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August 2002
Volume 66 |
Number 8
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| A New Beginning
for Anesthesia Critical Care: Changes and Challenges for the
Workforce |
ASCCA Task Force on Resident Recruitment
The past several years have brought important changes to critical
care in the United States. The most important change has been
the emerging national focus on patient safety and improved processes
of patient care. This national movement is changing how hospitals
view critical care and has dramatically changed the future of
the specialty.
The Institute of Medicine (IOM), a branch of the National Academy
of Sciences committed to advancing and disseminating scientific
knowledge to improve human health, generated front-page headlines
when it released its 1999 report To Err Is Human.1
This monograph highlighted the prevalence of medical errors and
estimated that close to 100,000 patients die in U.S. hospitals
annually because of avoidable complications. Not surprisingly,
intensive care units (ICUs) were identified as major sites for
medical errors. To Err Is Human created public awareness of a
previously unappreciated health problem. As a direct result of
this publication, patient safety has become a major topic of discussion
and a priority for hospital executives.
The most visible part of this discussion has been the efforts
of the Leapfrog Group, which is a consortium of Fortune 500 companies
that have banded together to demand better health care for their
insured employees and retirees.2 In
2000, the Leapfrog Group announced three purchasing standards
that they would use to determine where their employees would go
for hospital care. These purchasing standards, based on their
assessment of which medical processes have the greatest effect
on patient safety and clinical outcomes, included a call for dedicated
intensivist staffing for all nonrural hospitals by 2003. Leapfrog
estimated that widespread implementation of dedicated intensivist
staffing would save between 50,000 to 175,000 lives annually.
Leapfrog then launched a progressive introduction of these purchasing
standards, starting with seven regions – Georgia (Atlanta),
California, Michigan, Minnesota, Missouri (St. Louis), Tennessee
(eastern region) and Washington (Seattle) – which recently
expanded into 12 additional areas. Despite some resistance by
hospitals, Leapfrog has expanded its influence and enlisted additional
supporters, including the Centers for Medicare & Medicaid Services.
In New York, Empire Blue Cross/Blue Shield recently announced
higher reimbursement rates for hospitals meeting the Leapfrog
standards. Leapfrog's call for intensivist staffing has now added
a powerful financial driver for hospitals to change ICU physician
coverage. In support of this perspective, the Joint Commission
on Accreditation of Healthcare Organizations, the primary regulatory
organization for U.S. hospitals, has recently convened a task
force to identify performance metrics for ICUs. Suddenly, all
eyes are on the ICU.
Outcomes Research and Care Delivery Systems
Another force for the adoption of dedicated intensivist staffing
models is the emerging prominence of outcomes research and the
recognition that standardization of care processes and implementation
of systematic changes in care delivery result in superior outcomes.
Over the past several years, a number of multicenter clinical
trials and meta-analyses in ICU patients have identified preferred
therapies and have been published in high-profile general medicine
journals. Examples include low tidal volume ventilation in acute
lung injury, standardized protocols for sedative administration
and ventilator weaning, aggressive control of blood sugar, appropriateness
of transfusion thresholds, preventive strategies to reduce the
incidence of ventilator-associated pneumonia and the identification
of patients requiring prophylactic therapies to prevent deep venous
thrombosis and upper gastrointestinal bleeding. Many of these
have been identified by the Agency for Healthcare Research and
Quality (AHRQ) as health care priorities.3
The emergence of this compelling data supporting specific care
practices creates an additional rationale for centralizing and
standardizing ICU care, but this requires a knowledgeable physician
leader who has a consistent presence in the ICU.
Last year, IOM released a second report, Crossing the Quality
Chasm: A New Health System for the 21st Century, that examined
the causes of medical errors and put forth recommendations as
to how hospitals and physicians must change.4
Central to this monograph was the recognition that errors are
primarily the result of outmoded systems of care that are ill-equipped
to deal with the complexities of modern medicine. Quality experts
are focusing on the ICU because of the inherent instability of
critically ill patients, their vulnerability to adverse events
and the disproportionate amount of resources allocated to their
care. While no one would argue that implementing dedicated intensivist
coverage would eliminate all potential sources of error, it clearly
represents a superior care model.
Current trends suggest that hospitals will have to adopt a dedicated
intensivist care model or risk severe financial consequences.
Public and payer demand for improved patient safety shows no sign
of abating. The baby boomer population is aging and soon will
become the major consumer of health care. This group is well-informed,
highly selective and mobile. There is little doubt that they will
select hospitals based on quality and safety. Even if hospitals
do not recognize the operational (and economic) advantages associated
with improved ICU management, they will need to offer better ICU
coverage to compete for patients. As hospital leadership recognizes
the need for changing ICU staffing models, it will suddenly find
the will to tackle the political issues and the financial resources
to create appropriate incentives.
