Antoinette Spevetz

Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model

Patients receiving medical care in intensive care units (ICUs) account for nearly 30% of acute care hospital costs, yet these patients occupy only 10% of inpatient beds (1, 2). In 1984, the Office of Technology Assessment concluded that 80% of hospitals in the United States had ICUs, >20% of hospital budgets were expended on the care of intensive care patients, and approximately 1% of the gross national product was expended for intensive care services (3). With the aging of the U.S. population, greater demand for critical care services will occur. At the same time, market forces are evolving that may constrain both hospitals’ and practitioners’ abilities to provide this increasing need for critical care services. In addition, managed care organizations are requesting justification for services provided in the ICU and for demonstration of both efficiency and efficacy. Hospital administrators are continually seeking methods to provide effective and efficient care to their ICU patients. As a result of these social and economic pressures, there is a need to provide more data about the type and quality of clinical care provided in the ICU. In response, two task forces were convened by the Society of Critical Care Medicine leadership. One task force (models task force) was asked to review available information on critical care delivery in the ICU and to ascertain, if possible, a “best” practice model. The other task force was asked to define the role and practice of an intensivist. The task force memberships were diverse, representing all the disciplines that actively participate in the delivery of health care to patients in the ICU. The models task force membership consisted of 31 healthcare professionals and practitioners, including statisticians and representatives from industry, pharmacy, nursing, respiratory care, and physicians from the specialties of surgery, internal medicine, pediatrics, and anesthesia. These healthcare professionals represented the practice of critical care medicine in multiple settings, including nonteaching community hospitals, community hospitals with teaching programs, academic institutions, military hospitals, critical care medicine private practice, full-time academic practice, and consultative critical care practice. This article is the consensus report of the two task forces. The objectives of this report include the following: (1) to describe the types and settings of critical care practice (2); to describe the clinical roles of members of the ICU healthcare team (3); to examine available outcome data pertaining to the types of critical care practice (4); to attempt to define a “best” practice model; and (5) to propose additional research that should be undertaken to answer important questions regarding the practice of critical care medicine. The data and recommendations contained within this report are sometimes based on consensus expert opinion; however, where possible, recommendations are promulgated based on levels of evidence as outlined by Sacket in 1989 (4) and further modified by Taylor in 1997 (5) (see Appendix 1).

Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care.

ObjectivesTo describe three levels of hospital-based critical care centers to optimally match services and personnel with community needs, and to recommend essential intensive care unit services and personnel for each critical care level. ParticipantsA multidisciplinary writing panel of professionals with expertise in the clinical practice of critical care medicine working under the direction of the American College of Critical Care Medicine (ACCM). Data Sources and SynthesisRelevant medical literature was accessed through a systematic Medline search and synthesized by the ACCM writing panel, a multidisciplinary group of critical care experts. Consensus for the final written document was reached through collaboration in meetings and through electronic communication modalities. Literature cited included previously written guidelines from the ACCM, published expert opinion and statements from official organizations, published review articles, and nonrandomized, historical cohort investigations. With this background, the ACCM writing panel described a three-tiered system of intensive care units determined by service-based criteria. ConclusionsGuidelines for optimal intensive care unit services and personnel for hospitals with varying resources will facilitate both local and regional delivery of consistent and excellent care to critically ill patients.

Multisociety task force recommendations of competencies in Pulmonary and Critical Care Medicine.

