The Hospital Intensivist: what you need to know

The Hospital Intensivist: what The Hospital Intensivist: what you need to knowyou need to know

John Rickelman Jr., D.O.John Rickelman Jr., D.O.CCU Medical DirectorCCU Medical Director

Co-Director Hospitalist ProgramCo-Director Hospitalist ProgramNortheast Regional Medical CenterNortheast Regional Medical Center

Kirksville, MissouriKirksville, Missouri

ObjectivesObjectives

Give a brief history surrounding the Critical Give a brief history surrounding the Critical Care and the Intensivist specialtyCare and the Intensivist specialty

Review the training required of an Review the training required of an IntensivistIntensivist

Review literature supporting the benefits Review literature supporting the benefits of an Intensivistof an Intensivist

Future directions surrounding the Future directions surrounding the Intensivist specialty and Critical CareIntensivist specialty and Critical Care

HistoryHistory

18541854-Florence Nightingale writes about -Florence Nightingale writes about the advantages of establishing a separate the advantages of establishing a separate area of the hospital for patients recovering area of the hospital for patients recovering from surgery.from surgery. Reduced the death rate of British soldiers in Reduced the death rate of British soldiers in

the hospitals from 42 percent to 2 percent the hospitals from 42 percent to 2 percent during the Crimean War during the Crimean War

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

1950s1950s-The development of mechanical -The development of mechanical ventilation leads to the organization of ventilation leads to the organization of respiratory intensive care units (ICUs) in respiratory intensive care units (ICUs) in many European and American hospitals. many European and American hospitals. 19581958-Approximately 25 percent of -Approximately 25 percent of

community hospitals with more than 300 beds community hospitals with more than 300 beds report having an ICU. By the late 1960s, most report having an ICU. By the late 1960s, most United States hospitals have at least one ICUUnited States hospitals have at least one ICU

19701970- The Society of Critical Care - The Society of Critical Care Medicine (SCCM) is established as a Medicine (SCCM) is established as a multiprofessional intensive care advocatemultiprofessional intensive care advocate

19861986-The American Board of Medical -The American Board of Medical Specialties (ABMS) approves a certification Specialties (ABMS) approves a certification of special competence in critical care for of special competence in critical care for the four primary boards: anesthesiology, the four primary boards: anesthesiology, internal medicine, pediatrics, and surgery internal medicine, pediatrics, and surgery

TrainingTraining

Critical CareCritical Care

Internal MedicineInternal Medicine Pulmonary, Infectious Diseases, NephrologyPulmonary, Infectious Diseases, Nephrology

3 years3 years Stand alone Stand alone

2 years2 years AnesthesiologyAnesthesiology SurgerySurgery PediatricsPediatrics

BenefitsBenefits

Financial ModelingFinancial Modeling

Using published data, evaluated costs and Using published data, evaluated costs and saving for 6, 12, and 18-bed ICU’ssaving for 6, 12, and 18-bed ICU’s

Cost savings ranged from $ 510, 000 to Cost savings ranged from $ 510, 000 to $ 3.3 million$ 3.3 million

Pronovost etal, CCM 2004; 32(6):1247- 1253

Mortality reductionMortality reduction

9 study meta-analysis looking at mortality 9 study meta-analysis looking at mortality reductionreduction 15% to 60% relative reductions15% to 60% relative reductions 15% would equal 53, 850 lives each year15% would equal 53, 850 lives each year

Young etal, Eff Clin Pract. 2001; 3(6):284-289

Esophageal resectionEsophageal resection

Presence vs Absence of daily rounds by Presence vs Absence of daily rounds by IntensivistIntensivist In- hospital mortality rate, length of stay, In- hospital mortality rate, length of stay,

hospital cost, and complicationshospital cost, and complications 35 hospitals35 hospitals

Dimick etal, CCM 2001; 29(4): 753-758

Esophageal resectionEsophageal resection

Lack of ICU physician on roundsLack of ICU physician on rounds 73% increase hospital LOS73% increase hospital LOS 61% increase in total hospital costs61% increase in total hospital costs

No association with in-hospital mortality No association with in-hospital mortality raterate

Dimick etal, CCM 2001; 29(4): 753-758

Nurse Job SatisfactionNurse Job Satisfaction

Change from “mandatory” to “semiclosed” Change from “mandatory” to “semiclosed” SICUSICU

Survey of SICU nursing staffSurvey of SICU nursing staff Hospital spending on agency nurses Hospital spending on agency nurses

decreased ( p= .0098)decreased ( p= .0098) Job turnover rate dropped from 25% to 16%Job turnover rate dropped from 25% to 16%

Haut etal, CCM 2006; 34(2): 387-395

Neurointensive careNeurointensive care

The effect of a neurointensivist run ICUThe effect of a neurointensivist run ICU 1,087 patients before, 1, 279 patients 1,087 patients before, 1, 279 patients

after appointmentafter appointment 42% risk reduction of death 42% risk reduction of death 17% reduction in LOS17% reduction in LOS

Varelas etal, CCM 2004; 32(11): 2191-2198

LEAPFROGLEAPFROG

LeapfrogLeapfrog

The Leapfrog Group is made up of more The Leapfrog Group is made up of more than 170 companies and organizations than 170 companies and organizations that buy health care that buy health care

Officially launched in 2000Officially launched in 2000

LeapfrogLeapfrog

Computer Physician Order Entry (CPOE):Computer Physician Order Entry (CPOE): With CPOE systems, With CPOE systems, hospital staff enter medication orders via computer linked to hospital staff enter medication orders via computer linked to prescribing error prevention software. CPOE has been shown to prescribing error prevention software. CPOE has been shown to reduce serious prescribing errors in hospitals by more than 50%.reduce serious prescribing errors in hospitals by more than 50%.

