Physician Staffing in the ICU 10 Years from Now J. A. Russell and A. Sutherland

(1)

Introduction

Physician staffi ng of intensive care units (ICUs) is a key element of the success of the clinical, teaching and research programs of an ICU. Indeed, recent studies show that the nature of physician staffi ng is highly associated with ICU and hospital mortality and length of stay [1]. Furthermore, regional and national shortages of resident physicians to cover ICUs have lead to the recruitment of full-time and part-time ICU hospitalists. It is likely that there will be further changes in the number and nature of physician staffi ng of ICUs over the next decade.

Physician staffi ng is already an issue in many ICUs for several reasons. First, ICU patient volume and complexity both continue to increase. Second, there is clear evidence that staffi ng an ICU with dedicated intensivists decreases mortality, morbidity and costs. Third, the quality improvement revolution in health care has entered the ICU and has impacted the skill sets and activities expected of ICU physicians. Fourth, training of residents and fellows in critical care medicine has been accredited in most countries and increases the rigor of training requirements, teaching and need for excellent clinical experience. Fifth, hospitals, health maintenance organizations (HMOs) and regional health dis- tricts have rationalized and re-organized hospital services (such as the volume and types of specifi c surgeries) that have impacted the size and nature of ICUs.

Sixth, intensivists are entering into areas of clinical care outside the ICU such as medical emergency teams (METs), air transport, and other consultative services. Seventh, research in intensive care continues to be scientiﬁ cally stronger, deeper and more widely appreciated, increasing the need for clinician-scientists in intensive/critical care medicine. Eighth, there are growing leadership needs in administrative, clinical, teaching and research arenas of intensive care. Ninth, the ‘baby boomer’ age of physicians will be entering retirement age and will be decreasing clinical activities and then fully retiring from clinical intensive care.

Finally, changes in health care budgets have impacted the number and types of physician services in intensive care.

Because changes in physician status due to disability, retirement and death do not change the net number of full time equivalents (FTEs) in an ICU, I will focus on changes that will impact net FTEs of ICU physician services and will assume that disability, retirement and death will be dealt with by recruitment to those FTE slots of new intensivists.

J. A. Russell and A. Sutherland

(2)

What will the nature of ICU staffi ng be in 10 years from now? We will address this question by reviewing in more detail current physician staffi ng. Then, we will discuss in more detail the drivers that will infl uence physician staffi ng over the next decade. Then, we will present a model of future physician staffi ng that is a mix of projection, conjecture and a vision for future ICU physician staffi ng.

The template that we will use for this discourse will be a case study of the ICU of St. Paul’s Hospital in Vancouver, BC, Canada, where one of us (JR) has worked as an intensivist, as the ICU Director, and then as Chair of the Department of Medicine. We will use this case study to build the general case and draw on the literature to illustrate and support key observations and recommendations.

Current Physician Stafﬁ ng of Intensive Care Units

The ICU of St. Paul’s Hospital is a 14 bed multidisciplinary, closed Medical Sur- gical ICU closely affi liated with the University of British Columbia. There is a strong teaching program for medical students, rotating residents (from Medi- cine, Surgery, Anesthesia and Emergency Medicine), and Critical Care Medicine Fellows. There are about 700 admissions per year; about 85% of the patients require mechanical ventilation, and 40% of the patients are referred from other hospitals and the tertiary care programs of the hospital. There is a comprehensive research program ranging from molecular mechanisms of myocardial dys- function and of epithelial injury, to genomics of sepsis and acute lung injury (ALI), to clinical trials in sepsis and ALI, to population research in critical care medicine. With that understanding of the ICU, how would one expect it to be staffed by physicians? At present, there are fi ve full-time intensivists who rotate on call for one week at a time. The intensivist faculty member is the leader of the physician team (Fig. 1). There is almost always a fi rst or second year critical care medicine Fellow on a 2-3 month rotation in the St. Paul’s ICU. There are three to four residents from other services (Anesthesia, Medicine, Surgery and Emergency Medicine) who do a 2-3 month rotation in ICU. At all times there are one to three medical students doing an elective in intensive care medicine. The primary in-house call in the ICU is by the residents with a faculty intensivist on call each night. The critical care medicine Fellows take call every third or fourth night. Because of resident vacations and differences from month to month in resident numbers on ICU rotation, there is a cadre of intensive care Clinical As- sociates who provide clinical care on selected night and weekend day shifts.

