Chapter 133. The Role of the Hospitalist in Critical Care

1. How did intensive care units (ICUs) and critical care medicine develop in the United States?

2. Who currently provides critical care in the United States?

3. What is an intensivist?

4. What are the evidence-based recommendations for ICU staffing?

5. What are some of the challenges of nationwide ICU staffing?

6. What is the role of hospitalists in future critical care provision?

Current estimates indicate that approximately 6000 adult intensive care units (ICUs) provide complex care for 55,000 to 70,000 patients per day in the United States. The number of ICUs continues to rise despite a nationwide decrease in hospitals. ICU beds account for over 10% of all US hospital beds with over 4.4 million patient admissions annually. Costs associated with ICUs account for 1% of the US annual gross national product and approximately 20% of individual hospital expenditures. These national trends are the likely results of medical advances compounded by the surge of baby boomers reaching more advanced age and the growing obesity epidemic.

The United States faces current and future ICU critical care physician staffing shortages. The most recent estimates suggest that only one-third of critically ill patients receive medical care from a physician with specialized critical care training, commonly referred to as an “intensivist.” The intensivist shortage coupled with the explosive growth of hospitalists over the past decade has led to more than 75% of hospitalists providing critical care as part of their clinical practice. A brief historical review of ICU development and of relevant medical literature will provide insight into current US physician staffing practices. While their role is not yet clearly defined, hospitalists will certainly continue to play a major role in future critical care provision.

The first American ICU is attributed to Dr. W. E. Dandy, a surgeon who created a three-bed unit in 1926 dedicated to the postoperative care of neurosurgical patients at The Johns Hopkins Hospital in Baltimore. In response to the nursing shortages after World War II, patients requiring intensive postoperative care or mechanical ventilation were located together within hospitals to improve medical care efficiency. The polio epidemic in the late 1940s and subsequent advances in mechanical ventilation in the early 1950s fostered the expansion of ICUs. An anesthesiologist and pioneer of cardiopulmonary resuscitation, Dr. Peter Safar, started the first 24-hour, physician-staffed ICU in 1958 at Baltimore City Hospital. Since the 1960s, most hospitals have maintained at least one ICU. There are presently more than 65,000 adult ICU beds and 20,000 pediatric ICU beds distributed unevenly among hospitals in the United States.

In 1970, a group of subspecialists with shared interests established the Society of Critical Care Medicine (SCCM) and defined critical care medicine as “the multidisciplinary healthcare specialty that cares for patients with acute, life-threatening illness or injury.” SCCM remains the largest multispecialty medical group in the United States today with 14,000 current members. In 1979, the American Board of Medical Specialties (ABMS) proposed to make critical care a multidisciplinary ...