Optimizing Intensive Care Unit Staffing in the United States

摘要 医疗保健质量受到结构和组织的影响。大约有600万美国人被录取 每年都有许多人被送到重症监护室（ICU），许多人因急性呼吸衰竭而需要机械通气。 了解最佳的ICU组织对于确保向这些人提供高质量的护理至关重要，我们 最虚弱的病人在过去的20年里，随着美国ICU床位的数量和所提供护理的复杂性 急剧增加，重症监护医生（专门接受过重症监护培训的医生）， ICU跨专业团队（包括护士、呼吸治疗师、临床药师等）已成为 这是许多ICU的标准。研究强调了重症监护的积极影响， 因此，重症监护医学会建议“高强度重症监护人员配置”。 同样，多学科团队对患者结局的积极影响也得到了很好的证实。什么不是 然而，已知的是ICU护理提供者如何在团队结构和工作量的背景下影响患者护理。 我们最近在英国的研究表明， 每名重症监护医生护理的患者及其患者的死亡率;这种关系在美国是否相同 以及它如何受到其他ICU护理提供者的影响尚不清楚。最后，自2000年一项具有里程碑意义的研究以来， 强调了美国重症医学需求和供应之间的差距，很明显，更新的ICU 人力资源规划需要人力资源预测，但是，如果人力资源预测受到以下因素的限制， “筒仓”（例如，在不考虑其他护理提供者的缓解效果的情况下预测重症监护需求）， 低估了最佳人员配置结构与目前使用的结构的不同之处。本研究 将使用与美国多个ICU现有患者水平数据相关联的初步调查， 系统动力学建模的方法，以解决3个目标：（1）确定详细的人员配置模型，目前 在美国使用;（2）量化患者与护理提供者比率与患者结局的相关性， 选择ICU;（3）估计当前和未来ICU劳动力需求。这个项目将产生重要的见解 ICU护理提供的最佳人员配置模式以及未来必须如何分配资源以关闭 ICU护理人员缺口。虽然专注于ICU护理，但该项目将为（1）创建可复制的框架 根据其他工作人员的可用性，通过每日患者普查量化提供者的工作量，以及（2）使用系统 动态建模，以模拟劳动力的供应和需求，这将是有用的计划的任何方面， 健康护理我们将为临床医生和政策制定者提供有关ICU人员配置的关键信息，以改善患者的 安全为代价的

ABSTRACT Healthcare quality is impacted by structure and organization. Approximately 6 million Americans are admitted to an intensive care unit (ICU) yearly and many require mechanical ventilation for acute respiratory failure. Understanding optimal ICU organization is essential to ensure high quality care is delivered to these, our sickest patients. Over the past 20 years as the number of US ICU beds and the complexity of care provided has increased dramatically, intensivists (physicians trained specifically in critical care) working with interprofessional ICU teams (including nurses, respiratory therapists, clinical pharmacists, etc.) have become the norm in many ICUs. Studies highlight the positive impact of having an intensivist care for critically ill patients; for this reason, the Society of Critical Care Medicine recommends “high intensity intensivist staffing”. Similarly, the positive impact of a multidisciplinary team on patient outcomes is well established. What is not known, however, is how ICU care providers impact patient care in the context of team structure and workload. Our recent work in the United Kingdom suggests there is a significant relationship between the number of patients each intensivist cares for and their patients’ mortality; whether this relationship is the same in the US and how it is affected by other ICU care providers is unknown. Finally, since a landmark study in 2000 highlighted the gap between intensivist demand and supply in the US, it has become clear that updated ICU workforce projections are needed to aid in resource planning; however, these will fail if they are limited by “siloing” (e.g., projecting intensivist need without considering the mitigating effect of other care providers) and an underappreciation of how optimal staffing structures may differ from what is in use today. In this study we will use primary surveys linked with existing patient- level data across multiple US ICUs and a novel methodology of System Dynamics Modeling to address 3 aims: (1) determine detailed staffing models currently used across the US; (2) quantify the association of patient-to-care provider ratio with patient outcomes across selected ICUs; and (3) estimate current and future ICU workforce need. This project will yield critical insights into the best staffing models for ICU care delivery and how resources must be allocated in the future to close ICU care provider gaps. While focused on ICU care, this project will create a replicable framework for (1) quantifying provider workload by daily patient census in light of other staffing availability and (2) using System Dynamics Modeling to simulate workforce supply and demand which will be useful to plan for any aspect of healthcare. We will provide clinicians and policy makers with key information on ICU staffing to improve patient safety.