How does this template compare to national guidelines for intensive care physician stafﬁ ng? Recommendations from the Canadian Critical Care Society

Fig. 1. Current ICU physician stafﬁ ng at St. Paul’s Hospital

(3)

have been updated and recommend one faculty intensivist for each ICU up to a maximum of about 14 beds. This recommendation is founded on the assumption that there is a separate in-house on-call physician such as a senior resident or a Clinical Associate.

How does this template compare to reports in the literature? Pronovost and colleagues did an extensive survey of ICU physician stafﬁ ng in the USA [1]. They systematically reviewed 26 papers and abstracts representing 27 studies examining ICU attending physician stafﬁ ng strategies in over 150 ICU in the United States, Europe and Asia. Study sample sizes varied from 177 to 5415 patients (mean: 1001, SD: 1190) and included ICU patients treated between 1979 and 2000.

Study populations included medical ICUs (41%) surgical ICUs (9%), mixed medical-surgical ICUs (15%) and pediatric ICUs (11%) [2-27]. Eleven of the studies were from academic medical centers, six were from community teaching hospitals, four were from non-teaching community hospitals, and fi ve included a vari- ety of hospitals [1]. Pronovost and colleagues categorized ICU physician staffi ng in the studies as ‘high intensity’ (mandatory intensivist consultation or closed ICU [the intensivist is the patient’s primary attending physician]) or ‘low intensity’ (no intensivist or elective intensivist consultation). The hospital mortality, ICU mortality, hospital length of stay and ICU length of stay were compared as outcome measures between patients treated in a high intensity staffi ng environment versus a low intensity staffi ng environment. Pronovost et al. calculated the random-effects, summary relative risk (RR) of mortality and the relative reduc- tion for length of stay data from the studies for which the data was available.

Seventeen of the studies Pronovost and colleagues examined reported hospital mortality. Sixteen of the 17 studies showed a decrease in hospital mortality for ICU patients treated in a high intensity physician staffi ng environment, while one study reported a non-signifi cant increase in hospital mortality with high intensity physician staffi ng. Fifteen studies reported ICU mortality according to ICU physician staffi ng. Fourteen of the 15 showed a decrease in ICU mortality for patients in a high intensity staffi ng environment. Thirteen of the studies that Pronovost et al. examined reported the hospital length of stay according to ICU physician staffi ng. Hospital length of stay was reduced for patients treated in a high intensity staffi ng environment (7-24 days for high intensity vs. 8-33 days for low intensity). Eighteen studies evaluated the ICU length of stay according to ICU physician staffi ng. ICU length of stay was reduced for patients treated in a high intensity staffi ng environment (2-10 days for high intensity vs. 2-13 days for low intensity). Overall, increased use of intensivists in the ICU led to signifi - cant reductions in hospital and ICU mortality and length of stay. In 1999, it was estimated that only one third of ICU patients in the United States were treated by intensivists as the primary physicians [28]. Since the greater use of intensivists in the ICU appears to be associated with reductions in ICU and hospital mortality and length of stay, increased intensivist staffi ng of ICUs may improve ICU patient outcomes.

