Charles Durbin Jr., MD, FCCM
President
Society of Critical Care Medicine

Building a Strong Critical Care Team for Tomorrow

The soon to be released Health Resources and Services Administration (HRSA) report will confirm what we know is true – there is a growing shortage of healthcare workers in the United States. This shortage is a particular problem in our intensive care units (ICUs). The actual and projected growing demand for our services is placing stress on workforce numbers. While the government may be able to entice some to enter healthcare fields by offering more scholarships and loans or by increasing loan forgiveness for those choosing ICU practice, it is up to us, the current workforce, to attract new recruits. It is up to us to convince others that critical care is an enjoyable, satisfying and worthwhile career choice.

Enhance the ICU Environment
A team of dedicated experts working at the patient’s bedside not only provides the best care to the critically ill and injured, but it also creates the best environment for personal satisfaction and professional growth. Each member of the team brings important skills to the care of the patient and supports the other members in creating a respectful and caring work environment. While individual members of the team, such as nurses, respiratory therapists, critical care pharmacists and critical care physicians, contribute to improved patient outcomes, the team itself contributes to patient care and caregiver satisfaction in a major way.
ICUs vary in clinical performance and efficiency. Clinical performance often is measured by comparing the actual, observed mortality rate to that predicted by patient acuity and diagnosis. The severity-adjusted mortality rate can be calculated by using simple physiological variables, patient diagnosis and age (e.g., using the APACHE II system) or by using commercially available software. Calculating ICU length of stay and the actual costs of care, either overall or for specific diagnoses, will help estimate the unit’s efficiency. The structural and organizational characteristics of ICUs with large differences in clinical outcomes and efficiency have been examined. Superior units demonstrate strong teamwork with a patient-centered culture, strong medical and nursing leadership, effective communication, consistent coordination of care, and an open, collaborative approach to problem solving and conflict resolution.
Surprisingly, the best units seem to experience more than the average amount of conflict, but they have effective and transparent means for achieving resolution. Caregivers favor the team practice model. Active and open resolution of conflict is essential to a healthy work environment, one that will keep competent clinicians at the bedside and attract new individuals to this highly satisfying work.

Empower Your Colleagues
Teamwork cannot be measured directly, but surveys given to members of the ICU team uncover interesting perceptions. In a study published in the March 2003 issue of Critical Care Medicine titled “Discrepant Attitudes About Teamwork Among Critical Care Nurses and Physicians,” physicians and nurses were asked about their collaborative interactions with each other. Of the physicians surveyed, 73% rated their interactions with nurses as highly collaborative. However, only 33% of the nurses surveyed considered their interactions with physicians to be highly collaborative. There was no objective measure of team success, but analysis of individual survey items revealed that nurses felt that it was difficult to speak up to physicians and disagreements often were not properly resolved. Although physicians said nurses needed to be more involved in decision making, nurses said they felt their input was not well received. The fact that members of the same team viewed the team interactions differently is not a surprise. The ideal critical care team facilitates ownership and empowerment for all team members and serves to improve patient outcomes as well as the success of individual members.

If You Measure It, It Will Improve
The Society of Critical Care Medicine (SCCM) now offers the ICU Resource, Evaluation, and Patient Outcomes Rating Tool® (ICU Report®), which includes the ICU Index.^TM The ICU Index^TM evaluates 16 essential areas of ICU function and structure, one of which is teamwork. A spider diagram then provides a snapshot of the ICU, which can help identify strong areas and those needing improvement. By making changes, movement toward the “ideal” is stimulated. This is particularly true when aiming to improve teamwork. If a great discrepancy exists when participants are asked how well the team works together or if less-than-perfect scores are reported through the spider diagram, responsible individuals feel compelled to investigate the situation. This leads to improved communication, collaboration and respect. The process of measurement alone can stimulate an improvement in practice.

Our Responsibility
In the final analysis, if we, the members of the current critical care teams, don’t believe in the value of the “team” as a tool to improve the quality of patient care or to improve our own professional development, we will not attract new, young practitioners to the ICU. The shortage at the bedside will increase and care will suffer. Ultimately, the members of the current workforce will solve the caregiver shortage in the ICU. I believe we are up to this challenge.