The Value of 24/7 In-House Intensivist Coverage
Hospitals across the country are implementing 24/7 in-house Intensivist coverage. The pressure COVID-19 places on ICUs has accelerated this trend. Regardless of the pandemic’s impact, numerous studies show that in-house Intensivist services positively impact patient outcomes, nursing and provider satisfaction, and overall quality and efficiency, especially in high acuity, high volume hospitals such as tertiary care centers. Our ICU programs reflect these results. After beginning a dedicated ICU program, we consistently see improvements in both quality and efficiency metrics. This post outlines the ICU management best practices we implement to establish a high-functioning ICU program that benefits patients, providers, and hospitals. If you are unsure whether in-house ICU coverage is cost effective and worthwhile for your hospital, consider these benefits.
Effective Management Contains Costs
The salary costs associated with in-house Intensivist coverage are a primary barrier to implementing in-house ICU coverage. However, this thought process may be misleading. Some studies show that there is a favorable cost-benefit ratio associated with dedicated Intensivist coverage, especially in hospitals with larger ICUs. [1] We find that in-house Intensivists often reduce the need for specialist consultations, which helps reduce costs. In addition, they optimize the management of ancillary services, diagnostic procedures, medications, and lab work, which streamlines resource use. These benefits, combined with the reduced Medicare penalties hospitals with in-house ICU coverage see, can have a net-positive effect on your hospital’s bottom line.
Timely Consultations Reduce Length of Stay
Dedicated Intensivists are able to focus entirely on critical care, which expedites ICU care and shortens the length of stay. In-house ICU coverage enables critical care patients to receive virtually immediate (within 15 minutes) Intensivist consultations, no matter when they need critical care. Facilities without dedicated Intensivist coverage often rely on community providers or Hospitalists to manage critical care needs. These providers balance other responsibilities and/or are only available during certain hours. These limitations can hinder patient care quality. In fact, epidemiological studies report that acute care admissions occurring during Intensivist off-hours (i.e., nights and weekends) are independently associated with higher patient mortality. [2] The results of a large Finnish study raise similar concerns, showing that the risk of death while in the ICU was significantly higher during “out of office” times (defined as 4:00 p.m. to 8:00 a.m.) than regular daytime hours.[3]
In addition, the longer a patient stays in the ICU, the higher the risk of complication. So, dedicated Intensivists prioritize helping patients reach mobility goals and/or discontinue ventilation, among other milestones specific to each patient, to help them shorten their stay in the ICU.
Specialized Training, Thorough Communication Improves Leapfrog Scores
A 24/7 Intensivist model improves adherence to evidence-based care protocols, decreases ICU-related complications, and decreases the length of stay.[4] This approach also boosts Leapfrog scores. The focus of Leapfrog’s hospital ratings and its hospital recognition and reward programs includes a range of hospital quality and safety practices. The Leapfrog Group’s recommendations regarding critical care delivery have driven, in-part, the initiative to provide 24/7 Intensivist coverage. One of their recommended practices is to staff with physicians certified in critical care medicine, or “Intensivist physician staffing (IPS).” IPS models are associated with an impressive decrease in ICU-related mortality in hospitals with Intensivist-heavy staffing.[5]
In-house Dedicated Intensivist coverage ensures the sickest patients receive timely care from a board-certified provider with critical care experience. Intensivists have specialized training on intubation, vascular catheters, ventilators, and other common aspects of critical care that Hospitalists and other critical care coverage options may not. This reduces complications and leads to reductions in:
- Medicare penalties
- Length of Stay
- ICU-related complications
- Days on Ventilator
- Hospital-Acquired Conditions (HAC)
- Mortality
- Patient transfers
- Readmission rates
Communication and Care Team Approach Improves Patient Care Quality and Consistency
All experienced Intensivists know that being detail-oriented, calm, and prioritizing thorough communication with patients, patient families, and other providers is key to providing quality critical care. The importance of communication cannot be understated. In our ICU programs, we prioritize meeting with a patient’s family as soon as possible to ensure they are informed. In our experience, involving patients and their families in communication within the first 72 hours of care is crucial, especially when it comes to palliative care discussions. Setting goals and realistic expectations positively impacts patient satisfaction.
We also take a care team approach to daily patient rounds to make sure that key members of each patient’s care team, such as case management, nursing, respiratory, dietetics, rehabilitation, and pharmacy, are involved. This multi-disciplinary approach improves throughput, provides an effective communication channel among the critical care team, and improves patient care quality. During rounds, our critical care teams use an evidenced-based ICU bundle checklist to track key metrics such as patient blood sugar and days on ventilator, catheter, and prophylactics. This checklist is intended to ensure each patient receives detail-oriented, high-quality care and that corrective actions are taken quickly if issues arise. Every month, leaders from each team involved in multi-disciplinary ICU rounds meet to review the bundle and identify opportunities for improvement.
