Intensive Care Unit Administration and Performance Improvement
THE PRESENT-DAY CRITICAL CARE LANDSCAPE
IDEALIZED DESIGN FOR CRITICAL CARE PRACTICE
STATE OF CRITICAL CARE REIMBURSEMENT
The delivery of critical care services continues to represent a disproportionate share of health care expenditures relative to the proportion of patients who use these services. The federal Medicare program has become the largest provider of health care insurance in the United States and in 2002 accounted for nearly 30% of annual payments to hospitals.1 An analysis of Medicare admissions in 2000 determined that cases involving a stay in an intensive care unit (ICU) cost nearly three times as much as those limited to the general care wards. Nevertheless, only 83% of the cost of the care of ICU patients was reimbursed, compared with 105% for patients cared for on the general care floors.2 Over the subsequent 5 years, critical care costs reportedly increased another 44%.3
Accordingly, the principal consideration for ICU administrators becomes a question of what type of structure and leadership their ICU will need to accomplish its mission. Typically, ICUs have been structured along the lines of tertiary, large community, and small community hospitals. These hospitals have different aims and goals and differing capacities to respond to acuity in the care of patients. Likewise, most ICUs have a designated ICU director with roles and responsibilities commensurate with those goals. Standards of care for typical arrangements have been described in the literature.4 An essential function of ICU administration is to determine and specifically articulate the ICU’s compliance with these standards.
The Present-Day Critical Care Landscape
Surveys of critical care delivery in the United States date back to the early 1990s.5,6 Reports of the supply and demand of adult critical care were most recently completed in 2000 through a joint effort on behalf of the American Thoracic Society (ATS), the American College of Chest Physicians (ACCP), and the Society of Critical Care Medicine (SCCM).7 Estimates on current and future requirements for adult critical care and pulmonary medicine physicians in the United States were reported by the Committee on Manpower for the Pulmonary and Critical Care Societies (COMPACCS). Angus and coworkers, on behalf of the COMPACCS group, extended their inquiry in 2006 to profile the organization and distribution of ICU patients and services in the United States.8
In response to the COMPACCS study report, an analysis was requested by the U.S. Senate. In 2006 a report to Congress from the U.S. Department of Health and Human Services’ Health Services and Resource Administration (HSRA) updated the findings in COMPACCS, reiterating their projections with respect to the critical care workforce.9 The HSRA workforce analysis indicated that the growth and aging of the population alone will increase demand for adult intensivist services by at least 38% between 2000 and 2020. Similarly, critical care nursing availability remains woefully inadequate to meet the demand. Proactive recruitment and retention strategies are paramount to maintain high-quality nursing care (Box 70.1).
The shortfall in supply of intensivists may drive administrators to consider an alternative critical care delivery team model, which may include nonintensivist physicians and physician extenders. Consideration to hopitalists partnering with intensivists as an option to fill the gap in intensivist supply is being addressed by two task forces, first in a publication of the 2004 Framing Options for Critical Care in the United States (FOCCUS) report and second in 2007 Prioritizing the Organization and Management of Intensive Care Services in the United States (PrOMIS) Conference Report.10,11 Reports from these task forces made three recommendations in an attempt to address the situation: to include (1) uniform protocols for intensive care treatment, (2) a process for certification of physicians providing critical care services with a competency assurance process, and (3) health service research with a focus on outcomes of ICU patients cared for by hospitalists.12 In another model, use of physician extenders may include physician assistants (PAs) and nurse practitioners (NPs). Limited research exists examining the use of NPs and PAs in the critical care setting with the majority focused on their impact on patient care management. Despite the small sample sizes and limited studies, NPs and PAs have demonstrated enhanced patient flow, improved clinical and financial outcomes for mechanically ventilated patients, reduction in ICU and hospital length of stay, and improved management in the heart failure patient population.13 Because the lack of intensivist staffing is unlikely to change significantly over the next few years, alternative models may be on the horizon.
