For your Competency Discussion, identify and review an evidence-based practice or decision in a healthcare facility with which you are familiar. One example of an evidence-based practice would be the management guidelines for the COVID-19 pandemic in a hospital setting which recommends the use of high-filtration masks including N95, goggles, and gowns by healthcare professionals when having direct contact (within 3 – 6 feet) with infected patients. Reflect on your findings regarding the evidence-based data and how the data influenced the decision or practice you identified. Then, think about the advantages and disadvantages to finding the data to support the decision or practice. What are the barriers to finding and using data?
To begin this Competency and meet your required engagement, post in the Discussion area a brief description of the evidence-based practice or decision you identified. Next, explain your findings regarding the evidence-based data and how the data influenced the decision or practice you identified. Then, describe the advantages and disadvantages of finding the data to support the decision or practice including any barriers to finding and using the data. Finally, explain what the advantages, disadvantages, and barriers are to using data in decision making for healthcare leaders. Be sure to cite the appropriate sources in your response.
Overview
In this Assessment, you will evaluate clinical and administrative data to support evidence-based decisions that affect healthcare organizations and patient care.
To complete this Assessment:
This Assessment requires submission of one (1) narrated slide presentation. Save this file as OM009_firstinitial_lastname (for example, OM009_J_Smith).
You may submit a draft of your assignment to the
Turnitin Draft Check
area to check for authenticity. When you are ready to upload your completed Assessment, use the Assessment tab on the top navigation menu.
Instructions
Before submitting your Assessment, carefully review the rubric. This is the same rubric the assessor will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively.
Rubric
Access the following to complete this Assessment:
Read the case study and prepare a narrated presentation that will guide the CEO and board of directors to follow the recommendation presented to expand the hospital’s ICU unit. As you complete the Assessment, be sure that the presentation:
Your narrated presentation should contain references to academic resources and include the following:
Part One: Introduction
Explain the importance of evidence-based decision making in healthcare. Your slide must include (1 slide):A definition of evidence-based decision making.An explanation of the relevance of evidence-based decision making in the healthcare industry.
Part Two: Recommendation and Rationale
The slides should include:An overview of three options for the ICU that you analyzed.In your narration, be sure to provide a thorough analysis of the three options and refer to academic resources to support your options.A description of how each option will address the issues in the ICU.The presenter’s narration should provide a detailed explanation of how each option will address the issues in the ICU.A graphic comparison between the current state of the ICU versus the remote monitoring ICU implementation in 5 years.A final recommendation for one of the options and an explanation of why it will maximize the benefits to the hospital, patients, and community.The slide narration should include:A detailed rationale justifying your recommendation.The presenter notes should include citations for the sources of your graphics.An explanation of the impact of your recommendation on staffing, productivity, competitiveness, and finances, using appropriate qualitative and quantitative data to support your explanation.The presenter’s narration should include an explanation regarding how the data supports your explanation.
Part Three: Evidence Evaluation
Knowing that United General’s leadership team focuses on evidence-based decision making, address the following, in 3–4 slides:Summarize the evidence used in developing the opportunity statement and recommendation.Describe why each piece of evidence is relevant to patients, the community, and the hospital.Summarize the analysis used to create the recommendation.Evaluate the validity and reliability of the data. OM009: Data-Driven Decision Making: Evaluate clinical and administrative data to support evidence-based decisions
that affect healthcare organizations and patient care.
Assessment Rubric
Rubric Criteria
Needs Improvement
Meets Expectations
Presentation does not define
inaccurately or incompletely defines
evidence-based decision making.
Presentation accurately and
thoroughly defines evidencebased decision making.
Definition is not supported by
academic/professional resources or
the resources are not relevant.
Definition is supported by
relevant
academic/professional
resources.
Exceeds Expectations
Part 1: Introduction
Learning
Objective 1.1:
Define evidencebased decision
making.
Response does not include
references to academic/professional
resources, or the resources are not
relevant.
Learning
Objective 1.2
Explain the
relevance of
evidence-based
decision making in
the healthcare
industry.
© 2021 Walden University
Presentation does not explain,
inaccurately or incompletely explains
the relevance of evidence-based
decision making in the healthcare
industry.
Presentation accurately and
thoroughly explains the
relevance of evidence-based
decision making in the
healthcare industry.