In-House Support Increases Nurse and Provider Satisfaction, Effective Patient Transfers
Reduced Burden on Providers and Nursing: 24/7 Intensivist coverage benefits patients first and foremost. It also positively impacts provider and nurse satisfaction. A dedicated ICU program frees up community physicians and Hospitalists to focus on their primary practice responsibilities. Without ample, dedicated Intensivist coverage, burnout from juggling priorities among providers is common. Our Intensivists work with other specialists to co-manage inpatient care. Specialists who also manage an outpatient practice appreciate the support on in-hospital Intensivists because the Intensivist manages their patient’s critical conditions, allowing them to concentrate on the primary cause of hospitalization.
In addition to alleviating the burden on providers, dedicated Intensivist coverage also improves nurse satisfaction. Nurses appreciate in-house Intensivist coverage because it represents being able to help a patient right away or having to call an offsite specialist to help a patient.
“HAVING IN-HOUSE INTENSIVISTS HELPS OUR NURSES CARE FOR PATIENTS. WE ARE ABLE TO ASSIST NURSES RIGHT AWAY, WITHOUT THEM HAVING TO CALL OFFSITE SPECIALISTS. OUR METRICS SPEAK FOR THEMSELVES: WE SHORTEN LENGTH OF STAY, LOWER DAYS ON VENTILATOR, REDUCE COMPLICATIONS, AND IMPROVE THE PATIENT AND PATIENT-FAMILY EXPERIENCE.”
ZAFIA ANKLESARIA, MD, ICU MEDICAL DIRECTOR, CALIFORNIA HOSPITAL MEDICAL CENTER
Positive Relationships with Community Providers: A key best practice we follow in our ICU programs is building a strong, collaborative relationship with community providers. We find that this prevents undue complications around the transfer of patients. We hold routine meetings between Intensivists, hospital administration, and care providers in the community to streamline processes and improve patient experience.
More Effective Patient Transfers: Handoffs are the most vulnerable points in the care of our patients. When transitions of care are ineffective, there are higher rates of adverse events, hospital readmissions, and healthcare costs. According to The Joint Commission (TJC), communication gaps that often occur during a patient handoff are estimated to contribute to 80% of medical errors.[6] That is why we prioritize making patient hand-offs and sign-outs detailed and effective. When possible, we work to ensure handoffs are in-person and include a thorough outline of patient complaints, pertinent history and labs, and criteria for admission and appropriate transfer to a lower level of care.
“…EVIDENCE HAS CONVINCED ADVOCACY GROUPS TO ADOPT THIS STAFFING MODEL AS A STANDARD OF CARE IN THE ICU SO THAT MORE HOSPITALS ARE OFFERING AROUND-THE-CLOCK INTENSIVIST COVERAGE. EVEN SO, OPPONENTS HAVE POINTED TO HIGH ICU STAFFING COSTS AND A SHORTAGE OF PHYSICIANS TRAINED IN CRITICAL CARE AS BARRIERS TO IMPLEMENTING THIS MODEL. WHILE THESE ARGUMENTS MAY HOLD TRUE IN LOW-ACUITY, LOW-VOLUME ICUS, EVIDENCE HAS SHOWN THAT IN HIGH-ACUITY, HIGH-VOLUME CENTERS SUCH AS TEACHING HOSPITALS AND TERTIARY CARE CENTERS, THE BENEFITS OUTWEIGH THE COSTS.”
SOURCE: IS 24/7 IN-HOUSE INTENSIVIST STAFFING NECESSARY IN THE INTENSIVE CARE UNIT?
Bottom Line: Dedicated ICU Coverage can Lead to Overall Economic Benefits and Improved Patient Outcomes, especially for High-Volume, High-Acuity Hospitals
Due to the effectiveness of 24/7 in-house Intensivist coverage, the American College of Critical Care Medicine and the Society of Critical Care Medicine recommend it as the ideal model. It is preferred because it benefits patients, providers, and hospitals. Beyond that, optimizing ICU staffing with 24/7 in-house coverage (or tele-ICU support for smaller hospitals) ensures that patients who are acutely ill receive the level of care we would want for ourselves and our loved ones, no matter when they need it.
[1] https://www.atsjournals.org/doi/full/10.1164/rccm.201004-0651ED
[2] https://www.atsjournals.org/doi/full/10.1164/rccm.201004-0651ED
[3] https://www.atsjournals.org/doi/full/10.1164/rccm.201004-0651ED
[4] https://www.atsjournals.org/doi/full/10.1164/rccm.201004-0651ED
[5] https://www.atsjournals.org/doi/full/10.1164/rccm.201004-0651ED