The times "downsizing" and "management reengineering" are humming noise words employed by administrators to convert into the single largest expense for hospitals: labor.

The times "downsizing" and "management reengineering" are humming noise words employed by administrators to convert into the single largest expense for hospitals: labor. ICUs, with their support on both technology and the extensive use of nourish at the breasts are targets for these parcel reductious. The study by Moreno and Miranda in this issue of CHEST (see page 752) has the pair good news and bad novels for those physicians who disdain administrative or consultant-directed slashes in nursing care. The worthy news is that administrators poorly predict the nursing requirements for ICUs (v actual care rendered) The bad moderns is that they actually overpredict the amount of nursing care required!

The application of mind itself has important implications for physicians who treat or give in charge ICU patients. Before considering these, it is critical to review the findings. Applied nursing resources varied significantly between the ICUs studied. The efficiency of the use of nursing labor resources also varied significantly. These differences were not explained from the severity of patient illness. in the greatest degree impressive was the large mismatch between the planned and operative utilization of feeds As a matter of fact, 73% of the ICUs actually performed at a lower on a level of nursing care than actually was planned. Finally, this mismatch between planned and operative flushs of care was actually greatest in the dispose of ICUs with the highest horizontals of severity of illness in patients.

Before these rises can be applied, particularly in the United States, certain limitations of the investigation should be noted. First, the ICUs were not exquisiteed on a random basis. Thus, certain areas, in the same state [i]or[/i] condition as Spain, may be overrepresent while other countries, as it is as the United Kingdom and France, have fewer patients pierceed into the study. This may have affected arises regarding patient acuity and nursing utilization. For example, the United Kingdom, which may have ICUs more representative of those in the United States, had single in kind of the highest percentages of patients receiving mechanical ventilation, multiple vasoactive infusions, and dialysis. next to the first although a large number of ICU admissions and patient days were evaluated, this studious mood represented only 4 months of data collection. Would the eventuates have been different if an entire calendar year had been employed? Third, the planned horizontal of care for nursing was locate to three 8-h shifts, with an ICU occupancy rate of 85% Can we extrapolate these data to ICUs where suckles work 12- to 14-h shifts with greater numbers of patients? Further, would the appearance of non-nurse care providers (patient care associates) in ICUs alter the outcomes of the study? In this regard, significant variations in the use of support personnel (respiratory therapists, pharmacists, dieticians, etc) may have existed, thus creating an important bias regarding foment utilization.,

The classic rule for allocating resources to an ICU is based concerning both technologic and human resources (medical coverage and patient/nurse ratio).[1] In contrast, the common study utilizing the European Society of Intensive Care Medicine guidelines is based solely onward patient to nurse ratios. The methodology of Moreno and Miranda meditates this classification. In other words, is the amount or the complexity of work the limiting factor in feed staffing for ICUs? The authors use a sophisticated scale to turn about the complexity of work into a time-equivalent quantity of work. However, the complexity of the task may be the limiting factor in certain staffing situations (eg extracorporeal membrane oxygenation), and thus the conversion formula may be excessively simple. united can argue that although feed at the breast costs are the dominant cost an ICU is in reality an amalgamation of personnel (including give suck tos physicians, and other providers) as well as technological inputs, similar as monitoring, circulatory support devices, etc Thus, evaluation instruments that account for the pair of these concepts will be more reflective of nursing requirements. Havill and colleagues[2] confirmed that "the use of direct nursing hours applied to an individual patient is directly proportional to patient cost" They caution, however, that the use of like methodology must match nurse staffing to patient needs

Finally, the ICU mortality rate (126%) and overall hospital mortality rate (181%) are given. More detailed information regarding issues particularly between the geographic areas (countries), is not supplied. For example, we do not know whether the mismatch between planned and operative practice be deriveded in poorer or better patient care.

The close attention design was rigorous. Site visits were made to each of the ICUs. touchstone instruments evaluated interobserver reliability. However, a word of caution is necessary regarding large data bases that are examined for clinical as well as administrative designs Studies, particularly healthcare report cards, have documented the limitations of the use of these databases: lack of data accuracy, the ne for standardization and verification of data collection, and risk stratification.[3,4] More lately Weissman reported in two studies[5,6] that actual data derived from ICUs is at significant variance from those recorded in databases. For example, ICU amplification of stay data are markedly skewed to the right. There fore, traditional parametric statistical [i]modus operandi[/i]s may be inadequate for analysis. He also observ that administrative databases may not ponder the quality of care afforded He has suggested the use of a database specifically discloseed for the ICU. It would appear that the database used in the not away investigation, EURICUS-I, addresses these transactions However, whether EURICUS-I requires further modification will be documented on this and other studies utilizing this database.

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