It is a fundamental belief of the

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1 Team model: Advocating for the optimal method of care delivery in the intensive care unit Charles G. Durbin Jr, MD, FCCM Objective: To review published data on the team model of intensive care unit (ICU) care delivery. Design: Nonexhaustive, selective literature search. Setting: Review of literature published in the English language. Patients/Subjects: Humans cared for in ICUs. Interventions: None. Results: The team model for delivery of ICU care reduces mortality, ICU length of stay, hospital length of stay, and cost of care. Convincing data suggest that merely having daily rounds led by an intensivist enhances patient care significantly. Further improvements can be obtained by maintaining a nurse-to-patient ratio of no greater than 1:2, adding critical care pharmacists, and providing dedicated respiratory therapists to the ICU team. Conclusion: Current and looming shortages of all ICU healthcare providers is a barrier to universal implementation of the team model. Advocating for the ICU team model for critical care delivery requires local, regional, national, and international activities for success. (Crit Care Med 2006; 34[Suppl.]:S12 S17) KEY WORDS: critical care; intensive care; models of care; intensivist; outcome; advocacy; mortality; critical illness; quality improvement; shortage; resources; efficiency From the Departments of Anesthesiology and Surgery, University of Virginia Health System, Charlottesville, VA. The author has no financial conflicts of interest to declare. Copyright 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins DOI: /01.CCM D1 It is a fundamental belief of the Society of Critical Care Medicine that the optimal method for care delivery in the intensive care unit (ICU) is the team model. In the first editorial in Critical Care Medicine, Max Harry Weil, MD, PhD (the first president of the Society of Critical Care Medicine), stated, It is the purpose of our Society to improve the care of patients with acute life-threatening illnesses and injuries and to provide optimum facilities for this purpose. We commit ourselves to these ends by creating a good hospital environment with qualified teams of physicians, nurses, technicians and medically oriented engineers (italics added for emphasis) (1). Further, he stated that the goal of these teams was to bring increased orderliness and expertise to the management of the critically ill. The understanding of the value of the team to optimal care of the critically ill continues as a cornerstone in our Society today. After a recent retreat, the leadership of the Society of Critical Care Medicine reaffirmed this belief and stated that the goal of the ICU team is the timely delivery of needed care to the patient in the bed. This has directly led to the development and deployment of the Right Care, Right Now campaign. It was further affirmed by the leadership that the best way to achieve this outcome is to have an integrated team of dedicated experts at the patient s bedside, actively solving problems and delivering care. Although the team concept seems to have intuitive value, the contributions of individual members of the team are most strongly supported in the published literature. The purpose of this article is to briefly review the data supporting using such a team model for ICU care, detail the contributions that specific members of the team have added to improve the outcome from critical illness, and identify areas that need additional study. A brief review of barriers to achieving this optimal model in all ICUs will be included. Finally, suggestions will be offered of how to present the value of the team of dedicated experts to local administrators, fellow caregivers, and legislators to support the team model of ICU care delivery. Value of the Intensivist Having an intensivist involved in the care of ICU patients is undoubtedly the most effective intervention to improve survival of the critically ill that has been devised in the past 30 yrs. It is estimated that between 30% and 50% fewer patients would die if an intensivist rounded daily on all critically ill patients. There are a large number of reported examples in which hospitals have made the transition to having an intensivist in the ICU, and mortality is less after this change. In addition to specialized knowledge and clinical skills, the intensivist brings an attitude of collaboration, supporting other team members and coordinating care for the sickest individuals. By having no higher competing priorities, the intensivist-led team is able to make earlier interventions, thus averting potentially catastrophic events. The underpinning of critical care clinical practice is this early identification of undesired trends and timely interventions to head off disaster. Besides reducing the cost of critical care with early interventions and prevention of complications, intensivists shorten ICU length of stay by moving patients through the hospital system more efficiently. Patient placement decisions and rehabilitation can be initiated earlier if the decision maker is at the patient s bedside throughout the early ICU treatment course. This contributes to other benefits of the intensivist team, shortening of ICU and hospital length of stay, and reduction in the cost of care. S12

