Intensivists in U.S. Acute Care Hospitals

Sustainability of the Subspecialty of Anesthesiology Critical Care: An Expert Consensus and Review of the Literature

While considerable literature exists with respect to clinical aspects of critical care anesthesiology (CCA) practice, few publications have focused on how anesthesiology-based critical care practices are organized and the challenges associated with the administration and management of anesthesiology critical care units. Currently, numerous challenges are affecting the sustainability of CCA practice, including decreased applications to fellowship positions and decreased reimbursement for critical care work. This review describes what is known about the subspecialty of CCA and leverages the experience of administrative leaders in adult critical care anesthesiologists in the United States to describe potential solutions.

In-Hospital Triage

The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain can influence ICU triage decisions, which rely heavily on clinical judgment. Having an admission and triage protocol with which clinicians are very familiar can mitigate difficult, inappropriate admissions. This article reviews these concepts and methods of in-hospital triage.

Application of Machine Learning Models to Biomedical and Information System Signals From Critically Ill Adults

BACKGROUND

Machine learning (ML)-derived notifications for impending episodes of hemodynamic instability and respiratory failure events are interesting because they can alert physicians in time to intervene before these complications occur.

RESEARCH QUESTION

Do ML alerts, telemedicine system (TS)-generated alerts, or biomedical monitors (BMs) have superior performance for predicting episodes of intubation or administration of vasopressors?

STUDY DESIGN AND METHODS

An ML algorithm was trained to predict intubation and vasopressor initiation events among critically ill adults. Its performance was compared with BM alarms and TS alerts.

RESULTS

ML notifications were substantially more accurate and precise, with 50-fold lower alarm burden than TS alerts for predicting vasopressor initiation and intubation events. ML notifications of internal validation cohorts demonstrated similar performance for independent academic medical center external validation and COVID-19 cohorts. Characteristics were also measured for a control group of recent patients that validated event detection methods and compared TS alert and BM alarm performance. The TS test characteristics were substantially better, with 10-fold less alarm burden than BM alarms. The accuracy of ML alerts (0.87-0.94) was in the range of other clinically actionable tests; the accuracy of TS (0.28-0.53) and BM (0.019-0.028) alerts were not. Overall test performance (F scores) for ML notifications were more than fivefold higher than for TS alerts, which were higher than those of BM alarms.

INTERPRETATION

ML-derived notifications for clinically actioned hemodynamic instability and respiratory failure events represent an advance because the magnitude of the differences of accuracy, precision, misclassification rate, and pre-event lead time is large enough to allow more proactive care and has markedly lower frequency and interruption of bedside physician work flows.

A faculty-led resident strike team as a force expander during disaster

The emergence of the coronavirus disease 2019 (COVID-19) pandemic produced an unprecedented strain on the United States medical system. Prior to the pandemic, there was an estimated 20,000 physician shortage. This has been further stressed by physicians falling ill and the increased acuity of the COVID-19 patients. Federal medical team availability was stretched to its capabilities with the large numbers of deployments. With such severe staffing shortages, creative ways of force expansion were undertaken. New Orleans, Louisiana, was one of the hardest hit areas early in the pandemic. As the case counts built, a call was put out for help. The Louisiana State University (LSU) system responded with a faculty-led resident strike team out of the LSU Health Shreveport Academic Medical Center. Residents and faculty alike volunteered, forming a multispecialty, attending-led medical strike team of approximately 10 physicians. Administrative aspects such as institution-specific credentialing, malpractice coverage, resident distribution, attending physician oversight, among other aspects were addressed, managed, and agreed upon between the LSU Health Shreveport and the New Orleans hospital institutions and leadership prior to deployment in April 2020. In New Orleans, the residents managed patients within the departments of emergency medicine, medical floor, and intensive care unit (ICU). The residents assigned to the medical floor became a new hospitalist service team. The diversity of specialties allowed the team to address patient care in a multidisciplinary manner, leading to comprehensive patient care plans and unhindered team dynamic and workflow. During the first week alone, the team admitted and cared for over 100 patients combined from the medical floor and ICU. In a disaster situation compounded by staff shortages, a resident strike team is a beneficial solution for force expansion. This article qualitatively reviews the first published incidence of a faculty-led multispecialty resident strike team being used as a force expander in a disaster.

A Review and Discussion of Full-Time Equivalency and Appropriate Compensation Models for an Adult Intensivist in the United States Across Various Base Specialties

OBJECTIVES

Physicians with training in anesthesiology, emergency medicine, internal medicine, neurology, and surgery may gain board certification in critical care medicine upon completion of fellowship training. These clinicians often only spend a portion of their work effort in the ICU. Other work efforts that benefit an ICU infrastructure, but do not provide billing opportunities, include education, research, and administrative duties. For employed or contracted physicians, there is no singular definition of what constitutes an intensive care full-time equivalent (FTE). Nevertheless, hospitals often consider FTEs in assessing hiring needs, salary, and eligibility for benefits.

DATA SOURCES

Review of existing literature, expert opinion.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Not applicable.

DATA SYNTHESIS

Not applicable.

CONCLUSIONS

Understanding how an FTE is calculated, and the fraction of an FTE to be assigned to a particular cost center, is therefore important for intensivists of different specialties, as many employment models assign salary and benefits to a base specialty department and not necessarily the ICU.

Characteristics of victims of trauma requiring invasive mechanical ventilation with a short stay in critical care

BACKGROUND

Many patients who are admitted to the intensive care unit (ICU) have needs which rapidly resolve and are discharged alive within 24 h. We sought to characterize the outcomes of critically ill trauma victims at our institution with a short stay in the ICU.

METHODS

We conducted a retrospective cohort study of all critically ill adult trauma victims presenting to our ED between January 1st, 2011 and December 31st, 2019. We included patients who were endotracheally intubated in either the prehospital setting or the ED and were admitted either to the operating room (OR), angiography suite, or ICU. Our primary outcome was the proportion of patients who were discharged alive from the ICU within 24 h.

RESULTS

We included 3869 patients meeting the criteria above who were alive at 24 h. This population was 78% male with a median age of 40 and 76% of patients suffered from blunt trauma. The median injury severity score (ISS) of the group was 21 [inter-quartile range (IQR) 11-30]. In-hospital mortality amongst the group was 12%. 17% of the group were discharged alive from the ICU within 24 h. Thirty-four percent of the group had an ISS ≤ 15. Of the group which left the ICU alive within 24 h, six patients (0.9%) died in the hospital, 2 % of patients were re-admitted to an ICU, and 0.6% of patients required re-intubation.

CONCLUSIONS

We found that 17% of patients who were intubated in the prehospital setting or emergency department and subsequently hospitalized were discharged alive from the ICU within 24 h.

Defining Intensivists: A Retrospective Analysis of the Published Studies in the United States, 2010-2020

OBJECTIVES

The Society of Critical Care Medicine last published an intensivist definition in 1992. Subsequently, there have been many publications relating to intensivists. Our purpose is to assess how contemporary studies define intensivist physicians.

