Research shows their presence in the ICU improves outcomes, yet most hospitals
are without these specialists
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By: Ken Krizner
Managed Healthcare Executive
The Intensive Care Unit (ICU) is, in many ways, the most significant section of a hospital, because it is where life-threatening issues occur almost daily. The ICU is the one area where most hospitals don't employ specialists—board-certified intensivists with expertise and training in critical care medicine.
Scientific evidence suggests that quality of care in the ICU is strongly influenced by whether intensivists are providing that care, according to the Leapfrog Group, leading the organization to recommend that hospitals staff their ICUs with trained intensivists.
Intensivists spend their time exclusively in the ICU and are immediately available when complications arise in a patient's condition.
"Intensivists are specifically trained to handle critical care patients," says Barbara Rudolph, director, leaps and measures, for the Leapfrog Group. "Most ICU patients have suffered traumatic events or experienced system failure. Intensivists are trained to quickly identify and treat these patients to prevent further complications."
In ICUs without trained intensivists, an attending physician typically makes rounds once a day and is called if an emergency occurs. There is no ongoing physician presence in these ICUs.
"On a practical level, well-meaning [attending] physicians try to take care of ICU patients, but they don't have the expertise and don't spend much time in the unit," says Paul M. Vespa, MD, director of neurocritical care at UCLA Medical Center in Los Angeles, which staffs its ICU with specialists. "Critically ill patients experience continual changes in their conditions and [these] physicians aren't in the ICU long enough to see those changes."
CRITICAL CARE TRAINING
Intensivists, on the other hand, are trained in a multi-disciplinary approach to critical care medicine. Their medical practice is focused entirely on the care of the critically ill or injured.
Intensivists direct a team of practitioners that includes nurses, pharmacists, respiratory therapists and nutritionists—all with experience in dealing with critically ill patients.
"The intensivist is trained to coordinate the group and make sure everyone is on the same page," says Margaret Parker, MD, director of the Pediatric Intensive Care Unit at Stoneybrook University Hospital in Stoneybrook, N.Y., who served as president of the Society for Critical Care Medicine (SCCM) from 2004 to 2005.
At Rose Medical Center in Denver, which began using intensivists from nearby National Jewish Medical and Research Center in 2006, an increasing number of patients have been admitted to the ICU, and there is a higher rate of acuity, says Stephen Frankel, MD, section head for critical care and hospital medicine at National Jewish. This is a direct result of Rose Medical Center bringing intensivists into its ICU.
ISSUES HAMPER WIDESPREAD USE
Despite this, there is an intensivist presence in only 20% of the nation's 6,000 ICUs, which have an aggregate total of 55,000 patient days in an average year. Larger and academic hospitals are apt to have intensivists on staff, but it is a much different story for smaller community and rural hospitals.
There are two issues—cost and a lack of intensivists.
Without trained intensivists, critical care medicine is expensive. While ICU patients comprise 5% to 10% of hospital beds nationwide, ICU services comprise 20% of hospital budgets. Adding four intensivists to ensure around-the-clock coverage of an ICU could add another $1 million to $2 million annually to the cost.
There are currently about 6,000 board-certified intensivists, according to SCCM, and for every hospital in the country to employ a staff of intensivists, there needs to be about 36,000.
The shortage will continue to be felt as the population grows older and hospitals find more patients filling their ICU beds.
Part of the problem is the nation's medical schools aren't turning out enough intensivists to fill the need. The number of students choosing critical care as their specialties is expected to remain flat, or even decrease until at least 2030, according to SCCM.
HOSPITALS STAFF ICUS REMOTELY
Some hospitals are getting around the issues of cost and numbers by using telemedicine to remotely staff their ICUs with intensivists.
"We got started because there were mid-sized community hospitals that wanted intensivists in their ICUs," says Mary Jo Gorman, MD, founder of Advanced ICU Care, which began operations in 2006 and currently services nine hospitals nationwide. "But because of the labor shortage and lack of opportunity, they were having trouble finding those individuals."
"Our clinicians, sitting in front of their monitor, can communicate with a patient, physician or nurse, analyze patient information, make clinical assessments, and give orders to the nursing staff," Dr. Gorman says.
If there is a sudden change in the patient's condition, the intensivist will alert the on-site nurse and give instructions on a course of treatment.
For St. Clare's Hospital in Weston, Wis., which opened in October 2005, Advanced ICU Care was the option after there were difficulties recruiting intensivists for its 12-bed ICU. The hospital does have one intensivist on staff. Prior to the hospital's opening, there was a commitment to staff the ICU with intensivists.
"A year before we opened, we realized we didn't have the [human] resources to fulfill our goal," says Richard H. Bailey, MD, medical director of inpatient care and hospitalist services for Saint Clare's. "We had to go to Plan B, which was an electronic ICU."
INTENSIVIST CAN LEAD TO LOWER COSTS
Dr. Bailey says length of stay in the ICU and the hospital is significantly shortened because St. Clare's ICU is operated by intensivists, even though it is on a remote basis.
"Our data suggests that we have seen reductions in predicted mortality by 50%, and length of stay in the ICU lowered by as much as 50%," he says.
Overall, research shows that in ICUs where intensivists manage or co-manage all patients, there is a 40% reduction in ICU mortality and 30% reduction in hospital mortality, compared with ICUs without the presence of trained intensivists, according to the Leapfrog Group.
There is also a significant reduction in the length of stay in an ICU, which usually means there are fewer complications.
The average daily charge for an ICU bed is $2,000 to $3,000. If an ICU treats 1,000 patients a year and if an intensivist can avoid one day per patient, the annual cost savings would be between $2 million and $3 million.
"It is a huge number for cost savings," Dr. Vespa says. "There is no single thing you can do to save that money. It is the integrated action of a specialist dedicated toward running the ICU in an efficient way."
Ken Krizner is a Cleveland-based freelance writer.