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Shaefi S, Pannu A, Mueller AL, Flynn B, Evans A, Jabaley CS, Mladinov D, Wall M, Siddiqui S, Douin DJ, Boone MD, Monteith E, Abalama V, Nunnally ME, Cobas M, Warner MA, Stevens RD. Nationwide Clinical Practice Patterns of Anesthesiology Critical Care Physicians: A Survey to Members of the Society of Critical Care Anesthesiologists. Anesth Analg 2023; 136:295-307. [PMID: 35950751 PMCID: PMC9840646 DOI: 10.1213/ane.0000000000006160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite the growing contributions of critical care anesthesiologists to clinical practice, research, and administrative leadership of intensive care units (ICUs), relatively little is known about the subspecialty-specific clinical practice environment. An understanding of contemporary clinical practice is essential to recognize the opportunities and challenges facing critical care anesthesia, optimize staffing patterns, assess sustainability and satisfaction, and strategically plan for future activity, scope, and training. This study surveyed intensivists who are members of the Society of Critical Care Anesthesiologists (SOCCA) to evaluate practice patterns of critical care anesthesiologists, including compensation, types of ICUs covered, models of overnight ICU coverage, and relationships between these factors. We hypothesized that variability in compensation and practice patterns would be observed between individuals. METHODS Board-certified critical care anesthesiologists practicing in the United States were identified using the SOCCA membership distribution list and invited to take a voluntary online survey between May and June 2021. Multiple-choice questions with both single- and multiple-select options were used for answers with categorical data, and adaptive questioning was used to clarify stem-based responses. Respondents were asked to describe practice patterns at their respective institutions and provide information about their demographics, salaries, effort in ICUs, as well as other activities. RESULTS A total of 490 participants were invited to take this survey, and 157 (response rate 32%) surveys were completed and analyzed. The majority of respondents were White (73%), male (69%), and younger than 50 years of age (82%). The cardiothoracic/cardiovascular ICU was the most common practice setting, with 69.5% of respondents reporting time working in this unit. Significant variability was observed in ICU practice patterns. Respondents reported spending an equal proportion of their time in clinical practice in the operating rooms and ICUs (median, 40%; interquartile range [IQR], 20%-50%), whereas a smaller proportion-primarily those who completed their training before 2009-reported administrative or research activities. Female respondents reported salaries that were $36,739 less than male respondents; however, this difference was not statistically different, and after adjusting for age and practice type, these differences were less pronounced (-$27,479.79; 95% confidence interval [CI], -$57,232.61 to $2273.03; P = .07). CONCLUSIONS These survey data provide a current snapshot of anesthesiology critical care clinical practice patterns in the United States. Our findings may inform decision-making around the initiation and expansion of critical care services and optimal staffing patterns, as well as provide a basis for further work that focuses on intensivist satisfaction and burnout.
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Affiliation(s)
- Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ameeka Pannu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ariel L. Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brigid Flynn
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
| | | | - Craig S. Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University, Atlanta, GA
| | - Domagoj Mladinov
- Department of Anesthesiology and Perioperative Medicine, University of Alabama Hospital, Birmingham, AL
| | - Michael Wall
- Department of Anesthesiology, University of Minnesota Medical Center, Minneapolis, MN
| | - Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David J. Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
| | - M. Dustin Boone
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Erika Monteith
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vivian Abalama
- International Anesthesia Research Society (IARS), Society of Critical Care Anesthesiologists (SOCCA), San Francisco, CA
| | - Mark E. Nunnally
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Langone Health, New York, NY
| | - Miguel Cobas
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Jackson Memorial Hospital, Miami, FL
| | - Matthew A. Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Schwalb A, Armyra E, Méndez-Aranda M, Ugarte-Gil C. COVID-19 in Latin America and the Caribbean: Two years of the pandemic. J Intern Med 2022; 292:409-427. [PMID: 35411985 PMCID: PMC9115176 DOI: 10.1111/joim.13499] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Worldwide, nations have struggled during the coronavirus disease 2019 (COVID-19) pandemic. However, Latin America and the Caribbean faced an unmatched catastrophic toll. As of March 2022, the region has reported approximately 15% of cases and 28% of deaths worldwide. Considering the relatively late arrival of SARS-CoV-2, several factors in the region were determinants of the humanitarian crisis that ensued. Pandemic unpreparedness, fragile healthcare systems, forthright inequalities, and poor governmental support facilitated the spread of the virus throughout the region. Moreover, reliance on repurposed and ineffective drugs such as hydroxychloroquine and ivermectin-to treat or prevent COVID-19-was publicised through misinformation and created a false sense of security and poor adherence to social distancing measures. While there were hopes that herd immunity could be achieved after the region's disastrous first peak, the emergence of the Gamma, Lambda, and Mu variants made this unattainable. This review explores how Latin America and the Caribbean fared during the first 2 years of the pandemic, and how, despite all the challenges, the region became a global leader in COVID-19 vaccination, with 63% of its population fully vaccinated.
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Affiliation(s)
- Alvaro Schwalb
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru.,London School of Hygiene and Tropical Medicine, London, UK
| | - Eleonora Armyra
- Health Innovation Lab, Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Melissa Méndez-Aranda
- Facultad de Ciencias y Filosofía, Laboratorio de Investigación en Enfermedades Infecciosas, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - César Ugarte-Gil
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru.,London School of Hygiene and Tropical Medicine, London, UK.,School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
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Michael Robie E, Cole S, Suwal A, Coustasse A. Tele-ICU in the Unites States: Is a cost-effective model? INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2022. [DOI: 10.1080/20479700.2022.2040877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- E. Michael Robie
- Healthcare Administration Program, Lewis College of Business, Marshall University, South Charleston, WV 25303 USA
| | - Stephanie Cole
- Healthcare Administration Program, Lewis College of Business, Marshall University, South Charleston, WV 25303 USA
| | - Archana Suwal
- Healthcare Administration Program, Lewis College of Business, Marshall University, South Charleston, WV 25303 USA
| | - Alberto Coustasse
- Healthcare Administration Program, Lewis College of Business, Marshall University, South Charleston, WV 25303 USA
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Intensive Care Unit prioritization: The impact of ICU bed availability on mortality in critically ill patients who requested ICU admission in court in a Brazilian cohort. J Crit Care 2021; 66:126-131. [PMID: 34544015 DOI: 10.1016/j.jcrc.2021.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/24/2021] [Accepted: 08/31/2021] [Indexed: 02/01/2023]
Abstract
PURPOSE To assess hospital mortality in patients who requested ICU admission in court due to the scarcity of ICU beds in the Brazilian public health system and the consequences of these judicial litigations. MATERIAL AND METHODS Retrospective cohort study that included adult patients from the public health system of the Federal District, Brazil, who claimed ICU admission in court from January 2017 to December 2019. RESULTS Of the 1752 patients, 1031 were admitted to ICU (58.8%). Hospital mortality was 61.1% (1071/1752). Of the requests, 768 (43.8%) were made by patients with priority levels III or IV, resulting in the ICU admission of 33.9% of these patients. Denial of ICU admission (p < 0.001) increased mortality. ICU admission reduced hospital mortality in patients classified as priority level I (p < 0.001), priority level II (p < 0.001), and priority level III (p < 0.001), but not as priority level IV (p = 0.619). CONCLUSION A large proportion of patients was denied ICU admission and it was associated with an increased mortality. A considerable portion of the ICU-admitted patients were classified as priority level III and IV, impairing the ICU admission of patients with priority level I which are the ones with the greatest benefit from it.