DESIGN

Systematic search of PubMed, Embase, and Web of Science (2010-2020) for publication titles with the terms intensivist, and critical care or intensive care physician, specialist, or consultant. We included studies focusing on adult U.S. intensivists and excluded non-data-driven reports, non-U.S. publications, and pediatric or neonatal ICU reports. We aggregated the study title intensivist nomenclatures and parsed Introduction and Method sections to discern the text used to define intensivists. Fourteen parameters were found and grouped into five definitional categories: A) No definition, B) Background training and certification, C) Works in ICU, D) Staffing, and E) Database related. Each study was re-evaluated against these parameters and grouped into three definitional classes (single, multiple, or no definition). The prevalence of each parameter is compared between groups using Fisher exact test.

SETTING

U.S. adult ICUs and databases.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 657 studies, 105 (16%) met inclusion criteria. Within the study titles, 17 phrases were used to describe an intensivist; these were categorized as intensivist in 61 titles (58%), specialty intensivist in 30 titles (29%), and ICU/critical care physician in 14 titles (13%). Thirty-one studies (30%) used a single parameter (B-E) as their definition, 63 studies (60%) used more than one parameter (B-E) as their definition, and 11 studies (10%) had no definition (A). The most common parameter "Works in ICU" (C) in 52 studies (50%) was more likely to be used in conjunction with other parameters rather than as a standalone parameter (multiple parameters vs single-parameter studies; 73% vs 17%; p < 0.0001).

CONCLUSIONS

There was no consistency of intensivist nomenclature or definitions in contemporary adult intensivist studies in the United States.

Surgical Emergencies in Patients with Significant Comorbid Diseases

Emergency surgery in patients with significant comorbidities benefits from a structured approach to preoperative evaluation, intra-operative intervention, and postoperative management. Providing goal concordant care is ideal using shared decision-making. When operation cannot achieve the patient's goal, non-operative therapy including Comfort Care is appropriate. When surgical therapy is offered, preoperative physiology-improving interventions are far fewer than in other phases. Reevaluation of clinical care progress helps define trajectory and inform goals of care. Palliative Care Medicine may be critical in supporting loved ones during a patient's critical illness. Outcome evaluation defines successful strategies and outline opportunities for improvement.

Racial & ethnic disparities in geographic access to critical care in the United States: A geographic information systems analysis

OBJECTIVE

It is important to identify gaps in access and reduce health outcome disparities, understanding access to intensive care unit (ICU) beds, especially by race and ethnicity, is crucial. Our objective was to evaluate the race and ethnicity-specific 60-minute drive time accessibility of ICU beds in the United States (US).

DESIGN

We conducted a cross-sectional study using road network analysis to determine the number of ICU beds within a 60-minute drive time, and calculated adult intensive care bed ratios per 100,000 adults. We evaluated the US population at the Census block group level and stratified our analysis by race and ethnicity and by urbanicity. We classified block groups into four access levels: no access (0 adult intensive care beds/100,000 adults), below average access (>0-19.5), average access (19.6-32.0), and above average access (>32.0). We calculated the proportion of adults in each racial and ethnic group within the four access levels.

SETTING

All 50 US states and the District of Columbia.

PARTICIPANTS

Adults ≥15 years old.

MAIN OUTCOME MEASURES

Adult intensive care beds/100,000 adults and percentage of adults national and state) within four access levels by race and ethnicity.

RESULTS

High variability existed in access to ICU beds by state, and substantial disparities by race and ethnicity. 1.8% (n = 5,038,797) of Americans had no access to an ICU bed, and 26.8% (n = 73,095,752) had below average access, within a 60-minute drive time. Racial and ethnic analysis showed high rates of disparities (no access/below average access): American Indians/Alaskan Native 12.6%/28.5%, Asian 0.7%/23.1%, Black or African American 0.6%/16.5%, Hispanic or Latino 1.4%/23.0%, Native Hawaiian and other Pacific Islander 5.2%/35.0%, and White 2.1%/29.0%. A higher percentage of rural block groups had no (5.2%) or below average access (41.2%), compared to urban block groups (0.2% no access, 26.8% below average access).

CONCLUSION

ICU bed availability varied substantially by geography, race and ethnicity, and by urbanicity, creating significant disparities in critical care access. The variability in ICU bed access may indicate inequalities in healthcare access overall by limiting resources for the management of critically ill patients.

Descriptive Comparison of Two Models of Tele-Critical Care Delivery in a Large Multi-Hospital Health Care System

Introduction: The Society of Critical Care Medicine Tele-Critical Care (TCC) Committee has identified the need for rigorous comparative research of different TCC delivery models to support the development of best practices for staffing, application, and approaches to workflow. Our objective was to describe and compare outcomes between two TCC delivery models, TCC with 24/7 Bedside Intensivist (BI) compared with TCC with Private Daytime Attending Intensivist (PI) in relation to intensive care unit (ICU) and hospital mortality, ICU and hospital length of stay (LOS), cost, and complications across the spectrum of routine ICU standards of care. Methods: Observational cohort study at large health care system in 12 ICUs and included patients, ≥18, with Acute Physiology and Chronic Health Evaluation (APACHE) IVa scores and predictions (October 2016-June 2019). Results: Of the 19,519 ICU patients, 71.7% (n = 13,993) received TCC with 24/7 BI while 28.3% (n = 5,526) received TCC with PI. ICU and Hospital mortality (4.8% vs. 3.1%, p < 0.0001; 12.6% vs. 8.1%, p < 0.001); and ICU and Hospital LOS (3.2 vs. 2.4 days, p < 0.001; 9.8 vs. 7.2 days, p < 0.001) were significantly higher among 24/7 BI compared with PI. The APACHE observed/expected ratios (odds ratio [OR]; 95% confidence interval [CI]) for ICU mortality (0.62; 0.58-0.67) vs. (0.53; 0.46-0.61) and Hospital mortality (0.95; 0.57-1.48) vs. (0.77; 0.70-0.84) were significantly different for 24/7 BI compared with PI. Multivariate mixed models that adjusted for confounders demonstrated significantly greater odds of (OR; 95% CI) ICU mortality (1.58; 1.28-1.93), Hospital mortality (1.52; 1.33-1.73), complications (1.55; 1.18-2.04), ICU LOS [3.14 vs. 2.59 (1.25; 1.19-1.51)], and Hospital LOS [9.05 vs. 7.31 (1.23; 1.21-1.25)] among 24/7 BI when compared with PI. Sensitivity analyses adjusting for ICU admission within 24 h of hospital admission, receiving active ICU treatments, nighttime admission, sepsis, and highest third acute physiology score indicated significantly higher odds for 24/7 BI compared with PI. Conclusion: Our comparison demonstrated that TCC delivery model with PI provided high-quality care with significant positive effects on outcomes. This suggests that TCC delivery models have broad-ranging applicability and benefits in routine critical care, thus necessitating progressive research in this direction.

An Elderly Case of Altered Metabolic Profile Presenting With Respiratory Distress: A Radical Display

Acute respiratory distress syndrome (ARDS) is a pulmonary pathology that itself can harm and further lead to many other significant hazardous sequelae. Pulmonary vasculature can be distressed by several diseases, but among all the causes, sepsis is one of the main culprits. Its consequences include significant alveolar injury, refractory hypoxemia, ventilation-perfusion mismatch, and destruction of the alveolar-capillary membrane. Dyspnea with diffuse infiltration on a chest X-ray is the most prevalent clinical symptom. Here, we discuss a case of a 62-year-old male patient who presents with ARDS and metabolic anomalies. The patient was treated medically with drug regimens.

