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August 2001
Volume 65 |
Number 8
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| Critical Care:
The Times They Are a Changin’! |
Todd Dorman, M.D.
Anesthesiologists have played a pivotal role in the formation,
ongoing development and maturation of critical care medicine.
Anesthesiology-based critical care practitioners were among the
founding members of the Society of Critical Care Medicine more
than 27 years ago. In 1987, the American Board of Anesthesiology
was the first to offer a special qualification examination process
in critical care medicine. However, as of 2000, there were twice
as many surgeons (~1,800) and almost eight times as many internists
(~6,800) carrying special qualifications in critical care medicine
than anesthesiologists (~900). 1
Reversing this trend is of vital importance to anesthesiology.
Market forces, both internal and external to anesthesiology, were
once inhibiting many physicians from choosing critical care medicine.
However, the November 2000 release of the Leapfrog Group’s
standard regarding Intensive Care Unit Physician Staffing (IPS)
has essentially removed the external constraints, leaving the
door wide open for anesthesiologists to rush in and fill the supply-demand
void.2 The opportunities are great, if we anesthesiologists will
remove our self-imposed internal constraints.
Supply and Demand
Only five years ago, residents were somewhat reluctant to go
into critical care medicine fellowships following their anesthesiology
residencies because of concerns about finding a job afterward.
Since health care enterprises were not clamoring for more intensivists,
supply and demand seemed to already be matched. In fact, there
were many examples of anesthesiology practices forcing members
to abandon the practice of critical care medicine. The decision
to focus on intraoperative care was made under the guise of fiscal
responsibility, as many practices viewed the provision of critical
care as unprofitable. This retraction from critical care created
the vicious cycle of fewer jobs, and so fewer residents were interested,
leading to fewer providers forcing more groups to withdraw because
of staff shortages.
External to anesthesiology, the market did not seem ready to
accept intensivists. The critical care community failed to educate
patients, physicians, administrators and payers regarding the
benefits of physician-led critical care services. Consequently,
it appears that less than 30 percent of adult patients in intensive
care units have access to a full-time intensivist.
The Leapfrog Group
Fortunately, the external market decided to look at the data
regarding the value of intensivists. The Fortune 500 companies
and other large health care purchasers, committed to a common
set of purchasing principles to drive leaps in patient safety,
founded the Leapfrog Group. The Leapfrog Group’s goal is
to mobilize employer purchasing power to initiate breakthrough
improvements in the safety and overall value of health care to
American consumers. The group meticulously reviewed the literature
on the impact of an intensivist on both the quality and cost of
intensive care unit (ICU) care. The result of that review was
the IPS standard. A brief summary of that literature is quite
informative.
A systematic review of the literature demonstrates that critical
care specialists reduce mortality. The studies by Li, Pollack,
Reynolds, Brown, Carson, Manthous, Multz, Ghorra, Pronovost and
Rosenfeld demonstrate a median absolute risk reduction of 10 percent,
or a number needed to treat of 10.3-13 The studies by Ghorra,
Hanson, Pronovost and Rosenfeld demonstrate a reduction in complications.10-14
In the Pronovost study of all abdominal aortic aneurysm surgery
in Maryland over a three-year period, there was an odds ratio
of 1.8 for septicemia, 2.0 for reintubation, 2.2 for acute renal
failure and 2.9 for cardiac arrest when a critical care specialist
was not involved in the postoperative management of the patient.
These major complications clearly affect patient mortality and
the cost of care. The studies by Brown, Manthous, Multz, Hanson,
Pronovost and Rosenfeld demonstrate reduced ICU length of stay,
and this reduction in length of stay persisted through to hospital
discharge in the three studies that followed patients for that
outcome variable.7-14 Four studies by Li, Pollack, Carson and
Multz demonstrate reduced use of ICU resources for those patients
at low risk. This improved throughout by establishing appropriateness
of admission and lowering the cost of care for a population of
patients who did not require ICU services, but without which the
intensivist-led team would have indeed consumed those resources.3,4,7,9
Two studies demonstrated that a critical care specialist reduced
patient charges, and two demonstrated a reduction in consultation
and professional fee charges.9,12,14
In addition, we are aware of two additional studies similar to
the statewide study by Pronovost et al. that examine outcomes
in patients undergoing esophageal resections or hepatic resections.
These manuscripts are under peer review but appear to demonstrate
the identical findings as the seminal work done with aortic aneurysm
surgery. In summary, the body of scientific literature that exists
strongly supports a model of ICU care that includes a critical
care specialist-led process.
The Leapfrog Group IPS standard is scheduled for full implementation
by December 31, 2003. You might be wondering if health care is
going to pay attention to this standard. The early impression
is absolutely yes. Many institutions have already contacted the
Leapfrog Group and asked for assistance in establishing the standard
in their institution. In addition, I am aware of a conversation
between the head of a major timber firm that called its local
health care facility asking if they met the standard now and,
if not, would they meet the standard by the implementation date.
Furthermore, this CEO went on to state that if the facility did
not meet the standard by the implementation date, his corporation
would no longer support its employees seeking health care at that
institution.
