
Caring for critically ill patients is not the same thing as critical care
medicine. This is one source of misunderstanding between services
subscribing to ICU care (eg, advanced procedural services, oncologists)
and dedicated intensive care specialists. Both groups may be equally
competent to care for a given patient, but their focus will be different.
Attention to all organ systems and detail, the recognition of a patient who
is not the canonical archetype, and consistent all-hours clinician presence
near or at the bedside are elements that a highly functioning ICU team
can add to established models of critical care. A well-articulated vision for
critical care should address these differences and discuss ways to
optimize roles. The ICU team can be expected to lead and coordinate
interdisciplinary care of the critically ill patient. They have the primary
responsibility for ICU patients’ care, overseeing the many decisions
involved in their trajectories, and coordinating all of the other services
that the patient may need including those from specialists.
Collaborative specialists should be allowed to practice their expertise
in a complementary manner. Erasing misunderstandings by changing
the language and discussing contingencies can help, as can negotiating
care pathways and establishing expectations through goal setting or
other mechanisms. Measures as simple as fluid administration guidelines
after cardiac surgery and establishing the archetype of an expected path
of care (eg, “plan A” patients) can help frame subsequent discussions
when some patients fall away from typical patterns. These common
concepts establish guidelines for escalation and a framework for
improved communications, both of which can enhance collaboration
and trust.
What is an ICU or a perioperative service brand? The answer is
individualized to the situation, but the architect of an ICU service should
directly account for the elements of collaboration, responsibility, care
goals, specialization, and outreach, and assign a value to the service on
the basis of its complexity and mission. One element to consider is the
interface with other services. The more a team “touches” other services in
the hospital, the more likely it is to be complex and the more thought
should go into resourcing and selling the brand of loss leader that
facilitates complex care. In the ICU, more touches make the case for an
integrated service. Fewer touches favor a leaner approach, accountability
to metrics, and a measurable value proposition. In most cases, elements
of both approaches should be utilized.
’ Financials and Operational Efficiency
Being a loss leader does not mean a critical care or a perioperative

service should necessarily lose substantial money and the financial order of
the service is always a priority. Sources of profitability or cost savings are
driven by incentives. The critical trade-off in finances should balance

aligned incentives with efficiency. Incentives (eg, for relative value unit
billing) can lead to increased use of intensive care beds and increased
procedures where a less resource-intensive approach may be appropriate.21
The SCCM’s “Choosing Wisely” campaign is based on a line of evidence
suggesting that it is possible to deliver superior care while minimizing
expense.22 Removing incentives for clinical productivity on the basis of
billing can facilitate this. Operational efficiencies should be emphasized.
This can be part of a scorecard approach, whereby strategic goals are
translated into tangible metrics and subject to repeated evaluation cycles.23
Coding is complex and requires ongoing oversight. Attention to documen-
tation improves service case mix index and billing justification, and can thus
improve financial remuneration. A sound profit and loss assessment
strategy takes into account appropriateness of care, costs of care, and
potential reimbursement as competing incentives and disincentives should
be weighed to find the optimal approach.
Critical care resources work best when maximizing throughput
(Fig. 1). This allows a health care organization to minimize costly ICU
bed and staffing resources while sustaining the operations that use them.
Throughput is maximized through operational efficiencies such as
identification of patients needing or not needing transfer to the ICU,23
preemptive discharge planning,25 and prearranged care pathways.9,26 In
the case of the former, identification systems can help flag patients for
discharge or transfer planning hours to days in advance. These include
automated alerts from the electronic medical record and care planning
Figure 1. Patient throughput and obstacles. A, Systemic factors slow patient progression to
discharge. Elements of a productive intensive care unit (ICU) service help overcome the obstacles. B,
Patient throughput is hampered by the need to move patients, especially during high census, when the
hospital “goes solid.”24 *Hospital-acquired conditions.
rounds.27 Care pathways can help optimize staffing, which, in many

