The Hospitalist phenomenon is changing the way that inpatient medical care is delivered across the country. Several different and compelling reasons support the use of the Hospitalist (Table 1); however, there are features of Hospitalist practice that may promote concerns among observers. Perhaps the biggest feature for concern is the “handoff.”

Physicians and nurses have been exchanging data about patients among themselves, both verbally and in writing, for as long as the professions have existed. Why is it then that this type of exchange between Hospitalists is subject to additional scrutiny?

By definition, a handoff occurs when one Hospitalist “signs off” or “signs out” a patient to another Hospitalist. This is the case whenever a patient’s care must be turned over to another clinician – it generally happens at the end of a shift. As with any meaningful communication, it is complicated and, if done poorly, it can result in inefficiency or a poor outcome for the patient.

Since it involves people, the handoff is not analogous to copying a file from a hard drive to a floppy disc. When data is exchanged electronically, redundant safeguards are invoked automatically to prevent corruption of the original file. When patient information is exchanged between clinicians, there is tremendous potential for the essential data to be confused, disorganized, or omitted.

Some reasons why the transmission of data between Hospitalists is challenging are common to all human transactions: the inherent tendency for people not to listen, or to listen poorly, and the lack of an organized approach to the data. Other impediments are unique to demanding settings: the magnitude of fatigue or anxiety the Hospitalists are experiencing, the quality and complexity of the information, the degree of similarity between cases, and the extent to which trust and respect forms the foundation of the relationship between the parties. These hurdles must be minimized for Hospitalist programs to be successful.Physicians often practice in a technological paradox, because we readily accept and seek high-tech equipment yet ignore and even suppress beneficial innovations in the way we practice medicine. We continually convince ourselves that our current cache of capital products is downright inferior and hence we splurge on the latest gizmos and toys to help us “care” for our patients. All too frequently, today’s high quality state-of-the-art gadget quickly becomes tomorrow’s low-quality obsolete antique.
In critical care for example, despite the absence of meaningful data to support a clear-cut benefit of one type of ventilator or ventilatory mode, ventilators that deliver preset tidal volumes at a desired FiO2 at a clinically acceptable rate with a multitude of alarms quickly become passé, as a brief visit to a colleague’s unit across town convinces us that our ventilators must be equipped with real-time graphs to plot pressure and volume along with hot keys to measure and display autoPEEP.
The paradox which emerges is one that embraces and even solicits new technology, regardless of the paucity of data which fails to document an improvement in clinical outcome, yet ignores and even discourages newer and more efficient methods of manpower organization, especially those which recommend organizational changes for physicians and changes in their relationship to their colleagues and their patients. Organizational restructuring often engenders emotional pleas for preservation of the “traditional” physician-patient relationship, and may even meet with fierce, vociferous resistance against any administrative tampering and meddling. While physicians should probably approach any proposal for restructuring, revision, or reengineering with a healthy degree of skepticism and should perhaps, in a positive sense, challenge major upheaval, they also should support efforts which critically evaluate health care delivery systems if the goal of such efforts is to improve overall quality.
Critical care medicine is a unique specialty in that it is not limited to a specific organ system, but rather is defined by severity of illness and patient acuity. It also may present a challenge to traditional medical specialties because it crosses traditional specialty borders, has practitioners certified through several primary parent boards, has a broad multidisciplinary focus, and is more fundamentally concerned with administrative and organizational issues. Additionally, critical care is relatively new on the medical horizon and is still an unknown to large segments of the general population and even the medical community.
