The Wall Street Journal Recognizes the eICU® System as Intensivist Solution November 21st, 2002 If major surgery or a bad accident lands you in the intensive-care unit, your life could depend on whether you are under the care of an emerging kind of specialist trained to spot signs of pneumonia, infections, or other life-threatening complications before they take hold. They're called "intensivists," and studies show your chances of dying may be reduced by as much as 30% if you have one. The problem is that there is a huge shortage of trained intensivists -- and there are no prospects for sharply increasing their numbers anytime soon. As few as 10% of hospitals employ full-time intensivists. Though some new training programs are under way at teaching hospitals, others have been cut for budgetary reasons, and not all hospital administrators agree that full-time intensivists are necessary. Also, some doctors are reluctant to turn their patients over to an intensive-care specialist. Still, a growing number of studies show that these specialists help save lives and get patients released from the hospital faster and in better condition. A recent report in the Journal of the American Medical Association concluded that greater use of intensivists could sharply reduce the 500,000 annual deaths in U.S. intensive-care units and help cut the $1.8 billion cost of intensive care. "Patients are dying, and that has to be one of the key levers in getting hospitals to do this," says Peter Pronovost, an intensivist at Johns Hopkins University who led the JAMA study. It would take 35,000 intensivists to cover all intensive-care units in the U.S. 24-hours-a-day, researchers estimate, but that could save 53,000 to 175,000 lives per year. Dr. Pronovost recommends that patients and families insist on knowing whether an intensivist will be caring for them in the ICU or if one can consult on the case. If not, he recommends asking to be moved to a hospital that has full-time intensivists on staff. Even though intensive-care admissions are often initially unplanned, most patients can be transferred by ambulance. Unlike renal, pulmonary or cardiology experts, who are trained to focus on one system in the body, intensivists are trained to look at a more comprehensive picture and notice subtle changes on a patient's monitoring devices. So if a patient with heart disease gets an infection and goes into septic shock, an intensivist might be best qualified to balance the body's needs for fluids with therapy to protect the heart and the vascular system. Much of the pressure to beef up intensive care is coming from the Leapfrog Group, an employer health-care coalition, which selected ICU staffing as one of three key measures by which it rates hospitals. Leapfrog says 21% of hospitals responding to a recent survey have intensivists overseeing intensive care at least eight hours a day. About 16% more plan to enlist intensivists by 2004. "If your hospital doesn't have an intensivist dedicated to the ICU on staff, you should be calling or writing to the hospital president to ask why," says Dr. Pronovost. Recognizing that few hospitals will be able to quickly meet its standards for intensivists on staff, Leapfrog is working with the Joint Commission on Accreditation of Healthcare Organizations to come up with a list of additional measures to rate the quality of intensive care. The two groups aim to make that data available on the Leapfrog Web site. The proposed measures include how well ICUs do at preventing pneumonia for patients on ventilators, what steps they take to prevent dangerous developments such as peptic ulcer disease and deep vein thrombosis, and how well they manage pain. Consumers can use the guidelines to get answers to questions, such as how patients are weaned from sedation. (Studies show patients can be removed from ventilators and released from intensive care sooner if their daily infusion of sedatives is interrupted for a short period of time every day.) A full list of the 11 proposed measures can be found on the accreditation group's Web site, www.jcaho.org. Hospital groups say that while intensivists are a great idea, the shortage makes it tough for many hospitals to make the grade. "Our biggest concern is the implication that you won't get good care in an ICU if there isn't a full-time intensivist," says Susan Van Gelder, senior vice president of the Federation of American Hospitals. "There are lot of ways to measure quality care, and that shouldn't be the only one." Nurse-to-patient ratios, for example, are widely considered an important barometer of care. Timothy G. Buchman, president-elect of the Society of Critical Care Medicine, says the group is holding special courses to train regular doctors and nurses in critical care. One high-tech solution that holds promise was developed by Visicu, a company formed by two Johns Hopkins physicians in Baltimore. Its "eICU®" system lets intensivists operating from a remote location electronically monitor several hospital ICUs at the same time, much like air-traffic controllers watching flight patterns. They can call staffers on the ICU instantly if a patient needs attention. Several hospitals, including New York Presbyterian Hospital, are installing the eICU®, and Tripler Army Medical Center will connect patients from Guam to intensivists 4,000 miles away in Hawaii early next year. In Norfolk, Va., where Sentara Health Care uses the eICU® to monitor patients at six area hospitals, medical director Steven Fuhrman says intensivists using the system saved 91 patients in 2001. "We think this is only the first hint of what technology can do to help save lives," he says.