Critical care workforce

Inadequate intensive care physician supply in France: a point-prevalence prospective study

BACKGROUND

The COVID-19 pandemic has highlighted the importance of intensive care units (ICUs) and their organization in healthcare systems. However, ICU capacity and availability are ongoing concerns beyond the pandemic, particularly due to an aging population and increasing complexity of care. This study aimed to assess the current and future shortage of ICU physicians in France, ten years after a previous evaluation. A national e-survey was conducted among French ICUs in January 2022 to collect data on ICU characteristics, medical staffing, individual physician characteristics, and education and training capacities.

RESULTS

Among 290 ICUs contacted, 242 responded (response rate: 83%), representing 4943 ICU beds. The survey revealed an overall of 300 full time equivalent (FTE) ICU physician vacancies in the country. Nearly two-thirds of the participating ICUs reported at least one physician vacancy and 35% relied on traveling physicians to cover shifts. The ICUs most affected by physician vacancies were the ICUs of non-university affiliated public hospitals. The retirements expected in the next five years represented around 10% of the workforce. The median number of physicians per ICU was 7.0, corresponding to a ratio of 0.36 physician (FTE) per ICU bed. In addition, 27% of ICUs were at risk of critical dysfunction or closure due to vacancies and impending retirements.

CONCLUSION

The findings highlight the urgent need to address the shortage of ICU physicians in France. Compared to a similar study conducted in 2012, the inadequacy between ICU physician supply and demand has increased, resulting in a higher number of vacancies. Our study suggests that, among others, increasing the number of ICM residents trained each year could be a crucial step in addressing this issue. Failure to take appropriate measures may lead to further closures of ICUs and increased risks to patients in this healthcare system.

21st century critical care medicine: An overview

Critical care medicine in the 21st century has witnessed remarkable advancements that have significantly improved patient outcomes in intensive care units (ICUs). This abstract provides a concise summary of the latest developments in critical care, highlighting key areas of innovation. Recent advancements in critical care include Precision Medicine: Tailoring treatments based on individual patient characteristics, genomics, and biomarkers to enhance the effectiveness of therapies. The objective is to describe the recent advancements in Critical Care Medicine. Telemedicine: The integration of telehealth technologies for remote patient monitoring and consultation, facilitating timely interventions. Artificial intelligence (AI): AI-driven tools for early disease detection, predictive analytics, and treatment optimization, enhancing clinical decision-making. Organ Support: Advanced life support systems, such as Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy provide better organ support. Infection Control: Innovative infection control measures to combat emerging pathogens and reduce healthcare-associated infections. Ventilation Strategies: Precision ventilation modes and lung-protective strategies to minimize ventilator-induced lung injury. Sepsis Management: Early recognition and aggressive management of sepsis with tailored interventions. Patient-Centered Care: A shift towards patient-centered care focusing on psychological and emotional well-being in addition to medical needs. We conducted a thorough literature search on PubMed, EMBASE, and Scopus using our tailored strategy, incorporating keywords such as critical care, telemedicine, and sepsis management. A total of 125 articles meeting our criteria were included for qualitative synthesis. To ensure reliability, we focused only on articles published in the English language within the last two decades, excluding animal studies, in vitro/molecular studies, and non-original data like editorials, letters, protocols, and conference abstracts. These advancements reflect a dynamic landscape in critical care medicine, where technology, research, and patient-centered approaches converge to improve the quality of care and save lives in ICUs. The future of critical care promises even more innovative solutions to meet the evolving challenges of modern medicine.

Analysis of the National Resident Matching Program for Surgical Critical Care Training in the United States: 2008-2022

BACKGROUND

Few studies have assessed the pipeline for surgical intensivists despite projected shortages in the United States' critical care workforce. We had 3 primary objectives in analyzing the Surgical Critical Care Match: (1) understand growth in the number of applicants relative to training positions; (2) compare match rates for United States Allopathic Graduates versus non-United States Allopathic Graduates; and (3) analyze the number of unfilled training positions over time.

METHODS

This was a national cohort study of Surgical Critical Care Match applicants (2008-2022). Annual match rates and applicant-to-training position ratios were calculated. Cochrane-Armitage tests elucidated temporal trends during the study period.

RESULTS

There was a greater increase in the number of annual applicants (276% increase) relative to training positions (128% increase) during the study period (P < .001). The applicant-to-training position ratio increased (0.5-0.9, P < .001). Annual match rates increased for both United States Allopathic (92%-97%, P = .015) and non-United States Allopathic (81%-96%, P < .001) Graduates. Match rates for United States Allopathic Graduates exceeded those for non-United States Allopathic Graduates (P < .05) but were similar from 2020 to 2022 (P > .05). The percentage of applicants that matched at their top fellowship choice decreased from 69%-50% (P < .001). From 2008 to 2022, fewer available training positions went unfilled (52%-13%, P < .001).

CONCLUSION

The pipeline for surgical intensivists in the United States appears to be increasing along with rising interest in Surgical Critical Care training. Future research is needed to understand disparities in match rates by applicant and fellowship program characteristics.

