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RESEARCH ARTICLE
Efforts to reduce the length of stay in a low-
intensity ICU: Changes in the ICU brought
about by collaboration between Certified
Nurse Specialists as head nurses and
intensivists
Tomohide FukudaID 1*, Hironori Sakurai2☯, Masanori Kashiwagi3☯
1 Faculty of Nursing, Kyoritsu Women’s University, Tokyo, Japan, 2 Department of Anesthesiology, National
Hospital Organization Tokyo Medical Center, Tokyo, Japan, 3 Department of Anesthesiology, Tokyo
Saiseikai Central Hospital, Tokyo, Japan
☯ These authors contributed equally to this work.
Abstract
Certified Nurse Specialists (CNS) are advanced practice nurses that often play a role in
management. This study aims to investigate whether cooperation between CNSs in the
position of Intensive Care Unit (ICU) head nurse and intensivists change the length of stay
for ICU patients. A single centered retrospective cohort study design was followed. A multi-
variable regression analysis was performed to determine whether there is a difference in
patients’ length of ICU stay for two years before and after CNS as ICU head nurse and an
intensivist started collaborating. The patients’ diagnosis, age, gender, scheduled/emer-
gency admission, surgical history, length of ICU stay, usage of ventilator, and details of ICU
treatment were collected from the institution’s electronic medical records. During the study
period (April 2015 to March 2019), 3,135 patients were admitted to ICU, with 1,471 in the
before collaboration group and 1,664 in the after-collaboration group. Collaboration between
the CNS as head nurse and intensivists was significantly associated with shorter length of
ICU stay (coefficient -0.03 [95% CI, -0.05–0.01], p < 0.001, t-statistic -3.29). Our main find-
ing illustrates that in low-intensity ICUs, collaboration between CNSs as head nurses and
intensivists may reduce patients’ length of ICU stay.
Introduction
A low-intensity ICU employs a system in which only doctors in each medical department treat
patients in the Intensive Care Unit (ICU) and intensivists get involved only at the request of
the attending physician or surgeon. [1] In such ICUs, collaboration between the attending
physician, intensivists, the ICU nurse, and other actors is vital. Specifically, the Advanced Prac-
tice Nurse (APN) plays a significant role in intensive care, improving bedside care, consulta-
tion, and ethical coordination. [2–7]
PLOS ONE
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Citation: Fukuda T, Sakurai H, Kashiwagi M (2020)
Efforts to reduce the length of stay in a low-
intensity ICU: Changes in the ICU brought about by
collaboration between Certified Nurse Specialists
as head nurses and intensivists. PLoS ONE 15(6):
e0234879. https://doi.org/10.1371/journal.
pone.0234879
Editor: Robert Ehrman, Wayne State University,
UNITED STATES
Received: February 3, 2020
Accepted: June 3, 2020
Published: June 15, 2020
Copyright: © 2020 Fukuda et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: This work was supported by JSPS
KAKENHI Grant Number JP 19K24268. There was
no additional external funding received for this
study. The funders had no role in study design,
data collection and analysis, decision to publish, or
preparation of the manuscript.
An APN has a master’s or doctoral degree and contributes to the development of bedside
care through evidence-based direct care, multi-professional collaboration, and education. Cer-
tified Nurse Specialist (CNS) is one of the titles recognized as an APN in Japan. A CNS
received education in a graduate school master’s program and performs nursing practice with
the background of knowledge in nursing management, nursing education, and nursing
research, as well as their specialized field. The system is modeled on the same principal as that
of clinical nurse specialists in the United States. [6,8]
Similar to other countries, the CNS in Japan is expected to provide advanced nursing prac-
tice and education and provide care and decision support to patients with complex clinical
problems as well as multi-professional teams experiencing difficult issues. Approximately 20%
of CNSs work as nurse directors, vice nursing directors, and head nurses [9].
In low-intensity ICUs where no intensivists are stationed, it is necessary to combine the
expertise of each profession to treat and care for patients and to improve their condition.
Therefore, CNSs who specialize in critical care not only support collaboration among different
professions and provide advanced care to patients based on their specialized knowledge, but
also participate in organizational management as the head nurse of the ICU.
As their chosen career, experienced CNSs sometimes manage wards as head nurses. The
duties of a head nurse include organizational development by being responsible for interper-
sonal relationships between nurses and patient care, work planning, intrinsic motivation,
workload, unit size, and leadership to improve the job satisfaction of nurses and quality of the
care. [10] Moreover, to support the recovery of as many ICU patients as possible, effective use
of ICU beds—a limited resource in hospitals—is essential. This is one of the important mis-
sions of doctors and nurses in charge of ICUs.