RATIONALE Numerous accrediting organizations are calling for competency-based medical education that would help define specific specialties and serve as a foundation for ongoing assessment throughout a practitioners career. Pulmonary Medicine and Critical Care Medicine are two distinct subspecialties, yet many individual physicians have expertise in both because of overlapping content. Establishing specific competencies for these subspecialties identifies educational goals for trainees and guides practitioners through their lifelong learning. OBJECTIVES To define specific competencies for graduates of fellowships in Pulmonary Medicine and Internal Medicine-based Critical Care. METHODS A Task Force composed of representatives from key stakeholder societies convened to identify and define specific competencies for both disciplines. Beginning with a detailed list of existing competencies from diverse sources, the Task Force categorized each item into one of six core competency headings. Each individual item was reviewed by committee members individually, in group meetings, and conference calls. Nominal group methods were used for most items to retain the views and opinions of the minority perspective. Controversial items underwent additional whole group discussions with iterative modified-Delphi techniques. Consensus was ultimately determined by a simple majority vote. MEASUREMENTS AND MAIN RESULTS The Task Force identified and defined 327 specific competencies for Internal Medicine-based Critical Care and 276 for Pulmonary Medicine, each with a designation as either: (1) relevant, but competency is not essential or (2) competency essential to the specialty. CONCLUSIONS Specific competencies in Pulmonary and Critical Care Medicine can be identified and defined using a multisociety collaborative approach. These recommendations serve as a starting point and set the stage for future modification to facilitate maximum quality of care as the specialties evolve.

Entrustable Professional activities and curricular milestones for fellowship training in pulmonary and critical care medicine: Executive summary from the multi-society working group

Assessment of graduate medical trainee progress via the accomplishment of competency milestones is an important element of the Next Accreditation System of the Accreditation Council for Graduate Medical Education. This article summarizes the findings of a multisociety working group that was tasked with creating the entrustable professional activities and curricular milestones for fellowship training in pulmonary medicine, critical care medicine, and combined programs. Using the Delphi process, experienced medical educators from the American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine, and Association of Pulmonary and Critical Care Medicine Program Directors reached consensus on the detailed curricular content and expected skill set of graduates of these programs. These are now available to trainees and program directors for the purposes of curriculum design, review, and trainee assessment.

Training internists to meet critical care needs in the United States: A consensus statement from the critical care societies collaborative (CCSC)

Objectives:Multiple training pathways are recognized by the Accreditation Council for Graduate Medical Education (ACGME) for internal medicine (IM) physicians to certify in critical care medicine (CCM) via the American Board of Internal Medicine. While each involves 1 year of clinical fellowship training in CCM, substantive differences in training requirements exist among the various pathways. The Critical Care Societies Collaborative convened a task force to review these CCM pathways and to provide recommendations for unified and coordinated training requirements for IM-based physicians. Participants:A group of CCM professionals certified in pulmonary-CCM and/or IM-CCM from ACGME-accredited training programs who have expertise in education, administration, research, and clinical practice. Data Sources and Synthesis:Relevant published literature was accessed through a MEDLINE search and references provided by all task force members. Material published by the ACGME, American Board of Internal Medicine, and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force reached consensus using a roundtable meeting, electronic mail, and conference calls. Main Results:Internal medicine-CCM–based fellowships have disparate program requirements compared to other internal medicine subspecialties and adult CCM fellowships. Differences between IM-CCM and pulmonary-CCM programs include the ratio of key clinical faculty to fellows and a requirement to perform 50 therapeutic bronchoscopies. Competency-based training was considered uniformly desirable for all CCM training pathways. Conclusions:The task force concluded that requesting competency-based training and minimizing variations in the requirements for IM-based CCM fellowship programs will facilitate effective CCM training for both programs and trainees.

Don't confuse us with the evidence-are we doing the best we can?

