Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs

Impact of nonphysician staffing on outcomes in a medical ICU

BACKGROUND

As the number of ICU beds and demand for intensivists increase, alternative solutions are needed to provide coverage for critically ill patients. The impact of different staffing models on the outcomes of patients in the medical ICU (MICU) remains unknown. In our study, we compare outcomes of nonphysician provider-based teams to those of medical house staff-based teams in the MICU.

METHODS

We conducted a retrospective review of 590 daytime (7:00 am-7:00 pm) admissions to two MICUs at one hospital. In one MICU staffed by nurse practitioners and physician assistants (MICU-NP/PA) there were nonphysicians (nurse practitioners and physicians assistants) during the day (7:00 am-7:00 pm) with attending physician coverage overnight. In the other MICU, there were medicine residents (MICU-RES) (24 h/d). The outcomes investigated were hospital mortality, length of stay (LOS) (ICU, hospital), and posthospital discharge destination.

RESULTS

Three hundred two patients were admitted to the MICU-NP/PA and 288 to the MICU-RES. Mortality probability model III (MPM(0)-III) predicted mortality was similar (P = .14). There was no significant difference in hospital mortality (32.1% for MICU-NP/PA vs 32.3% for MICU-RES, P = .96), MICU LOS (4.22 ± 2.51 days for MICU-NP/PA vs 4.44 ± 3.10 days for MICU-RES, P = .59), or hospital LOS (14.01 ± 2.92 days for MICU-NP/PA vs 13.74 ± 2.94 days for MICU-RES, P = .86). Discharge to a skilled care facility (vs home) was similar (37.1% for MICU-NP/PA vs 32.5% for MICU-RES, P = .34). After multivariate adjustment, MICU staffing type was not associated with hospital mortality (P = .26), MICU LOS (P = .29), hospital LOS (P = .19), or posthospital discharge destination (P = .90).

CONCLUSIONS

Staffing models including daytime use of nonphysician providers appear to be a safe and effective alternative to the traditional house staff-based team in a high-acuity, adult ICU.

Unsupervised procedures by surgical trainees: a windfall for private insurance at the expense of graduate medical education

BACKGROUND

Surgical faculty cannot always be present while trainees perform minor procedures. Fees are not obtained for these unsupervised services because Medicare rules do not allow residents and fellows to bill. Medicare already supplements hospitals via medical education funds and thus reimbursement for trainee services would constitute double billing. Private insurance companies, however, do not supplement trainees' salaries and thus benefit when they are not charged for these procedures. The objective is to determine whether significant revenue is lost to private insurers for unsupervised procedures performed by surgical trainees.

METHODS

We retrospectively evaluated a prospective database of procedures performed by residents and fellows from March 1998 through 2007. All procedures were entered by the trainees into a computerized electronic note system. Unsupervised procedures were not billed to insurance carriers.

RESULTS

During the study period, 14,497 minor procedures were performed without attending supervision, of which 13,343 had valid current procedural terminology codes. Total charges for these procedures would have been $10,096,931. For patients with private insurance companies (PICs), $6,876,000 could have been billed. Using our historic collection ratios, $2,269,083 in revenue was lost, or $232,726 annually.

CONCLUSIONS

Trainees perform a significant number of unsupervised procedures on patients with private insurance without charge. This pro bono service represents a significant amount of lost income for teaching institutions. Private insurance companies benefit financially from Medicare billing regulations without contributing to education. Billing for these services might help offset the costs of graduate medical education.

Challenging issues in surgical critical care, trauma, and acute care surgery: a report from the Critical Care Committee of the American Association for the Surgery of Trauma

Critical care workforce analyses estimate a 35% shortage of intensivists by 2020 as a result of the aging population and the growing demand for greater utilization of intensivists. Surgical critical care in the U.S. is particularly challenged by a significant shortfall of surgical intensivists, with only 2586 surgeons currently certified in surgical critical care by the American Board of Surgery, and even fewer surgeons (1204) recertified in surgical critical care as of 2009. Surgical critical care fellows (160 in 2009) represent only 7.6% of all critical care trainees (2109 in 2009), with the largest number of critical care fellowship positions in internal medicine (1472, 69.8%). Traditional trauma fellowships have now transitioned into Surgical Critical Care or Acute Care Surgery (trauma, surgical critical care, emergency surgery) fellowships. Since adult critical care services are a large, expensive part of U.S. healthcare and workforce shortages continue to impact our healthcare system, recommendations for regionalization of critical care services in the U.S. is considered. The Critical Care Committee of the AAST has compiled national data regarding these important issues that face us in surgical critical care, trauma and acute care surgery, and discuss potential solutions for these issues.

Fatal gunshot wounds to the head: a critical appraisal of organ donation rates

BACKGROUND

Patients sustaining fatal gunshot wounds to the head are often young, without associated comorbidities, and are potentially ideal transplantation candidates.

METHODS

A 5-year review of a level I trauma center's prospective database was performed for all patients sustaining fatal gunshot wounds to the head. Demographic, physiologic, anatomic, and laboratory variables were collected.

