Barriers to Implementing the Leapfrog Recommendations

Abstract & Commentary

By David J. Pierson, MD Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington Dr. Pierson reports no financial relationships relevant to this field of study. This article originally appeared in the December 2007 issue of Critical Care Alert. It was peer reviewed by William Thompson, MD.

Synopsis: In this survey of US hospitals, more than half did not have an identifiable ICU director. Loss of autonomy and income for admitting primary physicians were perceived as important barriers to implementation of the Leapfrog Group's ICU physician staffing guidelines.

Source: Kahn JM, et al. Barriers to implementing the Leapfrog Group recommendations for intensivist physician staffing: A survey of intensive care unit directors. J Crit Care. 2007;22:97-103.

This paper reports on a telephone survey of us non-rural hospitals and the physician directors of their ICUs. Kahn and colleagues sought to determine the extent to which the recommendations of the Leapfrog Group about ICU staffing had been implemented, and to clarify the reasons for delays in, or resistance to, such implementation.

Sites were selected at random from hospitals participating in the database maintained by the Committee on Manpower for Pulmonary and Critical Care Societies, which includes US hospitals nationwide. Kahn et al stratified their target ICUs according to hospital size and the population served and classified the hospitals into either academic or community. Their survey addressed 4 domains with respect to the Leapfrog Group recommendations for intensivist staffing: knowledge and perceived utility of the recommendations, current compliance, potential barriers to implementing the recommendations, and possible solutions to these barriers. Seventy-two hospitals were surveyed in late 2003 and early 2004.

Among the 72 hospitals that were approached, 47 (65%) responded to initial telephone inquiries; 26 (55%) of these did not have an identifiable physician ICU director. The ICU directors of the remaining 21 hospitals were interviewed. Eleven (52%) of these considered themselves very familiar with the recommendations. Of the 20 physician ICU directors who answered questions about their respective hospitals' Leapfrog compliance, 8 (40%) considered their units to be Leapfrog-compliant, although only 5 of these ICUs (25%) actually proved to be compliant with all 4 recommendations. Of the 15 directors not in compliance, 13 indicated motivation to become so in the future.

The most significant barrier to implementation of the recommendations was concern over loss of control for physicians who would no longer be providing care to critically ill patients. Loss of income and increased cost to hospital administration were other perceived barriers. Perceived measures of potential importance in overcoming these barriers included increasing the numbers of available intensivists, increasing funds from hospital administrators, and assistance from government and third parties.


The Leapfrog Group is a consortium of health care purchasers formed in 2000 to advocate for improved quality and safety in healthcare. For the ICUs of all US non-rural hospitals, the Leapfrog Group recommends the following as the standard for intensivist staffing:

  • A board-certified or board-eligible intensivist physician should manage or co-manage all patients in the ICU;
  • The intensivist should be present in the ICU during daylight hours, with no competing clini- cal duties;
  • At other times, an intensivist should be able to return ICU pages within 5 minutes; and,
  • Another physician, or a nonphysician extender such as a physician assistant or advance prac- tice nurse certified in caring for critically ill patients, should always be available within 5 minutes of the ICU.

This study suggests that we are still a considerable way from implementing these recommendations. It points out a number of important barriers to such implementation, the most glaring of which is that over half of the hospitals surveyed did not even have an identifiable physician ICU director. As Kahn et al point out, without an ICU director to bring about change, there seems little likelihood that the Leapfrog Group's recommendations for physician staffing can be put into effect.

The cost of hiring intensivists — even if enough of them were readily available, something regarded by many as doubtful — is obviously a key obstacle to be overcome. However, this study points out that there are other important barriers, such as fear of loss of control and income on the part of primary physicians if their ICUs became "closed" through implementation of the Leapfrog guidelines.

Although quite a bit has been published in this subject area, the available evidence supporting the Leapfrog recommendations is hardly definitive, and considerable controversy remains as to whether their implementation would in fact improve the quality of ICU care and/or decrease adverse outcomes across the board. However, despite the limitations of this study, such as the small sample size and the fact that the survey was carried out 4 years ago in a rapidly evolving area, the message seems clear that major changes would have to take place in most US hospitals if the Leapfrog ICU recommendations were actually to be put into effect.