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Gigli KH, Davis BS, Martsolf GR, Kahn JM. Advanced Practice Provider-inclusive Staffing Models and Patient Outcomes in Pediatric Critical Care. Med Care 2021; 59:597-603. [PMID: 34100461 PMCID: PMC8187846 DOI: 10.1097/mlr.0000000000001531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric intensive care units (PICUs) are increasingly staffed with advanced practice providers (APPs), supplementing traditional physician staffing models. OBJECTIVES We evaluate the effect of APP-inclusive staffing models on clinical outcomes and resource utilization in US PICUs. RESEARCH DESIGN Retrospective cohort study of children admitted to PICUs in 9 states in 2016 using the Healthcare Cost and Utilization Project's State Inpatient Databases. PICU staffing models were assessed using a contemporaneous staffing survey. We used multivariate regression to examine associations between staffing models with and without APPs and outcomes. MEASURES The primary outcome was in-hospital mortality. Secondary outcomes included odds of hospital acquired conditions and ICU and hospital lengths of stay. RESULTS The sample included 38,788 children in 40 PICUs. Patients admitted to PICUs with APP-inclusive staffing were younger (6.1±5.9 vs. 7.1±6.2 y) and more likely to have complex chronic conditions (64% vs. 43%) and organ failure on admission (25% vs. 22%), compared with patients in PICUs with physician-only staffing. There was no difference in mortality between PICU types [adjusted odds ratio (AOR): 1.23, 95% confidence interval (CI): 0.83-1.81, P=0.30]. Patients in PICUs with APP-inclusive staffing had lower odds of central line-associated blood stream infections (AOR: 0.76, 95% CI: 0.59-0.98, P=0.03) and catheter-associated urinary tract infections (AOR: 0.73, 95% CI: 0.61-0.86, P<0.001). There were no differences in lengths of stay. CONCLUSIONS Despite being younger and sicker, children admitted to PICUs with APP-inclusive staffing had no increased odds of mortality and lower odds of some hospital acquired conditions compared with those in PICUs with physician-only staffing. Further research can inform APP integration strategies which optimize outcomes.
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Affiliation(s)
- Kristin H. Gigli
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas
| | - Billie S. Davis
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Grant R. Martsolf
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
- RAND Corporation, Pittsburgh, Pennsylvania
| | - Jeremy M. Kahn
- CRISMA Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
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Mathews KS, Seitz KP, Vranas KC, Duggal A, Valley TS, Zhao B, Gundel S, Harhay MO, Chang SY, Hough CL. Variation in Initial U.S. Hospital Responses to the Coronavirus Disease 2019 Pandemic. Crit Care Med 2021; 49:1038-1048. [PMID: 33826584 PMCID: PMC8217146 DOI: 10.1097/ccm.0000000000005013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The coronavirus disease 2019 pandemic has strained many healthcare systems. In response, U.S. hospitals altered their care delivery systems, but there are few data regarding specific structural changes. Understanding these changes is important to guide interpretation of outcomes and inform pandemic preparedness. We sought to characterize emergency responses across hospitals in the United States over time and in the context of local case rates early in the coronavirus disease 2019 pandemic. DESIGN We surveyed hospitals from a national acute care trials group regarding operational and structural changes made in response to the coronavirus disease 2019 pandemic from January to August 2020. We collected prepandemic characteristics and changes to hospital system, space, staffing, and equipment during the pandemic. We compared the timing of these changes with county-level coronavirus disease 2019 case rates. SETTING AND PARTICIPANTS U.S. hospitals participating in the Prevention and Early Treatment of Acute Lung Injury Network Coronavirus Disease 2019 Observational study. Site investigators at each hospital collected local data. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty-five sites participated (94% response rate). System-level changes (incident command activation and elective procedure cancellation) occurred at nearly all sites, preceding rises in local case rates. The peak inpatient census during the pandemic was greater than the prior hospital bed capacity in 57% of sites with notable regional variation. Nearly half (49%) expanded ward capacity, and 63% expanded ICU capacity, with nearly all bed expansion achieved through repurposing of clinical spaces. Two-thirds of sites adapted staffing to care for patients with coronavirus disease 2019, with 48% implementing tiered staffing models, 49% adding temporary physicians, nurses, or respiratory therapists, and 30% changing the ratios of physicians or nurses to patients. CONCLUSIONS The coronavirus disease 2019 pandemic prompted widespread system-level changes, but front-line clinical care varied widely according to specific hospital needs and infrastructure. Linking operational changes to care delivery processes is a necessary step to understand the impact of the coronavirus disease 2019 pandemic on patient outcomes.
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Affiliation(s)
- Kusum S. Mathews
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kevin P. Seitz
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University, Nashville, Tennessee
| | - Kelly C. Vranas
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care , Oregon Health & Science University, Portland, Oregon
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Thomas S. Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, Michigan
| | - Bo Zhao
- Department of Geography, University of Washington, Seattle, Washington
| | - Stephanie Gundel
- Department of Medicine, University of Washington, Seattle, Washington
| | - Michael O. Harhay
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven Y. Chang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, David Geffen School of Medicine at UCLA, Ronald Reagan-UCLA Medical Center, Los Angeles, California
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care , Oregon Health & Science University, Portland, Oregon
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Characteristics of U.S. Acute Care Hospitals That Have Implemented Telemedicine Critical Care. Crit Care Explor 2021; 3:e0468. [PMID: 34235456 PMCID: PMC8245115 DOI: 10.1097/cce.0000000000000468] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: Telemedicine critical care is associated with improved efficiency, quality, and cost-effectiveness. As of 2010, fewer than 5% of U.S. hospitals had telemedicine critical care, and fewer than 10% of ICU beds were covered. We evaluated recent telemedicine critical care implementation and bed coverage rates in the United States and compared characteristics of hospitals with and without telemedicine critical care. DESIGN: Cross-sectional study of 2018 American Hospital Association Annual Survey Database. SETTING: U.S. hospitals. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We obtained data regarding telemedicine critical care implementation, ICU capability (defined as ≥ 1 ICU bed), other hospital characteristics, and the Herfindahl-Hirschman Index, a measure of ICU market competition based on hospital referral regions. Among 4,396 hospitals (response rate 71%), 788 (17.9%) had telemedicine critical care, providing potential coverage to 27,624 (28% of total) ICU beds. Among 306 hospital referral regions, 197 (64%) had a respondent hospital with telemedicine critical care. Telemedicine critical care implementation was associated with being a nonprofit (odds ratio, 7.75; 95% CI, 5.18–11.58) or public (odds ratio, 4.16 [2.57–6.73]) compared with for-profit hospital; membership in a health system (odds ratio, 3.83 [2.89–5.08]; stroke telemedicine presence (odds ratio, 6.87 [5.35–8.81]); ICU capability (odds ratio, 1.68 [1.25–2.26]); and more competitive ICU markets (odds ratio per 1,000-point decrease in Herfindahl-Hirschman Index 1.11 [1.01–1.22]). Notably, rural critical access hospitals had lower odds of telemedicine critical care implementation (odds ratio, 0.49 [0.34–0.70]). Teaching status, geographic region, and rurality were not associated with telemedicine critical care implementation. CONCLUSIONS: About one fifth of respondent hospitals had telemedicine critical care by 2018, providing potential coverage of nearly one third of reported ICU beds. This represents a substantial increase in telemedicine critical care implementation over the last decade. Future expansion to include more rural hospitals that could benefit most may be aided by addressing hospital financial and market barriers to telemedicine critical care implementation.
