Look before you leap: how do intensivists improve care for critically ill patients?

Barriers to implementing the Leapfrog Group recommendations for intensivist physician staffing: a survey of intensive care unit directors

PURPOSE

The Leapfrog Group, representing a consortium of health care purchasers, has promoted standards for intensive care unit (ICU) staffing in nonrural areas. The purpose of this study was to examine the perception of the Leapfrog standards among ICU directors and determine the potential barriers to implementing these standards.

MATERIALS AND METHODS

We performed a telephone survey of physician ICU directors using a stratified random sample of hospitals in the Committee on Manpower for Pulmonary Critical Care Societies database.

RESULTS

Seventy-two ICUs in 72 hospitals were surveyed. Forty-seven ICUs responded to telephone inquires. Of these, 21 (45%) could identify an ICU director, 20 of which answered questions about their own hospital's compliance. Only 5 ICU directors (25%) cited current compliance with the Leapfrog standard for intensivist staffing. Of the 15 directors not in compliance, 13 were motivated to adopt the recommendations in the future. Loss of control, loss of income, and increased cost to hospital administration were cited as important barriers to implementing the recommendations. Increased availability of intensivists, increased funds from hospital administrators, and assistance from government and third parties were viewed as important potential solutions to these barriers.

CONCLUSIONS

Numerous barriers exist to implementing the Leapfrog recommendations for intensivist staffing, not the least of which is the lack of an ICU director in many hospitals. Better strategies are needed to overcome these barriers before the widespread adoption of an intensivist care model similar to Leapfrog is feasible.

Management of patients with metastatic malignancy in the intensive care unit

Intensive care units serve to provide temporary physiologic support to patients with reversible organ failure. However, with increasing frequency, patients with end-stage and terminal illnesses are being admitted to the intensive care unit. Indeed, in the United States, a third of all patients with terminal metastatic malignancy are admitted to the intensive care unit, and 60% of all hospital deaths occur after such an admission. In many instances, admission to an intensive care unit serves only to transform death into a prolonged, painful, and undignified process. In patients with a terminal illness, the focus should be on measures that ensure comfort, and admission to an intensive care unit should generally be avoided. Intensivists, who are charged with making the best use of limited resources, should ultimately be the individuals who determine the appropriateness of admitting such patients to the intensive care unit.