Running head: ANALYSIS OF CRITICAL CARE DELIVERY

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Analysis of Critical Care Delivery
Brittany Thompson and Kaylee Keller
Auburn University School of Nursing
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Abstract
The critical care delivery system is a complex, advanced health care entity that provides care to
patients with extensive life-threatening injuries and illnesses. This paper analyzes the economic
impact, patient costs and outcomes, and the role of health care professionals in the critical care
setting. A focused case study was carried out in order to further examine the impact of these
factors in patient care delivery. The individualized case study depicted below took place in the
Intensive Care Unit at East Alabama Medical Center, located in Opelika, Alabama. Current
issues impacting the critical care delivery system such as open patient visitation, lack of federal
funding, and interprofesional relations are also addressed.
Keywords: Critical care, interprofesional teams, cost analysis, quality improvement



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Analysis of Critical Care
Critical care is one of the most complex and extensive care delivery systems offered in
health care. The variety of illnesses, patient acuity, and increasing patient population require
health care providers to be up-to-date with current treatment approaches and technological
advances. Treatment regimens utilizing this technology can be very costly to both the patient and
the hospital, which is one of the main issues this care delivery system is facing. Adequate
interprofessional collaboration and teamwork is another concern of critical care. These issues
must be addressed in order to ensure quality patient care and outcomes. The purpose of this
paper is to define critical care and determine the economic impact, patient costs and outcomes,
and the role of health care professionals in the critical care setting.
Overview of the Care Delivery System
Critical care, also known as intensive care, is a specialty designed to support patients
suffering from life threatening injuries and/or illnesses. Patients in this type of unit need constant
monitoring and generally require specialty care from a team of healthcare professionals (National
Health Service of Wales, 2013). In order to assist these patients, critical care units utilize special
monitoring systems and equipment, such as cardiac monitors, ventilators, and chest tubes. These
units also have higher levels of staffing, sometimes with a one-to-one nurse-to-patient ratio.
Every year, more than five million patients are admitted into critical care units across the
United States. The most common admission diagnosis into the critical care unit is respiratory
insufficiency or failure, followed by postoperative management, ischemic heart disorder, sepsis,
and heart failure (Society of Critical Care Medicine, 2014). There are currently more than six
thousand intensive care unit (ICU) beds in the United States, with the number increasing each
year. The average length of stay for a patient in the ICU is between six to nine days, depending
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on the type of care delivered. Care that is directed by an intensivist, rather than an attending
physician, tends to result in a shorter length of stay (Society of Critical Care Medicine, 2014).
According to the Society of Critical Care Medicine (2014), the mortality rate of patients in
critical care units range from 10% to 29%, with the leading causes of death being multiorgan
failure, cardiovascular failure, and sepsis.
There are a couple alternatives to the typical delivery of care in ICUs. One of these
alternatives is the utilization of telemedicine in patient care. Telemedicine is electronic
communication of medical information from one place to another. It uses both audio and visual
exchanges, and it allows medical staff to monitor and assist in bedside care of patients from a
separate location. Only 15% of US hospitals have 24-hour intensivists on staff, so telemedicine
provides the bedside nurse with someone to collaborate with while also providing extra
surveillance and support for the patient (MNA Position Paper, 2014). However, telemedicine
is still a fairly new development and it is sometimes difficult to implement.
Another alternative to traditional patient care in the ICU is the application of
complementary and alternative medicine (CAM). Because of the high stress environment
critically ill patients are placed in, the intensity of their treatment regimens can actually harm
their well being. Cooke, Mitchell, Tiralongo, and Murfield (2012) found that CAM can provide a
holistic approach to treatment by improving the patients physical and psychological well being.
These therapies can promote rest and reduce anxiety and discomfort, which aid in the patients
healing process. The most common CAMs used in the critical care settings in the United States
are diet, exercise, relaxation techniques, prayer, biofeedback, and counseling (Cooke et al.,
2012). The National Center for Complementary and Alternative Medicine (2014) also
recognizes other beneficial practices; these include acupuncture, massage therapy, spinal
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manipulation, and hypnotherapy. However, the applicability of these therapies depends on the
health status and needs of the patient.
Current Issues and Concerns
The United States health care system spends more than eighty billion dollars on critical
illness each year. This represents 3% of the nations total healthcare spending (Gooch & Kahn,
2014). Despite the large amount of funds dedicated to critical illness, there are still issues with
this area of health care.
