SCOPE OF CRITICAL CARE

BOX 2.1

Business case: sample headings

Title
Purpose
Background
Key issues
Costbenefit analysis
Recommendations
Risk assessment

In summary, the business case is an important tool t

hat
is increasingly required at all levels of an organisatio
n to
clearly define a proposed change or purchase. This d
ocument should include clear goals and outcomes, a
costbenefit analysis and timelines for achievement of
the
solution.

CRITICAL CARE ENVIRONMENT

A critical care unit is a distinct unit within a hospital t
hat
has easy access to the emergency department, o
perating
theatre and medical imaging. It provides care to pati
ents
with a life-threatening illness or injury and concentrat
es
the clinical expertise and technological and thera
peutic
resources required.26 The College of Intensive Care M
edicine (CICM) defines three levels of intensive
care to
support the role delineation of a particular h
ospital,
dependent upon staffing expertise, facilities and supp
ort
services.27 Critical care facilities vary in nature and ex
tent
between hospitals and are dependent on the operati
onal
policies of each individual facility. In smaller facili
ties,
the broad spectrum of critical care may be provi
ded in
combined units (intensive care, high-dependency,
coronary care) to improve flexibility and aid the efficient
use
of available resources.26

ORGANISATIONAL DESIGN
The functional organisational and unit designs ar
e governed by available finances, an operational brief and
the
building and design standards of the state or country

in
which the hospital is located. A critical care unit shou
ld
have access to minimum support facilities, which incl
ude
staf station, clean utility, dirty utility, store room
(s),
education and teaching space, staf amenities, pa
tients
ensuites, patients bathroom, linen storage, dis
posal
room, sub-pathology area and offices. Most notably, t
he
actual bed space/care area for patients needs to
be well
designed.26
The design of the patients bed-space has received c
onsiderable attention in the past few years. In Australia, m
ost
state governments have developed minimum guid
elines
to assist in the design process. Each bed space shoul
d be
a minimum of 20 square metres and provide for
visual
privacy from casual observation. At least one handba
sin
per single room or per two beds should be provi
ded
to meet minimum infection control guidelines.26 E
ach
bed space should have piped medical gases (oxygen
and
air), suction, adequate electrical outlets (essential
and

TABLE 2.3 Basic equipment requirements

Monitoring

Therapeutic

Monitors (including central station)

End-tidal CO2 monitoring
Arterial blood gas analyser
(electrolytes)
Invasive monitoring
arterial
Safety
central venous pressure
intracranial pressure Performance
PiCCO
Quality
pulmonary artery
Use
Access to image intensifier
Ultrasound
Access to CT/MRI

Ventilators (invasive and

non-invasive)
Infusion pumps
Syringe drivers
CVVHDF
EDD-f
Resuscitators
Temporary pacemaker
Defibrillator
Suctioning apparatus

Costbenefit analysis

CT computerised tomography; CVVHDF continuous veno-venous

haemodiafiltration; EDD-f extended daily dialysis filtration; MRI
Cleaning
magnetic resonance imaging;
PiCCO pulse-induced contour cardiac
output.

Regulatory control

non-essential), data points and task lighting sufficient for

to future technological
advancements
use during the Adaptability
performance
of bedside
procedures.
agreements are available in various
Further detailed Service
descriptions
requirements
26
health departmentTraining
documents.

EQUIPMENT
Since the advent of critical care units, healthcare delivery
has become increasingly dependent on medical techno-

logy to deliver that care. Equipment can be categorised

into several funding groups: capital expenditure (generally in excess of $10,000), equipment expenditure (all
equipment less than $10,000), and the disposable products and devices required to support the use of equipment. This section examines how to evaluate, procure and
maintain that equipment.

INITIAL SET-UP REQUIREMENTS

Critical care units require baseline equipment that allows
the unit to deliver safe and efective patient care. The list
of specific equipment required by each individual unit
will be governed by the scope of that units function. For
example, a unit that provides care to patients after neurosurgery will require the ability to monitor intracranial
pressure. Table 2.3 lists the basic equipment requirements
for a critical care unit.

