Lower mortality, LOS seen with intensivists: mortality differences shown in ICUs, hospitalwide - lengths of stay

HealthCare Benchmarks and Quality Improvement, March, 2003

Closed intensive care units (ICUs)--those in which an intensivist is the patient s primary attending physician--or ICUs that require mandatory critical care consultation with an intensivist experience lower mortality rates and shorter lengths of stay (LOS), according to a study published in the Nov. 6, 2002, Journal of the American Medical Association (JAMA), "Physician staffing patterns and clinical outcomes in critically ill patients."

The report, which examined 2,590 abstracts and identified 26 studies, resulted in 27 comparisons of differences as well as similarities. alternative staffing strategies regarding ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and LOS.

Among the results of the study:

* High-intensity staffing was associated with lower hospitality mortality in 16 of 17 studies (94%).

* High-intensity staffing also was associated with lower ICU mortality in 14 of 15 studies (93%).

* High-intensity staffing reduced hospital LOS in 10 of 13 studies.

The JAMA authors used the term "high-intensity" to denote hospitals that used either a closed ICU or required mandatory critical care consulting.

"When we pooled all the evidence together, as if it were one large study, the total body of evidence suggested high-intensity staffing would reduce hospital LOS by 29% and hospital mortality by 39%," adds Peter J. Pronovost, MD, PhD, lead author of the study and associate professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine in Baltimore, which cosponsored the study along with the University of Pittsburgh.

"We think that what makes the difference is the combination of knowledge and presence [in the ICU]--knowing what to do; which is greater, we don't know," he says.

There is a distinct difference in the amount of training an intensivist has received, as opposed to a typical attending physician in an ICU that does not employ high-intensity staffing.

"An intensivist has usually been trained in either surgical medicine or in pediatrics, and has then gone on to do a fellowship in critical care," Pronovost notes. "In the nonintensive model, you have mostly primary care docs."

In addition to not having the same training, these physicians are not present in the ICU during the day like intensivists are. "During the day, they go to the office, while intensivist staffing stays in the hospital," Pronovost observes.

This offers a double advantage. First, the intensivists quickly develop many more hours' experience in the ICU. In addition, "Since they are actually present in the ICU instead of in the office, they are there and available to make a decision on the spot," he points out.

A no-brainer?

No official numbers are available, but estimates are that only about 10% of hospitals in the United States employ the intensivist model. Is this because of financial limitations?

Quite the contrary, says Pronovost. "We've published studies that show hospitals can save millions of dollars a year if they used the intensivist model," Pronovost says. (The studies can be found on the Leapfrog Group web site: www.leapfroggroup.org.)

"It's more of a hospital leadership issue," he asserts. "If you changed the structure, several people would have to bite some bullets--docs won't be billed for consultations, and so on. Hospital leaders need to stand up and say, `We should do this.'"

There also may be some shortages of intensivists, Pronovost concedes, but he quickly adds, "Many hospitals have not made the effort to find out if the shortage is real."

Key Points

* Combination of knowledge, presence in hospital seem to make the difference.

* Despite lower cost, intensivist staffing seen at small minority of hospitals.

* It's up to hospital leadership to change strategies in staffing.

(Editor's note: The corresponding author for the JAMA study is: Derek C. Angus, MB, ChB, MPH, 604 Scifel, CRSA Laboratory, Department of Critical Care Medicine, University of Pittsburgh, 200 Lothrop St., Pittsburgh PA 15213. E-mail: angusdc@ccm.upmc.edu.)