Improving intensive care: Observations based on organizational case studies in nine intensive care units

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Prospective multicenter study. On-site organizational analysis; prospective inception cohort.


Nine ICUs (one medical, two surgical, six medical-surgical) at five teaching and four nonteaching hospitals.


A sample of 3,672 ICU admissions; 316 nurses and 202 physicians.

Materials and Methods:

Interviews and direct observations by a team of clinical and organizational researchers. Demographic, physiologic, and outcome data for an average of 408 admissions per ICU; and questionnaires on ICU structure and organization. The ratio of actual/predicted hospital death rate was used to measure ICU effectiveness; the ratio of actual/predicted length of ICU stay was used to assess efficiency.

Measurements and Main Results:

ICUs with superior risk-adjusted survival could not be distinguished by structural and organizational questionnaires or by global judgment following on-site analysis. Superior organizational practices among these ICUs were related to a patient-centered culture, strong medical and nursing leadership, effective communication and coordination, and open, collaborative approaches to solving problems and managing conflict.


The best and worst organizational practices found in this study can be used by ICU leaders as a checklist for improving ICU management. (Crit Care Med 1993; 21:1443–1451)

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