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The tug-of-war over ICU care

Hospitalists and intensivists stake out their turf

April 2009

Published in the April 2009 issue of Today’s Hospitalist

Five years ago, the pulmonary/critical care group working at St. John Medical Center in Tulsa, Okla., began lobbying hard for a closed ICU, recommending that both the hospitalist group and the community physicians no longer have ICU admitting privileges.

Related article: Survey results: Hospitalists working in the ICU

The specialists claimed the move would make the hospital compliant with highly publicized standards issued by the Leapfrog Group to switch to intensivist-only staffing. But given the cost of recruiting fellowship-trained intensivists, administrators realized that such an approach was unrealistic.

Not surprisingly, St. John turned to its hospitalist group, which was fully staffed, growing rapidly and enthusiastic about the idea of working in the ICU. A small cadre of hospitalists “seven of the group’s 27 physicians “evolved into de facto intensivists in what is described as a “semi-closed” ICU. Those seven hospitalists now work exclusively in the ICU while the rest of the hospitalists have no ICU admitting privileges.

James Rooks, MD, medical director of St. John Hospitalist Physicians, admits that while hospital administrators might have preferred an intensivist-only ICU, “they turned to us as a stop-gap measure that morphed into a permanent arrangement, given its success. The economic pressures on the hospital have been stronger than the political pressures.”

The hospitalists at St. John are hardly alone in their experience. While closed ICUs were all the rage a few years ago, the shortage of intensivists has left hospitals everywhere rethinking that strategy. At smaller hospitals, in fact, the trend to standardize ICU care has opened the door to almost exclusive coverage by hospitalists. And at larger hospitals that have intensivists, critical care physicians and quality improvement experts now use new buzzwords like “comanagement” and “team care,” rather than “closed.”

Intensivist shortage
While some studies have found that intensivist-only ICUs deliver better outcomes, the reality is that intensivists “typically, pulmonary/critical care specialists “direct the care of only one-third of critically ill patients in the U.S., according to the federal Health Resources and Services Administration. That number is expected to dwindle to one in four as the population ages.

Possible solutions to the intensivist shortage range from training more intensivists and increasing the use of telemedicine to regionalization, where the sickest critically ill patients would be sent to high-level ICUs. But at the annual meeting of the Society of Critical Care Medicine (SCCM) in February 2009, intensivists discussed a more practical solution: partnering with hospitalists.

“Hospitalists could take care of many ICU patients, with intensivists taking care of the sickest ones,” said Derek C. Angus, MD, chair of critical care medicine at the University of Pittsburgh, during an SCCM presentation. “It’s threatening to intensivists, but frankly I think it’s the only way if we think we need to keep the same number of ICUs.” There’s another factor: “On any given day, only a fraction of patients cared for in the nation’s ICUs require primary care delivered by physicians with specialized, advanced training in critical care medicine,” says Timothy G. Buchman, MD, professor of surgery, anesthesiology and medicine at Washington University in St. Louis.

And even if more intensivists were trained, “for some critical care-trained doctors, the ICU is simply the first step in their career,” Dr. Buchman adds. Some pulmonologists, he points out, will work in an ICU for a few years after training. “But then they shift their practices to focus on either ‘sleeps’ or ‘scopes’ “sleep medicine or bronchoscopy “both primarily outpatient, and both primarily with weekday clinical responsibilities.”

That leaves “a huge vacuum in the hospital,” explains Michael Menolasino, DO, medical director of community hospital physicians for the University Hospitals Medical Practices, whose members staff three small hospitals in suburban and rural Cleveland.

Hospitalist opportunities
For Dr. Menolasino’s group, difficulties staffing the ICU have meant a significant opportunity for hospitalists.

When administrators in Dr. Menolasino’s system analyzed their quality data in 2006, they found that many rapid response and code blue calls were originating in the ICU. As a result, hospital executives and medical staff leadership mandated that all patients admitted to the ICU by community physicians be “seen and evaluated in consultation with the hospitalists,” who are hospital-employed and on-site 24/7.

Everyone was opposed, recalls Dr. Menolasino. The community-based internists objected to no longer being able to bill for ICU care, while the private pulmonary/ critical care subspecialists feared that hospitalists were muscling in on their consult business. To make peace, the hospitalists agreed that initially, at least, they would not bill for their services. They also made a concerted effort to over-call and over-communicate with the specialists. (The hospital, which began tracking data, found that the hospitalists were able to decrease the number of code blues by almost 80%. Data also showed that they improved length of stay, cost per case and the rate of ICU bed diversions.)

The hospitalists have since started billing for critical care. The specialists realized that the hospitalists weren’t out to steal consults, which went a long way to mending fences. There was also this staffing reality, says Dr. Menolasino: Neither of the two pulmonologists in the community wanted to hire more colleagues to expand coverage or come into the hospital at night.

