Key Point:

Within the next decade, a shortage of critical care physicians is predicted in the US. If not prevented, this shortage will adversely affect patient care in the ICU.

NEW YORK CITY—Has critical care medicine in the United States reached a crisis? In 1995, the American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine formed COMPACCS (the Committee on Manpower for Pulmonary and Critical Care Societies) to investigate whether a sufficient number of physicians were available to meet current and future ICU needs. The committee’s results, published in 2000, suggested that a severe shortage in ICU staffing is likely in the near future.

According to COMPACCS, intensivists currently care for only 37% of ICU patients in the US. Yet, having trained intensivists in the unit decreases mortality and both ICU and hospital lengths of stay. Unfortunately, increasing the proportion of intensivists in the ICU does not appear to be possible because an insufficient number of such specialists are being trained. The supply of critical care nurses and pharmacists is also far below current and future demand.

These shortages could not come at a worse time. As the nation ages, the demand for ICU services is rising sharply. COMPACCS estimates that the shortages in ICU staffing will reach a crisis level within the next three years.

“This has been a long time in coming,” said Donald B. Chalfin, MD, MS, Director of Health Services Research in the Division of Critical Care Medicine at Montefiore Medical Center in Bronx, New York. “COMPACCS showed that the demand for critical care services is going to increase and the supply is not going to keep pace with the increasing demand. Not only is the population getting older, it’s getting larger, and we’re dealing with diseases such as immunosuppression and sepsis.”

In response to these findings, the FOCCUS (Framing Options for Critical Care in the United States) Task Force has issued recommendations addressing the future of critical care medicine.[1]

RECOMMENDATIONS

FOCCUS made the following four recommendations[2]:

1. The critical care profession should adopt common standards to ensure uniformity, promote quality, and rationalize resources. The committee noted that the major challenge would be implementing these standards in all ICUs in the country. Standards would range from using evidence-based practice to employing guidelines for end-of-life care. Making common standards a reality will require a concerted effort from critical care professionals and hospital administrators.

2. Information technology (IT) should be leveraged in critical care to promote standardization and improve efficiency. The use of modern IT systems could integrate—in real time—physiologic, laboratory, and imaging data with medications and interventions. A common, government-sanctioned ICU information platform with a decision-support function should be available to all ICUs. Telemedicine, with continuous remote intensivist staffing using videoconferencing and a computer-based data transmission, could also improve ICU patient outcomes. The costs may be prohibitive and pose a considerable barrier, but such technology would improve the quality of care and mitigate the effects of workforce shortages.

3. Policy makers should develop incentives to attract health care professionals into critical care. Currently, intensivists spend 25% of their time in the ICU; in contrast, critical care nurses spend more than 70% of their time in the unit. With the threat of cuts to Medicare reimbursement for professional services, the income of intensivists—already lower than those of some other specialists—may fall even more. The federal government should ensure that payment for critical care services is competitive and add incentives for critical care training.

4. Policy makers should sponsor research that defines the optimum role for intensive care professionals in the delivery of critical care. Research should identify ways to provide the best care for critically ill patients and match ICU patient needs with available resources. This might include the use of multidisciplinary staffing—for example, expanding the duties of critical care nurses, pharmacists, and respiratory therapists.

CRITICAL CARE DIFFERS WORLDWIDE

There is a striking difference between the way ICU care is administered in the US and in Europe, Australia, New Zealand, and Asia. “In the United States there’s a lot more variability in critical care organization,” explained Dr. Chalfin, who is a member of the FOCCUS Task Force. This is seen in the number of open units and closed units, how units are organized and staffed, and who has control and primary responsibility for the patients. “In a closed unit, the intensivist is the one with primary responsibility,” he continued. “While you have an increasing number of closed units in the United States, you also have more subspecialty consultations and a lot more instances where the primary care physician has the primary responsibility for the patient.

“The literature categorically suggests that having closer intensivist supervision is better for the patient, and you have better outcomes that are provided cost-effectively,” noted Dr. Chalfin. “You need a situation where intensivists have more control and responsibility.”

Based on trends in current practice, there will be a severe shortage of critical care physicians within the next decade. Without some sort of intervention, the field of critical care medicine is at risk—and so is the health of patients.

—Gale Jurasek

References
1. Irwin RS, Marcus L, Lever A. The critical care professional societies address the critical care crisis in the United States. Chest. 2004;125:1512-1513.
2. Kelley MA, Angus D, Chalfin DB, et al. The critical care crisis in the United States: a report from the profession. Chest. 2004;125:1514-1517.

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