PURCHASING
The procurement of any equipment or medical device
requires a rigorous process of selection and evaluation.
This process should be designed to select functional, reliable products that are safe, cost-efective and environmentally conscious and that promote quality of care
while avoiding duplication or rapid obsolescence.28 In
most healthcare facilities, a product evaluation committee exists to support this process, but if this is not the case
it is strongly recommended that a multidisciplinary committee be set up, particularly when considering the purchase of equipment requiring capital expenditure.29

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23
supply unit (CSSU), administration, infectio
n control,
end users and other departments that ma
y have similar
needs. Once a product evaluation committ
ee has been
established, clear, objective criteria for the ev
aluation of
the product should be determined (Box 2.2). I
deally, the
committee will screen products and me
dical devices
before a clinical evaluation is conducted t
o establish its
viability, thus avoiding any unnecessary ex
penditure in
time and money.28
Resourcing Critical Care

BOX 2.2 Example criteria for product

evaluation28,29

purpose
ease of

include disposables

central sterilising supply unit (CSSU)

infection control

Therapeutic Goods Administration

Australian Standards

The product evaluation committee should include

members who have an interest in the equipment
being
considered and should comprise, for example, biome
dical engineers and representatives from the central st
erile

The decision to purchase or lease equipment

will, to some
extent, be governed by the purchasing strate
gy approved
by the hospital or state government. The
advantages of
leasing equipment include the capital expendi
ture being
defrayed over the life of the lease (usuall
y 36 months),
with ongoing servicing and product upgrad
es built into
the lease agreement and price structure. Any
final presen-

tation from the product evaluation committee sh

ould
therefore include a recommendation to purchase or l
ease,
based on a costbenefit analysis of the ongoing expe
nditure required to maintain the equipment.

REPLACEMENT AND MAINTENANCE

provided in-house by individual facility biomedical

departments or as part of a service contract arrangement
with the vendor company. The provision of a maintenance/
service plan should be clearly identified during the procurement phase of the equipments purchase process.
While equipment maintenance is not the direct responsibility of the nurses in charge of the unit, they should be
aware of the maintenance plan for all equipment and
ensure that timely maintenance is undertaken.

The process for replacement of equipment is Routine ongoing care of equipment is outlined in the
closely
product information and user manuals that accompany
aligned with the process for the purchase of new equidevices. This documentation clearly outlines routine care
prequired for cleaning, storage and maintenance. All staf
ment. The stimulus for the process to begin, however involved in the maintenance of clinical equipment should
, can
be trained and competent to carry it out. As specialist
be either the condemning of equipment by biom equipment is a fundamental element of critical car
edical
e,
engineers or the planned replacement of equi efective resourcing includes consideration of the purpment
chase, set-up, maintenance and replacement of equipnearing the end of its life cycle. In general, capital eq ment. Equipment is therefore an important aspect of the
uipbudget process.
ment is deemed to have a life cycle of five years. Thi
s time
STAFF
frame takes into account both the longevity of the ph
Staffing critical care units is an important human resource
ysiconsideration. The focus of this section is on nursing
cal equipment and its technology.
Ongoing maintenance of equipment is an important staf, although the important role that medical staf and
other ancillary health personnel provide is acknowledged.
part
Nurses salaries consume a considerable portion of any
of facilitating safety within the unit. Maintenance ma unit budget and, owing to the constant presence of nurses
at the bedside, appropriate staffing plays a significant role
y be
in the quality of care delivered. Nurse staffing levels influence patient outcomes both directly, through the initiation of appropriate nursing care strategies, and indirectly,
by mediating and implementing the care strategies of
other members of the multidisciplinary healthcare team.
Therefore, ensuring an appropriate skill mix is an important aspect of unit management. This section consider
s
how appropriate staffing levels are determined and the
factors, such as nursepatient ratios and skill mix, that
influence them.

