Intensive care units (ICUs) are essential for the survival of critically ill patients. In addition to the complexity of the patients treated in these units, their organizational characteristics also pose challenges for health care administrators.

The recent COVID-19 pandemic highlighted the importance of ICU organization and the relationship between management and patient outcomes,1–3 and data also indicate an association with moral distress among health care workers.4,5 Despite recognition of the relevance of ICU management and organization, the literature remains scarce. Documents exist that propose guidelines for calculating the number of physicians required, both nationwide6 and in health systems other than our own,7,8 while others, such as those produced by SEMICYUC working groups, include evidence-based recommendations on organization but without an in-depth focus on management.9,10 More global documents were drafted 15 years ago, and the evolution of the specialty raises doubts about their validity today.11 Fortunately, in recent years, in addition to the logical concern for the quality of care delivered to critically ill patients, increasing attention has been paid to the humanization of ICUs, addressing both patient well-being and occupational health of staff.12

The aim of this document is to establish recommendations for ICU management and organization to deliver high-quality care to patients within an environment that respects the occupational health of intensivists.

The Galician Society of Intensive Care and Coronary Units (SOGAMIUC) prioritized the creation of a foundational document on ICU management and organization to promote quality of care in ICUs while simultaneously protecting the occupational health of intensivists. The project was initiated by the SOGAMIUC Board of Directors. After a literature review confirmed the lack of evidence to address most of the domains considered fundamental, it was decided to use a Delphi methodology.13

Criteria for expert selection included members of the Board of Directors, department heads and section chiefs of ICUs in Galicia, and specialists designated by department heads based on their specific involvement in ICU management. The resulting panel of 20 experts (10 women and 10 men) included a range of contractual situations, practice across all public hospitals in Galicia and varying levels of experience (Supplementary data). Experts were invited in April 2024 and agreed to participate voluntarily and without compensation.

A total of 2 virtual meetings were held with the expert group to explain the methodology and project objectives (May 22nd and May 27th, 2024).

A Delphi process was used to achieve consensus. Questions were generated in various formats: initially open-ended, later Likert scale, dichotomous, multiple-choice, and numerical (Supplementary data).

PVC was responsible for preparing the 1st round of questions, analyzing responses and formulating subsequent rounds.

Responses to the 1st round were received between June 8th and July 4th, 2024 (19 experts responded); the 2nd round (18 experts) between July 23rd and September 7th, 2024; the 3rd between November 13th and November 25th, 2024 (18 experts); and the 4th and final round between November 28th and December 17th, 2024 (18 experts).

Consensus was defined as agreement (either in favor or against) >65%. For calculation, the following responses were grouped: “Strongly disagree” with “Disagree,” “Agree” with “Strongly agree,” “Not important” with “Somewhat important,” and “Important” with “Very important.” Agreement percentages are reported and presented in parentheses alongside recommendations. Full expert responses are available in the Supplementary data.

Once the document was drafted, endorsement was sought from the Spanish Society of Intensive Care, Critical and Coronary Units (SEMICYUC) and from the regional intensive care societies of Spain. Endorsement was obtained from SEMICYUC, the Asturian Society of Intensive Care (SAMI), the Balearic Society of Intensive Care, Critical and Coronary Units (SBMICIUC), the Canary Society of Intensive Care, Critical and Coronary Units (SOCAMICYUC), the Northern Society of Intensive Care and Coronary Units (SNMIUC), the Castile and León Society of Intensive Care, Critical and Coronary Units (SCLMICYUC), the Catalan Society of Intensive and Critical Care Medicine (SOCMIC), the Extremadura Society of Intensive Care and Coronary Units, and the Murcia Society of Intensive Care and Coronary Units (SOMIUC).

This document seeks to provide a set of consensus-based recommendations for the organization of ICUs, with the aim of ensuring high-quality care for critically ill patients and fostering a healthy work environment for professionals. The results, obtained through a Delphi methodology, achieved a high degree of consensus among participating experts, which lends strength and applicability to the proposed recommendations.

One of the main recommendations concerns the need to structure ICUs into subunits adapted to patient severity and condition, and to the size and complexity of the service. This organization facilitates continuity of care and enables more specialized management, both of which have a positive impact on clinical outcomes and on the experience of patients and their families.

