Download PDF
Semin Respir Crit Care Med 2015; 36(06): 842-850
DOI: 10.1055/s-0035-1564853
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Intensivist Staffing: Evolving Challenges and Solutions

Jonathan D. Holdorf
1   Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
2   UMass Memorial Health Care, Worcester, Massachusetts
,
Craig M. Lilly
1   Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
2   UMass Memorial Health Care, Worcester, Massachusetts
3   Department of Anesthesiology and Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
4   Clinical and Population Health Research Program, University of Massachusetts Medical School, Worcester, Massachusetts
› Author Affiliations
Further Information

Publication History

Publication Date:
23 November 2015 (online)

    Permissions and Reprints

Abstract

Increases in critical care utilization related to aging of our population, static supplies of critical care specialists, and reduced availability of physicians in training to staff intensive care units (ICUs) have led many institutions to reevaluate their ICU prescribing provider staffing plans. The epidemiology of critical care staffing needs, regulations, requirements, standards, and professional society staffing recommendations are reviewed and the components of a prescribing provider staffing plan are described along with their costs. Factors that impact staffing costs including the availability of intensivist extenders, electronic support, and telemedicine tools that impact the efficiency of care delivery are evaluated in the context of staffing plan evaluation. Financial modeling is used to compare the costs of common prescribing provider staffing plans for typical referral medical center ICUs, community hospital ICUs, and rural health centers that care for the critically ill.