STAFFING ROLES
There are a number of diferent nursing roles in the ICU
nursing team, and various guidelines determine the
requirements of these roles. Both the Australian College
of Critical Care Nurses (ACCCN) (see Appendix B2) and
the World Federation of Critical Care Nurses (WFCCN)
(see Appendix A2) have position statements surrounding
the critical care workforce and staffing. A designat
ed
nursing manager (nursing unit manager/clinical nurse
consultant/nurse
practice
coordinator/clinical
nurse
manager, or equivalent title) is required for each unit to
direct and guide clinical practice. The nurse manager
must possess a post-registration qualification in critical
care or in the clinical specialty of the unit.27,30 A clinical
nurse educator (CNE) should be available in each unit.
The ACCCN recommends a minimum ratio of one fulltime equivalent (FTE) CNE for every 50 nurses on the
roster, to provide unit-based education and staf development.27,30 The clinical nurse consultant (CNC) role is

utilised at the unit, hospital and area health service level

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SCOPE OF CRITICAL CARE

24

to provide resources, education and leadership.30

Registered nurses within the unit are generally nurses
with
formal critical care postgraduate
qualifications
and
varying levels of critical care experience.
Prior to the mid-1990s, when specialist critical care n
urse
education moved into the tertiary education sector, c
ritical care education took the form of hospital-based ce
rtificates.31 Since this move, postgraduate, universitybased
programs at the graduate certificate or postgr
aduate
diploma level are now available, although some hosp
italbased courses that articulate to formal university
programs continue to be accessible. The ACCCN
(see
Appendix B1) and the WFCCN (see Appendix A1)
have
developed position statements on the provision of cri
tical
care nursing education. Various support staf are
also
required to ensure the efficient functioning of the de
partment, including, but not limited to, administra
tive/
clerical staf, domestic/ward assistant staf and biom
edical engineering staf.

STAFFING LEVELS
A staf establishment refers to the number o
f nurses
required to provide safe, efficient, quality care to
patients. Staffing levels are influenced by many f
actors,
including the economic, political and individual ch
aracteristics of the unit in question. Other factors,
such
as the population served, the services provided
by the
hospital and by its neighbouring hospitals, and the su
bspecialties of medical staf working at each hospital a
lso
influence staffing. Specific issues to be considered
include nurse-to-patient ratios, nursing compete
ncies
and skill mix.

The starting point for most units in the establishment

of
minimum, or base, staffing levels is the patient
census
approach. This approach uses the number and classi
fication (ICU or HDU) of patients within the unit to determine the number of nurses required to be roster
ed on
duty on any given shift. In Australia and New Zealand
a
registered nurse-to-patient ratio of 1 : 1 for ICU
patients
and 1 : 2 for high-dependency unit (HDU) patient
s has
been accepted for many years. Recently in Australia t
here
have been several projects examining the use of end
orsed
enrolled nurses (EEN) in the critical care setting. The
New
South Wales project identified difficulties with
EENs
undertaking direct patient care, but determined that
there
may be a role for them in providing support and
assistance to the RN.27,30,32 Other countries, such as the US
A,
have lower nurse staffing levels, but in those co
untries
nursing staf is augmented by other types of clin
ical or
support staf, such as respiratory technicians.33 The li
mitations of this staffing approach are discussed later in
this
chapter. Once the base staffing numbers per shif
t have
been established, the unit manager is required to cal
culate the number of full-time equivalents that are requ
ired
to implement the roster. In Australia, one FTE is equal
to
a 38-hour working week.
The development of the nursing establishment is dep

endent on many variables. Historical data from pre

vious
years of patient throughput and patient acuity as
sist in
the determination of future requirements. It is
often

helpful for new units to contact a unit of similar size and

service profile to ascertain their experiences.