In the last twenty years, there has been an increase in the amount of patients receiving
care through life-sustaining technologies in the ICU. These technologies increase the cost of
health care as well as the potential for patient harm. Therefore, there is an increasing focus on
quality and safety in patient care (Chelluri, 2008). The Institute of Medicine (IOM) found that
inappropriate use of resources is one of the primary issues that impacts quality of care. In order
to reduce the overuse, under use, and misuse of resources, quality improvement methods have
been utilized in many institutions. These methods include efforts to reduce the occurrence of
ventilator associated pneumonia, sepsis, and MRSA infections. Other methods focus
interventions that result in effective, safe, efficient, and patient-centered care. The institutions
that successfully implement these initiatives tend to have physician and nurse leadership support,
incentives for senior leaders, and the involvement of bedside caregivers (Chelluri, 2008).
Another concern with critical care is visitation policies. The typical policy for most US
hospitals is highly restricted ICU visitation rights. These hospitals are concerned that open
visitation policies in the ICU could harm the patient by increasing stress and exposure to
infection (Liu, Read, Scruth, & Cheng, 2013). Recently, however, more healthcare providers
have recommended open visitation policies. Those who survive critical illness can develop post-
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intensive care syndrome, which is a type of post-traumatic stress disorder that includes physical
and neurocognitive disability. Family members of these patients can also develop similar
symptoms from all the stress. Open visitation policies could decrease the occurrence of these in
patients and families (Liu et al., 2013). Open visitation is also associated with improved
psychiatric well-being, improved trust between staff and family members, and overall
satisfaction. However, due to the variability in practice, it is unknown whether or not these
findings are applicable to all critical care units. Therefore, more research needs be done on this
topic.
Provision of Care
According to a study conducted by the Department of Health and Human Services, there
are 503,124 US nurses who care for critically ill patients in hospital settings (American
Association of Critical-Care Nurses, 2014). These nurses must be proficient in providing care for
acutely and critically ill patients and their families. These patients require constant monitoring,
complex assessments, and intensive interventions. One of the most important roles of a critical
care nurse is being a patent advocate. The nurse must support the beliefs of the patient and
intervene when those beliefs are being infringed upon. The nurse must also act as a liaison
between the patient, their family, and their healthcare providers (American Association of
Critical-Care Nurses, 2014). Critical care nurses who decide to further their education can work
as clinical nurse specialists (CNS) or as acute care nurse practitioners (ACNP). Due to the
increasing number and severity of illnesses in the ICU, it is important that critical care nurses
stay up-to-date with the latest information and technologies.
According to Rose (2011), effective interprofesional collaboration leads to improved
outcomes in critically ill patients. However, due to factors like shift rotations, staff attrition, and
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patient changes, teamwork and communication are poor in critical care units. In order to form a
productive interdisciplinary team, patient care plans; decision-making, and overall patient care
needs to be conducted by all members of the team (Rose, 2011). Other health care providers
found in the ICU include intensivists and other physicians, respiratory therapists, physical
therapists, pharmacists, social workers, and dieticians. The intensivist is a physician who is
specialized in critical care medicine. The respiratory therapist helps monitor and maintain the
patients airway, while physical therapist works on the patients range of motion and overall
rehabilitation. The pharmacist advises the intensivist on the best drug regimen and makes sure
the patients receive the right drug at the right dose. Social workers help the family with making
plans for the future and with acquiring financial resources if theyre needed. The dietician makes
sure that the patient is receiving all the nutrients necessary to promote healing and well-being.
When all of these providers work together on a patients care, as opposed to caring for him or her
independently, the best patient outcome ensues.
Focused Case Study
Patients admitted into the Intensive Care Unit at East Alabama Medical Center receive
extensive medical care for acute, life-threatening injuries and illnesses. One particular patient
receiving care on the unit was Ms. C.F. She was first admitted to East Alabama Medical Center
on March 3, 2014 for a pacemaker/implantable cardioverter defibrillator (ICD) insertion. Ms. C.
F. was then transferred to the ICU later that day following an episode of cardiac and respiratory
arrest. Ms. C. F. had a history of respiratory arrest following surgical procedures. After being
transferred to the telemetry floor, a nursing aid noticed a decline in Ms. C.F.s condition. The
nurse was notified, but no action was taken. A few hours later, the patient was found slumped
over in her bed. She was apneic with a cardiac status of pulseless electrical activity. It is
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unknown how long Ms. C.F. was apneic before she was discovered in her room. The apneic
period was prolonged even further because emergency room physician experienced difficulty
when attempting to intubate due to the patients size and short neck. Upon the intubation attempt,
the physician caused a laceration to the patients tonsils resulting in airway trauma and bleeding.
