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Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study

Bagshaw, Sean M. MD, MSc1,2,3; Opgenorth, Dawn RN1,3; Potestio, Melissa PhD4; Hastings, Stephanie E. PhD5; Hepp, Shelanne L. Med5; Gilfoyle, Elaine MD, MMEd6; McKinlay, David MA2; Boucher, Paul MD7; Meier, Michael MD1,2,3; Parsons-Leigh, Jeanna PhD3; Gibney, R. T. Noel MD1,2; Zygun, David A. MD, MSc1,2,3; Stelfox, Henry T. MD, PhD3,4,7

doi: 10.1097/CCM.0000000000002093
Online Clinical Investigations

Objectives: Discrepancy in the supply-demand relationship for critical care services precipitates a strain on ICU capacity. Strain can lead to suboptimal quality of care and burnout among providers and contribute to inefficient health resource utilization. We engaged interprofessional healthcare providers to explore their perceptions of the sources, impact, and strategies to manage capacity strain.

Design: Qualitative study using a conventional thematic analysis.

Setting: Nine ICUs across Alberta, Canada.

Subjects: Nineteen focus groups (n = 122 participants).

Interventions: None.

Measurements and Main Results: Participants’ perspectives on strain on ICU capacity and its perceived impact on providers, families, and patient care were explored. Participants defined “capacity strain” as a discrepancy between the availability of ICU beds, providers, and ICU resources (supply) and the need to admit and provide care for critically ill patients (demand). Four interrelated themes of contributors to strain were characterized (each with subthemes): patient/family related, provider related, resource related, and health system related. Patient/family-related subthemes were “increasing patient complexity/acuity,” along with patient-provider communication issues (“paucity of advance care planning and goals-of-care designation,” “mismatches between patient/family and provider expectations,” and “timeliness of end-of-life care planning”). Provider-related factor subthemes were nursing workforce related (“nurse attrition,” “inexperienced workforce,” “limited mentoring opportunities,” and “high patient-to-nurse ratios”) and physician related (“frequent turnover/handover” and “variations in care plan”). Resource-related subthemes were “reduced service capability after hours” and “physical bed shortages.” Health system–related subthemes were “variable ICU utilization,” “preferential “bed” priority for other services,” and “high ward bed occupancy.” Participants perceived that strain had negative implications for patients (“reduced quality and safety of care” and “disrupted opportunities for patient- and family-centered care”), providers (“increased workload,” “moral distress,” and “burnout”), and the health system (“unnecessary, excessive, and inefficient resource utilization”).

Conclusions: Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.

1Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.

2Department of Critical Care Medicine, Edmonton Zone, Alberta Health Services, Edmonton, AB, Canada.

3Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada.

4Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

5Workforce Research and Evaluation, Alberta Health Services, Calgary, AB, Canada.

6Section of Critical Care, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

7Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

This work was performed at the University of Alberta, Edmonton, Alberta, Canada.

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Supported, in part, by a Partnership for Research and Innovation (PRIHS) in the Health System award from Alberta Innovates—Health Solutions (AIHS) (grant number, 201309 AIHS PRIHS).

Dr. Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology. He received funding from Baxter Healthcare Corp (not related to present work). Dr. Opgenorth’s institution received funding from Alberta Innovates—Health Solutions. Dr. Hasting disclosed work for hire. Her institution received funding (Dr. Bagshaw; her work unit was contracted to do focus group analysis). Dr. Hepp received funding from Dr. Bagshaw. Dr. Gilfoyle’s institution received funding from the Heart and Stroke Foundation of Canada (research grant) and Zoll Corporation (in kind donation of equipment for research purposes). Dr. Gibney received funding from Baxter International and disclosed other support (advisory board, Baxter International). Dr. Stelfox is supported by a Population Health Investigator Award from AIHS. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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