For example, the Society of Critical Care Medicine was only formed a little over 25 years ago; the first critical care board examination was given back in 1987 and many hospitals did not even have ICUs back in the late sixties and the early seventies. Only recently so it seems, has organized medicine accepted the uniqueness of critical care as a distinct medical specialty. For example, the study a few years back by Hsiao and others which described the methodology for resource-based relative value unit (RBRVU) failed to include critical care practitioners in it’s determination of RBRVU’s for procedures commonly performed by intensivists.1 Yet despite its relative youth, critical care is nevertheless a vital component of inpatient medicine, and from an economic standpoint it looms ominously because of the disproportionate level of resources devoted to the critically ill.
ICUs account for approximately 5%-10% of all inpatient beds yet they consume over 30% of inpatient budgets, a figure which ultimately extrapolates to over 1% of the nation’s gross domestic product, or $62 billion.2 Clearly, the push towards office-based and outpatient care will have an effect upon the makeup of hospital wards and critical care services, as the inpatient case mix will in all likelihood have a higher level of acuity and inpatient care will come increasingly under the domain of the intensivist and other dedicated inpatient specialists.
With the ongoing seismic changes in health care delivery, organizational changes in medical care services will in all likelihood go beyond how, when, and where patients see physicians and how referrals are made. Instead, some very familiar foundations of the health care infrastructure will be altered. As health care assumes and embraces a stronger corporate culture and persona, practice styles, practice patterns, and other organizational issues will be subject to scrutiny and revision. Reduced reimbursement and limited budgets will demand greater fiscal efficiency and accountability. The difficult issue will be to ensure that the quality of care does not suffer and will, in fact, improve in the “new world order.”
From a clinical standpoint, intensivists probably gained respect from their peers by sheer perseverance, and by their continuous bedside presence and diligence for individual patients under their care. Yet as more and more critical care specialists graduated from training programs, sat for the boards, and entered the market, it became apparent that critically ill patients under the direct care and supervision of an intensivist had a better chance for survival than patients under the care of a disjointed group of single organ physicians.
It is true that the cardiologist knows more about the heart and the management of difficult arrhythmias, the pulmonologist has a greater grasp of lung physiology and respiratory mechanics, the general surgeon can better assess an acute abdomen, and the infectious disease specialist has a greater appreciation of antibiotic pharmacology and microbial resistance. However despite this “expertise-by-committee”, the intensivist has the best appreciation for delicate pathophysiologic interrelationships and hence is most fit to manage the multi-system organ dysfunctions that afflict the vast majority of ICU patients.
Gladly enough, this sentiment depends less and less on anecdote and now draws more and more on hard, empiric data. Over the past few years many studies have appeared in the literature which support the benefit of a formally organized critical care service that is directed by intensivists as opposed to looser consultative services which have minimal intensivist input. From a managerial and an organizational perspective, there has emerged two distinct poles and dichotomous views of ICU structure. At one end lies the open system, a model in which all patients remain on the service of their admitting primary attending who is free to conduct care as he or she seems fit, with or without the input of an intensivist.
At the other end of the spectrum lies the closed unit, a more rigid model in which all care and responsibility is transferred to the service of an attending intensivist. In a closed unit system of organization, only members of the critical care team can write orders, request consults, and admit or discharge patients from the unit. In a growing number of ICUs, attending intensivists remain physically present in the ICU, around the clock every hour of every day.
While these two models of organization represent the polar extremes and are important from a descriptive standpoint, it is important to realize that many ICUs fall somewhere in the middle. For instance, many ICUs may not mandate transfer of patients to the service of an intensivist, but rather require intensivist approval of all admissions and discharges along with critical care consultation and input during the entire course of a patient’s ICU stay. Similarly, other units, especially those in teaching hospitals, often mandate intensivist supervision of house staff and fellows on ICU rotations, therefore insuring at least some modicum of intensivist input into the care of the critically ill.
