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Abstract
PURPOSE OF REVIEW Traditionally, hospitals have coped with chronically high ICU census by building more ICU beds, but this strategy is unlikely to be tenable under future financial models. Therefore, ICUs need additional tools to manage census, inflow, and throughput. RECENT FINDINGS Higher ICU census, without compensatory surges in nursing capacity, is associated with several adverse effects on patients and providers, but its relationship to mortality is uncertain. Providers also discharge patients more aggressively during times of high census. Little's Law (L = λ W), a cornerstone of queuing theory, provides an eminently practical basis for managing ICU census and throughput. One target for improving throughput is minimizing process steps that are without value to the patient, e.g., waiting for a bed at ICU discharge. Larger gains in ICU throughput can be found in ICU quality improvement. For example, spontaneous breathing trials, daily wake-ups, and early physical/occupational therapy programmes are all likely to improve throughput by reducing ICU length of stay. The magnitude of these interventions' effects on ICU census can be startling. SUMMARY ICUs should actively manage throughput and census. Operations management tools such as Little's Law can provide practical guidance about the relationship between census, throughput, and patient demand. Standard ICU quality improvement techniques can meaningfully affect both ICU census and throughput.
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Perceived effects of attending physician workload in academic medical intensive care units: a national survey of training program directors. Crit Care Med 2012; 40:400-5. [PMID: 22001582 DOI: 10.1097/ccm.0b013e318232d997] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Increases in the size and number of American intensive care units have not been accompanied by a comparable increase in the critical care physician workforce, raising concerns that intensivists are becoming overburdened by workload. This is especially concerning in academic intensive care units where attending physicians must couple teaching duties with patient care. METHODS We performed an in-person and electronic survey of the membership of the Association of Pulmonary and Critical Care Medicine Program Directors, soliciting information about patient workload, other hospital and medical education duties, and perceptions of the workplace and teaching environment of their intensive care units. RESULTS Eighty-four out of a total 121 possible responses were received from program directors or their delegates, resulting in a response rate of 69%. The average daily (SD) census (as perceived by the respondents) was 18.8 ± 8.9 patients, and average (SD) maximum service size recalled was 24.1 ± 9.9 patients. Twenty-seven percent reported no policy setting an upper limit for the daily census. Twenty-eight percent of respondents felt the average census was "too many" and 71% felt the maximum size was "too many." The median (interquartile range) patient-to-attending physician ratio was 13 (10-16). When categorized according to this median, respondents from intensive care units with high patient/physician ratios (n = 31) perceived significantly more time constraints, more stress, and difficulties with teaching trainees than respondents with low patient/physician ratios (n = 40). The total number of non-nursing healthcare workers per patient was similar in both groups, suggesting that having more nonattending physician staff does not alleviate perceptions of overwork and stress in the attending physician. CONCLUSIONS Academic intensive care unit physicians that direct fellowship programs frequently perceived being overburdened in the intensive care unit. Understaffing intensive care units with attending physicians may have a negative impact on teaching, patient care, and workforce stability.
