Essential and Expensive

Despite the documented benefits, however, only about 25% to 30% of hospitals have adopted some variation of the intensivist model, Rainey estimates. The problem often is competing physician interests, says Ivor S. Douglas, MD, director of the medical ICU at Denver Health Medical Center, a 477-bed level-one trauma center in Colorado. Many nonintensivists are accustomed to ICU access, and hospital administrators are sometimes tempted to endorse the status quo as a way of avoiding a physician relations nightmare. "It boils down to political will within the organization," he says.

For smaller hospitals, the model may just not be practical. "You have to have a certain level of volume to support a full-time intensivist. You need a reasonably sized unit, probably a minimum of eight beds in order to be economically feasible," says Thomas Higgins, MD, chief of adult critical care services at Baystate Medical Center, a 653-staffed-bed level one trauma center in Springfield, MA, that has received the Beacon Award for Critical Care Excellence from the American Association of Critical-Care Nurses four out of the past five years.

Although the main hospital prefers the intensivist model, two of Baystate Health's smaller satellite hospitals aren't big enough to support intensivists, primarily because there isn't enough volume to keep the physicians well-paid and happy. One way a hospital can get around that is by subsidizing intensivists, which is why many intensivists are hospital-employed rather than private practitioners. Another, more preferred option, particularly for smaller ICUs, is to operate instead under an open or modified model that doesn't rely solely on intensivists.

Success Key No. 2: Build multidisciplinary teams
Although intensivists are important, intensive care done right is less physician-centric than most service lines. Physicians, nurses, pharmacists, dieticians, physical therapists, respiratory therapists, social workers, and others are required to deliver 24/7 patient care, so ICU teams must avoid the common pitfalls that accompany hierarchical collaboration.

"Healthcare has become so complex now that no one person has all the information that's needed for the care of a patient," says Higgins. "I rely heavily on my pharmacist to keep track of the patient's organ dysfunction and to make recommendations for dosage changes; I rely on my dieticians to help me order enteral and parenteral nutrition; I rely heavily on nurses to give me information that I may not be seeing on two or three visits a day to the patient but they're seeing by being at bedside 24/7."

While most hospitals pay lip service to multidisciplinary collaboration, achieving it is another matter. For Central DuPage Hospital, a 313-bed hospital in central Illinois, one of the keys was multidisciplinary rounds, which ICU Medical Director Jeffrey Huml, MD, implemented in the fall of 2003 in the 16-bed ICU.

"Within months our length of stay decreased by 1.2 days, our time on ventilators decreased 50%, and risk adjusted mortality markedly improved." To put that in perspective, the Institute for Healthcare Improvement estimates that decreasing length of stay in a 12-bed unit by one day can save $3.5 million every six months and equal to a cost savings of 32 full-time equivalent nurses, Huml says.

Nurses, pharmacists, and other members of the patient team accompany a physician to check on each ICU patient. The benefits are twofold, Huml says. Multidisciplinary rounds serve primarily as an education tool; every member of the team, not just the physician, understands each patient's physiology and treatment plan and is able to intervene in the event of an emergency. That, in turn, affects the group dynamic.

"As the nurse becomes comfortable with the patient's physiology, that nurse becomes an active partner in the patient's care. That has wonderful aspects. One, the nurse feels comfortable challenging the physician on issues. And two, it creates an environment where it's magnetic for nurses to work in because they make a difference at the bedside." Huml says.