Organisation, staffing and resources of critical care units in Kenya

OBJECTIVE

To describe the organisation, staffing patterns and resources available in critical care units in Kenya. The secondary objective was to explore variations between units in the public and private sectors.

MATERIALS AND METHODS

An online cross-sectional survey was used to collect data on organisational characteristics (model of care, type of unit, quality- related activities, use of electronic medical records and participation in the national ICU registry), staffing and available resources for monitoring, ventilation and general critical care.

RESULTS

The survey included 60 of 75 identified units (80% response rate), with 43% (n = 23) located in government facilities. A total of 598 critical care beds were reported with a median of 6 beds (interquartile range [IQR] 5-11) per unit, with 26% beds (n = 157) being non functional. The proportion of ICU beds to total hospital beds was 3.8% (IQR 1.9-10.4). Most of the units (80%, n = 48) were mixed/general units with an open model of care (60%, n = 36). Consultants-in-charge were mainly anesthesiologists (69%, n = 37). The nurse-to-bed ratio was predominantly 1:2 with half of the nurses formally trained in critical care. Most units (83%, n = 47) had a dedicated ventilator for each bed, however 63% (n = 39) lacked high flow nasal therapy. While basic multiparametric monitoring was ubiquitous, invasive blood pressure measurement capacity was low (3% of beds, IQR 0-81%), and capnography moderate (31% of beds, IQR 0-77%). Blood gas analysers were widely available (93%, n = 56), with 80% reported as functional. Differences between the public and private sector were narrow.

CONCLUSION

This study shows an established critical care network in Kenya, in terms of staffing density, availability of basic monitoring and ventilation resources. The public and private sector are equally represented albeit with modest differences. Potential areas for improvement include training, use of invasive blood pressure and functionality of blood gas analysers.

CHARACTERISTICS AND PREDICTORS OF PATIENTS WITH SEPSIS WHO ARE CANDIDATES FOR MINIMALLY INVASIVE APPROACH OUTSIDE OF INTENSIVE CARE UNIT

Objective: To identify and describe characteristics of patients with sepsis who could be treated with minimally invasive sepsis (MIS) approach without intensive care unit (ICU) admission and to develop a prediction model to select candidates for MIS approach. Methods: A secondary analysis of the electronic database of patients with sepsis at Mayo Clinic, Rochester, MN. Candidates for the MIS approach were adults with septic shock and less than 48 hours of ICU stay, who did not require advanced respiratory support and were alive at hospital discharge. Comparison group consisted of septic shock patients with an ICU stay of more than 48 hours without advanced respiratory support at the time of ICU admission. Results: Of 1795 medical ICU admissions, 106 patients (6%) met MIS approach criteria. Predictive variables (age >65 years, oxygen flow >4 L/min, temperature <37°C, creatinine >1.6 mg/dL, lactate >3 mmol/L, white blood cells >15 × 10 9 /L, heart rate >100 beats/min, and respiration rate >25 breaths/min) selected through logistic regression were translated into an 8-point score. Model discrimination yielded the area under the receiver operating characteristic curve of 79% and was well fitted (Hosmer-Lemeshow P = 0.94) and calibrated. The MIS score cutoff of 3 resulted in a model odds ratio of 0.15 (95% confidence interval, 0.08-0.28) and a negative predictive value of 91% (95% confidence interval, 88.69-92.92). Conclusions: This study identifies a subset of low-risk septic shock patients who can potentially be managed outside the ICU. Once validated in an independent, prospective sample our prediction model can be used to identify candidates for MIS approach.

Evaluation of Digital Health Strategy to Support Clinician-Led Critically Ill Patient Population Management: A Randomized Crossover Study

To investigate whether a novel acute care multipatient viewer (AMP), created with an understanding of clinician information and process requirements, could reduce time to clinical decision-making among clinicians caring for populations of acutely ill patients compared with a widely used commercial electronic medical record (EMR).

DESIGN

Single center randomized crossover study.

SETTING

Quaternary care academic hospital.

SUBJECTS

Attending and in-training critical care physicians, and advanced practice providers.

INTERVENTIONS

AMP.

MEASUREMENTS AND MAIN RESULTS

We compared ICU clinician performance in structured clinical task completion using two electronic environments-the standard commercial EMR (Epic) versus the novel AMP in addition to Epic. Twenty subjects (10 pairs of clinicians) participated in the study. During the study session, each participant completed the tasks on two ICUs (7-10 beds each) and eight individual patients. The adjusted time for assessment of the entire ICU and the adjusted total time to task completion were significantly lower using AMP versus standard commercial EMR (-6.11; 95% CI, -7.91 to -4.30 min and -5.38; 95% CI, -7.56 to -3.20 min, respectively; p < 0.001). The adjusted time for assessment of individual patients was similar using both the EMR and AMP (0.73; 95% CI, -0.09 to 1.54 min; p = 0.078). AMP was associated with a significantly lower adjusted task load (National Aeronautics and Space Administration-Task Load Index) among clinicians performing the task versus the standard EMR (22.6; 95% CI, -32.7 to -12.4 points; p < 0.001). There was no statistically significant difference in adjusted total errors when comparing the two environments (0.68; 95% CI, 0.36-1.30; p = 0.078).

CONCLUSIONS

When compared with the standard EMR, AMP significantly reduced time to assessment of an entire ICU, total time to clinical task completion, and clinician task load. Additional research is needed to assess the clinicians' performance while using AMP in the live ICU setting.

U.S. Adult Critical Care Beds Per Capita: A 2021 County-Level Cross-Sectional Study

Per capita geographic distribution of adult critical care beds can be utilized for healthcare resources assessments.

OBJECTIVES

Describe the per capita distribution of staffed adult critical care beds across the United States.

DESIGN SETTING AND PARTICIPANTS

Cross-sectional epidemiologic assessment of November 2021 hospital data from the Department of Health and Human Services' Protect Public Data Hub.

MAIN OUTCOMES AND MEASURES

Staffed adult critical care beds per adult population.

RESULTS

The percent of hospitals reporting was high and varied by state/territory (median, 98.6% of states' hospitals reporting; interquartile range [IQR], 97.8-100%). There was a total of 4,846 adult hospitals accounting for 79,876 adult critical care beds in the United States and its territories. Crudely aggregated at the national-level, this calculated to 0.31 adult critical care beds per 1,000 adults. The median crude per capita density of adult critical care beds per 1,000 adults across U.S. counties was 0.00 per 1,000 adults (county, IQR 0.00-0.25; range, 0.00-8.65). Spatially smoothed county-level estimates were obtained using Empirical Bayes and Spatial Empirical Bayes approaches, resulting in an estimated 0.18 adult critical care beds per 1,000 adults (range from both methodological estimates, 0.00-8.20). When compared to counties in the lower quartile of adult critical care bed density, counties in the upper quartile had higher average adult population counts (mean 159,000 vs 32,000 adults per county) and a choropleth map demonstrated high densities of beds in urban centers with low density across rural areas.

