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Improving Patient Safety In Rural Hospitals
Improving ICU Safety
Michael Young, M.D., M.S., Medical Intensive Care Unit (ICU) Director, Division of Pulmonary and Critical Care, University of Vermont, Fletcher Allen Health Center, Burlington, VT.
Dr. Michael Young, Medical Director of the medical ICU at the University of Vermont, addressed challenges to caring for critically ill patients in rural hospitals. He explained the scope and cost of ICU care, reviewed methods of assessing their performance, presented research findings supporting intensivist models, and suggested options that may be realistic for rural ICUs to implement for the care of critically ill patients.
Young explained that ICU care is ubiquitous, expensive, and associated with high mortality. He stated that 4.4 million people are admitted to ICUs in the US every year. Currently, over 70% of US hospitals have ICUs and ICU beds account for approximately 10% of total hospital beds. ICUs consume 20-30% of total hospital costs and approximately 1-1.5% of the Nation's gross domestic product. (Groeger, 1992; Jacobs, 1990). Mortality rates in ICUs vary widely between individual ICUs due to case mix and other factors. Two large surveys of ICUs found mean mortality rates of 12% and 16%. Nationwide, approximately 500,000 people die annually in ICUs (Zimmerman, 1998; Shortell, 1994).
Young attributed variation in ICU outcomes to various factors including:
- Type of illness.
- Acuity of illness.
- Age of patients.
However, Young also explained that the mortality differences between ICUs cannot all be explained by patient characteristics. In other words, some ICUs perform much better than others. Young explained that characteristics of better performing ICUs often include:
- Size of institution (Some studies reveal that outcome appears independent of size).
- Teaching status of institution (Some research reveals that outcomes were independent of teaching status).
- Access to newest technologies.
- Nursing ratios.
- "Open" versus "closed" ICU models.
- Dedicated intensivists.
He defined an "open" ICU model as one that allows many or most physicians on staff to admit and care for ICU patients (85% of ICUs are open model), and defined a "closed" ICU model as one that only allows ICU staff physicians to admit and write orders. Closed model ICU physicians are also known as intensivists. The Leapfrog Group considers hospitals to have fulfilled their ICU Physician Staffing standard if they operate adult ICUs that are managed by physicians board-certified (or -eligible) in critical care medicine who:
- Are present during daytime hours and provide clinical care exclusively in the ICU.
- At all other times can return more than 95% of calls to the ICU within 5 minutes and, 95% of the time arrange for a FCCS (Fundamental Critical Care Support of the Society for Critical Care Medicine) certified physician or physician extender to reach the ICU patient within 5 minutes. (Leapfrog Group Fact Sheet, 2000).
Young presented research data to demonstrate that hospital mortality rates tend to decline markedly when an intensivist model is employed, suggesting that an intensivist model does improve outcomes. He also presented data that showed that patient to nurse ratios also have an effect on mortality and that outcomes worsen when the patient to nurse ratio is elevated from the tradition 2:1 to 3:1. Young explained that outcomes tend to improve with an intensivist model because it is likely to provide:
- Increased on-site physician availability.
- Increased physician expertise.
- Increased use in protocols; and decreased variation in care.
- Increased collaborative care (with other doctors, nurses, respiratory therapists, physical therapists, social services, and pharmacies, etc.).
- Decreased delays to treatment.
- Decreased specialty or "organ-focused" care with increased focus on entire patient.
- Likelihood that intensivist team goals are aligned with institutional goals.
- Improved communication with families.
While intensivist models have many benefits, implementing them can have costs and disadvantages. It can have disadvantages including a potential loss of continuity of care, a reduction of ICU skills among non-ICU physicians, costs of supporting ICU physicians, and manpower issues that could require ICU regionalization. Also, certain political constraints can inhibit adopting an intensivist model, such as the facts that historically there has been little physician focus on ICU organization, administrators are wary of the medical complexity in ICUs, and intensivist models may pose a threat to physicians' autonomy and income.