2 Studies Supporting the Value of an Intensivist Reynolds et al. (2) reported that the mortality from septic shock was reduced from 74% to 57% at a university hospital after introduction of an intensivist model in a medical ICU. Severity of illness, as judged by Acute Physiology and Chronic Health Evaluation (APACHE) II scores, was identical in the study periods, and there was no change in length of stay of these very ill patients, suggesting that something about having an intensivist involved in care made the improvement. There was an increase in the use of invasive devices, including systemic and pulmonary artery catheters with the change to intensivists. Despite the increased risk of more aggressive care, the mortality in the sickest ICU patients was less. In another medical ICU, Brown and Sullivan (3) demonstrated a 52% reduction in ICU mortality, from 27.8% to 13.4%, when a full-time intensivist was added at a Canadian teaching hospital. Similar effects on mortality have been seen in community ICUs as well. Manthous et al. (4) studied mortality and length of stay before and after an intensivist model was instituted. The medical ICU mortality decreased from 20.9% to 14.9% and in-hospital mortality decreased from 34.0% to 24.6% after the change in this universityaffiliated community teaching hospital in Bridgeport, CT. Pediatric ICUs in the United States have a higher percentage of intensivist coverage than adult ICUs. A survey performed in 1994 identified that almost 80% of the pediatric ICUs had full-time intensivist-trained medical directors. A pediatric intensivist was available to 70% of the units. Dedicated physician coverage for 24 hrs/day of the pediatric ICU was present in almost half of the hospitals surveyed (5). Having an intensivist involved in the care of critically ill children increases the likelihood of survival (6). The specific role of the intensivist in the management of ICU patients may be important in optimizing medical, psychological, and economic outcomes. Units that have converted from the intensivist acting as consultant to one in which the intensivist actively manages all the patients generally show further improvements in mortality, length of stay, and costs of care (7). Ghorra et al. (8) reported these improvements in a surgical unit studied before and after changing to an intensivist management model. In this unit, mortality declined by more than half, from 14.4% to 6.0%, with intensivists assuming full patient management responsibility. There was also a decrease in the overall complication rate, from 56% to 44%, with this change. The number of consults obtained was also decreased from an average of 0.6 to 0.4 per patient, and the rate of renal failure was markedly reduced from 12.8% to 2.7% of patients. Others have reported similar improvements with this type of management change in other types of ICUs (9). In a concurrent study by Hanson et al. (10) in a surgical ICU, in which part of an ICU was managed by an intensivist-led team model and the rest of the patients were managed by primary surgeons, improved economics were observed, with a shortened length of stay, fewer daily costs, and fewer outside consultations obtained. Risk-adjusted mortality was unaffected, but there were fewer complications with the intensivist team model. Another approach to identifying and quantifying the impact of having an intensivist make management rounds in an ICU is the analysis of large databases. Because of the huge number of patients and wide variety of types of units studied, these analyses are very powerful. However, there is little information about the specifics of the unit organization, and of the care team, because broad generalizations are used to classify care in a large group of diverse units. In a study of hospital discharge data for patients in nonfederal acute care hospitals in the state of Maryland who had a principal procedure code for abdominal aortic surgery from January 1994 through December 1996, Pronovost et al. (11) demonstrated that not having daily rounds with an ICU physician increased mortality by a factor of three. This effect was observed after adjustment for patient demographics, presence of co-morbid disease, severity of illness, hospital case volume, and surgeonspecific volume. Furthermore, not having daily rounds by an ICU physician was associated considerable additional morbidity, including an increased risk of cardiac arrest, acute renal failure, septicemia, and reintubation. The presence of an ICU physician seemed to lead to earlier recognition of developing problems and thus earlier treatment. Also noted in this powerful study was that having an ICU nurse-to-patient ratio of less than 1:2, not having at least a monthly review of morbidity and mortality, and extubating patients in the operating room after abdominal aortic aneurysm repair were associated with increased resource use