SAN DIEGO – Converting some conventional hospitalists to intensive care unit hospitalists reduced the average length of stay, duration on ventilators, and rate of catheter-related bloodstream infections, worth an estimated $1.45 million per year in savings at one community hospital.
After a year with the intensivist hospitalist team in action, the rate of catheter-related bloodstream infections decreased by 75%, the average length of ICU stay declined by 22%, ventilator days decreased by 35%, and the rate of ventilator-associated pneumonia was brought down to 0%. In addition, 30% more general ward patients were discharged before noon by non-ICU hospitalists, Dr. Min Hlaing and Dr. Rod Felber reported in a joint presentation at the annual meeting of the Society of Hospital Medicine.
Sherry Boschert/IMNG Medical Media
Dr. Min Hlaing
Surveys of other hospital staff suggested that having the intensivist hospitalist team improved communication between physician and nurses and between hospitalists and subspecialists. ICU nursing staff, respiratory technicians, and the sole pulmonologist reported being very satisfied with the ICU hospitalist care, said Dr. Hlaing and Dr. Felber of Lodi (Calif.) Memorial Hospital. The center has 270 beds.
The reductions in length of stay, ventilator days, and infections alone represent a savings to the hospital of $1.45 million per year, the speakers and their associates estimated.
Patient- and family-satisfaction scores increased after institution of the ICU hospitalist service. Job satisfaction among nurses improved, which increased retention of nurses in both the ICU and general ward. The hospital found it easier to recruit and retain specialists and easier to recruit general ward hospitalists because they no longer needed to have ICU skills. Satisfaction and retention among hospitalists as a whole improved at the hospital, said Dr. Felber, medical director of the hospitalist program.
To start the trial, Dr. Hlaing, who is an associate director of the hospitalist program, identified four of his hospitalists who were comfortable in caring for critically ill patients. He assigned them and himself to manage the 10-bed ICU and closed the ICU to other hospitalists. Team members became credentialed to perform procedures such as ultrasound-guided central venous catheter placement, arterial catheter insertion, lumbar puncture, paracentesis, endotracheal intubation, and ventilator management. They completed a course in the fundamentals of critical care support, and utilized evidence-based standardized order sets that were developed for common ICU conditions.
The ICU hospitalists had dedicated times for multidisciplinary rounds, family meetings, ICU-specific committees, and education of nurses. An emphasis on continuity of care enabled ICU patients to be admitted, rounded on daily in the ICU, followed after transfer to the medical/surgical floor, and discharged home by the same hospitalist.
After a year of the ICU hospitalist service in action, the investigators conducted a 360-degree evaluation and review of the major hospital stakeholders.
The workload of caring for an ICU patient was considered to be 1.5 times that of medical/surgical floor patients, so the intensivist hospitalists saw fewer patients than other hospitalists. The ICU hospitalists were paid $5 per hour more than other hospitalists. The Relative Value Units for ICU patient care and performance of procedures also led to higher compensation compared with medical/surgical hospitalists, Dr. Felber said.
Sherry Boschert/IMNG Medical Media
Dr. Rod Felber
During the year, the hospital administration requested expansion of the ICU hospitalist model from 12 hours per day of coverage to 24 hours per day.
"If you have hospitalists who are capable of doing it, an ICU hospitalist model is one of the most sustainable and economically viable options to provide quality care to our most critically ill patients," Dr. Felber said.
Previous studies suggest that, in general, only 23% of critically ill patients are seen by intensivists, the speakers said. ICUs consume a quarter of hospital budgets on average. The aging U.S. population will increase demand for intensivist services by 38%. Strategies proposed for hospitals to cope with this evolution include hiring more intensivists, greater use of telemedicine, and partnering with hospitalists, as in the current study.
Dr. Hlaing and Dr. Felber did not report financial disclosures.