Characterizing Hospitalist Practice and Perceptions of Critical Care Delivery
BACKGROUND: Intensivist shortages have led to increasing hospitalist involvement in critical care delivery.
OBJECTIVE: To characterize the practice of hospitalists practicing in the intensive care unit (ICU) setting.
DESIGN: Survey of hospital medicine physicians.
SETTING: This survey was conducted as a needs assessment for the ongoing efforts of the Critical Care Task Force of the Society of Hospital Medicine Education Committee. PARTICIPANTS: Hospitalists in the United States.
INTERVENTION: An iteratively developed, 25-item, web-based survey.
MEASUREMENTS: Results were compiled from all respondents then analyzed in subgroups. Various items were examined for correlations.
RESULTS: A total of 425 hospitalists completed the survey. Three hundred and twenty-five (77%) provided critical care services, and 280 (66%) served as primary physicians in the ICU. Hospitalists were significantly more likely to serve as primary physicians in rural ICUs (85% of rural respondents vs 62% of nonrural; P < .001 for association). Half of the rural hospitalists who were primary physicians for ICU patients felt obliged to practice beyond their scope, and 90% at least occasionally perceived that they had insufficient support from board-certified intensivists. Among respondents serving as primary physicians for ICU patients, 67% reported at least moderate difficulty transferring patients to higher levels of ICU care. Difficulty transferring patients was the only item significantly correlated with the perception of being expected to practice beyond one’s scope (P < .05 for association). CONCLUSIONS: Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals. Without major changes in intensivist staffing or patient distribution, this is unlikely to change.
© 2018 Society of Hospital Medicine
Despite calls for board-certified intensivist physicians to lead critical care delivery,1-3 the intensivist shortage in the United States continues to worsen,4 with projected shortfalls of 22% by 2020 and 35% by 2030.5 Many hospitals currently have inadequate or no board-certified intensivist support.6 The intensivist shortage has necessitated the development of alternative intensive care unit (ICU) staffing models, including engagement in telemedicine,7 the utilization of advanced practice providers,8 and dependence on hospitalists9 to deliver critical care services to ICU patients. Presently, research does not clearly show consistent differences in clinical outcomes based on the training of the clinical provider, although optimized teamwork and team rounds in the ICU do seem to be associated with improved outcomes.10-12
In its 2016 annual survey of hospital medicine (HM) leaders, the Society of Hospital Medicine (SHM) documented that most HM groups care for ICU patients, with up to 80% of hospitalist groups in some regions delivering critical care.13 In many United States hospitals, hospitalists serve as the primary if not lone physician providers of critical care.6,14 HM, with its team-based approach and on-site presence, shares many of the key attributes and values that define high-functioning critical care teams, and many hospitalists likely capably deliver some critical care services.9 However, hospitalists are also a highly heterogeneous work force with varied exposure to and comfort with critical care medicine, making it difficult to generalize hospitalists’ scope of practice in the ICU.
Because hospitalists render a significant amount of critical care in the United States, we surveyed practicing hospitalists to understand their demographics and practice roles in the ICU setting and to ascertain how they are supported when doing so. Additionally, we sought to identify mismatches between the ICU services that hospitalists provide and what they feel prepared and supported to deliver. Finally, we attempted to elucidate how hospitalists who practice in the ICU might respond to novel educational offerings targeted to mitigate cognitive or procedural gaps.
METHODS
We developed and deployed a survey to address the aforementioned questions. The survey content was developed iteratively by the Critical Care Task Force of SHM’s Education Committee and subsequently approved by SHM’s Education Committee and Board of Directors. Members of the Critical Care Task Force include critical care physicians and hospitalists. The survey included 25 items (supplemental Appendix A). Seventeen questions addressed the demographics and practice roles of hospitalists in the ICU, 5 addressed cognitive and procedural practice gaps, and 3 addressed how hospitalists would respond to educational opportunities in critical care. We used conditional formatting to ensure that only respondents who deliver ICU care could answer questions related to ICU practice. The survey was delivered by using an online survey platform (Survey Monkey, San Mateo, CA).
The survey was deployed in 3 phases from March to October of 2016. Initially, we distributed a pilot survey to professional contacts of the Critical Care Task Force to solicit feedback and refine the survey’s format and content. These contacts were largely academic hospitalists from our local institutions. We then distributed the survey to hospitalists via professional networks with instructions to forward the link to interested hospitalists. Finally, we distributed the survey to approximately 4000 hospitalists randomly selected from SHM’s national listserv of approximately 12,000 hospitalists. Respondents could enter a drawing for a monetary prize upon completion of the survey.
None of the survey questions changed during the 3 phases of survey deployment, and the data reported herein were compiled from all 3 phases of the survey deployment. Frequency tables were created using Tableau (version 10.0; Tableau Software, Seattle, WA). Comparisons between categorical questions were made by using χ2 and Fischer exact tests to calculate P values for associations by using SAS (version 9.3; SAS Institute, Cary, NC). Associations with P values below .05 were considered statistically significant.
