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This synthesis focuses on the reduction of errors and improvement of health care quality using intensivist staffing in intensive care units (ICUs). More than 80 percent of U.S. general hospitals have intensive care units (ICUs) where medical professionals from multiple disciplines care for patients who have sustained, or are at risk of sustaining, acutely life-threatening disease or injury (Berenson, 1984). Timely, high-quality care in an ICU can significantly improve the chances of survival for such critically ill patients. Some hospitals may devote separate units to the care of patients with specific critical health care needs (e.g., neonatal ICUs, pediatric ICUs, surgical ICUs and neurological ICUs). How are intensive care units structured? While ICUs vary in their organization and structure, there are three commonly used staffing models.
Recent studies show that converting open-model units into closed-model units improves clinical outcomes and even reduces costs in the long-term. Who are intensivists? Intensivists are physicians who have extensive training and experience in critical care medicine. A relatively new sub-specialty, it attracts physicians from a variety of specialties. Typically, an intensivist completes a fellowship in critical care after having completed a residency in internal medicine, pulmonary medicine, anesthesia, or surgery. The Society of Critical Care Medicine (SCCM) was founded in 1970 and serves physicians, nurses, scientists, and technicians employed in the field. The American Boards of Internal Medicine, Anesthesiology, Pediatrics, and Surgery began certifying critical care medicine as a sub-specialty in the 1980s. Most intensivists on staff in ICUs are Board-certified or eligible for Board certification in critical care medicine. Purchaser Tips (top) Purchasers of health care need to know how to identify hospitals with high-quality, cost-effective ICUs. The Leapfrog Group, composed of more than 110 large health care purchasers working to encourage hospitals to meet higher standards for patient safety, has introduced the following standards for intensivist staffing in ICUs:
The Leapfrog Group estimates that currently only 10 percent of ICUs in the United States conform to all three of these standards (The Leapfrog Group, 2000). Best Practices (top) There is no generally accepted organizational model for the practice of intensive care medicine in the United States. There is considerable organizational variation among hospitals, and ICU morbidity and mortality rates vary widely among institutions. The addition
of a full-time intensivist to the ICU staff promotes better decision-making,
which improves quality and reduces cost. The majority of existing studies
report significant reductions in inpatient hospital mortality (ranging
from a 2 percent to 17 percent reduction in risk, with a median reduction
of 10 percent) when patient care is managed by a certified intensivist
(Pronovost, 2001). One study examining the effects of ICU organizational
change found that patient and family satisfaction were higher after the
unit had been converted into a closed-model ICU. Intensive care provided
by critical care specialists results in more patients appropriately discharged
from the ICU to other hospital wards in fewer days. Similarly, it results
in more patients appropriately discharged to home in less time. In a telling
study, intensive care nurses were far more confident in the clinical judgement
of intensivists (41 percent) than they were in that of primary care physicians
(7 percent) (Carson et al., 1996). Synthesis of Research (top) ICUs are specialized hospital wards that provide care for patients suffering from life-threatening medical conditions. ICUs provide monitoring, treatment, and nursing services - generally for short periods. Because many patients in the ICU are in critical condition, their survival is directly affected by the quality of care they receive there. Today, the open-model ICU is the most common, but research indicates that semi-closed- or closed-model ICUs provide higher quality care if either includes proactive clinical management of patients in the ICU by intensivists, including mandatory consultation. In an open-model ICU, the physician who manages care may be any physician with privileges to admit patients to the hospital. In contrast, the physician who manages care in a closed-model ICU is an intensivist, or intensive care specialist. The research literature provides compelling evidence that the full-time presence of an intensivist in an ICU is associated with lower mortality rates. In closed-model intensive care units patients are transferred to the care of a critical care specialist (intensivist) or team of intensivists. This team assumes full responsibility for the patient while she or he is in the ICU. A recent systematic review of the research literature estimates that hospital mortality rates are reduced by 10 percent, on average, when intensivists manage or co-manage patients in the ICU (Pronovost, 2001). Elsewhere it is reported that the oversight of an intensive care specialist decreases the number of consultations needed per patient by one-third (from 0.6 to 0.4), the rate of complications by 12 percent (from 56 percent to 44 percent) and average length of stay (LOS) by one or more days (Ghorra et al., 1999). This evidence supports the view that having a full-time physician managing the ICU improves patient outcomes. Supply shortages and cost concerns inhibit the adoption of closed ICUs and intensivist staffing on a broader scale. In 1995, less than 30 percent of ICUs were staffed by full-time intensivists. By 1999, they