Explanation is not supported by
academic/professional resources or
the resources are not relevant.
Explanation is supported by
relevant
academic/professional
resources.
Presentation
demonstrates the same
level of achievement as
“Meets,” plus the
following:
Presentation clearly
defines evidence-based
decision making using a
specific example of
evidence-based decision
making from an authentic
healthcare setting.
Presentation
demonstrates the same
level of achievement as
“Meets,” plus the
following:
Presentation provides one
example that illustrates
the relevance of evidencebased decision making in
an authentic healthcare
setting.
1
Rubric Criteria
Needs Improvement
Part 2: Recommendation and Rationale
Learning
Presentation does not provide or
Objective 2.1:
provides an unclear or inaccurate
analysis of the issues in an ICU.
Analyze options to
resolve issues in an
ICU.
Meets Expectations
Exceeds Expectations
Presentation clearly defines
the issues in an ICU and
offers three options to resolve
them.
Response demonstrates
the same level of
achievement as “Meets,”
plus the following:
Presentation provides one
logical option for no additional
beds and two logical options
for additional beds.
Presentation explains
which evidence was the
most compelling in
defining the problem and
analyzing the issues of the
ICU.
Response demonstrates
the same level of
achievement as “Meets,”
plus the following:
.
Learning
Objective 2.2:
Presentation does not recommend
or recommends an illogical option for
the lack of additional beds and fewer
Recommend
than two logical options for
potential options to additional beds or the options for
resolve issues in an additional beds are illogical.
ICU.
Presenter includes vague support
from the facts given in the case
study and/or illogical evidence from
academic/professional resources.
Learning
Graphic comparison between the
Objective 2.3
current state of the ICU versus the
remote monitoring ICU
Compare data over implementation in 5 years is missing,
time to support
inaccurate, or unclear.
recommendations.
Presenter does not include detailed
empirical support from the facts
© 2021 Walden University
Presenter includes detailed
empirical support from the
facts given in the case study
and evidence from relevant
academic/professional
resources.
Graphic comparison between
the current state of the ICU
versus the remote monitoring
ICU implementation in 5
years is accurate and clear.
Presenter includes detailed
empirical support from the
Presentation provides a
clear explanation of the
benefits and challenges
for each of the three
options.
Response demonstrates
the same level of
achievement as “Meets,”
plus the following:
Graphic comparison
addresses the current
state of the ICU vs the
2
given in the case study and
evidence from relevant
academic/professional resources.
Learning
Objective 2.4
Explain the impact
of
recommendations
on staffing,
productivity,
competitiveness,
and finances.
Presentation does not provide or
provides an illogical or inaccurate
explanation of the impact of the
recommendation on staffing,
productivity, competitiveness, or
finances.
Explanation excludes the
appropriate qualitative or
quantitative data used in the
analysis, or the qualitative and
quantitative data is included
inaccurately or inappropriately in the
analysis.
The presenter does not include
detailed empirical support from the
facts given in the case study.
Rubric Criteria
facts given in the case study
and evidence from relevant
academic/professional
resources.
Presentation logically
explains the impact of the
recommendation on staffing,
productivity, competitiveness,
and finances.
Explanation includes the
appropriate qualitative and
quantitative data used in the
analysis.
The presenter includes
detailed empirical support
from the facts given in the
case study.
Needs Improvement
Meets Expectations
Presentation does not include or
includes a verbose, unclear or
inaccurate summary of the evidence
used in developing an opportunity
statement and recommendation.
Presentation provides a
summary that is succinct in
explaining the evidence used
to develop an opportunity
statement and
recommendation.
remote monitoring ICU
implementation over 10
years.
Response demonstrates
the same level of
achievement as “Meets,”
plus the following:
Explanation of the impact
of the recommendation on
staffing, productivity,
competitiveness, and
finances is supported by
least two or more
academic resources.
Exceeds Expectations
Part 3: Evidence Evaluation
Learning
Objective 3.1:
Summarize
evidence used in
developing an
opportunity
© 2021 Walden University
Presentation
demonstrates the same
level of achievement as
“Meets,” plus the
following:
3
statement and
recommendation.
Learning
Objective 3.2
Describe why
evidence is
relevant to patients,
the community, and
the hospital.
