Introduction
The way departments and divisions are organized in hospitals and medical schools has evolved over time as a consequence of myriad infl uences. The evolu- tion of these organizational structures is reminiscent of the way hospitals grow by adding new wings and remodeling old wards. But, any nurse or doctor, who has worked for a while in a ‘modernized’ but still old hospital and then has trans- ferred to a brand new state-of-the-art facility, will tell you that one can go only so far by updating an obsolete structure. The workfl ow is far better in the newer facility, the quality of life is better for both patients and staff, and, in some in- stances, even quality of care is improved. Therefore, it is reasonable to ask: if we could start from scratch, would we still organize the specialties and subspecial- ties of medicine the way we do now, or would the ‘org chart’ look different?
Changing Physician Grouping
As the reader may have guessed by now, the author suspects that the most ra- tional and effi cient way to group physicians in hospitals and medical schools is quite different from current practice. Specifi cally, consider the case of emer- gency medicine physicians, hospitalists, and intensivists. Often, patients with an acute serious illness enter the health care system through the emergency de- partment (ED). After being stabilized, many such patients are admitted to an intensive care unit (ICU), either directly or, if emergency surgery is required, via the operating room (OR). If the outcome in the ICU is favorable, then patients typically are transferred to a general medical or surgical ward to recuperate fur- ther before either going home or receiving additional rehabilitation at a facility specializing in this component of the continuum of care.
Thus, emergency medicine physicians, intensivists and hospitalists all ‘touch’
many patients requiring hospitalized care. The types of patients and the kinds of problems encountered by these three specialties are distinct. For example, many patients presenting to the ED can be discharged to home to be followed by a physician or surgeon on an out-patient basis. By the same token, many ‘ward patients’ are never so sick as to require care in an ICU, and much of the emphasis during hospitalization is (or should be) on discharge planning and education
of Critical Care Services
M. P. Fink
to minimize the likelihood of unnecessary repeat hospitalization for the same problem.
But, the similarities among these specialties are greater than the differences.
Indeed, emergency medicine specialists, hospitalists and intensivists all must be broadly trained and capable of viewing patients in an integrated fashion rather than focusing only on one specifi c organ system or type of procedure. Further- more, specialists in all three of these fi elds should be able to intervene in a timely fashion to deal with acute life-threatening problems, such as airway emergen- cies, hemorrhage, and derangements in electrolyte status. And, of course, all three groups of physicians focus on those patients that require care – even if only transiently – in a hospital.
Since the ED, the ICU, and the ward are all components of the continuum of care within the hospital environment, these three areas are all intimately co-de- pendent with respect to the allocation and availability of resources. Thus, when beds are unavailable on the wards, patients ‘back up’ in the ICUs, even when a lower intensity of monitoring and intervention is warranted. Lack of ICU beds leads to crowding and delay of services in the ED, compromising care and leav- ing patients and families dissatisfi ed.
Ideally, the practice of high quality critical care medicine does not begin when the patient arrives in the ICU, but rather begins as soon as critical illness is iden- tifi ed by health care workers, whether these individuals are emergency medical technicians, paramedics, nurses, emergency medicine specialists, surgeons or intensivists. Certainly, as pointed out recently by Cawdery and Burg, rapid stabi- lization and diagnosis are fundamental principals in both emergency medicine and critical care medicine [1]. These authors also point out that the demand for critical care services in the ED has increased over the past decade and continues to rise. For example, in California, the number of critically ill patients present- ing to EDs increased by 57% from 1990 to 1999 [2]. In the United States, ED visits have increased by about 20% from 1992 to 2002 while the number of hospitals has decreased by 15% [3]. In 2002, 22% of patients were classifi ed as true emer- gencies and 919,000 required “immediate medical attention” [3].
Most tertiary and quarternary care medical centers are large enough to sup- port full-time staffi ng in the ED and the ICUs and many also incorporate hos- pitalist services to provide round-the-clock attending-level coverage for ward patients. But, few secondary community hospitals can support ‘7-by-24’ staffi ng of the ED, ICUs and wards. In practice, the ED is staffed on a full-time basis and except for brief periods when daily rounds are being conducted or during extreme emergencies, patients in the ICUs and the wards are ‘covered’ from phy- sicians’ offi ces or homes by telephone. Emergency coverage for ward and ICU patients – to deal with airway crises or hypotension unresponsive to intravenous fl uid administration – typically is provided by the emergency physician or, pos- sibly, an in-house anesthesiologist.
