Intensivist To Patient Ratio
Intensivist To Patient Ratio
Objectives: Increases in the number, size, and occupancy Data Synthesis and Conclusions: The taskforce concluded that
rates of ICUs have not been accompanied by a commensu- while advocating a specific maximum number of patients cared for is
rate growth in the number of critical care physicians leading unrealistic, an approach that uses the following principles is essential:
to a workforce shortage. Due to concern that understaffing 1) proper staffing impacts patient care; 2) large caseloads should not
may exist, the Society of Critical Care Medicine created a preclude rounding in a timely fashion; 3) staffing decisions should factor
taskforce to generate guidelines on maximum intensivists/pa- surge capacity and nondirect patient care activities; 4) institutions should
tient ratios. regularly reassess their staffing; 5) high staff turnover or decreases
Data Sources: A multidisciplinary taskforce conducted a review in quality-of-care indicators in an ICU may be markers of overload;
of published literature on intensivist staffing and related topics, a 6) telemedicine, advanced practice professionals, or nonintensivist
survey of pulmonary/Critical Care physicians, and held an expert medical staff may be useful to alleviate overburdening the intensivist, but
roundtable conference. should be evaluated using rigorous methods; 7) in teaching institutions,
Data Extraction: A statement was generated and revised by the feedback from faculty and trainees should be sought to understand the
taskforce members using an iterative consensus process and implications of potential understaffing on medical education; and 8) in
submitted for review to the leadership council of the Society of academic medical ICUs, there is evidence that intensivist/patient ratios
Critical Care Medicine. For the purposes of this statement, the less favorable than 1:14 negatively impact education, staff well-being,
taskforce limited its recommendations to ICUs that use a closed and patient care.(Crit Care Med 2013; 41:638645)
model where the intensivists control triage and patient care. Key Words: ICU; intensivist; rationing; ratios; staffing; workforce
S
1
Rhode Island Hospital Brown/Alpert Medical School, Providence, RI. ince their inception in the 1950s, the number and size of
2
Mayo Clinic, Rochester, MN. ICUs have grown steadily in the United States. More re-
3
Rush University Medical Center, Rush University College of Nursing, cently, their growth has begun to outpace that of many
Chicago, IL. other sectors of medicine. A 2004 study showed that from 1985
4
Departments of Critical Care Medicine and Surgery, University of Pitts- to 2000 the number of U.S. hospitals decreased by 9% and the
burg Medical Center, Pittsburg, PA.
number of hospital beds decreased by 26%, but the number
5
Advocate Healthcare and Rush University Medical Center, Chicago, IL.
6
Division of Pulmonary, Critical Care & Sleep Medicine Beth Israel Dea-
of ICU beds increased by 26% (1). In a follow-up study, the
coness Medical Center Boston, MA. authors demonstrated further growth of critical care services
7
Critical Care Medicine, Memoral Sloan Kettering Cancer Center, New York, NY. in the United States. Critical care medicine beds increased by
8
Clinical Research, Investigations and Systems Modeling of Acute Illness, 6.5% from 2000 to 2005, even though the number of hospitals
Department of Critical Care Medicine, University of Pittsburg School of
Medicine, Pittsburgh, PA.
declined and the percentage of hospitals with ICUs continued
For full list of members, see Appendix 2. to decline. ICU days, occupancy rates, and annual critical care
Dr. Tisherman has submitted a patent for "Emergency Preservation and Re- expenditures also increased significantly (2).
