The pressure's on for hospitals to manage their intensive care units with critical care specialists, but a dearth of intensivists makes the highly touted ICU staffing model a mere pipedream for some facilities.
"The data are unambiguous," says Timothy Buchman, M.D., president of the Society for Critical Care Medicine. "Critical care that is delivered by a qualified team led by an intensive care professional saves lives and saves money."
Yet, what appears to be a straightforward way to improve ICU quality is complicated by a workforce shortage where demand for critical care specialists is outpacing supply. Even if every hospital adopted the intensivist model, Buchman says, there are only enough intensivists to cover 15% to 20% of the ICU beds in the country.
"The crisis in critical care is about access to care," says Buchman, co-director of the surgical ICU and director of the trauma center at Barnes Jewish Hospital in St. Louis. "The assumption that in your spouse's or parent's or child's hour of greatest need there will be a team of appropriately qualified professionals is just an assumption."
With the shortage in critical care doctors expected to worsen as the population ages, ICU teams are changing the way they care for patients. While attempting to combat the shortage with systems adjustments, intensivists in the trenches say generating public awareness and changing expectations are crucial for a large-scale remedy.
At 737-bed St. John Medical Center, one of five acute care hospitals in Tulsa, Okla., Gerald Plost, M.D., director of adult critical care, describes the incremental steps his ICU has taken to maximize available resources. Plost's department includes four boarded intensivists who staff 35 adult ICU beds in three ICUs: medical, cardiac and surgical. An expansion to 50 beds is planned by 2005 because demand is so high.
In 1995, St. John decided to credential for critical care and, to avoid inappropriate admissions, granted ICU admitting privileges based on a point system, reserving category-one privileges for intensivists. The second step, in 1999, was the decision to organize with an interdisciplinary approach using protocols.
"We shaved two days off ventilator length of stay, which is well below the national average," Plost says.
With nurses in charge, protocol compliance rates have reached 98% to 100%, he says. Treatment has been standardized, errors have been reduced, and staff can follow some 25 protocols that do not require a physician's order for each step.
Plost says the use of family care specialists has improved patient, family and staff satisfaction. Another big area for improvement is advanced care planning for terminal and incurable patients, though Plost concedes that the data are mixed and change could require a major cultural shift that is beyond the scope of physician influence.
"Introducing palliative care concepts into the ICU or hospital in general will help with this shortage, because we do see patients that really aren't appropriate for critical care end up in the ICU," he says. "Nobody has taken time to do the hard talk, to discuss prognosis and what we can realistically expect for the patient from critical care."
The Leapfrog Group has said hospital ICUs are best managed by intensivists, but there are different ways to meet its ICU physician-staffing standard. Leapfrog recently broadened its definition of intensivist to include doctors who received their training before 1987, when the first critical care fellowships started.
The standard also allows for electronic ICU monitoring (see March, page 26) and nighttime on-call coverage that allows the intensivist to return pages within five minutes and to arrange for staff with fundamental critical care support certification to reach ICU patients within five minutes.
"We knew there was a shortage, but we hoped by highlighting the importance of this kind of staffing we would actually stimulate supply," says Leapfrog Executive Director Suzanne Delbanco. "We know two of three intensivists are not working in an ICU right now. We hope to coax them back into the ICU at least part-time.
"We also try to convince physicians in training that this is a highly respected and incredibly important kind of training to have, to get more physicians to seek the role and close the gap."
Joint Commission ICU Measure SetThe Joint Commission for Accreditation of Healthcare Organizations has identified an initial set of eight adult ICU performance measures, including one that looks at use of critical care physicians.
"It's an understatement to say it is a controversial measure, but the data supports it," says Jerod Loeb, vice president for research and performance measurement at Oakbrook Terrace, Ill.-based JCAHO.
The Joint Commission is alpha-testing the measures at 10 hospitals this month, with beta testing at 100 hospitals to take place later this year. By 2005, JCAHO could make the ICU set one of the a la carte core measurement offerings in its ORYX initiative, which integrates outcomes and other performance measurement data into the accreditation process.
The proposed measures are:
- Use of intensivists
- Patient positioning for ventilator-associated pneumonia prevention
- Stress ulcer disease prophylaxis
- Deep vein thrombosis prophylaxis
- Daily interruption of sedation
- Central line-associated bloodstream infection rate and central line utilization ratio by type of ICU
- Risk-adjusted ICU length of stay by type of ICU
- Risk-adjusted ICU mortality