Ground rules
In Tulsa, Dr. Rooks points out that his group voluntarily narrowed the pool of their doctors who can admit to the ICU by requiring them to get at least 10 hours of critical care-directed CME per year and admit 20 or more patients a year. “It essentially ended up closing the unit,” he says, “with dedicated-hospitalist ICU doctors.”

Dr. Rooks admits that hospitalists and intensivists occasionally clash over issues concerning who manages which aspects of care. The only way to deal with those conflicts is “diplomacy,” he says, and to set concrete ground rules.

Dr. Rooks meets regularly with the ICU director, who is also the pulmonary group director, to develop protocols that reduce variability. (They currently have 37 protocols covering everything from hypothermia treatment to VAP prophylaxis.) “We aren’t left to guess who is going to be there that particular day and how they are going to do things,” he explains.

They’ve also agreed that hospitalists will “always refer and defer to the pulmonary doctors” when it comes to ventilator management, says Dr. Rooks. “The rule is that a tie goes to the specialist.”

At St. Joseph Hospital in Bryan, Texas, Mack Blanton, MD, a board certified pulmonologist/critical care physician who now works solely as a hospitalist, says the two groups have likewise “defined lanes” so they won’t step on each other’s toes.

A good example is pneumonias. According to Dr. Blanton, both groups agreed that hospitalists “pretty much take care of every pneumonia; we don’t need a pulmonologist.” If a patient is on a ventilator for 48 hours, however, a pulmonary consult is mandatory.

“The success of a program like ours is dependent on the leadership of the pulmonary/critical care doctors first of all, and secondly, persistence and humility on our part to make it a team effort and to make it work,” Dr. Blanton says. “And honestly, there is plenty of business for them. They have sleep labs, they have consults, they have outpatient practices.”

“Turf battles and bruised egos”
On the other hand, Dr. Blanton says, a well-oiled partnership may be the exception rather than the rule. At another hospital he works with in his role as regional medical director for Cogent Healthcare, Dr. Blanton and the hospital’s vice president of medical affairs (VPMA) are trying to nurture an intensivist-hospitalist relationship that has so far been marked by “turf battles and bruised egos.”

The administration, which pursued an intensivist program to meet quality goals and lower costs, encouraged intensivists and hospitalists to communicate on such issues as admitting guidelines and “clearly delineated” responsibilities between the two groups. (The intensivist workforce, Dr. Blanton says, consists of a private pulmonary/ critical care group, and critical care staff and fellows from an academic program.)

Because that communication didn’t take place, however, the VPMA is now brokering sessions between the two groups to establish consultation criteria and what Dr. Blanton calls “management lanes.”

“The intensivists do not have the manpower to close the unit and provide 24/7 coverage,” he says. “We’ve agreed that an intensivist consultation will not be required for all ICU cases, but we’re still working toward a smooth and collegial relationship.”

The new concept of team care
While physician supply is causing many hospitals to rethink their ICU staffing strategy, health policy experts point out that ICU “demand” may be even more pertinent. Some, for example, wonder whether every small hospital even needs its own ICU.

There’s no question that many patients who were treated in ICUs only a few years ago are now routinely cared for on wards. That’s in part due to better evidence-based protocols, computerized order sets and decision-support tools, not to mention advances in drug therapy and procedures. Hospitalists on the floors regularly care for standard diabetic ketoacidosis and even some straightforward sepsis cases where patients are on stable doses of vasopressors.

“We are blurring the lines between ICU and non-ICU care,” says Rohit Uppal, MD, medical director of the hospital medicine service at Grant Medical Center in Columbus, Ohio. At his 400-bed level I trauma center, relations between hospitalists and intensivists are “positive,” he says, due to the personalities of the physicians, but also because of the shortage of critical care specialists. “They need us and we need them, so we work together.”

That assessment is seconded by Phil Hawley, MD, of Grant Pulmonary Physicians, the hospital’s ICU director: “If we had five or six pulmonary/critical care docs, then there might be a turf battle, but we have two,” Dr. Hawley points out. “It’s in everyone’s best interest that intensivists and hospitalists are all on the same page.”

That doesn’t mean, however, that hospitalists are merely the intensivists of last resort. Even if there were unlimited money and manpower and he could have a closed unit, Dr. Hawley says he would prefer a comanagement model, although he admits that sentiment isn’t necessarily shared by colleagues.

“The hospitalists hurt us in terms of fewer consults from the floor,” he explains. “But overall that doesn’t bother me because we are so short-handed.” Plus, hospitalists who work in the ICU, he points out, bring a lot of information about patients that intensivists would not otherwise have. They also are more skilled at writing orders that can bridge patients’ transition from the ICU to the wards.