suscitation Method." Dr. Kahn has received grant support from the National
Institutes of Health and Health Services Resource Administration, and he has
also received travel reimbursements from the American Thoracic Society. The Copyright 2013 by the Society of Critical Care Medicine and Lippincott
remaining authors have not disclosed any potential conflicts of interest. Williams & Wilkins
For information regarding this article, E-mail: [email protected] DOI:10.1097/CCM.0b013e3182741478
This expansion of critical care services has not been accom- fore, we sought to make recommendations that would have ap-
panied by a commensurate increase in the number of critical plicability to all kinds of ICU practices, analyzing universal
care physicians. Although delineating the precise number of in- issues common to all such as patient care, burnout, staffing,
tensivists needed is difficult, the growing shortage and aging of and hospital expectations. We also chose to limit our focus to
critical care trained physicians available to work in these ICUs the ratio of attending intensivists of record to patients in adult
have been well recognized (3, 4). Other factors also serve to worsen closed ICUs with the understanding that each intensivist may
the strain on the critical care workforce, including the national have multiple assisting providers or none. Finally, recognizing
efforts to staff ICUs around the clock with intensivists (5) and that many ICU services cover patients outside of their physical
duty-hour restrictions for physicians in training (6), which in ICU, we focused on intensivist/patient ratios and not intensiv-
academic medical centers may shift the burden of staffing the ist/bed ratios.
ICU away from trainees onto attending physicians.
The unstated implication of the expanding demand for criti- Literature Review
cal care in the face of a static workforce is that individual inten- An initial focused literature search was conducted using PubMed
sivists will increasingly be required to care for greater numbers of and Google Scholar through November 2010; updated search-
patients. This issue is of great concern to the Society of Critical es were conducted through September 2011. Major subtopics
Care Medicine (SCCM), an organization whose mission is to included physician/patient ratios, nurse/patient ratios, critical
secure the highest quality care for all critically ill and injured care education, ICU workforce, burnout syndrome, and the use
patients. In recent years, the SCCM became aware through its of telemedicine and advance practice providers to staff ICUs.
membership of a perceived need for guidance regarding the Taskforce subgroups were assigned specific topics, asked to re-
ideal number of patients a critical care physician should care view all pertinent literature as it pertains to intensivist/patient
for at any one time. Given the paucity of data pertaining to in- ratio, and prepare a report. In addition, taskforce members con-
tensivist/patient ratios, the SCCM convened a multidisciplinary ducted a review of national and international critical care orga-
taskforce to better address this problem. The taskforces stated nizations, hospital (inpatient) medicine organizations, and other
mission was to provide recommendations for intensivists and related professional organizations administrative and staffing
hospitals regarding maximum patient workloads based on ex- recommendations, including nursing groups. Taskforce sub-
isting data and expert opinion. groups were asked to review all significant literature on subtopics
and create a summary report with emphasis on how the literature
METHODS pertains to optimal physician staffing in ICUs.
An SCCM taskforce was established to review the literature and
develop recommendations about intensivist physician/patient Survey of ICU Physicians
ratios in ICUs. Members of the committee included ICU A taskforce subgroup conducted a mixed mode survey (e-mail
physicians, nurses, pharmacists, and nurse practitioners (NPs) and paper) of the membership of the Association of Pulmonary
from academic and community settings as well as hospital and Critical Care Medicine Program Directors soliciting infor-
quality assurance officers and medical and surgical Critical mation about their current ICU workloads and hospital duties
Care fellowship program directors. Along with their knowledge as well as their perceptions of workplace stress, workforce issues,
of critical care medicine, members were chosen for their ex- patient care, and teaching environment of their ICUs. The results
pertise in the fields of health services research, medical ethics, from this survey showed that physician/patient ratios correlated
health care rationing, telemedicine, and quality improvement with perceptions of stress, patient care, staffing, and training prob-
research. The group generated a statement based on examina- lems. These results were distributed to the rest of the taskforce and
tion of multiple data sources, including 1) a comprehensive published separately (7).
