A new ICU paradigm: Intensivists as primary critical care physicians
After nearly a half-century, the subspecialty of critical care medicine—uniquely trained physicians caring for critically ill or injured patients in specialized, discrete nursing units—continues to suffer from an identity crisis.
Too often, the role of the intensivist in caring for the patient is unclear, to the patient, to the family, and to other physicians. Is the intensivist merely a consultant, or does he or she have a larger role?
The time has come to end the identity crisis with a fundamental paradigm shift, to identify intensivists as the principal caregivers of critically ill patients, ie, the “primary critical care physicians,” or PCCPs. We think this is necessary based not only on evidence from clinical studies, but also on our decades of experience as intensivist caregivers in a high-intensity, closed-staffing model.
REASONS FOR THE IDENTITY CRISIS
The reasons for the continued identity crisis of intensivists are many and complex.
To begin with, other physicians tend to be ambiguous about the duties of intensivists, and the general population is mostly unaware of the subspecialty. In contrast to mature subspecialties such as cardiology or gastroenterology, where responsibilities are generally known to physicians and the lay public alike, or in contrast even to recently evolved specialties such as emergency medicine, the enigmatic roles of an intensivist may differ depending on primary specialty (anesthesiology, internal medicine, surgery) and the patient population, or even among intensive care units (ICUs) within the same hospital.
Moreover, that an identity crisis exists is even more surprising given the disproportionately large consumption by critical care medicine of finite economic resources. One would expect that a sector of health care that expends 1% of the GNP1 would have clearly explicit roles and responsibilities for its physicians.
Nearly three-quarters of the care by intensivists in the United States is delivered in what is considered an “open” or “low-intensity” ICU staffing model2: an intensivist makes treatment recommendations but otherwise has no overarching authority over patient care. In this model, the admitting physician is not trained in critical care and is not available throughout the day to make decisions concerning the management of the patient. In addition, various consulting physicians and single-organ specialists may not be aware of the overall management plan, resulting in potentially unnecessary or conflicting orders and increased expense.2 What is more, in an open ICU model, critical care nurses are often left to detect and correct a significant change in a patient’s status without the necessary immediate physician availability, resulting not only in a stressful working environment for nursing staff, but also in potential harm associated with individuals providing care outside their scope of practice.3
In only a small percentage of ICUs—mostly medical ICUs and ICUs in teaching hospitals—is critical care provided in a “high-intensity” or “closed” staffing pattern, in which treatment decisions are cohesively managed under the guidance of an intensivist.2
EVIDENCE IN THE MEDICAL LITERATURE
Staffing patterns in the ICU
Several studies have attempted to identify the consequences of these different ICU staffing patterns on patient care.
Hanson et al4 examined two concurrent patient cohorts admitted to a surgical ICU. The study cohort was cared for by an on-site critical care team supervised by an intensivist, while the control cohort received care from a team with patient care responsibilities in multiple sites, supervised by a general surgeon. The results showed that patients cared for by the critical care team spent less time in the ICU, used fewer resources, had fewer complications, and had lower total hospital charges. The difference between the two cohorts was most evident in patients with the worst Acute Physiology and Chronic Health Evaluation (APACHE) II scores.
According to Hanson et al, the lack of an accepted prototype for the delivery of critical care is due to factors such as the relative youth of the discipline, contention over control of individual patient management, and the absence of a single academic advocate.4
Moreover, Pronovost et al5 concluded that high-intensity staffing (mandatory intensivist consultation or closed ICU) was associated with lower ICU mortality rates in 93% of studies and with a reduced ICU length of stay in the high-intensity staffing units when compared with ICUs with low-intensity staffing (no intensivist or elective intensivist consultation).
Critics of our PCCP paradigm may point to a study by Levy et al6 that, using a database of more than 100,000 patients, could not demonstrate any survival benefit with management by critical care physicians. Indeed the study found that patients managed by intensivists had a higher mortality rate than patients managed by physicians not trained in critical care. However, they also showed that more patients managed for the entire stay by intensivists received interventions such as intravenous drugs, mechanical ventilation, and continuous sedation and that they had a higher mean severity of illness as measured by the expanded Simplified Acute Physiology Score (SAPS II) and higher hospital mortality rates than patients who were not managed by a critical care team.
According to Levy et al, most ICUs in the United States are structured as completely open units in which the admitting physicians retain full clinical and decisional responsibility and thus have the option to care for their patients with or without input from intensivists.6
However, a recent study by Kim et al7 likely rebuts the findings of Levy et al. Kim et al analyzed more than 100,000 ICU admissions and found that the lowest odds of death within 30 days were in ICUs that had high-intensity physician staffing and multidisciplinary care teams, suggesting that the presence of an intensivist confers a survival benefit.
Other studies have also shown that high-intensity staffing improves patient outcomes in the ICU.5,8,9
Issues of cost and use of resources
Issues concerning cost and human resources for staffing ICUs have acquired increasing importance. According to Angus et al,10 intensivists provided care to only 36.8% of all ICU patients. The demand for critical care services will continue to grow rapidly as the population ages. It is this shift in the care of the critically ill that requires intensivists to take on the role of the PCCP, so as to provide high-quality, evidence-based critical care and to promote a long-term sustainable model of physician and nursing care.
