Question about Intensivist

[MD Dreams]

Does a board certified Intensivist make all the decisions regarding the care of ICU patients or does he/she consult other specialties such as renal, cardio, etc?

Also, would an Intensivitst be comfortable reading the main imaging studies used in the ICU (not the high end stuff that only radiologists can read, rather the garden variety x-rays, CT scans, etc.)?

Thank you.

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[southerndoc]

Any consultant only offers suggestions. It is (and should be) the responsibility of the primary provider (in this case the intensivist) to use those suggestions/recommendations. For instance, a cardiologist might state that a cardiac tamponade is possible and the patient should have a pericardiocentesis. However, the intensivist isn't obligated to do it, but usually does listen and implement suggestions made by consultants. Consultants should never be doing anything to the patient or entering orders on a patient. That is the responsibility of the primary provider/team.

 

[Eidolon6]

Does a board certified Intensivist make all the decisions regarding the care of ICU patients or does he/she consult other specialties such as renal, cardio, etc?

Also, would an Intensivitst be comfortable reading the main imaging studies used in the ICU (not the high end stuff that only radiologists can read, rather the garden variety x-rays, CT scans, etc.)?

Thank you.

Depends on the ICU model. An open ICU may employ an intensivist as a consultant in which another physician requests things like ventilator, ARDS or sepsis management.

In the closed ICU model, the intensivist acts as the admitting attending of record and is responsible for primary decision making, guided as they see fit, the recommendations of consultants.

As for radiography...most intensivists are fairly skilled in reading CXRs, chest and abdominal CTs and some cranial imaging. This is oft a necessity when waiting for the radiology reading is not an option. Some are also cross-trained in performing and interpreting echo and ultrasound...

 

[Wallachia]

Any consultant only offers suggestions. It is (and should be) the responsibility of the primary provider (in this case the intensivist) to use those suggestions/recommendations. For instance, a cardiologist might state that a cardiac tamponade is possible and the patient should have a pericardiocentesis. However, the intensivist isn't obligated to do it, but usually does listen and implement suggestions made by consultants. Consultants should never be doing anything to the patient or entering orders on a patient. That is the responsibility of the primary provider/team.

so if as a cardiology consultant you see a patient in vtach, you walk outside the room as a consultant and write in orders for defibrillation?

 

[southerndoc]

so if as a cardiology consultant you see a patient in vtach, you walk outside the room as a consultant and write in orders for defibrillation?

Give me a break. Let's be realistic here. There is a difference in being a consultant for something that's ongoing v. something that is emergent and immediately life-threatening.

 

[waterski232002]

so if as a cardiology consultant you see a patient in vtach, you walk outside the room as a consultant and write in orders for defibrillation?

Anyone who consults cardiology for a patient in pulseless V-tach needs to go back through med school (or better be in psych, derm, or ortho).

Congratulations, you've killed your first patient!

 

[rn29306]

Any consultant only offers suggestions. It is (and should be) the responsibility of the primary provider (in this case the intensivist) to use those suggestions/recommendations. For instance, a cardiologist might state that a cardiac tamponade is possible and the patient should have a pericardiocentesis. However, the intensivist isn't obligated to do it, but usually does listen and implement suggestions made by consultants. Consultants should never be doing anything to the patient or entering orders on a patient. That is the responsibility of the primary provider/team.

Hey southerndoc...that is an interesting perspective of ICU training, something I have never seen. What part of the country are you specifically speaking? And is the above model where consultants don't order...orders on the patient, is that strictly the model you have seen?

I have worked at a fair amount of private practice ICUs in Atlanta, Georgia (insert your favorite Georgia joke here) and the primary care MD consults out to the respective needed consultants....and the consultants do indeed write orders and procedural / pharmacologic intervention. I have seen a fair amount of not so pleasant interactions because of what one physician perceived as violating another physician in his or her 'specialty', but for the most part it works very well.

Do you think this is a teaching rule or have you seen this in private practice?
Thanks for the clarification.

