Surviving ICU: The value of a qualified, specialist intensive care nurse

Each year, nearly 200,000 people are admitted to an intensive care unit (ICU) in Australia.

An ICU is the place in a hospital where patients go when experiencing life-threatening illness. It’s where machines provide “life support”, such as mechanical ventilators and kidney support (renal replacement therapy).

Life-sustaining drugs are also infused, to keep the heart pumping and to maintain a blood pressure compatible with living. Vigilant observation is needed, with continuous monitoring of the heart and oxygenation, among other things.

Australia has some of the best intensive care outcomes in the world, so good that an Australian and New Zealand specific mortality prediction tool was developed to measure and help monitor ICU care.

For patients admitted to an Australian ICU, 8% die either in ICU or while still in hospital. In the UK, the hospital mortality for patients admitted to ICU is 18.1%, and in the US, the rate ranges from 10-29%.

What’s different about Australian ICUs?

For a developed country, we have a relatively modest number of ICU beds per capita, less than half the OECD average. Thus, there’s pressure on ICU beds.

One component of Australian intensive care that’s distinctly different to many other countries is highly educated ICU nurses, and how they practice.

Australian ICU nurses possess advanced knowledge and skills acquired through postgraduate qualification, and their scope of practice is expansive and holistic.

One ICU nurse looks after one ventilated ICU patient or two non-ventilated ICU patients. This one nurse attends to all patient care needs, including clinical assessment and monitoring of all body functions, providing all hygiene needs, delivering nutrition (usually either by a tube or a drip), attending to wounds and dressings, administering all medication, and managing and titrating all machinery.

For example, an ICU nurse in Australia would take a blood sample and run the test, adjust the ventilator settings according to the result, and ensure the machine-provided breathing targets are met.

They also communicate with, and support, family members of the patients in their care. This is quite a different scope of practice compared to the US, for example, where nurses in ICU routinely get two ICU ventilated patients to care for, but there are respiratory therapists who manage the breathing machines.

The postgraduate qualification factor

However, not all nurses working in Australian ICUs possess a postgraduate ICU nursing qualification.

We recently conducted a study to examine whether the proportion of ICU nursing staff with a postgraduate specialty ICU nursing qualification in an ICU made a difference to patient outcomes.

Using the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database, and the pandemic-inspired Critical Health Resources Information System (CHRIS), we were able to link individual patient data with daily ICU nursing data in more than 16,000 patients admitted to one of 20 Victorian public and private ICUs between 1 December, 2021, and 30 September, 2022.

Patients admitted to an ICU that had 50-75% qualified ICU nurses during their admission were 21% more likely to die than patients admitted to an ICU with more than 75% qualified ICU nurses. The impact on mortality was even higher when only patients who needed a breathing machine or advanced support were examined – a 35% higher chance of dying.

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The ANZICS Adult Patient Database is a high-quality registry, and these differences were observed while controlling for factors we know increase mortality, such as, age, frailty, emergency admission and severity of illness.

There was no difference in mortality for ICU patients that did not receive advanced support or need a breathing machine.

There was also no statistical difference for patients cared for in ICUs with less than 50% qualified ICU nursing staff. However, the magnitude of mortality difference was similar to the 50-75%; it just did not reach statistical significance, most likely due to the small numbers of patients in this category.

Further, it wasn’t just mortality that was different. Patients cared for in ICUs with more than 75% qualified ICU nurses were less likely to develop a pressure sore, experience delirium, and they had a shorter-observed ICU length of stay than what was predicted.

Clearly, a qualified ICU nurse providing care to an ICU patient makes a difference. The advanced knowledge and skills achieve better outcomes, as qualified ICU nurses are proactive in the care of their patients, actively and effectively weaning life-sustaining drugs and machinery, confidently advocating for changes in care as part of the ICU team, and critically thinking and using clinical reasoning.

They also supervise and provide support to novices on a daily basis, thereby influencing the quality of care other patients are receiving.

Critical shortage of qualified ICU nurses

Sadly, the COVID-19 pandemic has amplified a critical shortage of qualified ICU nurses. Burnout is at an all-time high, and it’s estimated that 27% of ICU nurses intend to leave ICU. High rotations onto night duty and the need to support a growing number of inexperienced staff contributes to stress and burnout.

Further, on the odd occasion when there might be a chance for a breather because there’s an empty ICU bed, an ICU nurse will be sent to another ward area to help out. This equates to sending a specialist criminal barrister to the tax law department, and fails to recognise the expertise of the nurse, making them feel undervalued and just a number in the system.

Government policy has sought to address the ICU nursing shortage by supporting more general nurses to become specialist ICU nurses. However, the workforce gap and critical shortage relates to experienced, qualified ICU nurses.

There’s no shortage in attracting nurses to postgraduate specialty ICU nursing education. But there’s an urgent need to address retention of experienced, qualified ICU nurses if the best patient outcomes we currently see in Australian ICUs are to continue.

It’s time to think of highly-educated and skilled ICU nurses as an intervention – a drug with this sort of outcome would command investment. It’s time we invested in experienced nurses so we can improve their retention and maintain our high standards of ICU patient care.