Korean J Crit Care Med.  2016 May;31(2):111-117. 10.4266/kjccm.2016.31.2.111.

Major Obstacles to Implement a Full-Time Intensivist in Korean Adult ICUs: a Questionnaire Survey

• Lee JW
• Moon JY
• Youn SW
• Shin YS
• Park SI
• Kim DC
• Koh Y

• KMID: 2350917
• DOI: http://doi.org/10.4266/kjccm.2016.31.2.111

Abstract

BACKGROUND
Critical care physician staffing is a crucial element of the intensive care unit (ICU) organization, and is associated with better outcomes in ICUs. Adult ICUs in Korea have been suffering from inadequate full-time intensivists and nurses because of insufficient reimbursement rates (<50% of the original critical care cost) from the National Health Insurance System. Recently, full-time intensivists have been introduced as a prerequisite for adult ICUs of tertiary hospitals in Korea. The purpose of this study was to examine the perception of intensivist staffing among critical care program directors regarding the barriers and solutions when implementing an intensivist model of critical care in Korea.
METHODS
An email survey of critical care program directors in designated teaching hospitals for critical care subspecialty training by the Korean Society of Critical Care Medicine was performed. The survey domains included vision, culture, resources, barriers, and potential solutions to implementing intensivist physician staffing (IPS).
RESULTS
Forty-two critical care program directors were surveyed. A total of 28 directors (66.7%) responded to email queries. Of these, 27 directors (96.4%) agreed that IPS would improve the quality of care in the ICU, although half of them reported a negative perception of relevant clinical colleagues for the role of full-time intensivists and poor resources for IPS in their hospitals. Increased financial burden due to hiring full-time intensivists and concerns regarding exclusion from the management of their critically ill patients in the ICU, together with loss of income for primary attending physicians were stated by the respondents to be major barriers to implementing IPS. Financial incentives for the required cost from the health insurance system and enhancement of medical law relevant to critical care were regarded as solutions to these issues.
CONCLUSIONS
Critical care program directors believe that intensivist-led critical care can improve the outcome of ICUs. They indicated the financial burden due to IPS and underestimation of a full-time intensivist's role to be major barriers. The program directors agreed that a partnership between hospital leaders and the Ministry of Health and Welfare was needed to overcome these barriers.

Keyword

intensive care; intensive care unit; personnel staffing and scheduling

MeSH Terms

Adult*
Critical Care
Critical Illness
Electronic Mail
Hospitals, Teaching
Humans
Insurance, Health
Intensive Care Units
Jurisprudence
Korea
Motivation
National Health Programs
Personnel Staffing and Scheduling
Surveys and Questionnaires
Tertiary Care Centers

Reference

References

1. Carmel S, Rowan K. Variation in intensive care unit outcomes: a search for the evidence on organizational factors. Curr Opin Crit Care. 2001; 7:284–96.

2. Nguyen YL, Wunsch H, Angus DC. Critical care: the impact of organization and management on outcomes. Curr Opin Crit Care. 2010; 16:487–92.

3. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systemic review. JAMA. 2002; 288:2151–62.

4. Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet. 2000; 356:185–9.

5. Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O’Brien CR, Rubenfeld GD. Hospital volume and the outcomes of mechanical ventilation. N Engl J Med. 2006; 355:41–50.

6. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999; 282:267–70.

7. Pronovost PJ, Holzmueller CG, Clattenburg L, Berenholtz S, Martinez EA, Paz JR, et al. Team care: beyond open and closed intensive care units. Curr Opin Crit Care. 2006; 12:604–8.

8. Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA, et al. Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006; 34:1016–24.

9. Gasperino J. The Leapfrog initiative for intensive care unit physician staffing and its impact on intensive care unit performance: a narrative review. Health Policy. 2011; 102:223–8.

10. Villa RA, Thousand JS. Restructuring for caring and effective education: piecing the puzzle together. 2nd ed. Baltimore: Brooks;2000. p. 93–128.

11. Kahn JM, Matthews FA, Angus DC, Barnato AE, Rubenfeld GD. Barriers to implementing the Leapfrog group recommendations for intensivist physician staffing: a survey of intensive care unit directors. J Crit Care. 2007; 22:97–103.

12. Koh Y. How to enhance critical care in Korea: challenges and vision. Korean J Crit Care Med. 2014; 29:246–9.

13. Pronovost PJ, Needham DM, Waters H, Birkmeyer CM, Calinawan JR, Birkmeyer JD, et al. Intensive care unit physician staffing: financial modeling of the Leapfrog standard. Crit Care Med. 2004; 32:1247–53.

14. Moon YJ, Park JS, Ahn IW. Investigation on the management status of incentive pay system in hospital and strategy to invigorate. Korean J Health Service Management. 2011; 5:31–44.

15. Ward NS, Afessa B, Kleinpell R, Tisherman S, Ries M, Howell M, et al. Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing. Crit Care Med. 2013; 41:638–45.

16. Epstein AM. Public release of performance data: a progress report from the front. JAMA. 2000; 283:1884–6.

17. Millenson ML. Pay for performance: the best worst choice. Qual Saf Health Care. 2004; 13:323–4.

18. Shahian DM, Wolf RE, Iezzoni LI, Kirle L, Normand SL. Variability in the measurement of hospital-wide mortality rates. N Engl J Med. 2010; 363:2530–9.

19. Mackenzie SJ, Goldmann DA, Perla RJ, Parry GJ. Measuring hospital-wide mortality-pitfalls and potential. J Healthc Qual. 2015; Jul. 14. http://dx.doi.org/10.1111/jhq.12080.

20. Pronovost PJ, Thompson DA, Holzmueller CG, Dorman T, Morlock LL. The organization of intensive care unit physician services. Crit Care Med. 2007; 35:2256–61.

21. Cho J, Lee HJ, Hong SB, Suh GY, Park MS, Kim SC, et al. Structure of intensive care unit and clinical outcomes in critically ill patients with influenza A/H1N1 2009. Korean J Crit Care Med. 2012; 27:65–69.

22. Kim JH, Hong SK, Kim KC, Lee MG, Lee KM, Jung SS, et al. Influence of full-time intensivist and the nurse-to-patient ratio on the implementation of severe sepsis bundles in Korean intensive care units. J Crit Care. 2012; 27:414.e11–21.

23. Kim KD, Lee JW, Park HK. Feasibility and early outcomes of intensivist-led critical care after major trauma in the Korean ICU. Yonsei Med J. 2013; 54:432–6.

24. Park CM, Chun HK, Lee DS, Jeon K, Suh GY, Jeong JC. Impact of a surgical intensivist on the clinical outcomes of patients admitted to a surgical intensive care unit. Ann Surg Treat Res. 2014; 86:319–24.

25. OECD. OECD Health Care Quality Review: Korea Assessment and recommendations. [accessed on 9 July 2015]. Available at http://www.oecd.org/els/healthsystems/49818570.pdf.

26. Kellerman SE, Herold J. Physician response to surveys. A review of the literature. Am J Prev Med. 2001; 20:61–7.

27. Garland A, Gershengorn HB. Staffing in ICUs: physicians and alternative staffing models. Chest. 2013; 143:214–21.