models, exceeds 50% of all costs. Discharge or transfer before a specified
time for appropriate patients is a metric that can be used for feedback for
clinical teams to improve performance and set standards.28 Care pathways
work well in high-volume services where many of the patients progress in
their recovery at an expected rate, allowing progression by set deadlines.
Minimizing movement during patient progression speeds throughput.
Acuity flexibility allows a patient to progress without changing beds,
minimizing delays for preparation, cleaning, and transport.
Quality metrics can directly correlate to throughput. Through
penalties, they directly influence finances. Healthcare associated con-
ditions (HACs) result in financial penalties to a medical organization,29
and efforts at their reduction directly affect revenue.30 These should be
scrutinized directly by clinical leadership through reviews such as
Apparent Cause Analyses,31 with results provided as open feedback with
a short update time. Clinical teams can learn about risky practices and
respond to pertinent changes by learning about their HACs on a regular
basis through mechanisms such as dashboards.32 Unwanted consequen-
ces of quality metrics include trade-offs and loss of focus. For example,
too much emphasis on early extubation statistics may increase
reintubation rates and deadlines for discharge can affect risks of
readmission. Weighing risks and benefits against metrics and interpret-
ing priorities are skills for an integrated critical care team that
understands the details of quality initiatives and consequences of their
implementation in the clinical setting.
Data feedback provides a powerful tool for quality improvement.
Integration of perioperative services offers, among other advantages, an
opportunity for competitive improvement by focusing the clinical leaders
of different units on their results in comparison with their peers.
Sophisticated dashboards can take into account comorbidities and
compliance with appropriate testing guidelines. Careful review of HACs
allows ICU leaders to assess for proximal causes. Interdisciplinary,
multiunit intensive care councils provide a forum for comparison and
discussion about improvement projects. Sometimes HACs, which are
defined rigidly, do not represent clinical entities that are harmful, rather
the artifact of false-positive testing. Appropriate screening and testing are
beneficial in avoiding penalties and inappropriate treatments.29,33 An
interface with a strong infection prevention service can help improve the
appropriateness of testing, search for sources of infectious HACs, and
help conceive and enforce good practices. It is common for beneficial
measures to cost money, such as the purchase of antimicrobial wipes to
decrease the rate of multidrug-resistant organism infections. Costs can be
justified by relating them to projected savings by avoiding penalties and
increased lengths of stay. Critical care leadership in collaboration with
hospital epidemiology plays a role in making the comparison.
Throughput helps optimize the use of critical care beds, but efforts to
reduce ICU occupancy further improve efficiency. Effective triage reduces
costs to the organization by several mechanisms. Some patients can receive
care at a lower intensity as long as specific services, such as frequent
neurological, vascular, or respiratory monitoring, can be provided. End-of-
life patients, identified by end-stage progressive disease coupled with acute
processes, need not always have care escalated to the ICU, where
aggressive therapies are unlikely to change the outcome or benefit the
patient.34,35 Early involvement of palliative care services can reduce
resource use and improve outcomes.36,37 Frequently, impartial and
accurate messaging in coordination with the entire care team can help
patients and their surrogates cooperate on a care plan that maximizes
achievable goals, such as pain and anxiety control, over escalating therapies
and organ failure support.35 Some patients have requirements that exceed
regular, acute inpatient care, but fall short of needing full intensive care
services. These patients can be followed by a critical care clinical team, but
cared for outside of the ICU,17,38 decreasing the need for ICU staffing.
Throughput and appropriateness of staffing and testing are 2 themes
that every effective clinical service should assess on a regular basis.
Building the metrics, reporting, and feedback systems takes time,
multiple iterations, and avid efforts at updating. Because the types of
patients and diseases cared for in the ICUs change over time, efforts to
improve efficiencies must be sustained to maintain financial gains.
Critical care leadership should be prepared to demonstrate the results of
these efforts in terms that nonclinical leadership can link to finances.
’ Interdisciplinary Staffing in the ICU
How best to meet the needs of differing populations of ICU patients

remains an unanswered question, with various staffing models currently in
use.39,40 Despite conflicting evidence linking intensivist staffing and optimal
patient outcome, the American College of Critical Care Medicine Task Force
on Models of Critical Care states that an intensivist-led, high-performing,
interdisciplinary team dedicated to the ICU is an integral part of effective
care delivery.41 Highly complex ICUs may staff with a core ICU team
consisting of an intensivist and bedside nurse, along with some combination
of fellows, advanced practice providers (APPs) [Nurse Practitioner (NP) or
Physician Assistant (PA)], residents, clinical pharmacists, respiratory therapists,
social workers, case managers, nutritionists, physical and or occupational
therapy, palliative, and pastoral care (Fig. 2). Different specialties complement
one another with varied expertise and insights. Individual providers will
sometimes fill specific roles, such as therapists taking a lead role in assessing
fitness for participation in rehabilitation or early mobilization.43 Units caring
for less complex patients are often staffed more leanly or without the
Figure 2. Interdisciplinary team for a patient on extracorporeal life support. Many services overlap
in the care of a patient and the cooperation and relations between these services define a highly
functioning, interdisciplinary team. Used with permission from Nurok et al.42 Source: Mayumi
Kharabi, Lead Design Strategist, Human Centered Design, Cedars-Sinai Medical Center. NEJM
Catalyst (catalyst.nejm.org), © Massachusetts Medical Society.
continuous availability of all of these personnel. Both high-acuity and low-

