Look before you leap: how do intensivists improve care for critically ill patients?

Statements such as these have provoked anxiety within hospitals, and particularly among hospital administrators. What is the basis for such statements, and what is the quality of evidence to support them? The Leapfrog Group was established by the Business Roundtable, which consists of the chief executive officers of several large corporations. These corporations purchase health insurance for more than 34 million healthcare consumers, and therefore have considerable influence on health policy (2). The Business Roundtable established the Leapfrog Group to “work with medical experts throughout the U.S. to identify problems and propose solutions that it believes will improve hospital systems that could break down and harm patients” (2). One of the first recommendations by this group was that trained intensivists should staff intensive care units. An article by Manthous in this issue of the Journal evaluates the quality of the data upon which the group bases its recommendations on intensive care unit staffing (3). The data supporting the general concept of intensivist staffing is persuasive. Pronovost (one of the authors of the Leapfrog Guidelines) recently published a meta-analysis of physician staffing in intensive care units. The study compared low-intensity physician staffing (no intensivist or elective intensivist consultation) with high-intensity staffing (mandatory intensivist consultation or a closed intensive care unit that is directed by an intensivist) (4). The results seemed to indicate that high intensity staffing was associated with a lower risk of both intensive care unit and hospital mortality and a reduced length of stay in the critical care setting. As discussed by Manthous (3), this meta-analysis has some limitations. Nevertheless, there is an overall commonsense agreement that the availability of an intensivist to assist in the care of critically ill patients will improve patient outcomes in the intensive care unit, although rigorous, scholarly studies are not available. If the need for more intensivists is accepted, then there is a problem with implementing the Leapfrog recommendations. For example, the findings of the Committee on Manpower for Pulmonary and Critical Care Societies states that currently, intensivists provide care to only 37% of all critically ill patients, and that by the year 2030 there will be a shortfall of critical care specialist hours by 35% (5). How can we mandate intensivist staffing when such a large shortage of intensivists exists? Moreover, how should we evaluate the recommendations of the Leapfrog Group? Whereas some guidelines may lend themselves to formal, evidence-based analysis, such as “intensive care units should be staffed by boardcertified intensivists,” other recommendations, such as “intensivists should respond to more than 95% of calls for assistance within 5 minutes”, are unlikely to undergo a randomized, prospective trial. The Leapfrog Group recommendations represent an area where health care policy may be driven more by opinion than by solid scientific studies. Whereas changes in clinical practice are usually driven by guidelines and recommendations from professional societies, the Leapfrog recommendations carry additional impetus from hospital administrators and insurers eager to please large consumers of healthcare services. Perhaps the most important question to ask is: “How do intensivists improve care for critically ill patients?” In addition to bedside clinical skills, a favorable impact of the intensivist on clinical outcomes may depend largely on the intensivist’s ability to implement evidence-based practices in the intensive care unit. Critical care medicine has been revolutionized over the last 10 years with the publication of a number of pivotal clinical trials that have significantly transformed the way we care for critically ill patients. For example, the National Heart Lung and Blood Institute Acute Respiratory Distress Syndrome Network conducted a multicenter, randomized, prospective trial of 6 ml/kg versus 12 ml/kg tidal volume for patients with acute lung injury. This trial demonstrated an impressive 9% reduction in mortality when the lower tidal volume was used (6). In another recent study, Ely et al demonstrated that therapist-driven ventilator weaning protocols decrease the duration of mechanical ventilation in patients with acute respiratory failure (7). Also, Van den Berghe et al reported that tight control of blood gluAm J Med. 2004;116:206 –207. From the Departments of Anesthesia and Medicine, Cardiovascular Research Institute, University of California at San Francisco. Reprint requests to Michael A. Gropper, MD, PhD, Critical Care Medicine, 505 Parnassus Avenue, Room M917, University of California, San Francisco, San Francisco, CA 94143-0624. gropperm@anesthesia.ucsf.edu.