Critical care delivery in the United States: Distribution of services and compliance with Leapfrog recommendations*

Angus, Derek C.; Shorr, Andrew F.; White, Alan; Dremsizov, Tony T.; Schmitz, Robert J.; Kelley, Mark A.

doi:10.1097/01.ccm.0000206105.05626.15

Cited by 418 publications

(296 citation statements)

References 34 publications

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“…This finding is consistent with evidence from the United States, where it has been demonstrated that less than half of the ICUs had coverage by an intensivist or a dedicated physician. 17 However, before determining the projected workforce needed to staff an expanded number of critical care beds, problems with intensivist shortages, physician burnout, and rising physician costs may lead to further difficulties in the appropriate staffing of current ICUs that lack intensivists. 18,19 Some issues regarding rising physician costs may be mitigated by the potential health care savings generated by intensivist staffing.…”

Section: Discussionmentioning

confidence: 99%

“…Additionally, while the data may be specific to Ontario, it is consistent with other reports that highlight the need for significant planning for the delivery of critical care services. 3,8 In conclusion, the combination of an aging population and inefficiencies in the management of critical care services will not only be a major challenge to the delivery of critical care over the coming years, but will also have a major impact on patients and their health care providers. It is evident that a rather dramatic fiscal investment in the critical care environment will be needed, together with a significant increase in the number of health care workers.…”

Section: Discussionmentioning

confidence: 99%

“…2 Given advances in technology and therapeutics and an aging population, current evidence suggests that the demand for critical care services will increase. 3,4 It is expected that the severe shortages in critical care human resources will result in further challenges to the current health care system. 3 The 2003 outbreak of severe acute respiratory syndrome (SARS) in Ontario, Canada resulted in tremendous pressures on the critical care system.…”

Section: Introductionmentioning

confidence: 99%

“…3,4 It is expected that the severe shortages in critical care human resources will result in further challenges to the current health care system. 3 The 2003 outbreak of severe acute respiratory syndrome (SARS) in Ontario, Canada resulted in tremendous pressures on the critical care system. 5,6 The unexpected influx of approximately 80 SARS patients, coupled with closures of several hospitals due to quarantine, highlighted not only a shortage of critical care capacity but also a system that was functioning at or above capacity with little or no ability to respond appropriately to unexpected surges in demand.…”

Section: Introductionmentioning

confidence: 99%

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Critical care services in Ontario: a survey-based assessment of current and future resource needs

Hill

Fan

Stewart

et al. 2009

Can J Anesth/J Can Anesth

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Purpose In response to the challenges of an aging population and decreasing workforce, the provision of critical care services has been a target for quality and efficiency improvement efforts. Reliable data on available critical care resources is a necessary first step in informing these efforts. We sought to describe the availability of critical care resources, forecast the future requirement for the highestlevel critical care beds and to determine the physician management models in critical care units in Ontario, Canada. Methods In June 2006, self-administered questionnaires were mailed to the Chief Executive Officers of all acute care hospitals, identified through the Ontario government's hospital database. The questionnaire solicited information on the number and type of critical care units, number of beds, technological resources and management of each unit.Results Responses were obtained from 174 (100%) hospitals, with 126 (73%) reporting one or more critical care units. We identified 213 critical care units in the province, representing 1789 critical care beds. Over half (59%) of these beds provided mechanical ventilation on a regular basis, representing a capacity of 14.9 critical care and 8.7 mechanically ventilated beds per 100,000 population. Sixty-three percent of units with capacity for mechanical ventilation involved an intensivist in admission and coordination of care. Based on current utilization, the demand for mechanically ventilated beds by 2026 is forecast to increase by 57% over levels available in 2006. Assuming 80% bed utilization, it is estimated that an additional 810 ventilated beds will be needed by 2026. Conclusion Current utilization suggests a substantial increase in the need for the highest-level critical care beds over the next two decades. Our findings also indicate that non-intensivists direct care decisions in a large number of Dr. Sibbald is deceased.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Critical care services in Ontario: a survey-based assessment of current and future resource needs

Hill

Fan

Stewart

et al. 2009

Can J Anesth/J Can Anesth

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“…First, our data are derived from Medicare for a single year, and thus we cannot evaluate whether transfer patterns are different for nonMedicare patients or how they might change over time. However, over half of ICU patients are elderly, (41) and Medicare is a domain of public policy interest in its own right. Second, our data reflect transfers between critical care hospitalizations; limitations in the data prevent us from examining only direct ICU-to-ICU transfers.…”

Section: Discussionmentioning

confidence: 99%

The Structure of Critical Care Transfer Networks.

