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The Hospital Intensivist: what you need to know John Rickelman Jr., D.O. CCU Medical Director Co-Director Hospitalist Program Northeast Regional Medical Center Kirksville, Missouri Objectives Give a brief history surrounding the Critical Care and the Intensivist specialty

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the hospital intensivist what you need to know

The Hospital Intensivist: what you need to know

John Rickelman Jr., D.O.

CCU Medical Director

Co-Director Hospitalist Program

Northeast Regional Medical Center

Kirksville, Missouri

  • Give a brief history surrounding the Critical Care and the Intensivist specialty
  • Review the training required of an Intensivist
  • Review literature supporting the benefits of an Intensivist
  • Future directions surrounding the Intensivist specialty and Critical Care
1854-Florence Nightingale writes about the advantages of establishing a separate area of the hospital for patients recovering from surgery.
    • Reduced the death rate of British soldiers in the hospitals from 42 percent to 2 percent during the Crimean War
World War II-Isolated rooms in the hospital, called shock wards, are established to resuscitate and care for soldiers injured in battle or undergoing surgery.
1950s-The development of mechanical ventilation leads to the organization of respiratory intensive care units (ICUs) in many European and American hospitals.
    • 1958-Approximately 25 percent of community hospitals with more than 300 beds report having an ICU. By the late 1960s, most United States hospitals have at least one ICU
1970- The Society of Critical Care Medicine (SCCM) is established as a multiprofessional intensive care advocate
  • 1986-The American Board of Medical Specialties (ABMS) approves a certification of special competence in critical care for the four primary boards: anesthesiology, internal medicine, pediatrics, and surgery
critical care
Critical Care
  • Internal Medicine
    • Pulmonary, Infectious Diseases, Nephrology
      • 3 years
    • Stand alone
      • 2 years
  • Anesthesiology
  • Surgery
  • Pediatrics
financial modeling
Financial Modeling
  • Using published data, evaluated costs and saving for 6, 12, and 18-bed ICU’s
  • Cost savings ranged from $ 510, 000 to $ 3.3 million

Pronovost etal, CCM 2004; 32(6):1247- 1253

mortality reduction
Mortality reduction
  • 9 study meta-analysis looking at mortality reduction
    • 15% to 60% relative reductions
    • 15% would equal 53, 850 lives each year

Young etal, Eff Clin Pract. 2001; 3(6):284-289

esophageal resection
Esophageal resection
  • Presence vs Absence of daily rounds by Intensivist
    • In- hospital mortality rate, length of stay, hospital cost, and complications
  • 35 hospitals

Dimick etal, CCM 2001; 29(4): 753-758

esophageal resection14
Esophageal resection
  • Lack of ICU physician on rounds
    • 73% increase hospital LOS
    • 61% increase in total hospital costs
  • No association with in-hospital mortality rate

Dimick etal, CCM 2001; 29(4): 753-758

nurse job satisfaction
Nurse Job Satisfaction
  • Change from “mandatory” to “semiclosed” SICU
  • Survey of SICU nursing staff
    • Hospital spending on agency nurses decreased ( p= .0098)
    • Job turnover rate dropped from 25% to 16%

Haut etal, CCM 2006; 34(2): 387-395

neurointensive care
Neurointensive care
  • The effect of a neurointensivist run ICU
  • 1,087 patients before, 1, 279 patients after appointment
    • 42% risk reduction of death
    • 17% reduction in LOS

Varelas etal, CCM 2004; 32(11): 2191-2198

  • The Leapfrog Group is made up of more than 170 companies and organizations that buy health care
  • Officially launched in 2000
  • Computer Physician Order Entry (CPOE):  With CPOE systems, hospital staff enter medication orders via computer linked to prescribing error prevention software.  CPOE has been shown to reduce serious prescribing errors in hospitals by more than 50%.
  • Evidence-Based Hospital Referral (EHR):  Consumers and health care purchasers should choose hospitals with extensive experience and the best results with certain high-risk surgeries and conditions. Research indicates that a patient’s risk of dying could be reduced by 40%.
  • ICU Physician Staffing (IPS):  Staffing ICUs with doctors who have special training in critical care medicine, called ‘intensivists’, has been shown to reduce the risk of patients dying in the ICU by 40%.
  • Leapfrog’s initial three recommended quality and safety practices have the potential to save up to 65,341 lives and prevent up to 907,600 medication errors each year (Birkmeyer,2004). 
  • Implementation could also save up to $41.5 billion annually (Conrad, 2005).
icu categorization
ICU Categorization
  • Level I, Level II, Level III
  • Similar to Trauma Classification
  • Could determine reimbursement

Haupt etal, CCM 2003; 31(11): 2677-2683

  • In 1997, intensivists provided care to 36.8% of all ICU patients.
  • Care in the ICU was provided more commonly by intensivists in regions with high managed care penetration.
  • The current ratio of supply to demand is forecast to remain in rough equilibrium until 2007.
  • A shortfall of specialist hours equal to 22% of demand by 2020 and 35% by 2030, primarily because of the aging of the US population.
  • Sensitivity analyses suggest that the spread of current health care reform initiatives will either have no effect or worsen this shortfall.

Angus etal, JAMA 2000;284:2762-2770

  • American Thoracic Society position paper
    • Severe shorage of intensivists by 2007
    • Shortage to worsen by 2030

American Thoracic Assoc., CHEST 2004; 125(4): 1518-1521

fundementals of critical care support
Fundementals of Critical Care Support
  • To better prepare the non-intensivist for the first 24 hours of management of the critically ill patient until transfer or appropriate critical care consultation can be arranged.
  • To assist the non-intensivist in dealing with sudden deterioration of the critically ill patient.
  • To prepare house staff for ICU coverage.
  • To prepare nurses and other critical care practitioners to deal with acute deterioration in the critically ill patient.
  • Remote ICU telemedicine program
  • Before- and- after trail to asses the effect
  • Two adult ICUs of a tertiary care hospital
    • 2, 140 patients from 1999- 2001

Breslow etal, CCM 2004; 32(1): 31-38

  • Supplemental monitoring for 19 hrs/day
  • Hospital mortality
    • 9.4% vs. 12.9%(RR 0.73: 95% CI 0.55- 0.95)
  • ICU length of stay
    • 3.63 vs 4.35 days

Breslow etal, CCM 2004; 32(1): 31-38