Is there a better way to deliver optimal critical care services?

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84 Is There a Better Way to Deliver Optimal Critical Care Services? Ian J. Barbash and Jeremy M. Kahn

INTRODUCTION Critical illness is defined by life-threatening organ dysfunction leading to excess morbidity and mortality. While overall mortality in hospitalized patients is less than 5%, more than 10% of patients die after admission to the intensive care unit (ICU).1,2 In the most severe forms of critical illness such as septic shock and acute respiratory distress syndrome, mortality approaches 50%.3,4 In addition to this human toll, critical illness imposes substantial financial costs: annual ICU spending in the United States exceeds US$100 billion and accounts for nearly 15% of hospital costs and almost 1% of the gross domestic product.5 Given our tremendous social and financial investment in critical care, it is imperative that we optimize the organization and management of critical care delivery. For most of their history, ICUs were physically separate from other areas of the hospital but were managed without specific attention to physician staffing patterns or team-based care models. In the 21st century, a growing body of evidence supports specific approaches to optimal ICU organization and management. Simultaneously, in the era of value-based care, there is increasing interest from payers, government agencies, and regulators in implementing strategies that improve the outcomes of critically ill patients while minimizing costs.6–8 These maturing forces—an increasingly robust evidence base and the drive to implement strategies that improve the value of health care—have created an environment in which the tools of evidence-based medicine are essential to optimizing the delivery of ICU services. An evidence-based approach is particularly important because the effectiveness of a given approach to critical care delivery often depends on the local context in which it is implemented—that is, ICU organization and management are not “one size fits all.” This observation parallels the precision medicine movement for patient-level treatments, in which there is increasing recognition that a particular intervention may be more effective for some critically ill patients

than for others.9 For many organizational strategies, there is a mix of studies with “positive” and “negative” results; rather than this representing evidence of ineffectiveness, it is likely that contextual factors render a given organizational strategy more effective in some ICUs than in others.

THE INTERPROFESSIONAL TEAM There is a growing consensus that the key to a high-quality ICU is a collaborative team of individuals from multiple health professions.10 In their most expansive forms, these teams comprise intensive care physicians and advanced practice providers, nurses, respiratory therapists, clinical pharmacists, physical and occupational therapists, speech and language pathologists, dieticians, social workers, case managers, and spiritual support. It is impractical to expect representatives from all of these disciplines to participate directly in daily ICU rounding, and many of these individuals have competing responsibilities beyond the ICU that necessitate communication outside a formal rounding structure. However, compared with isolated physician rounding, some form of interprofessional rounding is associated with reductions in ICU length of stay, medication errors, and mortality.11,12 The best evidence supports, at a minimum, the inclusion of the ICU physician, bedside nurse, and clinical pharmacist in a synchronous discussion on rounds.11 Clearly, engaging respiratory therapists is essential for patients with respiratory failure, for whom protocolized daily spontaneous breathing trials speed liberation from mechanical ventilation.13,14 Depending on local ICU case mix, integrating additional professions into daily bedside rounds may prove beneficial. It seems intuitive that ICU quality depends not only on the physical presence of multiple health professionals but also on how they function together as a team. Well-functioning teams are characterized by role clarity, shared goals, effective information exchange, and collaborative processes for decision making and conflict resolution.15,16 A recent systematic review of interventions to improve team functioning in the 605

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ICU found that simulation-based team training can improve team climate.17 Other hospital- and ICU-based interventions addressing teamwork and collective efforts to identify and mitigate errors can improve the climate of safety.18,19 In general, even studies showing a robust effect of interventions on team function did not show a significant impact on patientcentered outcomes. In part, this probably reflects the difficulty in defining and measuring team performance, which is an important area of future research in ICU teamwork, and its impact on patient outcomes.

INTENSIVIST STAFFING MODELS Under the current gold-standard model of the interprofessional ICU team, an intensivist physician provides leadership and directs the overall plan of care.20 This intensivist is typically board-certified with specific subspecialty training in critical care medicine. There are two traditional models under which an ICU can operate: a “closed” unit, in which the intensivist takes direct responsibility for all patients admitted to the ICU; or an “open” unit, in which a nonintensivist primary physician retains responsibility for patients admitted to the ICU and consults an intensivist for co-management for some patients. Early versions of ICU organization guidelines endorsed the closed models as the preferred approach.21 However, a large study in 69 US centers failed to show a difference in outcomes between closed and open ICUs, and current guidelines no longer emphasize that a closed model is paramount.2,20 While there is general agreement that some form of intensivist involvement benefits critically ill patients, several systematic reviews point to a lack of consensus as to the optimal intensity of physician staffing patterns during daylight hours.22–24 Most studies compared “high-intensity” with “low-intensity” physician staffing models: a high-intensity model is a closed ICU or one with mandatory intensivist consultation; a low-intensity model is an open ICU without