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Increasing incidence of prolonged acute mechanical ventilation. Crit Care Med 2012; 40:298-9. [DOI: 10.1097/ccm.0b013e318232d4ab] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Preparing your intensive care unit to respond in crisis: considerations for critical care clinicians. Crit Care Med 2011; 39:2534-9. [PMID: 21926569 DOI: 10.1097/ccm.0b013e3182326440] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In recent years, healthcare disaster planning has grown from its early place as an occasional consideration within the manuals of emergency medical services and emergency department managers to a rapidly growing field, which considers continuity of function, surge capability, and process changes across the spectrum of healthcare delivery. A detailed examination of critical care disaster planning was undertaken in 2007 by the Task Force for Mass Critical Care of the American College of Chest Physicians Critical Care Collaborative Initiative. We summarize the Task Force recommendations and available updated information to answer a fundamental question for critical care disaster planners: What is a prepared intensive care unit and how do I ensure my unit's readiness? DATA SOURCES Database searches and review of relevant published literature. DATA SYNTHESIS Preparedness is essential for successful response, but because intensive care units face many competing priorities, without defining "preparedness for what," the task can seem overwhelming. Intensive care unit disaster planners should, therefore, along with the entire hospital, participate in a hospital or regionwide planning process to 1) identify critical care response vulnerabilities; and 2) clarify the hazards for which their community is most at risk. The process should inform a comprehensive written preparedness plan targeting the most worrisome scenarios and including specific guidance on 1) optimal use of space, equipment, and staffing for delivery of critical care to significantly increased patient volumes; 2) allocation of resources for provision of essential critical care services under conditions of absolute scarcity; 3) intensive care unit evacuation; and 4) redundant internal communication systems and means for timely data collection. CONCLUSION Critical care disaster planners have a complex, challenging task. Experienced planners will agree that no disaster response is perfect, but careful planning will enable the prepared intensive care unit to respond effectively in times of crisis.
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Reynolds HN, Rogove H, Bander J, McCambridge M, Cowboy E, Niemeier M. A Working Lexicon for the Tele-Intensive Care Unit: We Need to Define Tele-Intensive Care Unit to Grow and Understand It. Telemed J E Health 2011; 17:773-83. [DOI: 10.1089/tmj.2011.0045] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- H. Neal Reynolds
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
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Ali NA, Hammersley J, Hoffmann SP, O'Brien JM, Phillips GS, Rashkin M, Warren E, Garland A. Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing. Am J Respir Crit Care Med 2011; 184:803-8. [PMID: 21719756 DOI: 10.1164/rccm.201103-0555oc] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Little is known about the consequences of intensivists’ work schedules, or intensivist continuity of care. OBJECTIVES To assess the impact of weekend respite for intensivists, with consequent reduction in continuity of care, on them and their patients. METHODS In five medical intensive care units (ICUs) in four academic hospitals we performed a prospective, cluster-randomized, alternating trial of two intensivist staffing schedules. Daily coverage by a single intensivist in half-month rotations (continuous schedule) was compared with weekday coverage by a single intensivist, with weekend cross-coverage by colleagues (interrupted schedule). We studied consecutive patients admitted to study units, and the intensivists working in four of the participating units. MEASUREMENTS AND MAIN RESULTS The primary patient outcome was ICU length of stay (LOS);we also assessed hospital LOS and mortality rates. The primary intensivist outcome was physician burnout. Analysis was by multivariable regression. A total of 45 intensivists and 1,900 patients participated in the study. Continuity of care differed between schedules (patients with multiple intensivists = 28% under continuous schedule vs. 62% under interrupted scheduling; P < 0.0001). LOS and mortality were nonsignificantly higher under continuous scheduling (ΔICU LOS 0.36 d, P = 0.20; Δhospital LOS 0.34 d, P = 0.71; ICU mortality, odds ratio = 1.43, P = 0.12; hospital mortality, odds ratio = 1.17,P = 0.41). Intensivists experienced significantly higher burnout, work–home life imbalance, and job distress working under the continuous schedule. CONCLUSIONS Work schedules where intensivists received weekend breaks were better for the physicians and, despite lower continuity of intensivist care, did not worsen outcomes for medical ICU patients.