After the unsuccessful attempt to intubate patient via endotracheal tube, a tracheostomy was put
in place to establish an airway.
Ms. C.F. had a history of morbid obesity, asthma, thrombotic cerebral infarction, chronic
obstructive pulmonary disease, peripheral vascular disease, coronary artery disease, Diabetes
Mellitus type two, essential hypertension, neoplasm of the respiratory tract, and sleep apnea. She
was transferred to the Intensive Care Unit on March 3, 2014 with the primary medical diagnoses
of post cardiac and respiratory arrest. After being transferred to the ICU, the Ear, Nose, and
Throat physician was able to identify the source of bleeding in the patients throat and injected
lidocaine with epinephrine to slow the bleeding. She was kept on the Intensive Care Unit until
March 9, 2014 when she was moved to the step-down unit for monitoring and mechanical
ventilation.
Ms. C.F.s condition worsened from the date of admission until her transferal to Bethany
House on the morning of March 14, 2014. On the night of March 5, the patient experienced a
seizure and bit her tongue causing it to swell and protrude outside the oral cavity. A cold, moist
drainage sponge was constantly applied to the patients tongue in order to keep the mucus
membranes moist and prevent further injury. Packing was inserted between the patients tongue
and bottom row of teeth to prevent further breakdown of the soft tissue.
On March 6, there was a copious amount of drainage noted from the mouth and nose,
multiple small clots, and the patients tongue was still swollen and protruding. On March 7, Ms.
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C.F.s hemoglobin and hematocrit values began to drop from a hemoglobin value of 7.6 gm/dL
on March 6 to 7.4gm/dL on the seventh, and a hematocrit value of twenty-four percent to twenty
three percent. After the decrease in hemoglobin and hematocrit, a blood transfusion was ordered
on March 7, 2014. The physician was notified of Ms. C.F.s elevated temperature of 101.4
degrees Fahrenheit, and instructed the nurse to proceed with the transfusion.
Throughout her stay in the ICU, Ms. C. F. required mechanical ventilation on
Assist/Control Mode. Her fraction of inspired oxygen was forty percent, the positive end
expiratory pressure was set at five millimeters of mercury, and a respiratory rate was set at
fifteen breaths per minute in order to maintain a peripheral capillary saturation of at least ninety-
two percent. Mouth care was performed every four hours in order to prevent ventilator-
associated pneumonia. However, patient suspected for ventilator-associated pneumonia because
of positive sputum cultures, elevated white blood cell count of 13,400, and an elevated oral
temperature of 101.4 degrees Fahrenheit. She was given a rectal suppository of Tylenol as
needed for elevated temperature and started on Rocephin March 6, 2014. Her antibiotic was later
switched to Zosyn after sputum cultures were further studied.
Ms. C.F.s renal function rapidly declined during her stay in the Intensive Care Unit. Her
Blood Urea Nitrogen levels increased from twenty milligrams per deciliter on admission to forty-
six milligrams per deciliter on March 12, 2014. The creatnine levels slightly increased from 1.4
milligrams per deciliter to 1.5 milligrams per deciliter. Her urine output decreased from an
average of sixty milliliters an hour on March 6, 2014 to an average of fifteen milliliters an hour
on March 12, 2014.
The patients neurological status also steadily declined from admission to discharge. On
the morning of March 10, 2014, Ms. C.F. was not responsive to painful stimuli in the upper
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extremities, responsive to touch in the lower extremities, and her pupils were fixed and dilated.
Later that night, she was unresponsive to painful stimuli via sternal rub, her right pupil became
fixed and opaque, and her left pupil was totally unresponsive. Throughout hospitalization, the
patient showed no signs of increasing neurological function.
Ms. C.F. had a peripherally inserted central line, or PICC line, in her right upper arm and
a peripheral saline lock inserted in her right forearm. A continuous infusion of Amiodarone was
administered via the PICC line with five percent dextrose in water to prevent cardiac
dysrhythmias and to lower her blood pressure. A continuous infusion of regular insulin was also
administered through the patients PICC line and titrated according to blood glucose levels. She
received scheduled doses of intravenous Pepcid and Zosyn, and the respiratory therapist
performed scheduled Albuterol treatments. Ms. C.F. received Opexa tube feedings via the
nasogastric tube inserted into her right nare. Feedings were initiated on March 6, 2014 at twenty
milliliters per hour and increased by increments of ten milliliters every eight hours until the goal
rate of thirty-five milliliters an hour was reached on March 7, 2014.