intensivists or with elective intensivist consultation. Whereas earlier systematic reviews, including studies from the 1980s and 1990s, indicated a potential mortality benefit to highintensity staffing, data from the most recent decade are less convincing.24,25 Table 84.1 summarizes existing multicenter studies that compared mortality in critically ill patients under high-intensity vs. low-intensity staffing models,25–32 and Table 84.2 provides an overview of the four major staffing models. The fact that high-intensity daytime intensivist physician staffing is not strongly and independently associated with mortality in the modern era may reflect the fact that other aspects of critical care delivery, including interprofessional, team-based care, are more widely available and improve components of quality previously addressed primarily by individual physicians. In addition to the debate regarding high-intensity vs. lowintensity daytime staffing, a recent systematic review suggests that “around-the-clock,” 24-hour in-house intensivist coverage does not improve mortality in most ICUs.33 This review evaluated one randomized controlled trial (RCT) and 17 observational studies; the pooled odds ratio for mortality associated with 24-hour intensivist coverage was 0.99, with a 95% confidence interval (CI) of 0.75–1.29. The single RCT compared in-house intensivist coverage by critical care attendings and fellows to intensivist consultation by phone to in-house residents and nurses.34 In-house nocturnal intensivist coverage did not reduce ICU length of stay (rate ratio for the time to ICU discharge 0.98; 95% CI 0.88–1.09; P 5 .72) or ICU mortality (relative risk 1.07; 95% CI 0.90–1.28). The primary limitation of this study was that it was conducted in a single academic center, and even the control intervention included on-demand consultation with intensivists by phone, constraining its generalizability to other environments. We should not take from these intensivist staffing data a message that intensivists “don’t matter,” but rather that their impact is probably context-dependent. The optimal physician staffing of a small, 8-bed ICU in a rural hospital with few

TABLE 84.1  Summary of Multicenter Cohort Studies on Intensivist Physician Staffing for

Critically Ill Adults. Study

Population

Centers (N)

Patients (N)

Outcome Measure

Risk Estimatea

Pronovost et al., 1999

Abdominal aortic surgery

46

2987

In-hospital mortality

0.33 (0.20–0.52)

Diringer and Edwards, 200127

Intracerebral hemorrhage

42

1038

In-hospital mortality

0.39 (0.22–0.67)

Dimick et al., 200128

Esophageal resection

35

366

In-hospital mortality

0.66 (0.16–2.5)

Nathens et al., 2006

Trauma

68

2599

In-hospital mortality

0.78 (0.58–1.04)

Treggiari et al., 200730

Acute lung injury

23

1,075

In-hospital mortality

0.68 (0.53–0.89)

Levy et al., 200831

All ICU patients

100

101,832

In-hospital mortality

1.40 (NP)

Kim et al., 201232

Severe sepsis

25

251

In-hospital mortality

0.46 (0.22–0.93)

All ICU patients

49

65,752

In-hospital mortality

0.86 (0.65–1.14)

26

29

Costa et al., 2015

25

Adjusted odds ratio or risk ratio comparing patients managed under a high-intensity staffing model to patients managed under a low-intensity staffing model. Definitions of high- and low-intensity staffing models differed among studies; high-intensity staffing typically refers to complete transfer of care to an intensivist or a mandatory consult model. ICU, intensive care unit; NP, not provided. a

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TABLE 84.2  Overview of Daytime

Intensivist Staffing Models. High-Intensity Models

Low-Intensity Models

Closed • All patients are seen by an intensivist on daily rounds • Intensivist takes primary responsibility for all aspects of patient care • Other physicians may be involved as consultants

Open, Optional Consult • Nonintensivist physician takes primary responsibility for patient care • Intensivist sees some patients as a consultant at the discretion of the primary physician

Open, Mandatory Consult • All patients are seen by an intensivist on daily rounds • Intensivist shares responsibility for patient care with primary physician • Additional physicians may be involved as consultants

Open, no Intensivist • Nonintensivist physician takes primary responsibility for patient care • There is not an intensivist available for in-person consultation

mechanically ventilated patients is unlikely to mirror that of a 24-bed ICU in a large tertiary referral hospital. In addition, many of the mechanisms by which intensivists improved outcomes in the past may be less important in the modern age of highly functional, interprofessional ICU teams using standardized protocols to deliver evidence-based critical care. Indeed, even ICUs with dedicated intensivists can fail to comply with evidence-based practices.4 The shortage of intensivists and physicians in general35 along with the relatively high costs of physician salaries present barriers to universal adoption of high-intensity care models; given the existing evidence, some hospitals and ICUs might reasonably apply models of care other than one involving high-intensity daytime intensivist coverage with an in-house nocturnal intensivist.