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Qiao R, Marciniuk DD, Buckley JD, Levine SM, Wu S, Wang C. The Strategic Establishment of Pulmonary and Critical Care Medicine as a Subspecialty in China: Third Report From the China-CHEST PCCM Fellowship Project. Chest 2021; 157:1082-1085. [PMID: 32386637 DOI: 10.1016/j.chest.2019.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/17/2019] [Accepted: 12/19/2019] [Indexed: 10/24/2022] Open
Affiliation(s)
- Renli Qiao
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Southern California, Los Angeles, CA.
| | - Darcy D Marciniuk
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - John D Buckley
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Stephanie M Levine
- Department of Medicine, University of Texas San Antonio, San Antonio, TX
| | - Sinan Wu
- Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Chen Wang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Hussain RS, Kataria TC. Adequacy of workforce - are there enough critical care doctors in the US-post COVID? Curr Opin Anaesthesiol 2021; 34:149-153. [PMID: 33606396 DOI: 10.1097/aco.0000000000000970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW The ICU is a complex ecosystem in which intensive care physicians, advanced practice providers (APPs), pharmacists, and respiratory therapists work in concert to take care of critically ill patients. The SARS COV2 pandemic highlighted weaknesses in the American healthcare system. This article explores the ability of American healthcare to adapt to this challenge. RECENT FINDINGS With the COVID-19 pandemic, intensivists, and ventilators have been identified as the most critical components leading to shortages in ICU capacity. Anesthesiologists play a unique role in being able to provide 'flex capacity' with critical care staffing, space, and equipment (post-anesthesia care units, operating rooms, and ventilators). With the advent of APPs, intensive care physician staffing ratios may potentially be increased to cover patients safely in a physician-led team model. Tele-medicine expands this further and can allow hospital coordination for optimizing ICU bed use. SUMMARY Although intensivists have been able to take care of the increased ICU caseload during the COVID-19 pandemic through recruiting other specialties, the question of what is the appropriate staffing model for the future is yet to be elucidated. Creating stronger multidisciplinary care teams that have the capacity to flex up critical care capacity may be the most prudent longer-term solution.
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Affiliation(s)
- Rashid S Hussain
- Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
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Kerlin MP, Costa DK, Kahn JM. The Society of Critical Care Medicine at 50 Years: ICU Organization and Management. Crit Care Med 2021; 49:391-405. [PMID: 33555776 DOI: 10.1097/ccm.0000000000004830] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Meeta Prasad Kerlin
- Division of Pulmonary, Allergy, and Critical Care Medicine and Palliative and Advanced Illness Research Center, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA
| | - Deena Kelly Costa
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor, MI
- Institute for Healthcare Innovation & Policy, University of Michigan, Ann Arbor, MI
| | - Jeremy M Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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Du J, Gunnerson KJ, Bassin BS, Meldrum C, Hyzy RC. Effect of an emergency department intensive care unit on medical intensive unit admissions and care: A retrospective cohort study. Am J Emerg Med 2021; 46:27-33. [PMID: 33714051 DOI: 10.1016/j.ajem.2021.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 01/23/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Evaluate the impact of an emergency critical care center (EC3) on the admissions of critically ill patients to a critical care medicine unit (CCMU) and their outcomes. METHODS This was a retrospective before/after cohort study in a tertiary university teaching hospital. To improve the care of critically ill patients in the emergency department (ED), a 9-bed EC3 was opened in the ED in February 2015. All critically ill patients in the emergency department must receive intensive support in EC3 before being considered for admission to the CCMU for further treatment. Patients from the emergency department account for a significant proportion of the patients admitted to the CCMU. The proportions of patients admitted to the CCMU from the ED were analyzed 1 year before and 1 year after the opening of the EC3. We also compared the admission data, demographic data, APACHE III scores and patient outcomes among patients admitted from ED to the CCMU in the year before and the year after the opening of the EC3. RESULT The establishment of the EC3 was associated with a decreased proportion of patients admitted to the CCMU from the ED (OR 0.73 95% CI 0.63-0.84, p < 0.01), a decrease in the proportion of patients with sepsis admitted from the ED (OR 0.68, 95% CI, 0.54-0.87, p < 0.01) and a decrease in the proportion of patients with gastrointestinal bleeding admitted from the ED (OR 0.49, 95% CI 0.28-0.84, p < 0.05). Following the establishment of the EC3, patients admitted to the CCMU had a higher APACHE III score in 2015 (74.85 ± 30.42 vs 72.39 ± 29.64, p = 0.015). Fewer low-risk patients were admitted to the CCMU for monitoring following the opening of the EC3 (112 [6.8%] vs. 181 [9.3%], p < 0.01). Propensity score matching analysis showed that the opening of the EC3 was associated with improved 60-day survival (HR 0.84, 95% CI 0.70-0.99, p = 0.046). CONCLUSION Following the opening of the EC3, the proportion of CCMU admissions from the ED decreased. The EC3 may be most effective at reducing the admission of lower-acuity patients with GI bleeding and possibly sepsis. The EC3 may be associated with improved survival in ED patients.
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Affiliation(s)
- Jiang Du
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA; Shanghai General Hospital of Shanghai Jiaotong University, Shanghai, China
| | - Kyle J Gunnerson
- Emergency Department, The University of Michigan Health System, MI, USA
| | - Benjamin S Bassin
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA
| | - Craig Meldrum
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA
| | - Robert C Hyzy
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA.
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Sechrist E, Dong F, Lee C, Chon K, Neeki A, Winston L, Borger R, Neeki MM. Patients' Perception of Telemedicine in a Large Urban Inner-City Emergency Department: A Cross-Sectional Survey. Cureus 2020; 12:e11091. [PMID: 33240689 PMCID: PMC7681748 DOI: 10.7759/cureus.11091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Introduction Telemedicine has the potential to ease emergency department (ED) overcrowding, improve ED throughput, and decrease the cost of medical care. Much of the current knowledge of telemedicine systems focuses on bringing more specialty care to the ED or improving access in rural areas. Limited research exists on patients’ perception of telemedicine in an urban ED. Methods A survey exploring perceptions of telemedicine encounters was distributed to both providers and patients following mirrored encounters between October 2015 and August 2016. Chi-square analysis was conducted to identify associations between factors and openness to telemedicine from the patients’ perspective. Results A total of 174 patients were included in the analysis. Factors associated with patient willingness to try telemedicine included: having access to a tablet with internet (p=0.0023), having access to a tablet with camera (p=0.0025), having downloaded apps in the past (p=0.0028), having used an app in the past (p<0.0001), and had frequent video chat in the past (p=0.0142). Conclusion With widespread access to smartphones with internet connectivity and pressing demands for healthcare services, telemedicine may provide a potential solution to low acuity medical care needs.
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Affiliation(s)
- Eric Sechrist
- Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - Fanglong Dong
- Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - Carol Lee
- Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - Kaitlin Chon
- Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - Arianna Neeki
- Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - Lori Winston
- Emergency Medicine, Kaweah Delta Medical Center, Visalia, USA
| | - Rodney Borger
- Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA
| | - Michael M Neeki
- Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA
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Smith A, Kelly DP, Hurlbut J, Melvin P, Russ CM. Initiation of Noninvasive Ventilation for Acute Respiratory Failure in a Pediatric Intermediate Care Unit. Hosp Pediatr 2020; 9:538-544. [PMID: 31253646 DOI: 10.1542/hpeds.2019-0034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Noninvasive ventilation (NIV) is increasingly used to manage acute respiratory failure in children, decreasing the need for mechanical ventilation. Safely managing these patients outside of the ICU improves ICU resource use. We measured the impact of a guideline permitting initiation of NIV in an intermediate care unit (IMCU) on ICU bed use. METHODS A guideline for an NIV trial for acute respiratory failure was implemented in a 10-bed IMCU. The guideline stipulated criteria for initiation and maintenance of NIV. There were 4.5 years of intervention data collected. Baseline data were gathered for patients with acute respiratory failure who were transferred from the IMCU to the ICU for NIV initiation in the 3.25 years before guideline implementation. RESULTS Three hundred eight patients were included: 101 in the baseline group and 207 in the intervention group. In the intervention group, 143 patients (69%) remained in the IMCU after NIV initiation, and 64 (31%) transferred to the ICU. A total of 656.4 ICU bed-days were saved in the intervention period (3.3 days per patient initiated on NIV in the IMCU). There was a significant decrease in the rate of intubation in the IMCU for patients awaiting ICU transfer (3 patients in the baseline group versus 0 patients in the intervention group; P = .035). CONCLUSIONS The initiation of NIV in the IMCU for pediatric patients with acute respiratory failure saved ICU bed-days without increasing intubation in the IMCU for patients awaiting transfer. Close monitoring of these critically ill patients is a key component of their safe care.