The CNS as head nurse has a background of expertise in managing both the organization
and patient care. In this position as a clinical care specialist, multidisciplinary collaboration
and interdisciplinary collaboration for organizational management are combined. In ICUs,
treatment and care are especially critical. Effective collaboration between physicians and
nurses is needed as the first step in multidisciplinary collaboration to ensure that appropriate
knowledge-based and evidence-based care is provided to improve patient outcomes and the
quality of treatment and care. Outcomes and goals are set in collaboration between the head
nurse, who is responsible for the ward, and the doctor, who is responsible for the treatment,
enabling the entire organization to deliver treatment and care in the same direction.
However, no study has examined patient outcomes associated with intensivists’ and CNSs’
collaborative management of an ICU. The aim of this study is to investigate whether CNSs as
head nurses can work with intensivists to make changes to patients’ length of stay in low-inten-
sity ICUs.
Method
Research design
A single centered retrospective cohort study was conducted at the ICU of a Japanese Hospital
during a 4-year period (April 2015 to March 2019).
Collaboration between CNS and intensivists
The ICU in the target facility has 10 beds and is a general ICU that accepts patients with sud-
den changes in their health status from the hospital’s other wards; mainly postoperative
patients and tertiary emergency patients. As this is a low-intensity ICU, surgeons were concur-
rently in charge of the ICU until March 2017; however, from April 2017, the anesthesiology
department (the department in which intensivists normally practice) became the center of the
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Competing interests: The authors have declared
that no competing interests exist.
ICU’s management and started participating in the treatment of ICU patients while concur-
rently performing surgery.
In an interview with CNS, several intensivists, and surgeons about the changes in manage-
ment, the following points were clarified after CNS as head nurse and intensivists were
included in the management of the ICU.
1. The system of providing medical care in the ICU was changed from a system in which each
department provided medical care by itself to a system in which the attending physician
consulted with the intensivists when necessary (so-called “elective care consultations”). [11]
Prior to the introduction of elective care consultations, the CNS would discuss issues related
to the treatment plan and the patient’s background with the primary physician and make
prior arrangements to facilitate the intervention of the intensivists.
2. The CNS as ICU head nurse and intensivists now play central roles in providing nursing
education through the preparation for changes in ICU management and the preparation
and implementation of various protocols. This involves providing advice and support for
treatment in each department and arranging consultations, coordination, and conferences
concerning long-term patients and cases with ethical problems.
3. In regular morning meetings, the conditions of all the patients in the ICU were outlined/
communicated to the intensivists.
4. Considering ICU bed control, the CNS comprehensively examines the severity of the
patients’ conditions and the necessity of daily life support in the ICU to select patients to
enter or leave the ward, while the intensivists examines the medical necessities to make the
final decision.
5. The CNS as head nurse serves as the link between the primary physician and the intensi-
vists, as well as between the ICU nurse and the anesthesiologist.
As a result of the implementation of these items, the ICU—in which the primary physician
used to decide on the treatment plan—has been transformed into a collaborative ICU, in
which the CNS and the intensivists determine the treatment plan and the nursing policy of the
medical team (Fig 1).
Data collection
This is a secondary study that uses datasets collected during a previous related study. [12] This
means that this study did not involve any intervention; therefore, acquiring informed consent
from patients was judged to be unnecessary. Patients admitted to the ICU of the target hospital
in Japan between April 2015 and March 2019 are included in the participant group. The
patients’ diagnosis, age, gender, scheduled or emergency admission, surgical history, length of
ICU stay, severity, and degree of medical and nursing needs were collected from the hospital’s
electronic medical records. Patients whose data had missing values were excluded.
Research ethics approval was obtained from the internal review board of Kyoritsu Women’s
University (approved ID: KWUIRBA#19011) and the internal review board of the Tokyo Sai-
seikai Central Hospital (Approved ID: 30–88). Consent was not required from participants
due to the de-identified nature of the data and the retrospective study design.
