Chapter 79: Governance

Critical care medicine (CCM) has made significant strides since its inception as a unique specialty almost 50 years ago. In the United States, the use and costs of CCM continues to rise. Between 2000 and 2010, critical care beds increased 17.8% (88,235-103,900) in nearly 3000 acute care hospitals with intensive care unit (ICU) beds. In 2010, critical care in the United States accounted for 13.2% of hospital costs, 4.1% of national health expenditures, and 0.74% ($108 billion) of the gross domestic product.¹ As critical care consumes significant portion of hospital beds and resources and plays a major role in throughput of emergency departments and operating rooms, it is of vital interest to hospital leadership to unify, standardize, and control this resource.

In response to the perceived shortage of trained intensivists in the United States,² proposals to mitigate this shortfall have been developed including tiered regionalization of critical care services³ and providing alternative coverage options with hospitalists,⁴ advance practice providers (nurse practitioners and physician assistants),⁵ and ICU telemedicine in community hospitals.⁶

In recent years, there has been an increasing tendency for critical care services in academic medical centers to consolidate their staffing and resources, and to form advanced governance organizations, above the level of departmental divisions or sections.⁷ The designation varies greatly from service lines, systems, signature programs, centers, institutes, and clinical departments. To date, only one academic university department of critical care exists in North America at the University of Pittsburgh. Introduction of service line models to critical care, mandates to improve quality and safety of healthcare,^8,9 and transparent public disclosure have added momentum to the health care industry recognizing the need for well-governed critical care as an important tool in business management of medical centers. Among the many aspects that need unified critical care governance include patient management, protocol institution, technology acquisition, education, training, and interactions with other hospital areas.

The organization and management of critical care services are key components that contribute to ICU performance and may impact patient outcomes and health care costs. The guidelines for critical care delivery, clinical roles, and best practice model in the ICU from the Society of Critical Care Medicine published in 2001 and updated in 2015 are excellent resources for how ICUs should be administered.^10,11 The 2001 recommendations were based on 6 tenets: (1) Medical interventions should be provided by intensivists leading multidisciplinary groups; (2) Patient care should be directed by ICU teams using a “closed” format in which dedicated critical care teams take ownership of all aspects of care in the ICU; (3) ICU physicians should be available for medical and administrative tasks without competing clinical responsibilities; (4) ICU physicians and nurses should have critical care credentials; (5) Care teams should include critical care pharmacists and full-time respiratory care practitioners as well as ICU physicians and nursing staff; and (6) ICU governance should be conducted by multidisciplinary groups.

The most recent guidelines highlighted the importance of process of care and ICU structure to improved outcomes and offered four important recommendations (Table 79–1).¹¹ The task force highlighted, among others, the importance of sustaining process improvements through education of all ICU staff and education of and support from hospital leadership as well as an understanding and use of process improvement methodology to assess the impact of changes in ICU structure.

Within the past several years, critical care leaders at academic medical centers and large community hospitals have increasingly examined their ICU infrastructure and clinical staff and take on “battles” to pull the ICUs away from departments and place them into a hospital-based environment and political and administrative infrastructure. From the hospital’s perspective, a critical care organization (CCO) offers an excellent opportunity to bring together all ICUs under one leadership with defined accountability. Added advantages include improved opportunities to contain costs; implementation of local and national patient safety and quality initiatives through protocols, standardization of technologies across ICUs with resultant savings from volume-based equipment and supply purchases, warranties, and staff training; enhanced critical care research; and improved recruitment or retention of faculty through a more stable environment.⁷ We recently reported a descriptive multicenter study on the structure, governance, and experience to date of CCOs in hospitals in North American academic medical centers.⁷ We identified very few CCOs (n = 27). Of the 27 CCO physician directors from 23 institutions (19 sites in the United States and 4 in Canada), 24 (89%) completed the survey. Nearly 80% of the CCOs were created in the last 15 years. Majority of these CCOs were located in larger urban hospitals (> 500 beds) and 79% were primary university medical centers. The transition to a CCO was initiated by the hospital administration in 46% and/or existing critical care service or division in 42% and by consensus of department chairmen in 13%. There were various models of CCM governance, reporting structures, hospital support, and general satisfaction. Almost 90% indicated that their CCO governance structure was either moderately or highly effective, and are still evolving. On average, there were 6 ICUs per hospital with an average of 4 ICUs under CCO governance. In-house intensivists were present 24/7 in 49%, nonphysician advanced practice providers (nurse practitioners, physician assistants) in 63%, hospitalists in 21%, and telemedicine coverage in 14%. Nearly 60% indicated that they had a separate hospital budget to support data management and reporting, oversight of all ICUs, and rapid response teams. We attributed the relatively small number of CCOs that currently exist to several factors including, perhaps, the reluctance of department chairpersons to give their ICUs up to a CCO as they perceive potential loss of billing, triage, and patient and staffing control. Furthermore, CCM has been very intertwined with other disciplines in terms of fellowship training and attending staffs (ie, medicine, pulmonary, anesthesiology, surgery, neurosciences, and pediatrics) due to the absence of a unified critical care fellowship track and certification examination. Thus existing departments have come to believe that their ICUs and intensivists especially in specialty ICUs have little in common with each other. Finally, very few CCM graduates have the necessary skill set to champion the creation and lead CCOs despite CCM fellowship program training in management and team leadership.⁷

