This high-intensity model mandates an intensivist consultation for every patient. In addition, the intensivists conduct procedures, such as ventilator management, placement of central lines, and sedation. The hospital medicine service then handles patient medical management. Hospitalists write orders for antibiotics, nutrition, and fluid management. Splitting the patient management with their hospitalist colleagues allows the intensivists to care for more patients than in a completely “closed” ICU. (In “closed” systems, only intensivists are authorized to care for ICU patients.)
For this model to be effective, however, participating hospitalists should have experience and feel comfortable working in the ICU. “I don’t think you would want to pluck the average hospitalist and throw him into the ICU,” cautions Dr. Gropper. “But a hospitalist who started to consistently spend some time in the ICU would be very good. In collaboration with an intensivist, I think it’s a model that allows high-quality patient care.”
Inpatient Physician Associates, a privately owned hospital medicine group in Lincoln, Neb., headed by Brian Bossard, MD, found a slightly different way to collaborate with a group of intensivists to deliver high-quality care at the city’s two community hospitals, BryanLGH Medical Center and St. Elizabeth Regional Medical Center. Dr. Bossard and Bill Johnson, MD, a pulmonologist certified in intensive care, and director of the ICU at both hospitals, crafted an open ICU model. Although intensivists conduct multidisciplinary rounds at Bryan and St. Elizabeth, consults are not mandatory. Hospitalists provide 24/7 coverage, often placing central lines and doing other procedures. Intensivists are available for consultations and more complicated critical care procedures, such as chest tube placement, Swan-Ganz catheters, and difficult ventilator management.
This system evolved out of necessity; the hospitalist program predated the intensivist program at BryanLGH. “When I started the group, we needed docs who were comfortable in the ICU,” explains Dr. Bossard. With the open ICU model, that requirement still applies today.
When recruiting new hospitalists, Dr. Bossard looks for those who function well in the ICU environment, understand evidence-based practice, and have an aptitude for learning procedures. He also seeks out doctors comfortable with cognitive critical care.
The system seems to work.
“There are many patients who are admitted and discharged from the ICU who don’t require an intensivist’s care,” Dr. Bossard says. Hospitalists in his group cooperatively manage most patients, with intensivist consultation.
“We have a very good collaborative approach here,” says Dr. Johnson, adding that it’s difficult to have a closed ICU at a community hospital because of intensivist shortages and resistance from primary care physicians who want access to their patients. The key to the success of the program in Lincoln is that all physicians know their limits. “We don’t force ICU consults upon anybody,” Dr. Johnson says. “But I think the hospitalists do recognize when it benefits them to have the intensivist involved.”
The proof is in the proverbial pudding. Since the co-managed ICU program began in 2006 in Lincoln, the ICU mortality rate has dropped 50%, and there have been no ventilator-acquired pneumonias or central line-related infections for two years.
Ideals Versus Reality
The Leapfrog Group identified around-the-clock coverage of surgical and medical intensive care units by intensivists as one of its three safety standards.5 “In an ideal world,” says Bradley A. Sharpe, MD, associate division chief in the Division of Hospital Medicine at UCSF, “every critically ill patient would be seen, managed, or co-managed by a critical care specialist.”
David A. Hoffmann, DO, agrees certain standards in the ICU should exist, but says community hospitals will never be able to reproduce the academic model. “They don’t have the labor from residencies,” says Dr. Hoffman, medical director of Hospitalists of Franklin County, an HM group at Chambersburg Hospital, a community hospital in Chambersburg, Pa.