Sean Townsend, Christa Schorr and Carolyn Bekes

Chapter Outline

The Present-Day Critical Care Landscape

Establishing an agenda for administrators and leaders of ICUs starts with a critical analysis of their current position in critical care delivery. This section describes the ongoing evolution of the critical care landscape in regard to patterns of use, costs, and current configurations.

Surveys of critical care delivery in the United States date back to the early 1990s.5,6 Reports of the supply and demand of adult critical care were most recently completed in 2000 through a joint effort on behalf of the American Thoracic Society (ATS), the American College of Chest Physicians (ACCP), and the Society of Critical Care Medicine (SCCM).⁷ Estimates on current and future requirements for adult critical care and pulmonary medicine physicians in the United States were reported by the Committee on Manpower for the Pulmonary and Critical Care Societies (COMPACCS). Angus and coworkers, on behalf of the COMPACCS group, extended their inquiry in 2006 to profile the organization and distribution of ICU patients and services in the United States.⁸

The initial COMPACCS study concluded that in 1997, intensivists provided care to 36.8% of all ICU patients and that intensivist level care was more common in regions with high managed care penetration. The 2006 update estimated that there were 5980 ICUs in the United States, caring for approximately 55,000 patients per day. Sixty-five percent of ICUs were combined medical-surgical ICUs; 71% were located in nonteaching community hospitals; and 62% of all ICUs were located in hospitals with fewer than 300 beds. Another important finding was the projected shortfall of critical care physicians of 22% by 2020 and 35% by 2030.

In response to the COMPACCS study report, an analysis was requested by the U.S. Senate. In 2006 a report to Congress from the U.S. Department of Health and Human Services’ Health Services and Resource Administration (HSRA) updated the findings in COMPACCS, reiterating their projections with respect to the critical care workforce.⁹ The HSRA workforce analysis indicated that the growth and aging of the population alone will increase demand for adult intensivist services by at least 38% between 2000 and 2020. Similarly, critical care nursing availability remains woefully inadequate to meet the demand. Proactive recruitment and retention strategies are paramount to maintain high-quality nursing care (Box 70.1).

The shortfall in supply of intensivists may drive administrators to consider an alternative critical care delivery team model, which may include nonintensivist physicians and physician extenders. Consideration to hopitalists partnering with intensivists as an option to fill the gap in intensivist supply is being addressed by two task forces, first in a publication of the 2004 Framing Options for Critical Care in the United States (FOCCUS) report and second in 2007 Prioritizing the Organization and Management of Intensive Care Services in the United States (PrOMIS) Conference Report.10,11 Reports from these task forces made three recommendations in an attempt to address the situation: to include (1) uniform protocols for intensive care treatment, (2) a process for certification of physicians providing critical care services with a competency assurance process, and (3) health service research with a focus on outcomes of ICU patients cared for by hospitalists.¹² In another model, use of physician extenders may include physician assistants (PAs) and nurse practitioners (NPs). Limited research exists examining the use of NPs and PAs in the critical care setting with the majority focused on their impact on patient care management. Despite the small sample sizes and limited studies, NPs and PAs have demonstrated enhanced patient flow, improved clinical and financial outcomes for mechanically ventilated patients, reduction in ICU and hospital length of stay, and improved management in the heart failure patient population.¹³ Because the lack of intensivist staffing is unlikely to change significantly over the next few years, alternative models may be on the horizon.

Regardless of the expected reductions in available staffing, calls for increased access to intensivists continue with a goal of increasing intensivist coverage in-house around the clock. Despite the challenge by one recent study,¹⁴ multiple studies have demonstrated mortality rate and cost-savings benefits to critically ill patients receiving care by intensivists. Young and Birkmeyer estimated that in the context of 360,000 deaths occurring each year in ICUs, 54,000 lives may be saved annually with intensivist staffing.¹⁵ Similarly, Pronovost and colleagues have estimated that more than $5 billion could be saved annually.¹⁶ A report generated for the Agency for Healthcare Research and Quality (AHRQ) notes that these benefits alone underestimate the potential improvement in the quality of care in terms of fewer complications, avoiding inappropriate utilization, decreased patient suffering, and better end-of-life care.¹⁷

