Numberand case mix of patients to be admitted

It is generallyaccepted that the case mix may be characterized by age, severity ofillness, diagnosis, type of admission (medical or surgical, scheduledor unscheduled), and origin of the patients (operatingtheater/recovery room, ward, other ICU, other hospital, etc.). It hasbeen shown that each of these characteristics exerts a significantinfluence upon the use of resources and the outcome of patientsadmitted to the ICU.

The type and number of patients admitted, and of the related tasks to be performed, are the major determinantsof the type and number of the staff in the ICU. The case mix of theadmitted patients (when describing risk of death) should be primarilyrelated to the professional expertise of the staff, whereas thepatient turnover (number of admissions) should be related to thenumber of staff. The two examples below may help to explain theserelations.

An ICU with a high patient turnover (more than 80admissions per bed annually) will use a large proportion of its staffto ensure efficient functioning of the infrastructure associated withfrequent admission and discharge of patients. The medical conditionsto be dealt with are usually predictable, the overall risk ofmortality is low, and the patients can usually be classified into arelatively small number of case-mix groups (usually postoperativediagnoses). The work required is usually the monitoring and treatmentof rather short periods of cardiovascular and/or respiratorydysfunction or failure. Therefore the nursing tasks performed inthese ICUs usually have a low grade of differentiation, and protocolscan easily be designed for many of the tasks performed by physicians.In this ICU leadership, planning, and judgment can be concentrated ontraining and supervision, so that the variety and number ofdifferentiated professionals equired are reduced.

An ICUadmitting predominantly patients with a higher risk of mortality(e.g. older, with unscheduled medical and surgical problems, oradmitted from the ward, other ICUs, or other hospitals) willnecessarily have a lower turnover of patients and therefore requireless manpower for administrative tasks. However, this ICU willrequire more personnel for the clinical care of individual patients.These patients will not only be sicker and need more care, but theywill also present a larger variety of often unpredictable criticalillnesses (e.g. multiple organ and system dysfunction or failure).Therefore these ICUs will have a high grade of differentiation oftasks performed, the size and type of the ICU and staff to attend to families so that a higher grade of professionaldifferentiation will be required among the staff. Moreover, centralization will be difficult, except for leadership, andprotocols will only be possible for the less differentiated tasks. Inother words, the medical and nursing staff providing daily care tothe patients will need to have a high degree of professionalautonomy.

Patient numbers and case mix can easily be assessedif the ICU is already operative. If the organization of the unit isbeing planned prior to opening, the survey should be performed in twosteps: first, a comparative study of two or three ICUs withcharacteristics similar to the one being planned which are operatingin similar hospitals; second, submission of the original staffplanning to revision and approval after the first and second years ofoperational experience.

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