Measurement
The severity of each patient’s condition and the extent of their required medical and nursing
care were determined. The former was assessed using a scale that measures the degree of
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dependence on medical care for patients admitted to the ICU created by the Japanese Ministry
of Health, Labour and Welfare (Supplementary material, S1 and S2 Tables). [12] The higher
the score, the greater the degree of dependence on medical treatment and nursing care (sever-
ity). The scale is divided into items A and B. Item A scores medical dependency out of a maxi-
mum of 15 points. The points are based on the presence or absence of electrocardiogram
monitor, infusion pump, syringe pump, A-line, central venous catheter, respirator attachment,
use of transfusion and/or blood products, Swan-ganz catheter, and special treatment (intra-
aortic balloon pumping; IABP, Continuous hemodiafiltration; CHDF, percutaneous cardio-
pulmonary support; PCPS, intracranial pressure measurement; ICP measurement, ventricular
assist device; VAD, extracorporeal membrane oxygenation; ECMO). Item B scores the degree
of dependence on nursing care out of a maximum of 12 points. These points include turning
over (unable to, can with assistance, can), transfer (cannot, needs assistance or observation,
can), oral care (cannot perform, can perform), food intake (cannot feed self, requires assis-
tance, can feed self), removing clothes (cannot, requires assistance, can), understanding
instructions regarding medical treatment (cannot understand, can understand), and danger-
ous behavior (yes, no). The evaluation criteria for each item apply nationwide and are evalu-
ated daily in patients admitted to the ICU.
ICU nurses were responsible for evaluating patients based on this scale after completing
training on how to do so via e-learning. After completing the training, all the nurses passed a
computer-based examination. [12]
Data analysis
The study period was divided into two periods: before collaboration (April 2015 to March
2017) and after collaboration (April 2017 to March 2019) between CNS as head nurse and
intensivists. The two periods were compared using a Fisher’s exact test for categorical variables
and a Mann-Whitney U test for continuous variables. To determine whether the collaboration
Fig 1. Changes in ICU due to collaboration of CNS as head nurse and intensivists.
https://doi.org/10.1371/journal.pone.0234879.g001
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between the CNS as head nurse and the intensivists was associated with long-term admission
of ICU patients, a multivariable regression analysis was performed. The independent variables
were age, gender, and variables that were significantly different in univariate analysis. The
dependent variable, the length of ICU stay, was translated logarithmically. This is to avoid
affecting the data owing to some long-term ICU admissions. In addition, variables with a Vari-
ance Inflation Factor (VIF) value of 10 or more were excluded. Prior to the analysis, the differ-
ence in the assignment of ICU nurses between the two periods was examined to consider the
possibility of the assignment of ICU nurses affecting the study results. The difference was sig-
nificant/non-significant with a p-value< 0.05. All statistical analyses of the data collected were
performed using the Excel statistical software package (BellCurve for Excel; Social Survey
Research Information Co., Ltd., Tokyo, Japan).
Results
Patient characteristics
Included in the analysis were 3,135 patients admitted to ICU during the study period: 1,471 in
the before group and 1,664 in the after group. The patients’ characteristics are summarized in
Table 1. The age, sex, and number of patients on a ventilator did not differ between the two
groups. The anesthesiology department provided intensive ICU management in the after
group and a system was established to allow patients who are at high risk of postoperative com-
plications to admission the ICU for their preoperative medical examination. As a result, the
number of postoperative ICU patients increased. There was also an increase in the number of
patients with gastrointestinal (p< 0.001) and respiratory (p< 0.001) diseases. However, the
establishment of a new 10-bed ICU in the hospital as a result of ward reorganization led to a
decrease in the number of patients with cardiovascular disease (p< 0.001). As the number of
patients admitted to the hospital after surgery increased, the severity of patients’ medical and
nursing needs evaluated by item A of the scale increased (p< 0.001), while those evaluated by
item B decreased (p< 0.001). These scales were weakly correlated in the analysis with Spear-
man’s rank correlation coefficient (r = .254 p< .001). An increase in the number of elective
surgery patients also led to a decrease in their ICU length of stay (p = 0.001), the number of
ventilator users (p = 0.001). Furthermore, we aimed to determine whether there was a differ-
ence in the number of nurses between the two periods and found that there was no difference
between the two groups.