Ideally, a properly structured fellowship training program should prepare physicians from any specialty eligible for Accreditation Council for Graduate Medical Education (ACGME)—accredited training to manage a medical, surgical, cardiac surgery, and neuroscience ICU without any problem. The barriers to operating critical care and deriving benefits from economies of scale by full-time intensivists in the United States are frequently derailed by the desire of physicians required to practice their primary specialty/subspecialty (eg, pulmonary medicine, surgery, anesthesiology) creating a system of many part-time intensivists devoting only a small portion of their clinical time to the dedicated care of ICU patients.² Other specialists are convinced that only intensivists with specialized fellowship training are appropriate to work in specialty ICU, such as neurocritical care. Thus, intensivists in US ICUs often have multiple departmental appointments and may be full- or part-time ICU clinicians and hospital-based or voluntary staff members. Whereas large academic institutions have closed model ICUs (ie, intensivists have exclusive or primary authority for patient triage, ICU admission and discharge decisions, and patient care), in nonacademic hospitals, the majority of ICUs are open units with many requiring critical care consultation and intensivists co-managing patients with the primary attending physicians. In contrast, the traditional model of critical care as a division or service of a department is not typical for many European countries where freestanding critical care departments are commonplace. For example, in the United Kingdom, most ICUs are integrated medical-surgical ICUs and the vast majority of intensivists have an anesthesiology background. Similarly, in Canada, most ICUs are combined medical-surgical units; however, the intensivists in many AMCs come from varying training backgrounds (eg, anesthesiology, surgery, internal medicine, emergency medicine) similar to the United States.

Movement toward unification of governance starts with the education of intensivists during their fellowship training. Critical care fellowship programs should focus on administrative and business concepts, including cost containment, finance, and team leadership.^12,13 A few advanced governance organizations have developed professionalism training series to prepare fellowship graduates to deal with the need for a sophisticated approach to budgets and job market needs as they enter the workforce and assume leadership roles.¹⁴

Among the most powerful tools that may be useful to new leaders of critical care in their hospitals are the outreach programs of having intensivists responding rapidly to medical and surgical emergencies outside of the ICU. In addition to expert resuscitation and stabilization, the intensivist controlling the admission to a higher level of care has the ability to select patients who would derive the highest benefit from a trial of ICU management. In addition, though the opinions vary as to the effectiveness of medical emergency or rapid response teams in modifying outcomes,¹⁵ the clear institutional benefit in rapid decision by the most qualified physicians cannot be denied. The ability to rapidly institute comfort or palliative measures for the patients not likely to benefit from a trial of ICU care is also very important.¹⁶ At the same time, intensivists do have the skills to determine success or failure of a trial of ICU care and provide a time limit to the effort.¹⁷ Unfortunately, despite our best efforts and initiatives, the population of chronically critically ill patients in the United States runs into hundreds of thousands,¹⁸ with most of these patients suffering from prolonged cerebral and neuromuscular dysfunction and risk of early death after failure of a trial of ICU care. Access to, and benefit from, alternative sites, such as long-term acute care (LTAC) facilities, is being questioned¹⁹ and subject to moratoriums, state-level certificate of need, and demonstration of limited benefit to patients and the health care industry.

In conclusion, critical care leaders across the United States are increasingly faced with the rising patient demand for critical care services at a time of intensivist workforce shortage and mandates from external organizations to improve on the efficiency and quality of care. These leaders must also respond to the need to educate new generations of ICU physicians and nonphysician care providers (nurse practitioners and physician assistants); standardize care and technologies in hospitals with many ICUs; optimize ICU integration within the hospital; and participate in cost control, research, and fundraising initiatives. Movement toward unification of governance starts with the education of intensivists during their fellowship training. The creation of more advanced governance CCOs in acute care hospitals led by effective and successful leaders²⁰ can ensure not only the delivery of high-quality safe patient care but also more effective use of resources and assistance in organizational operations and development.