Role of the Intensivist Physician
Although there are no definitive data about the preferred structure
of ICUs, there is much more evidence supporting the role of the intensivist in the
management of critically ill patients. For general and subspecialty patient populations,
most studies suggest that critically ill patients
should be cared for by an intensivist. For example, Pronovost and associates[6]
studied whether the organizational characteristics of ICUs could influence outcome
in patients undergoing abdominal aortic aneurysm (AAA) surgery. They analyzed almost
3000 patients who underwent AAA repair in the state of Maryland and found that in
risk-adjusted patients, not having daily ICU rounds by an intensivist was associated
with a threefold increase in mortality.[6]
In addition
to increased mortality, the patients not seen by an intensivist also had increased
risk of cardiac arrest, renal failure, septicemia, platelet transfusion, and reintubation.
[6]
In a large meta-analysis examining physician staffing and outcomes
for critically ill patients, Pronovost and colleagues[3]
compared "low-intensity" ICU staffing, with no or elective intensivist consultation,
with "high-intensity" staffing, with mandatory intensivist consultation or a closed
ICU. This study found that the relative risk of hospital mortality was reduced 29%
and the relative risk of ICU mortality was reduced by 39% high-intensity staffing.
[3]
Table
74-2
demonstrates the overall impact of intensivist staffing on ICU mortality.
This and other studies have led to significant consumer and regulatory pressure
mandating that intensivists staff all ICUs. The Leapfrog Group (www.leapfroggroup.org)
was established by the Business Roundtable, which consists of the chief executive
officers of several large corporations. These corporations purchase health insurance
for more than 34 million health care consumers and therefore have considerable influence
on health policy. The Business Roundtable established the Leapfrog Group to "work
with medical experts throughout the United States to identify problems and propose
solutions that it believes will improve hospital systems that could break down and
harm patients." One of the first recommendations by this group was that trained
intensivists should staff ICUs. Although this recommendation
TABLE 74-2 -- Impact of intensivist staffing on intensive care unit mortality*
|
Source |
Risk Ratio |
95% CI |
|
Brown and Sullivan[193]
|
0.48 |
0.32–0.72 |
|
Baldock et al[194]
|
0.69 |
0.52–0.91 |
|
Kuo et al[195]
|
0.6 |
0.49–0.73 |
|
Al Asadi et al[196]
|
0.82 |
0.61–1.10 |
|
Ghorra et al[5]
|
0.42 |
0.20–0.90 |
|
Manthous et al[197]
|
0.71 |
0.54–0.94 |
|
Marini et al[198]
|
0.54 |
0.26–1.10 |
|
Pollack et al[199]
|
0.53 |
0.17–1.64 |
|
Reich et al[200]
|
0.61 |
0.41–0.92 |
|
DiCosmo[201]
|
0.59 |
0.44–0.79 |
|
Rosenfeld et al[202]
|
0.15 |
0.05–0.50 |
|
Goh et al[203]
|
0.38 |
0.27–0.53 |
|
Topell[204]
|
1.44 |
1.00–2.07 |
|
Overall values |
0.61 |
0.5 |
|
Adapted from Pronovost PJ, Angus DC, Dorman T, et
al: Physician staffing patterns and clinical outcomes in critically ill patients:
A systematic review. JAMA 288:2151–2162, 2002. |
has a strong evidence base, the other Leapfrog recommendations are not as strongly
supported.[7]
In addition to the factors discussed
earlier, these pressures will create a significant demand for trained intensivists.
