Exploring Operational Efficiency and Environmental Sustainability in Critical Care: A Qualitative Study of Healthcare...

Intensive care units (ICUs) represent among the most resource-intensive environments in modern healthcare, generating significant operational, financial, and environmental pressures. Despite growing policy interest - including guidance from the European Society of Intensive Care Medicine (ESICM) and the Société Française d'Anesthésie et de Réanimation (SFAR) - the integration of operational efficiency and environmental sustainability within ICU practice remains poorly understood at the level of frontline professionals. Qualitative evidence exploring how ICU staff and managers perceive and navigate these dual pressures is particularly limited in the German healthcare context.

A qualitative-dominant mixed-methods study was conducted in a 520-bed acute care hospital in North Rhine-Westphalia, Germany. Seventeen semi-structured interviews were conducted with purposively sampled ICU professionals, including physicians, nursing leadership, respiratory therapists, administrative staff, bed management specialists, and IT managers. Interviews lasted 35-50 min (mean 41 min) and were audio-recorded and transcribed verbatim. Data were analysed using the six-phase thematic analysis framework of Braun and Clarke. Secondary operational data - including 2025 ICU bed occupancy reports from the hospital's Medical Controlling department, staffing documentation, and hospital sustainability reports - were used for contextual triangulation. No patient-level clinical data were accessed.

Six major themes influencing ICU operational efficiency and sustainability were identified: (1) workforce shortages and staffing pressures; (2) patient flow and bed management constraints; (3) administrative workload and bureaucratic complexity; (4) technological infrastructure and resource management; (5) economic pressures and financial governance; and (6) sustainability awareness and environmental challenges. ICU bed occupancy, as reported in the hospital's 2025 Medical Controlling data, consistently exceeded 85%, confirming capacity pressures described by participants. Sustainability was broadly acknowledged as a relevant concern but perceived as secondary to immediate clinical priorities. Two preliminary conceptual frameworks (Figures S1 and S2) - an ICU Operational Efficiency Model and a Sustainability Integration Model - were developed from the findings and require further external validation.

This study provides qualitative evidence that operational efficiency and environmental sustainability are perceived as interconnected but competing priorities by ICU professionals in a German communal hospital. Key barriers include staffing constraints, administrative burden, and limited institutional sustainability infrastructure. The two conceptual models should be regarded as preliminary frameworks derived from a single-site study rather than validated practical tools. Future research should examine their external applicability and longitudinal impact through multi-site evaluation.