U.S. Critical Care Delivery System in Critical Condition

The demand for critical care services in the United States will soon outpace the supply of specialists trained in intensive care – a situation that, if not remedied, may prove fatal for critically ill patients. The solution to this problem lies not in recruiting and training more personnel, but in reorganizing the critical care system nationwide, according to a report from a group of critical care stakeholders, led by University of Pittsburgh School of Medicine researchers and published in the April issueof the journal Critical Care Medicine.

“The number of Americans over the age of 65 is expected to double by 2030. In addition to non-elective medical admissions for critical illness among chronically ill elders, the growth rate in elective surgical procedures requiring intensive care unit admission, such as bypass surgery, is growing fastest among this age group,” said Amber E. Barnato, M.D., M.P.H., M.Sc., assistant professor, department of medicine, University of Pittsburgh School of Medicine. “All of this means more and more people will demand already strained intensive care services. This anticipated mismatch between supply and demand is perhaps no different for critical care services than for other medical care disproportionately serving elders – ranging from emergency services to long-term care services – but the opportunities for improving the efficiency of the existing system to meet demand are probably greater.”

The report, developed following a meeting of critical care stakeholders called the Prioritizing the Organization and Management of Intensive care Services (PrOMIS) Conference held in September 2005, calls for creation of a tiered, regionalized system for critical care services in an effort to centralize expertise, equipment and facilities. This would make the necessary critical care servicesreadily available to the patients who are most in need.

“Prior conferences aimed at addressing this problem sought input only from critical care professionals, who are a fraction of all the stakeholders,” said Dr. Barnato, lead author of the report. “These groups often stated the need for more trained providers. Surveying a wider group of interested parties, we found that this isn’t necessarily the best or only solution.”

For the PrOMIS Conference, organizers attempted to identify problems in the current U.S. critical care system as seen by all stakeholders, including those from professional organizations, critical care and non-critical care physicians, federal and private health insurers, federal and private funding organizations, and the general public. Prior to the conference, attendees selected from each of the stakeholder groups were asked to fill out a survey aimed at identifying problems in the organization and delivery of critical care services. Respondents then attended a two-day conference held in the Washington, D.C. area, where current data on organization and management of critical care services was presented. Attendees then participated in break-out groups where they discussed the themes and issues identified by the pre-conference survey.

In the paper, researchers say the primary concern voiced by participants was that the “utilization, organization and management of intensive care services in the United States was not optimal.” They broadly agreed that there was a need to regionalize and tier the critical care system, similar to what previously had been done by the U.S. trauma system. Such a system would require the most critically ill patients to be seen in top-level critical care centers. Lower-level centers would not provide ongoing critical care services, but would need to transfer critically ill patients to higher-level centers.

Participants also cited the need to acknowledge that some critical care services should be provided by physicians, such as hospitalists and emergency physicians, who currently are not certified by the existing critical care boards.

Conference organizers hope that critical care societies will support a second stakeholder meeting, PrOMIS II, charged with developing concrete accreditation criteria for the proposed regionalized tiered system, defining explicit triage and quality surveillance criteria for each tier, developing a comprehensive set of core competencies for critical care providers and endorsing a method to train and certify critical care providers in these competencies.

The PrOMIS Conference was supported by grants from the American Association of Critical Care Nurses, the American College of Chest Physicians, the American Thoracic Society and the Society of Critical Care Medicine. The opinions and conclusions published in Critical Care Medicine are those of the PrOMIS participants,but not necessarily those of the sponsoring societies.

Other authors on the paper include: Derek C. Angus, M.D., M.P.H., University of Pittsburgh School of Medicine; Jeremy M. Kahn, M.D., M.Sc., and Gordon D. Rubenfeld, M.D., M.Sc., University of Washington; Kathleen McCauley, Ph.D., R.N., B.C., and David A. Asch, M.D., M.B.A., University of Pennsylvania; Dorrie Fontaine, R.N., D.N.Sc., University of California-San Francisco ; Joseph J. Frassica, M.D., F.C.C.P., Baysate Medical Center; Rolf Hubmayr, M.D., Mayo Clinic College of Medicine; Judith Jacobi, Pharm.D., Methodist Hospital/Clarian Health Partners, Indianapolis; Roy G. Brower, M.D., Johns Hopkins University School of Medicine; Donald Chalfin, M.D., M.S., Montefiore Medical Center and Albert Einstein College of Medicine; William Sibbald, M.D., M.P.H., Sunnybrook and Women’s Health Sciences Center and Universityof Toronto; and Mark Kelley, M.D., Henry Ford Health System, Detroit.