L. Telci, M.D., Ph.D.
Head of Multidisciplinary Intensive Care
Unit, International Hospital, Istanbul, Turkey
e-mail: [email protected]
Professor at the Medical Faculty of Istanbul University and Head of the Multidisciplinary Intensive Care Unit at the International Hospital, Istanbul, Professor Telci aims for conformity of Turkey’s ICU departments to international standards and a nurse to patient ratio of 1:1.
Lütfi Telci has been Head of the Intensive Care Unit (ICU) at the International Hospital, Istanbul, and Professor of Anaesthesiology and Intensive Care at the Medical Faculty of Istanbul University since 1987. Istanbul has around 50 private hospitals with ICU departments, providing approximately 500 beds in total. The most common admissions in Istanbul are for sepsis, trauma, polytrauma and cerebro-vascular accidents. Professor Telci coordinates an 8-bed department with a staff of 6 specialists in Anaesthesiology and Intensive Care, 11 nursing staff and a nurse to patient ratio of 1:2. Recent numbers for admissions and mortality are as follows: 2002 179 admissions; mortality rate 5.81% (30/179 patients); 2003 190 admissions; mortality rate 3.5% (26/190 patients); 2004 102 admissions to date.
What are the Main Directives of Your Role?
The main directives of my role are:
• Patient admission;
• Responsibility for treatment;
• Patient discharge;
• Organisation of the department.
Our strategy is to keep a qualified team,fully capable of covering any medical or management issue, available at all times. My role mainly involves directing the unit, keeping up with current international medical standards and dealing with ethical issues. I’m also responsible for the education of my staff members. I feel that knowledge, experience and management skills are all essential in ICU management. Making decisions about selection of medical staff members is one of the hardest decisions I need to make as an ICU Manager. I would describe the relative time demands of my duties as highest for clinical issues, then personnel issues, and thirdly training. I also need to address legal issues from time to time and because there are still no national legal arrangements, these are solved or evaluated with remaining ethical concerns.
How Would a Typical Day Proceed?
In the morning we brief with staff members at 8.30am to cover occurrences the night before and to discuss and plan main treatments for the day. These treatments, for example catheterisations etc., are then carried out by the staff during the day. The afternoon patient consultations are more detailed and carried out in the presence of at least 4 staff members – both day and night shift members – during which time new approaches and literature are also discussed.
Describe Two Extreme Tasks in Your Role
My first aim is to enable all intensive care units in Turkey to reach international standards, both academically and institutionally. My second aim is to achieve a nurse to patient ratio of 1:1 in intensive care units (currently 1:2 in our unit).
What has been the most Satisfying Experience as an ICU Manager?
Running the department with minimal problems and discharge of patients in good or improved health conditions are my most satisfying experiences. I feel our department excels in the speed and accuracy of patient admission, and in making diagnoses and necessary diagnostic interventions seamlessly through shift changes and during holidays. We would like to improve our department by taking responsibility of all emergency cases; we have a well qualified team for this.
What are the Difficult Issues that You Feel ICU Departments Currently Need to Address?
In general these are the legal and ethical issues, for example, making decisions over withdrawal or withholding treatment. It’s also difficult not being able to take an active part in some of the managerial decision making.
What Training, Contacts and Support do You have for Your Work?
There is no specific ICU training programme and departments are generally headed by specialists in Anaesthesia and Reanimation, such as myself, with a special interest in intensive care. As Intensive Care practice is carried out by Anaesthesiologists in Turkey, training is included as part of the Anaesthesiology training. We have mostly self-training in the Medical Faculty and our supports are EAS, ESICM and SSCM. I’m a member of the National Anaesthesiology and Intensive Care Society, National Enteral and Parenteral Nutrition Society and ESICM. Within our hospital, we are supported by heads of the other medical departments, the Medical Director, Executive Manager of the hospital, and the hospital’s Nursing Supervisor. Organisation is dependent upon the hospital’s financial and personnel resources, with responsibility being given to the department of Anaesthesiology and Reanimation.
What Clinical Management Issues are You Dealing with?
Treatment guidelines are based on International programmes and literature; I’m currently updating the treatment protocols to meet international standards. I also deal with equipment issues such as renewal of the necessary equipment to fulfil current needs, for which costeffectiveness is our main policy. The majority of my time is spent dealing with financial problems of patients who are without insurance cover, for example, lengthening their ICU stay and keeping up their medical treatment programmes.
What Sort of Financial Management Issues Prove Challenging?
Keeping the unit cost at optimal level and targeting cost-effectiveness are challenges. An important time consuming aspect is dealing with financial problems of patients whose insurance policies do not cover private hospital expenses or who have no insurance at all.
Our purchasing is carried out premised on the principle of getting the cheapest, but safest product possible. This is mostly accomplished through research by the Purchasing Department of the hospital management. Measures of cost effectiveness are achieved by working on the daily costs and by discussing the relevant issues.
What Sort of Personnel Issues are You Currently Dealing With?
There is a relatively rapid turnover of trained, experienced nursing and auxiliary staff. We aim to retain staff through proper payment, social benefits and the training offered. Training is carried out by the Nursing Department and the hospital also has a Personnel Orientation Programme, which includes training and regular updating programmes.
Although turnover is relatively higher in the nursing and auxiliary staff group, our medical team has remained the same for the last 6 years. Performance ratings are evaluated within the general management policy of the hospital, which is based on the accreditation standards. Career development is based on interhospital and outside educational programs.
Our department is supervised by a specialist in Anaesthesiology and Intensive Care at all times, 24 hours 7 days a week. Doctors work in 2 shifts, from 9.00am to 7.00pm during the day, with 2 specialists present, and from 7.00pm to 9.00am with one specialist present during the night shift. Only one member of staff is ever off duty during the day, and there is always a member on call to support the night shift. A specialist is always on duty during holidays and weekends, with a second specialist on call 24 hours. Treatment policies are continued without interruption through the day and night shifts. At the beginning of each shift, patient visits with full coverage of medical and management staff ensure smooth handover. Nurses and auxiliary staff also work in two shifts during week days and holidays, and their schedules are supervised by the Supervisory Nursing department. The role definitions of each staff group are well delineated and every member of the medical team has equal responsibility in medical decision making and carrying out procedures and treatments.
Thank you, Professor Telci, for this insight into the management of your department