review of published literature on ICU physician staffing and
other related topics; 2) a national survey of pulmonary/Criti- Multidisciplinary Expert Roundtable Conference
cal Care fellowship program directors about workload and In January 2009 and January 2010, members of the taskforce
staffing concerns; and 3) a multidisciplinary expert roundtable met in person at the SCCM Annual Congress. At these meet-
conference tasked with generating specific recommendations. ings, taskforce members discussed the findings of the litera-
For the purposes of this statement, the taskforce limited its ture, reviewed recommendations and guidelines from related
recommendations to ICUs that use a closed model where the professional societies, and assessed the results of the program
intensivists control triage and patient care. We chose to exclude directors survey. The taskforce leadership then drafted a state-
theopenmodel because intensivists are not necessarily assigned ment based on the discussions at the in-person meeting. The
to a defined number of patients in an open model. In addition, document was revised by the taskforce members using an it-
in open ICUs, multiple outside providers care for patients erative consensus process in which successive versions of the
and the physician supply will adjust as volume increases. The document were edited by the taskforce members, circulated
taskforce further recognizes that there are currently many for review, and then reedited based on additional feedback.
different ICU staffing models (combinations of intensivists, The statement was then submitted for review to the leadership
fellows, house staff trainees, hospitalists, NPs and physician council of the SCCM, which approved the final manuscript
assistants [PAs], and telemedicine coverage programs). There- and recommendations.
Physician Burnout. Concern about burnout syndrome in teaching staff, and administrative duties can also occupy much of
physicians has grown due to the heavier caseloads placed on the work shift. Family meetings, especially end-of-life discussions,
physicians because of workforce shortages and financial have become an integral component of modern ICU care but can
constraints limiting hiring. Seventeen recent studies have require a lot of time to arrange and conduct. In both academic-
shown a high prevalence of ICU staff burnout. Risk factors and community-based ICUs, quality improvement (including
for burnout include many continuous shifts (34), long shifts, the development, implementation, and monitoring of treatment
night shifts (35), feeling overloaded at work (36), and poor guidelines and care protocols) can also command a tremendous
workplace organization (37). Consequences of burnout in- amount of time from ICU physicianswho often double as ICU
clude decreased job performance and quality of patient care administrators. Documentation of these activities consumes sig-
(38), absenteeism (39), reduced commitment to the job (40), nificant time as well. In our survey, 91% of intensivists had at least
and a desire to leave the field (35, 37, 41). Based on these data, one duty outside the ICU (such as code team or triaging) and 52%
the taskforce concluded that physician burnout is a significant had two or more (7). ICU staffing models, therefore, need to con-
concern for both quality of care and workforce stability and sider time spent in duties beyond ICU patient care.
should factor into institutions staffing models. Physician Support With Trainees and Other Medical Profes-
sionals. In an academic setting, intensivists may have a variety of
Factors That Might Influence the Optimal Ratio trainees working with them, including students, residents, and
The taskforce recognized from its inception that determining fellows. On one hand, this additional manpower may improve
optimal or maximum intensivist/patient ratios is a complex intensivist efficiency, allowing coverage for more patients. On the
task that must allow for multiple variables including patient other hand, the additional demands for teaching and monitoring
acuity and turnover, duties outside the ICU, educational re- the trainees can slow down the intensivist and take time away
sponsibilities, and the availability of other forms of provider from patient care. Because billing for critical care services is based
support. Most of these variables differ by hospital and, in the on time devoted to patient care, exclusive of teaching time, the
case of patient acuity, can differ by day. Recognition of these academic intensivist must address the dilemma of seeing fewer
other duties and the variability of demands is essential for cre- patients or decreasing teaching time. Limiting time for education
ating proper staffing. could easily impact the ability for fellowship programs to fulfill
Case Mix and Turnover. ICU patients can vary significantly the needs of critical care trainees (43). In our survey of program
in their severity of illness. While many are admitted for mul- directors, having additional trainees (residents and fellows) did
tiple organ failures, many others are admitted for observation to not seem to reduce intensivists perceptions of feeling overbur-
prevent further decline. One critically ill patient can occupy the dened. This finding suggests that the support of trainees may be
time of an intensivist for a large fraction of the day. In nursing, offset by their educational needs.