RESULTS

Sixty-eight patients were identified, of whom 10 (14.7%) were organ donors. Of 25 admitted to the intensive care unit who eventually did not become donors, 15 (60%) were due to lack of consent.

CONCLUSIONS

Despite frequent intensive care unit admissions, organ donation is infrequent following fatal gunshot wounds to the head, primarily because of lack of consent. Improved communication with next of kin could improve organ recovery and reduce futile care in this group.

Intensive Care Medicine: Where We Are and Where We Want To Go?

Intensive care medicine can be defined as the science and art of detecting and managing patients with impending or established critical illness, in order to prevent further deterioration and revert the disease process or its consequences, so as to achieve the best possible outcomes.

Training and certification in surgical critical care: a position paper by the Surgical Critical Care Program Directors Society

Delivery of Surgical Critical Care in the United States is facing multiple challenges including increasing complexity of care, escalating costs, shortage of well-trained physicians, and controversies about appropriate training and credentialing methods. In this position paper, the Surgical Critical Care Program Directors Society discusses some of these important issues and suggests a number of possible solutions.

Long-term acute care hospital utilization after critical illness

CONTEXT

Long-term acute care hospitals have emerged as a novel approach for the care of patients recovering from severe acute illness, but the extent and increases in their activity at the national level are unknown.

OBJECTIVE

To examine temporal trends in long-term acute care hospital utilization after an episode of critical illness among fee-for-service Medicare beneficiaries aged 65 years or older.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort study using the Medicare Provider Analysis and Review files from 1997 to 2006. We included all Medicare hospitalizations involving admission to an intensive care unit of an acute care, nonfederal hospital within the continental United States.

MAIN OUTCOME MEASURES

Overall long-term acute care utilization, associated costs, and survival following transfer.

RESULTS

The number of long-term acute care hospitals in the United States increased at a mean rate of 8.8% per year, from 192 in 1997 to 408 in 2006. During that time, the annual number of long-term acute care admissions after critical illness increased from 13,732 to 40,353, with annual costs increasing from $484 million to $1.325 billion. The age-standardized population incidence of long-term acute care utilization after critical illness increased from 38.1 per 100,000 in 1997 to 99.7 per 100,000 in 2006, with greater use among male individuals and black individuals in all periods. Over time, transferred patients had higher numbers of comorbidities (5.0 in 1997-2000 vs 5.8 in 2004-2006, P < .001) and were more likely to receive mechanical ventilation at the long-term acute care hospital (16.4% in 1997-2000 vs 29.8% in 2004-2006, P < .001). One-year mortality after long-term acute care hospital admission was high throughout the study period: 50.7% in 1997-2000 and 52.2% in 2004-2006.

CONCLUSIONS

Long-term acute care hospital utilization after critical illness is common and increasing. Survival among Medicare beneficiaries transferred to long-term acute care after critical illness is poor.

Discharge delay, room for improvement?

AIM

Patients treated in the intensive care unit (ICU) and identified as suitable for discharge to the ward should have their discharge planned and expedited to improve patient outcomes and manage resources efficiently. We examined the hypothesis that the introduction of a critical care outreach role would decrease the frequency of discharge delay from ICU.

METHODS

Discharge delay was compared for two 6-month periods: (1) after introduction of the outreach role in 2008 and (2) in 2000/2001 (from an earlier study). Patients were included if discharged to a ward in the study hospital. Discharge times and reason for delay were collected by Critical Care Outreach Nurses and Critical Care Nurse Specialists.

RESULTS

Of the 516 discharges in 2008 (488 patients compared to 607 in 2000/2001), 31% of the discharges were delayed from ICU more than 8h, an increase of 6% from 2000/2001 (p<0.001). Patients in 2008 spent more in hospital from the time of their ICU admission when their discharge was delayed (p<0.001). The most common reasons for delay in 2008 were due to no bed or delay in bed availability (53%) and medical concern (24%). This is in contrast to 2000/2001 when 80% of delays were due to no bed or delay in bed availability and 9% due to medical concern. Many factors impact on patient flow and reducing ICU discharge delays requires a collaborative, multi-factorial approach which adapts to changing organisational policy on patient flow through ICU and the hospital, not just the discharge process in ICU.

Currents in contemporary ethics. Should health care providers get treatment priority in an influenza pandemic?

The 2009 pandemic of influenza A (H1N1) was relatively mild, but a subsequent outbreak of pandemic influenza could be much worse. According to projections from the Department of Health and Human Services, the potential health consequences of a severe (1918-like) influenza pandemic in the United States could be literally overwhelming: up to 1.9 million deaths; 90 million people sick; 45 million people needing outpatient care; 9.9 million people hospitalized, of whom 1.485 million would need treatment in an intensive care unit (ICU); and 742,500 patients needing mechanical ventilators. Even a less cataclysmic, moderate pandemic (like 1958 or 1968) would result in 209,000 deaths; 90 million people sick; 45 million people needing outpatient care; 865,000 people hospitalized, of whom 128,750 would need treatment in an ICU; and 64,875 patients needing mechanical ventilators.