Hospitalists work to find their way in the ICU

The majority of hospitalists report that they treat ICU patients, and many feel insufficiently trained and supported.

Most hospitalists work in ICUs, often without adequate training or support, according to a recent survey. More than three-quarters of U.S. hospitalists reported treating ICU patients, about two-thirds in a primary role, and 40% of rural hospitalists and 26% of nonrural hospitalists said they were expected to practice critical care beyond their scope.

“Something has to change,” said Eric Siegal, MD, senior author of the study, which was published in the January Journal of Hospital Medicine. “We can't continue the status quo of very, very sick people being managed by people who are telling us they are in over their heads.”

Photo by Thinkstock
Photo by Thinkstock.

The survey had a low response rate (about 10%), but other studies have documented a chronic shortage of intensivists and hospitalists' expanding role in ICUs, experts noted. “I can't say for sure, but I believe our results probably are representative of the situation nationally,” said Joseph Sweigart, MD, FACP, first author of the study and assistant professor of medicine at the University of Kentucky, Lexington.

“Anecdotally, the issue of hospitalists in smaller hospitals caring for critically ill patients while undertrained and undersupported has been one of the dirty little secrets of hospital medicine,” said Dr. Siegal, a critical care physician at Aurora St. Luke's Medical Center in Milwaukee.

Factors underlying this problem include population aging, increasing patient acuity, lack of regionalization of critical care, and even changes in training programs, Dr. Siegal said. He noted that internal medicine residencies have increased emphasis on ambulatory medicine training while curtailing acute inpatient and ICU responsibilities. “We also have dramatically cut total hours spent in residency training, almost all of which came out of inpatient duties.”

Hospitals and medical societies are working on various solutions to this challenge, but the going has been slow.

When hospitalists need help

Many ICU patients do well under a hospitalist's care, but research in this area has also found serious shortcomings.

In one study of more than 800 ICU patients, overall length of stay and mortality were similar when intensivists led the care team and when hospitalists took charge while consulting with intensivists. However, patients on mechanical ventilators had shorter lengths of stay and lower mortality rates when managed by intensivists.

The findings, published in the March 2012 Journal of Hospital Medicine, highlight some gaps in hospitalists' critical care skills.

For example, internal medicine residents usually receive thorough training on stabilizing bleeding, respiratory failure, septic shock, or severe metabolic or electrolyte derangements, said Scott Flanders, MD, FACP, a professor of medicine at the University of Michigan in Ann Arbor.

“But if patients don't improve in 24 to 72 hours, that's where you really begin to need expertise in nuanced ventilator management or ultrasound-based invasive procedures,” he said. “If a patient doesn't improve quickly, hospitalists may need guidance on plan B.”

This limited depth of critical care knowledge also can leave hospitalists feeling underprepared for certain parts of leading an ICU, said Dr. Flanders, who directs Michigan's Hospital Medicine Safety Consortium. “Hospitalists might have experience leading multidisciplinary teams, but unless they've done a fellowship, they may be hard-pressed to develop an ICU protocol for something like complex ventilator management.”

Tailoring solutions

Frustrated by a perceived lack of dialogue about these issues, Dr. Siegal and his colleagues wrote a position paper calling for a one-year, accredited critical care training pathway for experienced hospitalists. The program would cover the most important parts of the traditional two-year critical care fellowship, the experts proposed in the May/June 2012 Journal of Hospital Medicine.

Their suggestion drew sharp rebukes six years ago and remains unpopular now. “Why abandon successful training models for a model that is yet untried [and] may place patients in harm's way?” leaders of the American College of Chest Physicians and the American Association of Critical-Care Nurses wrote in the July 2012 American Journal of Critical Care.

A one-year program would not solve the current problems, according to Jeremy Kahn, MD, MS, professor of critical care medicine and health policy at the University of Pittsburgh and UPMC Health System. Even with more physicians gaining training, some hospitals would still face shortages of critical care expertise and a shorter fellowship could overprepare hospitalists for some types of patients and underprepare them for others, he said.

“There are already six training pathways for intensivists in the United States,” he added. “We don't need a seventh. System-level strategies customized to local needs are a much better idea.”

Such strategies could include a small hospital having an intensivist oversee ICU care pathways and protocols for the most complex patients while hospitalists perform other care, Dr. Kahn said. Advanced practice providers trained in critical care, both nurse practitioners and physician assistants, are an underutilized resource, he added. “The data would suggest they provide excellent critical care when allowed to practice to the full extent of their training

Another systems-level solution is regionalization of critical care—for example, transporting critically ill patients to hospitals with specialized ICUs instead of to the local hospital. “Many [smaller] hospitals partner with larger hospitals to facilitate patient transfers,” Dr. Flanders explained.

However, he noted that many of the hospitalists in the survey published in January reported encountering barriers when they tried to transfer ICU patients, such as full hospitals, delays, or lack of responsiveness. “Centers need to find ways to deliver critical care more effectively, minimizing patients who don't need to be in the ICU and making beds available for those who do.”

Other potential solutions include using teleconsultation and telemonitoring to link hospitalists with intensivists. For example, an intensivist can monitor a critically ill patient by video and instruct the ICU team to adjust ventilator settings or intravenous medications as needed. “Many studies support this model as providing the same caliber of care as having an intensivist on site,” said Dr. Flanders.

Training opportunities

Geographic and financial constraints, among other issues, keep most hospitalists who want to improve their critical care skills from pursuing fellowships. Instead, they choose from a la carte options ranging from textbooks and CME courses to podcasts (see sidebar).

The Critical Care Task Force of the Society of Hospital Medicine, the Society of Critical Care Medicine, and the American Academy of Emergency Medicine are collaborating to create a more cohesive training pathway for hospitalists, but the product is at least a year away, experts said.

In the meantime, hospitalists should take a systematic, carefully planned approach to educating themselves in critical care, said David Aymond, MD, a hospitalist at Byrd Regional Hospital in Leesville, La.

Dr. Aymond was first asked to care for a critically ill patient during the first year of his medicine residency. Realizing he had very little idea how to do so, he began spending “every waking minute” in the ICU.

His pulmonary and critical care medicine faculty were supportive, although other critical care physicians on staff were not, he said. Undeterred, he continued teaching himself to assess, triage, and resuscitate critically ill patients and also pursued a fellowship in hospital medicine.

For each ICU case, Dr Aymond reviewed multiple textbooks, “studying every detail of the pathology [to] provide care at an intensivist level.” He supplemented textbook review with deep dives into advanced cardiovascular life support, lectures on critical care topics, and board-review questions.

For hospitalists, building critical care skills and keeping them fresh requires this type of focused, long-term commitment, according to Dr. Aymond. “Stand at the bedside, successfully resuscitate and manage these sick patients, and learn from every experience,” he advised. “Take notes on encounters. Attend rapid responses and cardiac arrests in your hospital. If you do not understand something, slow down, call the specialist, and learn it.”

To learn or refresh airway management skills, he suggested completing online courses and attending medical conferences that offer critical care training. “Find the gaps in your critical care knowledge and then spend the next year filling those gaps. Repeat this process yearly,” he said.

His parting advice: “Remember, hospitalists are currently providing this level of care, and that's not going away. We will be held to the same medico-legal standard as all other physicians, including board-certified intensivists, when caring for these patients.”