Neil A. Halpern

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.

Acute care nurse practitioners in oncologic critical care: the memorial Sloan-Kettering cancer center experience.

Nurse practitioners (NPs) are increasingly being used to fill the physician-staffing void in intensive care units. This article describes the initiation and role development of our collaborative physician-NP critical care medicine (CCM) program at the Memorial Sloan-Kettering Cancer Center. The challenges that our program encountered with recruiting, training, transitioning, collaborating, communicating, and addressing end-of-life issues are detailed in this article. Finally, we delve into the emotional impact NPs have on this new role and propose future directions to strengthen the CCM NP model. We hope that this descriptive article of the development of our CCM NP group will allow others who are seeking to cultivate their own CCM NP teams to benefit from our experience.

BIOARTIFICIAL ORGAN SUPPORT FOR HEPATIC, RENAL, AND HEMATOLOGIC FAILURE

The current strategy to the treatment of SIRS and MODS uses a multidisciplinary approach that emphasizes supportive therapy. Herein, we have presented a futuristic approach that focuses on replacing the function of failed organs using bioartificial technology (Table 1). Bioartificial organ technology may allow the intensivist to provide physiologic organ replacement either as a bridge to transplantation or as a time-buying element until native organs that have become acutely dysfunctional or nonfunctional in a variety of clinical settings, can recover their function or regenerate their mass. As bioartificial organ technology matures, it is conceivable as an ultimate goal that non-immunogenic bioartificial organs would be miniaturized or redesigned and acutely placed within the intracorporeal space as replacement organs.

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.

Understanding the Russell equation and projection estimates to describe critical care costs in the USA

The delivery of critical care medicine (CCM) services in the USA is expensive [1, 2], exceeding US

Challenging family dialogues within the intensive care unit: An intensivist's perspective

80 billion in 2005 [2]. However, despite the CCM cost magnitude, CCM costs are never reported by any US governmental agency; instead, they are calculated periodically, since the 1980s, by various groups of investigators [1–5]. An understanding of how CCM costs are determined in the USA is important to help gauge their accuracy, consistency, usefulness, and comparability to CCM costing in other countries. There are two national US administrative databases that track hospital use and cost data: the federal Healthcare Cost Report Information System (HCRIS) [6] and the proprietary Hospital Statistics data set of the American Hospital Association (AHA) [7]. However, as a result of fiscal data limitations within these two data sets, the national cost of CCM cannot be directly determined from either of them. The two conventional approaches to estimating the ‘‘big picture’’ of CCM costs in the USA involve the use of the Russell equation and national projections (Fig. 1).

In Between the Intensive Care Unit and the Ward

To the seasoned intensivist, discussions with family members of critically ill patients in the intensive care unit (ICU) can be very predictable. However, this does not imply that these dialogues are straightforward or simple. Each day, we spend a significant amount of time meeting with family members at different stages of their loved one’s ICU stay. Some family members are satisfied with these exchanges while others leave them distraught or in emotional shambles. At times, intensivists do not always effectively communicate with family members. Both the team and the families come to the ‘‘ICU table’’ with different sets of perspectives, expectations, conversational skill sets, life experiences, and tolerances for stress. These differences are magnified when the ICU course turns rocky. We thought it useful to illustrate ICU dialogues with family members as we perceive them. We focus on the potential checkpoints where miscommunication and misunderstanding may occur throughout the roller coaster ICU experience. To this end, over the past few years, our Critical Care Medicine group has been collecting thought-provoking comments from various family conferences. Herein, we present the dynamic phases of an ICU encounter contextually inserting relevant quotes. The specter of a loved one lying helplessly in an ICU bed, attached to imposing machines, with tubes coming out on all sides can be quite numbing and frightening. No amount of schooling or training can really prepare a person for this emotionally taxing situation. Disbelief reigns! We frequently hear, ‘‘How can a person go from being fine one day to being so sick the next?’’ or ‘‘He was shoveling snow just last week!’’ or, ‘‘She was just fine after surgery, talking, walking, and eating.’’ Not only is the ICU a strange and scary place, but oftentimes, in the midst of our first meeting with family members of newly admitted ICU patients, we quickly realize that they are not really sure who we are or what we do. It seems to us that Critical Care Medicine as a medical specialty suffers from a lack of brand recognition. Often the family members say, ‘‘You’re a what? An intensivist?’’ ‘‘We’ve never heard of an intensivist.’’ ‘‘Do The authors thank the current and past critical care fellows for their contributions to this manuscript. We are particularly indebted to the ICU nurses, patient representatives and social workers of the Memorial Sloan-Kettering Cancer Center, New York, New York who provide daily clinical and emotional support to our ICU patients and their families and to the CCM attending team.