 

[waterski232002]

the primary care MD consults out to the respective needed consultants....and the consultants do indeed write orders and procedural / pharmacologic intervention. I have seen a fair amount of not so pleasant interactions because of what one physician perceived as violating another physician in his or her 'specialty', but for the most part it works very well.

Do you think this is a teaching rule or have you seen this in private practice?
Thanks for the clarification.

You are correct rn29306... It all depends on the Unit model of the hospital you are in (open vs closed ICU, academic vs community).

In general, Academic hospitals tend to have closed ICUs where there is dedicated Cricital Care attendings, residents, students who are responsible for managing the patients overall care. Consultants do not write orders, but make suggestions as southerndoc pointed out. It is up to the primary team to decide if they would like to implement the rec's. This is possible because the primary team is focused on ICU care and is usually in the unit all day managing their patients and can frequently check on the patient, re-assess, and check consultant rec's throughout the day. They also tend to round at least twice per day on their patients.

In general, Community hospitals tend to have open ICUs (due to the CCM attending shortage in the US, although more are changing to closed units). In this model, the primary care doctor (IM, FP) will manage the patient's overall care and he will consult subspecialties as needed. Of course, IM/FP doc's have tons of other patients both in clinic and on the wards which require attention too. In general, they only round briefly on their patient in the morning and will not have time to re-round. There is usually no dedicated staff (attendings, residents, medical students) who continually manage the patient, so when consultants come by, they write their orders for labs and pharmacotherapy in the chart to be executed. However, large interventions or drastic changes in management or potentially controversial/hazy recommendations are usually written in the note for the Primary doctor to consider(not ordered)... if it is emergent, the primary doctor should be paged and notified before extreme measures are taken, otherwise, the consultant has free range. The reason for this, is that the primary doctor is not in the ICU and a rec in the note probably won't be seen by the primary doc for nearly 24 hours, and then won't be executed by nursing for almost 30 hrs. Of course, this could be catastrophic in a critically ill patient.

This is also why open units are changing to closed units, and another reason why the push is for ICU's to be staffed by dedicated critical care doctors, not the primary doctors.

 

[rn29306]

During the time I was in Atlanta, our pulmonary group essentially acted as the ICU docs. The pulmonary group itself was basically a dumping ground for the ER as these guys would admit ANYONE, even neuro (then of course consult neuro). The PAs for the group mostly took care of the floor stuff and the MDs rounded in the units. We were a part of a multi-system healthcare group and at least two pulmonary MDs were at our site during most of the day.

Right before I left to go to CRNA school, the pulmonary MDs had it out with hopsital administrators (imagine that) and therefore did not admit anyone, except with pulmonary issues. Thus primary practice docs now had to come into the unit and deal with issues I'm sure they had not had to deal with for some time. Needless to say, it was a major adjustment for everyone.

So I have been on both sides of the fence...and I like having dedicated ICU physicians. It appears the delivery of medicine was much more congruent and efficient. But that's just me.

 

[rn29306]

The reason for this, is that the primary doctor is not in the ICU and a rec in the note probably won't be seen by the primary doc for nearly 24 hours, and then won't be executed by nursing for almost 30 hrs. Of course, this could be catastrophic in a critically ill patient.

That's a terrible method of managing unit patients or any pt for that matter.

 

[MD Dreams]

To me it seems a lot safer for the patient to be in a closed unit. I'm not sure if primary care physicians have the training and experience required to take care of those sick patients, especially if they all the other stuff to worry about.

 

[waterski232002]

During the time I was in Atlanta, our pulmonary group essentially acted as the ICU docs. The pulmonary group itself was basically a dumping ground for the ER as these guys would admit ANYONE, even neuro (then of course consult neuro).

Welcome to the real world of community hospitals across the country. The Medicine/Hospitalist service is always the dumping ground of the ER. Nobody gets admitted to subspecialty services... they only consult. This is the norm, your hospital in Atlanta is no exception.

Prior to 5 years ago, there were virtually no IM practicing hospitalists... At places which had pulmonary docs, they tended to function as the hospitalist service so they could admit floor patients AND manage ICU patients as well. It was safer than having PMDs admit over the phone (when available).