Regardless of how an ICU is organized and where it stands on the spectrum between a purely open and a purely close unit, it has become more apparent that greater intensivist input leads to better patient outcomes and even more efficient use of scarce resources. In the early 1980’s, Li and colleagues documented improved ICU and hospital survival for critically ill patients in a community teaching hospital after intensivists were hired to staff the units and round with the assigned ICU teams.3 Similarly, a few years later in Saskatchewan, Canada, Brown and Sullivan showed a 52% reduction in ICU mortality and a 31% decrease in overall hospital mortality as a result of the presence of intensivists, a difference that was noted throughout all ranges of severity, according to APACHE II scores.4
Other investigations showed similar results and benefits as a result of intensivists. Reynolds and colleagues, for example, showed that patients with septic shock fared better when intensivists were present to supervise their care,5 and Pollack et. al. also demonstrated more efficient triage and use of resources in intensivist directed pediatric ICUs.6 More recently, Carson and colleagues performed a prospective evaluation on the effect of changing to a closed ICU. In this study, length of stay was similar under both models, use of radiology, pharmacy, and laboratory services were similar, and the closed service tended to insert more PA catheters and central lines. However, the closed unit appeared more efficient in terms of triage and outcome, as its patients had higher APACHE II scores and a lower ratio of actual to predicted mortality. Of further note, nursing confidence in treatment plans were significantly higher under the closed model, as a larger majority of the ICU nursing staff expressed more comfort patient quality when intensivists were present.7
Recently, my colleagues and I completed a prospective study comparing patient outcome and resource utilization in an open and a closed ICU in two tertiary hospitals in suburban New York City. This study demonstrated improved cost-effectiveness as a result of the closed organization, because similar outcomes were achieved among patients with similar severity of illness with reduced resource utilization and lower length of stay.8
Clearly then, intensivists do make a difference and critical care units which are under the direct supervision of a hands-on intensivist will have better outcomes than those without. Still, old habits die hard and many physicians, hospitals, and health care systems are loathe “to rock the boat” in order to make organizational changes. Intensivists therefore need to take the lead and become more vociferous about their contributions and their clinical and organizational worth.
Although data now exists which strongly suggests a benefit from both the presence of intensivists and the formal organization of ICU care into closed units or at least closely supervised services, intensivists must continue to collect data and supportive information. I remain optimistic, because ultimately, patient benefit and improved outcomes remain the final arbiters and are the most important standard, even in the current climate of managed care, cost-containment, and fiscal constraint. Even as we propose changes and begin to move to models of closed units, we must remain committed to a dynamic process, one which encourages continuous scrutiny and evaluation and which never remains content to passively accept current systems of care.
References
1. Hsaio WC, Braun P, Dunn D, et al. Resource-based relative values:an overview. JAMA 1988;260:2347-53.
2. Chalfin DB, Cohen IL, Lambrinos J. The economics and cost-effectiveness of critical care medicine. Intensive Care Med 1995;21:952-61.
3. Li TCM, Phillips MC, Show L, et al. On-site physician staffing in a community hospital intensive care unit. JAMA 1984;252:2023-27.
4. Brown JJ, Sullivan G. Effect on ICU mortality of a full-time critical care specialist. Chest 1988;96:127-29.
5. Reynolds HN, Haupt MT, Thill-Baharozian, Carlson MC. Impact of critical care physician staffing on patients with septic shock in a university hospital medical intensive care unit. JAMA 1988;260:3446-50.
6. Pollack MM, Katz RW, Ruttiman UE, Getson PR. Improving the outcome and efficiency of intensive care: the impact of an intensivist. Critical Care Medicine 1988;16:11-17.
7. Carson SS, Stocking C, Pocksadecki T, et. al. Effect of organizational change in the medical intensive care unit of a teaching hospital: a comparison of “open” and “closed” formats. JAMA 1996;276:322-328.
8. ChalfinDB, Multz AS, Flaster E, et al. Differences in resource utilization in critically ill patients in an open versus a closed medical intensive care unit (MICU): a prospective study (abstract). AJRCCM 1995;151:A487.
 

-by Donald Chalfin, MD

Dr. Chalfin MD, MS, FCCM, is the Associate Division Chief, Critical Care Medicine, and Director, Section of Surgical Critical Care, at Beth Israel Medical Center.

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