Models of critical care delivery: physician staffing in the ICU

Organizational predictors of coordination in inpatient medicine

BACKGROUND

As the care of hospitalized patients becomes more complex, intraprofessional coordination among nurses and among physicians, and interprofessional coordination between these groups are likely to play an increasingly important role in the provision of hospital care.

PURPOSE

The purpose of this study was to identify the independent effects of organizational factors on provider ratings of overall coordination in inpatient medicine (OCIM).

METHODOLOGY/APPROACH

This was an exploratory cross-sectional, descriptive study. Primary data were collected between June 2010 and September 2011 through surveys of inpatient medicine nurse managers, physicians, and chiefs of medicine at 36 Veterans Health Administration medical centers. Secondary data from the 2011 Veterans Health Administration national survey of nurses were also used. Individual-level data were aggregated and analyzed at the facility level. Multivariate linear regression models were used to assess the relationship between 55 organizational factors and provider ratings of OCIM.

FINDINGS

Organizational factors that were common across models and associated with better provider ratings of OCIM included provider perceptions that the goals of senior leadership are aligned with those of the inpatient service and that the facility is committed to the highest quality of patient care, having resources and staff that enable clinicians to do their jobs, and use of strategies that enhance interactions and communication among and between nurses and physicians.

PRACTICE IMPLICATIONS

To improve intraprofessional and interprofessional coordination and, consequently, patient care, facilities should consider making patient care quality a more important strategic organizational priority; ensuring that providers have the staffing, training, supplies, and other resources they need to do their jobs; and implementing strategies that improve interprofessional communication and working relationships, such as multidisciplinary rounding.

The effect of an intensive care unit staffing model on tidal volume in patients with acute lung injury

Introduction

Little is known about the mechanisms through which intensivist physician staffing influences patient outcomes. We aimed to assess the effect of closed-model intensive care on evidence-based ventilatory practice in patients with acute lung injury (ALI).

Methods

We conducted a secondary analysis of a prospective population-based cohort of 759 patients with ALI who were alive and ventilated on day three of ALI, and were cared for in 23 intensive care units (ICUs) in King County, Washington.

Results

We compared day three tidal volume (V_T) in open versus closed ICUs adjusting for potential patient and ICU confounders. In 13 closed model ICUs, 429 (63%) patients were cared for. Adjusted mean V_T (mL/Kg predicted body weight (PBW) or measured body weight if height not recorded) for patients in closed ICUs was 1.40 mL/Kg PBW (95% confidence interval (CI) = 0.57 to 2.24 mL/Kg PBW) lower than patients in open model ICUs. Patients in closed ICUs were more likely (odds ratio (OR) = 2.23, 95% CI = 1.09 to 4.56) to receive lower V_T (≤ 6.5 mL/Kg PBW) and were less likely (OR = 0.30, 95% CI = 0.17 to 0.55) to receive a potentially injurious V_T (≥ 12 mL/Kg PBW) compared with patients cared for in open ICUs, independent of other covariates. The effect of closed ICUs on hospital mortality was not changed after accounting for delivered V_T.

Conclusions

Patients with ALI cared for in closed model ICUs are more likely to receive lower V_T and less likely to receive higher V_T, but there were no other differences in measured processes of care. Moreover, the difference in delivered V_T did not completely account for the improved mortality observed in closed model ICUs.

Possibilities for cost containment in intensive care

An intensive care unit (ICU) is valuable but consumes a disproportionately high amount of health-care resources. Accordingly, cost containment has been deemed a mandatory task. A review of the literature from many countries was completed to determine the strategies for reducing the cost of care in the ICU. The results of this review show that cost reduction can be achieved by using a variety of the following strategies: (i) instituting a closed ICU, where all the patient care is directed by intensivists or full-time critical care trained physicians; (ii) the utilization of interdisciplinary approaches to the care of patients in the ICU; (iii) developing and implementing a program of television-guided remote intensivists; (iv) the use of an alerting and reminding system; and (v) increasing the number of intermediate care beds for patients who require only monitoring and intensive nursing. The conclusion reached is that many of these strategies provide evidence for hospital manager decisions regarding cost containment strategies for the delivery of health care in the ICU.