The Hospital Intensivist: what you need to know

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The Hospital Intensivist what you need to know

• John Rickelman Jr., D.O.
• CCU Medical Director
• Co-Director Hospitalist Program
• Northeast Regional Medical Center
• Kirksville, Missouri

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Objectives

• Give a brief history surrounding the Critical
  Care and the Intensivist specialty
• Review the training required of an Intensivist
• Review literature supporting the benefits of an
  Intensivist
• Future directions surrounding the Intensivist
  specialty and Critical Care

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History
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• 1854-Florence Nightingale writes about the
  advantages of establishing a separate area of the
  hospital for patients recovering from surgery.
• Reduced the death rate of British soldiers in the
  hospitals from 42 percent to 2 percent during the
  Crimean War

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• World War II-Isolated rooms in the hospital,
  called shock wards, are established to
  resuscitate and care for soldiers injured in
  battle or undergoing surgery.

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• 1950s-The development of mechanical ventilation
  leads to the organization of respiratory
  intensive care units (ICUs) in many European and
  American hospitals.
• 1958-Approximately 25 percent of community
  hospitals with more than 300 beds report having
  an ICU. By the late 1960s, most United States
  hospitals have at least one ICU

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• 1970- The Society of Critical Care Medicine
  (SCCM) is established as a multiprofessional
  intensive care advocate
• 1986-The American Board of Medical Specialties
  (ABMS) approves a certification of special
  competence in critical care for the four primary
  boards anesthesiology, internal medicine,
  pediatrics, and surgery

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Training
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Critical Care

• Internal Medicine
• Pulmonary, Infectious Diseases, Nephrology
• 3 years
• Stand alone
• 2 years
• Anesthesiology
• Surgery
• Pediatrics

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Benefits
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Financial Modeling

• Using published data, evaluated costs and saving
  for 6, 12, and 18-bed ICUs
• Cost savings ranged from 510, 000 to 3.3
  million

Pronovost etal, CCM 2004 32(6)1247- 1253
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Mortality reduction

• 9 study meta-analysis looking at mortality
  reduction
• 15 to 60 relative reductions
• 15 would equal 53, 850 lives each year

Young etal, Eff Clin Pract. 2001 3(6)284-289
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Esophageal resection

• Presence vs Absence of daily rounds by
  Intensivist
• In- hospital mortality rate, length of stay,
  hospital cost, and complications
• 35 hospitals

Dimick etal, CCM 2001 29(4) 753-758
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Esophageal resection

• Lack of ICU physician on rounds
• 73 increase hospital LOS
• 61 increase in total hospital costs
• No association with in-hospital mortality rate

Dimick etal, CCM 2001 29(4) 753-758
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Nurse Job Satisfaction

• Change from mandatory to semiclosed SICU
• Survey of SICU nursing staff
• Hospital spending on agency nurses decreased ( p
  .0098)
• Job turnover rate dropped from 25 to 16

Haut etal, CCM 2006 34(2) 387-395
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Neurointensive care

• The effect of a neurointensivist run ICU
• 1,087 patients before, 1, 279 patients after
  appointment
• 42 risk reduction of death
• 17 reduction in LOS

Varelas etal, CCM 2004 32(11) 2191-2198
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LEAPFROG
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Leapfrog

• The Leapfrog Group is made up of more than 170
  companies and organizations that buy health care
• Officially launched in 2000

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Leapfrog

• Computer Physician Order Entry (CPOE)  With CPOE
  systems, hospital staff enter medication orders
  via computer linked to prescribing error
  prevention software.  CPOE has been shown to
  reduce serious prescribing errors in hospitals by
  more than 50.
• Evidence-Based Hospital Referral (EHR) 
  Consumers and health care purchasers should
  choose hospitals with extensive experience and
  the best results with certain high-risk surgeries
  and conditions. Research indicates that a
  patients risk of dying could be reduced by 40.
• ICU Physician Staffing (IPS)  Staffing ICUs with
  doctors who have special training in critical
  care medicine, called intensivists, has been
  shown to reduce the risk of patients dying in the
  ICU by 40.

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Leapfrog

• Leapfrogs initial three recommended quality and
  safety practices have the potential to save up to
  65,341 lives and prevent up to 907,600 medication
  errors each year (Birkmeyer,2004). 
• Implementation could also save up to 41.5
  billion annually (Conrad, 2005).

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Future (present) of Critical Care
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ICU Categorization

• Level I, Level II, Level III
• Similar to Trauma Classification
• Could determine reimbursement

Haupt etal, CCM 2003 31(11) 2677-2683
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Workforce

• In 1997, intensivists provided care to 36.8 of
  all ICU patients.
• Care in the ICU was provided more commonly by
  intensivists in regions with high managed care
  penetration.
• The current ratio of supply to demand is forecast
  to remain in rough equilibrium until 2007.
• A shortfall of specialist hours equal to 22 of
  demand by 2020 and 35 by 2030, primarily because
  of the aging of the US population.
• Sensitivity analyses suggest that the spread of
  current health care reform initiatives will
  either have no effect or worsen this shortfall.

Angus etal, JAMA 20002842762-2770
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Workforce

• American Thoracic Society position paper
• Severe shorage of intensivists by 2007
• Shortage to worsen by 2030

American Thoracic Assoc., CHEST 2004 125(4)
1518-1521
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Fundementals of Critical Care Support

• To better prepare the non-intensivist for the
  first 24 hours of management of the critically
  ill patient until transfer or appropriate
  critical care consultation can be arranged.
• To assist the non-intensivist in dealing with
  sudden deterioration of the critically ill
  patient.
• To prepare house staff for ICU coverage.
• To prepare nurses and other critical care
  practitioners to deal with acute deterioration in
  the critically ill patient.

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eICU

• Remote ICU telemedicine program
• Before- and- after trail to asses the effect
• Two adult ICUs of a tertiary care hospital
• 2, 140 patients from 1999- 2001

Breslow etal, CCM 2004 32(1) 31-38
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eICU

• Supplemental monitoring for 19 hrs/day
• Hospital mortality
• 9.4 vs. 12.9(RR 0.73 95 CI 0.55- 0.95)
• ICU length of stay
• 3.63 vs 4.35 days

Breslow etal, CCM 2004 32(1) 31-38
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• www.sccm.org
• www.accp.org
• www.thoracic.org

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Any Questions?