and costs of care. In a systematic meta-analysis of articles published reporting both physician staffing patterns and patient outcomes, Pronovost et al. (12) defined a highintensity model as one in which there was a mandatory consult by an intensivist on all ICU patients or a closed unit in which all orders were overseen by an intensivist, and they defined a low-intensity model as one in which there was no required or only elective consultation by an intensivist. Sixteen of 17 studies that had enough information to determine the intensivist staffing model reported lower hospital mortality with a high-intensity model compared with a low-intensity model. This difference was highly significant (odds ratio, 0.71; 95% confidence interval, ). Fourteen of the 15 studies that reported ICU mortality demonstrated lower mortality with the highintensity model (odds ratio, 0.61; 95% confidence interval, ). The high-intensity model was also associated with shorter ICU and hospital length of stay in most of the reviewed studies. Overall, no articles demonstrated statistically significant increases in mortality or length of stay when a high-intensity model of staffing was employed. This meta-analysis included consideration of all articles published between 1979 and 2000, and the selected 27 studies comprised 27,000 critically ill individuals, including adults and children. In summary, having an intensivist rounding daily in an ICU reduces mortality and complications. If the intensivist participates actively in the management of all the ICU patients, a further improvement in survival occurs. Effect of Nurses on ICU Outcomes Nurses are essential to delivery of medical care. They are a part of the dedicated team of experts at the bedside of each critically ill patient. Staffing levels and experience of the nurses in the ICU are known to influence several important outcome measures. Using non-icu trained nurses to care for patients with central venous catheters inserted for hyperalimentation was found to be associated with a higher rate of catheter infection than when these vulnerable patients were cared for by ICU-specialist nurses S13

3 (13). Providing additional nursing hours reduced the number of errors, even when the additional nursing staff was not ICU trained (14). This was probably due to freeing up the ICU-trained nurses and allowing them to concentrate on the higher level, more risk-prone activities. Nursing inexperience contributed to at least half of the 1,400 adverse events reported in the Australian survey of ICU outcomes study (15). Rapidity of weaning of patients with chronic obstructive pulmonary disease was inversely correlated with the quality and quantity of nursing staff during a 6-yr period in a medical ICU in Switzerland (16). Nurse-to-patient ratios directly influence the rate of preventable adverse events. In a study of unplanned extubations in pediatric ICUs, the important factors identified were agitation of the patient and a nurse-to-patient ratio of greater than 1:1 (17). The latter observation had a confidence interval of , making it highly significant. As mentioned above, having a nurse-topatient ratio of greater than 1:2 in caring for patients after repair of an abdominal aortic aneurysm increased the length of stay in a large study of Maryland hospitals. Pharmacist Contributions Adding an advanced-practice pharmacist to the ICU team makes intuitive sense. Many of the errors identified as occurring in an ICU are related to drug choice, dose, or delivery method. Preventable adverse drug events are at least twice as frequent in the ICU as on acute patient wards. In one study, these adverse drug events are reported as occurring at a rate as high as 19 per 1000 patient-days in the ICU (18). Adding a senior pharmacist to the ICU rounding team reduces this rate substantially. In one unit studied, the adverse drug events rate before initiating this change was 10.4 per 1000 patient-days and decreased to 3.5 per 1000 patient-days, a 66% reduction, after addition of a pharmacist to daily ICU rounds (19). Others have highlighted this improved patient safety and several other benefits of including a critical care trained pharmacist as part of the ICU team. Additional benefits of having a pharmacist involved during the time when medication decisions are being made in the ICU include the cost savings of using equivalent but less expensive medications, optimizing dosing intervals in patients with altered drug metabolism, reducing the duration of sedation and the occurrence of drug-induced coma, having up-to-date drug information, suggesting alternative appropriate therapies, identifying drug interactions, and promoting therapeutic drug monitoring (20). Respiratory Therapist s Contributions to Patients in the ICU Because many critically ill patients require mechanical ventilation and almost all require airway support, the role of the respiratory therapist as a valued member to the ICU team is a given. In recent years, advances in practice and science have solidified this role. The use of patient-driven protocols for increasing and withdrawal of respiratory support