Implementation of Tele-Intensive Care Unit Services During the COVID-19 Pandemic: A Systematic Literature Review and Updated Experience from Shandong Province

Background: While the use of telemedicine had been expanding before the initial outbreak of COVID-19, the pandemic has dramatically accelerated its implementation and expanded its usage in many hospitals. Tele-intensive care unit (ICU) is a specialized type of telemedicine that adapts available technologies to the unique needs of critically ill patients. We published an editorial in 2020 describing our initial experiences of Tele-ICU application in Shandong Province. Here, we update our insights gained over the past 2 years, and we provide a systematic review of the literature to compare our perspectives with those from other institutions. Methods: We performed a systematic literature review of publications describing the use of telemedicine in an ICU setting during COVID-19. The PubMed database was searched for studies published after January 1, 2020, which offered detailed descriptions of tele-ICU usage. Extracted data included details regarding tele-ICU technologies, descriptions of the institution, usage cases, assessments of tele-ICU effectiveness, and site-reported opinions (e.g., advantages, disadvantages). Results: We screened 162 studies resulting from the PubMed literature search, along with one expert recommendation. Of the 112 full-text articles retrieved, 11 were selected for inclusion in this qualitative summary. All were retrospective descriptions of tele-ICU experiences at a single site. Some pairs of included articles reported results from the same institution, with seven unique sites being described. Three sites employed centralized models of tele-ICU, while four allowed staff to participate from distant locations. Five sites collected user-reported feedback regarding tele-ICU. While the advantages and disadvantages described rarely overlapped directly between sites, many reported positive opinions of tele-ICU use overall. Conclusions: The potential applications of tele-ICU technologies vary widely, making them highly adaptable to the needs of individual institutions. Tele-ICU has proven invaluable to some hospitals during COVID-19 due to its effectiveness at aiding patient care while mitigating risk to health care workers.

Factors Associated With Nurses' Acceptance of the Electronic Intensive Care Unit

BACKGROUND

Telemedicine intensivist-led intensive care (electronic intensive care unit [eICU]) is recommended when on-site intensivist-led intensive care is not available. Although the effects of eICU on patient outcomes are comparable with bedside intensivist-led care, not all implementations of eICU are successful in improving patient outcomes. Therefore, the aims of this study were to (1) examine the associations of perceived usefulness, perceived ease of use, nurses' attitudes toward eICU, and intention to use and (2) determine which participant characteristics were associated with these four dependent variables.

METHODS

This cross-sectional, correlational study asked bedside registered nurses to complete an anonymous online survey to explore their acceptance of eICU.

RESULTS

Nurses' attitude toward eICU and intention-to-use eICU demonstrated the strongest association, r(120) = 0.83, p < .001. The most significant variable associated with perceived usefulness, perceived ease of use, nurses' attitudes toward eICU, and intention to use was support from nurses. In addition, support from physicians was significantly associated with perceived usefulness, perceived ease of use, and nurses' attitudes toward eICU.

CONCLUSIONS

Support from both bedside physicians and registered nurses in the intensive care unit had the most association with acceptance of the eICU service. Gaining their support to use an eICU service is essential.

Characteristics of Pulmonary Critical Care Medicine and Pulmonary Medicine Applicants and Fellowships

Background: Little is known about historical and recent application trends for pulmonary critical care medicine (PCCM) or pulmonary medicine (PM) fellowship programs. Describing trends in and characteristics of PCCM and PM applications, applicants, and fellowship programs can help program directors and medical educators understand trainees’ interest in and application patterns for these fellowship programs.

Objective: The objective of this study was to use National Residency Match Program data to assess recent trends in PCCM and PM fellowship applications and compare characteristics of applicants and fellowship programs.

Methods: In 2019, we used National Residency Match Program data to evaluate applicant ranking and matching in PCCM and PM fellowship programs and to compare applicant and fellowship program characteristics.

Results: From 2008 through 2019, the majority of applicants (59.1%) matched into PCCM were graduates of U.S. allopathic or osteopathic medical schools, whereas 87% of PM fellows were non-U.S. graduates. PCCM was the preferred specialty for 90.8% of matched applicants versus only 31.6% of matched PM applicants (P < 0.001). The match rate for PCCM applicants was 67.2% versus 23.8% for PM applicants (P < 0.001). Of PCCM applicants, 36.6% matched into their top choice versus 10.8% of PM applicants (P < 0.001). There are far fewer PM fellowship positions (n = 23) and programs (n = 12) than PCCM positions (n = 450) and programs (n = 131). The mean fill rates from the 2004 through 2016 appointment years are 94.1% in PCCM and 97.4% in PM (P = 0.009).

Conclusion: PCCM is a prevailing specialty choice over PM among residency graduates, with matched applicants more likely to list PCCM than PM as their preferred specialty. Further exploration into applicants’ interest in critical care compared with PM may prove beneficial in guiding applicants to programs that will best meet their career goals.

The Present State of Neurointensivist Training in the United States: A Comparison to Other Critical Care Training Programs

OBJECTIVE

This manuscript describes the state of neurocritical care fellowship training, compares its written standards to those of other critical care fellowship programs, and discusses how programmatic oversight by the United Council for Neurological Subspecialties should evolve to meet American College of Graduate Medical Education standards. This review is a work product of the Society of Critical Care Medicine Neuroscience section and was reviewed and approved by the Council of the Society of Critical Care Medicine.

DATA SOURCES

We evaluated the published training criteria and requirements of American College of Graduate Medical Education Critical Care subspecialty fellowships programs of Internal Medicine, Surgery, and Anesthesia and compared them with the training criteria and required competencies for neurocritical care.

