Chapter 2 The Intensivist in the New Hospital Environment
Patient Care and Stewardship of Hospital Resources
Many studies in the literature have reported that management of the ICU and critically ill patients by intensivists increases survival rates and decreases resource utilization.1–4 In addition to improvement in resource utilization, Gajic et al.3 reported that the presence of a critical care specialist was associated with improved staff satisfaction, an important consideration when considering the increasing staffing limitations. Not all studies have reported a benefit in outcome, however. In sharp contrast to the many studies showing improved outcomes associated with intensivist staffing, Levy et al.5 reported that patients managed by intensivists had a higher risk of death than did those who were not managed by them. It is not clear why this study had such disparate results from previous studies, but one likely reason is that the study design was very different from that of previous studies, as were the definitions used.6 The systematic review by Pronovost et al.1 defined high-intensity staffing as the ICU policy requiring that the intensivist have responsibility for care for all of the patients in the ICU (closed ICUs) or that there be a mandatory consultation by an intensivist. In the study by Levy et al.,5 the involvement of the intensivist was elective (i.e., not decided at the unit level but by the choice of the attending physician). According to the definition by Pronovost et al.,1 ICUs that allow the choice of whether to involve an intensivist are low-intensity staffing models. The effect of intensivists in low-intensity–staffed ICUs has not been studied adequately. Levy et al.5 did a separate analysis of no-choice ICUs versus choice ICUs and reported that the mortality rate was higher in the no-choice ICUs, raising the question again as to whether intensivist staffing may increase mortality rates, although a mechanism by which this outcome might occur is not apparent. The preponderance of available studies continues to show a benefit of management by an intensivist.
Unlike adult critical care units, nearly all pediatric ICUs have trained pediatric intensivists who manage most (if not all) of the patients. In the United States, only about 30% of the adult ICUs are staffed by trained intensivists. Regionalization of trauma services for adults has improved outcomes of trauma patients.7 Regionalization has been recommended as a way to improve the care of critically ill or injured adults and children, although the barriers to regionalization are far greater for adults than for children.8,9 Regionalization effectively puts limited resources together to maximize the effectiveness and availability of these resources to a greater number of patients, although at the expense of travel for many patients and their families.
Organization and Quality Issues
During the past 2 decades, the cost of health care in the United States has increased dramatically, with hospital costs increasing more rapidly than other cost indexes. Controlling critical care medicine costs will be an important issue as health care reform is discussed. Critical care consumes an increasing proportion of hospital beds as the acuity of hospital inpatients increases. Although the cost of critical care is rising, the proportion of national health expenses used in critical care medicine has decreased over time.10,11 Different methods for calculating critical care medicine costs create some discrepancies in the estimates of these costs, making it difficult to ensure that efforts to control costs are really effective. The ICU provides support to a variety of services that could not be offered without ICU care, such as cardiac surgery and transplantation. Defining the ICU as the cost center gives a very different picture of the expense of ICU care than would attributing the costs of such patients to the services that use the ICU. Similarly, attributing some of the revenue that such services generate to the ICU and critical care physicians rather than solely to the surgical service per se provides a different view of the value of the ICU to the institution. Different strategies for controlling costs have potential benefit but often have unintended consequences. Shifting costs from the ICU to the supporting hospital services further complicates efforts to account for accurate ICU costs. True critical care medicine cost containment is extremely difficult, if not impossible.12
Effective multidisciplinary care requires developing a teamwork model in the ICU. True teamwork recognizes the importance of the role of each member of the team and requires respect and trust for the other professions represented on the team. Effective communication between all members of the health care team and the patient/family cannot be overemphasized. A collaborative partnership with shared responsibility for maintaining communication and accountability for patient care includes the recognition that no one provider can perform all parts of patient care; the whole team is much more effective than each member of the team alone. True teamwork is a complementary relationship of interdependence.13
An effective team is critical to both the clinical and financial health of the ICU.14 Good teamwork requires a number of skills. A team performance framework for the ICU requires communication, leadership, coordination, and team decision making. Effective team leadership is crucial for guiding effective team interactions and coordination. Leadership performance can be measured; the leadership performance of attending intensivists is associated with accomplishment of daily patient goals.15 Important leadership characteristics include communication skills, conflict management, time management, acknowledging others’ concerns and one’s own limitations, focus on results, setting high standards, and showing appreciation for the work of the team.
Quality improvement is an important part of ICU management. The intensivist must be responsible for leading and ensuring quality improvement efforts. The Institute of Medicine’s “six aims for improvement” are safety, effectiveness, equity, timeliness, patient centeredness, and efficiency.16 These aims are certainly relevant to pediatric critical care practice and can provide a framework for improving quality in the pediatric ICU (PICU). Acuity scores have been used as tools for measuring quality in the ICU. It is important for the intensivist to understand the various available scoring systems and how they can be used to ensure appropriate use of these tools.17
The use of clinical pathways has been shown to improve efficiency of care and decrease resource utilization.18 The intensivist, as leader of the team, must ensure that these guidelines are developed with input from all members of the ICU team to optimize acceptance and smooth implementation of such guidelines. Standardization of care increases the likelihood that every patient will get the appropriate treatments at the right time. A common objection to standardization is that ICU patients are too complex or too different to be able to standardize their care. However, some aspects of care should be provided to most, if not all, patients and can be overlooked easily if they are not standardized. One example is insertion of central venous catheters using full-barrier precautions to prevent line-associated bloodstream infections. Checklists are helpful to remind all members of the team to carry out the “routine” steps every time. In the case of a patient who has a contraindication to “standard” care, the contraindication should be documented. In an environment that is increasingly complex, ensuring reliability in processes of care is exceedingly difficult. Standardizing the processes means that everyone on the team knows what to expect. Empowering every member of the team to speak up if he or she observes an unsafe condition further increases the safety of the patient and the reliability of care.
A systematic review by Carmel and Rowan19 described eight organizational categories that may contribute to patient outcome in the ICU. These factors include staffing, teamwork, patient volume and pressure of work, protocols, admission to intensive care, technology, structure, and error. Pollack and Koch20 demonstrated that organizational factors and management characteristics can influence health outcomes in the neonatal ICU. The intensivist, as captain of the ship, is responsible for ensuring that these important organizational factors are optimized in the ICU.
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