has shortened duration of mechanical ventilation and reduced the prevalence of ventilator-associated pneumonia in critically ill patients (21, 22). Avoiding intubation by using noninvasive ventilation in the appropriate patients in acute respiratory failure is an important intervention initiated by respiratory therapists that improves patient outcome (23 25). Identification and management of risk factors for the development of ventilator-associated pneumonia is an area of respiratory care in which large gains have been made. Large trials of ventilator equipment management techniques have led to changes that have reduced costs and reduced patient morbidity. Use of in-line suction devices and reducing the frequency of ventilator circuit changes have saved money and reduced ventilator-associated pneumonia (26, 27). Instituting therapist-initiated daily spontaneous breathing trials has the potential for further shortening the duration of mechanical ventilation and for reducing morbidity (28). Evidence Favoring the Team Model With the scientific evidence reviewed above supporting the positive impact of clinical practices of several of the ICU specialists, it seems obvious that a team of these experts continually present at the patient s bedside would provide the best possible patient outcome. Very little study of the team model has actually been performed. Patient survival is usually reported as the most important outcome in evaluating treatment effectiveness. Certainly, it is the easiest variable to determine. Outcome from treatment of critical illness varies considerably between different individuals, hospitals, and settings. Various factors are responsible for this variability. One of the most important contributors to outcome is the initial severity of illness. This, when coupled with intrinsic host factors such as nutritional status, age, immune function, and genetics, often determines survival or death, despite the quality of the treatment interventions that are applied. Most of the host factors are incompletely understood and difficult to measure. This is an intense area of basic science investigation. It will become very important in the future. Routine genomic screening will soon dictate changes in medical therapy in the ICU. Presently, simpler methods are used to compare treatments. Any comparison of outcome between different treatments, models, or systems must account for differences in severity of illness. Several techniques are commonly used to estimate severity of illness in the ICU patient. Obtaining simple physiologic, diagnostic, and host factors at presentation in individual patients allows a prediction of survival of groups of critically ill patients. By calculating the ratio of actual-to-expected deaths, specific units or treatments can be compared. One of the earliest, accurate predictive indexes for ICU mortality is the APACHE scoring system. This predictive model was derived from data prospectively collected in a series of patients cared for in 13 separate ICUs. Of the many variables measured in the first 24 hrs of ICU care, a smaller set, the APACHE II score set, was found to account for most of the variability in survival (29). By evaluating several simple physiologic variables, weighting them by how far they are from normal, and adding a value for the type of patient, from where the patient was admitted, and if they had one or more preexisting diseases, a composite score (from 0 to 54) correlates well (predicts) with group mortality. Other systems of risk adjustment or outcome prediction soon followed the APACHE II system (e.g., MPM II, Mortality Probability Model; SAPS II, Simplified Acute Physiology Score; PRISM, Pediatric Risk of Mortality; and PIM, Pediatric Index of Mortality). By calculating the ratio of actual-to-predicted mortality using any of these scoring systems, comparisons across units S14

4 and with different models of critical care delivery can be made (30). In reporting the actual-to-predicted mortality in the 13 units used for the original APACHE data set, one unit was found to perform significantly better (only 41 deaths when 69 were predicted) and one unit was found to perform significantly worse than average (58% more deaths than predicted) (31). Comparison of the organization of care in these units demonstrated increased coordination of care at the better-performing unit. Physicians and nurses worked together better in the best-performing unit. When caregivers work as a team, the patient outcome improves. In a later study, Zimmerman et al. (32) studied in detail the structural and organizational characteristics of nine units that were selected for their different performance in outcome and efficiency. Superior units had a patient-centered culture, strong medical and nursing leadership, effective communication, coordination of care, and an open, collaborative approach to problem solving and conflict resolution. These best units were not without conflict and problems. In fact, they experienced a more than average amount of conflict, but they had effective and open means for achieving resolution. No particular structure