STUDY SELECTION

We have reviewed the published training standards from American College of Graduate Medical Education as well as the United Council for Neurologic Subspecialties subspecialty training documents and clarified the definition and responsibilities of an intensivist with reference to the Leapfrog Group, the National Quality Forum, and the Joint Commission.

DATA EXTRACTION

No data at present exist to test the concept of similarity across specialty fellowship critical care training programs.

DATA SYNTHESIS

Neurocritical care training differs in its exposure to clinical entities that are directly associated to other critical care subspecialties. However, the core critical care knowledge, procedural skills, and competencies standards for neurocritical care appears to be similar with some important differences compared with American College of Graduate Medical Education critical care training programs.

CONCLUSIONS

The United Council for Neurologic Subspecialties has developed a directed program development strategy to emulate American College of Graduate Medical Education standards with the goal to have standards that are similar or identical to American College of Graduate Medical Education standards.

Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review

OBJECTIVES

To assess-by literature review and expert consensus-workforce, workload, and burnout considerations among intensivists and advanced practice providers.

DESIGN

Data were synthesized from monthly expert consensus and literature review.

SETTING

Workforce and Workload section workgroup of the Academic Leaders in Critical Care Medicine Task Force.

MEASUREMENTS AND MAIN RESULTS

Multidisciplinary care teams led by intensivists are an essential component of critical care delivery. Advanced practice providers (nurse practitioners and physician assistants) are progressively being integrated into ICU practice models. The ever-increasing number of patients with complex, life-threatening diseases, concentration of ICU beds in few centralized hospitals, expansion of specialty ICU services, and desire for 24/7 availability have contributed to growing intensivist staffing concerns. Such staffing challenges may negatively impact practitioner wellness, team perception of care quality, time available for teaching, and length of stay when the patient to intensivist ratio is greater than or equal to 15. Enhanced team communication and reduction of practice variation are important factors for improved patient outcomes. A diverse workforce adds value and enrichment to the overall work environment. Formal succession planning for ICU leaders is crucial to the success of critical care organizations. Implementation of a continuous 24/7 ICU coverage care model in high-acuity, high-volume centers should be based on patient-centered outcomes. High levels of burnout syndrome are common among intensivists. Prospective analyses of interventions to decrease burnout within the ICU setting are limited. However, organizational interventions are felt to be more effective than those directed at individuals.

CONCLUSIONS

Critical care workforce and staffing models are myriad and based on several factors including local culture and resources, ICU organization, and strategies to reduce burden on the ICU provider workforce. Prospective studies to assess and avoid the burnout syndrome among intensivists and advanced practice providers are needed.

Quantification of critical care medicine: An ICU survey

BACKGROUND

The shortage in intensivist workforce has been long recognized but no solution has been identified. Meanwhile, fellowships in pulmonary and critical care medicine (PCCM) are expanding, other critical care medicine (CCM) programs are contracting. No explanation exists for this contradictory trend, although understanding contributory factors may lead to a solution for the shortage. The fundamental difference between PCCM and other CCM programs lies in the residency training of trainees. We tested the hypothesis that the nature of CCM practice determines its attractiveness to potential candidates.

METHODS

A questionnaire-based survey was administered recording all daily activities in four different kinds of ICUs at two teaching hospitals one was public, and one was private. Activities were categorized into conventional CCM, respiratory, medical, and surgical interventions.

RESULTS

The average daily census was 17.6 ± 6.6. Across two MICU, one trauma/surgical and one cardiothoracic ICU the average daily activity ranged from 152 to 203 of these CCM formed 27%-36%, respiratory 10%-13%, medical 43%-59%, and surgical 1%-15%. The combination of medical and respiratory interventions represented >50% of daily activities among all the ICUs.

CONCLUSIONS

Quantitative description of ICU activities indicates that the majority of the ICU daily practice relies on medical and respiratory interventions, which may explain why PCCM remains popular.

When Will Telemedicine Appear in the ICU?

As our population ages and the demand for high-level intensive care unit (ICU) services increase, the ICU physician supply continues to lag. In addition, hospitals, physician groups, and patients are demanding rapid access for the highest level of expertise in the care of critically ill patients. Telemedicine in the ICU combined with remote patient monitoring has been increasingly touted as a model of care to increase efficiencies and quality of care. Telemedicine in the ICU provides the potential to connect critically ill patients to sophisticated specialty care on a 24/7 basis, even for those hospitalized in rural locations where access to timely specialty consultations are uncommon. Research on the use of telemedicine in the ICU has suggested improved outcomes, such as reductions in mortality, reductions in length of stay, and greater adherence to evidence-based guidelines. Although the clinical footprint of telemedicine in ICU has grown over the past 20 years, there has been a relative slowing of implementation. This review examines the clinical evidence supporting the use of telemedicine in the ICU and discusses the impact on clinical efficacy and costs of care. Additionally, we review the current hurdles to more rapid adoption, including the significant financial investment, different models of care affecting the return on investment, and the varied cultural attitudes that impact the success and acceptance of care models using telemedicine in the ICU.