scoring systems such as the Nine Equivalents of Nursing Man- The integration of NPs, PAs, and hospitalists into the ICU
power Use Score (42) are used to aid in staffing but, other than team may represent one solution for meeting the physician work-
conventional severity scores, no such tool exists for physician force shortage. Multiple studies have shown the benefit of NPs
staffing. If ICUs are staffed only to meet the average daily work- and PAs in improving continuity of care, increasing adherence to
load and additional buffer time is not factored into the workday, best practice guidelines, and enhancing communication, collab-
care for one high-intensity patient must come at the expense of oration, and education in the ICU (4451). A recent large study
time spent on other patients or on other duties. In addition, the looking at greater than 5,000 admissions over 3 years comparing a
case mix can change daily or with season. ICU services may ex- PA-staffed ICU with a resident-staffed ICU in the same institution
pand in times of high demand and this may happen without ad- showed that quality of care was the same in almost all outcomes
ditional staffing. In our survey, 33% reported that when service measured (52). In our survey of closed academic ICUs done in
size grew larger they were covering patients outside their physi- 200809, 22% reported using NPs or PAs in the ICU at the time
cal ICU and 26% reported no upper limit on service size (7). of the survey; this number will likely grow significantly in the
Finally, high demand for the ICU often results in high rates future (7).
of patient turnover (admission and discharge), which can Many hospitalists, as well, are staffing ICUs in the United States
consume extra personnel time. Surge capacity, either for case (53) and the number is reportedly increasing (54). A national
mix or service size, is an important component of any staffing survey conducted more than 10 years ago showed that 83% of
strategy. An ideal operations model would recognize that these physicians identifying themselves as hospitalists provided care
high-volume days occur with some frequency and be able to in the ICU (55). The Society of Hospital Medicine and others
handle the increased workload without significant compro- have begun exploring how hospitalists and intensivists should
mise in patient care. Staffing only for average daily census collaborate (56). A recent study in a community hospital showed
means that ICUs will be understaffed at times of peak demand. similar outcomes between an ICU-staffed predominantly with
Other Duties. Duties outside of the ICU or not related to direct hospitalists and a companion ICU with an intensivist model
patient care can also impose large time demands on ICU physi- (57). As of now, there is little more published information
cians. Outside the ICU these may include triaging, code teams, regarding the role of hospitalists in ICUs.
rapid response teams, and consultations. In the ICU, procedures, The taskforce concluded that NPs, PAs, and hospitalists
review of patient data, communicating with consulting doctors, could make a significant contribution to the critical care work-
force in the years to come, possibly easing the burden on the maximum intensivist/patient ratios, some common-sense
intensivists. However, they must have adequate training in the staffing rules can apply based on a simple analysis of the ex-
management of ICU patients, be credentialed and privileged, pectations of intensivists duties. For example, if one intensivist
and work in collaboration with the multidisciplinary team, as is covering 20 critically ill patients in a 12-hr shift, that phy-
they cannot replace all direct care by an attending intensivist. sician can only average 36 mins with each patient. Other es-
Physician Support With Technology. Advances in medical sential nonpatient care duties will reduce that time further. If
informatics and other technologies will undoubtedly make the some patients require more attention, the others will necessar-
practice of critical care more efficient in the years to come and ily receive less than 36 mins of direct care from that intensivist,
may alleviate some of the workforce problems. Within ICUs, which may be deemed unacceptable.