As far as the lag time for consultants writing rec's... that's why community hospitals let consultants write orders immediately (not rec's)... it's to prevent a 30 hr lag time, which doesn't occur at academic hospitals where there is 24 hr resident coverage.

This is all very standard care at community hospitals.

 

[threepeas]

I know this is not the direct question being asked, but here are the major articles regarding closed and open icus.

Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. AUPronovost PJ; Angus DC; Dorman T; Robinson KA; Dremsizov TT; Young TL SOJAMA 2002 Nov 6;288(17):2151-62. CONTEXT: Intensive care unit (ICU) physician staffing varies widely, and its association with patient outcomes remains unclear. OBJECTIVE: To evaluate the association between ICU physician staffing and patient outcomes. DATA SOURCES: We searched MEDLINE (January 1, 1965, through September 30, 2001) for the following medical subject heading (MeSH) terms: intensive care units, ICU, health resources/utilization, hospitalization, medical staff, hospital organization and administration, personnel staffing and scheduling, length of stay, and LOS. We also used the following text words: staffing, intensivist, critical, care, and specialist. To identify observational studies, we added the MeSH terms case-control study and retrospective study. Although we searched for non-English-language citations, we reviewed only English-language articles. We also searched EMBASE, HealthStar (Health Services, Technology, Administration, and Research), and HSRPROJ (Health Services Research Projects in Progress) via Internet Grateful Med and The Cochrane Library and hand searched abstract proceedings from intensive care national scientific meetings (January 1, 1994, through December 31, 2001). STUDY SELECTION: We selected randomized and observational controlled trials of critically ill adults or children. Studies examined ICU attending physician staffing strategies and the outcomes of hospital and ICU mortality and length of stay (LOS). Studies were selected and critiqued by 2 reviewers. We reviewed 2590 abstracts and identified 26 relevant observational studies (of which 1 included 2 comparisons), resulting in 27 comparisons of alternative staffing strategies. Twenty studies focused on a single ICU. DATA SYNTHESIS: We grouped ICU physician staffing into low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. High-intensity staffing was associated with lower hospital mortality in 16 of 17 studies (94%) and with a pooled estimate of the relative risk for hospital mortality of 0.71 (95% confidence interval [CI], 0.62-0.82). High-intensity staffing was associated with a lower ICU mortality in 14 of 15 studies (93%) and with a pooled estimate of the relative risk for ICU mortality of 0.61 (95% CI, 0.50-0.75). High-intensity staffing reduced hospital LOS in 10 of 13 studies and reduced ICU LOS in 14 of 18 studies without case-mix adjustment. High-intensity staffing was associated with reduced hospital LOS in 2 of 4 studies and ICU LOS in both studies that adjusted for case mix. No study found increased LOS with high-intensity staffing after case-mix adjustment. CONCLUSIONS: High-intensity vs low-intensity ICU physician staffing is associated with reduced hospital and ICU mortality and hospital and ICU LOS. ADDepartment of Critical Care Medicine, Hopkins University, Baltimore, Md, USA. PMID12413375 20 TIA "closed" medical intensive care unit (MICU) improves resource utilization when compared with an "open" MICU. AUMultz AS; Chalfin DB; Samson IM; Dantzker DR; Fein AM; Steinberg HN; Niederman MS; Scharf SM SOAm J Respir Crit Care Med 1998 May;157(5 Pt 1):1468-73. We hypothesized that a "closed" intensive care unit (ICU) was more efficient that an "open" one. ICU admissions were retrospectively analyzed before and after ICU closure at one hospital; prospective analysis in that ICU with an open ICU nearby was done. Illness severity was gauged by the Mortality Prediction Model (MPM0). Outcomes included mortality, ICU length of stay (LOS), hospital LOS, and mechanical ventilation (MV). There were no differences in age, MPM0, and use of MV. ICU and hospital