Presentation does not describe,
vaguely or inaccurately describes
why each piece of evidence is
relevant to patients, the community,
and the hospital.
Learning
Objective 3.3:
Presentation does not provide or
provides an incomplete or inaccurate
summary of the analysis used to
create the recommendation.
Summarize the
analysis used to
create the
recommendations.
Learning
Objective 3.4
© 2021 Walden University
Presentation clearly and
accurately describes why
each piece of evidence is
relevant to patients, the
community, and the hospital.
Or presentation describes why some
but not all pieces of evidence is
relevant to patients, the community.
or the hospital but not all three.
Presentation provides a
thorough and valid summary
of the analysis used to create
the recommendation.
Summary cites a peerreviewed study that support
the analysis used to create
the recommendation.
Presentation does not provide or
provides an unclear evaluation of the
validity and reliability of each piece
of data provided in the scenario.
Presentation provides a clear
evaluation of the validity and
reliability of each piece of
data provided in the scenario.
Summary describes two or
more pieces of data used
in the recommendation
and explains why they
were used.
Presentation
demonstrates the same
level of achievement as
“Meets,” plus the
following:
Presentation clearly and
accurately describes how
each piece of the
evidence is relevant or
impactful to the healthcare
continuum beyond the
immediate community.
Presentation
demonstrates the same
level of achievement as
“Meets,” plus the
following:
Summary cites three peerreviewed studies that
support the analysis used
to create the
recommendation.
Response demonstrates
the same level of
achievement as “Meets,”
plus the following:
4
Evaluate the
validity and
reliability of data.
© 2021 Walden University
Presentation includes data
that were not considered
valid and reliable and
explains why they were
not used in the
recommendations.
5
United General Hospital ICU Expansion Case Study
Overview
United General Hospital is a 15-year-old, 220-bed hospital built to serve a suburban community of 90,000 residents, 60
miles outside Des Moines, Iowa. Of the beds, 10 are in the intensive care unit (ICU). Over the last 15 years, the
community has grown to over 190,000 residents, who are supported by United General and four urgent care facilities.
With the urgent care facilities able to address many of the population’s non-emergency issues, there is an increase in the
ratio between the use of the hospital’s non-ICU facilities and its ICU facilities. In a typical week, the ICU operates at 120%
capacity and 40% of patients experience a 6- to 8-hour delay transferring to the ICU. The patients remain either in the
emergency department, creating an overcrowded emergency department, or in post-op, causing overcrowding and delays
in scheduled surgeries.
The hospital has just received $15 million in funding and is considering expanding the ICU; however, the chief executive
officer (CEO) is not convinced that expanding the ICU department is the right solution for the hospital. The analysis is to
include options that combine expanding the ICU department with using remote ICU monitoring.
The ICU senior staff brought you, Raul Hemply, in as a consultant to build a business case to support the decision to
expand the ICU and use remote ICU monitoring. You will work with the ICU’s senior staff to build a business case and
present it to the CEO and board of directors for final consideration. There will be great emphasis placed on data and
analyses that support your recommendation. Because of this, you need to use data derived from informed or objective
sources, or evidence-based data, to build the recommendation. The CEO will want to know the sources, validity, and
reliability of the evidence presented.
As you create your presentation, there are several options to consider:
1. Subscribe to remote ICU monitoring services with a per usage model so that you only pay for services as they are
rendered.
2. Expand the ICU with a combination of ICU beds and regular beds managed by a combination of bedside and
remote ICU monitoring.
3. Expand the ICU with ICU rooms managed by bedside teams.
4. Expand the ICU and subscribe to remote ICU monitoring for rooms that will serve patients with more serious
conditions.
© 2020 Walden University
1
Conversation Excerpts
Conversation With George Mallory, the Senior Staff Representative
George: Hello, Raul. It is good to meet you. We are looking forward to working with you on this business case to expand
the ICU. We have already completed some research on the right size of the ICU, and we will share that with you over the
course of your investigation.
Raul: Hi George, I appreciate you taking the time for this interview. This will help me in my research of how much to
expand the ICU. I am also considering the use of remote ICU monitoring service as a complement to expanding the ICU.
George: Remote ICU monitoring services is a topic that will cause a lot of consternation here at United General. We have
a number of staff members that fear that a remote service will put them out of a job, so I would touch lightly on that
subject.
