The realities of 21st century healthcare economics are hacking away at the 20th century ideal of the intensive care unit as a single space housing the hospital’s sickest patients and marshaling, by cookie-cutter departmental structuring, the skills of intensivist physicians, specialized nurses and ICU-dedicated ancillary staffers.

The old model was nice while it lasted. However, it’s almost certainly not sustainable for long, given the aging of the population and, with it, the expected shortfall of qualified healthcare workers to meet soaring demands for critical care services.

That’s the opinion of Deena Kelly Costa, PhD, RN, University of Michigan, and Jeremy Kahn, MD, MS, University of Pittsburgh, who outline the particulars of the problem and suggest ways to get ahead of it in a JAMA “Viewpoint” piece published Feb. 23.

To face the present challenges before they become a future crisis, they write, “it is necessary to move beyond the current model of intensivist-led, multi-disciplinary critical care and toward a more flexible approach to ICU organization that is feasible and sustainable over the long term.”

Costa and Kahn propose focusing on five adjustments:  

1. New organizational models.

As hospitals vary widely by case mix, illness severity and ICU staffing, institutions with lower-acuity patients would do well to experiment with new organizational models. ICU teams could cease being led by intensivist physicians and start getting behind alternative team leaders who might be nurse practitioners, physician assistants or hospitalists.

“These individuals would still be supported by intensivists, in the form of either a local intensivist ICU director or remote consultation via telemedicine,” write Costa and Kahn. “Safety could be ensured through tiered regional delivery systems in which the sickest patients at these hospitals are routinely transferred to tertiary referral hospitals with intensivist-staffed ICUs.”

2. New quality-improvement strategies.

The authors point to novel strategies emanating from industrial engineering, such as checklists and automated prompting, which could be tapped to make sure evidence-based practices are prioritized over entrenched human habits.

“These strategies should be rigorously tested because their effect on ICU quality is still uncertain, and they may have unintended consequences such as overstandardization of care,” Costa and Kahn write. “However, these practices offer an important opportunity to improve critical care quality independent of any particular ICU staffing model.”

3. Smarter use of IT.

To date, most ICUs haven’t made good use of clinical data generated by critically ill patients in spite of the fact that they’ve had decades of experience with risk prediction and physiological monitoring. Going forward, patients could be risk-stratified by continuously updated risk data in the EHR, which would facilitate, for example, triaging patients across sites in regional health systems.

Meanwhile, smarter clinical prompts, “ones that only alert clinicians to quality gaps when and where those alerts are most needed, could prevent alarm fatigue and lead to electronic health records that make workflows easier.”

4. Renewed emphasis on organizational behavior.

It’s well established that coordinated teamwork is central to high-quality critical care, but teamwork in the ICU “has become a platitude, often espoused as beneficial but too vague to be meaningful as a quality improvement strategy,” write Costa and Kahn. They call for research to address the gap.

“This research should be based on social sciences that are specifically designed to understand and improve how teams learn and interact, such as network science, medical anthropology, and organizational behavior,” they write. “Ultimately, this research would overcome a critical barrier to progress in the field of ICU organization, which is too frequently focused on the ‘who’ of critical care rather than the ‘how.’”

5. Reducing demand for critical care.

A lot of patients in the ICU are either too well to be there or too sick to benefit. Reducing ICU admissions might completely reframe the debate, not least by forcing clinicians to use ICU beds only for demonstrably appropriate cases.

“The United States already has more ICU beds per capita than most developed nations and as a consequence admits more low-risk patients for observation and more high-risk patients who go on to die,” Costa and Kahn write. “Policy makers could take active steps to constrain future growth in critical care beds, easing the burden on the critical care enterprise.”

Costa and Kahn wrap their case with the qualifier that their five-part proposal does not represent a cure-all.

None of the steps, they write, “should be interpreted as discounting the unique skills and experiences of trained critical care physicians, nurses and allied health professionals. Just the opposite. Only by first acknowledging the value of experienced and well-trained clinicians is it possible to consider models that improve care in their absence.”