On the CUSP: STOP BSI
ICU Physician Staffing
© 2009
Learning Objectives
• To review the evidence on the benefits of ICU
physician staffing
• To explore strategies to improve ICU physician staffing
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Organizing Principles for Intensive Care
Why?
The Patient is North Star
What?
Right Care, Right Now
How?
Integrated
Team of Dedicated Experts
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Intensivists Reduce Mortality Costs
Question is not Whether to but How to implement IPS
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Intensivists Reduce Mortality:
Hospital Mortality
Hospital Mortality
Risk ratio
(95% CI)
Study
% W eight
Li
0.93 (0.78,1.13)
11.0
Reynolds, et al
Brown, et al
0.77 (0.63,0.94)
0.69 (0.52,0.93)
10.8
8.6
Multz et al retrospective
Multz et al prospective
0.81 (0.62,1.07)
0.74 (0.53,1.05)
9.0
7.5
Manthous et al
Carson et al
0.72 (0.59,0.89)
1.39 (0.91,2.11)
10.6
6.2
Hanson et al
0.67 (0.19,2.29)
1.2
Pronovost et al
Dimick et al
0.58 (0.43,0.79)
0.26 (0.12,0.59)
8.3
2.5
Dimick et al
0.19 (0.07,0.55)
1.6
Baldock et al
Rosenfeld et al
0.65 (0.51,0.83)
0.39 (0.19,0.81)
9.7
2.9
Blunt et al
0.69 (0.54,0.87)
10.0
Overall (95% CI)
0.71 (0.62,0.82)
.1
1
10
Risk ratio
© 2009
Pronovost JAMA 2002
Intensivists Reduce Mortality:
ICU Mortality
ICU Mortality
Risk ratio
(95% CI)
Study
% Weight
Pollack et al
0.53 (0.17,1.64)
2.5
Brown et al
0.48 (0.32,0.72)
8.4
Kuo et al
0.60 (0.49,0.73)
11.3
Al-Asadi et al
0.82 (0.61,1.10)
9.9
Manthous et al
0.71 (0.54,0.94)
10.1
Marini et al
0.54 (0.26,1.10)
4.7
DiCosmo et al
0.59 (0.44,0.79)
10.0
Ghorra et al
0.42 (0.20,0.90)
4.4
Baldock et al
0.69 (0.52,0.91)
10.0
Rosenfeld et al
0.15 (0.05,0.50)
2.3
Goh et al
0.38 (0.27,0.53)
9.3
Reich et al
0.61 (0.41,0.92)
8.2
Topeli et al
1.44 (1.00,2.07)
8.9
Overall (95% CI)
0.61 (0.50,0.75)
.1
1
10
Risk ratio
© 2009
Pronovost JAMA 2002
Net Savings of IPS for
Hospitals in $000
Pronovost CCM 2004
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Leapfrog model
Net savings for hospital $000
Conrad, Gardner 2004 Leapfrog report
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Net Savings per ICU day
Leapfrog model $
Conrad, Gardner 2004 Leapfrog report
© 2009
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LEAPFROG SAFETY STANDARDS
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and Blue Shield in an innovative program designed to save lives by
providing financial incentives to hospitals that rapidly achieve proven
patient safety standards.
Key Attributes of Physician Staffing
• Present
• Posses skill/knowledge
• Communicates/works with team of caregivers
• Manages the ICU
Little is known about the relative value of each attribute
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Extremes
No
Intensivist
24 X 7
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Team Care
• Avoid Open versus Closed debate
– Both primary care and ICU physician add value
• Obtain financial support from hospital for physician staffing
• Create Compact of what is expected
• Include performance measures in contract
• Obtain admission and discharge authority
© 2009
Strategies for
Implementing Intensivists
• Meet with medical staff
– Review evidence
– Discuss team approach rather than open closed
• Create Compact with hospital
– Hospital to provide financial support
– Intensivists will staff ICU, monitor and improve quality
– Review performance quarterly
© 2009
How Can You Realize these
Attributes without Intensivists
• Discuss alternative models
–
–
–
–
Hospitalist
Regionalization
NP/PA
Other
• Ensure a physician rounds on all patients every day
• Call list
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Action Plan
• Discuss with team and hospital your current ICU
physician staff, are you meeting the 4 attributes
• Develop plan to enhance ICU physician staffing
• Ensure nurses know which physician to page for all
patients at all times
• Create explicit Compact; hospital will provide
financial support and physician will provide services
© 2009
References
•
Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association
between critical care physician management and patient mortality in the
intensive care unit. Ann Int Med 2008;148:801-9.
•
Pronovost PJ, Holzmueller CG, Clattenburg L, Berenholtz S, Martinez EA, Paz JR,
Needham DM. Team care: beyond open and closed intensive care units. Curr
Opin Crit Care 2006;12:604-8.
•
Pronovost PJ, Needham DM, Waters H, Birkmeyer CM, Calinawan JR,
Birkmeyer JD, Dorman T. Intensive care unit physician staffing: Financial
modeling of the Leapfrog standard. Crit Care Med 2006;34:S18-24.
•
Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL.
Physician staffing patterns and clinical outcomes in critically ill patients: a
systematic review. JAMA 2002;288:2151-62.
•
Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA,
Lipsett PA, Bass E. Organizational characteristics of intensive care units related
to outcomes of abdominal aortic surgery. JAMA 1999;281:1310-17.
© 2009