NURSE-TO-PATIENT RATIOS
Nurse-to-patient ratios refer to the number of nursing
hours required to care for a patient with a particular set
of needs. With approximately 30% of Australian and New
Zealand units identified as combined units incorporating
intensive care, coronary care and high-dependency
patients,34 diferent nurse-to-patient ratios are required
for these often diverse groups of patients. It is important
to note that nurse-to-patient ratios are provided
merely as a guide to staffing levels, and implementation
should depend on patient acuity, local knowledge and
expertise.
Within the intensive care environment in Australia and
New Zealand, there are several documents that guide
nurse-to-patient ratios (Table 2.4). The ACCCN has developed and endorsed two position statements that identify
the need for a minimum nurse-to-patient ratio of 1 : 1 for
intensive care patients and 1 : 2 for high-dependency
patients.30,35 In New Zealand, the Critical Care Nurses
Section of the New Zealand Nursing Organisation
(NZNO)32 also determines that critically ill or ventilated
patients require a minimum 1 : 1 nurse-to-patient ratio.
Both of these nursing bodies state that this ratio is clinically determined. The WFCCN states that critically ill
patients require one registered nurse to be allocated at all
times.36 The College of Intensive Care Medicine (CICM)
also identifies the need for a minimum nurse-to-patient

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ratio of 1 : 1 for intensive care patients and 1 : 2 for highdependency patients.27,37

The ACCCN30 and the NZNO Critical Care Nurses
Section32 have outlined the appropriate nurse staffing
standards in Australia and New Zealand for ICUs within
the context of accepted minimum national standards and
evidence that supports best practice. The ACCCN statement identified 10 key principles to meet the expected
standards of critical care nursing (Table 2.5).
These recommendations serve merely to guide nurse-topatient ratios, as extraneous factors such as the clinical
practice setting, patient acuity and the knowledge and
expertise of available staf will influence final staffing patterns. In particular, patient dependency scoring tools are
designed to guide these staffing decisions and are discussed below.

PATIENT DEPENDENCY
Patient dependency refers to an approach to quantify the
care needs of individual patients, so as to match these
needs to the nursing staf workload and skill mix.38 For
many years, patient census was the commonest method
for determining the nursing workload within an ICU.
That is, the number of patients dictated the number of
nurses required to care for them, based on the accepted
nurse-to-patient ratios of 1 : 1 for ICU patients and 1 : 2
for HDU patients. This reflects the unit-based workload,
and is also the common funding approach for ICU
bed-day costs.

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TABLE 2.4 Documents that guide the nurse-to-patient ratios in critical care
Document

Recommendations

ACCCN: Position statement on

determined)
intensive
care nurse staffing30

ICU patients (clinically determined) should have a 1 :1 nurse-to-patient ratio.

a
Require
standard
nurse-to-patient
ratio of at
least have
1 :1. a 1 :2 nurse-to-patient ratio.
HDU
patients
(clinically determined)
should

ACCCN: Position statement on the

(clinicallyworkers
determined)
healthcare
other than
Division 1 Registered Nurses in
Intensive Care35
leader)

All intensive care patients must have a registered nurse (division 1) allocated exclusively to their care.
a
Require
standard nurse-to-patient
ratiopatients
of at least
1 :2
High-dependency
or step-down
(in intensive
care) who require a nurse-to-patient ratio of
1:2 should have a registered nurse (division 1) allocated exclusively to their care.
Enrolled nurses (division 2) and unlicensed assistive personnel may be allocated roles to assist the
There must
be a designated
senior
nurse
per shift
is supernumerary
registered
nurse, but critical-care-qualified
any activities that involve
direct
contact
with who
the patient
must always and
be whose
performed in the immediate presence of the registered nurse (division 1).

NZNO, Critical Care Section:

Philosophy and Standards for
Nursing Practice in Critical Care32

WFCCN: Declaration of Buenos

Aires, Position Statement on the
Provision of Critical Care Nursing
Workforce36

CICM: Minimum Standards for

Intensive Care Units27

CICM: Recommendations on
Standards for High-Dependency
Units Seeking Accreditation for
Training in Intensive Care
Medicine37