LOS were lower when "closed" (ICU LOS: prospective 6.1 versus 12.6 d, p < 0.0001; retrospective 6.1 versus 9.3 d, p < 0.05; hospital LOS: prospective 19.2 versus 33.2 d, p < 0.008; retrospective 22.2 versus 31.2 d, p < 0.02). Days on MV were lower when "closed" (prospective 2.3 versus 8.5 d, p < 0.0005; retrospective 3.3 versus 6.4 d, p < 0.05). Pooled data revealed the following: MV predicted ICU LOS; ICU organization and MPM0 predicted days on MV; MV and ICU organization predicted hospital LOS; mortality predictors were open ICU (odds ratio [OR] 1.5, p < 0.04), MPM0 (OR 1.16 for MPM0 increase 0.1, p < 0.002), and MV (OR 2.43, p < 0.0001). We conclude that patient care is more efficient with a closed ICU, and that mortality is not adversely affected. ADDivision of Pulmonary and Critical Care Medicine, Long Island Jewish Medical Center, Albert Einstein College of Medicine, New Hyde Park, New York 11040, USA. PMID9603125 21 TIIntensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. AUDimick JB; Pronovost PJ; Heitmiller RF; Lipsett PA SOCrit Care Med 2001 Apr;29(4):753-8. OBJECTIVE: To determine whether having daily rounds by an intensive care unit (ICU) physician is associated with clinical and economic outcomes after esophageal resection. DESIGN: ICU information was obtained from a prospective survey and linked to retrospective patient data from the Maryland Health Services Cost Review Commission. The main outcome variables were in-hospital mortality rate, length of stay, hospital cost, and complications after esophageal resection. SETTING: Nonfederal acute care hospitals in Maryland that performed esophageal resection (n = 35 hospitals) during the study period, 1994-1998. PATIENTS: Adult patients who underwent esophageal resection in Maryland (n = 366 patients) from 1994 to 1998. INTERVENTIONS: Presence vs. absence of daily rounds by an ICU physician. MEASUREMENTS AND MAIN RESULTS: After adjusting for patient case-mix and other hospital characteristics, lack of daily rounds by an ICU physician was independently associated with a 73% increase in hospital length of stay (7 days; 95% confidence interval [CI], 1-15; p =.012) and a 61% increase in total hospital cost ($8,839; 95% CI, $ 1,674-$19,192; p =.013), but there was no association with in-hospital mortality rate. In addition, the following postoperative complications were independently associated with lack of daily rounds by an ICU physician: pulmonary insufficiency (odds ratio [OR], 4.0; CI, 1.4-11.0), renal failure (OR, 6.3; CI, 1.4-28.7), aspiration (OR, 1.7; CI, 1.0-2.8), and reintubation (OR, 2.8; CI, 1.5-5.2). CONCLUSIONS: Having daily rounds by an ICU physician is associated with shorter lengths of stay, lower hospital cost, and decreased frequency of postoperative complications after esophageal resection. Healthcare providers and policymakers should use this information to help improve quality of care and reduce costs for patients undergoing high-risk surgical procedures. ADDepartment of Surgery, The Johns Hopkins University School of Medicine and Hygiene and Public Health, Baltimore, MD, USA. PMID11373463 22 TIOn-site physician staffing in a community hospital intensive care unit. Impact on test and procedure use and on patient outcome. AULi TC; Phillips MC; Shaw L; Cook EF; Natanson C; Goldman L SOJAMA 1984 Oct 19;252(15):2023-7. To determine whether on-site physician staffing changed test and procedure use and improved patient outcome in a community hospital intensive care unit (ICU), we studied all ICU admissions for matched periods before and after the staffing change. Compared with the 463 year-1 patients, the 491 year-2 patients were no more likely to receive life-support interventions (respirators, dialysis, or pacemakers), but had substantially more monitoring interventions, such as pulmonary artery catheters (22% v 2%, P less than .0001) and arterial catheters (9% v 0%, P less than .0001). After controlling for factors that predicted death (age, mental status at time of admission, reason for ICU admission), year-2 patients were significantly more likely to survive the ICU and subsequent hospital stay (P = .01). Nearly all of the improvement of survival