in this small observational study was predictive of superior performance, but the factors in Table 1 were found more frequently in the bestperforming units, and those listed in Table 2 were seen in the worst-performing units. Unit organizational factors are important in many ways in determining clinical and financial performance outcomes. Although the American College of Critical Care Medicine was unable to unequivocally define the one best model for ICU care delivery, in a review of existing data reported by Brilli et al. (33) in 2001, it was concluded that units where dedicated ICU personnel, specifically the intensivist, the ICU nurse, respiratory care practitioner, and pharmacist, all work as a team, have the best patient survival and lowest cost. Actual team function is important to success. The ICU Index developed by the Society of Critical Care Medicine is a tool to assess multiple aspects of ICU function. It includes a measure of Teamness. Characteristics of the functioning of successful ICU teams are suggested in Table 3 (34). Successful teams use data to improve their processes and outcomes. Suggestions on improvement in team function are listed in Table 4 (34). Recent work with highly functional teams suggests that team performance can be improved with group practice. Using skills developed in the aviation industry (35), team simulation activities increase the reliability and the function of groups of caregivers, particularly during emergency situations (36). Simulation is becoming a tool for team development in medicine (37, 38). Communication improvement is an essential outcome for improving patient safety in critical care. Whereas the core ICU team may consist of the intensivist, nurse, and therapist, the team members may be different for each patient in the ICU, and other team members are added at different times during the care process. This added level of complexity makes understanding and analysis of optimal delivery of care to the critically ill very challenging (39). Further research must be performed to identify areas for improvement in ICU team composition and function. ICU safety may be significantly improved with team improvement activities. Barriers to Implementing the Team There are several significant barriers to implementing this model of a team of dedicated professionals providing critical care. The largest difficulty to overcome is existing local customs. To change a practice pattern in a hospital is challenging because it requires a huge organization and culture shift. Physicians and the health professions are often criticized because they are slow to accept change, even when the proposed changes are of proven benefit. Because several different independent groups must alter their behaviors and attitudes to achieve a new practice model at the bedside, implementing the team model is extremely difficult. Resistance comes from many sources: the hospital administration (it will cost too much), local unit administrators (the different authority/responsibilities of hospital-employed caregivers and those not hired by the hospital [i.e., physicians]), bedside caregivers (have to learn different ways of relating), and physician groups with competing needs and concerns. To work as a team requires individual members to relinquish some autonomy. Autonomy and its incumbent responsibility are highly regarded values in most medical environments. Although effective teams do develop in many areas of medical practice, usually dependent on developing personal relationships and trust, the shear number of caregivers necessary to provide critical care around the clock makes personal relationships between all the caregivers impossible. To work effectively, each person must be able to fill his or her role as a member of the team, regardless of personal relationships with others on the team. Studies of organizational change have suggested that there are several essential components for successfully making change (40). These include identifying and accepting the need for change, having a champion for the change at a high level within the organization, empowerment and encouragement to change for those not at the decision-making level, rewards and celebrations of the successes, and continued support at the highest levels during the time necessary for the culture to change. If any of these are lacking, change, if it occurs at all, will not be long lasting. Medical executives who want to accelerate the rate of diffusion of innovations, such as instituting the team model in the ICU, need to accomplish the following: find and support innovators, invest in early adopters of the innovation, make early adopter activity observable, trust and enable reinvention, create slack for change, and lead by example. In the ICU, personnel shortage is a complicating problem limiting the ability to achieve change. It is estimated that there are only enough board-certified intensivists in the United States to staff 20 25% of the current ICU beds if the dedicated team model were instituted universally (41). At least half of the ICUs in the United States are experiencing nursing and respiratory therapy shortages. Shortages of hospital pharmacists is a problem as well, although this situation may be improving somewhat (42). Because members of a well-functioning team rely on the other members of the team, support for and achieving adequate numbers of well-trained dedicated specialists is essential. Initiating Changes in ICU Care Delivery To advocate for change in the local, regional, or national system is a task for which few caregivers have formal training or experience. However, it is essential that each of us take responsibility for at S15