The Leapfrog Group, a consortium of companies that purchase health care for their employees, convened in an effort to leverage their purchasing power to improve the quality of care. This powerful group has focused on improving four key areas central to patient safety and to cost containment in health care: (1) the use of computerized physician order entry, (2) the oversight of critical care physicians in the care of ICU patients, (3) the use of evidence-based hospital referral systems, and (4) Leapfrog safe practice scores.¹⁸ The influence of this group on both payers and health systems alike has contributed to the increasing demand for intensivists to care for critically ill patients. Unfortunately, the 2006 update to the COMPACCS study suggests that this need has gone essentially unmet. Loosely defining Leapfrog-compliant intensivist coverage for 80% of critically ill patients and the presence of 24-hour in-house physician coverage, Angus and colleagues found that only one in four ICUs had 80% intensivist coverage and that half had no intensivist coverage. Very few hospitals provided in-house physician coverage during off hours: 20% during weekend days, 12% during weekday nights, and 10% during weekend nights. Overall, only 4% of adult ICUs in the United States appeared to meet even a liberal interpretation of Leapfrog standards.⁸

Idealized Design for Critical Care Practice

In the face of an emerging demand-driven crisis in critical care, the task of effective ICU administration will only become a more difficult challenge. Nevertheless, efforts must be made to adapt care delivery patterns to the emerging demand crisis. Failure to develop new patterns of critical care delivery will ensure inadequate care for thousands of patients for years to come. In the absence of renewed planning, failure probably will evolve slowly, first affecting vulnerable populations, such as the uninsured and those located in rural areas. As time passes, a larger and larger proportion of Americans will receive less than the ideal standard of care.

A key first step is to halt further deterioration in present practice through effective coordination and communication to mitigate further erosion in practice standards (Boxes 70.2 and 70.3). Strategies to refine critical care delivery and meet predicted needs are present in the literature. Retaining tactics that have proved effective in trauma care are essential in building on current designs to streamline access to critical care. Hospital systems will need to collaborate on the care of critically ill patients in order to distribute critical care equitably as a resource, a social commodity. Finally, a realignment of values among health care leaders to build and reinforce a culture of efficiency, safety, and continuous improvement may stave off mediocrity.

Rational Model for Critical Care Delivery

Delivery of critical care should attempt to balance the needs of the community with access to the highest quality critical care services within that area. The American College of Surgeons (ACS) set the precedent for national practice standards for specific sets of critically ill patients when trauma centers were organized. When patients sustain injury with possible trauma, their care is initiated at appropriate trauma centers, depending on readiness and capacity to deliver care. Each designated level of classification (levels I to IV) has associated standards designated by the ACS. The structure has redefined the care of trauma patients and has been associated with improved outcomes and decreased mortality rates.19,20

Advancement in critical care delivery is feasible using a similar approach. The American College of Critical Care Medicine (ACCM) of the SCCM has developed a system to segregate hospitals into specific categories based on readiness and capacity to deliver critical care services (Box 70.4). These guidelines were first published in 1999 and revised in 2003.⁴ Appropriate application of these guidelines provides a gateway in developing collaborative relationships and to ensure a streamlined approach to critical care delivery.

Box 70.4

Levels of Critical Care

Level I critical care: Level I critical care centers have intensive care units (ICUs) that provide comprehensive care for a wide range of disorders requiring intensive care.⁴ They require the continuous availability of sophisticated equipment, specialized nurses, and physicians with critical care training. Support services including pharmacy services, respiratory therapy, nutritional services, pastoral care, and social services are comprehensive. Although most of these centers fulfill an academic mission in a teaching hospital setting, some may be community-hospital based.

Level II critical care: Level II critical care centers have the capability to provide comprehensive critical care but may not have resources to care for specific patient populations (e.g., cardiothoracic surgery, neurosurgery, trauma). Although these centers may be able to deliver high-quality care to most critically ill patients, transfer agreements must be established in advance for patients with specific problems. The ICUs in level II centers may or may not have an academic mission.

Level III critical care: Hospitals that have level III capabilities have the ability to provide initial stabilization of critically ill patients, but they are limited in the ability to provide comprehensive critical care. These hospitals require written policies addressing the transfer of critically ill patients to critical care centers that are capable of providing the comprehensive critical care required (level I or level II). These facilities may continue to admit and care for a limited number of ICU patients for whom care is routine and consistent with hospital and community resources.

Adapted from Haupt MT, Bekes CE, Brilli RJ, et al: Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care. Crit Care Med 2003;3:267-268.