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Affiliation(s)
| | | | | | - Patrice Melvin
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, Massachusetts
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Joyner RL, Strickland SL, Becker EA, Ginier E, Keene S, Rye K, Haas CF. Adequacy of the Provider Workforce for Persons With Cardiopulmonary Disease. Chest 2020; 157:1221-1229. [DOI: 10.1016/j.chest.2019.09.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 09/16/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022] Open
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Abstract
OBJECTIVES To determine the total numbers of privileged and full-time equivalent intensivists in acute care hospitals with intensivists and compare the characteristics of hospitals with and without intensivists. DESIGN Retrospective analysis of the American Hospital Association Annual Survey Database (Fiscal Year 2015). SETTING Two-thousand eight-hundred fourteen acute care hospitals with ICU beds. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 2,814 acute care hospitals studied, 1,469 (52%) had intensivists and 1,345 (48%) had no intensivists. There were 28,808 privileged and 19,996 full-time equivalent intensivists in the 1,469 hospitals with intensivists. In these hospitals, the median (25-75th percentile) numbers of privileged and full-time equivalent intensivists were 11 (5-24) and 7 (2-17), respectively. Compared with hospitals without intensivists, hospitals with privileged intensivists were primarily located in metropolitan areas (91% vs 50%; p < 0.001) and at the aggregate level had nearly thrice the number of hospital beds (403,522 [75%] vs 137,146 [25%]), 3.6 times the number of ICU beds (74,222 [78%] vs 20,615 [22%]), and almost twice as many ICUs (3,383 [65%] vs 1,846 [35%]). At the hospital level, hospitals with privileged intensivists had significantly more hospital beds (median, 213 vs 68; p < 0.0001), ICU beds (median, 32 vs 8; p < 0.0001), a higher ratio of ICU to hospital beds (15.6% vs 12.6%; p < 0.0001), and a higher number of ICUs per hospital (2 vs 1; p < 0.0001) than hospitals without intensivists. CONCLUSIONS Analyzing the intensivist section of the American Hospital Association Annual Survey database is a novel approach to estimating the numbers of privileged and full-time equivalent intensivists in acute care hospitals with ICU beds in the United States. This methodology opens the door to an enhanced understanding of the current supply and distribution of intensivists as well as future research into the intensivist workforce.
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Weissman GE, Kerlin MP, Yuan Y, Kohn R, Anesi GL, Groeneveld PW, Werner RM, Halpern SD. Potentially Preventable Intensive Care Unit Admissions in the United States, 2006-2015. Ann Am Thorac Soc 2020; 17:81-88. [PMID: 31581801 PMCID: PMC6944341 DOI: 10.1513/annalsats.201905-366oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/24/2019] [Indexed: 11/20/2022] Open
Abstract
Rationale: Increasing intensive care unit (ICU) beds and the critical care workforce are often advocated to address an aging and increasingly medically complex population. However, reducing potentially preventable ICU stays may be an alternative to ensure adequate capacity.Objectives: To determine the proportions of ICU admissions meeting two definitions of being potentially preventable using nationally representative U.S. claims databases.Methods: We analyzed claims from 2006 to 2015 from all Medicare Fee-for-Service (FFS) beneficiaries and from a large national payer offering a private insurance (PI) plan and a Medicare Advantage (MA) plan. Potentially preventable hospitalizations were identified using existing definitions for ambulatory care sensitive conditions (ACSCs) and life-limiting malignancies (LLMs).Results: We analyzed 420,369,434 person-years of insurance coverage, during which there were 99,793,416 acute inpatient hospitalizations, of which 16,646,977 (16.7%) were associated with an ICU admission. Of these, the proportions with an ACSC were 12.9%, 12.7%, and 15.8%, and with an LLM were 5.2%, 5.4%, and 6.4%, among those with PI, MA, and FFS, respectively. Over 10 years, the absolute percentages of ACSC-associated ICU stays declined (PI = -1.1%, MA -6.4%, FFS -6.4%; all P < 0.001 for all trends). Smaller changes were noted among LLM-associated ICU stays, declining in the MA cohort (-0.8%) and increasing in the FFS (+0.3%) and PI (+0.2%) populations (P < 0.001 for all trends).Conclusions: An appreciable proportion of U.S. ICU admissions may be preventable with community-based interventions. Investment in the outpatient infrastructure required to prevent these ICU admissions should be considered as a complementary, if not alternative, strategy to expanding ICU capacity to meet future demand.
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Affiliation(s)
- Gary E. Weissman
- Palliative and Advanced Illness Research Center
- Pulmonary, Allergy, and Critical Care Division, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Meeta Prasad Kerlin
- Palliative and Advanced Illness Research Center
- Pulmonary, Allergy, and Critical Care Division, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Yihao Yuan
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel Kohn
- Palliative and Advanced Illness Research Center
- Pulmonary, Allergy, and Critical Care Division, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - George L. Anesi
- Palliative and Advanced Illness Research Center
- Pulmonary, Allergy, and Critical Care Division, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Peter W. Groeneveld
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Rachel M. Werner
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Scott D. Halpern
- Palliative and Advanced Illness Research Center
- Pulmonary, Allergy, and Critical Care Division, and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; and
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Abstract
Telemedicine coverage of intensive care units is an organizational innovation that has been touted as a means to improve access to and quality of critical care. The purpose of this narrative review is to discuss the different organizational models of intensive care unit telemedicine and factors that have influenced its adoption and to review the existing literature to consider whether it has lived up to its promise. We conclude by suggesting future directions to fill in some of the existing gaps in the literature.
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The Present State of Neurointensivist Training in the United States: A Comparison to Other Critical Care Training Programs. Crit Care Med 2019; 46:307-315. [PMID: 29239885 DOI: 10.1097/ccm.0000000000002876] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Organizing Intensive Care for Patients Undergoing Cardiac Surgery. Crit Care Med 2019; 45:1572-1574. [PMID: 28816844 DOI: 10.1097/ccm.0000000000002584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rao AR, Clarke D. Exploring relationships between medical college rankings and performance with big data. BIG DATA ANALYTICS 2019. [DOI: 10.1186/s41044-019-0040-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Abstract
Critical care fellowship training in the United States differs based on specific specialty and includes medicine, surgery, anesthesiology, pediatrics, emergency medicine, and neurocritical care training pathways. We provide an update regarding the number and growth of US critical care fellowship training programs, on-duty residents and certified diplomates, and review the different critical care physician training pathways available to residents interested in pursuing a fellowship in critical care. Data were obtained from the Accreditation Council for Graduate Medical Education and specialty boards (American Board of Internal Medicine, American Board of Surgery, American Board of Anesthesiology, American Board of Pediatrics American Board of Emergency Medicine) and the United Council for Neurologic Subspecialties for the last 16 years (2001-2017). The number of critical care fellowship training programs has increased 22.6%, with a 49.4% increase in the number of on-duty residents annually, over the last 16 years. This is in contrast to the period of 1995 to 2000 when the number of physicians enrolled in critical care fellowship programs had decreased or remained unchanged. Although more than 80% of intensivists in the US train in internal medicine critical care Accreditation Council for Graduate Medical Education-approved fellowships, there has been a significant increase in the number of residents from surgery, anesthesiology, pediatrics, emergency medicine, and other specialties who complete specialty fellowship training and certification in critical care. Matriculation in neurocritical care fellowships is rapidly rising with 60 programs and over 1,200 neurocritical care diplomates. Critical care is now an increasingly popular fellowship in all specialties. This rapid growth of all critical care specialties highlights the magnitude of the heterogeneity that will exist between intensivists in the future.
