Update critical care 2009

Because of the deficit in training during orientation, residency and fellowship programs have expanded exponentially over the past decade Figure 3.

These 15 programs receive approximately applications per cycle but have funding for only trainees per year. This equates to , new graduate APPs seeking additional training in critical care while only are afforded the opportunity each year. Significant attention must be paid to the deficit of funded training seats. Healthcare institutions, federal payers, and academic centers must find novel ways to fund programs in which structured critical care training is available to all new graduate APPs seeking employment in critical care.

Until , most interns were limited to 16 consecutive hours and residents could work up to 24 consecutive hours. While ACGME work hour standards were intended to mitigate fatigued decision-making, evidence suggested that they may not have reduced medical errors as expected. Many residency programs are also attempting to ensure hour in-house coverage by fellows and intensivists despite the lack of conclusive data on ICU mortality with nighttime or round-the-clock in-house intensivist coverage.

The broad implications and unintended consequences of these changes will impact procedural proficiency and competency of providers without fellowship training.

These modifications in training requirements for residents will continue to add to the current critical care workforce shortage. FCCS primarily serves non-intensivist physicians, nurses, APPs, and other providers who often lack critical care training. Growth in FCCS participation has been steady. Overall, there has been a These programs are designed to help mitigate the ICU provider shortage but may not be able to fully address complex issues that may arise in the middle of the night when seasoned providers are not in house.

Implementation of an ICU telemedicine program is a practical way to increase access and reduce mortality and length of stay. CMS will pay for telehealth in a limited number of circumstances—rural hospitals with live videoconferencing and an approved telemedicine provider. The current options for telehealth reimbursement are very restrictive but additional data obtained from the use of telehealth may lead to broader acceptance.

Data from a pilot innovation project in electronic ICUs started 3 years ago have found reduced length of ICU stays, fewer readmissions, and costs reduced by millions of dollars. Preliminary data from this project also suggest savings at university medical centers.

Looking Ahead The next 10 years will be a challenging and interesting time for the practice of critical care medicine in the United States—challenging because the need for more trained intensivists is constantly increasing. On one hand, we may be doing well, largely because the workforce demographic has changed to incorporate APPs as a solid backbone of our CCM machinery.

On the other hand, this may be misleading since a lot of acute care hospitals do not have privileged intensivists staffing their ICUs. Intensivists in U. Crit Care Med. Trends in critical care beds and use among population groups and Medicare and Medicaid beneficiaries in the United States: Association of American Medical Colleges.

Workforce Studies. Accessed March 5, Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. The impact of open versus closed format ICU admission practices on the outcome of high risk surgical patients: a cohort analysis. BMC Surg. Intensivists improve outcomes and compliance with process measures in critically ill patients. J Am Coll Surg. Intensivist workforce in the United States: the crisis is real, not imagined.

American Association of Nurse Practitioners National Nurse Practitioner sample survey: update on acute care nurse practitioner practice. J Am Assoc Nurse Pract. Accreditation Council for Graduate Medical Education. History of Duty Hours. Abt Associates.

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