Changing Training
Critical care medicine requires fellowship training, but currently it is not a ‘pri- mary specialty’ in the United States or most European countries (Spain and Switzerland are notable exceptions). At least in the USA, critical care medicine is considered to be a subspecialty of one of four primary specialties: medicine, sur- gery, anesthesiology and pediatrics. The credentialing pathway requires board certifi cation in one of these primary specialties then subspeciality fellowship training, ultimately leading to a ‘certifi cate of added qualifi cations’ in critical care medicine. It is noteworthy that there is no accredited pathway in the United States for emergency medicine physicians to obtain certifi cation as experts in critical care medicine. Nevertheless, a sizeable number of emergency medicine physicians have received additional fellowship training in critical care medi- cine; many of these individuals are graduates of the Multidisciplinary Critical Care Training Program (MCCTP) at the University of Pittsburgh. Most of these physicians have obtained certifi cation in critical care medicine by sitting for an examination offered by the European Society of Intensive Care Medicine. Many but not all hospitals in the United States regard the European Diploma in Inten- sive Care as an acceptable credential to permit practice critical care medicine.
This view is the one taken by the University of Pittsburgh Medical Center.
Clearly, a far more rationale approach for providing the epoch of care that occurs in the hospital is to train a cadre of physicians, who are experts in emer- gency medicine, critical care medicine, and ward-based medicine. One way to achieve this goal is illustrated by the diagram shown in Figure 1. According to this concept, medical students could opt to obtain training in a Hospital-based Medicine (HBM) residency program. In contrast to conventional training in Internal Medicine, which appropriately emphasizes outpatient care, training in HBM would deal exclusively with the management of hospitalized patients.
Fig. 1. Pathways to training as a hospitalist, emergency medicine physician and/or intensiv- ist.
In addition to rotations on general medical and surgical wards, the three-year curriculum would include a substantial block of time in the OR, gaining experi- ence with airway management skills. Additional rotations would include time in medical and various surgical ICUs as well as the ED.
After completing training in HBM, trainees would be qualifi ed to sit for a cer- tifying examination in this specialty. Many graduates of HBM programs might elect to obtain no further formal training, but rather start careers as hospitalists.
However, other trainees might elect to complete two years of additional train- ing in Emergency Medicine, two years of additional training in Critical Care Medicine, or three years of additional training, leading to added qualifi cations in both Emergency Medicine and Critical Care Medicine.
Currently, in most tertiary care medical centers in the United States, the ED is staffed by full-time emergency physicians under the auspices of a Department of Emergency Medicine. The hospitalist service – if it exists at all – is managed by the Department of Medicine or division of this department (e.g., General Medi- cine Division). Typically, critical care services are barely organized at all. Often, a general medical intensive care unit (MICU) is staffed by members of the Divi- sion of Pulmonary Medicine in the Department of Medicine. Some surgical units may be staffed by members of the Department of Surgery or the Department of Anesthesiology (or members from both Departments). Other units, such as neurosurgical ICUs, transplant ICUs or cardiothoracic ICUs, may be staffed by members of the relevant Departments or Divisions or, remarkably, not be staffed at all (at least by a cadre of geographical full-time experts in critical care medi- cine). It is well-known that the organization structure for critical care medi- cine in most North American community hospitals is even more problematic.
Despite the availability of fairly convincing data to support the value – both in terms of lives and dollars saved – of ‘high intensity’ staffi ng of ICUs [4], the vast majority of ICUs in the United States adhere to a ‘low intensity’ model (i.e., open unit confi guration, no geographical full-time physician staff).