All of the studies that Pronovost and colleagues examined were observational studies. There have been no randomized controlled trials to compare outcomes of patients in low versus high intensity stafﬁ ng environments for practical and ethical reasons [1]. Three studies examined the impact of full time critical care

(4)

physician staffi ng and other quality-of-care factors on mortality in pediatric ICUs [12, 20, 21]. The remaining 24 studies examined the impact of physician staffi ng strategies on outcomes in adult ICUs. While ICU and hospital mortality rates and length of stay were the primary outcomes, a number of the studies compared other clinically relevant outcome measures of patients treated in high- and low-intensity staffi ng environments. A number of studies compared the number of patients requiring mechanical ventilation and the duration of mechanical ventilation in low- and high-intensity staffi ng environments [6, 7, 18, 19, 23, 27]. Three of the studies examining post-surgical ICU patient care found that complications such as cardiac arrest, acute renal failure, septicemia, platelet transfusion, and reintubation were associated with low-intensity staffi ng strategies [11, 22, 25]. Interestingly, one of these studies found that using telemedicine as a means of achieving 24-hr intensivist oversight improved clinical outcomes, suggesting an alternate strategy to an around-the-clock, on-site intensivist care model [25].

In summary, the current St. Paul’s Hospital ICU physician staffi ng is likely similar to physician staffi ng of other closed ICUs of similar size, patient complexity and with similar teaching and research responsibilities. What are the drivers that will impact physician staffi ng over the next decade at St. Paul’s Hos- pital and at other hospitals?

Drivers of Changes in Physician Stafﬁ ng in Intensive Care

Table 1 shows the major drivers that could impact physician stafﬁ ng needs of a typical, tertiary care ICU over the next decade.

Patient volume in ICU is likely to increase over the next decade because of an aging population, because of increased complexity of surgery, because of increasing immuno-suppression from cancer chemotherapy, because of the increasing incidence and prevalence of septic shock [29] and because of evidence

Table 1. Drivers of changes in physician stafﬁ ng in intensive care medicine

1. Patient volume – number of admissions per year

2. Patient complexity – source (e.g. Emergency, Medicine, Trauma, Surgery), severity of illness (e.g., APACHE II score), complexity of interventions (e.g., mechanical ventilation, vasopressor support, continuous renal replacement therapy [CRRT])

3. Quality improvement – clinical guidelines, clinical paths, quality improvement projects 4. Training requirements – medical students, residents, specialty fellows

5. Hospital and regional re-organization – impact on ICU beds

6. Other activities – research, teaching, administration, other clinical non-ICU programs 7. Budget – hospital, ICU, billing/fees/salaries

8. Leadership needs – administrative, research, teaching, clinical

(5)

of improved outcomes of intensive care medicine based on several randomized controlled trials. All of these factors are driving patient, family and referring physician demand for intensive care. At St. Paul’s Hospital, population growth in the Vancouver downtown core as well growth in the Greater Vancouver Region are being used to project growth in the number of ICU beds in the Vancouver region and in particular at St. Paul’s Hospital. Growth in speciﬁ c programs (such as cardiovascular surgery) has been and will likely continue to be a factor driving demand for ICU beds at St. Paul’s Hospital.

Complexity of patients and of the care that is delivered in the ICU is a second driver of ICU physician stafﬁ ng. In the St. Paul’s Hospital ICU, a comprehensive ICU database is used and captures all ICU admissions with data such as demographics, APACHE II scores, underlying diagnosis, interventions while in ICU and outcomes (ICU and hospital). This database is useful for tracking the ICU patient complexity and the impact on work-load and outcomes. Aver- age APACHE II scores have risen over the last decade and will likely continue to increase. The growing evidence of the potential value of aggressive dialysis has lead to an increase in the proportion and numbers of patients on continuous renal replacement therapy (CRRT). In cardiovascular disease, the emergence of left and right ventricular assist devices, the use of early interventional cardiol- ogy and of intra-aortic balloon pumps have improved outcomes and therefore have also increased the numbers of patients on these complex modes of support- ive care. The recent success of randomized controlled trials of therapies in intensive care medicine such as low (6 ml/kg) tidal volume [30], early cardiovascular resuscitation of sepsis and septic shock [31], activated protein C [32], intensive insulin therapy [33], and corticosteroids for septic shock, to name a few, while considered controversial by some, have generally increased recommendations for a comprehensive care approach to conditions such as sepsis and ALI. This complex care plan is likely best directed by full-time intensivists. It is likely that as even more therapies are ‘proven’, intensive care medicine will emerge as an even more independent evidence-based specialty which will increase demand for full-time intensivists to accurately and reliably apply best practice.