Raul: Has your group done any research on remote ICU monitoring services in the area?
George: We started to but realized that it was so controversial that it was not really an option. If you do look into a remote
service, please make sure to take the staff into account in the analysis.
Raul: What caused the controversy with the idea of remote ICU monitoring?
George: Physicians were reluctant to cede authority to a remote operation, and nurses were concerned about a loss of
autonomy. During a staff meeting, a couple of nurses voiced concerns because their colleagues complained of a poorly
executed implementation.
Raul: Thank you George. I will. Can you tell me who on your staff has the research on the remote ICU monitoring
services?
George: That would be Frank. Frank looked at the services from the standpoint of patient and staff benefits and cost
savings, as well as how the services help the patient. We suggested that he speak to staff in hospitals that have
implemented these services to get their reaction to the change but he never followed through because the staff here was
so set against it. It will be a hard sell to the staff.
© 2020 Walden University
2
Raul: Thank you for the heads up. Was there any other research completed about expanding the ICU that I may be able
to use?
George: I cannot think of anything else. As a part of your study, you may want to check with other hospitals that use
these services.
Raul: Thank you, George. I think I have enough to get started. I will check back with you if I need any help.
© 2020 Walden University
3
Conversation With Frank Bellamy, a Senior ICU Staff Member
Raul: Hi, Frank. My name is Raul, and I would like to talk to you about your research on remote ICU monitoring. I am
working on a business case to expand the ICU and to couple it with the use of remote ICU monitoring services.
Frank: Sure, I would be happy to talk with you about the research I have completed. Let me start with three general
benefits of these remote ICU monitoring services. Telemedicine is able to link a single physician to multiple clients using
remote computer technology, leveraging the specialist’s cognitive skills over multiple patients. However, it also mandates
significant process changes in how we provide ICU services. In short, the remote ICU represents a “re-engineering” of
how we provide ICU care, expanding the reach, scope, and availability of intensivists’ expertise. The re-engineering
occurs through a number of ways. First, the telemedicine connection is continuously available in a proactive fashion that
provides 24-7 coverage. Secondly, the system utilizes computerized clinical intelligence algorithms with direct electronic
links to physiologic, laboratory, and pharmacy data, as well as patient diagnoses to focus attention on potential adverse
outcomes or trends in individual patients and to notify caregivers before trends manifest as adverse outcomes. Third, the
traditional physician, nurse, and patient relationship is substantially augmented when there is an ICU physician
immediately available to address issues in patient care, particularly at night when physicians are less likely to be present
at the bedside.
Raul: During your research, did you speak with any staff members from hospitals currently using remote ICU services?
Frank: Yes, I spoke with Mark Panther from Practitioner Hospital in Indiana about their use of remote ICU monitoring. I
can tell you what he said, or you can give him a call for firsthand information.
Raul: Thank you Frank. Please do not be offended. I think I will give him a call directly. The information will be more valid
coming directly from the source.
Frank: I understand the need for a firsthand account. Here is his contact information.
© 2020 Walden University
4
Conversation With Peter Bella, United General Hospital’s Chief Financial Officer
Raul: Hi, Peter. My name is Raul, and I am working on a business case to address the potential expansion of the ICU
department. I understand that you have completed some research that may help me with the analysis for the business
case. I am investigating the addition of ICU beds and the use of remote ICU monitoring services. What has your research
shown in these areas?
Peter: Hi Raul, I am glad to help in your research. As far as remote monitoring costs are concerned, it costs $25,000 to
$30,000 per ICU bed, per year, to equip each room. In my research, I have seen a 30% reduction in the ICU length of
stay, or LOS, numbers. Overall, the savings for the hospital is about $4,000 per patient.
Raul: What have you uncovered in regards to staff and patient benefits?
Peter: One benefit we expect is for physicians who are tired due to long hours or stress. They are less prone to making
avoidable mistakes with the second set of eyes provided by the addition of a remote ICU service’s clinical surveillance
and support.
Raul: What about benefits that you might expect to see in in regards to patient satisfaction?
Peter: We expect patient satisfaction to increase because of their added confidence that both bedside staff and remote
ICU monitoring service will adequately cover them.
Raul: Thank you for the information, Peter. How do you see this applying to an expansion of the ICU department?
