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Intensivist Impact

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Like a visitor tiptoeing into a critical-care unit, Kootenai Medical Center introduced intensivists—physicians trained in critical care—into its ICU slowly.

Intensive care specialists at the 240-staffed-bed Coeur d’Alene, Idaho, hospital initially made rounds, consulted when asked and offered suggestions when appropriate. But responsibility for patient care remained with the admitting physician, says Joseph S. Bujak, M.D., Kootenai’s vice president of medical affairs.

Over time, however, hospital-contracted intensivists steadily gained ground in the unit, and a new care model is in sight. “I’m sure within another year or two in all likelihood we’ll close the unit,” says Bujak, meaning that intensivists will have primary responsibility for most, if not all, ICU patients.

The path Kootenai is following will become a familiar one to many hospitals in the years ahead. Intensivists are seeing demand for their services surge as evidence mounts that they provide better outcomes for a hospital’s most complex patients.

“When you can promote your best clinicians taking care of your sickest patients, you reduce the variability of care, improve the quality of the attention and thereby the quality of the outcome,” Bujak says.

Collectively, the outcome is an eye-popper: Hospitals in which intensivists manage or co-manage all patients have a 40 percent reduction in ICU mortality compared to hospitals in which intensivists manage some or none of the patients, according to research cited by The Leapfrog Group. That research prompted Leapfrog to set an ICU physician staffing standard requiring hospitals to staff their ICUs with intensivists who manage or co-manage patients during daytime hours. At other times, hospitals must have intensivists who can return ICU pages within five minutes or specially trained non-physicians who can reach ICU patients within that time.

Most hospitals are not yet hitting the standard, says Thomas Rainey, M.D., an intensivist and past president of the Society of Critical Care Medicine. “Probably 70 percent to 80 percent of ICUs in America are the every-doctor-in-and-out variety,” he says.

More than a decade ago, Rainey founded Bethesda, Md.-based CriticalMed Inc., which helps hospitals develop an “intensivist service model” in which intensive care specialists work with a multidisciplinary team to care for all patients in a unit.

Although some hospitals hire intensivists as staff members, most, like Kootenai Medical Center, contract with a group of physicians. “The fastest-growing model is an intensivist service contracted with the hospital to provide a clearly defined bundle of services for presence and management of the ICU,” Rainey says.

—Lola Butcher



Increasing Demand

Those darn baby boomers are wreaking havoc again.

“The demand for ICU services is projected to grow rapidly during the next decade as the average acuity of hospitalized patients rises with growth in the elderly population,” according to the Health Resources and Services Administration. In its May 2006 report to Congress, HRSA said more intensivists are needed now—and especially in the future.

As of 2000, some 1,900 intensivists were working in America’s ICUs, providing care for about one-third of critical-care patients. But HRSA wants the proportion of patients cared for by intensivists to grow; it considers two-thirds of patients to be “more optimal.” To make that happen, 4,300 intensivists will be needed by 2020—or 1,500 more than HRSA projects will be available by that time.

Pulmonologists pioneered critical-care medicine, and the majority of intensivists working today are trained in combined pulmonary and critical-care programs. A combined fellowship must be at least three years. HRSA says pay levels make “critical care less attractive to newly trained physicians” and warned Congress that higher rates may be needed to fill the pipeline.

Another idea: Recognizing that small hospitals may not be able to support full-time intensivists, The Leapfrog Group suggests consolidating ICU care into larger hospitals.

—Lola Butcher