Although the ACCM guidelines set the stage for ideal function of hospitals within each classification, a substantial performance gap between compliance with the guidelines and actual practice remains. Administrators should define their mission, thereby determining the range of services that their hospital seeks to effectively offer patients. Instrumental aspects to consider include the population the hospital serves, services provided by neighboring hospitals, and subspecialties of the staff physicians. Other factors that may be informative in redesign include a list of common diagnoses and acuity level in patients who are routinely treated.⁴

Even hospitals that appear to have well-integrated strategies can benefit from review of current operating procedures. As part of the overall strategy for evolution of hospitals into this operating model, it is reasonable to expect a large number of hospitals to be in transition at any given time. Resistance to regionalization at the local level can be anticipated. Local hospital administrators will not want to forgo revenue, community physicians will not want to “lose” patients to the referral hospital, and communities may resist loss of local services.

The specific standards that define level I and level II care are summarized in Box 70.5. Many hospitals will not be able to maintain these standards, and overlap with level II or level III critical care facilities may be considerable. Level II hospitals capable of providing comprehensive care for most diagnoses should attempt to emulate the level I guidelines for most conditions. For instance, a level II institution may not have the resources for optimal treatment of severe burns, but that facility may provide excellent surgical, cardiac, and posttransplantation medical care. Such a facility should aim to meet level I standards for conditions other than severe burns.

Box 70.5

Intensive Care Unit (ICU) Leadership

A A physician Unit Director is required. In general, the director should meet the guidelines for the definition of an intensivist as published by the Society of Critical Care Medicine. Specific requirements for the Unit Director include:

1. Training, interest, and time availability to give clinical, administrative, and educational direction to the ICU

2. Board certification in critical care medicine

3. Time and commitment to maintain active and regular involvement in the care of patients in the unit

4. Expertise necessary to oversee the administrative aspects of unit management, including formation of policies and procedures, enforcement of unit policies, and the education of unit staff

5. The ability to ensure the quality, safety, and appropriateness of care in the ICU

6. Availability (of either the Director or a similarly qualified surrogate) to the unit 24 hours a day, 7 days a week for both clinical and administrative matters

7. Active involvement in local or national critical care societies

8. Hospital privileges to perform relevant invasive procedures

9. Active involvement as an advisor and participant in the organization of the care of the critically ill patient in the community as a whole

10. Participation in the education of unit staff, other physicians, house staff, and medical staff as indicated

11. Participation in scholarly activity (case reports, clinical and basic research)

12. Active participation in the review of the appropriate utilization of ICU resources in the hospital

B A Nurse Manager is appointed to provide precise lines of authority, responsibility, and accountability for the delivery of high-quality patient care. Specific requirements for the Nurse Manager include:

1. An RN with a BSN or preferably an MSN degree

2. Certification in critical care or equivalent graduate education

3. At least 2 years of experience working in a critical care unit

4. Previous management experience, including experience with health information systems, quality improvement, risk management activities, and health care economies

5. Preparation to participate in the on-site education of critical care unit nursing staff and physicians-in-training

6. Ability to foster a cooperative atmosphere with regard to the training of nurses, physicians, respiratory therapists, and other personnel involved in the care of critical care unit patients

7. Regular participation in ongoing continuing nursing education

8. Ability to participate in, and foster cooperation for, scholarly activity in the ICU (e.g., presentations, clinical research)

9. Knowledge about current advances in the field of critical care nursing

10. Participation in strategic planning and redesign efforts

From Haupt M, Bekes CE, Bayly RW, et al: Critical care services and personnel: Recommendations based on a system of categorization into two levels of care. American College of Critical Care Medicine of the Society of Critical Care Medicine. Crit Care Med 1999;27:422.

For level II or III institutions, a critical requirement of the guidelines is to establish agreements for transfer of patients for higher levels of care. It should be a usual practice in such facilities to stabilize patients with the intention to invoke established agreements to transfer to collaborating facilities.²¹ Although completing transfers may be routine for ICU staff, the requirement for agreements established in advance with collaborating institutions to accept transfers may be novel. In order to develop the efficiencies that will be necessary in the emerging critical care environment, these types of prenegotiated arrangements will be necessary to ensure access to needed care.

The requirement to transfer also implies a burden of review on level II and level III centers to understand the treatment options available at more advanced centers with respect to a wide array of diagnoses. Although many administrators may assume that their clinicians maintain a full understanding of treatment options outside their facility, this assumption may be faulty. It is therefore appropriate with respect to specific diagnoses to develop codified procedures that demarcate established points in care suitable for transfer. These procedures may be incorporated as part of the envisioned interhospital agreement to coordinate transfers. Bed availability in the tertiary hospital may require alternative solutions in times of high occupancy.

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