CONCLUSIONS AND RELEVANCE

Among U.S. counties, the density of critical care beds per capita was not uniformly distributed, with high densities concentrated in highly populated urban centers and relative scarcity in rural areas. As it is unknown what defines deficiency and surplus in terms of outcomes and costs, this descriptive report serves as an additional methodological benchmark for hypothesis-driven research in this area.

Nationwide Clinical Practice Patterns of Anesthesiology Critical Care Physicians: A Survey to Members of the Society of Critical Care Anesthesiologists

BACKGROUND

Despite the growing contributions of critical care anesthesiologists to clinical practice, research, and administrative leadership of intensive care units (ICUs), relatively little is known about the subspecialty-specific clinical practice environment. An understanding of contemporary clinical practice is essential to recognize the opportunities and challenges facing critical care anesthesia, optimize staffing patterns, assess sustainability and satisfaction, and strategically plan for future activity, scope, and training. This study surveyed intensivists who are members of the Society of Critical Care Anesthesiologists (SOCCA) to evaluate practice patterns of critical care anesthesiologists, including compensation, types of ICUs covered, models of overnight ICU coverage, and relationships between these factors. We hypothesized that variability in compensation and practice patterns would be observed between individuals.

METHODS

Board-certified critical care anesthesiologists practicing in the United States were identified using the SOCCA membership distribution list and invited to take a voluntary online survey between May and June 2021. Multiple-choice questions with both single- and multiple-select options were used for answers with categorical data, and adaptive questioning was used to clarify stem-based responses. Respondents were asked to describe practice patterns at their respective institutions and provide information about their demographics, salaries, effort in ICUs, as well as other activities.

RESULTS

A total of 490 participants were invited to take this survey, and 157 (response rate 32%) surveys were completed and analyzed. The majority of respondents were White (73%), male (69%), and younger than 50 years of age (82%). The cardiothoracic/cardiovascular ICU was the most common practice setting, with 69.5% of respondents reporting time working in this unit. Significant variability was observed in ICU practice patterns. Respondents reported spending an equal proportion of their time in clinical practice in the operating rooms and ICUs (median, 40%; interquartile range [IQR], 20%-50%), whereas a smaller proportion-primarily those who completed their training before 2009-reported administrative or research activities. Female respondents reported salaries that were $36,739 less than male respondents; however, this difference was not statistically different, and after adjusting for age and practice type, these differences were less pronounced (-$27,479.79; 95% confidence interval [CI], -$57,232.61 to $2273.03; P = .07).

CONCLUSIONS

These survey data provide a current snapshot of anesthesiology critical care clinical practice patterns in the United States. Our findings may inform decision-making around the initiation and expansion of critical care services and optimal staffing patterns, as well as provide a basis for further work that focuses on intensivist satisfaction and burnout.

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Simulation-based Mastery Learning Improves Critical Care Skills of Advanced Practice Providers

Background

Advanced practice providers (APPs) are essential members of intensive care unit (ICU) interprofessional teams and are expected to be competent in performing procedures. There are no published criteria for establishing when APPs can independently perform procedures. Simulation-based mastery learning (SBML) is an effective strategy for improving critical care skills but has not been applied to practicing ICU APPs.

Objective

The purpose of this study was to evaluate if an SBML curriculum could improve the critical care skills and procedural self-confidence of ICU APPs.

Methods

We performed a pretest-posttest study of central venous catheter (CVC) insertion, thoracentesis, and mechanical ventilation (MV) management skills among ICU APPs who participated in an SBML course at an academic hospital. For each skill, APPs underwent baseline skills assessments (pretests) on a simulator using previously published checklists, followed by didactic sessions and deliberate practice with individualized feedback. Within 2 weeks, participants were required to meet or exceed previously established minimum passing standards (MPS) on simulated skills assessments (posttests) using the same checklists. Further deliberate practice was provided for those unable to meet the MPS until they retested and met this standard. We compared pretest to posttest skills checklist scores and procedural confidence.

Results

All 12 eligible ICU APPs participated in internal jugular CVC, subclavian CVC, and MV training. Five APPs participated in thoracentesis training. At baseline, no APPs met the MPS on all skills. At training completion, all APPs achieved the mastery standard. Internal jugular CVC pretest performance improved from a mean of 67.2% (standard deviation [SD], 28.8%) items correct to 97.1% (SD, 3.8%) at posttest (P = 0.005). Subclavian CVC pretest performance improved from 29.2% (SD, 32.7%) items correct to 93.1% (SD 3.9%) at posttest (P < 0.001). Thoracentesis pretest skill improved from 63.9% (SD, 30.6%) items correct to 99.2% (SD, 1.7%) at posttest (P = 0.054). Pretest MV skills improved from 54.8% (SD, 19.7%) items correct to 92.3% (SD, 5.0%) at posttest (P < 0.001). APP procedural confidence improved for each skill from pre to posttest.

Conclusion

SBML is effective for training APPs to perform ICU skills. Relying on traditional educational methods does not reliably ensure that APPs are adequately prepared to perform skills such as CVC insertion, thoracentesis, and MV management.

Graduates of a Multidisciplinary Critical Care Training Program from 2000 to 2020: Looking at Their First Job

Background

Little is known regarding the career paths of adult multidisciplinary critical care medicine (CCM) fellowship graduates.

Objective

The purpose of this study is to describe the demographic profiles and characteristics of the first jobs held by internal medicine-CCM fellowship graduates trained at a freestanding cancer center.

Methods

An electronic survey was developed via Research Electronic Data Capture that addressed first employment parameters and was sent between May 1, 2019, and December 31, 2021, to 133 CCM fellows who completed CCM fellowship training from 2000 to 2020 at our institution.

Results

A total of 93 fellows (70%) responded to the postfellowship job survey; 80 (60%) with complete responses were analyzed. Seventy-four percent of respondents were men, 41% were White, 81% were international medical graduates, and 31% were holders of J-1 exchange visitor (n = 8) or H-1B (n = 17) visas. The mean age at completion of CCM fellowship was 36 years. Twenty-seven respondents (34%) completed two years of fellowship training and 53 (66%) completed one year. Internal medicine was the primary residency training before CCM fellowship for 75 respondents (94%) and emergency medicine for 5 (6%). Of those who did one year of fellowship (n = 53), 45 (85%) had already completed two-year fellowships in pulmonary medicine. Thirty-two respondents (40%) completed training from 2000 to 2009 and 48 (60%) from 2010 to 2020. The first employment for the majority (>80%) of graduates was in community teaching hospitals. Of the graduates who spent ⩾50% of time clinically in CCM, 85% rounded in multiple intensive care units (ICU). Compensation sources were from hospitals for 81%, private billing for 15%, and through faculty practice plans for 4% of respondents. At the time of survey completion, 51 respondents (64%) were still at their first jobs; of these, slightly more than half (56%) had graduated from the fellowship program in the past 10 years.

Conclusion

The majority of CCM fellowship graduates from our program practiced CCM at community teaching hospitals, rounded in multiple ICUs, and were compensated primarily by the hospital.