How anesthesiologists respond to this opportunity is vitally
important. Critically ill patients require our expertise in airway
management skills, physiology, pharmacokinetics and pharmacodynamics
and pain management. One of the hottest topics currently in health
care is the avoidance of errors and the creation of safe systems.
Anesthesiologists are leaders in the science of safe systems in
health care, and our expertise in this domain is directly transferable
to the ICU environment. The anesthesiologist’s proactive
mindset is essential to the practice of anesthesiology and critical
care medicine. While reactionary care will always be a part of
critical care practice, proactive pattern recognition and intervention
produce far greater patient benefits. This message must be transmitted
clearly and effectively to all anesthesiologists, administrators
and the public. As a specialty, we should not permit our postoperative
role to become restricted to postanesthesia care units.
The fear of a negative financial impact that drove many groups
from providing critical care services must be surpassed. The relative
value unit (RVU) for critical care services was recently reinstated
to 4.0 for 99291 and 2.0 for 99292. The definition of critical
care services has been clarified to include both treatment and
prevention of major organ dysfunction. Inclusion of time for family
conferences that address major decision-making is now permitted.
Inclusion of time for documentation is also permitted. The RVU
for placement of a CVP has just increased, and it appears likely
that the RVU for placement of an arterial catheter will increase
as well. For those anesthesiologists who fear the murky waters
of the older critical care codes, the Office of the Inspector
General released a report on critical care services during this
past year stating that they found no major problems with critical
care billing. The times they are a changin’!
The demand is clearly there and growing. It has been estimated
that 35,000 critical care physicians will be required to staff
all adult ICUs. The supply, on the other hand, falls short, as
there are less than 9,500 critical care medicine-certified physicians
in this country! Industry, based on the literature, is pushing
health care centers to make a commitment to full-time ICU services.
At the same time, financial rewards from ICU services are improving.
Now is the time for all anesthesiologists to help advance the
role of the anesthesiologist/intensivist. There will not be a
better time for practice diversification! We must put away old
prejudices immediately because if we do not seize this opportunity
quickly, then others (i.e., pulmonologists and surgeons) will
surely do so.
References:
1. Personal communications with credentialing
staff at ABA, ABIM, ABS. May 2000.
2. Birkmeyer JD, Birkmeyer CM, Wennberg DE, Young
MP. Leapfrog Safety Standards: Potential Benefits of Universal
Adoption. Washington, DC.: The Leapfrog Group. 2000.
3. Li TC, Phillips MC, Shaw L, Cook EF, Natanson
C, Goldman L. On-site physician staffing in a community hospital
intensive care unit: Impact on test and procedure use and patient
outcome. JAMA. 1984; 252(15):2023-2027.
4. Pollack MM, Katz RW, Ruttiman UE, Getson PR.
Improving the outcome and efficiency of intensive care: The impact
of an intensivist. Crit Care Med. 1988; 16:11.
5. Reynolds HN, Haupt MT, Thill-Baharozian MC,
Carlson RW. Impact of critical care physician staffing on patients
with septic shock in a university hospital medical intensive care
unit. JAMA. 1988; 260(23):3446-3450.
6. Carson SS, Stocking C, Podsadecki T. Effects
of organizational change in the medical intensive care unit of
a teaching hospital. JAMA. 1996; 276:322-328.
7. Brown JJ, Sullivan G. Effect on ICU mortality
of a full-time critical care specialist. Chest 1989; 96(1):127-129.
8. Manthous CA, Amoateng-Adjepong Y, Al-Kharrat
T, Jacob B, Alnuaimat HM, Chatila W, Hall JB. Effects of a medical
intensivist on patient care in a community teaching hospital.
Mayo Clin Proc. 1997; 72:391-399.
9. Multz AS, Chalfin DB, Samson IM, Dantzker DR,
Fein AM, Steinberg HN, Niederman MS, Scharf SM. A “closed”
medical intensive care unit (MICU) improves resource utilization
when compared with an “open” MICU. Am J Resp Crit Care
Med. 1998; 157:1468-1473.
10. Ghorra S, Reinert SE, Cioffi W, Buczko G,
Simms H. Analysis of the effect of conversion from open to closed
surgical intensive care unit. Annals of Surgery. 1999; 229(2):163-171.
11. Pronovost P, Jenckes M, Dorman T, Garrett
E, Breslow MJ, Rosenfeld BA, Lipsett PA, Bass E. Organizational
characteristics of intensive care units related to outcomes of
abdominal aortic surgery. JAMA. 1999; 281(14):1310-1317.
12. Rosenfeld BA, Dorman T, Pronovost PJ, Breslow
MJ. Remote ICU management. Crit Care Med. 2000; 28(12):3925-3931.
13. Pronovost PJ, Young T, Dorman T, Angus DC.
Association between ICU physician staffing and outcomes: systematic
review. Crit Care Med.
14. Hanson CW, Deutschman CS, Anderson HL, Reilly
PM, Behringer EC, Schwab CW, Price J. Effects of an organized
critical care service on outcomes and resource utilization: cohort
study. Crit Care Med. 1999; (2):270-274.
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Todd Dorman,
M.D., is Associate Professor, Departments of Anesthesiology/
Critical Care Medicine, Surgery and Nursing, Johns Hopkins
University School of Medicine, Baltimore, Maryland. |
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