Coping with complexity in intensive care units: a systematic literature review of improvement interventions

Intensive care units (ICUs) are complex socio-technical systems. Logically and practically, improvement interventions in these environments should be consistent with their characteristics. This study presents a systematic literature review of 91 studies of interventions in adult ICUs, aiming at assessing the extent to which they account for five guidelines for coping with complexity: (i) supporting visibility of processes and outcomes; (ii) design slack; (iii) encouraging diversity of perspectives when making decisions; (iv) monitoring and understanding the gap between work-as-imagined and work-as-done; and (v) monitoring unintended consequences of improvements and changes. Both qualitative and quantitative assessments of adherence to the guidelines were conducted. In the former, examples of applying the guidelines were grouped under 40 descriptors, offering insights into practical ways of coping with complexity in ICUs. For the latter, guidelines (ii) and (iii) were adopted to a similar extent, greater than the other three guidelines. Results indicate that resilience is theoretically connected to the guidelines and therefore it may have been intuitively adopted by the interventions to some extent. An agenda for future research is proposed.