The Quality Improvement Initiative in health care lead by Donald Berwick [34] has had a substantial impact on virtually all ﬁ elds of medicine including intensive care. There has been a parallel demand from groups such as Leapfrog for high quality intensive care under the direction of full-time intensivists. There will be a growing need for intensive care physicians to be aware of and indeed to lead quality improvement projects in the ICU to assure patients, peers, payers, and society that patients admitted to an ICU are receiving optimal care. Recent examples at St. Paul’s Hospital of quality improvement projects are implementation of a sepsis care package developed by a Canadian Collaborative for Patient Safety with leadership from faculty at St. Paul’s Hospital and citrate-based CRRT for patients who require CRRT but cannot tolerate heparin.

There are large jurisdictions (such as Canada) that have a physician shortage that is still not stable. As a result, the number of medical student places in Canada will increase over the next decade. The University of British Columbia medical school is doubling in size so that in a few years there will be double the number of residents requiring intensive care training. While there are other ICUs in com-

(6)

munity hospitals, it is likely that many of these residents will receive ICU training in the two major teaching hospital ICUs in Vancouver. This increase in resident numbers will likely increase the teaching load and have an impact on the number of intensivist teaching hours and thus overall physician stafﬁ ng.

Regions and health maintenance organizations have re-organized in-patient services by rationalizing services such as trauma, cardiovascular surgery and neurosurgery. In Vancouver, St. Paul’s Hospital took on major roles in the deliv- ery of cardiovascular care, renal care and acquired immunodefi ciency syndrome (AIDS) care in the mid 1990s. As a result, there were secondary effects on services such as the ICU, which provide part of these comprehensive tertiary care programs. In other jurisdictions, the ICU is impacted by other similar changes and there are ‘ripple’ effects of the physician staffi ng needs. There will likely be continued efforts to reorganize and rationalize care within regions and states in publicly-funded systems and these changes will indirectly infl uence numbers and types of ICU beds and so needs for ICU physician staffi ng.

There are several non-ICU clinical programs and important research, teaching and administrative responsibilities that drive intensive care physician stafﬁ ng. At St. Paul’s Hospital, the intensivists are responsible for a British Columbia Ambu- lance Service Air Transport Advisor program. This program provides 24/7 on-call intensivists for the paramedic-based air transport program which logs about 7,200 ﬂ ights per year. The faculty intensivists provide emergent consultation by phone to the paramedics for all of the critical care transports. The faculty also provides a 24/7 Critical Care consultation service to a provincial maternity hospital in Vancouver for assessment and resuscitation of critically ill maternity cases. A recent example that will impact the St. Paul’s ICU is the establishment of an ICU-based MET.

Obviously, a signifi cant driver of changes in physician staffi ng is the overall ICU budget. Whether physicians bill fee-for–service, have overall service contracts or are salaried employees of an organization, there is usually a direct rela- tionship between the overall magnitude of the ICU budget and the overall budget available for ICU physician staffi ng. Thus, changes in negotiations of fees and contracts can also drive change in ICU physician staffi ng. The ICU is often not a ‘profi t center’ for for-profi t hospitals and is a great consumer of costs in state or publicly-funded hospitals. Therefore, there may be a tension between needs of the hospital for clinical care as opposed to the reimbursement the hospital receives for critical care. Furthermore, hospitals in the private and in the public sectors often receive higher funding for specialized programs such as cardiovascular surgery and transplantation so that there may be a better case for ICU beds to support such programs. In contrast, ICU beds to support Emergency Depart- ment referrals of pneumonia and septic shock may not be as easily funded.

