How to start, grow, and run an ICU

Transcription

1 How to start, grow, and run an ICU Thomas P Bleck MD MCCM FNCS Professor of Neurological Sciences, Neurological Surgery, Medicine, and Anesthesiology, Rush Medical College; Director, Clinical Neurophysiology, Rush University Medical Center 1

2 Disclosures No conflicts of interest for this topic I am a current member of the ABIM Critical Care Subspecialty Exam Committee. To protect the integrity of Board Certification, ABIM enforces strict confidentiality and ownership of exam content. As a member of an ABIM exam committee, I agree to keep exam information confidential. As is true for any ABIM candidate who has taken an exam for Certification, I have signed the Pledge of Honesty in which I have agreed not to share ABIM exam questions with others. No exam questions will be disclosed in my presentation.

3 Don t forget this This may be a calling to you, but it is a business to the administration

4 Where do you start? You want to start an ICU Why do you want to start an ICU? Why do you want to start an ICU? Who do you need on your side to get started Chairmen of relevant departments Chief medical officer Physician practice chief Nursing administration Directors of ICUs where your patients now reside

5 Don t forget this This may be a calling to you, but it is a business to the administration

6 Administration The administration is not on your side, no matter what it may tell you But you can t accomplish anything without it Dealing with the revenge of the C students This may be a calling to you, but it is a business to the administration It will see your unit as an expense, not as a revenue generator Although you can t rationally quantify them, you will make downstream revenues possible for many other services (neurosurgery, radiology, etc).

7 Don t forget this This may be a calling to you, but it is a business to the administration

8 The business plan The need for and value of the unit may be obvious to you, but in order to get the administration to pay attention, you will need a business plan What and who do you need to get the unit started Hospital revenue vs professional revenue The hospital is paid on a DRG (prospective payment) model Professionals are currently paid on a fee for service model (this will likely change in the future, so be prepared for it) Thus, a new service may generate professional revenue but may lose money for the hospital

9 The business plan How is overhead handled in your institution? Fixed vs variable costs Profit/loss vs contribution margin Personnel costs Nursing costs vary with patient volume and acuity Professional costs are fixed over the short term ACNPs/PAs may work 40 hrs/week, but most of that time is for the unit Residents may work 80 hrs/week, but will only work for the unit a limited number of weeks/yr Your institution is probably already over its house staff cap, so that 100% of the cost of residents and fellows has to be paid by the hospital

10 Don t forget this This may be a calling to you, but it is a business to the administration

11 Do a SWOT analysis They learned this in business school: Strengths Weaknesses Opportunities Threats Include items from within your institution and from the outside environment

12 SWOT analysis template S Strengths W Weaknesses O Opportunities T Threats

13 Outline in order of importance (the reverse of the order of significance) Politics Budgets Career development Science Patient care

14 Politics Always line up your support (and supporters) before proposing a change The hospital is full of entrenched interests; sometimes you can make them your allies, but sometimes you will encounter opposition

15 Budgets Who submits the budgets for your unit, and to whom (typically goes through nursing administration) Capital budgets vs operating budgets You ll seldom have another chance to get a big capital outlay for your ICU, so ask for everything up front But know what is essential and what could wait if necessary Everything that isn t capital will be in the operating budget

16 Budgets Service lines vs departments As Deep Throat said, follow the money. Know who has to approve your budget requests, and figure out what (and who) will convince them to agree to your requests When someone wants to add a service that will increase the workload of your unit, how will you cover the request (personnel and money)?

17 Career development From the start, have a career development plan for everyone who works in the unit, regardless of profession Know how credentialing works in your institution, and make sure your staff s credentials match what they do Demand that all professions are granted appropriate time and funding for continuing education Consider running ENLS and FCCS courses through your unit

18 Nurse certification Your institution may have specific rules regarding what percentage of ICU nurses must have what type of certification The two main certifications of interest to neuroicus are Critical care registered nurse (CCRN) Certified neuroscience registered nurse (CNRN) Know who gets certified and celebrate their achievement

19 Science The hospital administration has two interests in science: Will it enhance the reputation of the institution, thus bringing more patients How much will it cost, especially in nursing time and potentially in lost revenue Be prepared to answer these questions about any new projects

20 ICU research When starting a new unit, demand a funded research coordinator and a database manager from the start

21 Patient care This should have been the first thing on the list, but it is often taken for granted that you will run an excellent service So what will you need to run one? Dedicated colleagues High quality performance data Trained staff to help analyze the performance data and help with improvements

22 Growth Start with a manageable unit size, with plans to expand, rather than over-reaching at the start Staffing ratios are important and nonnegotiable Average 1:2 ICU nurse:patient ratio with floating charge nurse might consider 1:3 in stepdown areas

23 Physician staffing Not as much data to apply to physician staffing as nurse staffing In academic units, no more than 14 patients per attending This size service can be handled by one resident overnight with a fellow backing up The appropriate number of patients per ACNP or PA is not established, but is probably close to eight Very little data on staffing ratios in units without house staff

24 Running an ICU Work hour restrictions have destroyed the ICU experience for residents They have forced to change from physicians to shift workers They are less involved and less happy I can read the sleep deprivation literature as well as the next person, but I m too tired to do so since I have to do the residents work

25 So why would I want to do this? A chance to help mold a field that is still quite new and destined to grow If, like me, you find these patients interesting, then no other field will satisfy you You get to make some great saves And when you don t you get to help families through some of the roughest times of their lives

26 What s fun Working with the nurses, pharmacists, and fellows is still the best part of the job My intensivist colleagues (from all disciplines and all ICUs) remain great people with whom to work

27 Don t forget this This may be a calling to you, but it is a business to the administration