Performance analysis of an ICU according to GiViTI's StART approach
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KeywordsLimited Resource Open Space Adequate Level Logistic Constraint Sick Patient
ICU beds are a limited resource; their appropriate use is mandatory: only patients sick enough should be admitted to the ICU, and all admitted patients should receive the adequate level of care.
From 1 January 2008 to 9 March 2009, 716 admissions to a seven-bed general ICU were analyzed according to GiViTI's StART approach, to evaluate appropriateness of the ICU admission and stay. Available resources (ICU beds) were classified as High Level (HL) or Low Level (LL), according to equipment and staffing. Patients may require High (H), Low (L), or Ordinary (O) levels of care (HP, LP, OP, respectively) . OPs should not be admitted to the ICU and can stay in the ICU only briefly, following HL or LL periods. One nurse can attend two HPs, or one HP and two LPs, or four LPs, provided that each bed can be controlled easily (not in different rooms, for example) . For each day shift, matching of required and available care was analyzed: mismatch is expressed as nurse deficit: positive values indicate excess of care (too many nurses for not too sick patients), zero suggests that assistance requirements are met, with negative values available care is less than patients' needs.
In this ICU, all seven beds are fully equipped. Of the 716 ICU admissions, 20 (2.8%) were inappropriate OPs. One hundred and ninety-seven further ICU-days of the 2,711 available (7.3%) were used for OPs (mostly due to delayed discharges); altogether 217/3,427 (6.3%) ICU-days were inappropriately used for OPs. In the analysis of resources and requirements matching, if the seven beds were in the same room, available assistance would meet requirements in most nurse shifts, even if the staff would have worked at maximum almost always; in fact, in this ICU, four beds are in a room and there are three single-bed rooms - therefore, according to the suggested standards, a mean 1.9 nurse deficit per shift is observed. The relevance of this observation on patient outcome can be speculated only.
The relevance of the StART approach is the definition of inappropriateness both from excess and insufficiency of care points of view: both admissions and ICU stays of OPs and/or too many too sick patients for the amount of care available are equally inappropriate. Moreover, the available care is determined both by the number of ICU nurses and by logistic constraints: seven beds in an open space are different from four beds in a room and three beds in single rooms, and in fact this ICU pays a two nurse deficit per shift to its design.