SCCM Resource Library-The Tip of the Iceberg: Is the Physician-to-Patient Ratio the Full Picture?

Video Transcription

everyone. Thank you for the opportunity to be with you today and the opportunity also to discuss with you about workload, workload management, and required resources in critical  care, specifically regarding intensivists and other critical care professionals and how we meet the current and future demands in critical care.  First some disclosures. My name is Chris Farmer. I am no longer in active clinical practice. At the end of 2018, when I became eligible for emeritus status with Mayo Clinic,  I retired. And since that time, I am working independently with a variety of different healthcare systems and other entities to assist them with the development of programs and  also some of the very things that we're going to talk about today. I have no conflict of interest really to declare with the things that we will discuss today. There's nothing  financial that will make its way back to me as a consequence of this talk. The one disclosure  that I would like to make to you that I think is most relevant and was unpredicted for me is as I moved away from clinical medicine and started doing other things, I could feel  my inner spring unwind a little bit, and it was easier to be around people, even Department of Motor Vehicles type people, to get work done and assist with them. And my tolerance  for inefficiency most certainly improved. Okay. So about me, I think I've hit most of those things, but as they relate to workforce and workload, I think I've been stuck in the  same hamster wheel that all the rest of us have in terms of how much we work, how hard we work, it's never enough, keep going, et cetera. And that feeds into many things, including  burnout and other things like that. So let's go ahead and get started. We'll begin here. The question is the patient correction, the physician to patient ratio, the full picture  and the answer, and we all know this is obviously not. So I'd like to go through some of the reasons that I say that and point us to some of the future directions. So let's start  here and consider the root cause of what we try to do in the ICU and why we're trying to balance and optimize workforce and workload with each other. It's not just a ratio of  how many patients you're taking care of. As you can see in these two word clouds that we see that there's many, many things that impact our ability to provide those services  every day. And some of them, yes, in fact are related to direct patient care, but many of them are related to the milieu, the data barrage that we face, the exhausting workload  and all of these sorts of things. And so I want to talk about some of that going forward. Now one of my pet peeves with this are the folks that come to us in meetings and other  things and they say, Hey guys, you need to learn to work smarter, not harder. And to me, many times I see that almost as a form of cynicism. That's really not true. I've  captured a quote from a blog here. Let's read a couple of these sentences together because I think it states this very well. While it may often be true that there are many ways  to solve problems that are less resource intensive. And by the way, we're going to talk about  some of that. This is far from a universally applicable statement and can lead the manager to discount the effort required to identify and adequately deploy new problem solving  methods. I think what every one of us has experienced is the system succeeds most often, not because of the system, but because of the people who work in the system and make  it go. We all know that. One of the next things that we have to deal with, it impacts both workload and workforce is the simple question. Well, what is sick? And I've given  you two examples here to highlight exactly what we're trying to talk about here. So the first would be a community or a rural setting where they don't have a steady diet of very  high acuity patients. And therefore their calibration is in a different place for what constitutes sick. And you can see that by some of the comments here about insulin infusions  and multiple antibiotics and frequent labs and so forth. And that defines high acuity for that particular milieu and environment, as opposed to someone who is working in a  tertiary or a quaternary ICU. And they may be on a ventilator. They may be on suppressors. They may have some sepsis, but everything's under control. And in the sign out for this  patient, you may say, you know, this guy's on autopilot. He's not doing too bad. You've  got other things that you need to worry about where others would say this patient is incredibly  sick. So the absence of nomenclature that helps us to calibrate also impacts our ability to calibrate workload across a continuum of ICUs from a small rural setting all the  way to an urban tertiary quaternary ICU. So in that regard, what are those variables that impact sick? Like I have just discussed with you. So patient acuity, obviously we hit that  hard. The workload, and I'll show you a slide in a minute that defines that as to how we are impacted by this. The experience of the providers, their juggling skills, we'll talk  about that as well too. And then the available resources that are there in order to take care of those patients. And those include human resources for consultation of other  ancillary services, for the people that work with the equipment and the devices that are there and so forth. The next variable that impacts this is answering the question, who  needs an intensivist? And so what you see along this increasing continuum line from left to right is where we've gone basically with the history of critical care medicine.  And far to the left, you see low risk monitoring patients. Those that we worried were at risk  for deterioration, therefore we placed them in the ICU for surveillance. In the old days, rule out MIs and multiple enzymes and all the things that we did for those patients  that were requiring an ICU setting. And then it became who needs a central line? Well, then those people. Active resuscitation, active titration of multiple therapies, intubation,  and then all the way up to the far right of actively trying to die right before your eyes. And you can see the red arrows of historically how this line has changed over time about  who can care and who should care for this patient. And early on in the history of critical care medicine, it was more to the left as you see there. But as we, for example, we  said, well, this guy needs a central line. We need some sort of hemodynamic monitoring. He goes in the ICU. Well, now we put PICC lines in many of these patients and we're  able to monitor from those and no longer is that the exclusive purview of critical care.  Use of bedside ultrasound, point of care ultrasound, as it finds its way into the hands of our hospital medicine colleagues, to the nurses and others who care for these patients.  Again, it has impacted who needs critical care and who needs an intensivist. And now, especially during coronavirus, as we've used more and more telemedicine technologies,  we're able to augment and supplement this and keep patients in place. So you can see this is a moving target that also affects this. Now I made this picture to make a point for you.  