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Affiliation(s)
- Naeem A Ali
- Division of Pulmonary, Allergy, Critical CAre and Sleep Medicine, Indiana University, Indianapolis, Indiana, USA
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58
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Jones SF, Arroliga AC, Papazian L, Azoulay E. Thank God it's Friday!: achieving balance between continuity of care and intensivist burnout. Am J Respir Crit Care Med 2011; 184:749-50. [PMID: 21965009 DOI: 10.1164/rccm.201107-1304ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Kheterpal S, Tremper KK, Shanks A, Morris M. Workforce and Finances of the United States Anesthesiology Training Programs. Anesth Analg 2011; 112:1480-6. [DOI: 10.1213/ane.0b013e3182135a3a] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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61
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Challenging issues in surgical critical care, trauma, and acute care surgery: a report from the Critical Care Committee of the American Association for the Surgery of Trauma. ACTA ACUST UNITED AC 2011; 69:1619-33. [PMID: 21150539 DOI: 10.1097/ta.0b013e3182011089] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Critical care workforce analyses estimate a 35% shortage of intensivists by 2020 as a result of the aging population and the growing demand for greater utilization of intensivists. Surgical critical care in the U.S. is particularly challenged by a significant shortfall of surgical intensivists, with only 2586 surgeons currently certified in surgical critical care by the American Board of Surgery, and even fewer surgeons (1204) recertified in surgical critical care as of 2009. Surgical critical care fellows (160 in 2009) represent only 7.6% of all critical care trainees (2109 in 2009), with the largest number of critical care fellowship positions in internal medicine (1472, 69.8%). Traditional trauma fellowships have now transitioned into Surgical Critical Care or Acute Care Surgery (trauma, surgical critical care, emergency surgery) fellowships. Since adult critical care services are a large, expensive part of U.S. healthcare and workforce shortages continue to impact our healthcare system, recommendations for regionalization of critical care services in the U.S. is considered. The Critical Care Committee of the AAST has compiled national data regarding these important issues that face us in surgical critical care, trauma and acute care surgery, and discuss potential solutions for these issues.
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Corcoran SP, Niven AS, Reese JM. Critical care management of major disasters: a practical guide to disaster preparation in the intensive care unit. J Intensive Care Med 2011; 27:3-10. [PMID: 21220272 DOI: 10.1177/0885066610393639] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent events and regulatory mandates have underlined the importance of medical planning and preparedness for catastrophic events. The purpose of this review is to provide a brief summary of current commonly identified threats, an overview of mass critical care management, and a discussion of resource allocation to provide the intensive care unit (ICU) director with a practical guide to help prepare and coordinate the activities of the multidisciplinary critical care team in the event of a disaster.
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Affiliation(s)
- Shawn P Corcoran
- Department of Medicine, Madigan Army Medical Center, Tacoma, WA 98431, USA.
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Manno EM. Neurohospitalists: Challenges for the Integration of a New Field: A Neurointensivist's Perspective. Front Neurol 2010; 1:154. [PMID: 21191473 PMCID: PMC3010741 DOI: 10.3389/fneur.2010.00154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 12/07/2010] [Indexed: 12/03/2022] Open
Affiliation(s)
- Edward M Manno
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic Cleveland, OH, USA
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Evans TW. 24-Hour Staffing of Intensive Care Units by Trained Specialists. Am J Respir Crit Care Med 2010; 182:294-5. [DOI: 10.1164/rccm.201006-0829ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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65
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Cartin-Ceba R, Bajwa EK. 24-hour on-site intensivist in the intensive care unit: yes. Am J Respir Crit Care Med 2010; 181:1279-80. [PMID: 20558637 DOI: 10.1164/rccm.201004-0676ed] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Williams TA, Leslie GD, Brearley L, Leen T, O'Brien K. Discharge delay, room for improvement? Aust Crit Care 2010; 23:141-9. [PMID: 20347328 DOI: 10.1016/j.aucc.2010.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 02/19/2010] [Accepted: 02/22/2010] [Indexed: 11/16/2022] Open
Abstract
AIM Patients treated in the intensive care unit (ICU) and identified as suitable for discharge to the ward should have their discharge planned and expedited to improve patient outcomes and manage resources efficiently. We examined the hypothesis that the introduction of a critical care outreach role would decrease the frequency of discharge delay from ICU. METHODS Discharge delay was compared for two 6-month periods: (1) after introduction of the outreach role in 2008 and (2) in 2000/2001 (from an earlier study). Patients were included if discharged to a ward in the study hospital. Discharge times and reason for delay were collected by Critical Care Outreach Nurses and Critical Care Nurse Specialists. RESULTS Of the 516 discharges in 2008 (488 patients compared to 607 in 2000/2001), 31% of the discharges were delayed from ICU more than 8h, an increase of 6% from 2000/2001 (p<0.001). Patients in 2008 spent more in hospital from the time of their ICU admission when their discharge was delayed (p<0.001). The most common reasons for delay in 2008 were due to no bed or delay in bed availability (53%) and medical concern (24%). This is in contrast to 2000/2001 when 80% of delays were due to no bed or delay in bed availability and 9% due to medical concern. Many factors impact on patient flow and reducing ICU discharge delays requires a collaborative, multi-factorial approach which adapts to changing organisational policy on patient flow through ICU and the hospital, not just the discharge process in ICU.