acuity units may rely on teleICU coverage as an additional layer of care.44
Optimal staffing of a particular ICU will depend on the acuity of
patients being cared for and the skills of available personnel. The term
interdisciplinary refers to situations where health care discipline
specificity blurs and expertise overlaps on the basis of the requirements
of the particular interaction. ICU staffing is inherently an interdiscipli-
nary paradigm in that skills sets of personnel do overlap (Fig. 2). This fact
may explain the inability to demonstrate the superiority of any one ICU
staffing model over another.
Increasingly, APPs are being relied on to care for patients; between 2010
and 2016, NP and PA full-time equivalents grew an estimated 9.4% and
2.5%, respectively, compared with physicians (1.1%).45 Outcomes for units
staffed by APPs are comparable to those staffed by resident teams, and in one
study of an adult medical ICU, patients cared for by NPs had lower ICU
mortality (but not hospital mortality) than patients cared for by residents.46
The ICU becomes the APP home and there is a natural incentive to optimize
the culture and process of care. Moreover, APPs become highly familiar with
the patient population, processes, unit procedures, and the personalities of
caregivers, which all facilitate care.47–51
Although how to staff should be decided on the basis of local needs,
several operational principles apply to all models. These principles are
rooted in an acknowledgment that the “captain of the ship,” heroic
model of care is no longer helpful in contemporary practice, particularly
in the ICU.13 First, all units require a final common pathway of care to
avoid conflicting orders being executed on the same patient (eg, an order
to give fluid by one team and an order to diurese by another). Most units
will rely on the core ICU team to be this pathway and in many situations,
only this core team will be permitted to place orders; nursing staff will
not execute orders placed by other teams. Such a model relies on the
core team to reconcile different management approaches advocated by
other clinical teams. If they do not fulfill this responsibility, the system
will not function well. Second, clear escalation pathways are required in
the event that the core team is unable to reconcile differing management
strategies for a patient or if anyone caring for a patient is unable to
resolve their discomfort with an approach that is being taken. Finally,
under no circumstances can the bedside nurse or a trainee be left
to resolve disagreements between consulting teams about how to
conduct care.
’ Trust, Teamwork, and Communication
Although many ICU personnel may describe what they do as teamwork

(a cohesive group with shared team identity, clarity, interdependence,
integration, and shared responsibility), at least one observational study has
questioned how often these criteria are fulfilled.52 What most ICU team
members may actually do better fits a definition of “teaming”: teamwork on
the fly, coordinating and collaborating, across boundaries, without the
luxury of stable team structures.53 Effective interdisciplinary teaming is the
backbone of any ICU service, and may enhance other perioperative services.
Breakdowns in teaming can occur within the core team and between it and
other services.
It is important to recognize that different personnel may view success
at teaming differently and may prioritize different values in effecting
teaming work. For example, in a safety culture survey, surgeons and
support staff perceived better safety climate than nurses, perfusionists,
and anesthesiologists caring for the same patients.54 In a survey of critical
care nurses and physicians, only 33% of nurses rated the quality of
collaboration and communication with physicians as high or very high,
whereas 73% of physicians rated collaboration and communication with
nurses at that level.55
Clinicians of different specialties are known to value different aspects