Evaluation of Patients Critical Care
Unfortunately, the ultimate outcome for this particular patient was discharge to hospice
and later death after cessation of mechanical ventilation. Death is not an expected outcome for a
pacemaker/implantable cardioverter defibrillator (ICD) insertion, which is the initial procedure
that brought Ms. C.F. to East Alabama Medical Center. She should have been more closely
monitored following the insertion due to her history of respiratory arrest following surgical
procedures. Cerebral and renal damage could have been prevented if Ms. C.F. had been properly
monitored and promptly intubated during her apneic episode. If intubation had been initiated
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earlier, the physician may have had an adequate amount of time to properly intubate the patient
without causing trauma to the airway and requiring a tracheostomy.
Although death is not an expected outcome for the original procedure, it is an expected
outcome for the patients admitting diagnosis to the Intensive Care Unit, post cardiac and
respiratory arrest. An interprofesional team worked to provide Ms. C.F. with care that would
meet her needs and facilitate recovery. Ms. C.F.s needs were not achievable by the Care
Delivery System. The prolonged period of apnea that occurred before the patient was transferred
to the ICU resulted in irreversible damage to her vital organs, primarily her brain and kidneys.
Therefore, the only possible interventions by the interprofesional team in the Intensive Care Unit
were to monitor the patient for an increase in electrical activity in the brain.
Critically ill patients benefit from the use of interprofesional teams because studies show
interprofesional teams improve patient outcomes (Rose, 2011). Flexibility is a vital component in
the team structure in order to improve patient care and foster optimal team function (Lingard,
Espin, Evans, & Hawryluck, 2004). The interprofesional team for Ms. C.F. consisted of the
patients nurse, the nurse manager, the hospitalist, the pharmacist, the infection control nurse,
and the dietician. They met daily for rounds to discuss the patients plan of care. After observing
no promising changes, they decided to discuss referring the patient to palliative care and hospice
with the patients daughter.
The patients family was educated on palliative and hospice care by the palliative care
nurse and decided to transfer her to Bethany House, a hospice facility in Auburn. She was
discharged from East Alabama Medical Center on March 14, 2014 and moved to Bethany House.
At Bethany House, the patient was removed from mechanical ventilation and death consequently
followed.
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Cost of Care
The Critical Care Delivery System is one of the most costly care delivery systems
because the treatment provided is extensive and labor intensive. In 2010, the average cost of an
inpatient, intensive care room in a for-profit hospital in the state of Alabama was $1,239 per day
(Oh, 2012). This is a charge for the room itself as well as standard nursing care. Services such as
mechanical ventilation, emergency resuscitation, laboratory tests, diagnostic procedures, and
other various services are all charged separately. The patient is also charged separately for all
medications and medical/surgical supplies used. There are multiple factors that contribute to the
cost of critical care delivery. These patients require extensive care from multiple healthcare
professionals, as well as medical procedures that use costly equipment and technological
resources (Society of Critical Care Medicine, 2014).
Cost varies greatly between patients due to the vast differences in resource consumption.
These differences are influenced by factors such as length of stay, illness severity, and variations
in clinical practice. According to the Society of Critical Care Medicine, the average length of
stay is 9.3 days when an attending physician provides care (2014). Mechanical ventilation also
plays a huge role in the cost of care and length of stay in critically ill patients. A study done by
Dasta, McLaughlin, Mody, and Piech found that the average cost and length of stay in the
intensive care were $31, 574-42,4570 and 14.4-15.8 days for patients that required mechanical
ventilation (2005). This study also found that the cost of care is highest on the first two days of
admission and slowly stabilizes to a mean of 1,522 dollars per day for patients requiring
mechanical ventilation (Dasta, McLaughlin, Mody, & Piech, 2005).
Critical care can be paid for via public or private sources. The primary public programs
that fund intensive care units at public hospitals are Medicare and Medicaid. Federal grants are
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also given sporadically for specific initiatives and research projects. Private sources of funding
for the intensive care unit come from either the patients private insurance company or directly
out-of-pocket. Medicare is a very common method of payment for patients in the intensive care
and was the method of payment for the individual case study discussed above. According to a
study done by Cooper and Linde-Zwirbie, critical care costs are three times that of floor patients,
but intensive care units are only paid rates that are twice that of the floor patient (Cooper &
Linde-Zwirbie, 2004). On average, Medicare covers 83% of costs in the intensive care unit, but
covers an average of 105% of costs on a regular floor. This gap in funding creates substantial
loss from the hospital when intensive care is required. The lack of funding from programs like
Medicare has a direct impact on the cost of care for patients paying out-of-pocket not only in the
intensive care, but throughout the hospital (Cooper & Linde-Zwirbie, 2004).