Peter: If we expand the ICU department, one thing that you may want to consider is to expand the department and start
with regular beds tied to remote monitoring. We pay $4,000 a day for an ICU bed and $1,700 a day for a regular bed. If
we add the $500 per day cost of remote monitoring to the cost of supporting a regular bed, we will be able to provide ICU
services to a larger number of patients without incurring the full cost of an ICU bed. By starting patients in a non-ICU bed
and only transferring patients, if necessary, we can provide similar benefits at a fraction of the cost.
© 2020 Walden University
5
Conversation With Mark Panther, Senior ICU Staff Member at Practitioner Hospital
Raul: Hi, Mark. My name is Raul, and I am researching remote ICU monitoring services for possible use at United
General Hospital. I spoke with Frank Bellamy, and he told me that you have some good information on remote ICU
monitoring since your hospital has implemented these services. What can you tell me?
Mark: Hi, Raul. I am glad to help. For the most part, the idea of the services frightened many of the staff because they felt
that they would lose their positions if we subscribed to a remote ICU monitoring service. The nurses and physicians fought
the idea for a while, and we even found some sabotaging it when it was first implemented here. However, once we got
through the first 6 months, people started accepting it, and the service is now running more smoothly.
Raul: What did you find to be the benefits of remote monitoring?
Mark: One benefit is collaborations. An example was between a new nurse and an experienced nurse in the remote
center. The new nurse, just off orientation, prepared to transport a patient to radiology for a computerized tomography
(CT) scan. The patient had two chest tubes, and the new nurse felt uncertain about how to safely disconnect the chest
tubes from suction and prepare the patient for transport. The nurse brought the experienced remote monitoring nurse in
by camera to assist. The remote monitoring nurse coached the ICU nurse through the steps to prepare the chest tubes
and the patient for transport. The bedside nurse felt relieved, confident, and supported in caring safely for the patient.
Raul: What type of changes have you seen within the local operations at your hospital?
Mark: Interestingly enough, we have seen improvements to our pre-existing in-house intensivist care model with the
addition of the remote ICU monitoring. The reasons for this are that it provides proactive and hourly remote “virtual
rounds” on the most critically ill patients, and our ICU physicians use its computerized algorithms when triaging patients.
These algorithms are processes that are programmed into the system to guide physicians and nurses during ICU intake.
We also find that it supports our staff decisions, thereby reducing the number of errors in our critical care unit.
Raul: How did you address the cost of implementing the remote monitoring system?
Mark: During our research, we uncovered that remote monitoring was most effective for patients with a Simplified Acute
Physiologic Score over 50. We initially implemented remote monitoring in a small number of rooms to take advantage of
© 2020 Walden University
6
this benefit and found that constant remote and computerized monitoring reduced our mortality rate by 25% for these
patients.
Raul: Thank you for helping me research remote ICU monitoring services. Is there anything else that would be helpful in
my research?
Mark: You may want to talk to our hospital administrator, Becky Walters. She helped with the research and is currently
monitoring the benefits. She may have time to fit you into her schedule. I will give her a call and let her know that you
might be calling.
Raul: Thank you, Mark. May I use you as a reference in my report? Can I give people at United General your name if they
have any questions?
Mark: Sure, Raul. I am glad to help. I know the remote ICU monitoring services have provided both staff and patient
benefits here, and I hope United General adopts them as well.
© 2020 Walden University
7
Conversation With Becky Walters, Administrator at Practitioner Hospital
Raul: Hi, Becky. Mark Panther thought you might have some insights that would help me build a business case to expand
the ICU department at United General with the use of a remote ICU monitoring service.
Becky: Sure, Raul. We count on remote ICU monitoring services to keep track of patients in areas that enhance our own
capabilities. Even though we have a well-staffed and well-trained ICU department, the remote ICU monitoring services
alerted us to an early symptom of sepsis in one of our patients before a nurse would have identified it, and we were able
to remove a central line before it resulted in an infection in the blood system. In another case, an intensivist at the remote
command center detected instability in a patient, alerted the bedside team to the issue, and identified a new treatment
before the bedside staff would have recognized the issue. So far, in the first 2 years of implementation, we have seen a
10 to one ratio of these types of interventions that have benefitted the patient.
Raul: How has the staff reacted to these interventions?
