There are substantial opportunities to improve patient care that is provided in the hospital and intensive care unit (ICU). An Institute of Medicine report estimated that there are 44,000-98,000 preventable deaths every year in U.S. hospitals due to medical mistakes¹; that is more annual deaths in the United States than from either AIDS, motor vehicle accidents or breast cancer. Importantly, this number includes only errors of commission, that is, things that are done to patients that cause harm and does not include the far greater number of patients who are harmed from mistakes of omission. Indeed it is estimated that patients in this country can count on receiving only half of the therapies they should receive.² The impact of this failure is devastating and far exceeds the harm from mistakes of commission.

Estimates of the opportunity to improve care in the ICU are equally alarming. It has been estimated that on average nearly all of the 5 million patients admitted annually to ICUs suffer a serious preventable adverse event. In addition ICU care is expensive, accounting for approximately 30 percent of acute care hospital costs, or $180 billion annually. Beyond the human toll, we can only speculate the impact on families, on staff who are involved in caring for these patients and on the financial burden for society.

The demand from patients, providers, insurers, regulators, accreditators and purchasers for improved quality and safety in health care is transforming the way we practice critical care, and the pressure to improve will likely continue to increase. For example, the Leapfrog Group <www.leapfroggroup.org>, a health care purchasing consortium of more than 150 Fortune 500 companies, is making health care purchasing decisions based on stringent hospital patient safety practices and seeks to steer its employees to ICUs that are staffed by physicians trained in critical care medicine. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) also is developing quality measures for ICU care <www.jcaho.org>. These measures will be broadly implemented, including public reporting, in U.S. hospitals in 2004.

What Is the Value of an Intensivist?
There is a growing body of evidence that the presence of an intensivist in the ICU decreases morbidity, mortality and costs of care. Perhaps the strongest evidence comes from a systematic review of 17 randomized and observational controlled trials.³ These authors found that high-intensity (mandatory intensivist consultation or closed ICU where all care was directed by intensivists) was associated with a 39-percent relative risk reduction (RRR) in ICU mortality, a 29-percent RRR in hospital mortality and reduced hospital and ICU length of stay.

Despite the evidence to support intensivist staffing models, only 10 percent of ICUs are currently staffed by critical care physicians, and there is currently a significant shortage of physicians with critical care training. Based on the results from this study, up to 162,000 lives per year could be saved if the Leapfrog standard for ICU physician staffing was implemented by all nonrural U.S. hospitals.

How Can Anesthesiologist-Intensivists Improve ICU Care?
Future efforts in anesthesiology should focus on filling the shortfall in intensivists. Currently anesthesiology lags behind both internal medicine and surgery in the number of intensivists certified and the number in training. Anesthesiologist-intensivists are in a great position to lead efforts to improve ICU care nationally. Anesthesiology has a long history of “systems thinking” and improving quality and safety of intraoperative care. As a result, intraoperative anesthesia has never been safer. In addition high-quality intraoperative care requires extreme vigilance and a proactive approach. These core principles are directly translatable to the ICU environment.

Finally, many believe that the greatest opportunity to improve patient outcomes will likely come not from discovering new therapies but from discovering how to deliver therapies that are known to be effective. Consequently anesthesiology training should balance exposure to the science of discovery with opportunities to participate in health service research, including formal training in safety science and in the methodology of improvement.

The opportunities to improve patient care are significant, and the pressure to improve the quality of ICU care will continue to increase. Anesthesiologists are well poised to take advantage of the transformation currently taking place in how we provide critical care services and lead efforts to improve the quality and safety of ICU care.

“Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has.”

— Margaret Mead

References:

1. Institute of Medicine. To Err Is Human: Building a Safer Health System. Kohn L, Corrigan J, Donaldson M, eds. Institute of Medicine Report. Washington, DC: National Academy Press; 1999.

2. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348(26):2635-2645.

3. Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA. 2002; 288(17):2151-2162.

Sean Berenholtz, M.D., is Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland.

Todd Dorman, M.D., is Associate Professor in the departments of Anesthesiology, Critical Care Medicine, Internal Medicine, Surgery and the School of Nursing, Johns Hopkins University, Baltimore, Maryland.