The American Journal of Medicine
Volume 116, Issue 3 , Pages 206-207, 1 February 2004

Look before you leap: how do intensivists improve care for critically ill patients?

  • Michael A. Gropper, MD, PhD

      Affiliations

    • Corresponding Author InformationMichael A. Gropper, MD, PhD, Critical Care Medicine, 505 Parnassus Avenue, Room M917, University of California, San Francisco, San Francisco, CA 94143-0624, USA
    • Departments of Anesthesia and Medicine, Cardiovascular Research Institute, University of California at San Francisco, San Francisco, California, USA
    • ,
  • Michael A. Matthay, MD

      Affiliations

    • Departments of Anesthesia and Medicine, Cardiovascular Research Institute, University of California at San Francisco, San Francisco, California, USA

Article Outline

 

Arecent Wall Street Journal article recommends (1):

that patients and families insist on knowing whether an intensivist will be caring for them in the intensive care unit or if one can consult on the case … If not, [it] recommends asking to be moved to a hospital that has full-time intensivists on staff. Even though intensive care admissions are often initially unplanned, most patients can be transferred by ambulance.

Statements such as these have provoked anxiety within hospitals, and particularly among hospital administrators. What is the basis for such statements, and what is the quality of evidence to support them?

The Leapfrog Group was established by the Business Roundtable, which consists of the chief executive officers of several large corporations. These corporations purchase health insurance for more than 34 million healthcare consumers, and therefore have considerable influence on health policy (2). The Business Roundtable established the Leapfrog Group to “work 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” (2). One of the first recommendations by this group was that trained intensivists should staff intensive care units. An article by Manthous in this issue of the Journal evaluates the quality of the data upon which the group bases its recommendations on intensive care unit staffing (3).

The data supporting the general concept of intensivist staffing is persuasive. Pronovost (one of the authors of the Leapfrog Guidelines) recently published a meta-analysis of physician staffing in intensive care units. The study compared low-intensity physician staffing (no intensivist or elective intensivist consultation) with high-intensity staffing (mandatory intensivist consultation or a closed intensive care unit that is directed by an intensivist) (4). The results seemed to indicate that high intensity staffing was associated with a lower risk of both intensive care unit and hospital mortality and a reduced length of stay in the critical care setting. As discussed by Manthous (3), this meta-analysis has some limitations. Nevertheless, there is an overall commonsense agreement that the availability of an intensivist to assist in the care of critically ill patients will improve patient outcomes in the intensive care unit, although rigorous, scholarly studies are not available.

If the need for more intensivists is accepted, then there is a problem with implementing the Leapfrog recommendations. For example, the findings of the Committee on Manpower for Pulmonary and Critical Care Societies states that currently, intensivists provide care to only 37% of all critically ill patients, and that by the year 2030 there will be a shortfall of critical care specialist hours by 35% (5). How can we mandate intensivist staffing when such a large shortage of intensivists exists?

Moreover, how should we evaluate the recommendations of the Leapfrog Group? Whereas some guidelines may lend themselves to formal, evidence-based analysis, such as “intensive care units should be staffed by board-certified intensivists,” other recommendations, such as “intensivists should respond to more than 95% of calls for assistance within 5 minutes”, are unlikely to undergo a randomized, prospective trial. The Leapfrog Group recommendations represent an area where health care policy may be driven more by opinion than by solid scientific studies. Whereas changes in clinical practice are usually driven by guidelines and recommendations from professional societies, the Leapfrog recommendations carry additional impetus from hospital administrators and insurers eager to please large consumers of healthcare services.

Perhaps the most important question to ask is: “How do intensivists improve care for critically ill patients?” In addition to bedside clinical skills, a favorable impact of the intensivist on clinical outcomes may depend largely on the intensivist's ability to implement evidence-based practices in the intensive care unit. Critical care medicine has been revolutionized over the last 10 years with the publication of a number of pivotal clinical trials that have significantly transformed the way we care for critically ill patients. For example, the National Heart Lung and Blood Institute Acute Respiratory Distress Syndrome Network conducted a multicenter, randomized, prospective trial of 6 ml/kg versus 12 ml/kg tidal volume for patients with acute lung injury. This trial demonstrated an impressive 9% reduction in mortality when the lower tidal volume was used (6). In another recent study, Ely et al demonstrated that therapist-driven ventilator weaning protocols decrease the duration of mechanical ventilation in patients with acute respiratory failure (7). Also, Van den Berghe et al reported that tight control of blood glucose with insulin infusions may decrease mortality by 34% in surgical patients (8). Whereas each of these three trials demonstrated a decrease in mortality in specific populations, it is likely that the beneficial effects may be extrapolated to other critically ill patients. All three of these interventions also share a common requirement: execution of these protocols needs to be done with a protocol-driven methodology that requires supervision by a physician trained in intensive care medicine. It is likely that this is the area of responsibility where the intensivist may have the greatest effect on improving clinical outcomes. The intensivist needs to be available to establish regular communication with other physicians, nurses, respiratory therapists, and social workers to coordinate the clinical care for the complex, critically ill patient. The intensivist can also help to institute policies for minimizing nosocomial infections, thromboembolic complications, as well as practical, ethical procedures for withdrawal of life support when further critical care appears to be unlikely to restore the patients to some reasonable level of function (9). The intensivist also provides a resource for the consulting physicians in the intensive care unit, a physician to whom the consultant can turn to for an overall appreciation of the patient's prognosis for meaningful recovery. The intensivist can help to decide when life support measures such as mechanical ventilation and dialysis are indicated.

Intensivist staffing represents only one of three patient safety-based recommendations from the Leapfrog Group. Their other recommendations include referral of patients for high-risk procedures to hospitals that frequently perform those procedures, and finally, the group recommends implementation of computerized physician order entry. These recommendations for safety practices are controversial, partly because they are not based on solid evidence. The medical community is increasingly under pressure from both the public and private sectors to improve patient safety. Evidence for intensivist staffing in critical care units appears reasonably strong; however, without definitive Level 1 evidence for the efficacy of specific interventions, we will have to make choices about implementation of these practices driven in part by the public, payers, and hospital administrators. It is imperative that physicians who practice critical care determine the value of these interventions, and that the medical community, not external forces, takes the lead in outlining optimal, realistic strategies for patient safety in the critical care setting.

Back to Article Outline

References 

  1. Landra. L. The informed patient: improving your chances in intensive Care–‘Intensivists’ spot early signs of infections and pneumonia, but a shortage is looming. Wall Street Journal. November 21, 2002: page D1
  2. The Leapfrog Group. The Leapfrog Group for patient safety rewarding higher standards Accessed November 14, 2003
  3. Manthous C. Leapfrog and critical care: evidence- and reality-based intensive care for the 21st century. Am J Med. 2003;116:188–193
  4. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients (a systematic review). JAMA. 2002;288:2151–2162
  5. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease (can we meet the requirements of an aging population?). JAMA. 2000;284:2762–2770
  6. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342:1301-1308
  7. Ely EW, Baker AM, Dunagan DP, et al.  Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med. 1996;335:1864–1869
  8. van den Berghe G, Wouters P, Weekers F, et al.  Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359–1367
  9. Drazen JM. Decisions at the end of life. N Engl J Med. 2003;349:1109–1110

PII: S0002-9343(03)00722-8

doi:10.1016/j.amjmed.2003.11.010

The American Journal of Medicine
Volume 116, Issue 3 , Pages 206-207, 1 February 2004

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