So old days versus new days. And what this is supposed to graphically depict is an ICU with a number of beds in the pod that you can see there and the color coding of how sick the  patients are. So in the old days, there's the low risk monitoring that I talked about in green.  Some patients with a higher acuity or a medium acuity that may have a central line, like we  discussed about. High acuity patients, somebody that may need non-invasive ventilation or early  stages of invasive mechanical ventilation. And then very high acuity where we're using  high technology equipment like ECMO and other things at high level referral centers. And as you can see, going on the left side to the right side, what we do when we come to work  has changed. So if you're taking care of a number of patients in the old days, you could coast on  some of these patients. You could tuck them in and focus on the sicker patients and not worry  about the deterioration. However, when you look to the right, who are you going to coast on there?  Maybe there's a couple of medium acuity patients, but bed to bed to bed, the aggregate acuity of  illness is multiplying and it greatly complicates our requirements of what we need to take care of  these patients. So then for the intensivist who's working, the next question that you address is, hey, how many balls can you juggle for prioritizing tasks? These are clinical and  administrative tasks, medical decision-making, processing the deluge of data that comes at you,  communications at multi-levels with the people that you're co-managing, the surgeons, others  who are involved in the care of your patient, talking to others in the ICU, talking to family  members, all of these things, performing procedures, maintaining your focus, ensuring that the care  that you provide is compassionate, leading the team, coordinating the overall care plan,  and most importantly of all for the hospital, early recognition of impending badness. It's easier  to stay out of trouble than to get out of trouble. This is an enormous amount of work that dramatically  changes how many patients you can safely take care of, especially in the traditional systems that we  use for care models. And then there's burnout. So when you do all of those things and what you've  seen for the last two years, what all of us have seen with coronavirus, this is the impact of this,  the guy in the middle that you see there. How do I keep going day after day after day?  The end result of all of this looks something like this, and this is not my diagram, but it shows the fulcrum point. It shows the balance. Now we've talked about too many patients,  but notice to the left of this, too few patients. If you're not doing enough of this, then the  appropriate skill sets are not maintained. And all of those things that you see in the boxes on  the left can occur. So seeking that balance point, not too hot, not too cold, not so straightforward.  Now this paper was published by one of the tasks forced under the critical care of the Society of  Critical Care Medicine. And in particular, Steve Pastores has been amazing as we've been cranking  out these papers over the last few years in a variety of different areas, gathering data,  gathering survey information, and quantifying for us what's going on out there in the critical care  world and helping us to better understand. Now, all of these were focused on critical care  organizations. And as you can see here, and that's what these next two slides are to show you,  what's a critical care organization. And you see that for the most part, these are urban and academic settings with tertiary and quaternary ICUs where we see these full fledged  critical care organizations. Well, this has been incredibly helpful and useful to us, but remember, and I'm going to talk to you about this in a couple of minutes,  and that is that our critical care team is not just the ICU that you work in, and it's the entire  continuum of critical care all the way to the rural hospital, to the critical access hospital,  and how they participate in this system in the aggregate. So it's great that we're figuring out  these things, but we must remember that we have to include in our stream of consciousness other  forms of ICUs and not just the urban and academic ICUs and how we define future critical care  models of care for workforce and workload. So one last slide from this particular study, and I think it's helpful to see some of the questions that they address for both workforce  and workload about the critical care organization, meaning the needs of the organization. And some of these were things like organ transplant and supportive postoperative care  for these patients and so forth. Again, the point here is that this is a high density, high acuity workplace setting for critical care. And that's important that we recognize that,  again, because not every ICU looks like this. Okay, so here's another study, different one,  but also includes Steve Pastoris as well as his colleague, Neil Halpern with this. And so what we  see here, and this is from 2019, so a little bit earlier than the last paper I showed you,  is just a breakdown of where are the ICUs and the beds that are out there. And so you see the way  that they have parsed this, metropolitan, like we just talked about, micropolitan, so still an  urban setting or maybe a smaller community, community hospital, maybe doing some very high  level critical care in that hospital all the way to rural, and you can see the distribution. And the point that I want to make on this slide is take a look at the hospitals without  intensivists. So that's the second column for the right. And we can see is this model has more and more penetration as you get to so-called micropolitan and then to rural hospital,  this drops down. So as we are trying to address the entire continuum of critical care so that we  have the right ratios and the right capabilities for workforce and workload, we have to understand  that we've not yet penetrated those areas in a way that is needed. That could be telemedicine,  that could be other remote technologies, but the point is, and what you can see from this slide,  is we have a lot of work to do to make sure that there's equal access all the way across  the continuum of care. So what this means is we have an evolving definition of the multidisciplinary  critical care team. And the way I describe this for folks is critical care is not a place.  The ICU is a place, but critical care is not. So when we consider our multidisciplinary team,  traditionally we think about this exclusive to the ICU team in the ICU where you work. Well,  so that's on the list here, but so is the rest of the hospital and prevention of critical care,  a very important component of what we do now and in the future for these things. The most efficacious critical care is the critical care intervention that a patient never needs.  