Intensivists achieve better outcomes for less money. Surprise!

I can’t even begin to fathom the health system in the USA. But one thing I do know is that in many hospitals critically ill patients in ICU aren’t looked after by intensivists. So-called “open-unit ICU” is the norm where all specialists can admit their patients to ICU and manage them once there.

This interesting little before and after analysis by Parikh et al in this month’s edition of Critical Care Medicine shows that the introduction of specialist intensivists providing care for patients in a 12 bed mixed ICU in a community hospital is associated with some pretty impressive outcomes. What struck me most was that those patients who weren’t looked after by an intensivist were 6 times more likely to get ventilator associated pneumonia and 8 times more likely to get Central Line Associated Bloodstream Infection (CLABSI). What were the non-intensivists doing? Spitting on their hands before performing procedures?

Also of note was that those cared for by intensivists got out of ICU a day sooner and the hospital ended up with a net saving at the end of the year of about $800,000. This is amusing because apparently one of the most commonly cited reasons for not hiring intensivists is that they cost too much! I suspect the actual reason for intensivists not being ubiquitous in the US is simply territorial behaviour by other specialists.

Unfortunately the study didn’t show that intensivists saved lives, but it wasn’t powered to do so and previous studies have already shown that care provided by intensivists decreases both ICU and hospital mortality by 1/3.

Anyway, check it out for yourself if this kind of stuff floats your boat.
http://www.ncbi.nlm.nih.gov/pubmed/22824939

Crit Care Med. 2012 Jul 20. [Epub ahead of print]

Quality improvement and cost savings after implementation of the Leapfrog intensive care unit physician staffing standard at a community teaching hospital.

Parikh A, Huang SA, Murthy P, Dombrovskiy V, Nolledo M, Lefton R, Scardella AT.

From the UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ (AP, SAH, PM, VD, MN, ATS); and University Medical Center at Princeton, Princeton, NJ (MN, RL).

Abstract

BACKGROUND:
Prior studies have shown that implementation of the Leapfrog intensive care unit physician staffing standard of dedicated intensivists providing 24-hr intensive care unit coverage reduces length of stay and in-hospital mortality. A theoretical model of the cost-effectiveness of intensive care unit physician staffing patterns has also been published, but no study has examined the actual cost vs. cost savings of such a program.

OBJECTIVE:
To determine whether improved outcomes in specific quality measures would result in an overall cost savings in patient care

DESIGN:
Retrospective, 1 yr before-after cohort study

SETTING:
A 15-bed mixed medical-surgical community intensive care unit

PATIENTS:
A total of 2,181 patients: 1,113 patients preimplementation and 1,068 patients postimplementation.

INTERVENTION:
Leapfrog intensive care unit physician staffing standard

MEASUREMENTS:
Intensive care unit and hospital length of stay, rates for ventilator-associated pneumonia and central venous access device infection, and cost of care.

RESULTS:
Following institution of the intensive care unit physician staffing, the mean intensive care unit length of stay decreased significantly from 3.5 ± 8.9 days to 2.7 ± 4.7 days, (p < .002). The frequency of ventilator-associated pneumonia fell from 8.1% to 1.3% (p < .0002) after intervention. Ventilator-associated pneumonia rate per 100 ventilator days decreased from 1.03 to 0.38 (p < .0002). After intervention, the frequency of the central venous access device infection events fell from 9.4% to 1.1% (p < .0002). Central venous access device infection rate per 1000 line days decreased from 8.49 to 1.69. The net savings for the hospital were $744,001. The 1-yr institutional return on investment from intensive care unit physician staffing was 105%.

CONCLUSIONS:
Implementation of the Leapfrog intensive care unit physician staffing standard significantly reduced intensive care unit length of stay and lowered the prevalence of ventilator-associated pneumonia and central venous access device infection. A cost analysis yielded a 1-yr institutional return on investment of 105%. Our study confirms that implementation of the Leapfrog intensive care unit physician staffing model in the community hospital setting improves quality measures and is economically feasible.

PMID: 22824939
[PubMed – as supplied by publisher]

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