Leadership needs drive changes in ICU physician stafﬁ ng. Virtually all ICUs have a Director/Department Head who is responsible for physician administrative aspects of the ICU. The skills that these individuals need are increasingly business skills such as preparing business cases, negotiation skills, conﬂ ict reso- lution skills, and organizational skills, none of which are in the medical school or residency curricula. The ICU Director is primarily responsible for issues such as budget, external relationships (e.g., hospital and university department heads, hospital administration (e.g., Vice-President of Medicine), other hospital

(7)

departments (such as Nursing and Respiratory Therapy) and coordinates the ICU group’s divisional meetings. The other leadership skills that a teaching hospital ICU physician team must possess are a clinical champion, a teaching leader, and a research leader (Table 2). The clinical champion is the individual who is recognized as an outstanding clinician, who keeps abreast of the leading edge clinical and translational research literature, who is comfortable and can lead a quality improvement process, and can direct and lead implementation of clinical guidelines in the ICU. The teaching leader is the best teacher in the group, chosen for bedside teaching skills, for classroom teaching skills, and who has a special interest in the leading edge of adult education in medical care, such as in use of simulators for teaching or some other unique education niche. The research leader is an acknowledged strong scientist who has peer-reviewed grants and peer-reviewed manuscripts, mentors junior faculty, trains graduate students and critical care fellows, and is a resource for the group for research expertise.

Future Model of ICU Physician Stafﬁ ng

Figure 2 shows a model of likely future physician stafﬁ ng at St. Paul’s Hospital that may be representative of other teaching hospitals that face similar drivers of change. The growth in patient volume, complexity, teaching, and other drivers will

Table 2. Leadership skills of the ICU physician group

Leaders Director/

Dept. Head

Clinical champion

Teaching leader Research leader

Expertise &

Portfolios

Budget

External relations

Other Dept heads

Hosp (VP Med)

University (dean)

Nursing, RT Divisional meetings

Outstanding clinician Implements quality improvement projects Implements guidelines Implements clinical paths

Outstanding teacher

Bedside teaching leader

Classroom teaching leader Focus on adult medical education Niche expertise (e.g. simulators)

Outstanding researcher Peer-reviewed grants

Peer-reviewed manuscripts Mentors junior faculty

Trains graduate students and fellows

RT: respiratory therapy

(8)

likely increase the number of ICU beds such that there are at least two ICU physician teams in the ICU and likely a third team responsible for other clinical non-ICU activities such as the MET, air transport and maternity critical care. Each team will still be lead by a faculty intensivist and the composition of teams will likely include a mixture of housestaff/residents and clinical associates (also known as hospitalists). There may be a need for further differentiation of the ICU-based teams such as Team 1 for more acute recent admissions and Team 2 for subacute cases in ICU. The third team will likely be responsible for all clinical non-ICU activities.

We foresee that there will be an even greater need for a strong foundation under each team of quality improvement, research, teaching, and a robust, real- time database of all ICU and non-ICU activities to aid future planning, research and quality improvement initiatives.

Processes For Planning Future ICU Physician Stafﬁ ng

We have reviewed the current staffi ng of ICUs, drivers of changes in ICU physician staffi ng, and presented a model of a future ICU physician staffi ng example.

However, there will be a great need for a much more robust process to get from now to 2015 and to optimize the ICU physician stafﬁ ng in 2015. We suggest that there are (simplistically) three processes that most ICUs use to plan such changes in physician stafﬁ ng (Table 3).

We suggest that the least likely to be successful and effective is simple lobbying and whining to authorities such as hospital administrators. There is no

Table 3. Processes for planning changes in ICU physician stafﬁ ng

1. Business case proposals

2. Data-driven projections of ICU size and likely physician stafﬁ ng requirements 3. Lobbying (also known as whining)

Fig. 2. Future ICU stafﬁ ng

(9)

doubt that administrators will be overwhelmed by such lobbying and will more likely than not react negatively to emotional arguments without data and projections.

A common approach taken by many ICUs is to use a data-driven summary of current and future ICU volume and derive likely ICU physician staffi ng requirements. This is a step better than lobbying but does give the administrators the information they need to balance confl icting requests for funding and staffi ng.