ADVANCED PRACTICE PROVIDERS In light of the debate surrounding the effectiveness and practicality of universal intensivist physician staffing, there is increasing interest in the role of advanced practice providers such as nurse practitioners (NPs) and physician assistants (PAs) in critical care.36 The most recent systematic review on this topic is over a decade old; the included studies generally showed that inclusion of advanced practice providers in critical care teams was well-received by team members and associated with equivalent or somewhat improved processes of care and outcomes.37 In recent years, as more hospitals and ICUs have adopted advanced practice providers, several studies have confirmed that, in critical care environments, they achieve outcomes that are at least equivalent to those under alternative care models.38,39 In addition, a number of studies suggest that including advanced practice providers in ICU teams can improve the experience of resident and fellow

607

critical care trainees, perhaps by mitigating physician trainee workload.40,41 With increasing numbers of advanced practice providers entering the ICU workforce, the question is not whether to incorporate them into ICU care models, but how to do so in ways that optimize team function as well as patient and financial outcomes.

PROTOCOLIZATION AND DECISION SUPPORT Many decisions in medicine depend upon the judgment of clinicians, which is tailored to individual patients, but an increasing number of evidence-based practices lend themselves to standardization and protocolization for nearuniversal application. Several archetypal best practices relevant to the ICU are daily spontaneous breathing trials paired with daily interruption of sedation to facilitate liberation from mechanical ventilation in ICU patients.13,42 Importantly, the studies establishing the efficacy of these practices have employed standardized protocols driven by respiratory therapists and bedside nurses. In the years since these initial studies, systematic reviews of numerous other studies have confirmed that standardized, protocolbased approaches to sedation management and ventilator weaning improve patient outcomes by improving adherence to best practices.43,44 A 2008 survey of ICU directors in 90 academic medical centers confirmed that these protocols are common, with 86% of ICUs using respiratory therapist-driven ventilator weaning protocols and 73% using nurse-driven sedation protocols. Other protocols addressed lung-protective ventilation,45 early sepsis resuscitation, and postoperative glucose control.46–47 Rounding checklists can theoretically synergize with these protocols by helping ICU teams set shared goals, identify opportunities to improve adherence with evidence-based practices, and improve efficiency.48,49 ICU teams prefer checklists that are shorter, clinically relevant, and integrate seamlessly into rounding workflow.49 The evidence supporting the impact of checklists on care processes and outcomes is generally weak.50 A recent landmark cluster-randomized clinical trial evaluated the effect of a multicomponent intervention that included rounding checklists, goal setting, and clinician prompts in more than 100 Brazilian ICUs.51 This study showed that the intervention did improve several relevant care processes, including sedation practices, central venous catheter utilization, and lung-protective ventilation, although the magnitude of the changes was relatively small. There were no significant differences in any patient-centered clinical outcomes between the intervention and control arms. Future work will need to better define the contexts in which ICU checklists are most likely to be beneficial. As more hospitals adopt electronic health records (EHRs), automated clinical decision support systems (CDSS) operating within the EHR are an increasingly feasible approach to preventing errors and standardizing the delivery of accepted evidence-based practices. Existing CDSS based on relatively straightforward decision rules may reduce medication errors, improve compliance with blood transfusion guidelines, and

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increase rates of prophylaxis for venous thromboembolism.52–55 The future of CDSS in the ICU will include machine learning techniques employing more complex algorithms to identify deteriorating patients and gaps in evidence-based care, facilitating earlier interventions. However, clinical applications of machine learning in the ICU are currently limited by compartmentalization of data across platforms, issues with data precision and accuracy, and challenges in applying statistical models to the complex and dynamic conditions of critical illness.56 Ultimately, in order to add value to the clinical environment, CDSS must provide timely, actionable, and novel information to ICU teams without an excessive falsenegative rate that contributes to alarm fatigue.

QUALITY MEASUREMENT AND IMPROVEMENT As more hospitals adopt and refine their EHRs, ICUs directors have increasing access to timely, granular data on patient treatment processes and outcomes; these data can facilitate quality measurement and process improvement activities. Multiple critical care professional societies endorse the importance of developing and using both process- and outcome-based measures at multiple levels within the heath system, including in the ICU.20,57 Measurement alone, however, does not drive improvement—the measures must be tied to specific strategies to implement changes that improve processes and outcomes. Traditional approaches generally link evidence-based protocols with educational initiatives, performance measurement, and feedback of these results to spur behavior change in low performers. These resourceintensive strategies can be difficult to implement and sustain, and the effects are often modest.58 A complementary approach, known as pay for performance, links quality measurement to physician payment, although existing data suggest that pay for performance is associated with marginal improvements in treatment or outcomes for patients in the hospital and ICU.59,60 Thus, while the increasing availability of electronic data may facilitate quality measurement, the process of changing behavior in ways that improves patient care and outcomes remains a challenge.