Supplementing Intensivist Staffing With Nurse Practitioners: Literature Review

In the United States, providing health care to critically ill patients is a challenge. An increase in patients older than 65 years, a decrease in critical care physicians, and a decrease in work hours for residents cause intensivist staffing issues. In this article, use of nurse practictioners to fill the intensive care unit intensivist staffing gap is assessed and evidence-based recommendations are identified to better incorporate nurse practitioners as part of intensive care unit intensivist staffing. The literature reveals that when nurse practitioners are part of a staffing model, outcomes are either positively impacted or no different from physician outcomes. However, successfully integrating nurse practitioners into an intensive care unit team is not adequately discussed in the literature. This gap is addressed and 3 mechanisms to integrate nurse practitioners into the intensive care unit are identified: (1) use of a multidisciplinary staffing model, (2) completion of onboarding programs, and (3) evaluation of nurse practitioner productivity.

Characterizing Hospitalist Practice and Perceptions of Critical Care Delivery

BACKGROUND

Intensivist shortages have led to increasing hospitalist involvement in critical care delivery.

OBJECTIVE

To characterize the practice of hospitalists practicing in the intensive care unit (ICU) setting.

DESIGN

Survey of hospital medicine physicians.

SETTING

This survey was conducted as a needs assessment for the ongoing efforts of the Critical Care Task Force of the Society of Hospital Medicine Education Committee.

PARTICIPANTS

Hospitalists in the United States.

INTERVENTION

An iteratively developed, 25-item, webbased survey.

MEASUREMENTS

Results were compiled from all respondents then analyzed in subgroups. Various items were examined for correlations.

RESULTS

A total of 425 hospitalists completed the survey. Three hundred and twenty-five (77%) provided critical care services, and 280 (66%) served as primary physicians in the ICU. Hospitalists were significantly more likely to serve as primary physicians in rural ICUs (85% of rural respondents vs 62% of nonrural; P < .001 for association). Half of the rural hospitalists who were primary physicians for ICU patients felt obliged to practice beyond their scope, and 90% at least occasionally perceived that they had insufficient support from board-certified intensivists. Among respondents serving as primary physicians for ICU patients, 67% reported at least moderate difficulty transferring patients to higher levels of ICU care. Difficulty transferring patients was the only item significantly correlated with the perception of being expected to practice beyond one's scope (P < .05 for association).

CONCLUSIONS

Hospitalists frequently deliver critical care services without adequate training or support, most prevalently in rural hospitals. Without major changes in intensivist staffi ng or patient distribution, this is unlikely to change.

ICU Attending Handoff Practices: Results From a National Survey of Academic Intensivists

OBJECTIVES

To characterize intensivist handoff practices and expectations and to explore perceptions of the patient safety implications of attending handoffs.

DESIGN

Cross-sectional electronic survey administered in 2014.

SETTING

One hundred sixty-nine U.S. hospitals with critical care training programs accredited by the Accreditation Council for Graduate Medical Education.

SUBJECTS

Academic intensivists were recruited via e-mail invitation from a database of 1,712 eligible academic intensivists.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Six hundred sixty-one intensivists completed the survey (completion rate, 38.6%). Responses were received from at least one individual at 147 of 169 unique hospitals (87.0%) represented in the study database. Five hundred seventy-three (87%) respondents reported participating in handoffs at the end of each ICU rotation. A variety of communication methods were used for end-of-rotation handoffs, including in-person discussion (92.9%), telephone calls (83.9%), e-mail messages (69.0%), computer-generated documents (64.6%), and text messages (23.6%). Mean satisfaction with current handoff process was rated as 68.4 on a scale from 0 to 100 (SD, 22.6). Respondents (55.4%) said that attending handoffs should be standardized, but only 13.3% (76/572) of those participating in end-of-rotation handoffs reported using a standardized process. Specific handoff topics, including active clinical issues and resuscitation status, were reportedly discussed less frequently than would be ideal (p < 0.001 for the difference between reported frequency and ideal frequency). In free-text comments, 76 respondents (11.5%) expressed skepticism that attending handoffs were necessary given the presence of residents and fellows and given a lack of agreement about necessary content. Two hundred respondents (30.8%) reported knowing of an adverse event (inappropriate treatment, cardiac arrest, and death) attributable to inadequate attending handoffs.

CONCLUSIONS

ICU attending handoffs in the United States exhibit marked heterogeneity, and intensivists do not agree about the value of attending handoffs. In addition, some intensivists perceive a link between suboptimal attending handoffs, inappropriate treatment, and serious adverse events that warrants further study.

Paradigm shifts in critical care medicine: the progress we have made

There have really been no single, major, advances in critical care medicine since the specialty came into existence. There has, however, been a gradual, continuous improvement in the process of care over the years, which has resulted in improved patient outcomes. Here, we will highlight just a few of the paradigm shifts we have seen in processes of critical care, including the move from small, closed units to larger, more open ICUs; from a paternal "dictatorship" to more "democratic" team-work; from intermittent to continuous, invasive to less-invasive monitoring; from "more" interventions to "less" thus reducing iatrogenicity; from consideration of critical illness as a single event to realization that it is just one part of a trajectory; and from "four walls" to "no walls" as we take intensive care outside the physical ICU. These and other paradigm shifts have resulted in improvements in the whole approach to patient management, leading to more holistic, humane care for patients and their families. As critical care medicine continues to develop, further paradigm shifts in processes of care are inevitable and must be embraced if we are to continue to provide the best possible care for all critically ill patients.

