© 2009 on the cusp: stop bsi icu physician staffing
TRANSCRIPT
© 2009
On the CUSP: STOP BSI On the CUSP: STOP BSI ICU Physician StaffingICU Physician Staffing
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Learning ObjectivesLearning Objectives
• To review the evidence on the benefits of ICU physician staffing
• To explore strategies to improve ICU physician staffing
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Organizing Principles for Intensive Organizing Principles for Intensive CareCare
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Intensivists Reduce Mortality Intensivists Reduce Mortality CostsCosts
Question is not Whether to but How to implement IPS
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Intensivists Reduce Mortality:Intensivists Reduce Mortality:Hospital MortalityHospital Mortality
Hospital Mortality
Risk ratio.1 1 10
Study % Weight
Risk ratio (95% CI)
0.93 (0.78,1.13) Li 11.0
0.77 (0.63,0.94) Reynolds, et al 10.8
0.69 (0.52,0.93) Brown, et al 8.6
0.81 (0.62,1.07) Multz et al retrospective 9.0
0.74 (0.53,1.05) Multz et al prospective 7.5
0.72 (0.59,0.89) Manthous et al 10.6
1.39 (0.91,2.11) Carson et al 6.2
0.67 (0.19,2.29) Hanson et al 1.2
0.58 (0.43,0.79) Pronovost et al 8.3
0.26 (0.12,0.59) Dimick et al 2.5
0.19 (0.07,0.55) Dimick et al 1.6
0.65 (0.51,0.83) Baldock et al 9.7
0.39 (0.19,0.81) Rosenfeld et al 2.9
0.69 (0.54,0.87) Blunt et al 10.0
0.71 (0.62,0.82) Overall (95% CI)
Pronovost JAMA 2002
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ICU Mortality
Risk ratio.1 1 10
Study % Weight
Risk ratio (95% CI)
0.53 (0.17,1.64) Pollack et al 2.5
0.48 (0.32,0.72) Brown et al 8.4
0.60 (0.49,0.73) Kuo et al 11.3
0.82 (0.61,1.10) Al-Asadi et al 9.9
0.71 (0.54,0.94) Manthous et al 10.1
0.54 (0.26,1.10) Marini et al 4.7
0.59 (0.44,0.79) DiCosmo et al 10.0
0.42 (0.20,0.90) Ghorra et al 4.4
0.69 (0.52,0.91) Baldock et al 10.0
0.15 (0.05,0.50) Rosenfeld et al 2.3
0.38 (0.27,0.53) Goh et al 9.3
0.61 (0.41,0.92) Reich et al 8.2
1.44 (1.00,2.07) Topeli et al 8.9
0.61 (0.50,0.75) Overall (95% CI)
Intensivists Reduce Mortality:Intensivists Reduce Mortality:ICU MortalityICU Mortality
Pronovost JAMA 2002
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Net Savings of IPS for Net Savings of IPS for Hospitals in $000Hospitals in $000
Pronovost CCM 2004
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Leapfrog modelLeapfrog modelNet savings for hospital $000Net savings for hospital $000
Conrad, Gardner 2004 Leapfrog report
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Net Savings per ICU day Net Savings per ICU day Leapfrog model $Leapfrog model $
Conrad, Gardner 2004 Leapfrog report
FOUR FORTUNE 500 COMPANIESFOUR FORTUNE 500 COMPANIES
JOIN EMPIRE BLUE CROSS and BLUE SHIELD TOJOIN EMPIRE BLUE CROSS and BLUE SHIELD TORECOGNIZE AND REWARD HOSPITALS THAT ACHIEVE RECOGNIZE AND REWARD HOSPITALS THAT ACHIEVE
LEAPFROG SAFETY STANDARDSLEAPFROG SAFETY STANDARDS
Insurer to Provide Bonuses to HospitalsInsurer to Provide Bonuses to Hospitals
That Rapidly Adopt Proven Patient Safety Programs
NEW YORK (10/18/01) – IBM, PepsiCo, Inc., Verizon Communications and Xerox Corporation announced today that they will join Empire Blue Cross and Blue Shield in an innovative program designed to save lives by providing financial incentives to hospitals that rapidly achieve proven patient safety standards.
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Key Attributes of Physician StaffingKey Attributes of Physician Staffing
• Present
• Posses skill/knowledge
• Communicates/works with team of caregivers
• Manages the ICU
Little is known about the relative value of each Little is known about the relative value of each attributeattribute
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ExtremesExtremes
24 X 7 NoIntensivist
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Team CareTeam Care
• Avoid Open versus Closed debate– Both primary care and ICU physician add value
• Obtain financial support from hospital for physician staffing
• Create Compact of what is expected
• Include performance measures in contract
• Obtain admission and discharge authority
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Strategies for Strategies for Implementing IntensivistsImplementing Intensivists
• Meet with medical staff
– Review evidence
– Discuss team approach rather than open closed
• Create Compact with hospital
– Hospital to provide financial support
– Intensivists will staff ICU, monitor and improve
quality
– Review performance quarterly
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How Can You Realize these How Can You Realize these Attributes without IntensivistsAttributes without Intensivists
• Discuss alternative models– Hospitalist– Regionalization– NP/PA– Other
• Ensure a physician rounds on all patients every day
• Call list
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Action PlanAction Plan
• Discuss with team and hospital your current ICU physician staff, are you meeting the 4 attributes
• Develop plan to enhance ICU physician staffing
• Ensure nurses know which physician to page for all patients at all times
• Create explicit Compact; hospital will provide financial support and physician will provide services
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ReferencesReferences
• Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit. Ann Int Med 2008;148:801-9.
• Pronovost PJ, Holzmueller CG, Clattenburg L, Berenholtz S, Martinez EA, Paz JR, Needham DM. Team care: beyond open and closed intensive care units. Curr Opin Crit Care 2006;12:604-8.
• Pronovost PJ, Needham DM, Waters H, Birkmeyer CM, Calinawan JR, Birkmeyer JD, Dorman T. Intensive care unit physician staffing: Financial modeling of the Leapfrog standard. Crit Care Med 2006;34:S18-24.
• Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288:2151-62.
• Pronovost PJ, Jenckes MW, Dorman T, Garrett E, Breslow MJ, Rosenfeld BA, Lipsett PA, Bass E. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA 1999;281:1310-17.