100 Years of Critical Care in the Pages of Anesthesia & Analgesia

The founding of Anesthesia & Analgesia (A&A) in 1922 was roughly contemporaneous with the creation of the first intensive care unit (ICU) in the United States at Johns Hopkins in 1923. Throughout the next 100 years, the pages of A&A have mirrored the development of critical care as its own distinct specialty. Although primarily a journal focused on intraoperative anesthesia, A&A has maintained a small but steady presence in critical care research. This review highlights the history and development of critical care publications in the pages of A&A from early observations on the physiology of critical illness (1922-1949) to the groundbreaking work of Peter Safar and others on cardiopulmonary resuscitation (1950-1970), the growth of modern critical care (1970-2010), and the 2020 to 2022 coronavirus disease 2019 (COVID-19) era.

A Cost-Utility Analysis of Remote Pulse-Oximetry Monitoring of Patients With COVID-19

OBJECTIVES

Since 2020, COVID-19 has infected tens of millions and caused hundreds of thousands of fatalities in the United States. Infection waves lead to increased emergency department utilization and critical care admission for patients with respiratory distress. Although many individuals develop symptoms necessitating a ventilator, some patients with COVID-19 can remain at home to mitigate hospital overcrowding. Remote pulse-oximetry (pulse-ox) monitoring of moderately ill patients with COVID-19 can be used to monitor symptom escalation and trigger hospital visits, as needed.

METHODS

We analyzed the cost-utility of remote pulse-ox monitoring using a Markov model with a 3-week time horizon and daily cycles from a US health sector perspective. Costs (US dollar 2020) and outcomes were derived from the University Hospitals' real-world evidence and published literature. Costs and quality-adjusted life-years (QALYs) were used to determine the incremental cost-effectiveness ratio at a cost-effectiveness threshold of $100 000 per QALY. We assessed model uncertainty using univariate and probabilistic sensitivity analyses.

RESULTS

Model results demonstrated that remote monitoring dominates current standard care, by reducing costs ($11 472 saved) and improving outcomes (0.013 QALYs gained). There were 87% fewer hospitalizations and 77% fewer deaths among patients with access to remote pulse-ox monitoring. The incremental cost-effectiveness ratio was not sensitive to uncertainty ranges in the model.

CONCLUSIONS

Patient with COVID-19 remote pulse-ox monitoring increases the specificity of those requiring follow-up care for escalating symptoms. We recommend remote monitoring adoption across health systems to economically manage COVID-19 volume surges, maintain patients' comfort, reduce community infection spread, and carefully monitor needs of multiple individuals from one location by trained experts.

Outcomes Associated with ICU Telemedicine and Other Risk Factors in a Multi-Hospital Critical Care System: A Retrospective, Cohort Study for 30-Day In-Hospital Mortality

Introduction: Intensive care unit telemedicine (ICU-TM) is expanding due to increasing demands for critical care, but impact on outcomes remains controversial. This study evaluated the association of ICU-TM and other clinical factors with 30-day, in-hospital mortality. Methods: This retrospective, cohort study included 151,780 consecutive ICU patients admitted to nine hospitals in the Cleveland Clinic Health System from 2010 to 2020. Patients were identified from an institutional datamart and Acute Physiology and Chronic Health Evaluation IV (APACHE IV) registry. Primary outcome was 30-day in-hospital mortality. Analyses included multivariate logistic regression modeling, and survival analysis. Results: Overall, unadjusted 30-day, in-hospital mortality incidence was significantly different with (5.6%) or without ICU-TM (7.2%), and risk ratio was 0.78 (95% confidence interval [CI] 0.75-0.81) (p < 0.0001). Mortality rate for ICU-TM and no ICU-TM was 2.4/1,000 versus 3.2/1,000 patient days, respectively (p < 0.0001). Multivariate logistic regression showed that ICU-TM was associated with reduced 30-day mortality (odds ratio 0.78, 95% CI 0.72-0.83). Increased risk was seen with cardiac arrest admissions, males, acute stroke, weekend admission, emergency admission, race (non-white), sepsis, APACHE IV score, ICU length of stay (LOS), and the interaction term, emergency surgical admissions. Reduced risk was associated with hospital LOS, surgical admission, and the interaction terms (weekend admissions with ICU-TM and after-hour admissions with ICU-TM). The model c-statistic was 0.77. Median ICU and hospital lengths of stay were significantly reduced with ICU-TM, with no difference in 48-h mortality or 48-h mortality rate. Conclusion: ICU telemedicine exposure appears to be one of several operational and clinical factors associated with reduced 30-day, in-hospital mortality.

What Is Preparedness and Capacity of Intensive Care Service in Indonesia to Response to COVID-19? A Mixed-method Study

BACKGROUND: Pandemics can increase disease spread, as well as unpredictable and highly in patient demand, which can have a negative impact on hospital capacity and the overall functioning of the health-care system. The preparedness and capacity of intensive care services to respond to COVID-19 in Indonesia are remain unknown. AIM: This study aimed to investigate the preparedness and capacity of intensive care services in Indonesia to respond to the initial stage of the COVID-19 pandemic. METHODS: A mixed-method research design was used in this study using in-depth interviews and an online survey. An in-depth interview was conducted with the medical team (intensive care consultant and an anesthesiologist) who is actively involved in the provision of COVID-19 services in 15 national referral hospitals. The online survey was conducted to all medical teams that provide direct care to the COVID-19 patients. A total of 459 (response rate was 95.2%) agreed to join the survey. The content analysis technique was used to analyze qualitative data and a descriptive analysis was used to describe issues encountered in providing health services to COVID-19 patients. RESULTS: The analysis preparedness and capacity of intensive care service in Indonesia to respond to the initial stage of the COVID-19 pandemic resulting in 4 themes with 12 sub-themes. The four themes were limited quality and quantity of standardized intensive care unit (ICU) isolation room (inadequate zoning systems, adequacy of the standardized ICU isolation room, the readiness of the hospital infrastructure, and telemedicine facilities are not yet widely used, including in the COVID-19 isolation room), limited medical service support (lack of personal protective equipment (personal protective equipment [PPE], re-used PPE, lack of availability of medical devices), limitations in the medical team’s quality and quantity management (lack of number and distribution of expert doctors and medical team screening for ICU), and command systems (task shifting, effective communication, and leadership). CONCLUSION: Medical team encounters several difficulties, particularly related to the quality of facilities, staff preparedness, and systems for the provision of services to COVID-19 patients with critical conditions. There is a critical need for well-defined pathways, legal protection, and occupational health for medical teams providing services in the aftermath of a pandemic.

Prognosis and Risk Factors of Sepsis Patients in Chinese ICUs: A Retrospective Analysis of a Cohort Database

BACKGROUND

Sepsis-3 proposed a new definition of septic shock that excluded patients without hyperlactacidemia. The data from China might help to elucidate the prognosis of this special patient group.

OBJECTIVE

To study the clinical prognosis and factors affecting patients with sepsis based on data from Chinese intensive care units (ICUs).