rate took place among patients with intermediate likelihoods of death; this improved survival rate persisted at the 12-month follow-up (P = .01). PMID6481908 23 Effect on ICU mortality of a full-time critical care specialist. AUBrown JJ; Sullivan G SOChest 1989 Jul;96(1):127-9. APACHE II scoring was obtained retrospectively on patients admitted to the ICU of a university hospital for two consecutive years. During the first year the patients were treated by their attending physician (group 1); during the second year, by a trained critical care specialist in cooperation with the attending physician (group 2). There were 223 patients in group 1 and 216 in group 2. The mean APACHE II scores were equivalent (group 1, 19.0 +/- 9.1 vs group 2, 18.3 +/- 8.2, p = NS). ICU mortality was reduced by 52 percent (group 1, 27.8 percent mortality vs group 2, 13.4 percent mortality p less than 0.01) and overall hospital mortality was reduced 31.0 percent (group 1, 35.5 percent vs group 2, 24.5 percent, p less than 0.01). No increased significance in ICU or hospital mortality reduction could be shown between subgroups of patients with APACHE II scores of 0 to 14, 15 to 24, and greater than 25. This retrospective analysis suggests that a full-time, trained critical care specialist may have made a significant impact on the management of critically ill patients at our institution. ADFaculty of Medicine, Section of Respiratory Diseases, University of Manitoba, Winnipeg, Canada. PMID2736969 24 Effects of organizational change in the medical intensive care unit of a teaching hospital: a comparison of 'open' and 'closed' formats. AUCarson SS; Stocking C; Podsadecki T; Christenson J; Pohlman A; MacRae S; Jordan J; Humphrey H; Siegler M; Hall J SOJAMA 1996 Jul 24-31;276(4):322-8. OBJECTIVE: To compare the effects of change from an open to a closed intensive care unit (ICU) format on clinical outcomes, resource utilization, teaching, and perceptions regarding quality of care. DESIGN: Prospective cohort study; prospective economic evaluation. SETTING: Medical ICU at a university-based tertiary care center. For the open ICU, primary admitting physicians direct care of patients with input from critical care specialists via consultation. For the closed ICU, critical care specialists direct patient care. PATIENTS: Consecutive samples of 124 patients admitted under an open ICU format and 121 patients admitted after changing to a closed ICU format. Readmissions were excluded. MAIN OUTCOME MEASURES: Comparison of hospital mortality with mortality predicted by the Acute Physiology and Chronic Health Evaluation II (APACHE II) system; duration of mechanical ventilation; length of stay; patient charges for radiology, laboratory, and pharmacy departments; vascular catheter use; number of interruptions of formal teaching rounds; and perceptions of patients, families, physicians, and nurses regarding quality of care and ICU function. RESULTS: Mean +/- SD APACHE II scores were 15.4 +/- 8.3 in the open ICU and 20.6 +/- 8.6 in the closed ICU (P=.001). In the closed ICU, the ratio of actual mortality (31.4 percent) to predicted mortality (40.1 percent) was 0.78. In the open ICU, the ratio of actual mortality (22.6 percent) to predicted mortality (25.2 percent) was 0.90. Mean length of stay for survivors in the open ICU was 3.9 days, and mean length of stay for survivors in the closed ICU was 3.7 days (P=.79). There were no significant differences between periods in patient charges for radiology, laboratory, or pharmacy resources. Nurses were more likely to say that they were very confident in the clinical judgment of the physician primarily responsible for patient care in the closed ICU compared with the open ICU (41 percent vs 7 percent; P<.Ol), and nurses were the group most supportive of changing to a closed ICU format before and after the study. CONCLUSIONS: Based on comparison of actual to predicted mortality, changing from an open to a closed ICU format improved clinical outcome. Although patients in the closed ICU had greater severity of illness, resource utilization did not increase. ADDepartment of Medicine, University of Chicago, IL 60637, USA. PMID8656546