The critically ill and/or ventilated patient will require a minimum 1 :1 nurse-to-patient ratio.
At times, patients in the critical care unit may have higher or lower nursing acuity; the critical care
nurse in charge of the shift determines any variation from the 1 :1 ratio, taking into account context,
skill mix and complexity.
Critically ill patients (clinically determined) require one registered nurse at all times.
High-dependency patients (clinically determined) in a critical care unit require no less than one
nurse for two patients at all times.
A minimum of 1 :1 nursing is required for ventilated and other similarly critically ill patients, and
nursing staff must be available to greater than 1 :1 ratio for patients requiring complex management
(e.g. ventricular assist device).
The majority of nursing staff should have a post-registration qualification in intensive care or in the
specialty of the unit.
All nursing staff in the unit responsible for direct patient care should be registered nurses.
The ratio of nursing staff to patients should be 1 :2.
All nursing staff in the HDU responsible for direct patient care should be registered nurses, and the
majority of all senior nurses should have a post-registration qualification in intensive care or
high-dependency nursing.
A minimum of two registered nurses should be present in the unit at all times when a patient is
present.

ACCCN Australian College of Critical Care Nurses; NZNO New Zealand Nurses Organisation; WFCCN World Federation of Critical Care Nurses; CICM College of
Intensive Care Medicine.

TABLE 2.5 Ten key points of intensive care nursing staffing30

Point

Description

1. ICU patients (clinically

2. High dependency patients
3. Clinical coordinator (team
primary role is responsibility for the logistical management of patients, staff, service provision and resource
utilisation during a shift.
4. ACCESS nurses

These are nurses in addition to the bedside nurses, clinical coordinator, unit manager, educators and
non-nursing support staff. They provide Assistance, Coordination, Contingency, Education, Supervision
and Support.

5. Nursing manager

At least one designated nursing manager (NUM/CNC/NPC/CNM or equivalent) who is formally recognised as
the unit nurse leader is required per ICU.

6. Clinical nurse educator

At least one designated CNE should be available in each unit. The recommended ratio is one FTE CNE for
every 50 nurses on the ICU roster.

7. Clinical nurse consultants

Provide global critical care resources, education and leadership to specific units, to hospital and area-wide
services, and to the tertiary education sector.

8. Critical care nurses

The ACCCN recommends an optimum specialty qualified critical care nurse proportion of 75%.

9. Resources

These are allocated to support nursing time and costs associated with quality assurance activities, nursing
and multidisciplinary research, and conference attendance.

10. Support staff

ICUs are provided with adequate administrative staff, ward assistants, manual handling assistance/
equipment, cleaning and other support staff to ensure that such tasks are not the responsibility of nursing
personnel.

ACCCN Australian College of Critical Care Nurses; CNC clinical nurse consultant; CNE clinical nurse educator; CNM clinical nurse manager; FTE full-time
equivalent; NPC nurse practice coordinator; NUM nursing unit manager.

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SCOPE OF CRITICAL CARE

26

The nursing workload at the individual patient le

vel,
however, is also reflective of patient acuity, the com
plexity
of care required and both the physical and the
psychological status of the patient.38 Strict adherence to
the
patient census model leads to the inflexibility of matc
hing nursing resources to demand. For example, some
ICU
patients receive care that is so complex that mo
re than
one nurse is required, and an HDU patient may requir
e
less medical care than an ICU patient, but conversely
may
require more than 1 : 2 nursing care level secon
dary to
such factors as physical care requirements, patient c
onfusion, anxiety, pain or hallucinations.38 A patient c
ensus
approach therefore does not allow for the varying nur
sing
hours required for individual patients over a shift
, nor
does it allow for unpredicted peaks and troughs in ac

tivity, such as multiple admissions or multiple discharge

s.
There are many varied patient dependency/classifica

tion
tools available, with their prime purpose being to clas
sify
patients into groups requiring similar nursing care an
d to
attribute a numerical score that indicates the amount
of
nursing care required. Patients may also be class
ified
according to the severity of their illness. These s
coring
systems are generally based on physiological variabl
es, such
as the acute physiological and chronic health evaluat
ion
(APACHE) and simplified acute physiology score (SAP
S)
systems.Althoughthesescoringsystemshavevalueinde
termining the probability of in-hospital mortality, they
are not
good predictors of nursing dependency or workload.38
The therapeutic intervention scoring system (TISS
) was

