ASCCA: A Defining Role in Future Improved Outcomes

he American Society of Critical Care Anesthesiologists (ASCCA) is a subspecialty organization of ASA whose mission is to preserve and expand the pivotal role of critical care medicine as practiced by intensivists in critical care units within the scope of practice of anesthesiology. These goals will be accomplished through education and advocacy.¹

Why is critical care medicine important to the individual anesthesiologist? I will offer a few significant reasons. First, critical care has long been a vital component of anesthesiology. Second, considering patient safety is an integral part of the practice of anesthesiology, it is noteworthy that studies, many of which were published by anesthesia intensivists, indicate high-intensity staffing of intensive care units by intensivists improves patient outcome.² Third, an analysis by the ASA Task Force on Future Paradigms of Anesthesia Practice suggests that demand for anesthesiologists in the operating room will decrease over time. Moreover, analyses by other organizations predict there will be a shortage of critical care practitioners by as early as 2010.³ ASCCA believes the specialty of anesthesiology should be poised to respond to this shortfall of quality physicians.

Recent proposed changes in the curriculum for anesthesiology residents allow residents more exposure to critical care over four years in a graded fashion. This may increase the interest in critical care as a career choice. Other proposals such as dual certification in anesthesiology and critical care medicine at the end of an anesthesiology residency might also increase the number of critical care providers.

Even with dramatic increases in anesthesia-based intensivists and intensivists from other specialties, the projected shortfall will not be alleviated. A recent paper proposes that accreditation bodies work cooperatively to enable a pathway for emergency medicine physicians who have completed a critical care medicine fellowship⁴ to obtain certification. Other proposals include common standards for intensive care unit care, information technology and monetary incentives.5 Lastly, members of ASCCA are serving on a Society of Critical Care Medicine task force to examine the future of critical care as a specialty. Scenarios being explored include the establishment of a common critical care board examination that all specialties would use, a standard critical care curriculum, although each specialty would still have individual fellowships, and critical care medicine as a distinct and separate specialty. There are, however, threats from other specialties whose members seek to expand their purview despite lack of proper training in critical care medicine — most notably hospitalists.6

ASCCA and its members have been working on several other important issues.

Pay for Performance
In collaboration with providers, hospitals and other stakeholders, the Centers for Medicare & Medicaid Services (CMS) is in the process of developing pay-for-performance (P4P) initiatives. With these initiatives, physicians who meet or exceed performance standards would receive a bonus payment over and above the base compensation.

P4P will be coming to anesthesiology and critical care. As intensivists we must be prepared to drive the process to ensure quality patient care and fairness in physician reimbursement. A recent informal survey of other critical care professional organizations showed that, to date, little has been done to develop initiatives. Under the energetic leadership of Gerald A. Maccioli, M.D. (ASCCA President-Elect and Chair of the ASA Committee on Critical Care Medicine) and other members of ASCCA, an initial set of critical care medicine P4P initiatives has been formulated: 1) prevention of catheter-related bloodstream infections, 2) prevention of ventilator-associated pneumonia and 3) daily interruption of sedation for patients being mechanically ventilated. Working with the ASA Committee on Performance and Outcomes Measurement, ASCCA liaison to the Critical Care Workgroup Todd Dorman, M.D., will represent ASCCA as the leading critical care professional organization in the development of P4P initiatives. The additional challenge for us will be to ensure that P4P is a bonus system with new money injected into the Medicare system, and not a pay cut.

Organ Donation
Several years ago, the Health Resources and Services Administration of the federal government formed an Organ Donation Breakthrough Collaborative seeking to bring the best practices of hospitals where organ donation rates were high to institutions with lower rates. The overall goal of the collaboration was to increase the conversion rate (actual donors/potential donors) to 75 percent nationwide. Members of ASCCA continue to be a vital part of this collaborative endeavor. More information may be found at <organdonation.iqsolutions.com>.

In April of this year, the United Network for Organ Sharing sponsored a national Donation after Cardiac Death (DCD) Consensus Conference. ASCCA member Stanley H. Rosenbaum, M.D., and Stephen O. Heard, M.D., chaired a group that included ASA members Susan K. Palmer, M.D., and Gail A. Van Norman, M.D. Examined issues included: 1) medical criteria to predict DCD candidacy following withdrawal of life support, 2) use of transplant-related interventions and medications during withdrawal of treatment and before declaration of death and 3) criteria that predict cardiac death after withdrawal of treatment. A summary report will be published in the near future.


References:
1. The American Society of Critical Care Anesthesiologists <www.ascca.org>. Accessed on October 5, 2005.
2. Hanson CW III, Durbin CG Jr, Maccioli GA, et al. The anesthesiologist in critical care medicine: Past, present and future. Anesthesiology. 2001; 95(3):781-788.
3. 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(21):2762-2770.
4. Huang DT, Osborn TM, Gunnerson KJ, et al. Critical care medicine training and certification for emergency physicians. Ann Emerg Med. 2005; 46(3):217-223.
5. Kelley MA, Angus D, Chalfin DB, et al. The critical care crisis in the United States: A report from the profession. Chest. 2004; 125(4):1514-1517.
6. Pham HH, Devers KJ, Kuo S, Berenson R. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005; 20(2):101-107.

Stephen O. Heard, M.D., is Professor and Chair, Department of Anesthesiology, UMass Memorial Medical Center and University of Massachusetts Medical School, Worcester.