of their work. For example, sociologists have shown how technical skill
and quick action are valued by surgeons, whereas the ability to theorize
a process before acting is valued by internists.56,57 Surgeons may view
complications and poor outcomes as personal failures.58 As a result,
they may only be willing to perform a procedure if the patient is willing
to agree to ongoing aggressive therapy.59 Surgeons may also be
unwilling to withdraw life-sustaining therapy if it is initiated as a result
of a surgical error.60 Both of these scenarios, and the values from which
they derive, can lead to breakdowns in communication with the
perioperative care team if there is a different understanding of the
patient’s goals of care.
Working through these scenarios specifically, and interacting in a
complex care environment generally, should be viewed as a skill, similar
to procedural skills in that it requires training, repetition, supervision,
and mentoring.13 Emotional intelligence exercises61 may be particularly
helpful. Key to avoiding a breakdown in teaming is avoiding a violation
of what the medical sociologist, Charles Bosk, called the “rule of no
surprises.” The rule is violated when care has been delivered or an event
has occurred in a way that surprises a physician who reasonably had an
expectation of participating in a decision-making process or being
informed.58 Although the care that is delivered may be flawless, the
element of surprise drives conflict.13
ICU and hospital leadership commitment is particularly important
in ensuring optimal team behaviors. Teaming takes time and there is no
substitute for face-to-face interaction and discussion of sick patient needs
at the bedside on a daily basis during a preallocated time. Leadership
may consider mandating team-based rounds and joining these on an
ad hoc basis.42 Such rounds also increase clinical efficiency by ensuring
that a comprehensive plan is created in a coordinated manner as opposed
to waiting for chains of conversations to complete before instituting a care
plan (Fig. 3).
Although most clinicians caring for complex patients have appro-
priately adapted their practice pattern to a collaborative model, some
continue to struggle and attempt to uphold the heroic approach to
managing care.62 Hero-based care models are problematic in that they
are usually inefficient, laden with redundancies, and resource intensive.
It can be corrosive to team and institutional morale, and accompanied by
disruptive behavior.63
’ Provider Growth and Experience
Effective critical care is optimized through the interdisciplinary

team.41,17 However, the team operates at maximal effectiveness when
Figure 3. Delays in care because of uncoordinated decision-making. Multiple providers and plans
evolve assychronously. These create delays in decision-making. MCS indicates Mechanical Circulatory
Support team; NP, Nurse Practitioner. Source: Mayumi Kharabi, RN, MSN, CNL.
shared responsibilities are executed collaboratively. The team is more

important than the constituents. Its members should grow and develop
together. Setting the expectation that being part of a critical care team is
a specialty, requiring specific expertise, is important. All members of the
team need to have ownership of this ICU brand. Expectations, including
basic training and ongoing learning, should be explicit. Intensivist
physicians should have specialized training64 and be prepared to lead
multidisciplinary teams. Programs such as the ACCRN and FCCS
certifications provide a common expectation upon which additional topics
may be added.
Perioperative teams must grow into their roles, respecting estab-
lished professional relationships while brokering care plans. Consultative
effectiveness requires presence, good interpersonal skills and knowledge,
and team coordination. Efforts at educating and growing expertise
among providers on this team should mirror these attributes. Regular
training should address negotiating care plans, assessing patients in
terms of clinical trajectory, and the trade-offs between proposed courses
of care. Review of cases to assess triage and clinical assessments helps
inculcate a sense of ownership and presence. Review of needs and
mechanisms for escalation reinforces the role of the team to present a
united interface with all affiliated services. Diplomacy is a skill “better
taught than caught”; mentoring and modeling of negotiation and

conflict resolution skills should be available. Ongoing learning is essential
to critical care practice. All members of the team should pursue
continuing education through local initiatives (eg, journal clubs, quality
assurance review, grand rounds, didactics) and national programs
(major meetings, certifications and courses). Team-building stems from
collaborative efforts at work and group socialization. Simulation training
can, in the right hands, provide knowledge, skill, and teamwork.65,66
One common misperception is the role of procedural skills in critical
care expertise. These are complementary, but not fundamental, to
becoming an expert in the management of critically ill patients in a
highly functioning ICU. Procedural skills are best taught with a
combination of basic learning, simulation (which may be low-fidelity67),
and direct teaching and observation. Having peers serve in the role of
expert trainers builds a sense of camaraderie and nests expertise in rarer
procedures in specific clinicians, successfully demonstrated for central
venous catheter insertion training.68–70 Cognitive skills are more
important than procedural ones. Providers should be expected to
develop proficiency at presentation, diagnosis, and planning, demon-
strating skills at triage and escalation. Presenting on rounds, delivering
effective and efficient signouts,71 and mastering how to communicate
concerns72 are direct reflections of cognitive skills.
APPs in any perioperative setting should be prepared to respond to
the most common problems in that ICU. Septic shock, arrhythmia,
tamponade, and pulmonary embolism are scenarios that, if common to
the ICU, should be discussed and rehearsed as part of ongoing training
and practice improvement.73 One common difference between practice
outside and in an ICU setting is the need for providers (APPs, residents)
to present differential diagnoses, plans, and expected outcomes when
presenting new findings. Expectations should be that providers present
information with a tentative plan for therapy, diagnosis, and follow-up.
All clinicians should drill and understand systematic approaches to unit-
specific presentations of shock and acute respiratory failure. Asking
different members of the care team to teach their colleagues provides an
opportunity for team building. Recognizing illness, and being able to
map its trajectory, making an assessment of whether the patient is
improving or getting worse is a skill that, when used in communication,
allows the team to orient, compose, and execute a care plan.2
’ Metrics: Quality, Safety, and Long-term Outcomes
Quality in a perioperative or an ICU service should embrace