developed to determine severity of illness, to est registered nurses possessing a formal specialist critical
ablish
care qualification. The ACCCN recommends an optimum
nurse-to-patient ratios and to assess current bed qualified critical care nurse to unqualified critical care
utilisanurse ratio of 75%30 (see Appendix B2). In Australia and
tion.38 This system attributes a score to each pro New Zealand, approximately 50% of the nurses employed
cedure/
in critical care units currently have some form of critical
intervention performed on a patient, with the pre care qualification.34
mise
that the greater the number of procedures performed Debate continues in an attempt to determine the
optimum skill mix required to provide safe, efective
, the
4248 Much of the research fuelling
higher the score, the higher the severity of illne nursing care to patients.
this
debate
has
been
undertaken
in the general ward
ss, the
setting,
and
still
predominantly
in
the
USA. However, it
38
higher the intensity of nursing care required. Si
has provided the starting point for specialty fields of
nce its
development in the mid-1970s, TISS has undergone nursing to begin to examine this issue. The use of nurses
other than registered nurses in the critical care setting has
multiple revisions, but this scoring system, like APACHE a been discussed as one potential solution to the current
critical care nursing shortage. Projects in Australia trialnd
care environment have
SAPS, still captures the therapeutic requirements ling the use of EENs in the critical
49
largely
proved
inconclusive.
of the
patient. It does not, however, capture the entirety of Published research on skill mix has examined the substithe
tution of one grade of staf with a lesser skilled, trained
nursing role. Therefore, while these scoring systems or experienced grade of staf and has utilised adverse
may
events as the outcome measure. A significant proportion
provide valuable information on the acuity of the pati of research suggests that a rich registered nurse skill mix
ents
reduces the occurrence of adverse events.4248 A comprewithin the ICU, it must be remembered that they are hensive review of hospital nurse staffing and patient outnot
comes noted that existing research findings with regard
accurate indicators of total nursing workload. Other s to staffing levels and patient outcomes should be used to
pebetter understand the efects of skill mix dilution, and
cific nursing measures have been developed, but hav justify the need for greater numbers of skilled professione not
als at the bedside.50
gained widespread clinical acceptance in Australia or
While there has not been a formal examination of skill
New
in Australia and New
Zealand. (For further discussion of nursing wo mix in the critical care setting
51,52
Zealand,
two
publications
informing
this debate
rkload
emerged
from
the
Australian
Incident
Monitoring
Study
measures, see Measures of Nursing Workload or Ac
ICU (AIMSICU). Of note, 81% of the reported adverse
tivity in
events resulted from inappropriate numbers of nursing
this chapter.)
staf or inappropriate skill mix.51 Furthermore, nursing
While not strictly workload tools, various early w care without expertise could be considered a potentially
harmful intrusion for the patient, as the rate of errors by
arning
scoring systems are increasingly being used to f experienced critical care nurses was likely to rise during
periods of staffing shortages, when inexperienced nurses
acilitate
51
the early detection of the deteriorating patient. Trequired supervision and assistance. These important
findings
provide
some
insight
into
the
issues
surrounding
hese
skill
mix.
early warning systems generally take the format of a
stanIn Australia and New Zealand, an annual review of intendardised observation chart with an in-built track sive care resources53 reported that there were 6633.7 FTE
and
registered nurses currently employed in the critical care
trigger process.3941
nursing workforce (5587.2 in the public sector and
1046.5 in the private sector). More recently, in 2005,
categories of nurses in the workforce other than registered
SKILL MIX
Skill mix refers to the ratio of caregivers with va nurses were captured and reported for the first time,
showing that there were 53.9 FTE enrolled nurses currying
rently employed in the critical care setting in Australia
levels of skill, training and experience in a clinic (44.6 in the public sector and 9.3 in the private sector).34
al unit.
Enrolled nurse training has not occurred in New Zealand
In critical care, skill mix also refers to the proportion since 1993, and those who are currently employed in the
of
healthcare system are restricted to a scope of practice that
does not call for complex nursing judgements. Thus, no
enrolled nurses were reported to be working in cr