provided care to only one-third of all ICU patients (Angus et al., 2000). Today there are 6,000 to 7,000 actively practicing intensivists in the United States. They spend, on average, only about a quarter of their time providing ICU care (Rosenfeld et al., 2000). It is estimated that four times as many full-time intensivists would be needed to provide around-the-clock staffing for the more than 7,000 ICUs in this country. Experts project that as the U.S. population ages this shortage of intensivists will become increasingly acute. Angus and colleagues (2000) predict that by 2020 the supply of intensivists will meet only 22 percent of the demand for their services. In light of the intensivist shortage, an alternative to fully staffing ICUs with intensivists is remote monitoring of ICU patients by off-site intensivists, using telemedicine technology. One study found that around-the-clock remote monitoring by an intensivist reduced ICU mortality by 30 percent, incidence of ICU complications by 45 percent, ICU LOS by 30 percent and expenditures by 35 percent (Rosenfeld et al., 2000). With these dramatic results in mind, several researchers at the Johns Hopkins University launched VISICU, a company vending e-solutions for critical care. However, while VISICU proposes that the shortage of intensive care specialists may be overcome by using telemedicine technology, it should be noted that there are complicated reimbursement issues relating to telemedicine services. These issues would have to be resolved adequately by public and private payers before remote monitoring would alleviate at least some of the intensivist shortage problem. Intensive care is expensive; the cost of patient care in ICUs is three-to-four times higher than in regular hospital wards. Even though ICU patients occupy only 5-10 percent of hospital beds nationwide, ICU services consume 20 percent of hospital budgets (Hanson et al., 1988). Yet, though short of definitive, existing studies indicate that the use of intensivists in ICUs controls health care costs in the long run, not just because IPS results in better quality care, but because intensivists use ICU resources more efficiently. ICU staff physicians make better administrative and clinical decisions due to their specialized knowledge and experience in the critical care setting. They improve both communication and organization in the unit. Why are intensivists important for patient safety? The full-time commitment of an intensivist to providing care in the ICU affects patient outcomes in two ways:
Intensivists have specialized knowledge and technical skills from which patients, ICUs, and hospitals benefit. The research literature suggests that intensivist staffing enhances the likelihood that critical care decisions occur in a timely fashion and produce desired results. What are the cost factors? ICU patients occupy 5-10 percent of hospital beds nationwide, but consume 20 percent of hospital budgets. The cost of patient care in ICUs is three to four times higher than in regular hospital wards (Henning et al., 1987). It is difficult to draw definite conclusions about the costs of intensivist staffing. ICU care consists of several components: technically sophisticated and expensive equipment, specialized nursing and technician staff, tests and procedures, and physician staffing. Personnel costs are the greatest expense among these components, consuming 50 percent to 80 percent of ICU budgets (Henning et al., 1987). Intensivist physicians are the most expensive ICU personnel. However, research suggests they can help contain ICU costs in three main ways:
One study found that after a full-time intensivist joined the hospital’s ICU staff, total charges decreased by 42 percent ($555,200) during the first month by means of the cost-containment measures described above (Lima and Levy, 1995). On the other hand, St. Barnabas Hospital in Bronx, N.Y. reported a cost increase of $138,700 to fund intensivist staffing over a one-year period (Li et al., 1984). To some extent the decrease in hospital LOS among low-risk patients offset this cost, but the authors of this study concluded that overall costs increased. Clearly, these two studies offer conflicting results. We need more research comparing the cost of care in ICUs with and without a full-time intensivist on the staff before drawing definitive conclusions. Instensivists staffing may result in reductions in both hospital and ICU LOS. In a recent review of the literature, Pronovost reports significant reductions-ranging from 14 percent to 42 percent-in hospital LOS when ICUs are converted to a closed format. He also reports that ICU LOS is reduced by an average of 30 percent under the direction of a full-time intensivist. No study found a statistically significant increase in either hospital or ICU LOS upon conversion to a closed-model ICU (Pronovost, 2000). Other researchers found that ICU LOS decreased 33 percent (nine days to six days) and hospital LOS decreased 29 percent (31 days to 22 days) after intensivist staffing was implemented (Multz et al., 1998). Purchaser Support for Intensivist Staffing Standards. While some hospitals have adopted the Leapfrog Group’s recommended intensivist staffing standard, the practice is not widespread. In a study commissioned by The Leapfrog Group, researchers at Dartmouth Medical School estimate that 53,850 lives would be saved annually in the United States if the Leapfrog ICU staffing recommendation were adopted by all non-rural hospitals with ICUs (Birkmeyer et al., 2000). However, the current supply of intensivists renders the goal of widespread implementation infeasible in the near term. Nevertheless, the research literature supports