It is merely the ammunition but not delivered effectively.

The optimal and most likely successful process for planning physician staffing will be a well-written, well-documented business case that is carefully-pre- pared and can be read by several levels of the administration (e.g., Vice President Medicine, other Department Heads, Vice President Finance, Chief Executive Of- fi cer of the hospital and Dean of the medical school). The common sections of a business case include the ‘business’ of the ICU at present, the current ICU volume and complexity profi les, the drivers of change and likely impact on the specifi c ICU including patient volume and complexity and other anticipated drivers of change, the 5 (and even 10) year projections of physician staffi ng, the justi- fi cation of the proposed staffi ng, the benefi ts to patients, the ICU, the hospital and the communities served, the budget projections and summary cost/benefi t projections. The ability to articulate how altered physician staffi ng will enhance patient care and outcomes by activities such as QI and use of guidelines can be compelling for administrators. The needs for more and better teaching and research can be compelling for Deans and university department heads but are sometimes less compelling for those who hold the hospital purse strings.

Optimized ICU Physician Stafﬁ ng

The optimal ICU physician stafﬁ ng model has yet to be realized. There is con- vincing data now that a closed ICU or at least mandatory intensivist consultation model is associated with improved outcomes and length of ICU and hospital stay. As Pronovost et al. state in their discussion, it is not clear what components of the closed ICU or mandatory intensivist consultation process are the main cause(s) of improved outcomes. Is it knowledge and technical skills? Is it fre- quency of rounds and availability to respond knowledgeably to crises? Is it team leadership skills and optimizing the combined skill sets of all health care mem- bers of the ICU team? Is it application of most relevant care based on knowledge of the very specialized literature of critical care?

Figure 3 shows a model that we currently favor for future ICU physician staffing. The key elements are strong leadership in administrative, business, clinical care, teaching, and research, well-organized teams with clear responsibilities, and a foundation of quality improvement, clinical guidelines, research, teaching, and a comprehensive ICU and non-ICU (but critical care-related) clinical database.

(10)

References

1. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL (2002) Physi- cian stafﬁ ng patterns and clinical outcomes in critically ill patients: a systematic review.

JAMA 288:2151-2162

2. Al-Asadi L, Dellinger RP, Deutch J, Nathan SS (1996) Clinical impact of closed versus open provider care in a medical intensive care unit. Am J Respir Crit Care Med 153:A360 (abst)

3. Baldock G, Foley P, Brett S (2001) The impact of organisational change on outcome in an intensive care unit in the United Kingdom. Intensive Care Med 27:865-872

4. Blunt MC, Burchett KR (2000) Out-of-hours consultant cover and case-mix-adjusted mortality in intensive care. Lancet 356:735-736

5. Brown JJ, Sullivan G (1989) Effect on ICU mortality of a full-time critical care specialist.

Chest 96:127-129

6. Carson SS, Stocking C, Podsadecki T, et al (1996) Effects of organizational change in the medical intensive care unit of a teaching hospital: a comparison of ‘open’ and ‘closed’

formats. JAMA 276:322-328

7. DiCosmo BF (1999) Addition of an intensivist improves ICU outcomes in a non-teaching community hospital. Chest 116:238S (abst)

8. Dimick JB, Pronovost PJ, Lipsett PA (2000) The effect of ICU physician stafﬁ ng and hospital volume on outcomes after hepatic resection. Crit Care Med 28:A77 (abst)

9. Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA (2001) Intensive care unit physician stafﬁ ng is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Crit Care Med 29:753-758

10. Diringer MN, Edwards DF (2001) Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med 29:635-640

11. Ghorra S, Reinert SE, Ciofﬁ W, Buczko G, Simms HH (1999) Analysis of the effect of con- version from open to closed surgical intensive care unit. Ann Surg 229:163-171