Regardless of the expected reductions in available staffing, calls for increased access to intensivists continue with a goal of increasing intensivist coverage in-house around the clock. Despite the challenge by one recent study,14 multiple studies have demonstrated mortality rate and cost-savings benefits to critically ill patients receiving care by intensivists. Young and Birkmeyer estimated that in the context of 360,000 deaths occurring each year in ICUs, 54,000 lives may be saved annually with intensivist staffing.15 Similarly, Pronovost and colleagues have estimated that more than $5 billion could be saved annually.16 A report generated for the Agency for Healthcare Research and Quality (AHRQ) notes that these benefits alone underestimate the potential improvement in the quality of care in terms of fewer complications, avoiding inappropriate utilization, decreased patient suffering, and better end-of-life care.17
The Leapfrog Group, a consortium of companies that purchase health care for their employees, convened in an effort to leverage their purchasing power to improve the quality of care. This powerful group has focused on improving four key areas central to patient safety and to cost containment in health care: (1) the use of computerized physician order entry, (2) the oversight of critical care physicians in the care of ICU patients, (3) the use of evidence-based hospital referral systems, and (4) Leapfrog safe practice scores.18 The influence of this group on both payers and health systems alike has contributed to the increasing demand for intensivists to care for critically ill patients. Unfortunately, the 2006 update to the COMPACCS study suggests that this need has gone essentially unmet. Loosely defining Leapfrog-compliant intensivist coverage for 80% of critically ill patients and the presence of 24-hour in-house physician coverage, Angus and colleagues found that only one in four ICUs had 80% intensivist coverage and that half had no intensivist coverage. Very few hospitals provided in-house physician coverage during off hours: 20% during weekend days, 12% during weekday nights, and 10% during weekend nights. Overall, only 4% of adult ICUs in the United States appeared to meet even a liberal interpretation of Leapfrog standards.8
Idealized Design for Critical Care Practice
A key first step is to halt further deterioration in present practice through effective coordination and communication to mitigate further erosion in practice standards (Boxes 70.2 and 70.3). Strategies to refine critical care delivery and meet predicted needs are present in the literature. Retaining tactics that have proved effective in trauma care are essential in building on current designs to streamline access to critical care. Hospital systems will need to collaborate on the care of critically ill patients in order to distribute critical care equitably as a resource, a social commodity. Finally, a realignment of values among health care leaders to build and reinforce a culture of efficiency, safety, and continuous improvement may stave off mediocrity.
Rational Model for Critical Care Delivery
Delivery of critical care should attempt to balance the needs of the community with access to the highest quality critical care services within that area. The American College of Surgeons (ACS) set the precedent for national practice standards for specific sets of critically ill patients when trauma centers were organized. When patients sustain injury with possible trauma, their care is initiated at appropriate trauma centers, depending on readiness and capacity to deliver care. Each designated level of classification (levels I to IV) has associated standards designated by the ACS. The structure has redefined the care of trauma patients and has been associated with improved outcomes and decreased mortality rates.19,20
Advancement in critical care delivery is feasible using a similar approach. The American College of Critical Care Medicine (ACCM) of the SCCM has developed a system to segregate hospitals into specific categories based on readiness and capacity to deliver critical care services (Box 70.4). These guidelines were first published in 1999 and revised in 2003.4 Appropriate application of these guidelines provides a gateway in developing collaborative relationships and to ensure a streamlined approach to critical care delivery.
Although the ACCM guidelines set the stage for ideal function of hospitals within each classification, a substantial performance gap between compliance with the guidelines and actual practice remains. Administrators should define their mission, thereby determining the range of services that their hospital seeks to effectively offer patients. Instrumental aspects to consider include the population the hospital serves, services provided by neighboring hospitals, and subspecialties of the staff physicians. Other factors that may be informative in redesign include a list of common diagnoses and acuity level in patients who are routinely treated.4
The specific standards that define level I and level II care are summarized in Box 70.5. Many hospitals will not be able to maintain these standards, and overlap with level II or level III critical care facilities may be considerable. Level II hospitals capable of providing comprehensive care for most diagnoses should attempt to emulate the level I guidelines for most conditions. For instance, a level II institution may not have the resources for optimal treatment of severe burns, but that facility may provide excellent surgical, cardiac, and posttransplantation medical care. Such a facility should aim to meet level I standards for conditions other than severe burns.
For level II or III institutions, a critical requirement of the guidelines is to establish agreements for transfer of patients for higher levels of care. It should be a usual practice in such facilities to stabilize patients with the intention to invoke established agreements to transfer to collaborating facilities.21 Although completing transfers may be routine for ICU staff, the requirement for agreements established in advance with collaborating institutions to accept transfers may be novel. In order to develop the efficiencies that will be necessary in the emerging critical care environment, these types of prenegotiated arrangements will be necessary to ensure access to needed care.
