Table 5 Proposed definitions and benchmarks for indicators of ICU strain

ICU census

ICU not able to admit any new patients.

The exact percentage bed occupancy is less important than having capacity to admit.

< 10% of time

Queuing

Delay in time from orders to admit to ICU to ICU arrival.

Increasing delays for ICU admission result in suboptimal care for these critically ill patients. The most common timeframe in the literature was within 4 h of decision to admit.

< 4 h

Nurse-to-patient ratio

The number of nurses caring per patient.

A lower ratio of nurses per patient means less time can be spent per individual patient and increases nursing workload. To most common ratio studied in the literature was 1:2.

Adjusted nursing workload of < 1:2

Daily rounds by intensivist

Daily bedside visit by MRP to review patients’ medical condition and problem list.

Daily in-person rounds are critical when caring for ICU patients. These should occur daily in a formal fashion.

100%

ICU transfer

Inter-hospital transfer of an ICU patient due to lack of capacity.

This definition interplays with that of ICU census; however, it is an extension of the above, indicating that there are no mechanisms for increasing capacity at the strained institution.

None

ICU acuity

The average severity of illness of patients in the ICU.

More acutely ill patients provide both a physical and mental strain on ICU staff. The APACHE II score was most commonly used in the literature. However, institutionally specific scores may be used as well.

APACHE II Score

After-hours discharges

Unplanned discharges from the ICU outside of regular hours (as defined in per each individual institution)

Patients discharged outside of regular hours may not be evaluated by medical staff in a timely fashion. There were many definitions of ‘after-hours’ in the medical literature. ‘After-hours’ should relate to individual institutional practices.

None

Turnover

The number of admissions and discharges from an ICU per 24-h period.

Typically highest patient workload occurs on ICU admission and discharge.

n/a

Workload

The volume and pressure of work.

Higher workload can lead to increased stress and concerns regarding patient safety. An objective measure of workload is necessary to quantify this variable.

TISS-28 Score

Early ICU Discharge

Discharge from an ICU earlier than preferable as per the MRP.

Physicians must triage patients at time of ICU capacity strain to ensure that the sickest patients be those located in the ICU. This may require immediate decision-making regarding discharging of less acutely ill patients.

None

Refusal Rate

The ratio of patients refused entry to the ICU vs. total number of ICU consults.

As strain in the ICU increases, physicians are less likely to admit patients who may not truly require ICU level care. This needs to be balanced with referred patients who do not require ICU level care.

0% of appropriate ICU consultations

ICU Readmission

Avoidable ICU readmission within 48 h of discharge as adjudicated by admitting physician.

Most ICU readmissions are unavoidable and hence are not a reflection of ICU strain or quality. However, if an ICU is under strain and patients are discharged prematurely and this results in ICU readmissions, this may be a marker of strain. Avoidable readmissions should be adjudicated as per the admitting physician.

None

Standardized mortality ratio

Ratio between the observed number of deaths in a study population and the number of deaths that would be expected, based on age and sex-specific rates in a standard population and the age and sex distribution of the study population.

An increasing varying SMR may be related to varying ICU strain. Benchmark is based on data from all Alberta provincial ICUs.

< 15%

Burnout

Work-related stress leading to feelings of pressured, overwhelmed and desire to leave work.

As workload and patient acuity increases, healthcare providers may themselves feel overwhelmed and unable to carry on work. An objective measure of burnout syndrome (BoS) is necessary to quantify this variable and the Maslach Burnout Inventory has been extensively studied in the literature and may be referenced across ICUs.

Maslach Burnout Inventory

Job satisfaction

Healthcare workers reporting lack of satisfaction with their job.

With increasing strain and stress at the workplace, there is decreasing satisfaction on the job. An objective measure is necessary to quantify this variable.

Measurement of Job Satisfaction

Surgery cancellation

Surgeries that require cancelation of rescheduling due to ICU constrains.

Certain elective surgeries necessitate post-operative ICU monitoring. However, in cases of strain, these surgeries may be cancelled or rebooked.

None