Keywords

intensivist - critical care - management - workforce - staffing - resource
 

  • References

  • 1 Gillum RF. Sudden coronary death in the United States: 1980–1985. Circulation 1989; 79 (4) 756-765
    CrossrefPubMedGoogle Scholar
  • 2 Cardiopulmonary resuscitation. JAMA 1966; 198 (4) 372-379
    CrossrefPubMedGoogle Scholar
  • 3 Neumar RW, Otto CW, Link MS , et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122 (18) (Suppl. 03) S729-S767
    CrossrefPubMedGoogle Scholar
  • 4 Beck GJ, Barach AL. Value of mechanical aids in the management of a patient with poliomyelitis. Ann Intern Med 1954; 40 (6) 1081-1094
    CrossrefPubMedGoogle Scholar
  • 5 Galpine JF, Smith-Clarke GT. Artificial positive-pressure respiration. Lancet 1955; 268 (6866) 722-723
    PubMedGoogle Scholar
  • 6 Lilly CM, Zuckerman IH, Badawi O, Riker RR. Benchmark data from more than 240,000 adults that reflect the current practice of critical care in the United States. Chest 2011; 140 (5) 1232-1242
    CrossrefPubMedGoogle Scholar
  • 7 Hudson J, Caruthers TE, Lantiegne K. Intensive care nursing requirements: resource allocation according to patient status. Crit Care Med 1979; 7 (2) 69-75
    CrossrefPubMedGoogle Scholar
  • 8 Duke EM. The Critical Care Workforce: a Study of the Supply and Demand for Critical Care Physicians. Washington, DC: US Department of Health & Human Services; 2004
    Google Scholar
  • 9 Kelley MA, Angus D, Chalfin DB , et al. The critical care crisis in the United States: a report from the profession. Chest 2004; 125 (4) 1514-1517
    CrossrefPubMedGoogle Scholar
  • 10 Angus DC, Kelley MA, Schmitz RJ, White A, Popovich Jr J ; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? . JAMA 2000; 284 (21) 2762-2770
    CrossrefPubMedGoogle Scholar
  • 11 U. S. Census Bureau. United States Census 2010. Washington, DC: U.S. Census Bureau's Public Information Office;
    Google Scholar
  • 12 Hashmi A, Ibrahim-Zada I, Rhee P , et al. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg 2014; 76 (3) 894-901
    CrossrefPubMedGoogle Scholar
  • 13 Iwashyna TJ, Kramer AA, Kahn JM. Intensive care unit occupancy and patient outcomes. Crit Care Med 2009; 37 (5) 1545-1557
    CrossrefPubMedGoogle Scholar
  • 14 Bernstein SL, Aronsky D, Duseja R , et al; Society for Academic Emergency Medicine, Emergency Department Crowding Task Force. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 2009; 16 (1) 1-10
    CrossrefPubMedGoogle Scholar
  • 15 Huang DT. Clinical review: impact of emergency department care on intensive care unit costs. Crit Care 2004; 8 (6) 498-502
    CrossrefPubMedGoogle Scholar
  • 16 AHA Fast facts.; Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml . Accessed February 14, 2015
    PubMed
  • 17 Giardino AP, Giardino ER. Medical education and resident work hours. JAMA 1990; 263 (5) 620
    CrossrefPubMedGoogle Scholar
  • 18 Ward NS, Afessa B, Kleinpell R , et al; Members of Society of Critical Care Medicine Taskforce on ICU Staffing. Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing. Crit Care Med 2013; 41 (2) 638-645
    CrossrefPubMedGoogle Scholar
  • 19 Nasca TJ, Day SH, Amis Jr ES ; ACGME Duty Hour Task Force. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med 2010; 363 (2) e3
    CrossrefPubMedGoogle Scholar
  • 20 Pilcher JJ, Huffcutt AI. Effects of sleep deprivation on performance: a meta-analysis. Sleep 1996; 19 (4) 318-326
    PubMedGoogle Scholar
  • 21 Landrigan CP, Rothschild JM, Cronin JW , et al. Effect of reducing interns' work hours on serious medical errors in intensive care units. N Engl J Med 2004; 351 (18) 1838-1848
    CrossrefPubMedGoogle Scholar
  • 22 Barger LK, Cade BE, Ayas NT , et al; Harvard Work Hours, Health, and Safety Group. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005; 352 (2) 125-134
    CrossrefPubMedGoogle Scholar
  • 23 Dozois EJ, Holubar SD, Tsikitis VL , et al. Perceived impact of the 80-hour workweek: five years later. J Surg Res 2009; 156 (1) 3-15
    CrossrefPubMedGoogle Scholar
  • 24 Fifer S, Everett W, Adams M, Vincequere J, Massachusetts Technology C , New England Healthcare Institute. Critical Care, Critical Choices: the Case for Tele-ICUs in Intensive Care. Cambridge, MA: New England Healthcare Institute, Massachusetts Technology Collaborative; 2010