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Yeragunta Y, Leichtle SW, Qiao R. Quantification of critical care medicine: An ICU survey. CLINICAL RESPIRATORY JOURNAL 2019; 13:232-238. [PMID: 30724022 DOI: 10.1111/crj.13003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/19/2019] [Accepted: 01/26/2019] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
- Yashaswini Yeragunta
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Stefan W Leichtle
- Acute Care and Trauma Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Renli Qiao
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
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Udeh C, Udeh B, Rahman N, Canfield C, Campbell J, Hata JS. Telemedicine/Virtual ICU: Where Are We and Where Are We Going? Methodist Debakey Cardiovasc J 2018; 14:126-133. [PMID: 29977469 DOI: 10.14797/mdcj-14-2-126] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Intensive care unit telemedicine (tele-ICU) is technology enabled care delivered from off-site locations that was developed to address the increasing complexity of patients and insufficient supply of intensivists. Although tele-ICU deployment is increasing, it continues to cover only a small proportion of ICU patients. This is primarily due to expense, with first-year costs exceeding $50,000 per bed. Meta-analyses of outcomes indicate survival benefits and quality improvements, albeit with significant heterogeneity. Depending on the context, a wide range of estimated incremental cost-effectiveness ratios reflects variable effects on cost and outcomes, such as mortality or length of stay. Tele-ICUs may fit within a hybrid model of care to complement high-intensity ICU staff coverage. However, more research is required to foster consensus and determine best practices. This review summarizes data on tele-ICU structure, operations, outcomes, and costs. Evidence was extracted from meta-analyses, with secondary data from Cleveland Clinic's tele-ICU experience.
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A Case for Change in Adult Critical Care Training for Physicians in the United States. Crit Care Med 2018; 46:1577-1584. [DOI: 10.1097/ccm.0000000000003266] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wheeler DS, Dewan M, Maxwell A, Riley CL, Stalets EL. Staffing and workforce issues in the pediatric intensive care unit. Transl Pediatr 2018; 7:275-283. [PMID: 30460179 PMCID: PMC6212383 DOI: 10.21037/tp.2018.09.05] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
The health care industry is in the midst of incredible change, and unfortunately, change is not easy. The intensive care unit (ICU) plays a critical role in the overall delivery of care to patients in the hospital. Care in the ICU is expensive. One of the best ways of improving the value of care delivered in the ICU is to focus greater attention on the needs of the critical care workforce. Herein, we highlight three major areas of concern-the changing model of care delivery outside of the traditional four walls of the ICU, the need for greater diversity in the pediatric critical care workforce, and the widespread problem of professional burnout and its impact on patient care.
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Affiliation(s)
- Derek S Wheeler
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Maya Dewan
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrea Maxwell
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Carley L Riley
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Abstract
OBJECTIVES To describe physicians' and nurse practitioners' perceptions of the national and local PICU physician and other provider supply in institutions that employ PICU nurse practitioners, assess for differences in perceptions of supply, and evaluate the intent of institutions to hire additional nurse practitioners to work in PICUs. DESIGN National, quantitative, cross-sectional descriptive study via a postal mail survey from October 2016 to January 2017. SETTING Institutions (n = 140) identified in the 2015 American Hospital Association Annual Survey with a PICU who employ PICU nurse practitioners. SUBJECTS PICU physician medical directors and nurse practitioners. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 119 respondents, representing 93 institutions. Responses were received from 60 PICU medical directors (43%) and 59 lead nurse practitioners (42%). More than half (58%) of all respondents reported the national supply of PICU physicians is less than demand and 61% reported the local supply of PICU providers (physicians in all stages of training, nurse practitioners, and physician assistants) is less than demand. Of the respondents from institutions that self-reported a local provider shortage (n = 54), three fourths (78%) reported plans to increase the number of PICU nurse practitioners in the next 3 years and 40% were likely to expand the nurse practitioner's role in patient care. CONCLUSIONS Most PICU medical directors and lead nurse practitioners in institutions that employ PICU nurse practitioners perceived that national and local supply of providers to be less than the demand. Nurse practitioners are employed in PICUs as part of interdisciplinary models of care being used to address provider demand. The demand for more PICU nurse practitioners with expanded roles in care delivery was reported. Further evaluation of models of care and provider roles in care delivery can contribute to aligning provider supply with demand for care delivery.
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Gigli KH, Dietrich MS, Buerhaus PI, Minnick AF. Nurse Practitioners and Interdisciplinary Teams in Pediatric Critical Care. AACN Adv Crit Care 2018; 29:138-148. [DOI: 10.4037/aacnacc2018588] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Objective:
To describe the members of pediatric intensive care unit interdisciplinary provider teams and labor inputs, working conditions, and clinical practice of pediatric intensive care unit nurse practitioners.
Methods:
A national, quantitative, crosssectional, descriptive postal survey of pediatric intensive care unit medical directors and nurse practitioners was administered to gather information about provider-team members, pediatric intensive care unit nurse practitioner labor inputs, working conditions, and clinical practice. Descriptive statistics, cross-tabulations, and χ2 tests were used.
Results:
Responses from 97 pediatric intensive care unit medical directors and 59 pediatric intensive care unit nurse practitioners representing 126 institutions were received. Provider-team composition varied between institutions with and without nurse practitioners. Pediatric intensive care units employed an average of 3 full-time nurse practitioners; the average nurse practitioner-to-patient ratio was 1 to 5. The clinical practice reported by medical directors was consistent with practice reported by nurse practitioners.
Conclusion:
Nurse practitioners are integrated into interdisciplinary pediatric intensive care unit teams, but institutional variation in team composition exists. Investigating models of care contributes to the understanding of how models influence positive patient and organizational outcomes and may change future role implementation.
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Affiliation(s)
- Kristin H. Gigli
- Kristin H. Gigli is a doctoral student, Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240 . Mary S. Dietrich is Professor, Vanderbilt University School of Nursing, Nashville, Tennessee. Peter I. Buerhaus is Professor, Montana State University College of Nursing, Bozeman, Montana. Ann F Minnick is Senior Associate Dean for Research, Julia Eleanor Chenault Professor of Nursing, Vanderbilt University School of Nursing, Nashville, Tennessee
| | - Mary S. Dietrich
- Kristin H. Gigli is a doctoral student, Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240 . Mary S. Dietrich is Professor, Vanderbilt University School of Nursing, Nashville, Tennessee. Peter I. Buerhaus is Professor, Montana State University College of Nursing, Bozeman, Montana. Ann F Minnick is Senior Associate Dean for Research, Julia Eleanor Chenault Professor of Nursing, Vanderbilt University School of Nursing, Nashville, Tennessee
| | - Peter I. Buerhaus
- Kristin H. Gigli is a doctoral student, Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240 . Mary S. Dietrich is Professor, Vanderbilt University School of Nursing, Nashville, Tennessee. Peter I. Buerhaus is Professor, Montana State University College of Nursing, Bozeman, Montana. Ann F Minnick is Senior Associate Dean for Research, Julia Eleanor Chenault Professor of Nursing, Vanderbilt University School of Nursing, Nashville, Tennessee
| | - Ann F. Minnick
- Kristin H. Gigli is a doctoral student, Vanderbilt University School of Nursing, 461 21st Avenue South, Nashville, TN 37240 . Mary S. Dietrich is Professor, Vanderbilt University School of Nursing, Nashville, Tennessee. Peter I. Buerhaus is Professor, Montana State University College of Nursing, Bozeman, Montana. Ann F Minnick is Senior Associate Dean for Research, Julia Eleanor Chenault Professor of Nursing, Vanderbilt University School of Nursing, Nashville, Tennessee
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Wheeler DS, Hyzy RC. (Not) Everybody Is Working for the Weekend. Crit Care Med 2018; 46:337-338. [PMID: 29337798 PMCID: PMC5777519 DOI: 10.1097/ccm.0000000000002881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- David S. Wheeler
- Department of Pulmonary and Critical Care. University of Michigan. 1500 E Medical Center Dr. Ann Arbor, MI 48109-5361
| | - Robert C. Hyzy
- Department of Pulmonary and Critical Care. University of Michigan. 1500 E Medical Center Dr. Ann Arbor, MI 48109-5361
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Diffusion of Evidence-based Intensive Care Unit Organizational Practices. A State-Wide Analysis. Ann Am Thorac Soc 2018; 14:254-261. [PMID: 28076685 DOI: 10.1513/annalsats.201607-579oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Several intensive care unit (ICU) organizational practices have been associated with improved patient outcomes. However, the uptake of these evidence-based practices is unknown. OBJECTIVES To assess diffusion of ICU organizational practices across the state of Pennsylvania. METHODS We conducted two web-based, cross-sectional surveys of ICU organizational practices in Pennsylvania acute care hospitals, in 2005 (chief nursing officer respondents) and 2014 (ICU nurse manager respondents). MEASUREMENTS AND MAIN RESULTS Of 223 eligible respondents, nurse managers from 136 (61%) medical, surgical, mixed medical-surgical, cardiac, and specialty ICUs in 98 hospitals completed the 2014 survey, compared with 124 of 164 (76%) chief nursing officers in the 2005 survey. In 2014, daytime physician staffing models varied widely, with 23 of 136 (17%) using closed models and 33 (24%) offering no intensivist staffing. Nighttime intensivist staffing was used in 37 (27%) ICUs, 38 (28%) used nonintensivist attending staffing, and 24 (18%) had no nighttime attending physicians. Daily multidisciplinary rounds occurred in 93 (68%) ICUs. Regular participants included clinical pharmacists in 68 of 93 (73%) ICUs, respiratory therapists in 62 (67%), and advanced practitioners in 37 (39%). Patients and family members participated in rounds in 36 (39%) ICUs. Clinical protocols or checklists for mechanically ventilated patients were available in 128 of 133 (96%) ICUs, low tidal volume ventilation for acute respiratory distress syndrome in 54 of 132 (41%) ICUs, prone positioning for severe acute respiratory distress syndrome in 37 of 134 (28%) ICUs, and family meetings in 19 of 134 (14%) ICUs. Among 61 ICUs that responded to both surveys, there was a significant increase in the proportion of ICUs using nighttime in-ICU attending physicians (23 [38%] in 2005 vs. 30 [49%] in 2014; P = 0.006). CONCLUSIONS The diffusion of evidence-based ICU organizational practices has been variable across the state of Pennsylvania. Only half of Pennsylvania ICUs have intensivists dedicated to the ICU. Variable numbers use clinical protocols for life-saving therapies, and few use structured family engagement strategies. In contrast, the diffusion of non-evidence-based practices, including overnight ICU attending physician staffing, is increasing. Future research should focus on promoting implementation of organizational evidence to promote high-quality ICU care.