The effect of physician staffing model on patient outcomes in a medical progressive care unit

PURPOSE

Although evidence supports the impact of intensivist physician staffing in improving intensive care unit (ICU) outcomes, the optimal coverage for progressive care units (PCU) is unknown. We sought to determine how physician staffing models influence outcomes for intermediate care patients.

MATERIALS AND METHODS

We conducted a retrospective observational comparison of patients admitted to the medical PCU of an academic hospital during 12-month periods of high-intensity and low-intensity staffing.

RESULTS

A total of 318 PCU patients were eligible for inclusion (143 high-intensity and 175 low-intensity). We found that low-intensity patients were more often stepped up from the emergency department and floor, whereas high-intensity patients were ICU transfers (61% vs 42%, P = .001). However, Mortality Probability Model scoring was similar between the 2 groups. In adjusted analysis, there was no association between intensity of staffing and hospital mortality (odds ratio, 0.84; 95% confidence interval, 0.36-1.99; P = .69) or PCU mortality (odds ratio, 0.96; 95% confidence interval, 0.38-2.45; P = .69). There was also no difference in subsequent ICU admission rates or in PCU length of stay.

CONCLUSIONS

We found no evidence that high-intensity intensivist physician staffing improves outcomes for intermediate care patients. In a strained critical care system, our study raises questions about the role of the intensivist in the graded care options between intensive and conventional ward care.

Intensivist-to-patient ratios in ICUs: is there a number?

PURPOSE OF REVIEW

Growth in critical care services has led to a dramatic increase in the need for ICU physicians. The supply of intensivists is not easily increased and there is pressure to solve this problem by increasing the number of patients per intensivist. There is a scarcity of published data addressing this issue, and until recently, there were no guidelines on appropriate ratios of intensivists to patients.

RECENT FINDINGS

In 2013, the Society of Critical Care Medicine formed a task force to address this issue and published written guidelines to aid hospitals in determining their intensivist staffing. This study reviews the published data which can aid these decisions and summarize the SCCM Taskforce's recommendations.

SUMMARY

The complex nature of critical care patients and ICUs make it difficult to provide one specific maximum intensivist-to-patient ratio, but common-sense rules can be applied. These recommendations are predicated on the principles that staffing can impact patient care as well as staff well-being and workforce stability. Also, that worsening patient outcomes, teaching, and workforce issues can be markers of inappropriate staffing. Finally, if the predicted daily workload of an intensivist exceeds the time of a work shift, then adjustments need to be made.

The myth of the workforce crisis. Why the United States does not need more intensivist physicians

Intensivist physician staffing is associated with lower mortality in the intensive care unit (ICU), yet many ICUs are not staffed by trained intensivists. This gap has led to a number of proposals intended to increase the intensivist supply in the United States. In this perspective we argue that such efforts would be both ineffective and ill-advised. Because many ICU patients are not critically ill, workforce models that base demand projections on ICU admission rather than true critical illness substantially overstate the workforce gap. Even in the presence of a workforce gap, training new intensivists would not place them in hospitals where they are needed most, would not mitigate the shortage of nonphysician critical care providers, and would require a unrealistic increase in spending on physician training. In addition, efforts to train more intensivists require us to prioritize intensive care over other specialties that are also in short supply, without clear justification for why intensivists are more important. Rather than continuing an unwarranted push to increase the intensivist supply, we suggest alternative workforce policies that emphasize novel interprofessional care models (to improve ICU quality in the absence of intensivists) combined with limitations on the future growth of ICU beds (to reduce demand through implicit rationing of care). These policies offer opportunities to reduce the mismatch between critical care supply and demand without an unnecessary expansion of the intensivist supply.

Options for tele-intensive care unit design: centralized versus decentralized and other considerations: it is not just a "another black sedan"

This article seeks assist physicians or administrators considering establishing a Tele-ICU. Owing to an apparent domination of the Tele-ICU field by a single vendor, some may believe that there is only one design option. In fact, there are many alternative design formats that do not require the consumer to possess high-level technical expertise. As when purchasing any major item, if the consumer can formulate basic concepts of design and research the various vendors, then the consumer can develop the Tele-ICU system best for their facility, finances, availability of staff, coverage model, and quality metric goals.

The Burden of the U.S. Crisis in the Surgical Critical Care Workforce and Workflow

There will be a 46 per cent shortage of intensivists by 2030. Currently, only 3 per cent of U.S. critical care is provided by surgeon-intensivists. Measurement of the current workload is needed to understand the ramifications of the expected shortage of surgeon-intensivists. The purpose of this study is to evaluate the self-reported workload of U.S. surgeon-intensivists. Over a 2-month period, a voluntary and anonymous survey of the surgery section of the Society of Critical Care Medicine was performed using Survey Monkey. Only surgeons were invited to participate. We assessed personnel resources and surgeon-intensivists workload in the intensive care unit (ICU) and on their postcall day. Two hundred sixty-two persons responded. Sixty-nine per cent had administrative responsibilities and 42 per cent covered bed allocation/transfer center duties while in the ICU. Seventy-six per cent covered trauma and general surgery call and 72 per cent covered the outpatient clinic or had elective surgery cases while responsible for the ICU. Only 14 per cent had no other responsibilities. Twenty-one per cent did not round with residents and 50 per cent did not round with a fellow. Thirty-six per cent did not work with advanced practitioners. The majority of surgeon-intensivists have significant responsibilities in addition to providing ICU care. This workload should be factored into the expected shortage of surgical intensivists relative to the expected increase in critical care demand.