Intensivist Labor Shortage – Implications for Intensivists
and Others
The best information about ICU staffing comes from the Committee
on Manpower for Pulmonary and Critical Care Societies (COMPACCS)
survey performed in 1999 by Abt Associates and sponsored by the
Society of Critical Care Medicine, the American Thoracic Society
and the American College of Chest Physicians.5
This workforce survey found that only 15 percent of U.S. hospitals
have dedicated intensivists, and half of all ICU patients are
not seen by an intensivist. The survey also highlighted the presence
of a severe shortage of intensivists. There are approximately
5,500 practicing intensivists in the United States, and most of
these devote only a fraction of their time to critical care. Probably
less than 20 percent of these actually provide dedicated ICU care.
Depending on hours of coverage, between 10,000 and 25,000 full-time
intensivists would be required to implement dedicated intensivist
coverage for all U.S. ICUs. Moreover, the COMPACCS survey suggests
that the number of intensivists will likely not increase over
the next decade. The magnitude of the intensivist shortage will
create difficulties for hospitals trying to move to dedicated
staffing models.
How will intensivists be affected by hospital efforts to adopt
dedicated intensivist care models? The shortage of intensivists
will force hospitals to compete for a limited pool of new trainees.
Available data from physician recruitment agencies indicate a
substantial increase in starting salaries for hospital-based pulmonary
intensivists over the last three years ($110,000-$160,000 in 1998;
$160,000-$260,000 in 2001). Anecdotal reports suggest that anesthesia-based
intensivists completing their training have multiple job opportunities
in both academic and nonacademic hospitals and at salaries considerably
higher than in previous years. Salaries will likely continue to
climb as the demand for hospital-based intensivists increases.
However, the available supply of new trainees will not meet a
sustained demand. Hospitals most likely will try to induce established
intensivists to devote more time to critical care.
Older physicians, however, often are more concerned with lifestyle
than money, and it is very unlikely that the existing pool of
intensivists will be sufficient to meet the demand. Who then will
fill the void? As this information filters down to trainees, more
should opt for careers in critical care. Higher salaries and prestige
will attract larger numbers of medical students into critical
care, but the shortfall is sufficiently large enough that demand
will exceed supply for many years.
The future of critical care looks brighter today than at any
time since its emergence as a discrete specialty. The status of
intensivists within hospitals and within the academic community
is rising, and current trends suggest that this should continue
into the foreseeable future. Jobs are available in a variety of
different practice settings, including academic hospitals and
private practice. Salary levels are increasing as hospitals compete
to fill vacancies. Most medical students and anesthesiology residents
remain unaware of the exciting changes that are occurring and
these new opportunities. Getting this information to our students
and residents will help to augment the intensivist pool and foster
the growth of the anesthesia critical care. This should be our
highest priority.
References:
1. Kohn LT, Corrigan JM, Donaldson MS, eds. To
Err Is Human: Building a Safer Health System. Washington, DC:
National Academy Press, 2000.
2. The Leapfrog Group for Patient Safety: Rewarding
Higher Standards. < www.leapfroggroup.org
> . Accessed July 1, 2002.
3. Agency for Healthcare Research and Quality.
Making Health Care Safer: A Critical Analysis of Patient Safety
Practices < www.ahrq.gov./clinic/ptsafety
> . Accessed July 1, 2002.
4. Committee on Quality of Health Care in America.
Institute of Medicine. Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington, DC: National Academy
Press, 2001.
5. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich
J Jr. 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.
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William
E. Hurford, M.D., is Associate Professor of Anesthesia, Harvard
Medical School and Director, Critical Care, Department of
Anesthesia and Critical Care, Massachusetts General Hospital,
Boston, Massachusetts. |
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Gerald
A. Maccioli, M.D., is Medical Director, Medical/Surgical ICU,
Rex Healthcare, Raleigh, North Carolina. |
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Michael
J. Breslow, M.D., is Adjunct Associate Professor of Anesthesiology
and Critical Care Medicine, Medicine and Surgery, Johns Hopkins
School of Medicine, Baltimore, Maryland, and Executive Vice-President
for Clinical Research and Development, VISICU, Inc. |
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Charles
G. Durbin, Jr., M.D., is Professor of Anesthesiology and Surgery,
Department of Anesthesiology, University of Virginia Health
System, Charlottesville, Virginia. |
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