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Flanders SA, Cooke CR. Hospitalists in the ICU: Necessary But Not Sufficient. J Hosp Med 2018; 13:65-66. [PMID: 29240848 DOI: 10.12788/jhm.2891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
- Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Physician staffing needs in critical care departments. Med Intensiva 2017; 42:37-46. [PMID: 29174280 DOI: 10.1016/j.medin.2017.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 09/05/2017] [Accepted: 09/17/2017] [Indexed: 11/23/2022]
Abstract
Departments of Critical Care Medicine are characterized by high medical assistance costs and great complexity. Published recommendations on determining the needs of medical staff in the DCCM are based on low levels of evidence and attribute excessive significance to the structural/welfare approach (physician-to-beds ratio), thus generating incomplete and minimalistic information. The Spanish Society of Intensive Care Medicine and Coronary Units established a Technical Committee of experts, the purpose of which was to draft recommendations regarding requirements for medical professionals in the ICU. The Technical Committee defined the following categories: 1) Patient care-related aspects; 2) Activities outside the ICU; 3) Patient safety and clinical management aspects; 4) Teaching; and 5) Research. A subcommittee was established with experts pertaining to each activity category, defining criteria for quantifying the percentage time of the intensivists dedicated to each task, and taking into account occupational category. A quantitative method was applied, the parameters of which were the number of procedures or tasks and the respective estimated indicative times for patient care-related activities within or outside the context of the DCCM, as well as for teaching and research activities. Regarding non-instrumental activities, which are more difficult to evaluate in real time, a matrix of range versus productivity was applied, defining approximate percentages according to occupational category. All activities and indicative times were tabulated, and a spreadsheet was created that modified a previously designed model in order to perform calculations according to the total sum of hours worked and the hours stipulated in the respective work contract. The competencies needed and the tasks which a Department of Critical Care Medicine professional must perform far exceed those of a purely patient care-related character, and cannot be quantified using structural criteria. The method for describing the 5 types of activity, the quantification of specific tasks, the respective times needed for each task, and the generation of a spreadsheet led to the creation of a management instrument.
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Gunnerson KJ. The Emergency Department's Impact on Inpatient Critical Care Resources. Acad Emerg Med 2017; 24:1283-1285. [PMID: 28772343 DOI: 10.1111/acem.13268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Preparation and Evolving Role of the Acute Care Nurse Practitioner. Chest 2017; 152:1339-1345. [PMID: 28823758 DOI: 10.1016/j.chest.2017.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/26/2017] [Accepted: 08/07/2017] [Indexed: 11/21/2022] Open
Abstract
Acute care nurse practitioners (ACNPs) are increasingly being employed as members of critical care teams, an outcome driven by increasing demand for intensive care services, a mandated reduction in house officer hours, and evidence supporting the ability of ACNPs to provide high-quality care as collaborative members of critical care teams. Integration of adult ACNPs into critical care teams is most likely to be successful when practitioners have appropriate training, supervision, and mentoring to facilitate their ability to practice efficiently and effectively. Accomplishing this goal requires understanding the educational preparation and skill set potential hires bring to the position as well as the development of an orientation program designed to integrate the practitioner into the critical care team. Pediatric ACNPs are also commonly employed in critical care settings; however, this commentary focuses on the adult ACNP role.
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Kerlin MP, Adhikari NKJ, Rose L, Wilcox ME, Bellamy CJ, Costa DK, Gershengorn HB, Halpern SD, Kahn JM, Lane-Fall MB, Wallace DJ, Weiss CH, Wunsch H, Cooke CR. An Official American Thoracic Society Systematic Review: The Effect of Nighttime Intensivist Staffing on Mortality and Length of Stay among Intensive Care Unit Patients. Am J Respir Crit Care Med 2017; 195:383-393. [PMID: 28145766 DOI: 10.1164/rccm.201611-2250st] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Studies of nighttime intensivist staffing have yielded mixed results. GOALS To review the association of nighttime intensivist staffing with outcomes of intensive care unit (ICU) patients. METHODS We searched five databases (2000-2016) for studies comparing in-hospital nighttime intensivist staffing with other nighttime staffing models in adult ICUs and reporting mortality or length of stay. We abstracted data on staffing models, outcomes, and study characteristics and assessed study quality, using standardized tools. Meta-analyses used random effects models. RESULTS Eighteen studies met inclusion criteria: one randomized controlled trial and 17 observational studies. Overall methodologic quality was high. Studies included academic hospitals (n = 10), community hospitals (n = 2), or both (n = 6). Baseline clinician staffing included residents (n = 9), fellows (n = 4), and nurse practitioners or physician assistants (n = 2). Studies included both general and specialty ICUs and were geographically diverse. Meta-analysis (one randomized controlled trial; three nonrandomized studies with exposure limited to nighttime intensivist staffing with adjusted estimates of effect) demonstrated no association with mortality (odds ratio, 0.99; 95% confidence interval, 0.75-1.29). Secondary analyses including studies without risk adjustment, with a composite exposure of organizational factors, stratified by intensity of daytime staffing and by ICU type, yielded similar results. Minimal or no differences were observed in ICU and hospital length of stay and several other secondary outcomes. CONCLUSIONS Notwithstanding limitations of the predominantly observational evidence, our systematic review and meta-analysis suggests nighttime intensivist staffing is not associated with reduced ICU patient mortality. Other outcomes and alternative staffing models should be evaluated to further guide staffing decisions.
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Abstract
This review documents important progress made in 2015 in the field of critical care. Significant advances in 2015 included further evidence for early implementation of low tidal volume ventilation as well as new insights into the role of open lung biopsy, diaphragmatic dysfunction, and a potential mechanism for ventilator-induced fibroproliferation. New therapies, including a novel low-flow extracorporeal CO2 removal technique and mesenchymal stem cell-derived microparticles, have also been studied. Several studies examining the role of improved diagnosis and prevention of ventilator-associated pneumonia also showed relevant results. This review examines articles published in the American Journal of Respiratory and Critical Care Medicine and other major journals that have made significant advances in the field of critical care in 2015.