    Google Scholar
  • 25 Pronovost PJ, Needham DM, Waters H , et al. Intensive care unit physician staffing: financial modeling of the Leapfrog standard. Crit Care Med 2006; 34 (3, Suppl): S18-S24
    CrossrefPubMedGoogle Scholar
  • 26 Pronovost P, Thompson DA, Holzmueller CG, Dorman T, Morlock LL. Impact of the Leapfrog Group's intensive care unit physician staffing standard. J Crit Care 2007; 22 (2) 89-96
    CrossrefPubMedGoogle Scholar
  • 27 Brooke BS, Perler BA, Dominici F, Makary MA, Pronovost PJ. Reduction of in-hospital mortality among California hospitals meeting Leapfrog evidence-based standards for abdominal aortic aneurysm repair. J Vasc Surg 2008; 47 (6) 1155-1156 , discussion 1163–1164
    CrossrefPubMedGoogle Scholar
  • 28 Aiken LH, Sloane DM, Cimiotti JP , et al. Implications of the California nurse staffing mandate for other states. Health Serv Res 2010; 45 (4) 904-921
    CrossrefPubMedGoogle Scholar
  • 29 Centers for Medicare and Medicaid 2010; Available at: http://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol2/pdf/CFR-2010-title42-vol2-sec413-53.pdf
    PubMed
  • 30 Manthous CA. Leapfrog and critical care: evidence- and reality-based intensive care for the 21st century. Am J Med 2004; 116 (3) 188-193
    CrossrefPubMedGoogle Scholar
  • 31 Kahn JM, Matthews FA, Angus DC, Barnato AE, Rubenfeld GD. Barriers to implementing the Leapfrog Group recommendations for intensivist physician staffing: a survey of intensive care unit directors. J Crit Care 2007; 22 (2) 97-103
    CrossrefPubMedGoogle Scholar
  • 32 The Leapfrog Group. Fact Sheet for ICU Physician Staffing (IPS). 2011; Available at: http://www.leapfroggroup.org/media/file/FactSheet_IPS.pdf
    PubMedGoogle Scholar
  • 33 Cooper RA ; The Committee on Manpower for Pulmonary and Critical Care Societies. The COMPACCS Study: questions left unanswered. Am J Respir Crit Care Med 2001; 163 (1) 10-11
    CrossrefPubMedGoogle Scholar
  • 34 Halpern NA. Innovative designs for the smart ICU: Part 2: the ICU. Chest 2014; 145 (3) 646-658
    CrossrefPubMedGoogle Scholar
  • 35 Lilly CM, McLaughlin JM, Zhao H, Baker SP, Cody S, Irwin RS ; UMass Memorial Critical Care Operations Group. A multicenter study of ICU telemedicine reengineering of adult critical care. Chest 2014; 145 (3) 500-507
    CrossrefPubMedGoogle Scholar
  • 36 Lilly CM, De Meo DL, Sonna LA , et al. An intensive communication intervention for the critically ill. Am J Med 2000; 109 (6) 469-475
    CrossrefPubMedGoogle Scholar
  • 37 Pickering BW, Gajic O, Ahmed A, Herasevich V, Keegan MT. Data utilization for medical decision making at the time of patient admission to ICU. Crit Care Med 2013; 41 (6) 1502-1510
    CrossrefPubMedGoogle Scholar
  • 38 Gershengorn HB, Kocher R, Factor P. Management strategies to effect change in intensive care units: lessons from the world of business. Part II. Quality-improvement strategies. Ann Am Thorac Soc 2014; 11 (3) 444-453
    PubMedGoogle Scholar
  • 39 Irwin RS, Flaherty HM, French CT , et al; UMass Memorial Critical Care Operations Team. Interdisciplinary collaboration: the slogan that must be achieved for models of delivering critical care to be successful. Chest 2012; 142 (6) 1611-1619
    CrossrefPubMedGoogle Scholar
  • 40 McCauley K, Irwin RS. Changing the work environment in ICUs to achieve patient-focused care: the time has come. Chest 2006; 130 (5) 1571-1578
    CrossrefPubMedGoogle Scholar
  • 41 Lilly CM, Cody S, Zhao H , et al; University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA 2011; 305 (21) 2175-2183
    CrossrefPubMedGoogle Scholar
  • 42 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 (17) 2151-2162
    CrossrefPubMedGoogle Scholar
  • 43 Kerlin MP, Small DS, Cooney E , et al. A randomized trial of nighttime physician staffing in an intensive care unit. N Engl J Med 2013; 368 (23) 2201-2209
    CrossrefPubMedGoogle Scholar
  • 44 Wallace DJ, Angus DC, Barnato AE, Kramer AA, Kahn JM. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med 2012; 366 (22) 2093-2101
    CrossrefPubMedGoogle Scholar