the view that plans, purchasers, and consumers should consider the presence or absence of a full-time intensivist in a hospital’s ICU as a determining factor in hospital choice. Areas for Future Research (top) Although numerous studies have reported lower mortality when a full-time intensivist manages an ICU, there is a need for more research focused on other topics related to ICU staffing. There are few rigorous evaluations of the net costs of intensivist staffing over short-, medium-, and long-term periods. If hospitals, health plans, and purchasers are to be persuaded to make the organizational change to intensivist staffing, it is essential to be able to predict the short- and long-term costs and/or savings of adding a full-time intensivist to ICU staff. Why have ICUs in the United States been so slow to convert to having intensivists manage or co-manage the closed-model, managed by intensivists? There is some evidence that admitting physicians object to intensivist management because it disrupts continuity of care, transfers control over patient care to the intensivist, and may deprive them of lucrative compensation for services they otherwise would provide in the ICU. Therefore a second area for future research would determine the extent to which competition among doctors for control over the domain of intensive care hinder efforts to improve the quality of patient care (Abbott, 1989). Glossary (top) Admitting Physician: The physician responsible for admitting a patient to a hospital or other inpatient health facility. The admission could be to an ICU. Admitting physicians may, but do not necessarily, remain involved in the care of patients once they are admitted. Closed-model
ICU: Patients requiring ICU admission are transferred to the care
of a critical care specialist (intensivist) or team of intensivists. This
team assumes full responsibility for the patient while she or he is in
the ICU. Critical care medicine: A medical sub-specialty primarily involved in all aspects of management of the critically ill patient in the intensive care unit. The medical specialties of anesthesiology, internal medicine, neurological surgery, obstetrics and gynecology, pediatrics, and surgery currently offer sub-specialty certificates in critical care medicine. Gatekeeper: A health care professional, usually a physician, who provides referrals to - and sometimes monitors, oversees and coordinates the actions of - other health care professionals for a specific patient. Intensive Care Units: Specialist hospital wards that are dedicated to the (usually short-term) monitoring, treatment, and nursing of life-threatening conditions. Intensivist: A physician with extensive training and experience in critical care. Typically intensivists have completed a fellowship in critical care after completing residency in internal medicine, pulmonary medicine, anesthesia, or surgery. Most are Board-Certified or Board-eligible in critical care medicine. The Leapfrog Group: Composed of more than 110 public and private organizations that provide health care benefits, The Leapfrog Group works with medical experts throughout the U.S. to identify problems and propose solutions that it believes will improve hospital systems that could break down and harm patients. Representing more than 32 million health care consumers in all 50 states, Leapfrog provides important information and solutions for consumers and health care providers. Open-model ICU: In an open-model ICU, any physician with privileges to admit patients into a specific hospital oversees the care of their patients in the ICU. This model allows continuity of care and is the traditional and most common model in the United States. Semi-closed-model ICU: Similar to the closed-model, except that the admitting physician maintains close contact with the patient in the ICU even though the on-site intensivist manages care, acting as a gatekeeper for the allocation of critical care resources. Society of Critical Care Medicine (SCCM): Founded in 1970, the SCCM strives to improve care for acute life-threatening illnesses and injuries, to promote the development of optimal care facilities and to foster higher standards. Its membership of 9,500 includes approximately 6,000 physicians, as well as nurses, scientists, technicians, and engineers involved in critical care medicine. (For more information go to www.sccm.org). In 1995, SCCM launched Project IMPACT, a comprehensive critical care data system, designed to improve the quality of patient care in the ICU through electronic monitoring and comparative outcome evaluations. Related Links (top)
Related Topics (top)
Key Experts (top) Although agreeing to be listed, these experts are not necessarily endorsing the ideas presented in this synthesis. Also, the experts have not explicitly agreed to respond to inquiries about the topic. The list is meant as a reference point for those interested in learning more about this topic.
Works Cited (top)
Additional References (top)
Acknowledgements (top) This research was funded by the Robert Wood Johnson Foundation, under its National Health Care Purchasing Institute. Junette Williams, Laura McDaniel and Mark Chow provided research assistance. Suzanne Delbanco provided expert reviews and AcademyHealth colleagues provided editorial assistance. Although the analysis and conclusions are solely my own and do not necessarily reflect the views of the foundation or AcademyHealth colleagues, I am deeply indebted to them for their support and assistance, which made this work possible. Citation Guidance (top) Lee, J. "Intensivist
Staffing in Intensive Care Units (ICUs)," Research Synthesis,
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