METHODS

We conducted a retrospective, multicentre observational study in a larger Chinese cohort from January 1, 2014 to August 31, 2015. The patients were divided into four groups according to the presence or absence of hypotension/vasopressor delivery and hyperlactacidemia after fluid resuscitation. Descriptive statistics for the clinical characteristics were presented. The differences between groups were assessed. A survival curve was then plotted using the Kaplan-Meier method. Finally, to better understand the risk factors for the 28-day hospital mortality rates, Cox regression analysis was performed.

RESULTS

In total, 1,194 patients with sepsis were included: 282 with hypotension and hyperlactacidemia, 250 with hypotension but without hyperlactacidemia, 161 with hyperlactacidemia but without hypotension, and 501 without hypotension and hyperlactacidemia. The 28-day mortality rates of the four groups were 48.2%, 43.2%, 26.1%, and 24.8%, respectively. Age, the Acute Physiology And Chronic Health Evaluation (APACHE) II score, hyperlactacidemia, hypotension, intra-abdominal infection, and cancer increased the risk of the 28-day mortality, while soft tissue infection and coming from the operating room were associated with a decreased risk of mortality.

CONCLUSIONS

Patients with hypotension but without hyperlactacidemia in the ICU also show a high 28-day mortality, and some clinical factors may affect their prognosis and must be treated carefully in the future.

The Mount Sinai Hospital Institute for critical care medicine response to the COVID-19 pandemic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of critically ill patients. This was especially true in New York City. We present a roadmap for hospitals and healthcare systems to prepare for a Pandemic.

METHODS

This was a retrospective review of how Mount Sinai Hospital (MSH) was able to rapidly prepare to handle the pandemic. MSH, the largest academic hospital within the Mount Sinai Health System, rapidly expanded the intensive care unit (ICU) bed capacity, including creating new ICU beds, expanded the workforce, and created guidelines.

RESULTS

MSH a 1,139-bed quaternary care academic referral hospital with 104 ICU beds expanded to 1,453 beds (27.5% increase) with 235 ICU beds (126% increase) during the pandemic peak in the first week of April 2020. From March to June 2020, with follow-up through October 2020, MSH admitted 2,591 COVID-19-positive patients, 614 to ICUs. Most admitted patients received noninvasive support including a non-rebreather mask, high flow nasal cannula, and noninvasive positive pressure ventilation. Among ICU patients, 68.4% (n=420) received mechanical ventilation; among the admitted ICU patients, 42.8% (n=263) died, and 47.8% (n=294) were discharged alive.

CONCLUSIONS

Flexible bed management initiatives; teamwork across multiple disciplines; and development and implementation of guidelines were critical accommodating the surge of critically ill patients. Non-ICU services and staff were deployed to augment the critical care work force and open new critical care units. This approach to rapidly expand bed availability and staffing across the system helped provide the best care for the patients and saved lives.

The organizational and environmental characteristics associated with hospitals' use of intensivists

BACKGROUND

As large numbers of coronavirus disease 2019 (COVID-19) patients were admitted to intensive care units (ICUs) in 2020 and 2021, the United States faced a shortage of critical care providers. Intensivists are physicians specializing in providing care in the ICU. Although studies have explored the clinical and financial benefits associated with the use of intensivists, little is known about the organizational and market factors associated with a hospital administrator's strategic decision to use intensivists.

PURPOSE

The aim of this study was to use the resource dependence theory to better understand the organizational and market factors associated with a hospital administrator's decision to use intensivists.

METHODOLOGY

The sample consisted of the national acute care hospitals (N = 4,986) for the period 2007-2017. The dependent variable was the number of full-time equivalent intensivists staffed in hospitals. The independent variables were organizational and market-level factors. A negative binomial regression model with state and year fixed effects, clustered at the hospital level, was used to examine the relationship between the use of intensivists and organizational and market factors.

RESULTS

The results from the analyses show that administrators of larger, not-for-profit hospitals that operate in competitive urban markets with relatively high levels of munificence are more likely to utilize intensivists.

PRACTICE IMPLICATIONS

When significant strains are placed on ICUs like what was experienced during the COVID-19 pandemic, it is imperative that hospital administrators understand how to best staff their ICUs. With a better understanding of the organizational and market factors associated with the use of intensivists, practitioners and policymakers alike can better understand how to strategically utilize intensivists in the ICU, especially in the face of a continuing pandemic.

Management of ARDS - What Works and What Does Not

Acute respiratory distress syndrome (ARDS) is a clinically and biologically heterogeneous disorder associated with a variety of disease processes that lead to acute lung injury with increased non-hydrostatic extravascular lung water, reduced compliance, and severe hypoxemia. Despite significant advances, mortality associated with this syndrome remains high. Mechanical ventilation remains the most important aspect of managing patients with ARDS. An in-depth knowledge of lung protective ventilation, optimal PEEP strategies, modes of ventilation and recruitment maneuvers are essential for ventilatory management of ARDS. Although, the management of ARDS is constantly evolving as new studies are published and guidelines being updated; we present a detailed review of the literature including the most up-to-date studies and guidelines in the management of ARDS. We believe this review is particularly helpful in the current times where more than half of the acute care hospitals lack in-house intensivists and the burden of ARDS is at large.

Variation in Initial U.S. Hospital Responses to the Coronavirus Disease 2019 Pandemic

OBJECTIVES

The coronavirus disease 2019 pandemic has strained many healthcare systems. In response, U.S. hospitals altered their care delivery systems, but there are few data regarding specific structural changes. Understanding these changes is important to guide interpretation of outcomes and inform pandemic preparedness. We sought to characterize emergency responses across hospitals in the United States over time and in the context of local case rates early in the coronavirus disease 2019 pandemic.

DESIGN

We surveyed hospitals from a national acute care trials group regarding operational and structural changes made in response to the coronavirus disease 2019 pandemic from January to August 2020. We collected prepandemic characteristics and changes to hospital system, space, staffing, and equipment during the pandemic. We compared the timing of these changes with county-level coronavirus disease 2019 case rates.

SETTING AND PARTICIPANTS

U.S. hospitals participating in the Prevention and Early Treatment of Acute Lung Injury Network Coronavirus Disease 2019 Observational study. Site investigators at each hospital collected local data.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty-five sites participated (94% response rate). System-level changes (incident command activation and elective procedure cancellation) occurred at nearly all sites, preceding rises in local case rates. The peak inpatient census during the pandemic was greater than the prior hospital bed capacity in 57% of sites with notable regional variation. Nearly half (49%) expanded ward capacity, and 63% expanded ICU capacity, with nearly all bed expansion achieved through repurposing of clinical spaces. Two-thirds of sites adapted staffing to care for patients with coronavirus disease 2019, with 48% implementing tiered staffing models, 49% adding temporary physicians, nurses, or respiratory therapists, and 30% changing the ratios of physicians or nurses to patients.

CONCLUSIONS

The coronavirus disease 2019 pandemic prompted widespread system-level changes, but front-line clinical care varied widely according to specific hospital needs and infrastructure. Linking operational changes to care delivery processes is a necessary step to understand the impact of the coronavirus disease 2019 pandemic on patient outcomes.

