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The key to reducing intensive care unit (ICU) errors and improving outcomes may be the adoption of the intensivist model, suggests a Vermont-based physician. Michael Young, MD, MS, director of the medical ICU at the University of Vermont in Burlington, made his case before a group of hospital chief executives during the 13th Annual National Managed Health Care Congress, NMHCC/2001, held March 19-21 in Atlanta.
"Mounting data indicate that there is wide variation between medical outcomes and costs between ICUs that is not explained away after adjusting for patient differences," said Young, who based his talk on a recent review of literature dealing with intensivist-model ICUs published in Effective Clinical Practice.1
Intensivists are physicians who are either board-certified or board-eligible in critical care medicine. For hospitals to meet the Leapfrog Group’s hospital safety standards, Young noted, ICUs must be managed by these physicians, who must be present during daytime hours to provide clinical care exclusively in the ICU. At other times they should be able to return pages within five minutes and rely on in-hospital "effectors" (physicians or physician extenders) who can reach ICU patients within five minutes.
Young pointed out that the potential savings in the ICU are significant. His studies showed that mortality rates ranged from 5% to 50%, with an average in two large surveys of 12.4% to 16.6%. Health care costs are estimated to use 15% of the nation’s gross national product, and Young’s estimates indicate the total proportion of the health care dollar spent on inpatient care may be about 40%. He went on to note that several surveys of ICUs estimate that 25% to 40% of each hospital’s costs is spent caring for ICU patients.
"Many hospitals may underestimate the total burden of costs of their ICU because of the silo effect’ in costing systems," Young noted. "By silo effect, I mean the impact of costing systems that separate out departments or divisions such as laboratory, nursing, occupational therapy, physical therapy, radiology, physicians, and administrative costs leading to a systematic underestimation of actual resources applied to a given ICU patient."
Young’s review of the literature encompassed nine studies evaluating intensivist models; six were pre-post studies (mortality rates were compared pre- and post-implementation of the intensivist model) at single sites, and the other three were cross-sectional studies, where a control hospital ICU continued with nonintensivist care and was compared to intensivist models of ICU staffing.
"In the nine studies described . . . the reductions in mortality associated with the intensivist model ranged from 15% to 60%," Young told his audience. He went on to say that he and his fellow researchers estimated that 50,000 lives could be saved if hospitals in urban areas implemented intensivist staffing models. "This figure is our conservative estimation, based on the literature," he noted, pointing out that using a mid-range efficacy of intensivist model staffing, his team determined that more than 100,000 lives annually would be saved.
While data on cost changes is limited, in a majority of studies, use of the intensivist model reduced length of stay by 10% to 23%, Young reported. Taking a theoretical 250-bed hospital, assuming a cost of $3,000 per day for three days in the ICU and $1,000 a day for 10 days of ward care for ICU patients, Young’s team projected cost savings of $200,000 per year if length of stay was reduced by only 5% using the intensivist model.
Young said that the improved outcomes that the intensivist model seems to generate can be attributed to several causes:
"After 35 years [since the introduction of ICUs], we need to restructure ICU care to make it as careful as it is intense," Young concluded.
1. Young MP, Birkmeyer JD. Potential reduction in mortality rates using an intensivist model to manage intensive care units. Effective Clinical Practice 2000; 3:284-289.