Unanimous consensus on the need for specialized medical and nursing teams underscores the importance of having professionals specifically trained in Intensive Care Medicine. The inclusion of other professional profiles within the multidisciplinary team—such as pharmacists, physiotherapists, psychologists, and speech therapists—reflects a modern, holistic approach to critical care.

Another key aspect is the organization of daily care, which should prioritize quality, safetyand continuity. The existence of an individualized diagnostic–therapeutic plan and a designated clinician responsible for the patient promotes more coherent and effective care, minimizing clinical variability and adverse events.

The recommendation to limit workload in continuous care, both in the number of on-call shifts and in patient-to-intensivist ratios, responds to evidence on the negative impact of work overload on professionals’ health and on the quality of care. This is particularly relevant in the current context of growing concern for professional well-being and burnout prevention.4,5,14

Similarly, the need for specific clinical programs and for maintaining organized and recognized nonclinical activity is emphasized. These activities are fundamental for continuous improvement, innovation, and sustainability of quality care in ICUs.

Compared with previous national and international documents, this consensus provides an updated vision tailored to the Spanish context, integrating not only clinical and organizational criteria but also considerations of occupational health and humanization of care.

Our recommendations complement earlier proposals in Spain aimed at estimating ICU workforce needs based on categorization of clinical, extra-ICU, teaching, research, and clinical management/safety activities.6 However, beyond quantifying workloads, we consider it essential to structure ICU organization in ways that promote quality of care, patient safety and a sustainable professional environment. Promoting continuity of care and developing clinical leadership structures are key elements for achieving this objective.

The results of our work are also consistent with recent international trends in ICU organization. In this regard, the consensus document of the French Intensive Care Society reinforces the need to optimally structure working hours, ensure continuity of care, and protect the physical and mental health of intensivists. The recommendation to allocate specific time for nonclinical activities, limit consecutive working hours and rationalize night shifts responds to evidence of their impact on care quality and burnout prevention. These recommendations align with the principles in our consensus, underscoring the importance of an organizational model that combines efficiency, quality and professional sustainability in ICUs.12 Regarding the document of the German Interdisciplinary Association of Intensive Care and Emergency Medicine, which provides detailed recommendations on ICU structure, staffing, and organization, we agree on the classification of ICUs into 3 levels of care (although their document also classifies patients into 3 levels of complexity), the need for multidisciplinary work and the importance of professional well-being. A key difference lies in the level of training considered necessary for the care of critically ill patients.15

Unlike the Spanish consensus, the French and German recommendations calculate physician staffing needs based on the number of beds, albeit with very different recommended ratios.6,12,15

This work has some limitations. First, the regional composition of the expert panel may limit the generalizability of some recommendations. However, endorsement by multiple regional societies and SEMICYUC supports their applicability nationwide. Second, the Delphi panel consisted exclusively of physicians; thus, issues relevant to other professionals working in ICUs (nurses, nursing assistants, orderlies, administrative staff) were not addressed. Third, we did not explore the time required for nonclinical activities in detail. Fourth, the current work system (regular hours plus on-call hours) was assumed; although initiatives exist at different levels to modify this structure, they were not addressed here but are expected to be explored in a future project. Another limitation is the absence of recommendations regarding ICU architectural design, an important issue not covered in any of the Delphi rounds.

The choice of Delphi methodology constitutes one of the document’s main strengths. This systematic approach enables expert consensus in areas where scientific evidence is limited or heterogeneous, as is the case for ICU organization and management. Anonymous participation, iterative rounds, and controlled feedback encourage individual reflection and progressive adjustment of opinions, avoiding dominance bias by opinion leaders. Another major strength of our document is the endorsement it has received from multiple scientific societies.

These recommendations summarize the measures considered most relevant to improving ICU organization, thereby enhancing quality of care and occupational health. Limiting the number of patients per intensivist in both routine and continuous care, structuring clinical activities, recognizing nonclinical activities as part of workload, and regulating working hours in compliance with at least legal requirements are essential prerequisites for efficient ICU functioning.

Study design: Pablo Vidal-Cortés.

Recruitment and coordination of the expert panel: Pablo Vidal-Cortés.

Drafting of Delphi round questions: Pablo Vidal-Cortés.

Analysis of round results: Pablo Vidal-Cortés.

Responses to Delphi rounds: all authors.

Manuscript drafting: Pablo Vidal-Cortés.

Manuscript review: all authors.

No artificial intelligence was used in any phase of this study.

None declared.