Daytime Intensivist Physician Staffing and Mortality.

The number of intensive care unit (ICU) beds in the United Stateshascontinuedto increaseover the last3decades, ashave ICU utilization rates and costs,1,2 and this despite the lack of any federal, regional, or critical care society mandates to justify these increases. Some experts believe that the increase in the number of ICU beds has led to inappropriate use of these beds by patients who are either too healthy or too sick to benefit from intensive care.3,4 This may in part explain the stable national ICU occupancy rate of approximately68%between 1985and2010 and suggests that ICU utilization has simply risen tomeet the increased number of beds.1,2 Furthermore, it hasbeenover adecadeandahalf sincenational societyguidelines for ICUand intermediate careunit admission, discharge, and triagewere published.5,6 In the intervening years, changes have occurred in the demographic and other characteristics of ICUpatientpopulations; the ICUworkforce has evolved; the legislative landscape has altered; and newethical and end-of-life factors have been introduced that affect the appropriate utilization of ICU beds. Ideally, US hospitals and ICUs would follow some consistent and clinically appropriate approaches to the triage of sick patients. At a minimum, we would expect that triage would be similar for day andnight,weekdayandweekendwithin the same hospital or hospital network, andwewould expect it to be independent of ICU and hospital occupancy rates. The reality, however, is far more complex and confusing: ICU triage decisions are based on many factors, some quantifiable and others intangible. These factors can be classified into 2 categories:hospital (institutional)basedandICUrelated.Hospitalbased factors include size (small,medium, or large), teaching or nonteaching status, nurse to patient ratios, rules and regulations of the limits ofward-based care, attitudes toward risk, practice styles of physicians andnurses, availability of nurses andsupport staff (eg,hospitalists, advancepractitioners, rapid response teams), privileging of clinicians for ICU admission, and the presence of step-down units (ie, intermediate or progressive). The ICU-based parameters include ICU to hospital bed ratios, model of care (ie, open, closed, or collaborative), types (ie, multiple-specialty ICUs or single, large ICU), intensivist staffing (ie, high or low intensity, full time or part time), presence of resident trainees and/or advance care practitioners, and coverage (ie, in-house or telemedicine). In this issueofJAMAInternalMedicine,ChangandShapiro7 retrospectively analyze ICU utilization for 4 medical conditions (diabetic ketoacidosis, pulmonary embolism,upper gastrointestinalbleeding,andcongestiveheart failure) in94acutecare nonfederal hospitals in Washington state and Maryland between2010and2012. These common illnessesmaybe classified as “in-between” conditions if they are not presenting at extreme levels of severity. The authors found great variability in the ICU utilization between high and low ICU utilizers. Higher ICUutilizationoccurred in smallerhospitals and teaching hospitals. Of note, the vast majority of hospitals had concordant ICU utilization (high or low) for all 4 conditions, suggesting consistent ICU vs ward triage patterns. The ICU and hospital occupancy did not affect ICU utilization for each of these conditions. Similarly, risk-adjustedhospitalmortality (at 30 days) did not differ between the high and low ICU utilizers;however, onceapatientwasadmitted to the ICU, therewas an increase in the number of invasive procedures (eg, central venous catheters) and higher hospital costs compared with patients cared for on the wards. Although this study showed greater use of standardized care pathways (represented by invasive procedures and increased costs) in the higher ICUutilization centers than in the lower, outcomes were similar. Many factors influence hospiAuthor Audio Interview at jamainternalmedicine.com

Implementing an Electronic Medical Record

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.