Effects of collaboration between CNS as head nurse and intensivists on
long-term admissions in ICU patients
The results of our multivariable regression analysis to determine the length of ICU stay are
shown in Table 2. Collaboration between the CNS as head nurse and intensivists was shown to
be significantly associated with shorter ICU stay (coefficient -0.03 [95% CI, -0.05–0.01],
p< 0.001, t-statistic -3.29). Further, there were fewer long-term ICU admissions of males than
of females (coefficient -0.03 [95% CI, -0.05 –-0.01], p = 0.002, t-statistic -3.10). Emergency
admissions (coefficient 0.10 [95% CI, 0.06–.14], p< 0.001, t-statistic 5.03), patients on
mechanical ventilation (coefficient 0.12 [95% CI, 0.10–0.15], p< 0.001, t-statistic 8.39), and
the degree of severity of ICU needs item A score (coefficient 0.03 [95% CI, 0.03–0.04],
p< 0.001, t-statistic 12.9) and item B score (coefficient 0.01 [95% CI, 0.01–0.02], p< 0.001, t-
statistic 4.76) in patients with cardiovascular, gastrointestinal, and respiratory problems were
significantly associated with length of ICU stay.
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Discussion
This study aimed to investigate whether collaboration between a CNS as ICU head nurse and
intensivists changed the length of ICU stay. The period of collaboration between the CNS as
ICU head nurse and intensivists in a single center was shown to be associated with shorter
ICU stays for admitted patients.
Prognosis based on knowledge and experience and multidisciplinary treatment and care
may not only save the lives of ICU patients with severe and complex conditions, but may also
influence their subsequent activities of daily living and quality of life. Intensivists have a high
Table 1. Patient characteristics.
before after p-value
(n = 1,471) (n = 1,664)
Age (median, range) 71 (14–105) 71 (19–106) 0.30
Gender (Male, %) 1029 (70.0) 1165 (70.0) 0.30
Operation (%) 761 (51.7) 1141 (68.6) < 0.001
Emergency admission (%) 710 (48.3) 523 (31.4) < 0.001
Emergency Operation (%) 109 (7.4) 153 (9.2) 0.08
Diagnostic Category (%)
Cardiovascular 717 (48.7) 596 (35.8) < 0.001
Gastrointestinal 349 (23.7) 495 (29.7) < 0.001
Respiratory 120 (8.2) 204 (12.3) < 0.001
Neurological 58 (3.9) 85 (5.1) 0.12
hematologic 48 (3.3) 59 (3.5) 0.69
others 179 (12.2) 225 (13.5) 0.26
Severity, medical and nursing needs degree for ICU A score (median, range) 4 (1–15) 5 (1–15) < 0.001
Severity, medical and nursing needs degree for ICU B score (median, range) 8 (2–19) 7 (1–12) < 0.001
ICU stay (days) 3 (1–60) 2 (1–52) < 0.001
Patients with mechanical Ventilation (including NPPV, %) 569 (38.7) 544 (33.5) 0.001
Mechanical ventilation days (including NPPV, median, range) 3 (1–46) 3 (1–47) 0.003
ICU nurse staffing (median, range) 25(22–27) 25(20–27) 0.378
Data are presented as median. Fisher’s exact test, Mann-Whitney U test.
NPPV: Noninvasive Positive Pressure Ventilation
https://doi.org/10.1371/journal.pone.0234879.t001
Table 2. Association between CNS and intensivists collaboration and other predictor variables and ICU stay by multivariable regression analysis.
factors Regression coefficient (95% CI) p-value t-statistic VIF Collaboration of CNSs and intensivists -0.03 (-0.05 –-0.01) < 0.001 -3.29 1.17
Age 0.00(0.00–000) 0.45 0.00 1.03
Gender (0: male) -0.03 (-0.05 –-0.01) 0.002 -3.10 1.02
Operation (0: absence) -0.03 (-0.07–0.01) 0.09 -1.69 5.01
Emergency admission (0: absence) 0.10 (0.06–0.14) < 0.001 5.03 4.92
Patients on mechanical ventilation 0.12(0.10–0.15) < 0.001 8.39 1.21
Cardiovascular (0: none) -0.03(-0.06– -0.01) < 0.001 -2.69 1.93
Gastrointestinal (0: none) -0.10(-0.12– -0.08) < 0.001 -7.49 1.98
Respiratory (0: none) -0.08(-0.11– -0.05) < 0.001 -5.17 1.50
Severity degree and medical and nursing needs for ICU A score 0.03 (0.03–0.04) < 0.001 12.9 1.50
Severity degree and medical and nursing needs for ICU B score 0.01 (0.01–0.02) < 0.001 4.76 1.09
Adjusted R2 0.33
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level of expertise in managing the condition of critically ill patients, while CNSs in critical care
also performs advanced nursing care, education, and research against the background of their
own clinical experience and specialized medical and nursing knowledge [13–15]. This study
showed that collaboration between CNSs and intensivists may lead to the establishment of
effective treatment styles in a low-intensity ICU.