So as we move forward to the future, more and more of our emphasis needs to be focused on our  patients so that we keep them out of the ICU and keep them from getting to a level of acuity that  demands that level of care. Telemedicine, those folks are on our team too, and how we interact  with them. And right now, what we do for most of these, these are separate circles and they have  some degree of overlap, but for the most part, they are separate circles. And in the future,  as we move forward and we consider workload and workforce, we need to merge this Venn diagram more and more together. Other hospitals and importantly in the home, we have a lot of  patients now, an increasing population of those with chronic critical illness. Those patients are  never more than a few hours away from being in an ICU. How do we interact with them in a way  that we can assist them in maintaining a tenuous equilibrium state so that they don't fall off  their curve and land in your ICU as they get sick in the morning and they're intubated in the  afternoon? Okay, so traditionally, the way we do this is we have to think about the problems for  each of these patients, think about the data that we need, and then we have to go get it. We have to  go find it and then we have to pull it and look at it and analyze it and do those things to know  which of these patients. This paper was published some number of years ago by my colleagues in  Rochester and the point that was made from this that's important is we've got thousands of data  points that we're gathering on sick people every day with the frequency of vital signs, all their  labs, all the things that we commonly talk about. But ironically enough, the particular data points  that we use for medical decision making is a very limited subset of that total universe of data that  we're generating. And even more interesting is it's diagnosis independent. Irrespective of what  their diagnosis is, we keep going back over and over the same limited data set to make decisions.  So here also from that same study you can see, and this is survey information, and I want you  to look at the right-hand column that's there and that's the percent of people that say, yes,  I regularly and routinely use this information to assist me in data. And so you see vital signs  and you keep trickling down the list and you don't get too far down the list before you're  below 50 percent. And by the time you're halfway down the list or two-thirds of the way down the  list, you're at a very low numbers and this data just keeps pouring in and pouring in, but we're  not really using this information. It's almost as if it's psychological support for us. So how do we  do this? So my same colleagues, and we've worked on this, and this is not novel. Lots of places have  done this with the use of so-called data sniffers or syndromic surveillance. You build a rule set  for things and then it can look across the various different databases. It can see, for example,  acute kidney injury. Has this patient had a contrast study with IV contrast? Have they had  periods of hypotension? Are they receiving any drugs that are potentially nephrotoxic and so  forth? And then it puts all of these things together and flags the patient. And now instead  of pull, it's pushed to you. So that's very helpful. This particular study used these techniques  for patients who had potentially injurious mechanical ventilator settings. So the rules  were written for this. And if you think about that picture of the ICU with all those red and purple  patients that are there, it's really easy to miss somebody that may be drifting into dangerous  territories for acute lung injury related to the use of the mechanical ventilator. Well, what if  this taps you on the shoulder and says, hey, you need to go look at this guy. He may be getting  into trouble or he is at risk for getting into trouble with that. So this sort of approach is a way that we need to increase and utilize with our electronic health records.  Okay. So where does this team need to go and who is on the team? And so I've hit some of that with  you with the healthcare providers, but yes, it goes even further than that. ICU, multidisciplinary  team members, hospital, telemedicine, but look at this home care, skilled nursing facility,  rehabilitation. We've got to get those guys involved with it where we have a communication  pathway and a data pathway. So it's bidirectional and going back and forth. And we have some level  of asset visibility of what's going on with these patients. And then even between the hospitals,  we've been doing this with telemedicine, but more and more, this is going to, this is going to become  required. And finally, a new category that will be developed, I believe, and that's the data  managers and the people that work alongside our team, that there's some total job description  is to assist us with overall data management and aggregating and helping us to be more in tune  and more aware of what's going on with the patient. So I'm showing you this, it's a couple  of years old, but this is everything from impedance, plethysmography, to cardiac monitoring,  to Apple watches and so forth. These technologies have been applied to patients with heart failure  for early detection of decompensating heart failure. As the skin becomes edemonous, the skin plethysmography, that impedance plethysmography changes and we can detect it.  You see the foot insole there, people who have decompensating heart failure, they begin to change  their gait. And so you can see the change in those pressure points and it alerts you to these things.  So all of these different kinds of technologies, we're dabbling in all of these right now,  but this will continue to increase and we will be involved with this and it will impact workload  and workforce management in critical care. So I like to stop here and summarize with a couple  of quotes. First, the scientists and engineers who are building the future need the poets to  make sense of it. And that's what I'm talking to you about now with all the philosophy that's involved. Building the future and keeping the past alive are one and the same thing.  I think this next quote is particularly interesting. In 10 years, the electronic medical record will be a minor player. Isn't that amazing? If that really comes to fruition  after all of the concerns and problems we state about current generation electronic health records  and what Leslie Saxon means by this is in terms of where a person's health history lives,  most of that information will be kept on the phone or in a secure cloud and the patient will  be highly engaged with collecting, curating and sharing that data. We've seen some of that  already, but it will become more and more prominent in what we do is what she's saying here.  And then finally, this is my quote. As I've already told you, critical care is not a place.  Workforce and intensivist approaches that support this reality are significantly different than our  traditional ICU practice model. So I hope today I've lit a candle for this so that we can begin to talk about these things because all of us need to help build this future together.  So thank you very much for your time and I appreciate the opportunity to speak with you.

