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By Julie Crawshaw, CRC Plus Editor
Should any physician with hospital privileges be able to admit and manage patients in the icu? or should ICU patients be under the care of an intensivist team regardless of who manages them outside the unit?
These questions continue to concern intensivists and others who work in ICUs. Answers vary widely and feelings behind them run high.
Maurene Harvey, RN, and president-elect of the Society for Critical Care Medicine (SCCM), has been a critical care nurse for 35 years. As a nursing educator, she has spent time in hundreds of hospitals over the years. "In nursing we are very clear about this," Harvey says. "We do not let anybody take care of a critically ill patient unless they have critical care training. We don’t let any critical care patient be without a critical care nurse. I don’t understand why physicians don’t do the same thing."
Harvey observes that while an emergency room may get 1 critically ill patient per day, ICUs are filled with critically ill people. "Where do you find more devices, drugs, and tubes, more complications and disorders than are seen anywhere else?" she asks. "In the ICU. But where do we require a specialty trained physician 24/7? In the emergency room."
Intensivist vs. Hospitalist Studies Lacking
Studies show that those ICU patients under the care of an intensivist experience better outcomes than those under the care of an internist without critical care training. But John R. Nelson, MD, FACP, says those studies compare critical care doctors to all primary care doctors for whom hospital care is only a small part of their practice, and ICU care is a smaller part yet.
Nelson, who is cofounder and past president of the National Association of Inpatient Physicians (NAIP) and director of the hospitalist practice at Overlake Hospital in Bellevue, Wash, doubts that comparing intensivists to hospitalists would produce the same finding.
The NAIP, which represents more than 5000 hospitalists nationwide, takes the position that hospitalists should be able to admit to the ICU and manage patients to their level of expertise, consulting critical care specialists when appropriate.
"My view is that all those studies say My gosh, every ICU should have significant leadership, input, and supervision from doctors with critical care training if at all possible,’" Nelson says. "I agree that critical care physicians should lead ICUs where available. However, I think there are valuable contributions that can be made by noncritical-care doctors. And I don’t think that just because we have concluded that critical-care-trained doctors are a very valuable component, that means everyone else should be excluded."
Nelson points to studies that show patients with acute respiratory disease syndrome experience better outcomes at lower cost under doctors with critical care training than they do under those without it.
"The problem is that people want to assume that the same result would be obtained in a comparison between critical care doctors with hospitalists," he says.
Harvey observes that ICU nurses have to be trained in critical care and a specific number must be present. "Trained and present is best, but present is better than nothing," she says. "Hospitalists are filling a gap in hospitals that don’t have intensivists."
However, Ann E. Thompson, MD, current SCCM president and professor of anesthesiology/CCM and pediatrics at the University of Pittsburgh, observes that some hospitalists’ practice at more than 1 facility and may not be available when they’re needed.
"I see both hospitalists and intensivists as a kind of generalist," Thompson says. "The main separation is the immediately life-threatening nature of the disease. If you are present, you can get things done in a timely fashion. With critical care, patient care is titrated to patient care day and night. That’s the model that we advocate."
Nelson says he certainly would never try to persuade anyone that hospitalists and critical care physicians are equivalent. "I need help from a critical care doctor for any ICU patient I have," he says. "The question is, when my patients go into the ICU, should I stop at the door and hand the patient off entirely to the critical care doctor? Who should be in charge while my patient is in the ICU? I think perhaps it could be me, and I would ask the critical care doctor to serve as a consultant."
Team Leadership May be Most Important Factor
Few would refute the assertion that patients at high risk of dying should have physicians who are specifically trained in managing the critically ill. But the bottom line is that there aren’t enough intensivists or hospitalists to go around, and both groups expect the current situation will worsen.
Thompson thinks an intensivist should be the ICU team leader, but she says the potential for streamlining hospital care is immense if intensivists and hospitalists work together.
But Nelson points out that intensivist is a job description. "The word doesn’t tell you how that doctor was trained," he says. "When board-certified critical care physicians are available it makes sense for them to have a very significant role in the ICU. But even if you believe they should be doing it all, there aren’t enough of them."
Harvey sees the hospitals of the future having ICU teams comprised of intensivists, hospitalists, and acute care nurse practitioners. "The nurse practitioners will do not only what they need to do to help physicians care for the patients, but also will help teach the novice nurses as well," she says.
Pediatric ICU Care Isn’t Comparable
David M. Steinhorn, MD, associate professor of pediatrics at Children’s Memorial Hospital in Chicago, says that the current argument in the adult critical care world shouldn’t extend to pediatric critical care. Steinhorn, who coordinates a pediatric critical care fellowship training program, says ICU care for children absolutely requires a training that includes mentorship and supervision in a pediatric intensive care unit.
"You can’t get these skills from general pediatric training," Steinhorn says. "The board of surgery says that pediatric surgeons in general are thought to be qualified providers of pediatric critical care services. But the training the pediatric surgery fellow receives is not the same sort of rigorous, mentored, physiologically based training in critical care that a medical critical care specialist receives."
During their 2 years of fellowship, pediatric surgeons are responsible for managing their surgical and trauma patients in the ICU. Yet Steinhorn says the mentorship and training they receive is quite variable compared to the well-established curriculum that exists for pediatric medical intensive care training.