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Affiliation(s)
- Martin Dres
- 1 Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care and
| | - Jordi Mancebo
- 3 Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Gerard F Curley
- 1 Department of Critical Care, St. Michael's Hospital and the Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Ontario, Canada.,2 Interdepartmental Division of Critical Care and.,4 Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada; and
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Trends in Critical Care Beds and Use Among Population Groups and Medicare and Medicaid Beneficiaries in the United States: 2000-2010. Crit Care Med 2017; 44:1490-9. [PMID: 27136721 DOI: 10.1097/ccm.0000000000001722] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To analyze patterns of critical care medicine beds, use, and costs in acute care hospitals in the United States and relate critical care medicine beds and use to population shifts, age groups, and Medicare and Medicaid beneficiaries from 2000 to 2010. DESIGN Retrospective study of data from the federal Healthcare Cost Report Information System, American Hospital Association, and U.S. Census Bureau. SUBJECTS None. INTERVENTIONS None. SETTING Acute care U.S. hospitals with critical care medicine beds. MEASUREMENTS AND MAIN RESULTS From 2000 to 2010, U.S. hospitals with critical care medicine beds decreased by 17% (3,586-2,977), whereas the U.S. population increased by 9.6% (282.2-309.3M). Although hospital beds decreased by 2.2% (655,785-641,395), critical care medicine beds increased by 17.8% (88,235-103,900), a 20.4% increase in the critical care medicine-to-hospital bed ratio (13.5-16.2%). There was a greater percentage increase in premature/neonatal (29%; 14,391-18,567) than in adult (15.9%; 71,978-83,417) or pediatric (2.7%; 1,866-1,916) critical care medicine beds. Hospital occupancy rates increased by 10.4% (58.6-64.6%), whereas critical care medicine occupancy rates were stable (range, 65-68%). Critical care medicine beds per 100,000 total population increased by 7.4% (31.3-33.6). The proportional use of critical care medicine services by Medicare beneficiaries decreased by 17.3% (37.9-31.4%), whereas that by Medicaid rose by 18.3% (14.5-17.2%). Between 2000 and 2010, annual critical care medicine costs nearly doubled (92.2%; $56-108 billion). In the same period, the proportion of critical care medicine cost to the gross domestic product increased by 32.1% (0.54-0.72%). CONCLUSIONS Critical care medicine beds, use, and costs in the United States continue to rise. The increasing use of critical care medicine by the premature/neonatal and Medicaid populations should be considered by healthcare policy makers, state agencies, and hospitals as they wrestle with critical care bed growth and the associated costs.
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Hospital Contributions to Variability in the Use of ICUs Among Elderly Medicare Recipients. Crit Care Med 2017; 45:75-84. [PMID: 27526267 DOI: 10.1097/ccm.0000000000002025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Hospitals vary widely in ICU admission rates across numerous medical diagnoses. The extent to which variability in ICU use is specific to individual diagnoses or is a function of the hospital, regardless of disease, is unknown. DESIGN Retrospective cohort study. SETTING A total of 1,120 acute care hospitals with ICU capabilities. PATIENTS Medicare beneficiaries 65 years old or older admitted for five medical diagnoses (acute myocardial infarction, congestive heart failure, stroke, pneumonia, and chronic obstructive pulmonary disease) and a surgical diagnosis (hip fracture treated with arthroplasty) in 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used multilevel models to calculate risk- and reliability-adjusted ICU admission rates, examined the correlation in ICU admission rates across diagnosis and calculated intraclass correlation coefficients and median odds ratios to quantify the variability in ICU admission rate that was attributable to hospitals. We also examined the ability of a high ICU-use hospital for one condition to predict high ICU use for other conditions. We identified 348,462 patients with one of the eligible conditions. ICU admission rates were positively correlated within hospitals for included medical diagnoses (r range, 0.38-0.59; p < 0.01). The top hospital quartile of ICU use for congestive heart failure had a sensitivity of 50-60% and specificity of 79-81% for detecting top quartile hospitals for each other conditions. After adjustment for patient and hospital characteristics, hospitals accounted for 17.6% (95% CI, 16.2-19.1%) of variability in ICU admission, corresponding to a median odds ratio of 2.3, compared to 25.8% (95% CI, 24.5-27.1%) and median odds ratio 2.8 for diagnosis. This suggests a patient with median baseline risk of ICU admission would more than double his/her odds of ICU admission if moving to a higher utilizing hospital. CONCLUSIONS Hospitals account for a significant proportion of variation independent of measured patient and hospital characteristics, suggesting the need for further work to evaluate the causes of variation at the hospital level and potential consequences of variation across hospitals.
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Abstract
OBJECTIVES Although the number of intensive care beds in the United States is increasing, little is known about the hospitals responsible for this growth. We sought to better characterize national growth in intensive care beds by identifying hospital-level factors associated with increasing numbers of intensive care beds over time. DESIGN We performed a repeated-measures time series analysis of hospital-level intensive care bed supply using data from Centers for Medicare and Medicaid Services. SETTING All United States acute care hospitals with adult intensive care beds over the years 1996-2011. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We described the number of beds, teaching status, ownership, intensive care occupancy, and urbanicity for each hospital in each year of the study. We then examined the relationship between increasing intensive care beds and these characteristics, controlling for other factors. The study included 4,457 hospitals and 55,865 hospital-years. Overall, the majority of intensive care bed growth occurred in teaching hospitals (net, +13,471 beds; 72.1% of total growth), hospitals with 250 or more beds (net, +18,327 beds; 91.8% of total growth), and hospitals in the highest quartile of occupancy (net, +10,157 beds; 54.0% of total growth). In a longitudinal multivariable model, larger hospital size, teaching status, and high intensive care occupancy were associated with subsequent-year growth. Furthermore, the effects of hospital size and teaching status were modified by occupancy: the greatest odds of increasing ICU beds were in hospitals with 500 or more beds in the highest quartile of occupancy (adjusted odds ratio, 18.9; 95% CI, 14.0-25.5; p < 0.01) and large teaching hospitals in the highest quartile of occupancy (adjusted odds ratio, 7.3; 95% CI, 5.3-9.9; p < 0.01). CONCLUSIONS Increasingly, intensive care bed expansion in the United States is occurring in larger hospitals and teaching centers, particularly following a year with high ICU occupancy.
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Viglianti EM, Iwashyna TJ. Toward the Ideal Ratio of Patients to Intensivists: Finding a Reasonable Balance. JAMA Intern Med 2017; 177:396-398. [PMID: 28118655 PMCID: PMC5856229 DOI: 10.1001/jamainternmed.2016.8476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Theodore J Iwashyna
- Department of Internal Medicine, University of Michigan, Ann Arbor2Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan3Institute for Social Research, Ann Arbor, Michigan
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Rubenfeld GD. Rebuttal From Dr Rubenfeld. Chest 2016; 149:629-30. [PMID: 26965970 DOI: 10.1016/j.chest.2015.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 11/06/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- Gordon D Rubenfeld
- Program in Trauma, Emergency and Critical Care, Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
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Rubenfeld GD. COUNTERPOINT: Does the United States Need More Intensivist Physicians? No. Chest 2016; 149:625-8. [PMID: 26965968 DOI: 10.1016/j.chest.2015.11.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 12/01/2022] Open
Affiliation(s)
- Gordon D Rubenfeld
- Program in Trauma, Emergency and Critical Care, Interdepartmental Division of Critical Care Medicine, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
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Davidson BL. POINT: Does the United States Need More Intensivist Physicians? Yes. Chest 2016; 149:621-5. [PMID: 26965967 DOI: 10.1016/j.chest.2015.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- Bruce L Davidson
- Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA.
