The COVID-19 pandemic has shown us all the extraordinary, exhausting work performed by intensive care unit (ICU) doctors, nurses and other healthcare professionals as they try to save extremely ill patients. However, as hard as these dedicated professionals work, staffing issues can put patients at risk. In fact, even before the pandemic, many patients in ICUs in the US got sicker, or even died, due to staffing issues. Research shows that the availability of medical and nursing staff is associated with the survival of critically ill patients. Yet, there are few laws regulating ICU staffing requirements.
ICU patients are very sick and at risk.
As you likely know, ICUs treat the sickest patients. Since ICU patients are severely ill and undergo multiple complex interventions at the same time, they are extremely vulnerable to experiencing adverse outcomes. In fact, one study found that over 20% of ICU patients have experienced some kind of adverse event. Moreover, medical errors in an ICU are more likely due to the complexity of care. Certainly, the quantity, quality and experience of staff are critical factors in the care and outcomes of ICU patients.
Nurse staffing levels impact quality of care.
Nurses provide crucial, around-the-clock care to ICU patients. But, of course, ICU nurses cannot be with every patient every minute of their shifts. It’s easy to understand that nurses with a high workload could struggle to deliver quality, timely care due to conflicting demands of patients under their care. In a study published in 2017, researchers evaluated the workload of ICU nurses and the impact on patient outcomes. Since some ICU patients are sicker than others, their workload calculation considered not only the number of patients under a nurse’s care, but the severity of illness of each patient. Their analysis found that high workload/staffing ratios was associated with a substantial reduction in the odds of survival for critically ill patients in the ICU.
What about doctors?
What about the number of doctors in an ICU? One study found that higher numbers of nurses per bed along with higher numbers of doctors was associated with higher survival rates during the ICU stay and for up to 30 days after admission to hospital. Interestingly, the number of nurses in ICUs had the greatest impact on the most severely ill patients. In contrast, the number of doctors was important for all levels of patients, not only the most severely ill.
In addition to the number of doctors working in an ICU at any given time, the type of doctor is especially important. Intensivists, also known as critical care physicians, are specially trained to care for critically ill, vulnerable patients. Many studies have shown that hospitals with intensivists have lower mortality rates than those without. But, it’s not enough to hire intensivists – adequate training and proper implementation are critical.
What exactly does an intensivist do?
Intensivists spend their workday in the ICU (or trauma center). They use a comprehensive approach to treat patients in order to manage the complex needs of very sick patients. In addition to directly treating patients, intensivists coordinate with other medical staff to make sure patients get all needed care. For example, they work with other doctors, nurses, rehab specialists, respiratory therapists, and pharmacists. Furthermore, intensivists are familiar with the complications that can occur in the ICU and, therefore, are better equipped to minimize errors.
The goal of intensivists within an ICU is to:
- Improve patient survival rates.
- Improve quality of care.
- Decrease complications.
- Promote the safe use of medications.
Intensivists save lives.
Studies show a 40% improvement in patient survival rates when ICUs are staffed appropriately with intensivists. Furthermore, research suggests that over 54,000 lives could be saved every year if all US urban adult ICUs used intensivists.
What do experts recommend regarding ICU staffing requirements?
The Leapfrog Group, a national nonprofit watchdog organization, recommends the following staffing guidelines for intensivists:
- Hospitals should have at least one board-certified intensivist on staff.
- An intensivist should exclusively provide care in the ICU.
- Patients should have access to an intensivist eight hours per day, seven days a week.
- Intensivists must return calls within five minutes, 95 percent of the time.
- Hospitals can partially meet the standard by having intensivists available via telemedicine.
What are the laws pertaining to ICU staffing requirements?
Surprisingly, there are no federal rules regarding ICU staffing requirements. Each state can set their own rules, with many states deciding not to set specific staffing guidelines, leaving staffing decisions up to each hospital.