To improve the quality of hospitalist care, Dr. Uppal says his group is reorganizing its ICU coverage. Instead of each of the six hospitalist services providing its own coverage, all of the ICU patients will now be on the same service. “Each week, we will have a designated ICU-only hospitalist cover all the group’s patients,” he says, “instead of having all six hospitalists on duty coming in and out of the ICU.”

He also hopes to fit that ICU hospitalist into the unit’s regular intensivist-led multidisciplinary rounding.

As he sees it, a cooperative model is far better than the “closed” alternative, which is “the opposite of collaborative, team-based care that we are trying to create in every other aspect of health care.” Hospitalists following patients into the ICU, he says, can provide better continuity of care than just signing patients over for days into “the black box” of a closed ICU.

“If you believe different people have important knowledge to bring to a patient,” says Dr. Uppal, “you need team-based care. It’s no different in the ICU.”

Deborah Gesensway is a freelance health care writer based in Sierra Madre, Calif.

Pronovost: Talk about “closed” ICUs misses the point

ONE OF THE FOREMOST AUTHORITIES on health care quality, Peter Pronovost, MD, PhD, may have written the Leapfrog Group’s ICU physician staffing standard, which calls for intensivist-only ICU care, at least during the day. But he doesn’t believe in “closed” units.

In fact, the Johns Hopkins intensivist “and a MacArthur Foundation “genius award” winner “thinks the terms “closed” and “open” should be tossed out altogether. Not only are the words “confrontational,” he says, but the designations impede progress toward his goal of increasing opportunities for critically ill patients to benefit from specialty expertise.

On close reading, Dr. Pronovost’s numerous articles on the topic never directly call for closing ICUs. They instead discuss ways to increase patients’ exposure to intensivists while introducing more “team care.”

“I believe that there are things lost in a closed model,” Dr. Pronovost says. “I have gone into many health systems that wanted to close their ICU where the administrators have brought me in to speak to their medical staff, thinking I was going to catch their spears. I’ve gone in and said, ‘Hey guys, I don’t believe in a closed ICU. I believe in team care; I bring value and you bring value. Can we agree on some working rules to make this happen?’ And unanimously, the medical staff agrees.”

Hospitalists can bring, Dr. Pronovost adds, “strong medical knowledge and robust communication skills to the management of the care team and family.” His hallmark review in the Nov. 6, 2002, Journal of the American Medical Association concluded that “high-intensity staffing” in ICUs, with either mandatory intensivist consultation or all care directed by an intensivist, was associated with significantly lower hospital and ICU mortality and lengths of stay vs. “low-intensity staffing” with either no intensivist or elective-only intensivist involvement.

But Dr. Pronovost has never insisted that intensivists are the only solution. He has instead sought ways to move medical staffs beyond physician shortages, low reimbursement and physician defensiveness to more team-based care. In an article published in December 2006, he suggested that physicians working in the ICU need four attributes, which include a presence in the hospital, knowledge of evidence based practice, good communication skills and a willingness to standardize processes of care.

“A hospitalist could have all of these attributes,” Dr. Pronovost says. “What do we lose from a hospitalist not having board certification? I don’t know. But what we gain is probably a lot more than not having anybody there.”

Do young physicians have the skills to work in the ICU?

EVEN AS HOSPITALISTS take on an expanded presence in ICUs, there could be a roadblock ahead. There are concerns about how well the next generation of hospitalists is being trained to cover the ICU.

The conventional wisdom has generally held that outpatient internists become rusty in technical skills needed in critical care like intubation, central line placement and mechanical ventilation management. Young internists fresh out of their inpatient-intensive residencies, by contrast, have these skills in spades.

But some say that the skills of freshly minted internists have suffered. “They don’t get enough exposure to be really competent,” says Michael Menolasino, DO, medical director of community hospital physicians for the University Hospitals Medical Practices, which staffs three hospitals near Cleveland. “They’re training in institutions with closed ICUs where critical care fellows are doing all the central lines and basic vent management.” Although his hospitalist group sees a lot of applicants, many individuals “don’t have the skill set.”

That view is seconded by Peter Pronovost, MD, PhD, an intensivist and expert on ICU workforce and patient safety at Baltimore’s Johns Hopkins University. “We have created a training model over the last decade that hospitalists mean floor medicine, not ICU,” Dr. Pronovost says. “Yet when they go out into reality, they are often expected to cover the ICU, and we haven’t provided the experience.”

One solution, he adds, is for hospitalist residency programs “to include training in ICU care.”

Hospital medicine and critical care

FOR MOST HOSPITALISTS, ICU care is a fact of life. According to our 2008 Today’s Hospitalist Compensation & Career survey, 68% of hospitalists said they took care of patients in ICUs.