3317 Since its inception in 1970, The Society of Critical Care Medicine has been dedicated to the creation and dissemination of Clinical Practice Guidelines. The society published its initial guideline, Guidelines for training of physicians in critical care medicine, in the first volume of Critical Care Medicine (1). Continued development of guidelines is the major focus of the Society’s American College of Critical Care Medicine. The College has produced over 40 guidelines and has been an international leader in the development of critical care guidelines. A Medline query for articles on or about guidelines prior to 1990 yields few results; however, over the last 15 yrs there has been an explosion of guideline-related articles. From 1997 to 2001 there were 852 articles with “guidelines” in their title, from 2002 to 2006 there were 1,621, and in the last 5 yrs, there were 2,460 published articles on guidelines. Early guidelines in critical care medicine were predominantly the result of expert opinion not the result of a systematic review of evidence, partially due to the lack of high quality evidence in critical care medicine. Recently the Institute of Medicine released two documents attempting to quantify the optimum principles and standards for societies developing guidelines (2, 3). We now have a robust process for developing high quality, trustworthy, evidence-based guidelines. This process is now labor intensive and expensive for Societies. Despite this evolution of science and methodology for performing evidence-based reviews, there are still major gaps in our knowledge. With a few exceptions, there is a paucity of research on the application and adoption of clinical practice guidelines at the bedside. The research that has been conducted usually addresses a single specific guideline or occurs in institutions dedicated to guideline utilization. In this issue of Critical Care Medicine, Leone and colleagues (4) have attempted to determine the prevalence of guideline compliance across a broad range of guidelines and intensive care units in an effort to quantify the real world effectiveness of guideline compliance. In this article, total guideline adherence was assessed in 66 institutions in France. They found that guidelines were strictly followed in only 24% of patients. Could this really be true or are these just isolated intensive care units that are not practicing state of the art critical care medicine? Unfortunately, there are numerous examples in the literature that uphold this fact (5–8). Have you evaluated the guideline compliance in your own intensive care unit? Subjectively, we think that we practice medicine much better than the objective evidence supports and we are slow to implement state of the art guidelines (9). It may take up to 17 yrs for guidelines to be implemented into practice (10). Guideline implementation is most successful when outcomes are tied to reimbursement as in the Centers for Medicare and Medicaid Services (CMS) core measures. Even when practitioners have been compliant with these CMS measures, not all patient outcomes have improved. It is imperative to identify and select better markers than some of the current CMS measures to assess quality care. Both the practitioners and the guideline writers struggle with the reality that guidelines are difficult to bring to the bedside. Practitioners multitask to meet many requirements in medicine these days. In a given day while rounding in an academic medical center intensive care unit, we are expected to teach students of all levels, write detailed notes so CMS will pay us for the care we have delivered, perform multidisciplinary team rounds, deliver patient care based on appropriate guidelines, complete the daily check list, and comply with all Surgical Care Improvement Project measures. Other obligations include: maintenance of certification, assimilation of current literature, and documentation in the electronic health record. How does one find time to read new guidelines and then spend countless hours recruiting a team and write a protocol, which allows this new information to be put into practice? Finally, all the rotating residents need to understand the unit policies and adhere to the new guideline. Although everyone would agree that we need to practice state of the art critical care, implementation of new protocols is difficult. Reasons for nonadherence to guidelines have been grouped into three different areas: knowledge, attitudes, and behavior (11). Intensivists may agree with the guideline’s content but fail to implement it due to time constraints and the overwhelming volume of clinical responsibilities. Major changes pertaining to the practice of critical care medicine are required to obtain 100% compliance of all applicable guidelines for every patient. Although there are some tools available for guideline development, practitioners do not have the time to develop protocols and order sets for each and every guideline (12). Guidelines should be published with readily available tools and tool kits for the practitioner and could be modified for the individual hospital. Societies with similar interests should collaborate and create joint guideline publications. An easily accessible source for newly released guidelines is necessary. We need to develop system-wide hospital processes, which assist practitioners to provide optimal care for their patients. These processes should identify new guidelines, harmonize conflicting guidelines, and determine the appropriate guideline to apply to each patient. Tools and tool kits for implementing the guideline as well as data systems to monitor the guideline are required. This cannot be accomplished without developing improved computer information support services. A system that provides all of this information at the bedside would be an excellent application of the meaningful use of technology. Then the intensivist can focus on assuring that each guideline has been specifically tailored for each patient’s particular Don’t confuse us with the evidence—Are we doing the best we can?*