measures that improve team performance, reduce detrimental con-
ditions, and improve efficiencies. A united vision for stakeholders and
participants is the foundation of any quality program. Stakeholders

include the subscribing clinical teams entrusting the service with their
patients, the intensivists and other providers caring for the patients, the
administrators underwriting care in the ICU, and the various supporting
services that might have stakes to gain or lose from any quality initiative.
Quality in the abstract is too fungible to provide a useful platform for
discussions. Initiatives that gain vision and traction directly confront
concerns and set transparent goals. Measurability is useful, but metrics
may be indirect to the object of a good-quality vision. Of all metrics, costs
are consistent and tangible. Agreement about costs and their reduction is
a good starting point for collaborative quality initiatives. As an example,
reducing central line–associated bloodstream infections (CLABSIs) can
result in potential (mortality, length of stay) and real (government
payment penalties) cost savings to a hospital. Efforts at reduction should
address the definition of CLABSI used for penalties, but also consider
the nuances of the definition versus clinical diagnoses and good care.
Efforts that reduce CLABSIs using multiple criteria are more likely to
maximize benefits, and to gain traction with the clinicians entrusted with
carrying out policies and procedures underlying those efforts. Feedback
to all participants socializes initiatives and allows everyone to see the
results of efforts and adapt to embrace mutual goals.
ICU readmission is a frequently quoted indicator of ICU quality of
care that is not supported by evidence. Most ICU readmissions (close to
90% in a study at the University of Pittsburgh) may be considered
nonpreventable.74 As a result, ICU readmission rates may not be a good
indicator of the quality of ICU care delivery. Readmission rates can be
helpful in identifying system-wide opportunities to improve care for
hospitals that have high ICU readmission rates in general or for those
where preventable ICU readmissions follow a consistent pattern.
Safety is culturally defined. Acceptable operations are constrained by
trade-offs in performance, resources, and avoiding mishaps.75,76 Stakes
are high in any health care environment. They are higher in many ICUs,
especially those treating the most advanced acuity patients and perform-
ing with high throughput. Efforts at efficiencies (including some quality
initiatives) can push the acceptable margins of operations and make
adverse events more likely.77 Like quality, safety measures work best
when they confront trade-offs directly. Some trade-offs are easy to
articulate, such as relationships between reducing urinary catheter days
and increasing moisture-related sacral pressure ulcer risk or reduced
length of ICU stay and increased ICU readmission rate. Others may be
hidden, or so removed from a safety event as to be invisible without
thorough investigation. Accidents provide opportunities to learn about
the complexities of ICU operations, and many models exist78 that
facilitate timely, objective, expert, deep probing, and blame-mitigating
approaches to adverse events. Root Cause Analysis (RCA)79 provides a
forum for discussions of events, but efforts to produce enduring change

are frequently hampered by emotion, competing agendas, and unad-
dressed tensions. Sometimes, proposed solutions are so reactionary as to
degrade resilience in the system. An alternative solution, RCA2 (RCA
squared),80 makes the use of disinterested experts to speed investigation
and provides an inquiry framework that acknowledges the separation of
causative agents in time and proximity to the operations where the
accident occurred, or the “sharp end.”77
The SCCM states that all ICUs should have some form of continuous
process improvement in place to ensure that the right intervention is
done at the right time in a cost-effective manner.41 This focus should be a
part of the unit’s culture of continuous feedback and improvement. ICU
leadership should be encouraged to make the link between elements of
process improvement and the greater institutional mission and strategy,
often as tangible metrics. These efforts are not possible without appropriate
institutional support.
Which elements of process improvement to focus on should be
decided on the basis of local conditions and regulatory requirements.
Areas of frequent oversight include ventilator-associated events, hospital-
acquired infections, adverse drug events, readmission, unplanned
extubation, reintubation rates, lung-protective ventilation approaches,
and appropriate treatment of shock.
’ Structural and Organizational Aspects of ICU Care
Good design brings people together. In medicine, particularly ICU