Centralized monitoring and virtual consultant models of tele-ICU care: a systematic review

BACKGROUND

Increasing intensivist shortages and demand coupled with the escalating cost of care have created enthusiasm for intensive care unit (ICU)-based telemedicine ("tele-ICU"). This systematic literature review compares the Centralized Monitoring and Virtual Consultant tele-ICU Models.

MATERIALS AND METHODS

With an experienced medical reference librarian, we identified all language publications addressing the employment and efficacy of the centralized monitoring and virtual consultant tele-ICU systems through PubMed, CINAHL, and Web of Science. We performed quantitative and qualitative reviews of documents regarding financial sustainability, clinical outcomes, and ICU staff workflow and acceptance.

RESULTS

Of 1,468 documents identified, 1,371 documents were excluded, with the remaining 91 documents addressing clinical outcomes (46 documents [enhanced guideline compliance, 5; mortality and length of stay, 28; and feasibility, 13]), financial sustainability (9 documents), and ICU staff workflow and acceptance (36 documents). Quantitative review showed that studies evaluating the Centralized Monitoring Model were twice as frequent, with a mean of 4,891 patients in an average of six ICUs; Virtual Consultant Model studies enrolled a mean of 372 patients in an average of one ICU. Ninety-two percent of feasibility studies evaluated the Virtual Consultant Model, of which 50% were in the last 3 years. Qualitative review largely confirmed findings in previous studies of centralized monitoring systems. Both the Centralized Monitoring and Virtual Consultant Models showed clinical practice adherence improvement. Although definitive evaluation was not possible given lack of data, the Virtual Consultant Model generally indicated lean absolute cost profile in contrast to centralized monitoring systems.

CONCLUSIONS

Compared with the Virtual Consultant tele-ICU Model, studies addressing the Centralized Monitoring Model of tele-ICU care were greater in quantity and sample size, with qualitative conclusions of clinical outcomes, staff satisfaction and workload, and financial sustainability largely consistent with past systematic reviews. Attention should be focused on performing more high-quality studies to allow for equitable comparisons between both models.

Training internists to meet critical care needs in the United States: a consensus statement from the Critical Care Societies Collaborative (CCSC)

OBJECTIVES

Multiple training pathways are recognized by the Accreditation Council for Graduate Medical Education (ACGME) for internal medicine (IM) physicians to certify in critical care medicine (CCM) via the American Board of Internal Medicine. While each involves 1 year of clinical fellowship training in CCM, substantive differences in training requirements exist among the various pathways. The Critical Care Societies Collaborative convened a task force to review these CCM pathways and to provide recommendations for unified and coordinated training requirements for IM-based physicians.

PARTICIPANTS

A group of CCM professionals certified in pulmonary-CCM and/or IM-CCM from ACGME-accredited training programs who have expertise in education, administration, research, and clinical practice.

DATA SOURCES AND SYNTHESIS

Relevant published literature was accessed through a MEDLINE search and references provided by all task force members. Material published by the ACGME, American Board of Internal Medicine, and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force reached consensus using a roundtable meeting, electronic mail, and conference calls.

MAIN RESULTS

Internal medicine-CCM-based fellowships have disparate program requirements compared to other internal medicine subspecialties and adult CCM fellowships. Differences between IM-CCM and pulmonary-CCM programs include the ratio of key clinical faculty to fellows and a requirement to perform 50 therapeutic bronchoscopies. Competency-based training was considered uniformly desirable for all CCM training pathways.

CONCLUSIONS

The task force concluded that requesting competency-based training and minimizing variations in the requirements for IM-based CCM fellowship programs will facilitate effective CCM training for both programs and trainees.

Voices of family members and significant others in the tele-intensive care unit

BACKGROUND

Research suggests that tele-intensive care units (tele-ICUs) are associated with decreases in mortality rates, length of stay, and health care costs. However, little is known about the awareness and perceptions of the tele-ICU among patients' significant others.

OBJECTIVES

To assess whether patients' significant others were informed about the tele-ICU, what their preferences are regarding source and type of information about the tele-ICU, and what their perceptions are of the impact of the tele-ICU on patient care.

METHODS

A survey was conducted with a nonprobability, convenience sample of patients' significant others at 3 health systems.

RESULTS

Two-thirds of patients' significant others reported that they were uninformed about the tele-ICU and identified staff as the preferred source for this information. The 3 most important topics of information were patients' physical privacy, impact on patient care, and the technology. Most expressed favorable perceptions of the tele-ICU.

CONCLUSIONS

This pilot study demonstrated significant gaps in communication about the tele-ICU between staff and patients' significant others and revealed a preference to be informed about the tele-ICU by staff. Study findings will help define goals, objectives, and methods for further research to improve communication with patients' significant others about the tele-ICU.