5 least a part of the process if care of the critically ill is to improve. The first step leading to any change is education. We need to educate ourselves and our colleagues to the advantages of the critical care team. The information presented in this report can be used to help others understand that a dedicated and present team of specialists at the patient s bedside is currently the best way known to deliver and titrate care in these most severely ill patients. Establishing this team with an intensivist leader will reduce mortality and reduce ICU and hospital length of stay. Having this team of dedicated experts is the best way to support and attract expert bedside caregivers and manage scarce resources responsibly. Keeping quality individuals at the bedside is essential to maintaining open beds, allowing more patients access to the ICU and producing a positive bottom line for the institution. These are important messages that must be delivered to hospital administrators and those who influence and support change. The financial impact to an institution when establishing the team model with an intensivist has been elucidated in an article by Pronovost et al (43). Using conservative assumptions about the magnitude of impact on care, they project that cost savings would range from $510,000 to $3.3 million (U.S. dollars) for 6- to 18-bed ICUs by instituting an intensivistled model. The best-case scenario demonstrates savings of $4.2 to $13 million (U.S. dollars). These projections are derived from actual published information, and should carry weight and reassure those having financial responsibility for the institution. Reluctance of other physicians to support the intensivist model comes from fear of loss of authority, patient control, and personal income. The American healthcare system is very hierarchic, with the physician at the apex. Many physicians and patients believe this is the best system. However, with complicated patients in the ICU requiring around-theclock care and decisions, a well-functioning team will provide better care than a single physician dictating care from a remote site. By incorporating the patient and the patient s primary physician as intrinsic parts of the ICU team, many of these fears can be ameliorated. The positive effects on survival that the team contributes are the strongest data that can be used to influence primary physicians to support this change. Issues of power and authority are more complex and often interfere with doing the right thing. This is particularly true in academic institutions where considerations other than quality of care are active but unspoken. Having a team of dedicated experts and an intensivist should not affect significantly the income-generating ability of the primary physician as separate activities of each can be simultaneously billed to most insurance carriers. Certainly, the primary physician can spend more quality time with the patient s family and also have more time available to see clinic patients or perform surgery if they are freed of the need to provide care on a minute-tominute basis of a critically ill patient. Because of increased appropriate use of institutional resources and shortened length of stay, hospitals can afford to subsidize the start-up costs of establishing the intensivist team model in their ICUs. In addition to these local political issues, it is also necessary to seek support for the model at higher levels. One of the threats to universal institution of the model is lack of individual members of the team. Shortages are present in all categories. In the United States, there are fewer individuals selecting health care as a career than in the past. An aging population with more critical illness will stress the ICU and make the staffing problem even more difficult in upcoming years. The Society of Critical Care Medicine supports a satisfying and rewarding critical care career pathway for all members of the team. During a recent visit to Washington, DC, an interesting response was heard from several legislators and legislative aides when asked to support additional efforts to attract individuals to nursing, respiratory therapy, medicine, and pharmacy. Although healthcare practitioner visits are common on the Hill, most legislators had never heard physicians asking for more support for nurses (and others) or nurses asking for support for physician training. This got their attention, and they listened carefully to what we had to say about the value of the team. 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