"Their training will be hit-or-miss based upon who their surgical attending physician is, the period of time, the center they’re in, and the degree to which the surgeons are receptive to education, input, training, and insights from the medical intensivists who are spending literally all their training time in the intensive care unit," he says.
Thompson points out that because few pediatric patients require intensive care, every critically ill child should be transferred to a pediatric ICU. "It is just not appropriate for a child to be cared for in a small community hospital without pediatric expertise when every region in the country has access to an excellent pediatric ICU," Thompson says. "The difference in outcomes is so great it makes no sense to risk a child’s life."
According to Steinhorn, general pediatricians who received training during the last 8-10 years got the short end of the ICU training stick. "They’ve received much less mentored exposure in intensive care pediatrics than we did 15-20 years ago, when there were many more rotations in a 3-year residency," he says.
Pediatric surgical specialists, Steinhorn says, now also spend less time in formal, supervised intensive care training. And because they are less rigorously trained, he says they are less likely to be exposed to the areas of expertise a medical intensivist develops in the pediatric ICU for the most serious types of cardiovascular or respiratory failure or metabolic derangements.
ICU Patients Benefit from Partners in Care
Thompson says intensivists and hospitalists ought to be partners in care. "My own view is that currently there isn’t enough of either to take care of patients in hospitals around the country," she says. "Some sort of chaired effort is absolutely in order."
Thompson adds that the politics between organizations is different from what’s actually happening in hospitals where people are working together. As evidence, she cites St. John Mercy Hospital in St. Louis, where she says intensivists and hospitalists work very comfortably together.
"There’s a kind of moveable wall where one is primary and where the other becomes primary," Thompson says. "I think that’s probably pretty commonplace in many communities."
Nelson agrees, pointing out that hospitals with an increasing number of ICU beds may not find a parallel increase in the number of critical care trained physicians. He says studies that show critical care physician leadership is valuable don’t mean you should exclude everybody else.
"I think there are any number of good ways to organize care in the ICU," Nelson says. "But it will be hard to do with a history of excluding everyone who lacks specialized training in ICU care."
Steinhorn says almost any competent, meticulous medical physician or surgical physician can take care of a large number of patients who are admitted to an ICU. But developing and maintaining critical care skills mandates spending a lot of practice time in a mentored ICU setting.
"Having someone point out what you’re seeing may avoid your having to spend 3 years learning it for yourself," Steinhorn says. "That’s where the role of competent, qualified mentorship during critical care training is vital."
However, Steinhorn says it isn’t realistic for family practitioners or general internists to manage the most complex and sickest patients in the ICU without obtaining consultation and input from people who have dedicated their practice to critical care.
"Two-thirds of our patients can be managed with some degree of competence by meticulous, well-trained physicians," Steinhorn says. "The problem arises when you misjudge your capabilities with a patient in that one-third of more complex patients, and what you’ve done with the ventilator during the first day or two of intensive care has boxed you into a corner on day 4 or 5 of care."
What About More Training for Noncritical Care Personnel?
The shortage of both hospitalists and critical care trained ICU personnel looms large on the horizon. "The ideal is to have people who are trained and present," Harvey says. "But with our manpower shortage, we’re not going to have enough to fulfill either one of those requirements."
Not every physician or nurse who wants to work in an ICU can afford the time and money to acquire 2 or 3 more years of training. Is there an educational path that can provide at least a partial solution?
Steinhorn says that a general internist or family practitioner is unlikely to develop critical care skills unless they spend most of their training time in the intensive care setting.
"I would say that one could at best provide general insights and guidelines for the initial stabilization and management of patients," he says. "But it’s beyond the scope of a conventional general medicine or family practice or OB-GYN training program to give all of the insights and expertise one gains with 3 years of further specialized training."
"You can’t create critical care nurses in a short amount of time," Harvey says. "If all the ICU nurses left the ICU for 4 hours, the mortality rate would be incredible." Harvey says the shortage is a huge problem that requires a large infusion of funds for recruiting, training, and retaining critical care nurses.
"All of the organizations are trying hard to get Congress’s attention," she says. "I’m hopeful about current legislation being passed, but not about having enough critical care physicians or nurses in the next 10-20 years."
In the pediatric realm, Steinhorn says insights and expertise general pediatricians receive in managing very sick patients has been increasingly compromised, perhaps because most general pediatric practices are unlikely to have more than 1 or 2 ICU patients a year.
However, he notes, it is unrealistic to not increase the duration of training programs as the knowledge of the base increases. "Those of us who do pediatric intensive care need to do a minimum of 8-10 weeks a year of nothing but ICU to maintain expertise and insights," he says. "As intensive care has become more specific in therapeutic interventions available and our understandings of disease pathogenesis and how to modify the course of diseases, it has become as specialized as cardiology is from nephrology."
However the training issue shakes out, Thompson says that the person with the greatest expertise from training should be the one who has the greatest input into management of the critically ill patient.
"Cooperation and collaboration are absolutely essential," she says. "When we fight over these things it doesn’t benefit anyone. We need to figure out ways to work well together rather than to struggle over whose space it is."