Analysis of the variations between Accreditation Council for Graduate Medical Education requirements for critical care training programs and their effects on the current critical care workforce

Adult critical care medicine (CCM) is ill prepared for the demands of an aging US population. Sources have acknowledged a severe shortage of intensivists, yet there has been minimal discussion on the lack of critical care training opportunities. Inconsistencies in training options have led to fragmentation of how critical care services are provided to the US adult population. Significant differences exist between CCM without pulmonary and pulmonary critical care (PCCM) training as it relates to critical care coverage, patient population, and procedural skill of a trainee. The Internal Medicine Residency Review Committee appears more aligned with the PCCM vision of training rather than the CCM; thus, many PCCM programs are more available than pure CCM. Internal medicine offers the greatest pool of candidates to practice full-time CCM, yet there are minimal opportunities for internists wanting to go into straight CCM without also receiving pulmonary training. However, because many PCCM physicians spend a significant amount of time outside critical care, current PCCM training options do not meet the demand for critical care physicians. In this article, we review the barriers to critical care training opportunities and expanding the intensivist workforce and propose reasonable and practical solutions.

An extrapolation of Foucault's Technologies of the Self to effect positive transformation in the intensivist as teacher and mentor

In critical care medicine, teaching and mentoring practices are extremely important in regard to attracting and retaining young trainees and faculty in this important subspecialty that has a scarcity of needed personnel in the USA. To this end, we argue that Foucault's Technologies of the Self is critical background reading when endeavoring to effect the positive transformation of faculty into effective teachers and mentors.

The evolving model of pediatric critical care delivery in North America

The past 50 years have witnessed the emergence and evolution of the modern pediatric ICU and the specialty of pediatric critical care medicine. ICUs have become key in the delivery of health care services. The patient population within pediatric ICUs is diverse. An assortment of providers, including intensivists, trainees, physician assistants, nurse practitioners, and hospitalists, perform a variety of roles. The evolution of critical care medicine also has seen the rise of critical care nursing and other critical care staff collaborating in multidisciplinary teams. Delivery of optimal critical care requires standardized, reliable, and evidence-based processes, such as bundles, checklists, and formalized communication processes.

Critical care--where have we been and where are we going?

The first ICUs were established in the late 1950s and the specialty of critical care medicine began to develop. Since those early days, huge improvements have been made in terms of technological advances and understanding of the pathophysiology and pathogenesis of the disease processes that affect critically ill patients. Progress in therapeutics has been less dramatic, but process of care has improved steadily with important changes, including less iatrogenicity, better communication with patients and families, and improved teamwork, which have helped improve outcomes for ICU patients. Critical care medicine is one of the fastest-growing hospital specialties and, looking back, it is clear just how far we have come in such a relatively short period of time. With the ICU set to occupy an increasingly important place in hospitals worldwide, we must learn from the past and wisely embrace new developments in technology, therapeutics, and process, to ensure that the goals of critical care medicine are met in the future.

ACNP intensivist: a new ICU care delivery model and its supporting educational programs

The purposes of this article are to describe a physician (MD)/acute care nurse practitioner (ACNP) intensivist model for delivery of critical care services in a tertiary academic medical center and to describe an innovative nurse practitioner educational program developed to support the model. In an effort to address the current shortage of intensivists, Vanderbilt Medical Center has developed and refined a multidisciplinary intensivist MD/ACNP teams to provide expanded critical care services. The ACNPs, in collaboration with intensivist MDs, function as intensivist teams and are responsible for developing and executing the daily medical plan, bedside procedures, and emergency response. These teams provide 24-h a day coverage of tertiary level ICUs, and provide several unique benefits over traditional resident ICU staffing models. As the concept of the MD/ACNP intensivist team has developed, Vanderbilt University School of Nursing ACNP Program has expanded its curriculum to provide graduates with the knowledge, skills, and experiences to safely manage unstable critically ill patients. Multidisciplinary critical care teams of MD intensivists who work in collaboration with ACNP intensivists address the current shortfall of intensivists and represent a cost-effective means for expanding ICU coverage and increasing ICU bed availability while maintaining Leap Frog ICU staffing compliance.

Sustained effectiveness of a primary-team-based rapid response system

OBJECTIVE

Laws and regulations require many hospitals to implement rapid-response systems. However, the optimal resource intensity for such systems is unknown. We sought to determine whether a rapid-response system that relied on a patient's usual care providers, not a critical-care-trained rapid-response team, would improve patient outcomes.

DESIGN, SETTING, AND PATIENTS

An interrupted time-series analysis of over a 59-month period.

SETTING

Urban, academic hospital.

PATIENTS

One hundred seven-one thousand, three hundred forty-one consecutive adult admissions.

INTERVENTION

In the intervention period, patients were monitored for predefined, standardized, acute, vital-sign abnormalities or marked nursing concern. If these criteria were met, a team consisting of the patient's existing care providers was assembled.

MEASUREMENTS AND MAIN RESULTS

The unadjusted risk of unexpected mortality was 72% lower (95% confidence interval 55%-83%) in the intervention period (absolute risk: 0.02% vs. 0.09%, p < .0001). The unadjusted in-hospital mortality rate was not significantly lower (1.9% vs. 2.1%, p = .07). After adjustment for age, gender, race, season of admission, case mix, Charlson Comorbidity Index, and intensive care unit bed capacity, the intervention period was associated with an 80% reduction (95% confidence interval 63%-89%, p < .0001) in the odds of unexpected death, but no significant change in overall mortality [odds ratio 0.91 (95% confidence interval 0.82-1.02), p = .09]. Analyses that also adjusted for secular time trends confirmed these findings (relative risk reduction for unexpected mortality at end of intervention period: 65%, p = .0001; for in-hospital mortality, relative risk reduction = 5%, p = .2).

