John M. Oropello

Critical Care Medicine in the United States: Addressing the Intensivist Shortage and Image of the Specialty*

Intensivists are increasingly needed to care for the critically ill and manage ICUs as ICU beds, utilization, acuity of illness, complexity of care and costs continue to rise. However, there is a nationwide shortage of intensivists that has occurred despite years of well publicized warnings of an impending workforce crisis from specialty societies and the federal government. The magnitude of the intensivist shortfall, however, is difficult to determine because there are many perspectives of optimal ICU administration, patient coverage and intensivist availability and a lack of national data on intensivist practices. Nevertheless, the intensivist shortfall is quite real as evidenced by the alternative solutions that hospitals are deploying to provide care for their critically ill patients. In the midst of these manpower struggles, the critical care environment is dynamically changing and becoming more stressful. Severe hospital bed availability and fiscal constraints are forcing ICUs to alter their approaches to triage, throughput and unit staffing. National and local organizations are mandating that hospitals comply with resource intensive and arguably unproven initiatives to monitor and improve patient safety and quality, and informatics systems. Lastly, there is an ongoing sense of professional dissatisfaction among intensivists and a lack of public awareness that critical care medicine is even a distinct specialty. This article offers proposals to increase the adult intensivist workforce through expansion and enhancements of internal medicine based critical care training programs, incentives for recent graduates to enter the critical care medicine field, suggestions for improvements in the critical care profession and workplace to encourage senior intensivists to remain in the field, proactive marketing of critical care, and expanded engagement by the critical care societies in the challenges facing intensivists.

Staphylococcus lugdunensis: the coagulase-negative staphylococcus you don’t want to ignore

Staphylococcus lugdunensis is a virulent coagulase-negative staphylococcus (CoNS) that behaves like Staphylococcus aureus. Toxic shock syndrome, osteomyelitis, septic arthritis and postoperative endopthalmitis have been observed. Endocarditis complicated by heart failure, periannular abscess formation and embolic phenomenon have brought particular attention to this CoNS. Mortality rates for endocarditis appear higher when compared with other CoNS. Owing to the laboratory methods used, identification may be misleading. β-lactam antimicrobials are recommended pending sensitivities. Evaluation for endocarditis should be pursued in bacteremic patients due to its pathogenic potential.

Critical care organizations in academic medical centers in North America: A descriptive report

Objectives:With the exception of a few single-center descriptive reports, data on critical care organizations are relatively sparse. The objectives of our study were to determine the structure, governance, and experience to date of established critical care organizations in North American academic medical centers. Design:A 46-item survey questionnaire was electronically distributed using Survey Monkey to the leadership of 27 identified critical care organizations in the United States and Canada between September 2014 and February 2015. A critical care organization had to be headed by a physician and have primary governance over the majority, if not all, of the ICUs in the medical center. Measurements and Main Results:We received 24 responses (89%). The majority of the critical care organizations (83%) were called departments, centers, systems, or operations committees. Approximately two thirds of respondents were from larger (> 500 beds) urban institutions, and nearly 80% were primary university medical centers. On average, there were six ICUs per academic medical center with a mean of four ICUs under critical care organization governance. In these ICUs, intensivists were present in-house 24/7 in 49%; advanced practice providers in 63%; hospitalists in 21%; and telemedicine coverage in 14%. Nearly 60% of respondents indicated that they had a separate hospital budget to support data management and reporting, oversight of their ICUs, and rapid response teams. The transition from the traditional model of ICUs within departmentally controlled services or divisions to a critical care organization was described as gradual in 50% and complete in only 25%. Nearly 90% indicated that their critical care organization governance structure was either moderately or highly effective; a similar number suggested that their critical care organizations were evolving with increasing domain and financial control of the ICUs at their respective institutions. Conclusions:Our survey of the very few critical care organizations in North American academic medical centers showed that the governance models of critical care organizations vary and continue to evolve. Additional studies are warranted to improve our understanding of the factors that can foster the growth of critical care organizations and how they can be effective.