As a care provider, the CNS as head nurse can clearly explain the nursing perspective to
intensivists, surgeons, physicians and other medical personnel and discuss their positions. By
predicting the patients’ prognoses and physical/mental function based on the comprehensive
judgment of the various personnel members, it is possible to ensure that patients’ treatment and
care moves in the best direction from an early stage. Moreover, because CNSs are also APNs,
the quality of ICU care will be improved by coordinating treatment policies and nursing care
with the physician and intensivists. The CNS as head nurse also sets appropriate unit goals and
outcomes while managing and monitoring the unit to improve the quality of care. [16, 17]
As a head nurse, the CNS is able to set more detailed goals and outcomes in managing the
organization and make better use of human, physical, and financial resources, thereby
attempting to improve care. When the CNS assumes the role of head nurse, they are able to set
more detailed and realistic goals and outcomes by utilizing the perspective of an APN. This
allows human, physical, and financial resources to be utilized more effectively to enhance
patient care.
In a low-intensity ICU, the health care team (consisting of primary doctors, intensivists,
ICU nurses, and other medical personnel) needs to have a solid basis and to employ teamwork,
with the CNS as head nurse and intensivists managing the organization as the decision makers
based on advanced medical and nursing practices. Goals and policies for personnel providing
bedside care are realistic and are therefore likely to gain staff acceptance. Moreover, the CNS,
in their role as a manager, can seek better policies for each patient by discussing patient condi-
tions and ICU management with the physician, nurse, and other medical personnel from a
neutral standpoint, together with intensivists. In addition, by discussing treatment policies
among multiple professions, the ICU staff can learn about the interests and perspectives of
multiple professions, which is expected to have an educational effect.
This study suggests that intensivists—who were not in charge of patients as primary care
physicians—and the CNS as head nurse made a comprehensive change to patients’ conditions
and the burden of nursing care. As a result of fair and unbiased treatment and bed control,
timely patient flow management in the ICU may be related to reducing the length of ICU
patient stay.
A system in which intensivists advise on the treatment of critically ill patients, the CNS
manages the ICU as a head nurse, and the patient is treated and involved in complex problems
by an APN can be a useful model for low-intensity ICUs. It can contribute to solving patients’
problems through elective care consultation, intervention in teams and personnel facing diffi-
cult problems at the appropriate time, advanced care, goal setting, and efficient organizational
management.
Limitations
This study is a retrospective study that utilizes data from one situation; therefore, it may be dif-
ficult to apply this result to other institutions. Moreover, the long-term ICU admission of
patients is complicated by a number of factors and even though the results point toward col-
laboration having a positive effect, it cannot be determined whether the collaboration between
the CNS as head nurse and intensivists directly affected the long-term ICU admission of
patients.
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Therefore, it is necessary for future studies to increase the number of target facilities and
investigate the details of the collaboration between the CNS and intensivists. There may also
be confounding concerning outcomes other than those assumed here. In the future, it will be
possible to pursue an ideal ICU while simultaneously dealing with reality by accumulating
reports on efforts to improve the quality of medical care and their results in low-intensity
ICUs.
Conclusions
In low-intensity ICUs, collaboration between intensivists and the CNS may change the overall
ICU package and reduce the length of ICU stay for patients.
Supporting information
S1 Table. Evaluation sheet for severity, medical care, and nursing necessity for ICU admis-
sion (Original version).
(XLSX)
S2 Table. Evaluation sheet for severity, medical care, and nursing necessity for ICU admis-
sion (English version).
(XLSX)
Acknowledgments
We would like to thank all of the ICU medical and co-medical personnel for their cooperation
in improving the ICU.
Author Contributions
Conceptualization: Tomohide Fukuda.
Data curation: Tomohide Fukuda, Hironori Sakurai, Masanori Kashiwagi.
Formal analysis: Tomohide Fukuda.
Funding acquisition: Tomohide Fukuda.
Investigation: Tomohide Fukuda, Hironori Sakurai, Masanori Kashiwagi.
Methodology: Tomohide Fukuda, Hironori Sakurai, Masanori Kashiwagi.
Project administration: Tomohide Fukuda.
Writing – original draft: Tomohide Fukuda, Hironori Sakurai, Masanori Kashiwagi.
Writing – review & editing: Tomohide Fukuda.
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