Description of Treatment/Procedure

More than four million patients are admitted to intensive care units (ICU) each year in the United States (US). Despite specialized care, ICU mortality has been estimated to be 8-10% or about 400,000-500,000 patients annually. ICUs have begun implementing intensivists programs in order to improve clinical outcomes. Intensivists are board certified critical care physicians with initial training in internal medicine, surgery, or anesthesiology. Certification of intensivists began in the mid-1980s.
Intensivists have the skills to treat critically ill patients and are immediately available to detect and treat problems as they arise. They can decrease the traditional lag time that exists in trying to contact an attending physician. A decrease in resource utilization may also be possible with intensivist systems because intensivists can potentially reduce inappropriate ICU admissions, prevent complications that prolong length of stay (LOS), reduce the number of lab tests ordered, and recognize opportunities for prompt discharge.
The intensivist works with all physician specialists and helps develop a cohesive ICU team. Intensivist staffing varies widely in US hospitals but most ICUs can be separated into four groups: closed ICUs, mandatory intensivist consultation ICUs, elective intensivist consultation ICUs, and ICUs with no intensivist.
About 10% of all hospitals in the US have an intensivist overseeing care in the ICU at least 8 hours a day. There are 5,500 intensivists currently in practice and another 600 more in training. Approximately 30,000 intensivists would be needed to staff every ICU in the US. Intensivist programs have traditionally been limited to large tertiary medical centers and teaching hospitals. Many community hospital ICUs don’t have an intensivists managing patient care. Medical economics and a shortage of critical care physicians may make an intensivist model difficult to implement for some hospitals.

Committee Summary

With regard to board certified intensivists the ICSI Technology Assessment Committee finds:

1. High-intensity staffing of board certified intensivists (closed ICU or ICU with mandatory intensivist consultation) is associated with a decreased ICU mortality, decreased hospital mortality, decreased ICU length of stay, and decreased hospital length of stay in numerous non-randomized controlled studies (Conclusion Grade II).
   
2. The optimal model of high-intensity staffing is unclear and the mechanism whereby board certified intensivists decrease mortality and morbidity is unknown.
   
3. Intensivist systems are restricted due to manpower issues. There are not enough intensivists to properly staff all ICUs at this time. Hospitals should analyze the feasibility of board certified intensivists in terms of cost and adequate support teams including subspecialty consultations before implementation.
   
4. Board certified intensivist physicians described in the published literature are safe relative to non-intensivist physicians.