medicine, this has real effects on teamwork, information flow, and
satisfaction. In 2011, the European Society of Intensive Care Medicine
(ESICM) issued recommendations on the structural and organizational
aspects of ICUs, and in 2012, SCCM issued ICU design guidelines.81,82
In addition, there are good reviews on structural elements of critical care
programs in the literature.83,84 The ESICM recommendations call for
interprofessional rounds, standardized, and structured processes of
handover and of interdisciplinary and interprofessional information
transfer, and the use of a clinical information system (electronic medical
record). Both guidelines include functional criteria for ICU design to
provide comprehensive critical care. ICU floor plans should provide
rapid access to the emergency department, operating theaters, post-
operative areas, and imaging and testing facilities. The minimum size
recommendation for an ICU in the ESICM recommendation is 6 beds,
with 8 to 12 beds considered optimal. A minimum size of a patient room
is specified in the ESICM recommendations. The recommendations state
that an ICU should have a physician director supported by physicians
qualified in intensive care, and clinicians capable of providing 24/7 care.
Other requirements include a head nurse overseeing nursing staff,

physiotherapists, technicians, consulting dieticians, speech and language
therapists, psychologists, occupational therapists, and clinical pharma-
cists. The Societies make recommendations for spaces and capabilities
that optimize both patient and family experience in the ICU.
These recommendations can be codified in good designs. Histor-
ically, many ICU spaces were constructed to allow visualization of most, if
not all, patients and monitors from key vantage points. Large, chart-style
vitals logs consolidated and organized data in a central, organized
location. This encouraged teams to huddle around their patients and
regularly discuss information with the bedside nurse. Now that
information is available in multiple locations through the electronic
record and monitoring screens, other aspects of good design should
address interdisciplinary rounding and the interactions of services. Good
sight lines remain important for staff to interact with their patients, and,
when many patients and monitors can be seen from central areas, with
each other.
The SCCM presents an annual ICU Design award that is co-
sponsored by the SCCM, the American Association of Critical Care
Nurses, and the American Institute of Architects Academy on Archi-
tecture for Health. A 2018 publication by the Society reviews the top
projects since 1992.85
’ Conclusions
Perioperative and ICU care embrace a philosophy of facilitating the

advanced services of a modern hospital. They are as essential to modern
inpatient care as traditional anesthesiology, radiology, and pathology
services and, when viewed from this perspective, are vital infrastructure
with their own expertise and team dynamics. It is the last aspect,
enhanced by interdisciplinary cooperation, that enables these services to
achieve their highest functions.
The authors declare that they have nothing to disclose.
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What Does It Take To Run An ICU or Perioperative Medicine Service

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What Does It Take To Run An ICU or Perioperative Medicine Service

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What Does it Take to Run an ICU

and Perioperative Medicine

Mark E. Nunnally, MD, FCCM

Michael Nurok, MBChB, PhD, FCCM

Promoting an intensive care unit (ICU) or perioperative “brand”

INTERNATIONAL ANESTHESIOLOGY CLINICS

between an ICU, an advanced specialty (eg, coronary or respiratory

Choosing Models of Care

simpliﬁcation and control. The ICU should respond to needs for

Coordination Through Collaboration

’ Financials and Operational Efficiency

Being a loss leader does not mean a critical care or a perioperative

driven by incentives. The critical trade-off in ﬁnances should balance

rounds.27 Care pathways can help optimize stafﬁng, which, in many

’ Interdisciplinary Staffing in the ICU

How best to meet the needs of differing populations of ICU patients

continuous availability of all of these personnel. Both high-acuity and low-

’ Trust, Teamwork, and Communication

Although many ICU personnel may describe what they do as teamwork

Clinicians of different specialties are known to value different aspects

’ Provider Growth and Experience

Effective critical care is optimized through the interdisciplinary

shared responsibilities are executed collaboratively. The team is more

taught than caught”; mentoring and modeling of negotiation and

’ Metrics: Quality, Safety, and Long-term Outcomes

Quality in a perioperative or an ICU service should embrace

participants is the foundation of any quality program. Stakeholders

forum for discussions of events, but efforts to produce enduring change

’ Structural and Organizational Aspects of ICU Care

Good design brings people together. In medicine, particularly ICU

Other requirements include a head nurse overseeing nursing staff,

Perioperative and ICU care embrace a philosophy of facilitating the

The authors declare that they have nothing to disclose.

4. Buchman TG, Coopersmith CM, Meissen HW, et al. Innovative Interdisciplinary

69. Rosenthal ME, Adachi M, Ribaudo V, et al. Achieving housestaff competence in

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