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Kadri SS, Rhee C, Magda G, Strich JR, Cai R, Sun J, Decker BK, O'Grady NP. Synergy, Salary, and Satisfaction: Benefits of Training in Critical Care Medicine and Infectious Diseases Gleaned From a National Pilot Survey of Dually Trained Physicians. Clin Infect Dis 2016; 63:868-875. [PMID: 27358351 DOI: 10.1093/cid/ciw441] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/27/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND An increasing number of physicians are seeking dual training in critical care medicine (CCM) and infectious diseases (ID). Understanding experiences and perceptions of CCM-ID physicians could inform career choices and programmatic innovation. METHODS All physicians trained and/or certified in both CCM and ID to date in the United States were sent a Web-based questionnaire in 2015. Responses enabled a cross-sectional analysis of physician demographics and training and practice characteristics and satisfaction. RESULTS Of 202 CCM-ID physicians, 196 were alive and reachable. The response rate was 79%. Forty-six percent trained and 34% practice in the northeastern United States. Only 40% received dual training at the same institution. Eighty-three percent identified as either an intensivist with ID expertise (44%) or as equally an intensivist and ID physician (38%). Median salary was $265 000 (interquartile range [IQR], $215 000-$350 000). Practice settings were split between academic (45%) and community settings (42%). Two-thirds are clinicians but 62% conduct some research and 26% practice outpatient ID. Top reasons to dually specialize included clinical synergy (70%), procedural activity (50%), and less interest in pulmonology (49%). Although 38% cited less proficiency with bronchoscopy as a disadvantage, 87% seldom need pulmonary consultation in the intensive care unit. Median career satisfaction was 4 (IQR, 4-5) out of 5, and 76% would dually train again. CONCLUSIONS CCM-ID graduates prefer the acute care setting, predominantly CCM or a combination of CCM and ID. They find combination training and practice to be synergistic and satisfying, but most have had to seek CCM and ID training independently at separate institutions. Given these findings, avenues for combined training in CCM-ID should be considered.
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Affiliation(s)
- Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Chanu Rhee
- Division of Infectious Diseases, Brigham and Women's Hospital.,Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Gabriela Magda
- Department of Medicine, Medstar/Georgetown University Hospital, Washington D.C
| | - Jeffrey R Strich
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Rongman Cai
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Junfeng Sun
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Brooke K Decker
- Infectious Diseases Section, VA Pittsburgh Healthcare System, Pennsylvania
| | - Naomi P O'Grady
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
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DeWitt D, Canny BJ, Nitzberg M, Choudri J, Porter S. Medical student satisfaction, coping and burnout in direct-entry versus graduate-entry programmes. MEDICAL EDUCATION 2016; 50:637-645. [PMID: 27170082 DOI: 10.1111/medu.12971] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 09/21/2015] [Accepted: 11/13/2015] [Indexed: 06/05/2023]
Abstract
CONTEXT There is ongoing debate regarding the optimal length of medical training, with concern about the cost of prolonged training. Two simultaneous tracks currently exist in Australia: direct entry from high school and graduate entry for students with a bachelor degree. Medical schools are switching to graduate entry based on maturity, academic preparedness and career-choice surety. We tested the assumption that graduate entry is better by exploring student preferences, coping, burnout, empathy and alcohol use. METHODS From a potential pool of 2188 participants, enrolled at five Australian medical schools, a convenience sample of 688 (31%) first and second year students completed a survey in the middle of the academic year. Participants answered questions about demographics, satisfaction and coping and completed three validated instruments. RESULTS Over 90% of students preferred their own entry-type, though more graduate-entry students were satisfied with their programme (82.4% versus 65.3%, p < 0.001). There was no difference between graduate-entry and direct-entry students in self-reported coping or in the proportion of students meeting criteria for burnout (50.7% versus 51.2%). Direct-entry students rated significantly higher for empathy (concern, p = 0.022; personal distress, p = 0.031). Graduate-entry students reported significantly more alcohol use and hazardous drinking (30.0% versus 22.8%; p = 0.017). CONCLUSIONS Our multi-institution data confirm that students are generally satisfied with their choice of entry pathway and do not confirm significant psychosocial benefits of graduate entry. Overall, our data suggest that direct-entry students cope with the workload and psychosocial challenges of medical school, in the first 2 years, as well as graduate-entry students. Burnout and alcohol use should be addressed in both pathways. Despite studies showing similar academic outcomes, and higher total costs, more programmes in Australia are becoming graduate entry. Further research on non-cognitive issues and outcomes is needed so that universities, government funders and the medical profession can decide whether graduate entry, direct entry, or a mix, is ideal.
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Affiliation(s)
- Dawn DeWitt
- Rural Health Academic Centre, Melbourne Medical School, Shepparton, Victoria, Australia
| | - Benedict J Canny
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Michael Nitzberg
- School of Medicine and Dentistry, University of Rochester, Rochester, New York, US
| | - Jennifer Choudri
- School of Medicine and Dentistry, University of Rochester, Rochester, New York, US
| | - Sarah Porter
- School of Medicine and Dentistry, University of Rochester, Rochester, New York, US
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The Association Between Daytime Intensivist Physician Staffing and Mortality in the Context of Other ICU Organizational Practices: A Multicenter Cohort Study. Crit Care Med 2016; 43:2275-82. [PMID: 26308426 DOI: 10.1097/ccm.0000000000001259] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Daytime intensivist physician staffing is associated with improved outcomes in the ICU. However, it is unclear whether this association persists in the era of interprofessional, protocol-directed critical care. We sought to reexamine the association between daytime intensivist physician staffing and ICU mortality and determine if interprofessional rounding and protocols for mechanical ventilation in part mediate this relationship. DESIGN Retrospective cohort study of ICUs in the Acute Physiology and Chronic Health Evaluation clinical information system from 2009 to 2010. SETTING Forty-nine ICUs in 25 U.S. hospitals. PATIENTS Adults (17 yr and older) admitted to a study ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We defined high-intensity daytime intensivist staffing as either a mandatory consult or closed ICU model; interprofessional rounds as rounds that included a respiratory therapist, pharmacist, physician and nurse; and protocol use as having protocols for liberation from mechanical ventilation and lung protective mechanical ventilation. Using multivariable logistic regression, we estimated the independent effect of daytime intensivist physician staffing on in-hospital mortality controlling for interprofessional rounds and protocols for mechanical ventilation, as well as other patient and hospital characteristics. Twenty-seven ICUs (55%) reported high-intensity daytime physician staffing, 42 ICUs (85%) reported daily interprofessional rounds, and 31 (63%) reported having protocols for mechanical ventilation. There was no association between daytime intensivist physician staffing and in-hospital mortality (adjusted odds ratio, 0.86; 95% CI, 0.65-1.14). After adjusting for interprofessional rounds and protocols for mechanical ventilation, the effect of daytime intensivist physician staffing remained nonsignificant (adjusted odds ratio, 0.90; 95% CI, 0.70-1.17). CONCLUSION High-intensity daytime physician staffing in the ICU was not significantly associated with lower mortality in a modern cohort. This association was not affected by interprofessional rounds or protocols for mechanical ventilation.
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Critical Care Medicine Beds, Use, Occupancy, and Costs in the United States: A Methodological Review. Crit Care Med 2016; 43:2452-9. [PMID: 26308432 DOI: 10.1097/ccm.0000000000001227] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article is a methodological review to help the intensivist gain insights into the classic and sometimes arcane maze of national databases and methodologies used to determine and analyze the ICU bed supply, use, occupancy, and costs in the United States. Data for total ICU beds, use, and occupancy can be derived from two large national healthcare databases: the Healthcare Cost Report Information System maintained by the federal Centers for Medicare and Medicaid Services and the proprietary Hospital Statistics of the American Hospital Association. Two costing methodologies can be used to calculate U.S. ICU costs: the Russell equation and national projections. Both methods are based on cost and use data from the national hospital datasets or from defined groups of hospitals or patients. At the national level, an understanding of U.S. ICU bed supply, use, occupancy, and costs helps provide clarity to the width and scope of the critical care medicine enterprise within the U.S. healthcare system. This review will also help the intensivist better understand published studies on administrative topics related to critical care medicine and be better prepared to participate in their own local hospital organizations or regional critical care medicine programs.
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