Given the charge of this workshop to address issues of improving patient safety in rural hospitals, Dr. Young offered some suggestions of realistic options for ICU care in rural hospitals especially when adopting an intensivist model may not be feasible. He stressed that it is important for all hospitals, including rural ones, to establish clear criteria to define a critically ill patient. Such characteristics of criteria could include impending respiratory failure, new mechanical ventilation, use of vasopressors, and evidence of multi-organ failure.
Dr. Young suggested that rural hospitals pay particular attention to nursing and pharmacy staffing, adopt a 1:1 nurse to patient ratio for critically ill patients, and dedicate a clinical pharmacist to intensive care units. While an intensivist model may not be feasible for most hospitals with fewer than 200 beds, Young suggested that rural hospitals consider adopting a hospitalist model of physician staffing which is associated with improved ward outcomes (Wachter, 1996; Lurie, 1999). A hospitalist is a physician who specializes in inpatient medicine and manages the care of inpatients in the same way that a primary care physician manages the care of outpatients.
In addition to hospitalists, rural hospitals should consider expanding the depth of their current staff by utilizing physician extenders, such as nurse practitioners and physician assistants, in ICU settings. Given the isolated nature of some rural hospitals, Young suggested that rural hospitals consider regionalizing care for critically ill patients. He presented studies that revealed that regionalization improves outcomes for trauma, burn units, neonatal ICUs, and pediatric ICUs, and some limited data that suggests that mobile transport of the critically ill in adult ICU models can be safe (Gebremichael, 2000). Young also reviewed novel approaches to improving ICU outcomes in rural hospitals including increased use of electronic decision support tools and telemedicine.
To summarize, Young explained that providing the best ICU care in rural settings is challenging. When employing a dedicated intensivist is not a viable option, rural hospitals can utilize hospitalists and physician extenders. He also stressed the importance of setting explicit guidelines to identify patients for early transfer to regional centers. Finally, he raised the issue of making greater use of decision support mechanisms, telemedicine, and developing a common database to track outcomes in rural ICUs to identify opportunities for ongoing improvement.
AHRQ's Evidence-based Practice Program's report published in July 2001, Making Health Care Safer: A Critical Analysis of Patient Safety Practices (EPC report: http://www.ahrq.gov/research/findings/evidence-based-reports/er43/ptsafety/) includes several chapters with information pertinent to Dr. Young's presentation, such as:
Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment: Number 43. AHRQ Publication No. 01-E058, July 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/er43/ptsafety/
Dartmouth Atlas of Health Care 1999: The Quality of Medical Care in the United States. Center for the Evaluative Clinical Sciences; Hanover, NH: 1999: 43-94.
Gebremichael M, et al. Interhospital transport of the extremely ill patient: the mobile intensive care unit. Crit Care Med 2000 Jan;28(1):79-85.
Groeger JS et al. Descriptive analysis of critical care units in the United States. Crit Care Med 1992 Jun;20(6):846-63.
Jacobs P, Noseworthy TW. National estimates of intensive care utilization and costs: Canada and the United States. Crit Care Med 1990 Nov;18(11):1282-6.
Lurie JD, Miller DP, Lindenauer PK, Wachter RM, Sox HC. The potential size of the hospitalist workforce in the United States. Am J Med 1999 Apr;106(4):441-5.
Rosenfeld, B.A., Dorman, T., Breslow, M.J., Pronovost, P., Jenckes, M., Zhang, N., Anderson, G., & Rubin, H. Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care. Crit Care Med 2000 Dec; 28(12): 3925-31.
Shafazand, S., Shigemitsu, H., & Weinacker, A.B. A brave new world: remote intensive care unit for the 21st century. Crit Care Med 2000 Dec; 28(12): 3945-6.
Shortell SM, Zimmerman JE, Rousseau DM, Gilles RR, Wagner DP, Draper EA, Knaus WA, Duffy J. The performance of intensive care units: does good management make a difference? Med Care 1994 May;32(5):508-25.
Wachter RM, Goldman L. The emerging role of "hospitalists" in the American health care system. N Engl J Med 1996 Aug 15;335(7):514-7.
Zimmerman JE, Wagner DP, Draper EA, Wright L, Alzola C, Knaus WA. Evaluation of acute physiology and chronic health evaluation III predictions of hospital mortality in an independent database. Crit Care Med 1998 Aug;26(8):1317-26.
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