The Name Executive Critical
Car--The
I
N 1854, Florence Nightingale wrote in her quarterly report to the Ladies’ Committee at upper Harley Street, “A hospital is good for the seriously ill aloneotherwise it becomes a lodging house where the nervous become more nervous, the foolish more foolish, the idle & selfish more selfish & idle.” In the 138 years since that statement, hospitals have experienced varied patients from the seriously ill to the worried well. Now, as we enter the next century, MS Nightingale’s observation is being relived. Indeed, hospitals are becoming large intensive care units, and critical care services are expanding in kind. This scenario was played out recently in the opening of a 60-bed center for critical care medicine in a large tertiary care hospital. The publicity associated with this event stated that the center provided the finest possible patient care using the most highly trained personnel and the most advanced medical techniques. The staff is comprised of critical care nurses and physicians, cardiologists, pulmonary physicians, hemodynamic technologists, respiratory therapists, critical care pharmacists, and clinical nutritionists. Moreover, the facility is equipped to perform state-of-the art hemodynamic computer-processed ventilation, continuous monitoring, arterial-venous hemofiltration, intra-aortic balloon pumping therapy, and noninvasive respiratory monitoring. Within the center is located a critical care cardiology procedure room with sophisticated fluoroscopic, hemodynamic, scintigraphic, and echocardiographic technologies available. Now, if you were critically ill, wouldn’t you want to be here? Of course you would. It is the “Cadillac” of critical care-verything you would ever need and more. Regrettably, however, such care is not free. In fact, the medical technology revolution is the second largest factor contributing to the increasing costs of health care in the country. To this we add hospitals’ labor expenses per fulltime employee, which has more than doubled in the past 10 years: labor expenses make up nearly 60 per cent of the total hospital expenses. The increased nurse-patient ratios in critical care contribute to these increased costs as does the fact that nursing salaries have increased by 20 per cent since 1987. We have a dilemma. How can we control costs in a costly service? At least five areas should be considered: KATHLEEN G. ANDREOLI, DSN,
FAAN
Vice President and Dean Rush Cohge
ofNursing
Rush-Presbytwian-St.
Luke’s Medtcal Center
630 S Hermitage Ave Suite 204
Chrcago.IL 60612 Copyright 0 1992 by W.B. SaundersCompany 8755-7223192/0806-0003$03.00/O
Cost
of
Quality
facilities, technology assessment, physician practices, nurse management, and staffing and research. Briefly, it has been shown that when patients with similar problems such as acute myocardial infarction are placed in critical care facilities with technology, caregivers, and services dedicated to their needs, mortality rates drop significantly. Thus, patients convalesce faster and leave the hospital sooner than with traditionally geographically dispersed hospitalization. Second, the explosive proliferation of drugs, devices, and procedures in health care has been costly. However, assessment and regulation of these products is fragmented. The lack of clear regulatory authority and rigorous standards has given rise to misuse and overproduction. There has been some progress: the Prospective Payment System and other forms of capitated payment have included devices in the overall cost, and the use of devices within diagnosis-related groups are justified as needed by the patients in these groups. Nevertheless, a major plan is needed for technology assessment that provides guidelines for the systematic evaluation of new and established technologies to distinguish between those worthy of support and dissemination and those that should be restricted or discontinued. The participation of nursing in health care technology is essential. A third source of cost savings is standardizing physician practice behaviors so that doctors’ orders can be carried out in the most expeditious way. Nurses and physicians in critical care areas together can plan critical pathways for patients so that the plan of care for each day is predictable unless complications ensue. Clinical protocols are efficient and customer oriented. Customer focus reflects total quality management, which is the paradigm for critical care. Nurse staffing and management follow the premise that care is of high quality, is cost effective, and meets customer expectations. Nonnursing tasks are delegated to less expensive assistants with a mechanism to mentor, develop, and monitor the personnel. Of interest is the development of the acute care nurse practitioner specialty. These nurses perform traditional critical care nursing as well as perform bone marrow aspirations; insert arterial catheters, chest tube, and central venous lines; change tracheostomy tubes; and titrate intravenous infusions. Such multiskilled nurses have greater control over the care and the course of the acutely ill patient. Although their salaries are high, paying for their skills is more cost effective than paying all the salaries of traditional health team members. Finally, the research aspect of change can never be ignored. It is incumbent on us to take measurements beforehand of those variables describing cost, quality, patient satisfaction, and caregiver satisfaction that are affected by the changes described above. If we can show improvement in some or all, we must purse the better course. Critical care will be with us always. We must always be prepared to deliver it in the best way.