Critical Care Organizations: Business of Critical Care and Value/performance Building*

Objective: New, value-based regulations and reimbursement structures are creating historic care management challenges, thinning the margins and threatening the viability of hospitals and health systems. The Society of Critical Care Medicine convened a taskforce of Academic Leaders in Critical Care Medicine on February 22, 2016, during the 45th Critical Care Congress to develop a toolkit drawing on the experience of successful leaders of critical care organizations in North America for advancing critical care organizations (Appendix 1). The goal of this article was to provide a roadmap and call attention to key factors that adult critical care medicine leadership in both academic and nonacademic setting should consider when planning for value-based care. Design: Relevant medical literature was accessed through a literature search. Material published by federal health agencies and other specialty organizations was also reviewed. Collaboratively and iteratively, taskforce members corresponded by electronic mail and held monthly conference calls to finalize this report. Setting: The business and value/performance critical care organization building section comprised of leaders of critical care organizations with expertise in critical care administration, healthcare management, and clinical practice. Measurements and Main Results: Two phases of critical care organizations care integration are described: “horizontal,” within the system and regionalization of care as an initial phase, and “vertical,” with a post-ICU and postacute care continuum as a succeeding phase. The tools required for the clinical and financial transformation are provided, including the essential prerequisites of forming a critical care organization; the manner in which a critical care organization can help manage transformational domains is considered. Lastly, how to achieve organizational health system support for critical care organization implementation is discussed. Conclusions: A critical care organization that incorporates functional clinical horizontal and vertical integration for ICU patients and survivors, aligns strategy and operations with those of the parent health system, and encompasses knowledge on finance and risk will be better positioned to succeed in the value-based world.

Getting to zero: Reduction in the incidence of multidrug-resistant organism infections using an integrated infection control protocol in an intensive care unit

Environmental cleaning is a vital component of infection control. We describe the use of an integrated infection control protocol in an intensive care unit and its influence on multidrug-resistant organism infection rates. Sustained reductions in multidrug-resistant organism infections can be achieved if individual processes and weaknesses in intensive care unit environments are identified and addressed in a systematic and comprehensive manner.

Intensivist workforce in the United States: The crisis is real, not imagined

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Predeposit Autologous Blood Donation: a survey of patient attitudes

Attitudes to autologous blood donation have been surveyed in a group of 38 postoperative bariatric patients. Only two patients (5%) declined to participate. Twenty-eight of 38 (70%) successfully predeposited autologous blood. Twenty-five of 28 donors (90%) had done so at the suggestion of their surgeon. Concern about contracting AIDS was the motivating factor in the majority of patients (21 patients, = 55%). Lack of infectious complications in general was cited by an additional four (11%). All respondents would donate autologous blood in the future, and would recommend the procedure to others who were about to undergo elective surgery. There was an increase from 29% to 50% who stated that, following their autologous donation experience, they would consider being homologous volunteer blood donors in the future.

Daytime Intensivist Physician Staffing and Mortality.

To the Editor: We read with interest the article, in a recent issue of Critical Care Medicine, by Costa et al (1) who were unable to detect any “in-hospital” mortality benefit of high-intensity daytime intensivist physician staffing (IPS) in a retrospective analysis of 49 ICUs in 25 U.S. hospitals. They go on to suggest that high-intensity IPS does not reduce ICU mortality beyond what protocols, interprofessional rounds, The authors reply: We thank Mayette and Duranceau (1) for their detailed review of our article. They are correct in noting that shock index is calculated as heart rate divided by systolic blood pressure. As noted in their letter, our study calculates shock index in that manner. The two notations in the article that incorrectly define shock index as systolic blood pressure divided by heart rate are typographic errors and should read “heart rate divided by systolic blood pressure.” The authors have disclosed that they do not have any potential conflicts of interest.

Utility of Ultrasound Versus Landmark-Guided Axillary Artery Cannulation for Hemodynamic Monitoring in the Intensive Care Unit:

Objectives. To assess the utility of ultrasound-guided axillary artery catheterization compared with anatomical landmark technique catheterization in the intensive care unit. Design. Randomized controlled trial. Setting. University hospital surgical and neurosurgical intensive care unit. Patients. A total of 33 critically ill patients undergoing arterial line placement. Interventions. Axillary arterial line placement under ultrasound guidance or by using anatomical landmarks. Measurements and main results. Procedure duration, number of attempts (skin punctures), needle repositionings, and aborted procedures were compared. A total of 33 patients were randomly assigned to either the ultrasound group (n = 18) or the anatomical landmark group (n = 15). Aborted procedures were significantly greater in the landmark group (n = 4) than in the ultrasound group (n = 0); P = .019. Procedure duration (mean ± SD) in the ultrasound group was 7.01 ± 4.40 minutes compared with 9.29 ± 10.00 minutes in the landmark group; ...

Shifting Pneumothorax A Radiographic and Sonographic Evaluation

A 62-year-old woman was admitted for elective bilateral nephrectomies for symptomatic large bilateral polycystic kidneys. In the immediate postoperative period, the patient was hypotensive requirin...