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Affiliation(s)
- Teresa A Williams
- Curtin Health Innovation Research Institute, Curtin University and Critical Care Division, Royal Perth Hospital, Western Australia, Australia.
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Billington EO, Zygun DA, Stelfox HT, Peets AD. Intensivists' base specialty of training is associated with variations in mortality and practice patterns. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R209. [PMID: 20040087 PMCID: PMC2811951 DOI: 10.1186/cc8227] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 10/20/2009] [Accepted: 12/29/2009] [Indexed: 01/19/2023]
Abstract
Introduction Current evidence regarding whether the staffing of intensive care units (ICUs) with a trained Intensivist benefits patient outcomes is discordant. We sought to determine whether, among certified Intensivists, base specialty of training could contribute to variation in practice patterns and patient outcomes in ICUs. Methods The records of all patients who were admitted to one of three closed multi-system ICUs within tertiary care centers in the Calgary Health Region, Alberta, Canada, during a five year period were retrospectively reviewed. Outcomes for patients admitted by Intensivists with base training in General Internal Medicine, Pulmonary Medicine, or other eligible base specialties (Anesthesia, General Surgery, and Emergency Medicine combined) were compared. Results ICU mortality in the entire cohort (n = 9,808) was 17.2% and in-hospital mortality was 32.0%. After controlling for potential confounders, ICU mortality (odds ratio (OR): 0.69; 95% confidence interval (CI): 0.52 to 0.94) was significantly lower for patients admitted by Intensivists with Pulmonary Medicine as a base specialty of training, but not ICU length of stay (LOS) (coefficient: 0.11; -0.20 to 0.42) or hospital mortality (OR: 0.88; 0.68 to 1.13). There was no difference in ICU or hospital mortality or length of stay between the three base specialty groups for patients who were admitted and managed by a single Intensivist for their entire ICU admission (n = 4,612). However, we identified significant variation in practice patterns between the three specialty groups for the number of invasive procedures performed and decisions to limit life-sustaining therapies. Conclusions Intensivists' base specialty of training is associated with practice pattern variations. This may contribute to differences in processes and outcomes of patient care.
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Affiliation(s)
- Emma O Billington
- Department of Medicine, Foothills Medical Centre - Calgary AB, T2N 2T9, Canada.
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68
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Emergency traumatologists in trauma care. J Am Coll Surg 2009; 209:675; author reply 675-6. [PMID: 19854416 DOI: 10.1016/j.jamcollsurg.2009.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 08/19/2009] [Indexed: 11/22/2022]
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Sapirstein A, Lone N, Latif A, Fackler J, Pronovost PJ. Tele ICU: paradox or panacea? Best Pract Res Clin Anaesthesiol 2009; 23:115-26. [PMID: 19449620 DOI: 10.1016/j.bpa.2009.02.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Adam Sapirstein
- Department of Anesthesia and Critical Care Medicine. The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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71
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Respite for the critical care workforce crisis. Crit Care Med 2008; 36:2961-2; author reply 2962. [PMID: 18812817 DOI: 10.1097/ccm.0b013e3181872940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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