Becky: Initially, the staff resisted the remote ICU monitoring services and the interventions but, after the first 6 months,
the staff started to see the benefits to the patients and welcomed the collaboration with the remote center resources.
Raul: Are there any other benefits that Practitioner is seeing from the remote ICU monitoring services?
Becky: We had a great example of collaboration earlier this year. A nurse called the remote ICU monitoring service at 1
a.m. to describe a patient’s leg wound, which appeared to be worsening. The remote physician connected via cameras in
the patient’s room, visualized the patient’s leg, and realized the urgency of facilitating an immediate intervention. While the
remote nurse assembled and reviewed the patient’s lab results, the bedside nurse prepared the patient for the operating
room (OR), and the remote intensivist collaborated with the surgical team to activate the OR team for the emergent
procedure.
Raul: That is a great example of collaboration that I can use in the study. Are there any productivity benefits you have
noticed?
Becky: We have been able to increase the number of patients under care. Prior to subscribing to the service, an
intensivist was able to oversee about 10 patient beds. With the addition of the service, we have been able to take
advantage of one intensivist and four nurses in the remote command center to oversee the care of 50 to 75 beds. We
© 2020 Walden University
8
have seen a drop in the average length of stay of an ICU patient by 24%, or an average of 5 days. This reduces our costs
by about $5,000 per patient because we can move them to a regular hospital bed sooner.
© 2020 Walden University
9
You found through various discussions that one of the challenges to implementing a remote monitoring system is the
resistance to the system by ICU physicians and nurses. To dig deeper into this resistance, you request an interview with
the head ICU nurse.
Conversation With Francine Mueller, Head ICU Nurse at United General Hospital
Raul: Hi, Francine. I would like to discuss your thoughts on using a remote ICU monitoring service to augment an
expansion of the ICU department.
Francine: Sure, Raul. We are in support of the expansion because we are experiencing a significant increase in patient
wait times for admission into the ICU. It would be to the patients’ benefit to address this problem as soon as possible.
Raul: What are your thoughts on implementing a remote ICU monitoring service to help defray cost by reducing the
number of ICU beds that the hospital would need to add?
Francine: There are positives that we believe would result from using such a system, such as enhanced collaboration
with remote physicians and nurses and constant monitoring. However, that same collaboration raises our concern over a
loss of autonomy and heightened scrutiny. Without a remote system, we consult with local physicians about care and,
sometimes, have in-depth discussions about the advice for care. We would not look forward to adding another source of
contradictory advice. That advice would be coming from a source with which we are unfamiliar.
Raul: Francine, it sounds like you have reasonable concerns about a remote ICU monitoring service. How would you
consider addressing these concerns?
Francine: I would want to have the nursing leads very comfortable with the people providing the remote ICU monitoring
services. It would be critical for us to we understand their background and for them to understand and respect our
knowledge. Moreover, because I would worry about a potential service or equipment malfunction, I would want all staff
members fully trained on the system prior to implementation.
Raul: That sounds like a good suggestion and something that I need to include in any implementation plans. What would
you say if I told you that Mark Panthers from Practitioner Hospital stated that, once the hospital staff accepted the remote
monitoring system, they measured a significant increase in positive patient care? Would you believe that 96% of the
patients and 80% of staff stated that patient care quality increased because of their remote ICU monitoring system?
© 2020 Walden University
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Francine: Thank you, Raul, for listening to our concerns, and I am looking forward to reading your business case. I am
going to be especially interested in the implementation plans.
© 2020 Walden University
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Appendix A
United General Hospital and ICU Key Facts
Year
Hospital
Occupancy
Rate
Hospital
Total
Margin
ICU Beds
ICU
Capacity
Rate
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
60%
61%
70%
73%
74%
76%
76%
77%
79%
85%
95%
5%
4
3
2
2
1.7
1.6
1.6
2
1.2
1
5
5
5
8
8
8
9
9
10
10
10
75%
85%
95%
100%
115%
116%
117%
118%
129%
120%
120%
© 2020 Walden University
ICU
Average
Length of
Stay
(ALOS)
90
90
81
80
73
67
60
53
47
45
13.5
Patient
Wait
Times for
ICU Bed
(Hours)
.15
.5
1
3
3
4
5
6
6
7
7
12