An International Virtual COVID-19 Critical Care Training Forum for Healthcare Workers

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic resulted in redeployment of non-critical care-trained providers to intensive care units across the world. Concurrently, traditional venues for delivery of medical education faced major disruptions. The need for a virtual forum to fill knowledge gaps for healthcare workers caring for patients with coronavirus disease (COVID-19) was apparent in the early stages of the pandemic. Objective: The weekly, open-access COVID-19 Critical Care Training Forum (CCCTF) organized by the American Thoracic Society (ATS) provided a global audience access to timely content relevant to their learning needs. The goals of the forum were threefold: to aid healthcare providers in assessment and treatment of patients with COVID-19, to reduce provider anxiety, and to disseminate best practices. Methods: The first 13 ATS CCCTF sessions streamed live from April to July 2020. Structured debriefs followed each session and participant feedback was evaluated in planning of subsequent sessions. A second set of 14 sessions streamed from August to November 2020. Content experts were recruited from academic institutions across the United States. Results: As of July 2020, the ATS CCCTF had 2,494 live participants and 7,687 downloads for a total of 10,181 views. The majority of participants had both completed training (58.6%) and trained in critical care (53.8%). Physicians made up a majority (82.2%) of the audience that spanned the globe (61% were international attendees). Conclusion: We describe the rapid and successful implementation of an open-access medical education forum to address training and knowledge gaps among healthcare personnel caring for patients with COVID-19.

Beyond the Nuts and Bolts: Tele-Critical Care Patients, Workflows, and Activity Patterns

Background: Tele-critical care (TCC) adoption has been slow since its emergence in the early 2000s. The COVID-19 pandemic has renewed interest in telemedicine and may spur expansion or development of new TCC programs. This narrative addresses the Cleveland Clinic TCC service, (eHospital) to promote exchange of ideas to continually optimize the practice for current and future users. Methods: A descriptive narrative methodology is used in this report. Results: Cleveland Clinic's eHospital was established in 2014 to support nighttime critical care across system hospitals. It encompasses a tiered system of two-way audiovisual communication, telemetry, software platform that integrates the electronic health record, and a proprietary risk stratification algorithm for targeted electronic surveillance. The TCC team includes intensivists, advanced care providers, and registered nurses. Three coverage models evolved depending on onsite clinician availability. More than 133,000 patients have been served by eHospital to date, and span the typical spectrum of critical illness. Along with universal monitoring, ∼18% of patients received active interventions, the most common of which are categorized. Patterns of activity, typical workflows, and adaptations of bedside best practices are also described. Bookending the work shift are sign outs focused on pending critical issues, unstable patients, and those who can be triaged out of the intensive care unit. In between, TCC teams round periodically and interact with bedside teams. Conclusions: TCC adoption has proceeded slowly. Some acceleration is anticipated in a post-COVID-19 pandemic world. Our experience highlights operational practices that can facilitate successful TCC practice.

Adequacy of workforce - are there enough critical care doctors in the US-post COVID?

PURPOSE OF REVIEW

The ICU is a complex ecosystem in which intensive care physicians, advanced practice providers (APPs), pharmacists, and respiratory therapists work in concert to take care of critically ill patients. The SARS COV2 pandemic highlighted weaknesses in the American healthcare system. This article explores the ability of American healthcare to adapt to this challenge.

RECENT FINDINGS

With the COVID-19 pandemic, intensivists, and ventilators have been identified as the most critical components leading to shortages in ICU capacity. Anesthesiologists play a unique role in being able to provide 'flex capacity' with critical care staffing, space, and equipment (post-anesthesia care units, operating rooms, and ventilators). With the advent of APPs, intensive care physician staffing ratios may potentially be increased to cover patients safely in a physician-led team model. Tele-medicine expands this further and can allow hospital coordination for optimizing ICU bed use.

SUMMARY

Although intensivists have been able to take care of the increased ICU caseload during the COVID-19 pandemic through recruiting other specialties, the question of what is the appropriate staffing model for the future is yet to be elucidated. Creating stronger multidisciplinary care teams that have the capacity to flex up critical care capacity may be the most prudent longer-term solution.

Critical Care Medicine Practice: A Pilot Survey of US Anesthesia Critical Care Medicine-Trained Physicians

BACKGROUND

This survey assessed satisfaction with the practice environment among physicians who have completed fellowship training in critical care medicine (CCM) as recognized by the American Board of Anesthesiology (and are members of the American Society of Anesthesiology) and evaluated the perceived effectiveness of training programs in preparing fellows for critical care practice.

METHODS

A cross-sectional online survey composed of 39 multiple choice and open-ended questions was administered between August and December 2018 to all members of the American Society of Anesthesiologists (ASA) who self-identified as being CCM trained. The survey instrument was developed and revised in an iterative fashion by ASA committee on CCM and the Society for Education in Anesthesia (SEA). Survey results were analyzed using a mixed-method approach.

RESULTS

Three hundred fifty-three of the 1400 anesthesiologists who self-identified to the ASA as having CCM training (25.2%) completed the survey. Most were men (72.3%), board certified in CCM (98.7%), and had practiced a median of 5 years. Half of the respondents rated their training as "excellent." A total of 70.6% described currently working in academic centers with 53.6% providing care in open surgical intensive care units (ICUs). Most anesthesiologist intensivists (75%) spend at least 25% of their clinical time providing ICU care (versus clinical anesthesia). A total of 89% of the respondents were involved in educational activities, 60% reported being in administrative leadership roles, and 37% engaged in scholarly activity. Areas of dissatisfaction included fatigue, lack of collegiality or respect, lack of research training, decreased job satisfaction, and burnout. Analysis suggested moderate levels of job satisfaction (49%), work-life balance (52%), and high levels of burnout (74%). A significant contributor to burnout was with a perception of lack of respect (P = .005) in the work environment. Burnout was not significantly associated with gender or duration of practice. Qualitative analysis of the open-ended responses also identified these 3 variables as major themes.

CONCLUSIONS

This survey of CCM-trained anesthesiologists described a high rate of board certification, practice in academic settings, and participation in resident education. Areas of dissatisfaction with an anesthesia/critical care practice included burnout, work/life balance, and lack of respect. These results may increase recruitment of anesthesiologists into critical care and inform strategies to improve satisfaction with anesthesia critical care practice, fellowship training.

Nephrotoxin Stewardship

Drugs are the third leading cause of acute kidney injury (AKI) in critically ill patients. Nephrotoxin stewardship ensures a structured and consistent approach to safe medication use and prevention of patient harm. Comprehensive nephrotoxin stewardship requires coordinated patient care management strategies for safe medication use, ensuring kidney health, and avoiding unnecessary costs to improve the use of nephrotoxins, renally eliminated drugs, and kidney disease treatments. Implementing nephrotoxin stewardship reduces medication errors and adverse drug events, prevents or reduces severity of drug-associated AKI, prevents progression to or worsening of chronic kidney disease, and alleviates financial burden on the health care system.

Characterizing Critical Care Pharmacy Services Across the United States

Supplemental Digital Content is available in the text.

Involvement of clinical pharmacists in the ICU attenuates costs, avoids adverse drug events, and reduces morbidity and mortality. This survey assessed services and activities of ICU pharmacists.