Video Summary

The video transcript discusses the importance of workload management and required resources in critical care, specifically focusing on intensivists and other critical care professionals. The speaker emphasizes that workload should not just be determined by the number of patients, but also considers factors such as patient acuity, experience of providers, and available resources. The current model of critical care is limited to the ICU, but the speaker suggests that the definition of the multidisciplinary critical care team should include the entire continuum of care, including prevention, telemedicine, other hospitals, and even home care. The use of technology, such as data sniffers and remote monitoring devices, is also highlighted as a way to improve workload management and patient care. The speaker concludes by encouraging collaboration and innovation in order to build a future model of critical care that is more effective and efficient.

Asset Subtitle

Administration, Quality and Patient Safety, 2022

Asset Caption

A foundational aspect of high-quality critical care is the use of multidisciplinary healthcare teams that leverage the specialized training of each respective discipline. Evidence continues to demonstrate that the use of multidisciplinary critical care teams improves clinical outcomes. The level of healthcare professional staffing in the ICU correlates to patient outcomes and medical errors. It is clear that medical errors are independently associated with worse outcomes. However, the optimal practitioner-to-patient ratio needed to derive the benefits of this team-based approach and optimize safety is unknown. This session will feature a multidisciplinary panel who will communicate the synthesis of current evidence on optimization of healthcare professional-to-patient ratio for each discipline to educate ICU clinicians unfamiliar with these data and to spur the implementation of evidence-based healthcare professional-to-patient ratios in their ICUs.

Meta Tag

Content Type Presentation

Knowledge Area Administration

Knowledge Area Quality and Patient Safety

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Healthcare Delivery

Tag Evidence Based Medicine

Year 2022

Keywords

workload management

critical care

intensivists

patient acuity

multidisciplinary critical care team

technology

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