Critical Care Patient Costs
The cost for critical care varies from unit to unit depending on the extent of care
rendered, geographical location, and hospital resources. Ms. C.F. was billed $1,024 per night for
a single patient room in the intensive care unit. The cost of her single patient, intensive care
room is right in line with the Alabama state average of $1,239 (Oh, 2012). Ms. C.F.s stay in the
intensive care extended from the night of March 3, 2014 until March 9, 2014 when she was
transferred to a step down unit. Her total charges for the intensive care room alone came to
$7,168. After Ms. C.F. was transferred from the intensive care to the step-down unit, the charge
per night dropped to $869, which is below the national average of $972 (Richards, Fleming,
Shannon, Walters, & Harrigan, 2012). The total charge to Ms. C.F. for a room during her stay at
East Alabama Medical Center was $10, 644.
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Ms. C.F. required extensive care from multiple healthcare professionals and the use of
costly medical resources, these services make up the majority of Ms. C.F.s total charges.
Pharmacological services were required in order to provide various medications and intravenous
solutions, which made up $6,369.75 of Ms. C.F.s total expense. Medical-surgical supplies,
sterile and non-sterile, came to a total of $7,304. Ms. C.F. had a pacemaker inserted before her
episode of cardiac arrest that cost $11,220. Various laboratory procedures including blood
culture and chemistry tests were performed and cost a total of $7,264. Diagnostic procedures
such as radiography and computed tomography scans came to $3,005. Charges from the
pacemaker insertion included operating room services, anesthesia, and blood administration. The
total cost for the pacemaker insertion, excluding the device itself, was $15,354. Respiratory
charges for mechanical ventilation, $268 per day, and aerosol treatments totaled at $5,639.
Cardiology charges for emergency medications and a diagnostic echocardiography came to $847.
Emergency intubation and cardiopulmonary resuscitation following Ms. C.F.s cardiac arrest
cost $933. Finally, outpatient services came to a total of $384.
Ms. C.F.s total charges came out to $70,411. The total is above the average range of $31,
574-42,4570 total cost for patients in the intensive care requiring mechanical ventilation (Dasta,
McLaughlin, Mody, & Piech, 2005). Ms. C.F.s added expense primarily stemmed from her
pacemaker insertion that took place before the cardiac arrest or her admission into the intensive
care unit. Without this surgical procedure, Ms. C.F.s total charges and length of stay fall within
normal limits (Society of Critical Care Medicine, 2014). Medicare is the method of payment in
this case. They covered $68, 901.80 of the total charges; the remainder will be billed to the
patients family.
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Ms. C.F. was admitted to the intensive care unit following an episode of cardiac and
respiratory arrest that resulted in cerebral damage. Patients who experience a brain injury
following cardiac arrest have a very poor prognosis. Only eighteen percent of patients survive to
discharge after an in-hospital cardiac arrest, and of that eighteen percent, only three to seven
percent return to their previous level of functioning (Geocadin, Koenig, Jia, Stevens, & Perberdy,
2011). Ms. C.F.s outcome was not a favorable one, but it was not unforeseen. Her ultimate
outcome was not worth the final charge of $70,411. However, this was not a result of a
breakdown in the Critical Care Delivery System, but in the care provided prior to her admission
to the intensive care.
Summary
The demand for critical care is rising with increasing life expectancy and advancements
in medical technology. Highly functioning interprofesional teams are needed in critical care
delivery in order to improve the quality and efficiency of patient care. The issue of open
visitation hours in the intensive care setting should be further explored due to studies suggesting
better patient outcomes. Due to the rising number and acuity of critical care patients, it is more
important than ever before for critical care delivery systems to stay abreast to the current quality
improvement methods in order to provide safe and effective patient care.
Critical care is the most costly of the care delivery systems due to the rigorous care that is
required for patients in an intensive care setting. The lack of funding from both public and
private sources for intensive care services cost hospitals a great deal of money and inflates the
cost of healthcare as a whole. In order to meet the growing demand for critical care services and
avoid inflation of medical services even more, there must be an increase of funding supplied to
the Critical Care Delivery System in order to properly reimburse costs.

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