Evidence-Based Hospital Referral (EHR):Evidence-Based Hospital Referral (EHR): Consumers and Consumers and health care purchasers should choose hospitals with extensive health care purchasers should choose hospitals with extensive experience and the best results with certain high-risk surgeries and experience and the best results with certain high-risk surgeries and conditions. Research indicates that a patient’s risk of dying could be conditions. Research indicates that a patient’s risk of dying could be reduced by 40%.reduced by 40%.

ICU Physician Staffing (IPS): ICU Physician Staffing (IPS): Staffing ICUs with doctors who Staffing ICUs with doctors who have special training in critical care medicine, called ‘intensivists’, have special training in critical care medicine, called ‘intensivists’, has been shown to reduce the risk of patients dying in the ICU by has been shown to reduce the risk of patients dying in the ICU by 40%.40%.

LeapfrogLeapfrog

Leapfrog’s initial three recommended Leapfrog’s initial three recommended quality and safety practices have the quality and safety practices have the potential to save up to 65,341 lives and potential to save up to 65,341 lives and prevent up to 907,600 medication errors prevent up to 907,600 medication errors each year (Birkmeyer,2004). each year (Birkmeyer,2004).

Implementation could also save up to Implementation could also save up to $41.5 billion annually (Conrad, 2005). $41.5 billion annually (Conrad, 2005).

Future (present) of Future (present) of Critical CareCritical Care

ICU CategorizationICU Categorization

Level I, Level II, Level IIILevel I, Level II, Level III

Similar to Trauma ClassificationSimilar to Trauma Classification

Could determine reimbursementCould determine reimbursement

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

WorkforceWorkforce

In 1997, intensivists provided care to 36.8% of all ICU In 1997, intensivists provided care to 36.8% of all ICU patients. patients.

Care in the ICU was provided more commonly by Care in the ICU was provided more commonly by intensivists in regions with high managed care intensivists in regions with high managed care penetration. penetration.

The current ratio of supply to demand is forecast to The current ratio of supply to demand is forecast to remain in rough equilibrium until 2007. remain in rough equilibrium until 2007.

A shortfall of specialist hours equal to 22% of demand A shortfall of specialist hours equal to 22% of demand by 2020 and 35% by 2030, primarily because of the by 2020 and 35% by 2030, primarily because of the aging of the US population. aging of the US population.

Sensitivity analyses suggest that the spread of current Sensitivity analyses suggest that the spread of current health care reform initiatives will either have no effect or health care reform initiatives will either have no effect or worsen this shortfall. worsen this shortfall.

Angus etal, JAMA 2000;284:2762-2770

Workforce Workforce

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

American Thoracic Assoc., CHEST 2004; 125(4): 1518-1521

Fundementals of Critical Care Fundementals of Critical Care SupportSupport

To better prepare the non-intensivist for the first To better prepare the non-intensivist for the first 24 hours of management of the critically ill 24 hours of management of the critically ill patient until transfer or appropriate critical care patient until transfer or appropriate critical care consultation can be arranged. consultation can be arranged.

To assist the non-intensivist in dealing with To assist the non-intensivist in dealing with sudden deterioration of the critically ill patient. sudden deterioration of the critically ill patient.

To prepare house staff for ICU coverage. To prepare house staff for ICU coverage. To prepare nurses and other critical care To prepare nurses and other critical care

practitioners to deal with acute deterioration in practitioners to deal with acute deterioration in the critically ill patient. the critically ill patient.

eICUeICU

Remote ICU telemedicine programRemote ICU telemedicine program

Before- and- after trail to asses the effectBefore- and- after trail to asses the effect

Two adult ICUs of a tertiary care hospitalTwo adult ICUs of a tertiary care hospital 2, 140 patients from 1999- 20012, 140 patients from 1999- 2001

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

eICUeICU

Supplemental monitoring for 19 hrs/daySupplemental monitoring for 19 hrs/day Hospital mortalityHospital mortality

9.4% vs. 12.9%(RR 0.73: 95% CI 0.55- 0.95)9.4% vs. 12.9%(RR 0.73: 95% CI 0.55- 0.95) ICU length of stayICU length of stay

3.63 vs 4.35 days3.63 vs 4.35 days

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

www.sccm.orgwww.sccm.org www.accp.orgwww.accp.org www.thoracic.orgwww.thoracic.org

Any Questions?Any Questions?