Journal of Profarsional Nursing, Vol 8, No 6 (November-December),
1992:
p 3 19
319
Car--The
I
N 1854, Florence Nightingale wrote in her quarterly report to the Ladies’ Committee at upper Harley Street, “A hospital is good for the seriously ill aloneotherwise it becomes a lodging house where the nervous become more nervous, the foolish more foolish, the idle & selfish more selfish & idle.” In the 138 years since that statement, hospitals have experienced varied patients from the seriously ill to the worried well. Now, as we enter the next century, MS Nightingale’s observation is being relived. Indeed, hospitals are becoming large intensive care units, and critical care services are expanding in kind. This scenario was played out recently in the opening of a 60-bed center for critical care medicine in a large tertiary care hospital. The publicity associated with this event stated that the center provided the finest possible patient care using the most highly trained personnel and the most advanced medical techniques. The staff is comprised of critical care nurses and physicians, cardiologists, pulmonary physicians, hemodynamic technologists, respiratory therapists, critical care pharmacists, and clinical nutritionists. Moreover, the facility is equipped to perform state-of-the art hemodynamic computer-processed ventilation, continuous monitoring, arterial-venous hemofiltration, intra-aortic balloon pumping therapy, and noninvasive respiratory monitoring. Within the center is located a critical care cardiology procedure room with sophisticated fluoroscopic, hemodynamic, scintigraphic, and echocardiographic technologies available. Now, if you were critically ill, wouldn’t you want to be here? Of course you would. It is the “Cadillac” of critical care-verything you would ever need and more. Regrettably, however, such care is not free. In fact, the medical technology revolution is the second largest factor contributing to the increasing costs of health care in the country. To this we add hospitals’ labor expenses per fulltime employee, which has more than doubled in the past 10 years: labor expenses make up nearly 60 per cent of the total hospital expenses. The increased nurse-patient ratios in critical care contribute to these increased costs as does the fact that nursing salaries have increased by 20 per cent since 1987. We have a dilemma. How can we control costs in a costly service? At least five areas should be considered: KATHLEEN G. ANDREOLI, DSN,
FAAN
Vice President and Dean Rush Cohge
ofNursing
Rush-Presbytwian-St.
Luke’s Medtcal Center
630 S Hermitage Ave Suite 204
Chrcago.IL 60612 Copyright 0 1992 by W.B. SaundersCompany 8755-7223192/0806-0003$03.00/O
Cost
of
Quality
facilities, technology assessment, physician practices, nurse management, and staffing and research. Briefly, it has been shown that when patients with similar problems such as acute myocardial infarction are placed in critical care facilities with technology, caregivers, and services dedicated to their needs, mortality rates drop significantly. Thus, patients convalesce faster and leave the hospital sooner than with traditionally geographically dispersed hospitalization. Second, the explosive proliferation of drugs, devices, and procedures in health care has been costly. However, assessment and regulation of these products is fragmented. The lack of clear regulatory authority and rigorous standards has given rise to misuse and overproduction. There has been some progress: the Prospective Payment System and other forms of capitated payment have included devices in the overall cost, and the use of devices within diagnosis-related groups are justified as needed by the patients in these groups. Nevertheless, a major plan is needed for technology assessment that provides guidelines for the systematic evaluation of new and established technologies to distinguish between those worthy of support and dissemination and those that should be restricted or discontinued. The participation of nursing in health care technology is essential. A third source of cost savings is standardizing physician practice behaviors so that doctors’ orders can be carried out in the most expeditious way. Nurses and physicians in critical care areas together can plan critical pathways for patients so that the plan of care for each day is predictable unless complications ensue. Clinical protocols are efficient and customer oriented. Customer focus reflects total quality management, which is the paradigm for critical care. Nurse staffing and management follow the premise that care is of high quality, is cost effective, and meets customer expectations. Nonnursing tasks are delegated to less expensive assistants with a mechanism to mentor, develop, and monitor the personnel. Of interest is the development of the acute care nurse practitioner specialty. These nurses perform traditional critical care nursing as well as perform bone marrow aspirations; insert arterial catheters, chest tube, and central venous lines; change tracheostomy tubes; and titrate intravenous infusions. Such multiskilled nurses have greater control over the care and the course of the acutely ill patient. Although their salaries are high, paying for their skills is more cost effective than paying all the salaries of traditional health team members. Finally, the research aspect of change can never be ignored. It is incumbent on us to take measurements beforehand of those variables describing cost, quality, patient satisfaction, and caregiver satisfaction that are affected by the changes described above. If we can show improvement in some or all, we must purse the better course. Critical care will be with us always. We must always be prepared to deliver it in the best way.
Journal of Profarsional Nursing, Vol 8, No 6 (November-December),
1992:
p 3 19
319