CONCLUSIONS

A primary-team-based implementation of a rapid response system was independently associated with reduced unexpected mortality. This system relied on the patient's usual care providers, not an intensive care unit based rapid response team, and may offer a more cost-effective approach to rapid response systems, particularly for systems with limited intensivist availability.

Utilization of robotic "remote presence" technology within North American intensive care units

OBJECTIVE

To describe remote presence robotic utilization and examine perceived physician impact upon care in the intensive care unit (ICU).

STUDY DESIGN

Data were obtained from academic, university, community, and rural medical facilities in North America with remote presence robots used in ICUs. Objective utilization data were extracted from a continuous monitoring system. Physician data were obtained via an Internet-based survey.

RESULTS

As of 2010, 56 remote presence robots were deployed in 25 North American ICUs. Of 10,872 robot activations recorded, 10,065 were evaluated. Three distinct utilization patterns were discovered. Combining all programs revealed a pattern that closely reflects diurnal ICU activity. The physician survey revealed staff are senior (75% >40 years old, 60% with >16 years of clinical practice), trained in and dedicated to critical care. Programs are mature (70% >3 years old) and operate in a decentralized system, originating from cities with >50,000 population and provided to cities >50,000 (80%). Of the robots, 46.6% are in academic facilities. Most physicians (80%) provide on-site and remote ICU care, with 60% and 73% providing routine or scheduled rounds, respectively. All respondents (100%) believed patient care and patient/family satisfaction were improved. Sixty-six percent perceived the technology was a "blessing," while 100% intend to continue using the technology.

CONCLUSIONS

Remote presence robotic technology is deployed in ICUs with various patterns of utilization that, in toto, simulate normal ICU work flow. There is a high rate of deployment in academic ICUs, suggesting the intensivists shortage also affects large facilities. Physicians using the technology are generally senior, experienced, and dedicated to critical care and highly support the technology.

Twenty-four-hour intensivist staffing in teaching hospitals: tensions between safety today and safety tomorrow

There is an inherent tension between the training needs of inexperienced clinicians and the safety of the patients for whom they are responsible. Our society has accepted this tension as a necessary trade-off to maintain a competent workforce of physicians year after year. However, recent trends in medical education have diminished resident autonomy in favor of the safety of current patients. One dramatic example is the rapid increase in the number of academic ICUs that provide coverage by attending physicians at all hours. The potential benefits of this staffing model have strong face validity: improved quality and efficiency from the constant involvement of experienced intensivists, increased family and staff satisfaction from the immediate availability of attending physicians, and reduced burn-out among intensivists from reduced on-call responsibilities. Thus, many hospitals have moved toward 24-h coverage by attending intensivist physicians without evidence that these benefits actually accrue and perhaps without full consideration of possible unintended consequences. In this article, we discuss the potential benefits and risks of nocturnal intensivist staffing, considering the needs of current and future patients. Furthermore, we suggest that there remains sufficient uncertainty about these benefits and risks that it is both necessary and ethical to study the effects in earnest.

Neurohospitalists: an emerging subspecialty

Akin to the rapid growth in hospitalist medicine seen in the prior decade, there has been a recent explosion in the need for neurohospitalists. Factors driving this demand include nationally mandated quality and safety measures, the increasing complexity and age of the hospitalized patient, and diminished training in diagnosis and management of neurological illnesses for internal medicine residents. The role of the neurohospitalist is varied and may include not only providing neurological care to hospitalized patients but also serving as a leader in an institution's push to meet quality and safety measures. Close collaboration with intensivists, vascular neurologists, and outpatient neurologists is both a challenge and essential for successful delivery of care both during hospitalization and after discharge. Future challenges facing neurohospitalists include defining its relationship to other fields, instituting a pathway for certification, and conducting research to guide the development of evidence-based practice and quality measures.

The role of neurocritical care: a brief report on the survey results of neurosciences and critical care specialists

BACKGROUND

Neurocritical care is a new subspecialty field in medicine that intersects with many of the neuroscience and critical care specialties, and continues to evolve in its scope of practice and practitioners. The objective of this study was to assess the perceived need for and roles of neurocritical care intensivists and neurointensive care units among physicians involved with intensive care and the neurosciences.

METHODS

An online survey of physicians practicing critical care medicine, and neurology was performed during the 2008 Leapfrog initiative to formally recognize neurocritical care training.

RESULTS

The survey closed in July 2009 and achieved a 13% response rate (980/7524 physicians surveyed). Survey respondents (mostly from North America) included 362 (41.4%) neurologists, 164 (18.8%) internists, 104 (11.9%) pediatric intensivists, 82 (9.4%) anesthesiologists, and 162 (18.5%) from other specialties. Over 70% of respondents reported that the availability of neurocritical care units staffed with neurointensivists would improve the quality of care of critically ill neurological/neurosurgical patients. Neurologists were reported as the most appropriate specialty for training in neurointensive care by 53.3%, and 57% of respondents responded positively that neurology residency programs should offer a separate training track for those interested in neurocritical care.

CONCLUSION

Broad level of support exists among the survey respondents (mostly neurologists and intensivists) for the establishment of neurological critical care units. Since neurology remains the predominant career path from which to draw neurointensivists, there may be a role for more comprehensive neurointensive care training within neurology residencies or an alternative training track for interested residents.