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Patient Outcomes Can Be Associated With Organizational Changes: A Quality Improvement Case Study

Timmers, Tim K. MD, PhD; Hulstaert, Puck F. MD; Leenen, Luke P. H. MD, PhD

doi: 10.1097/CNQ.0000000000000011
Original Articles

Aims/Background: We report the results of a university surgical intensive care (SICU), which are influenced by a reorganization of the department because of a downsizing of beds with the corresponding reduction of personnel resulting in a decrease in nurse-to-bed ratio. Moreover, we report the subsequent interventions and adjustments resulting in favorable results.

Design: We performed a prospective observational cohort study of all consecutive surgical patients entering the SICU of our hospital, over the period 2000-2004.

Methods: In order to meet the budget cuts, a reduction of number of SICU beds with a corresponding reduction of nursing staff was implemented. In the subsequent period culminating on the year 2002, collaboration problems arose between medical and nursing staff: resulting in fierce discussions on the floor. Supported through external mediators, structures/work ethics/communication/collaborative behavior, and organization of the SICU were reviewed and restructured.

Results: A total of 1477 patients were admitted to the SICU. The characteristics, Acute Physiology and Chronic Health Evaluation II score and therapeutic intervention scoring system points, were not different throughout the years. The intensive care unit-length of stay (ICU-LOS) in the admission year 2002 was significantly longer (P = .001) and the crude ICU mortality was higher (P = .02) compared with the 2 admission years before. The adjusted mortality (ICU standardized mortality ratio) was also worse in 2002, however, statistically not different. After the intervention (2003 and 2004), a better result (crude ICU mortality, length of ICU stay, and ICU standardized mortality ratio) was achieved.

Conclusion: Intensive care reorganization, in which higher workload is seen in medical and nursing staff, could have a negative effect on ICU outcome and length of ICU stay.

Relevance to clinical practice: Interventions in ICU structures, communication, work ethics, and organization have a positive impact in conflict management.

Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.

Correspondence: Tim K. Timmers, MD, PhD, Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands (

Each author certifies that he or she has participated sufficiently in the intellectual content, the analysis of data, if applicable, and the writing of the work to take public responsibility for it. Each has reviewed the final version of the work, believes that it represents valid work, and approves it for publication. The authors herewith state that they provided an equal contribution to this study and act in concordance to the “Uniform Requirements.”

Timmers carried out the complete acquisition of data, carried out the full analysis and interpretation of data, and made the draft of the manuscript. Hulstaert carried out a substantial draft of the manuscript, had supervision of the study design, and had done critical revisions to the manuscript for important intellectual content. Leenen participated in the concept and design of the study, helped in the acquisition of data, and performed the analysis and interpretation of data.

The authors received no source of funding for their study.

The authors declared that they have no competing interests.

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins