CHANGING THE WORK ENVIRONMENT IN

INTENSIVE CARE UNITS TO ACHIEVE

PATIENT-FOCUSED CARE: THE TIME HAS COME
By Kathleen McCauley, RN, BC, PhD, and Richard S. Irwin, MD. From the University of Pennsylvania School
of Nursing and Hospital, Philadelphia, Pa (KM), and University of Massachusetts and UMass Memorial
Medical Center, Worcester, Mass (RSI).

The American Association of Critical-Care Nurses Standards for Establishing and Sustaining Healthy
Work Environments and the American College of Chest Physicians Patient-Focused Care project are com-
plementary initiatives that provide a road map for creating practice environments where interdisciplinary,
patient-focused care can thrive. Healthy work environments are so influential that failure to address the
issue would result in deleterious effects for every aspect of acute and critical care practice. Skilled commu-
nication and true collaboration are crucial for transforming work environments. The American College of
Chest Physicians project on patient-focused care was born out of a realization that medicine as currently
practiced is too fragmented, too focused on turf battles that hinder communication, and too divorced from a
real understanding of what patients expect and need from their healthcare providers. Communication as
well as continuity and concordance with the patients’ wishes are foundational premises of care that is
patient-focused and safe. Some individuals may achieve some level of genuine patient-focused care even
when they practice in a toxic work environment because they are gifted communicators who embrace true
collaboration. At best, most likely those efforts will be hit-or-miss and such heroism will be impossible to
sustain if the environment is not transformed into a model that reflects standards and initiatives set out by
the American Association of Critical-Care Nurses and the American College of Chest Physicians. Other
innovative models of care delivery remain unreported. The successes and failures of these models should
be shared with the professional community. (American Journal of Critical Care. 2006;15:541-548)

T he landmark Institute of Medicine (IOM) docu-

ment To Err Is Human: Building a Safer Health
System1 transformed the way we think about
patients’ safety. By making public the dangers that
patients face when they enter the current healthcare sys-
and changed the focus of error prevention from individ-
ual punishment to one of system redesign. In Crossing
the Quality Chasm: A New Health System for the 21st
Century,2 the IOM then attacked the dysfunctional pro-
cesses of our past and current healthcare system (eg,
tem, the IOM used its influence effectively to call for pervasive poor communication and noninterdisciplinary,
dramatic transformations in the way we evaluate errors often isolationist decision-making behavior). By focus-
ing on effective team performance, data-driven analysis
of system failures, and continuous process improve-
Corresponding author: Kathleen M. McCauley, RN, PhD, APRN-BC, University of ments to reduce risk, the IOM called for a revolution in
Pennsylvania School of Nursing and Hospital, 420 Guardian Dr, Philadelphia,
PA 19104-6096 (e-mail: kmccaule@[Link]).
the way we communicate with each other, anticipate and
modify patients’ risk, and evaluate our effectiveness.
To purchase electronic or print reprints, contact The InnoVision Group, 101
Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 The leaders of the American Association of Critical-
(ext 532); fax, (949) 362-2049; e-mail, reprints@[Link]. Care Nurses (AACN) and the American College of

[Link] AMERICAN JOURNAL OF CRITICAL CARE, November 2006, Volume 15, No. 6 541
Chest Physicians (ACCP) have a long history of Standards for establishing and sustaining healthy work
thoughtful dialogue about the important issues in critical environments put forth by the American Association of
care practice and have collaborated on key initiatives Critical-Care Nurses3(p189)
to enhance the practice knowledge of their members.
Over the years, as their relationship has matured, the Skilled communication: Nurses must be as proficient in
communication skills as they are in clinical skills.
organizations have come to respect and value each
other’s perspective, benefited from the unique knowl- True collaboration: Nurses must be relentless in
edge and worldview each brings to planning for the pursuing and fostering true collaboration.
future, and used this perspective to grow in ways that Effective decision making: Nurses must be valued and
would not have been possible without this collabora- committed partners in making policy, directing and
evaluating clinical care, and leading organizational
tive relationship.
operations.
As past presidents of AACN and ACCP, in this
article we describe how the AACN Standards for Appropriate staffing: Staffing must ensure the effective
match between patients’ needs and nurses’
Establishing and Sustaining Healthy Work Environ- competencies.
ments3 and the ACCP Patient-Focused Care project4
demonstrate true collaboration and synergy of thought. Meaningful recognition: Nurses must be recognized
and must recognize others for the value each person
Together, these complementary initiatives provide a brings to the work of the organization.
road map for creating the kind of practice environ-
ment where interdisciplinary, patient-focused care, as Authentic leadership: Nurse leaders must fully embrace
the imperative of a healthy work environment,
called for by the IOM, can thrive. authentically live it, and engage others in its
achievement.
Response to a Flawed Health System
AACN’s decision to establish standards for healthy
work environments grew from a strategic planning making, appropriate staffing, meaningful recognition,
process in which the association identified the 3 most and authentic leadership—were derived from a strong
important issues facing its members and critical care base of research evidence. Each standard is considered
nurses at large on which AACN’s voice and action essential, and the standards are designed to be used
would have the greatest effect. A healthy work envi- together, not as stand-alone organizational goals. The
ronment was one of those issues and was judged to be standards are forceful statements describing the actions
so influential that failure to address it would result in required to transform the health of the work environ-
deleterious effects for every aspect of critical care ment (see Table).
practice. A task force and national review panel led by Transforming our work environments is not nego-
past AACN president Connie Barden developed the tiable if we are to achieve 3 interconnected essential
standards that were launched at a Washington, DC, goals:
press conference in January 2005. More than 30 000 1. retention and, indirectly through improved pub-
copies of the standards were downloaded from the lic perception, recruitment of nurses at a time of per-
AACN Web site the first month after their release; the vasive and lingering nursing shortages;
number downloaded now exceeds 120 000. These 2. improved job satisfaction among all members
standards are guiding transformation of the care envi- of the healthcare team; and, perhaps most importantly,
ronment in many institutions across the United States. 3. improved outcomes for patients and patients’
families, particularly in the area of patients’ safety.
A growing body of research indicates the link
between nurse staffing and patients’ outcomes6,7; between
Transforming our work environments is staffing, nurse burnout, and job satisfaction7; and between
not negotiable to achieve nurse reten- work environments, nurses’ satisfaction, and nurses’
tion, job satisfaction, or improved out- clinical performance.8 Competence of multidisciplinary
comes for patients and their families. providers in leadership, care coordination, and conflict
resolution behaviors decreased mortality rates and
improved other key physiological risk variables among
infants in neonatal intensive care units.9 Nurse-physician
The standards have been presented in several AACN collaboration, specifically, has resulted in improved
publications.3,5 The 6 standards—addressing skilled outcomes for patients,10,11 including reduction in mor-
communication, true collaboration, effective decision tality rates.12

542 AMERICAN JOURNAL OF CRITICAL CARE, November 2006, Volume 15, No. 6 [Link]
Different Views of Collaboration A mutual purpose is one that is “more meaningful or
Evidence suggests, however, that nurses and physi- more rewarding than the ones that divide the various
cians who work together differ in the way they view sides.”16(pp85-86) In healthcare, the most effective mutual
the quality of collaboration and communication in their focus of purpose is the patient. Hence, we view the
workplace,13 with nurses tending to be much less pleased connection between care that is truly patient focused
with the quality of collaboration than physicians are in and creation of healthy work environments as critical
the same setting.14 A disturbing finding from a recent to our effectiveness as providers and to our success in
survey14 of safety attitudes revealed that more than one transforming our practice environments.
third of nurses reported finding it difficult to speak up
when they detected a problem with a patient. Pronovost Patient-Focused Care
and colleagues14(p1028) call this “interdependence without The concept of patient-focused care was born out
integration,” an apt phrase that describes the critical of a realization that medicine as currently practiced is
nature of nurse-physician work and a relationship that too fragmented, too focused on turf battles that hinder
must be improved if both nurses and physicians are to communication, and too divorced from a real under-
be effective. standing of what patients expect and need from their
Perhaps these different views of collaboration are healthcare providers. The solution lies in viewing every
related to the quality of the interaction. True collabora- encounter with a patient as an opportunity to deliver the
tion as directed by the standards builds over time, leading care we would want for our own family members. How
to joint decision making that embraces each discipline’s could we not want those we love to receive care from
worldview. True collaboration is normal, respectful, and competent, well-educated practitioners who embrace
ongoing.3 With true collaboration, each professional is a evidence-based practice and lifelong learning? Would
full partner in the dialogue; loud voices or lofty titles will we not expect that our families be treated with respect,
not dominate the discussion or the decision. their unique needs identified and met, and their wishes
Lip-service collaboration, on the other hand, is honored at the end of life? Continuous quality improve-
halfhearted. When we say that we want to hear the ment efforts would drive care processes, and we would
perspectives of others, we must really listen, and our do our best to accommodate patients and their fami-
actions must reflect an expanded worldview. Yet when lies even when, because of their limited knowledge or
the stakes are highest and the potential for disagree- broken systems, they contribute to the difficulties we
ment is the greatest, we are at the greatest risk for lip- face in doing our job well.4
service collaboration.15 As president of ACCP in 2003-2004, one of us
(R.S.I.) challenged members attending the annual
meeting to join a revolution in healthcare—a revolu-
tion that refocuses what we do on the patient.4 As an
Nurses are much less pleased with the organization, ACCP embraced patient-focused care by
quality of collaboration than are having members commit to the following pledge4(p1912):
physicians in the same setting.
I will strive to provide patient-focused care
wherever and whenever I have the privilege of
Therefore, we must agree about the best way to caring for patients. I will also work to ensure
help an anxious or angry family support their criti- that all health care systems in which I provide
cally ill loved one, and we must not respond by limit- care are patient-focused. Patient-focused care
ing their access to the patient. With true collaboration, is compassionate, is sensitive to the everyday
physicians, nurses, and patients’ family members will and special needs of patients and their families,
figure out together the best ways to communicate, gain and is based on the best available evidence. It is
the families’ insights into the patients’ needs, and har- interdisciplinary, safe, and monitored. To
ness their healing energies. ensure the provision of patient-focused care
True collaboration requires communicating effec- in my professional environments, I shall will-
tively. In Crucial Conversations: Tools for Talking ingly embrace the concepts of lifelong learn-
When Stakes Are High, a highly influential and practical ing and continuous quality improvement.
guide to improving relationships and successfully han-
dling difficult interactions, Patterson et al16 discuss the The ACCP visibly commemorated its commitment
importance of colleagues agreeing on a mutual purpose to a patient-focused care initiative in 2 ways. The orga-
in order to link seemingly disparate goals and strategies. nization mailed a “commit to patient-focused care” pin

[Link] AMERICAN JOURNAL OF CRITICAL CARE, November 2006, Volume 15, No. 6 543
and copy of the pledge to each ACCP member, urging • Interdisciplinary patient care rounds are the norm,
the members to wear the pin when caring for patients and each discipline’s contribution is considered so
and to sign, frame, and visibly display the pledge in the essential that decisions are not made without all care
members’ offices. ACCP also asked all new fellows of providers weighing in.
the group to recite the pledge during the convocation • Each patient, when able, and the patient’s family
ceremony as the final step before induction as fellows. are integral members of the decision-making team so
The favorable response provoked by this initiative that the patient’s values and wishes are key compo-
throughout the United States and worldwide was strik- nents of the planning process.
ing. The concept of seeking to provide every patient • All team members feel comfortable and sup-
with the same kind of care we would want for our fam- ported in challenging care processes when the pro-
ily members universally resonated with ACCP mem- cesses are perceived to be inaccurate, not evidence
bers, no matter where the members lived. based, or inconsistent with professional values or the
patient’s values.
• All team members actively seek and engage in
educational programs that improve their communica-
More than one third of nurses find it tion and collaboration skills. Colleagues support each
difficult to speak up when they detect other in skill development and hold each other account-
a problem with patients. able for correcting lapses in respectful communication
and collaboration patterns.
• Techniques such as SBAR18 (situation-background-
assessment-recommendation) are widely used to
increase effectiveness of communication, especially in
Two Critical Standards critical situations.
We embrace adoption of all 6 AACN standards as • Structured forums such as ethics committees are
crucial for transforming the work environment. Yet 2 of used effectively to support clinicians in resolving dis-
the standards, skilled communication and true collabo- putes, provide clinicians a broader view of the issues, and
ration, seem particularly necessary to achieve the goal ensure that patients’ values and wishes and, if appropri-
of patient-focused care because communication as well ate, those of the patients’ family members are identi-
as continuity and concordance with the patients’ wishes fied and incorporated.
are foundational premises of patient-focused care.17 • A high level of personal integrity characterizes
Some individuals may achieve some level of gen- the behavior of all team members.
uine patient-focused care even when they practice in a • Concerns about competence or collaborative
toxic work environment because they are gifted com- behaviors of team members are dealt with directly and
municators who embrace true collaboration. However, respectfully so that patients are not harmed and team
we contend that, at best, their efforts will be hit-or-miss, members receive support to correct communication
and such heroic efforts will be impossible to sustain if and practice deficits.
the environment is not transformed into a model that • Interdisciplinary educational efforts are the norm
reflects the AACN standards. The barriers to transform- for staff education in healthcare, with research find-
ing a toxic environment are indeed massive, but if those ings from each discipline incorporated into the con-
barriers are not overcome, the notion of “interdepen- tent of clinical education.
dence without integration” put forth by Pronovost and • “What is best for the patient” is driven by the
colleagues14 will prevail. patient’s perspective and values, integrating each dis-
Imagine, then, working in an environment where cipline’s best practice knowledge.
skilled communication and true collaboration form • Evaluation of care processes includes evaluation of
the foundation from which to promote patient-focused the burden that ineffective care systems place on patients
care. This would be an environment that embodies and patients’ families, with quality improvement efforts
the following: designed to monitor and repair these broken systems.
• The current, common practice of totally separate • Ongoing efforts to enhance patients’ safety include
medical and nursing schools would change. Physi- monitoring communication and collaboration patterns
cians and nurses have selected classes and clinical and explicitly linking process improvements in these
experiences together as students so that each group areas with improved outcomes related to patients’ safety.
enters practice with a respectful, accurate knowledge • An organization’s success (or failure) to trans-
of the other’s clinical contribution. form its work environment and achieve patient-focused

544 AMERICAN JOURNAL OF CRITICAL CARE, November 2006, Volume 15, No. 6 [Link]
care is systematically tracked and improved through a know each other as people can set or reinforce the tone
comprehensive outcome-monitoring program. for true collaboration.
• Professional associations and other influential • Invite the ethics committee chair to a unit staff
groups with a stake in the process support their members’ meeting and discuss how the committee can offer guid-
efforts to transform the members’ practice environments ance when tough disagreements happen. Do not focus
via Web sites, publications, and other strategies that foster solely on the familiar issues of discontinuing treat-
exchange of best practices, tools for effective transforma- ment and end-of-life care; also consider dilemmas such
tion, and recognition of centers of excellence (eg, the as providing quality care despite limited resources and
AACN Beacon Award for Critical Care Excellence). verbal abuse, which carry equally serious ethical impli-
• National regulatory and accrediting organiza- cations. Inviting the unit’s medical director and other
tions such as the Joint Commission on Accreditation team members to participate will create a climate of
of Healthcare Organizations incorporate quality-of- shared learning.
care metrics that support this culture transformation. • Develop a welcome-to-our-unit program so that all
new caregivers including physicians, nurses, respiratory
care practitioners, pharmacists, and others can learn how
to contribute in a culture of true collaboration and
Current practice is too fragmented and patient-focused care. Ensure that the unit’s nurse man-
too focused on turf battles that hinder ager and medical director speak with all new care
communication. providers about how true collaboration is the standard.
• Review all unit-based programs for improving
quality and patients’ safety to ensure that collabora-
tion and evaluation of effectiveness are integral to each
program.
Unit-Based Strategies for • Develop a fix-the-ineffective-work-arounds task
the Serious Organization force to identify and fix as many broken systems as
What interdisciplinary strategies could a critical care possible. Uncover the root causes of the broken system
unit put into action to indicate its seriousness in imple- by inviting and actively listening to input from nurses,
menting the AACN standards for healthy work environ- physicians, and all affected care providers. Work col-
ments3 with a strong focus on patients and patients’ laboratively, inviting hospital and nursing administra-
families? Here are some suggestions for making skilled tors to participate to abolish systems that do not work
communication and true collaboration the norm: and to design effective new ones.
• Use techniques such as SBAR18 to guide inter- • Engage the organization’s executive leaders,
disciplinary communication. including, as appropriate, the chief nursing officer, chief
• Assemble a small group of nurses, physicians, executive officer, and medical directors, in the chal-
respiratory care practitioners, pharmacists, and other lenge of transforming all systems for evaluating care
providers to develop processes for organizing truly col- providers to include assessment of communication
laborative interdisciplinary rounds. Set a 6-month goal and collaboration skills. Be sure to reward successful
by which time no patient will be discussed on rounds skill acquisition in meaningful ways.
without the contribution of the full team.
• Plan educational programs about new and inter-
esting care strategies that are taught jointly by at least
2 disciplines. Invite representatives from every disci- Imagine that interdisciplinary rounds are
pline with a role in patients’ care, and students, not just essential and that no decision can be made
medicine and nursing, to participate and contribute their without all care providers weighing in.
perspectives.
• Although acute and critical care units are often
considered the home base of nurses, ensure that other
team members are not considered or treated as visitors
or interlopers. Invite team members from all disciplines A Virtual Critical Care Department
to attend and contribute to unit-based social events, The virtual department of critical care at UMass
such as potluck meals, and be sure to invite everyone, Memorial Medical Center in Worcester, Mass, is an
not just the most collaborative ones who already know example of creating a better model for delivering criti-
and appreciate the valuable input of others. Getting to cal care services across the 21st century healthcare

[Link] AMERICAN JOURNAL OF CRITICAL CARE, November 2006, Volume 15, No. 6 545
 Leadership
Leadership Council
Council Medical
Medical Center
Center President
President

Clinical
Clinical Support
Support Services
Services Critical
Critical Care
care Hospitalists
Hospitalists
Nutrition,
Nutrition, Pharmacy,
Pharmacy, Respiratory
Respiratory therapy,
therapy,
Care
Care coordination,
coordination, Clinical
Clinical quality
quality
Operations
operations Committee
committee

eICU
eICU

Nurse Medical Nurse Medical Nurse Medical Nurse Medical Nurse Medical
Manager Director Manager Director Manager Director Manager Director Manager Director

NICU
NICU PICU
PICU Cardiac
Cardiac Medical
Medical Surgical
Surgical Neuro
Neuro
ICUs
ICUs ICUs
ICUs ICUs
ICUs ICU
ICU

Nurse Medical Nurse Medical

Manager Director Manager Director

Emergency
Emergency Departments*
Departments* Postanesthesia
Post Anesthesia Care
Care Units*
Units *

Organizational chart of the “Virtual” Department of Critical Care at UMass Memorial Medical Center. The Critical Care Operations
Committee is composed of representatives of all groups with a stake in critical care; it is cochaired by a physician critical care specialist
and the director of critical care services. The eICU refers to a live, real-time telemedicine program.
Abbreviations: ICUs, intensive care units; neuro, neurological; NICU, neonatal ICU; PICU, pediatric ICU.
*For critical care functions.

organization. In 2003, chief executive officer John leadership council, who look to the committee for deci-
O’Brien identified the need for a better model of sion-making guidance where critical care is involved.
delivering critical care. O’Brien charged a strategic Although the medical directors of each unit shown
planning committee with 21 interdisciplinary members in the Figure still primarily report to the chairs of their
with the daunting task of inventing the model and respective clinical departments, the days of silo building
establishing guiding principles for implementation. (ie, noninterdisciplinary, isolationist decision-making
After 13 months of deliberation, the committee pre- behavior) are gone. The critical care community as a
sented its report to the chief executive officer and a whole now monitors and manages all critical care activ-
leadership council that included the chairs of all clini- ities and budgetary matters. Activities, results, and/or
cal departments and the medical center president. behavior that fall outside what is expected are moni-
With the council’s unanimous support, a new era of tored in real time and managed by relying on data-
critical care began on September 1, 2004. driven peer pressure in collaboration with division
Critical care was defined as caring for critically ill chiefs and department chairs.
patients regardless of the patients’ location in the sys- UMass Memorial Medical Center has been able to
tem through a system-wide virtual department (see achieve impressive culture transformation and has
Figure) that uses a collaborative, interdisciplinary, and begun to note measurable improvements in patients’
patient-focused approach. outcomes through this innovative reorganization of
All issues related to critical care are discussed by critical care delivery. The model works because it was
a critical care operations committee that meets every 2 intentionally designed to support the medical center’s
weeks. The committee is composed of the entire criti- clinical, teaching, and research missions. Through the
cal care community; it is cochaired by a critical care model, clinicians, faculty members, and researchers col-
physician specialist and the medical center director for laborate to deliver accessible, excellent, patient-focused
critical care services. The committee’s recommenda- care, constantly evaluating and improving processes and
tions are presented to the medical center president and services with the goal of achieving evidence-based

546 AMERICAN JOURNAL OF CRITICAL CARE, November 2006, Volume 15, No. 6 [Link]
practice and high levels of satisfaction among patients, In designing a new and more effective structure,
patients’ families, and the healthcare team. the UMass Memorial Medical Center team learned that
Since September 2004, the following structural it needed to communicate more effectively and in the
and process changes have been implemented at UMass process has strengthened its interdisciplinary relation-
Memorial Medical Center: ships. Team members have more consistently come to
• Nurse managers and medical directors of the understand and appreciate the perspective of others and,
intensive care units (ICUs) are considered peers with by constantly focusing on what is best for patients and
equal accountability for clinical outcomes and the per- patients’ families, are better able to resolve conflicts,
formance of each group’s professional teams. solve problems, and refocus attention toward teamwork
• A policy applied to the entire medical center and quality evidence-based, patient-focused care. Only
requires that the care of every ICU patient be super- time will tell how successful the virtual department
vised by a critical care specialist. will be. However, it was clearly time for a change
• The care of all critically ill patients will be man- because the 20th-century model of delivering critical
aged around the clock by a critical care specialist care has too many flaws—flaws that the IOM says
whether on site or via telemedicine. Phasing in of eICU portray all of medicine.
(VISICU, Inc, Baltimore, Md) monitoring began June
27, 2006; full implementation by September 2007 is
anticipated.
• Appropriately educated and certified acute care Nurse managers and medical directors
nurse practitioners and physician assistants have been have equal accountability for clinical
recruited to join the clinical teams and work with inten- outcomes.
sivists, house staff, and nurses to ensure that standards
are consistently applied to achieve expert and rapid
response to patients’ acute needs. In order to facilitate
the entry of these providers into the system in the Essential Need for Innovative Care Models
future, a close collaborative educational and research We suspect that other innovative models remain
partnership has been established with the University of unreported, and we urge readers to communicate their
Massachusetts Graduate School of Nursing and a nurse successes and, yes, failures to the professional com-
practitioner/physician assistant critical care mentorship munity. We challenge readers to engage in this essen-
program has been established. tial work of designing innovative care delivery. Consider
• The need for additional ICU and progressive what is required so that skilled communication, true
care beds has been identified, and all disciplines are collaboration, and patient-focused care can become
involved in planning for these expanded services. the norm at your institution.
• All disciplines are involved in developing, imple- Which colleagues will be your immediate and eager
menting, and expanding an ever-growing list of clinical allies in designing, implementing, and evaluating these
practice guidelines so that the care critically ill patients changes? How will you ensure that all disciplines partici-
receive becomes uniformly evidence based. Front-line pate? What resources will be needed to support this
providers of patients’ care give their feedback about transformation? How will the requisite energy and enthu-
implementation of clinical practice guidelines to the siasm be sustained in order to persevere in such a strate-
leaders of the critical care operations committee during gically essential process? How will successes and failures
weekly interdisciplinary bedside rounds. Electronic be celebrated and learned from along the journey?
documentation will be used throughout ICUs and in If the healthcare system in which you work will not
the eICU to support and improve communication and allow the delivery of critical care to be transformed into
adherence to clinical practice guidelines. an efficient, patient-focused, healthy work environment,
• A tiered process for responding to the need for perhaps it is time for you and your colleagues to suggest
critical care beds has been developed and has greatly to the chief executive officer and other clinical leaders
improved collaboration between the emergency and that it might be time to undertake a strategic planning
critical care departments, proactively managing patient process with the goal of redesigning critical care.
throughput on the basis of the census and acuity levels Linking patient-focused care as defined by the
of patients in all areas. ACCP with work environment transformation based
• A scorecard for monitoring critical care data is on the AACN healthy work environment standards
used to track progress and indicate needed improvements will strengthen process and outcome by identifying a
in case mix, outcomes, care processes, and staffing. mutual purpose that unites disciplines in a common

[Link] AMERICAN JOURNAL OF CRITICAL CARE, November 2006, Volume 15, No. 6 547
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