  • 45 Kerlin MP, Harhay MO, Kahn JM, Halpern SD. Nighttime intensivist staffing, mortality, and limits on life support: a retrospective cohort study. Chest 2015; 147 (4) 951-958
    CrossrefPubMedGoogle Scholar
  • 46 Banerjee R, Naessens JM, Seferian EG , et al. Economic implications of nighttime attending intensivist coverage in a medical intensive care unit. Crit Care Med 2011; 39 (6) 1257-1262
    CrossrefPubMedGoogle Scholar
  • 47 Garland A, Gershengorn HB. Staffing in ICUs: physicians and alternative staffing models. Chest 2013; 143 (1) 214-221
    CrossrefPubMedGoogle Scholar
  • 48 Association MGM. Academic Practice Compensation and Production Survey for Faculty and Management: 2014 Report Based on 2013 Data. Englewood, CO: Medical Group Management Association; 2014
    Google Scholar
  • 49 Siegal EM, Dressler DD, Dichter JR, Gorman MJ, Lipsett PA. Training a hospitalist workforce to address the intensivist shortage in American hospitals: a position paper from the Society of Hospital Medicine and the Society of Critical Care Medicine. Crit Care Med 2012; 40 (6) 1952-1956
    CrossrefPubMedGoogle Scholar
  • 50 Lilly CM, Zubrow MT, Kempner KM , et al. Critical care telemedicine: evolution and state of the art. Crit Care Med 2014; 42 (11) 2429-2436
    CrossrefPubMedGoogle Scholar
  • 51 Wise KR, Akopov VA, Williams Jr BR, Ido MS, Leeper Jr KV, Dressler DD. Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models. J Hosp Med 2012; 7 (3) 183-189
    CrossrefPubMedGoogle Scholar
  • 52 Lizano D, Mehta G, Keith D, Shiloh A, Savel R. Physician Assistants in the ICU. ICU Director 2011; 2 (1–2) 20-24
    CrossrefPubMedGoogle Scholar
  • 53 Landsperger JS, Williams KJ, Hellervik SM , et al. Implementation of a medical intensive care unit acute-care nurse practitioner service. Hosp Pract (1995) 2011; 39 (2) 32-39
    PubMedGoogle Scholar
  • 54 Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med 2008; 36 (10) 2888-2897
    CrossrefPubMedGoogle Scholar
  • 55 Carpenter DL, Gregg SR, Owens DS, Buchman TG, Coopersmith CM. Patient-care time allocation by nurse practitioners and physician assistants in the intensive care unit. Crit Care 2012; 16 (1) R27
    CrossrefPubMedGoogle Scholar
  • 56 Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA 1998; 280 (9) 788-794
    CrossrefPubMedGoogle Scholar
  • 57 Harper DC, Johnson J. Workforce Policy Project Technical Report: Nurse Practitioner Education Programs, 1988–1995. Washington, DC: National Organization of Nurse Practitioner F; 1996
    Google Scholar
  • 58 Pastores SM, O'Connor MF, Kleinpell RM , et al. The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. Crit Care Med 2011; 39 (11) 2540-2549
    CrossrefPubMedGoogle Scholar
  • 59 Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual 2011; 26 (6) 452-460
    CrossrefPubMedGoogle Scholar
  • 60 Gershengorn HB, Wunsch H, Wahab R , et al. Impact of nonphysician staffing on outcomes in a medical ICU. Chest 2011; 139 (6) 1347-1353
    CrossrefPubMedGoogle Scholar
  • 61 Costa DK, Wallace DJ, Barnato AE, Kahn JM. Nurse practitioner/physician assistant staffing and critical care mortality. Chest 2014; 146 (6) 1566-1573
    CrossrefPubMedGoogle Scholar
  • 62 Burns SM, Earven S, Fisher C , et al; University of Virginia Long Term Mechanical Ventilation Team. Implementation of an institutional program to improve clinical and financial outcomes of mechanically ventilated patients: one-year outcomes and lessons learned. Crit Care Med 2003; 31 (12) 2752-2763
    CrossrefPubMedGoogle Scholar
  • 63 Gracias VH, Sicoutris CP, Stawicki SP , et al. Critical care nurse practitioners improve compliance with clinical practice guidelines in “semiclosed” surgical intensive care unit. J Nurs Care Qual 2008; 23 (4) 338-344
    CrossrefPubMedGoogle Scholar
  • 64 Russell D, VorderBruegge M, Burns SM. Effect of an outcomes-managed approach to care of neuroscience patients by acute care nurse practitioners. Am J Crit Care 2002; 11 (4) 353-362
    PubMedGoogle Scholar
  • 65 Office of Graduate Medical Education Policy #210. 2014–2015 Resident Compensation Rates. Memphis, TN: Office of Graduate Medical Education; 2014
    Google Scholar