The Lancet, Volume 363, Issue 9417, Pages 1314 - 1320, 17 April 2004

Dr Derek C Angus MD a , Nick Black MD b


Institutional and health-care system approaches complement bedside strategies to improve care of the critically ill. Focusing on the USA and the UK, we discuss seven approaches: education (especially of non-clinical managers, policy-makers, and the public), organisational guidelines, performance reporting, financial and sociobehavioural incentives to health-care professionals and institutions, regulation, legal requirements, and health-care system reorganisation. No single action is likely to have sustained effect and we recommend a combination of approaches. Several recent initiatives that hold promise tie performance reporting to financial incentives. Though performance reporting has been hampered by concerns over cost and accuracy, it remains an essential component and we recommend continued effort in this area. We also recommend more public education and use of organisational guidelines, such as admission criteria and staffing levels in intensive care units. Even if these endeavours are successful, with rising demand for services and continuing pressure to control costs, optimum care of the critically ill will not be realised without a fundamental reorganisation of services. In both the USA and UK, we recommend exploration of regionalised care, akin to US state trauma systems, and greater use of physician-extenders, such as nurse practitioners, to provide enhanced access to specialist care for critical illness.
This article is the last in a series of five focusing on improving care and safety of the critically ill. Previous articles introduced the concepts of critical illness, quality of care, and patients' safety1 and reviewed approaches to identify patients' safety concerns,2 measure quality of care,3 and improve care through modification of caregiver behaviour.4 Three themes emerged: care of the critically ill is fraught with potential hazards for patients; errors of omission (ie, failure to provide contemporary, evidence-based care) might be a greater threat to patients' safety than errors of commission; and improvement of care needs the appropriate cultural milieu, a system-wide commitment, active engagement of all relevant stakeholders, and constant measurement and feedback.