A recent article about Critical Care in Nepal asserted that the best ICU ever established in the country was one which existed in 1958.
Baseball in USA
I wonder when I read such things. “It was better in the old days…” Is a common refrain, especially when you yourself get older. But was it really?
We were all young once, and everyone is permitted some wistful nostalgia. Let’s think of how to improve hospital care forty years from now, not what it was like forty years ago.
Yankees vs Red Sox
In USA we have a national sport, baseball, which is only played in summer, and my brother-in-law is a devoted fan, able to quote historical statistics. So when I read the above, I thought of a winter evening when the discussion turned to comparing the 1927 Yankees against the 2004 Red Sox, speculating as to which team would have won the World Series if they competed against each other. I suppose it’s a fun exercise in which to engage, but – all the guys on the 1927 team are now dead. And we’ll never know what would have happened……
Same with 1958. If there is relevance to be gained, it is in analyzing *what makes a successful ICU* not the question of which one might have been good in a certain time and place. It’s a purely subjective statement which does not point a direction for modern day critical care. Sort of like asking which Bollywood actor is better – Salman Khan or Shah Ruhk Khan?
So – what makes a good ICU?
For the time being, I will leave out certain questions such as whether a given hospital needs one, or whether they can afford one, or the needs of the country. Nepal is clearly making a transition in the direction of more complex care for at least a portion of the citizens.
I would submit two criteria of my own, each is backed with ample research that I am not bothering to cite at present. And common sense based on fifteen years of ICU nursing.
The first is that an ICU measures the *patient outcomes* not just make an inventory of the equipment they possess or the procedures they can do. In many cases, the outcome is measured in terms of infection control and prevention of sepsis. A well-run ICU should be focused on reducing “excess deaths” in otherwise salvageable critical cases. There needs to be a linkage to “failure to rescue” that addresses the problem of failure to rescue. For example, if an ICU is capable of using intravenous lines that are placed in a central vein, it is irrelevant unless there is need for the technology and it can be done within acceptable guidelines for infection control. Similarly, to have a mechanical ventilator is not enough – there needs to be a parallel focus on VAP – “Ventilator-acquired pneumonia.”
So – a good ICU keeps statistics and also focuses on whether it is improving the quality of the patient’s subsequent life. decisions are made accordingly.
Second, all members of the ICU team need to be given respect and a voice in patient care. In USA it has long been recognized that it’s the quality of nursing care that makes the difference in critical care. Creating an atmosphere which promotes nursing initiative are on the top of the list. This relates directly to gender roles in Nepal, where women have been traditionally thought to be subservient. This is an obstacle to overcome.
Remarks from junior doctors that belittle the nurse’s knowledge or contribution are simply not tolerated in an effective ICU. The senior medical leader and senior nursing leader are willing to address the interpersonal relationships that exist, and will take positive steps to maintain a healthy work environment. Likewise, the nurses need to understand the doctor’s plan and to recognize how best to contribute. There should not be an excess of formality in ICU between members of the team and there needs to be mutual respect.
Does your ICU have this? If not, you can create it. Start here and now………