Iwashyna¹

2006

Critical Care Medicine

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Rationale-Moving patients from low performing hospitals to high performing hospitals may improve patient outcomes. These transfers may be particularly important in critical care, where small relative improvements can yield substantial absolute changes in survival.Objective-To characterize the existing critical care network in terms of the pattern of transfers.Methods-In a retrospective cohort study, the nationwide 2005 Medicare fee-for-service claims were used to identify the interhospital transfer of critically ill patients, defined as instances where patients used critical care services in 2 temporally adjacent hospitalizations.Measurements-We measured the characteristics of the interhospital transfer network and the extent to which ICU patients are referred towards each hospital in that network, a continuous quantitative measure at the hospital-level known as centrality. We evaluated associations between hospital centrality and organizational, medical, surgical and radiologic capabilities.Results-There were 47,820 transfers of critically ill patients among 3,308 hospitals. 4.5% of all critical care stays of any length involved an inter-hospital critical care transfer. Hospitals transferred out to a mean of 4.4 other hospitals. More central hospital position was associated with multiple indicators of increased capability. Hospital characteristics explained 40.7% of the variance in hospitals' centrality.Conclusions-Critical care transfers are common, and traverse an informal but structured network. The centrality of a hospital is associated with increased capability in delivery of services, suggesting that existing transfers generally direct patients toward better resourced hospitals. Studies of this network promise further improvements in patient outcomes and efficiency of care.Critical illness is a common and growing part of American medicine. (1) In this paper, we provide the first description of the informal system that has evolved for transferring critically ill Medicare beneficiaries among hospitals. Using nationwide data for 2005, we document the incidence of inter-hospital critical care transfers, and characterize the transfer network. In addition, we test two pre-specified hypotheses about the flow patients in the critical care network. "Centrality" is a hospital-level variable that quantifies the extent to which patients flow towards each hospital. (21) Most fundamentally, hospitals transfer more patients to central hospitals. We define centrality formally in the Methods. We hypothesized that observable hospital organizational characteristics and capabilities (organizational, medical, surgical, and radiologic capabilities) are associated with hospital centrality. Second, we hypothesized that the significant variation between hospitals' centrality in the network is associated with specified hospital characteristics. METHODS Analytic ApproachWe measured the interhospital transfer system using the tools of network analysis. Hospitals are the nodes in the network. Hospitals are connected by trans...

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The Effect of Multidisciplinary Care Teams on Intensive Care Unit Mortality

et al. 2010

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Background Critically ill patients are medically complex and may benefit from a multidisciplinary approach to care. Methods We conducted a population-based retrospective cohort study of medical patients admitted to Pennsylvania acute hospitals (N=169) from July 1, 2004 to June 30, 2006, linking a statewide hospital organizational survey to hospital discharge data. Multivariate logistic regression was used to determine the independent relationship between daily multidisciplinary rounds and 30-day mortality. Results 112 hospitals and 107,324 patients were included in the final analysis. Overall 30-day mortality was 18.3%. After adjusting for patient and hospital characteristics, multidisciplinary care was associated with significant reductions in the odds of death (OR=0.84, 95% CI: 0.76–0.93, p=0.001). When stratifying by intensivist physician staffing, the lowest odds of death were in ICUs with high-intensity physician staffing and multidisciplinary care teams (OR=0.78, 95% CI: 0.68–0.89, p<0.0001), followed by ICUs with low intensity physician staffing and multidisciplinary care teams (OR=0.88, 95%CI: 0.79–0.97, p=0.014), compared to hospitals with low intensity physician staffing but without multidisciplinary care teams. The effects of multidisciplinary care were consistent across key subgroups including patients with sepsis, patients requiring invasive mechanical ventilation, and patients in the highest quartile of severity of illness Conclusions Daily rounds by a multidisciplinary team are associated with lower mortality among medical ICU patients. The survival benefit of intensivist physician staffing is in part explained by the presence of multidisciplinary teams in high-intensity staffed ICUs.

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Critical care delivery in the United States: Distribution of services and compliance with Leapfrog recommendations*

Cited by 418 publications

References 34 publications

Critical care services in Ontario: a survey-based assessment of current and future resource needs

Critical care services in Ontario: a survey-based assessment of current and future resource needs

The Structure of Critical Care Transfer Networks.

The Effect of Multidisciplinary Care Teams on Intensive Care Unit Mortality

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