Changing Organization
The new training pathways outlined above suggest a better way to organize emergency medicine, hospitalist and intensivist services within hospitals. Ac- cording to this new model, the Department of Hospital-based Medicine would be responsible for staffi ng the ED and ICUs and would also provide hospitalist services for the wards. Large tertiary or quarternary centers might have multiple divisions in the Department (e.g., Emergency Medicine Division, Critical Care Medicine Division, Hospitalist Division), whereas smaller institutions might be better served by having a fl atter organizational scheme and utilizing the same cadre of physicians to provide services on the wards, ICUs and ED. But, whether constructed with multiple divisions or not, hospitals and patients would be well- served by the existence of a Department of HBM. What would be the advantages of this approach?
First, except for very small hospitals, enough physicians would work un- der the umbrella of the Department of HBM to make providing full-time –
‘7-by-24’ – in-house coverage feasible without burdening any single doctor with an excessive number of nights on call per month. Full-time in-house coverage by well-trained intensivists or hospitalists is essential for the proper functioning of medical emergency teams (METs) that can respond at any time of the day or night to the deterioration of a patient on wards or in special care units.
At the University of Pittsburgh Medical Center we do not (yet) have a Depart- ment of Hospital-based Medicine. Nevertheless, we do have a fully independent Department of Critical Care Medicine that includes approximately 50 full-time faculty members. Departmental status for Critical Care Medicine has permitted us to effectively implement the MET concept at our institution. At the University of Pittsburgh Medical Center, the MET consists of a fully trained ‘Resource Inten- sivist’, a critical care medicine fellow, an ICU nurse and a respiratory therapist.
The Resource Intensivist is not responsible for any particular ICU, but rather serves as the intensivist on call for the whole hospital, being available to respond to emergencies in the special care units, on the wards or in the ED. When a ‘Con- dition C’ (C stands for crisis) is called, the members of the MET coalesce together at the appropriate bedside. The critical care medicine fellow carries an ‘Orange Bag’ to the scene. The Orange Bag contains endotracheal tubes, laryngoscopes, and other intubation equipment (including tools for dealing with a diffi cult air- way) plus a small assortment of emergency medications (e.g., etomidate, succi- nyl choline, and naloxone). Thus, the MET is capable of transiently bringing an ICU environment to the bedside of any patient in the hospital. Since the MET is empowered under the hospital by-laws to make whatever interventions are med- ically indicated to stabilize the patient, correctable problems are often identifi ed and managed before the patient’s status deteriorates further. Implementation of the MET concept has resulted in a substantial decrease in the incidence of cardi- opulmonary arrests at the University of Pittsburgh Medical Center [5].
A second potential advantage of having a Department of HBM is the clear as- signment of responsibility for the quality of HBM services. Under the organiza- tional scheme that is common in most medical centers today, the seams between the ED and the ICU and the ICU and the ward are potential weak spots in the handling of care. Since no single Chair takes responsibility for patients in all three areas, the temptation to assign blame rather than fi x problems is some- times overwhelming.
A third advantage of having a Department of HBM is that it should be easier to lessen variations in practice across different settings in the hospital. For ex- ample, the approach used for resuscitating patients with severe sepsis ideally should be the same (or nearly so) for patients on the ward, in the ICU or in the ED. Although hard data regarding this issue are lacking, the author suspects that patients in many institutions are likely to be treated quite differently for the same problem, depending upon whether the care is delivered by hospitalists on a ward, emergency physicians in the ED, or intensivists in an ICU.
Conclusion
The author recognizes that each hospital has its own culture. Moreover, com- plex human organizations are rarely, if ever, designed from the ground up to optimize function and workfl ow. Thus, we almost always are confronted with making compromises between the traditional ways of doing our jobs and our notions of how we might do our work better. But, unless we try to envision a better model, we will be forever constrained by the imperfections in the current paradigm, or worse still, will change our practices only because of external fac- tors beyond our control.
References
1. Cawdery M, Burg MD (2004) Emergency medicine career paths less traveled: cruise ship medicine, Indian health, and critical care medicine Ann Emerg Med 44:79–83
2. Lambe S, Washington DL, Fink A, Herbst K, Liu H, Fosse JS, Asch SM (2002) Trends in the use and capacity of California’s emergency departments, 1990–1999 Ann Emerg Med 39:389–396
3. McCaig LF, Burk CW (2002) National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary. Advance Data 340:1–36
4. 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.
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5. DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL (2004) Medi- cal Emergency Response Improvement Team (MERIT). Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care 13:251–254