12. Goh AY, Lum LC, Abdel-Latif ME (2001) Impact of 24 hour critical care physician stafﬁ ng on case-mix adjusted mortality in paediatric intensive care. Lancet 357:445-446

13. Hanson CW, 3rd, Deutschman CS, Anderson HL 3rd, et al (1999) Effects of an organized critical care service on outcomes and resource utilization: a cohort study. Crit Care Med 27:270-274

Fig. 3. Optional ICU physician stafﬁ ng

(11)

14. Jacobs MC, Hussain E, Hanna A (1998) Improving the outcome and efﬁ ciency of surgical intensive care: the impact of full time medical intensivists. Chest 114:276S-277S

15. Kuo HS, Tang GJ, Chuang JH (2000) Changing ICU mortality in a decade: effect of full- time intensivist. Crit Care Shock 3:57-61

16. Li TC, Phillips MC, Shaw L, Cook EF, Natanson C, Goldman L (1984) On-site physician stafﬁ ng in a community hospital intensive care unit. Impact on test and procedure use and on patient outcome. JAMA 252:2023-2027

17. Manthous CA, Amoateng-Adjepong Y, al-Kharrat T, et al (1997) Effects of a medical intensivist on patient care in a community teaching hospital. Mayo Clin Proc 72:391-399 18. Marini CP, Nathan IM, Ritter G, Rivera L, Jurkiewicz A, Cohen JR (1995) The impact of

full-time surgical intensivists on ICU utilization and mortality. Crit Care Med 23:A235 (abst)

19. Multz AS, Chalﬁ n DB, Samson IM, et al (1998) A «closed» medical intensive care unit (MICU) improves resource utilization when compared with an «open» MICU. Am J Respir Crit Care Med 157:1468-1473

20. Pollack MM, Katz RW, Ruttimann UE, Getson PR (1988) Improving the outcome and ef- ﬁ ciency of intensive care: the impact of an intensivist. Crit Care Med 16:11-17

21. Pollack MM, Cuerdon TT, Patel KM, Ruttimann UE, Getson PR, Levetown M (1994) Im- pact of quality-of-care factors on pediatric intensive care unit mortality. JAMA 272:941- 946

22. Pronovost PJ, Jenckes MW, Dorman T, et al (1999) Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA 281:1310-1317 23. Reich HS, Buhler L, David M, Whitmer G (1998) Saving lives in the community: impact of

intensive care leadership. Crit Care Med 25:A44 (abst)

24. Reynolds HN, Haupt MT, Thill-Baharozian MC, Carlson RW (1988) Impact of critical care physician stafﬁ ng on patients with septic shock in a university hospital medical intensive care unit. JAMA 260:3446-3450

25. Rosenfeld BA, Dorman T, Breslow MJ, et al (2000) Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care. Crit Care Med 28:3925-3931 26. Tai DY, Goh SK, Eng PC, Wang YT (1998) Impact on quality of patient care and procedure

use in the medical intensive care unit (MICU) following reorganisation. Ann Acad Med Singapore 27:309-313

27. Topeli A (2000) Effect of changing organization of intensive care unit from «open policy without critical care specialist» to «closed policy with critical care specialist». Am J Respir Crit Care Med 161:A397 (abst)

28. Schmitz R, Lantin M, White A (1999) Future Workforce Needs in Pulmonary and Critical Care Medicine. Abt Associates, Cambridge

29. Annane D, Aegerter P, Jars-Guincestre MC, Guidet B (2003) Current epidemiology of septic shock: the CUB-Rea Network. Am J Respir Crit Care Med 168:165-172

30. The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301-1308

31. Rivers E, Nguyen B, Havstad S, et al (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368-1377

32. Bernard GR, Vincent JL, Laterre PF, et al (2001) Efﬁ cacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 344:699-709

33. van den Berghe G, Wouters P, Weekers F, et al (2001) Intensive insulin therapy in the critically ill patients. N Engl J Med 345:1359-1367

34. Berwick DM (1989) Continuous improvement as an ideal in health care. N Engl J Med 320:53-56