technology can significantly assist ICU coverage by provid- A calculator tool developed by the taskforce is available in
ing comprehensive dashboard information and alarms to the Appendix 1 and also at http://www.sccm.org/ that can assist in
intensivists. Remote monitoring through telemedicine pro- staffing based on specifications of individual ICUs. It does this
grams is another approach to providing medical coverage by by making explicit what are usually implicit assumptions about
remotely located health care providers. Telemedicine models staff workload and time allocation. This tool cannot determine
vary in covered time and beds, and clinical responsibilities of the ideal intensivist/patient ratio but can identify when there
the telemedicine team. Contractual arrangements take into ac- is a mismatch between an institutions expectations and its ac-
count technology and personnel capabilities and fiscal resourc- tual staffing. This tool may be useful in institutional discussions
es. Currently, more than 40U.S. health care systems and more about the number of physician staff need for a given ICU. Based
than 4,900 adult ICU beds have instituted active telemedicine on our analyses, the taskforce reached consensus that these im-
ICU programs in the United States (58). In many of these sys- portant principles and practices should be followed in develop-
tems, a single intensivist oversees up to 150 patients with the ing an institutions individual physician staffing policy.
telemedicine critical care nurses observing 3540 patients.
There are no published guidelines on maximum numbers of 1. Appropriate staffing of ICUs with intensivists impacts the
patients a telemedicine physician should care for. quality of patient care, patient safety, education, and inten-
The outcome benefits of telemedicine programs are still sivist and staff well-being. Individual ICUs should be aware
unclear despite multiple studies (5962). Ultimately, the rela- of their current intensivist/patient ratios and monitor these
tive utility of telemedicine as a way to extend the intensivist ratios to ensure staffing ratios are commensurate with the
workforce will depend on each individual ICUs current staff- institutions expectations for patient care and other duties.
ing model, the intensivist needs of particular hospitals, and 2. Caseloads should allow daily rounds to conclude in an
the degree to which ICU telemedicine functions as a work- amount of time that is acceptable in accordance with other
force extender (i.e., a way to increase the efficiency of the cur- valued duties, including teaching, non-ICU duties, and ad-
rent workforce) or a workforce substitute (i.e., a care model ministration.
that extends the reach but not the capability of an intensivist). 3. Staffing policies should factor in surge capacity and nondi-
ICU telemedicine may be an effective means of providing ad- rect patient care duties, such as family meetings, procedures,
ditional physician coverage to ICUs, but has not been tested consultations, duties outside the ICU, and teaching.
against alternatives in terms of burnout or other nontechno- 4. Institutions should regularly assess the appropriateness of their
logical strategies for improving quality. It is also worth consid- ICU staffing models via objective data. Assessments of staff
ering that telemedicine may extend the work life of intensiv- satisfaction, burnout, and stress should be part of the data
ists by enabling them to apply their skills and experience on collected. (Reference to internal standards or national
a part-time basis, although there are no empiric data for this. benchmarks are appropriate.)
5. High staff turnover or decreases in quality-of-care indicators
Recommendations in an ICU should be viewed as potential markers of overworked
It is clear that determining optimal or maximum provider/ staff and should prompt ICUs to evaluate their intensivist/
patient ratios is a complex task that must allow for multiple patient ratios.
variables. The taskforce further recognized that any physi- 6. The addition of telemedicine, advanced practice profes-
cian staffing model may still get overwhelmed in times of sionals, or nonintensivist medical staff may be useful ways
high patient volume or acuity and may, at other times, seem to alleviate overburdening the intensivist covering an ICU,
to be overstaffed. There is clearly a need to develop tools to but theirintroduction into the ICU should be predicated
better predict both the regularity and the severity of surges by needs assessments and evaluated using rigorous assess-
and such modeling has already been proposed by some (63). ment methods.
