Staffing has become a topic of much focus in intensive care medicine recently. Leapfrog recommendations and Society of Critical Care Medicine (SCCM) guidelines require high-intensity staffing models where intensivists are available and/or onsite 24 hours a day.19,20 These mandates are difficult to meet for many institutions. Strategies to improve critical care coverage are discussed in detail in the chapter “Alternate Staffing Models in the ICU.” As staffing pertains to the ICU as a part of the global hospital environment, two main questions for staffing arise: Is the responsibility of an intensivist only to care for patients in the ICU? Are there advantages and/or disadvantages to having physicians from other service areas be primarily responsible for the care of ICU patients?
An intensivist is a physician with board certification or extensive experience in critical care medicine.20,21,22 Traditionally, such a physician may be involved in triage for the critically ill before ICU admission but cares, primarily, for patients within the confines of an ICU. Recently, however, the role of the intensivist has been expanded under the rubric of an “ICU without walls.”23,24,25 Under this paradigm, the intensivist is expected to consult upon and provide care to critically ill patients prior to, following, and, sometimes, in the absence of, an ICU admission. Rapid response/medical emergency teams are the most commonly used method of delivering critical care expertise to non-ICU patients who become critically ill.26 While there is no standard structure for these teams, many include an intensivist and/or a critical care nurse.27,28,29 In essence, therefore, these teams can be viewed as expanding the ICU. Data on their impact is mixed,30,31,32,33 yet ward staff satisfaction is improved34,35 and these teams are being used with increasing frequency.36
Rather than waiting for a clinical deterioration that merits activation of such emergency response teams, some institutions provide critical care consultation by intensivist-led teams for patients who are either not critical enough to be transferred to an ICU or have been recently transferred out of one.25,37 These services can create a degree of critical care coverage that, while often lacking in the nursing and monitoring capabilities of an ICU, can benefit less critically ill patients. Staffing these services requires a commitment of an expanded workforce, however. Depending on the specifics of a given institution—available staff, ICU capacity, ICU occupancy, etc—staffing such teams may improve care for the critically ill throughout the hospital.
Bringing the intensivist out of the ICU may be one way to improve care throughout the hospital and another may be having appropriately trained clinicians from other departments work in the ICU. Most ICU patients in the United States do not receive care by an intensivist.21,38 Instead, many are cared for by physicians with no training in critical care medicine; care often falls to hospitalists39,40,41 and emergency medicine physicians.42 Recently, the SCCM and the Society of Hospitalist Medicine issued a joint position paper on the potential merits of accelerated training of experienced hospitalists in critical care.40,41 Such training is not currently available, but may be possible in the near future. Over the past several years, emergency medicine physicians have been granted permission to enter critical care medicine fellowships and sit for the critical care medicine certification examinations administered by the American Boards of Internal Medicine, Surgery, and Anesthesiology.43 Together, these actions promote an integration of critical care medicine with other disciplines. Hospital administrators can capitalize on the impact of this expanded pool of providers by hiring physicians trained in critical care, whose background makes them well suited to work in non-ICU environments as well. A critical care trained hospitalist will improve care delivery to newly critically ill patients on the general ward; additionally, if he/she also works in the ICU, he/she may enhance communication between the ICU staff and providers in noncritical care areas. Similarly, a critical care trained emergency medicine physician whose responsibilities extend into both environments can bridge care gaps and improve interactions between the ICU and the emergency department. Finally, in times of lower staffing (eg, overnight21), having someone available who is willing and able to cover an ICU and another clinical care area may be cost-effective. Critical care staffing can, if done thoughtfully, improve patient care throughout the hospital.
In planning for potentially more diversified ICU staff, hospital administrators must be mindful of competing responsibilities pulling intensivists away from the ICU, however. Most American ICUs have an “open” staffing structure in which there is no unified critical care team of providers looking after all patients in the ICU.6,39,44 The most common ICU staffing model practiced in other places in the world is a “closed” model in which the primary responsibility for care of all ICU patients is transferred to an intensivist for the time that the patients are in the unit.45,46,47 Leapfrog and SCCM advocate for high-intensity staffing, which is more often met by a closed ICU structure, but can be attained using an open model with mandatory critical care consultation. Data on the impact of a high-intensity staffing model on patient outcomes is mixed.48,49 Most intensivists split time between ICU and other responsibilities.38 In an open model, almost by definition, the primary physician caring for each patient has simultaneous non-critical care responsibilities—to care for either non-critically ill hospitalized patients or outpatients in the office setting. This set-up is often the case even for practitioners in closed model units. A potential disadvantage to having intensivists who have multiple additional skills is that they may be asked to multitask across disciplines; in so doing, needed focus may be inadvertently drawn away from ICU patients. Care must be taken to balance this potential negative consequence with the benefits of diversified staff.