REGIONALIZATION Regionalization is a system-wide approach to critical care organization and management by which selected patients are systematically transferred to regional referral centers.61,62 Regionalization leverages the observation that hospitals caring for higher case volumes have better patient outcomes in a variety of conditions, including sepsis,63,64 acute respiratory failure requiring mechanical ventilation,65,66 and acute myocardial infarction.67 However, the benefits of widespread regionalization of critical care services are largely theoretical,66,68 and need to be balanced against the potential harms, including delays in the early management of time-sensitive conditions69 and overwhelming the capacity available at tertiary facilities. New evidence also suggests that a regionalized

approach may help some critically ill patients but not others,70,71 again highlighting the fact that the benefits of a particular ICU organizational strategy are probably contextual, and varying, based on local and regional case mix and other patient and hospital factors.

ICU TELEMEDICINE In areas without local access to intensivist physicians, telemedicine is an approach that may bring the benefits of intensivist involvement in patient care without physically transferring patients to regional referral centers.68 Multiple models of ICU telemedicine exist, ranging from continuous multibed monitoring of an entire ICU to more selective monitoring and/or on-demand consultation.72 Studies of the impact of ICU telemedicine are largely limited by a before-and-after design, and systematic reviews indicate inconsistent effects on patient-centered outcomes despite substantial up-front financial investments.73–77 The largest national study of telemedicine adoption compared 132 hospitals that adopted ICU telemedicine programs to 389 similar control hospitals that did not adopt ICU telemedicine programs.75 In the overall comparison, ICU telemedicine adoption was associated with a small reduction in mortality among ICU admissions (relative risk 0.96; 95% CI 0.95–0.98), although there was dramatic heterogeneity, and only 16 individual hospitals experienced a statistically significant drop in mortality following ICU telemedicine adoption. This heterogeneity in effectiveness is probably due to a number of barriers and facilitators to telemedicine adoption, which are variably present across institutions and telemedicine programs.78

FUTURE DIRECTIONS We have come a long way from a system that simply centralized critically ill patients in a single location within a hospital to one that emphasizes team-based, interprofessional care. ICU directors must consider a number of variables that may affect patient outcomes, including the nature of intensivist staffing, the use of advanced practice providers, protocolization and decision support, quality measurement, regionalization, and ICU telemedicine. We are increasingly understanding that the impact of any one of these organizational strategies depends not on whether but how we use them, and the context in which we do so. Future research should seek to refine existing organizational strategies and better understand the contextual factors that mediate their success or failure in reference to important patient-centered outcomes. AUTHORS’ RECOMMENDATIONS • Interprofessional, team-based care is consistently associated with improved patient outcomes and is the goldstandard model of ICU medicine. • Intensivist physician staffing may benefit many critically ill patients, although there are probably contexts in which intensivist involvement does not improve mortality.

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• Complementary care models may bring some of the benefits of intensivist staffing and can help overcome barriers related to physician shortages and the direct financial costs of full-time intensivist staffing. These complementary care models include: • using advanced practice providers to increase the efficiency of intensivist leadership • protocolization and decision support systems to increase the consistent application of evidence-based practices • quality measurement to identify opportunities for improvement and monitor progress of improvement efforts • regionalization of critical care services to match patient severity of illness to the level of care needed • ICU telemedicine to expand the reach of intensivist expertise to locations where intensivists are not physically present. • The impact of these complementary care models probably depends on local context; patient, provider, and financial implications should be evaluated prior to and following the process of implementing a new organizational strategy in an ICU.

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e1 Abstract: Critical illness imposes substantial physical, emotional, and societal costs across the globe. It is therefore imperative that we optimize the organization and management of critical care delivery, in order to maximize the benefits and value of critical care services. A growing body of evidence supports several strategies that may improve critical care delivery. A coordinated interprofessional team is central to any effort to improve outcomes for critically ill patients and their families. Under the gold-standard model of the interprofessional intensive care unit (ICU) team, an intensivist physician provides leadership and overall responsibility for care delivery. Advanced practice providers, including physician assistants and acute care nurse practitioners, have a growing presence on ICU teams and may help increase the efficiency of intensivist oversight of critically ill patients. Clinical protocols and decision support systems can augment individual

decision making to increase compliance with key evidencebased practices. Quality measurement programs, linked with quality improvement processes, are critical to identifying and closing gaps in care delivery. A tiered, regionalized approach to critical care delivery might help match patients to an appropriate level of care without requiring all hospitals to adopt the same practices as referral centers that deliver resourceintensive treatment. ICU telemedicine programs extend the expertise of intensivist physicians to patients without physical access to an on-site intensivist. The impact of these complementary care models probably depends on local context; patient, provider, and financial implications should be evaluated prior to and following the process of implementing a new organizational strategy in an ICU. Keywords: intensive care, critical care, outcomes, health-care delivery, organization and management