Nevertheless, a good staffing model would recognize that 7. In teaching institutions, feedback from faculty and trainees
these high-volume days occur with some measurable fre- should be sought to understand the implications of
quency and be able to handle the increased workload with- potential understaffing on medical education. The tradeoffs
out significant compromise in patient care. between patient care and education must we weighed
The taskforce further concluded that while insufficient data objectively and explicitly when expanding the intensivists
exist in the medical literature to provide specific numbers on clinical duties. Reduction in the quality of education that
accompanies increased workload may be acceptable if they units: Structural and organizational aspects. Intensive Care Med 2011;
37:15751587
are anticipated side effects, but are not acceptable if they are
13. American Association of Critical-Care Nurses: AACN standards for es-
unforeseen unintended consequences. tablishing and sustaining healthy work environments. 2005. Available at:
8. In academic medical ICUs, there is evidence that intensivist/ http://www.aacn.org. Accessed November 12, 2011
patient ratios less favorable than 1:14 negatively impact 14. Collins M: Staffing an ED appropriately and efficiently. 2009. Available
perceptions of quality of teaching, stress, patient care, and at: http://www.acep.org/Content.aspx?id=46056&terms=staffing. Ac-
cessed November 12, 2011
workforce stability
15. American Academy of Emergency Medicine: Position Statement: Emer-
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CONCLUSIONS http://www.aaem.org/em-resources/position-statements/2001/physi-
cian-to-patient. Accessed November 12, 2011
The taskforce concluded that, while advocating a specific maxi-
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Appendix 1. Intensivist/Patient Ratio 2. Determine the average percentages of each patient group
Staffing Tool* (Reference Model on SCCM Web in the ICU
Site) a. Severe = S%
As an example of how one might determine if any ICU is un- b. Moderate = M%
derstaffed with physicians, we show the following distribution c. Low = L%
of time and activities and how this would influence our ability 3. Establish the typical size of the ICU service = average
to care for a certain number of patients. This is intended as an census (*census can be calculated as the number of oc-
example only and is not based on any validated instrument or cupied beds at a given time or, to reflect turnover, can
evidence. It is a device for determining if there is a mismatch be the total number of patients typically seen by service
between institutional demands and the available staff based on per day).
4. Establish the duration of normal work shift = work shift.
site-specific assumptions of ICU service census, case mix, shift
5. Calculate the approximate time for nondirect patient care
length, physician duties, and so on. The inputs need not be pre-
activities expected such as family meetings, admissions and
cise and they may be added or subtracted based on local char-
discharges, consultations, triaging, teaching, staff educa-
acteristics.
tion, administrative time, sign-out, and personal care per
1. Determine appropriate time per patient (T) for direct pa- shift = NPtime (*alternatively, family meetings can be in-
tient care (i.e., examination, data collection, procedures, corporated as Direct Patient Care time).
note writing) for three levels of patient acuity 6. Multiply each percentage of acuity by the ICU service size to
a. Severe acuity patients = Ts determine the minimum amount of time needed per day for
b. Moderate acuity patients = Tm direct patient care. We recommend that this time should not
c. Low acuity patients = TL exceed half of work shift.
7. Add the time needed for nondirect patient care activities. Total direct patient care time = 10 hrs 54 mins
8. If that time duration exceeds the normal work shift, the Other Duties
intensivists/patient ratio needs to be adjusted. Additional
[Family meetings: 60 mins/shift, triaging: 20 mins, teaching
time for high-volume (admissions/discharges) or high
of staff: 20 mins, consultations: 30 mins, administrative: 30 mins,
acuity days should also be factored in to this calculation
personal time: 30 mins, sign-out: 20 mins, emergency time:
as well.
20 mins]
Example: (numbers are for illustrative purposes only) Nondirect patient care time = 3 hrs 50 mins
ICU size = 18 beds, work shift = 10 hrs Total expected work time = 14 hrs 44 mins: by these cal-
Average census = 16 patients culations, a single intensivist in this ICU would not typically
Ts = 60 mins/patient, Tm = 40 mins/patient, TL = 30 mins/ be able to meet all daily expectations for a normal shift and
patient is unlikely to be able to finish rounding by half way through
S% = 0.20 (3.2 patients) M% = 0.50 (8.0 patients) L% = the shift. Furthermore, there is no significant time allowance
0.30 (4.8 patients) for high-volume or high acuity days. The institution should
3.260 mins = 192 mins; 8.040 mins = 320min; 4.830 consider additional staff or decreasing the patient load for
mins = 144 mins this ICU.