Hospital and ICU patient volume per physician at peak of COVID pandemic: State-level estimates

BACKGROUND

In anticipation of patient surge due to COVID-19, many states are working to increase the available healthcare workforce. To help inform state policies and initiatives aimed at physician deployment during COVID-19, we used predictions of peak patient volume for hospitals and intensive care units (ICU) and regional physician workforce estimates to measure patient to physician ratios at the peak of the pandemic for each state.

METHODS

We estimated the number of potentially available physicians based on Medicare Part B billings for the care of hospitalized and critically ill patients in 2017, adjusted for attrition due to exposure to SARS-CoV-2 and relevant experience. We used estimates from the Institute of Health Metrics and Evaluation to determine the number of hospitalized and ICU patients expected at the peak of the pandemic in each state. We then determined the expected ratio of patients per physician for each state at the peak of the pandemic.

RESULTS

The median number of hospitalized patients per physician was 13 (low estimate) to 18 (high estimate). At the high estimate of hospitalized patients, 35 states would have a patient to physician ratio of more than 15:1 (patient to physician ratios above 15:1 have been associated with poor outcomes). For ICU patients, the median number of patients each physician would treat across states would be 8-11 patients. Nine states would experience patient to physician ratios above 15:1 at the higher end of estimates. Patient-physician ratios decreased if the available physician pool was broadened to include physicians without recent experience treating hospitalized patients, and physicians in surgical specialties with experience treating acutely hospitalized patients.

CONCLUSIONS/IMPLICATIONS

We estimate that most states will have sufficient physician capacity to manage hospitalized patients at the peak of the pandemic. However, at the high estimates of hospitalized patients, some Midwestern states will experience high patient to provider ratios that may adversely affect patient outcomes.

LEVEL OF EVIDENCE

State.

Keeping a 2009 Design Award-Winning Intensive Care Unit Current: A 13-Year Case Study

In a complex medical center environment, the occupants of newly built or renovated spaces expect everything to "function almost perfectly" immediately upon occupancy and for years to come. However, the reality is usually quite different. The need to remediate initial design deficiencies or problems not noted with simulated workflows may occur. In our intensive care unit (ICU), we were very committed to both short-term and long-term enhancements to improve the built and technological environments in order to correct design flaws and modernize the space to extend its operational life way beyond a decade. In this case study, we present all the improvements and their background in our 20-bed, adult medical-surgical ICU. This ICU was the recipient of the Society of Critical Care Medicine's 2009 ICU Design Award Citation. Our discussion addresses redesign and repurposing of ICU and support spaces to accommodate expanding clinical or entirely new programs, new regulations and mandates; upgrading of new technologies and informatics platforms; introducing new design initiatives; and addressing wear and tear and gaps in security and disaster management. These initiatives were all implemented while our ICU remained fully operational. Proposals that could not be implemented are also discussed. We believe this case study describing our experiences and real-life approaches to analyzing and solving challenges in a dynamic environment may offer great value to architects, designers, critical care providers, and hospital administrators whether they are involved in initial ICU design or participate in long-term ICU redesign or modernization.

A national survey of critical care services in hospitals accredited for training in a lower-middle income country: Pakistan

PURPOSE

To describe the extent and variation of critical care services in Pakistan.

MATERIALS AND METHODS

A cross-sectional survey was conducted in all intensive care units (ICUs) recognised for postgraduate training to determine administration, infrastructure, equipment, staffing, and training.

RESULTS

There were 151 hospitals recognised for training, providing 2166 ICU beds and 1473 ventilators. Regional distribution of ICU beds per 100,000 population ranged from 1.0 in Sindh to none in Gilgit Baltistan (median 0.7). A senior clinician trained in critical care was available in 19 (12.1%) of units. One-to-one nurse-to-bed ratio during the day was available in 84 (53.5%) of units, dropping to 75 (47.8%) at night. Availability of 1:1 nursing also varied between provinces, ranging from 56.5% in Punjab compared to 0% in Azad Jamu Kashmir. Similarly, there was disparity in the availability of ventilators between provinces. All ICUs had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (electronic monitoring and infusion pumps).

CONCLUSION

Pakistan, a lower middle-income country, has an established network of critical care facilities with access to basic equipment, but inequalities in its distribution. Investment in critical care training for doctors and nurses is needed.

Caring for Critically Ill Adults With Coronavirus Disease 2019 in a PICU: Recommendations by Dual Trained Intensivists

OBJECTIVE

In the midst of the severe acute respiratory syndrome coronavirus 2 pandemic, which causes coronavirus disease 2019, there is a recognized need to expand critical care services and beds beyond the traditional boundaries. There is considerable concern that widespread infection will result in a surge of critically ill patients that will overwhelm our present adult ICU capacity. In this setting, one proposal to add "surge capacity" has been the use of PICU beds and physicians to care for these critically ill adults.

DESIGN

Narrative review/perspective.

SETTING

Not applicable.

PATIENTS

Not applicable.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The virus's high infectivity and prolonged asymptomatic shedding have resulted in an exponential growth in the number of cases in the United States within the past weeks with many (up to 6%) developing acute respiratory distress syndrome mandating critical care services. Coronavirus disease 2019 critical illness appears to be primarily occurring in adults. Although pediatric intensivists are well versed in the care of acute respiratory distress syndrome from viral pneumonia, the care of differing aged adult populations presents some unique challenges. In this statement, a team of adult and pediatric-trained critical care physicians provides guidance on common "adult" issues that may be encountered in the care of these patients and how they can best be managed in a PICU.

CONCLUSIONS

This concise scientific statement includes references to the most recent and relevant guidelines and clinical trials that shape management decisions. The intention is to assist PICUs and intensivists in rapidly preparing for care of adult coronavirus disease 2019 patients should the need arise.

Just-In-Time Tools for Training Non-Critical Care Providers. Troubleshooting Problems in the Ventilated Patient

Due to the limited number of critical care providers in the United States, even well-staffed hospitals are at risk of exhausting both physical and human resources during the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One potential response to this problem is redeployment of non–critical care providers to increase the supply of available clinicians. To support efforts to increase capacity as part of surge preparation for the coronavirus disease (COVID-19) outbreak, we created an online educational resource for non-intensivist providers to learn basic critical care content. Among those materials, we created a series of one-page learning guides for the management of common problems encountered in the intensive care unit (ICU). These guides were meant to be used as just-in-time tools to guide problem-solving during the provision of ICU care. This article presents five guides related to managing complications that can arise in patients receiving invasive mechanical ventilation.

Just-In-Time Tools for Training Non-Critical Care Providers. Basics of Respiratory Failure

Due to the limited number of critical care providers in the United States, even well-staffed hospitals are at risk of exhausting both physical and human resources during the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One potential response to this problem is redeployment of non-critical care providers to increase the supply of available clinicians. To support efforts to increase capacity as part of surge preparation for the coronavirus disease (COVID-19) outbreak, we created an online educational resource for nonintensivist providers to learn basic critical care content. Among those materials, we created a series of one-page learning guides for the management of common problems encountered in the intensive care unit (ICU). These guides were meant to be used as just-in-time tools to guide problem-solving during the provision of ICU care. This article presents five guides related to the evaluation and management of patients with hypoxemic respiratory failure and the basics of invasive mechanical ventilation.