Leapfrog and Critical Care: Evidence and Reality in the ICU

Abstract & Commentary

Synopsis: Leapfrog Group’s standards for critical care are not grounded sufficiently in evidence to mandate their stringent and universal implementation. Rather, most of the guidelines are grounded in common sense and rational extrapolation of the data. As such, they are a reasonable starting point for debate by physicians and policymakers about optimal methods of achieving intensivist-guided care of critically ill patients.

Source: Manthous CA. Am J Med. 2004;116:188-193.

The leapfrog group for patient safety (www.leapfroggroup.org) made some specific suggestions for improvement of hospital care. The Leapfrog Group was established by the Business Roundtable, which consists of the chief executive officers of several large corporations that purchase health insurance for more than 34 million health care consumers. They consider 3 practices to have tremendous potential for saving lives by reducing preventable mistakes in hospitals: computerized physician order entry; evidence-based hospital referral; and ICU physician staffing.

In this article, Manthous outlines the Leapfrog standards for critical care, which are available on the Web at www.leapfroggroup.org, and critically examines the evidence used to justify them.

The following are the primary recommendations for improvement of critical care as published in this article:

  1. Intensive care units should be staffed by board-certified intensivists, to coordinate and manage the care of patients;
  2. Intensivists should staff ICUs for a minimum of 8 hours per day, 7 days per week;
  3. Intensivists should respond to more than 95% of calls for assistance within 5 minutes;
  4. Either the intensivist—a "fundamentals of critical care" certified physician—or an appropriately certified "physician extender" should arrive at the bedside within 5 minutes in 95% of cases.

Certification of intensivists is achieved by completion of an accredited fellowship program sanctioned by the Boards of Internal Medicine, Surgery, Pediatrics, and Anesthesiology. Care "extenders" are physicians or allied health care personnel who provide critical care during hours when the intensivist is not available on site. (Certification to become an "extender" is achieved by attending to a 2-day course sponsored by the Society of Critical Care Medicine.)

In addition to maintaining the previous guidelines, the medical advisory panel of the Leapfrog Group suggested the following additional measures in 2003:

  1. Expanding Leapfrog standards to pediatric critical care;
  2. Loosening the criteria for qualifications of "intensivists" in order to "grandfather" practitioners who graduated before 1987;
  3. Limiting care by each intensivist to one ICU at any given time;

Manthous asserts that many of the Leapfrog Group’s standards for critical care are not grounded sufficiently in evidence to mandate their stringent and universal implementation. On the other hand, no published studies have demonstrated harm associated with intensivist care and, according to Manthous, these guidelines make common sense, and if sufficient manpower were available, they could serve as the starting point to formulate realistic goals. Added to that, he raises several important questions regarding the optimal model of ICU practice and the role of the emerging hospitalist movement in addressing the critical care manpower shortfall.

Comment by Francisco Baigorri, MD, PhD

My comment about the Manthous article is logically conditioned by my experience as an intensivist who has been working for more than 20 years in closed ICUs, in public university hospitals. This experience makes me hypercritical about this organizational structure. In my opinion, one of the main drawbacks of this system is that it can easily induce a fragmentation of the care process. It is quite obvious that critically ill patients should be treated by adequately qualified professionals. However, although they are absolutely not opposing concepts, I am not sure whether compliance with Leapfrog guidelines may complicate the development of critical care as a service to a particular patient population and the necessary multi-disciplinary approach that it requires.

There is an increasingly complex population of hospitalized patients on a continuum of severity of illness with critically ill patients. I feel strongly that critical care requires services that extend beyond the physical boundaries of intensive care to avoid what Shoemaker said: ". . .intensive care units give too much too late to too few.1" The evidence about the benefit of hemodynamic optimization in the early presentation of disease, such as in the emergency department,2 supports an organization that focuses on the level of care that individual patients need rather than on beds and buildings.

Nowadays advances in networking may help us to redefine the physical and organizational boundaries of the critical care unit. No longer a self-contained entity interacting as needed with other hospital departments, tomorrow’s critical care units are likely to regularly draw on resources—both human and technological—located outside the unit’s physical space.3 In April 1999, the UK Department of Health (www.dh.gov.uk/Home/fs/en) established a review of adult critical care services, and invited an expert group to develop a framework for the future organization and delivery of critical care. This group developed the concept of comprehensive critical care as a new approach based on severity of illness. The characteristics of such a service should ensure:

  1. Integration—A hospital-wide approach with services which extend beyond the physical boundaries of intensive care and high dependency units, making optimum use of available resources including beds
  2. Networks—A service that is provided across NHS Trusts, working to common standards and protocols, taking responsibility for all the critically ill in all specialties within a geographical area
  3. Workforce development—A planned approach to workforce development including the recruitment, training and retention of medical and nursing staff, and balancing the skill mix so that professional staff are able to delegate less skilled and non-clinical tasks
  4. A data collecting culture promoting an evidence base—A service underpinned by reliable information that will ensure the delivery of effective clinical care, demonstrated through comparative audit.

These characteristics together with Leapfrog guidelines are certainly a reasonable starting point for debate by physicians and policymakers about optimal methods of achieving intensivist-guided care of critically ill patients.

References

1. Shoemaker WC. N Engl J Med. 1996;334:799-800.
2. Rivers E, et al. N Engl J Med. 2001;345:1368-1377.
3. Craft RL. Crit Care Med. 2001;29(Supp l):N151-N158.

Francisco Baigorri, MD, PhD, Corporacio Sanitaria, Parc Tauli, Sabadell, Spain, is Associate Editor for Critical Care Alert.