However, there is some movement toward regulating nurse staffing. As of late 2019, only 14 US states had passed some sort of nurse staffing laws. However, 13 of these states have laws that merely require the presence of a general staffing plan to manage the ratio. Only California has a law that mandates a ratio of patients per nurse. For example, California requires one nurse for every 2 patients in ICUs. Unsurprisingly, studies have shown benefits to both nurses and patients in California in the years after the state enacted their staffing law. As more states are recognizing the importance of setting safe staffing levels for nurses, Pennsylvania and Massachusetts recently considered enacting laws regarding minimum nurse staffing standards.
How are US hospitals doing?
Unfortunately, not all hospitals hire intensivists. According to the results of a 2015 hospital survey, only 47% have Leapfrog’s recommended staffing for intensivists. Similarly, an analysis of the 2015 American Hospital Association Annual Survey Database found that 52% of the hospitals had intensivists. It is certainly possible that these numbers have increased since 2015.
Does your hospital use intensivists?
Use The Leapfrog Group’s Hospital Compare tool to determine if hospitals in your area meet the Leapfrog guidelines for intensivists (look under the Critical Care tab). If your hospital does not use intensivists, reach out to the administration, and let them know of your concern. If at all possible, try to use hospitals that have intensivists – your life might depend on it.
For more tools you can use to evaluate hospitals, visit the Zaggo resource center.
What should patients and families do about the lack of ICU staffing requirements?
Be involved! Patients and families can play a critical role in the care and outcome of ICU patients. Even when ICUs have adequate staff, it’s important to be involved.
Firstly, insist that the medical team include you in conversations and decisions regarding treatment options. Make sure you ask as many questions as you need about the risks and benefits of recommended treatments before making any decisions. Additionally, share any information pertinent to the health and care of the patient – you might notice things the staff missed.
Additionally, speak up if/when you sense something is wrong. As a patient, you know your body and you know when something doesn’t feel right. As a family member, your understanding of your loved one’s health, plus the time you spend with your loved one in the ICU, make your insights and concerns invaluable. Experts believe that speaking up about care concerns may contribute to the patient’s safety. For example, a family member may be the first to notice a change in a patient’s clinical status. Also, when patients and families share information among the medical team, continuity of care may improve. Finally, patients and families can detect errors, including errors that doctors and nurses don’t notice.
Would you feel comfortable speaking up?
In order to advocate for a patient’s safety and well-being patient and family must feel comfortable voicing their concerns. To determine comfort levels, researchers conducted in-person surveys with current ICU families in an urban US academic medical center. Additionally, they surveyed those with prior ICU stays through an internet survey. Unfortunately, 50-70% of the respondents indicated a hesitancy to share their concerns. People reported a reluctance to speak up about a range of topics, including possible mistakes, mismatched care goals, confusing/conflicting information, and inadequate hand hygiene. Why do people fear speaking up? Common reasons cited include not wanting to be a troublemaker, thinking the team is too busy or not knowing how. Interestingly, older, female participants and those with personal or family employment in healthcare were more likely to feel comfortable speaking up.
My advice – don’t worry about creating trouble or appearing pushy. Importantly, speaking up if you suspect a problem may literally save your own life or the life of your loved one. But remember to remain pleasant.
For information on what to expect if your loved one is in an ICU, read the guide by ICUSteps.
All hospital stays involve risk. Read these blog posts to reduce your risk of problems:
- What’s Your Hospital’s Safety Record? Is Your Hospital Safe?
- Germs in Hospitals and Doctor Offices – Watch Out!
- The Dangers of Missed Bedside Alarms.
- Why is Hand Washing in Healthcare So Important? What You Need to Do to Stay Safe.
- The Benefits of Participating in Hospital Rounds.
- How to Avoid Medication Errors in the Hospital and at Home.
- What You Need to Know About Pressure Sores.
- Do Hospital Policies to Prevent Falls Help or Harm Patients?
- How Hospital Patients Can Resolve Problems.
- Is Your Hospital Safe? Are Programs in Place to Avoid Dangerous “Never Events”?