The Strength of a Single Voice

2009 - 2 June - 38th Critical Care Congress Review
Mitchell M. Levy, MD, FCCM
The varied approach to critical care practice in North America sets it apart.
Call to Action
The Society of Critical Care Medicine often collaborates with other professional organizations to respond to issues most relevant to the critical care community. In our complex culture, there are many legislative, advocacy and educational issues that effect critical care professionals, as well as various economic, political and social activities and causes. It is important to SCCM's leadership that efforts focus on items most important to members. As the Society continues its collaboration efforts, it will consider this vital input. Several aspects of critical care in North America distinguish it from other parts of the world: the practice patterns in intensive care units (ICUs), critical care organization, and the variety of professional societies that represent practitioners.
The varied approach to critical care practice in North America sets it apart. While most ICUs throughout the rest of the world utilize a “closed ICU model” (managed by intensivists alone), the “open ICU model” is most popular in the United States and is used by 80% to 90% of ICUs. (1) In the open model, patients are managed by attending physicians in consultation with critical care physicians. The closed model, in which critically ill patients are transferred to the service of critical care physicians upon admission to the ICU, is only used in its strictest sense in about 5% to 10% of units in the United States.(2) Data evaluating these different models have been mixed (3-5) but we can conclude that the application of a team approach within the ICU culture is a key component in creating high-quality, high-performing ICUs.
This varied model, along with the American spirit of competition, likely is the primary reason why the United States is headquarters for at least three societies representing critical care physicians: the American College of Chest Physicians (ACCP), the American Thoracic Society (ATS), and the Society of Critical Care Medicine (SCCM). Most other countries have only one critical care society representing physicians. Of course, this list does not include those professional societies that have components related to critical care, such as the American College of Surgeons, the American Academy of Pediatrics, the American College of Emergency Physicians, and the American Society of Anesthesiologists, among others. The United States is also home to many more professional organizations that represent nurses, respiratory care therapists, pharmacologists, and other members of the critical care team.
Unfortunately, the competition among the three major societies – SCCM, ATS, and ACCP – has not always been beneficial for the field. Over the years, we’ve seen many examples of duplication and competition that have not necessarily been in the best interest of the practicing clinician (e.g., multiple task forces, white papers, and guidelines on the same subject). This duplication leaves the bedside clinician wondering, “To whom should I listen? Whose voice should be inside my head while at the bedside of intensive care patients?” Of course, the irony is that the members of these various task forces and the authors of these many white papers and guidelines are often the same people asking these confused questions at the bedside! Many of us have had the experience of sitting on three separate task forces on the same subject (e.g., end-of-life care), but representing different societies. Most of us have felt that activity wasn’t in the best interest of patient care.
The good news for bedside ICU clinicians and our intensive care patients is that the era of duplication and competing agendas has come to an end. These activities are being replaced with unified efforts and cooperation. The societies are working to ensure clinicians do not hear multiple voices at the bedside. Over the last several years, ACCP, ATS, and SCCM have joined with the American Association of Critical-Care Nurses (AACN) to form an informal group referred to as the "Quad Societies." Representatives from these associations meet regularly at each others’ meetings and independently during a group retreat. Increasing economic constraints, the need for cost containment, the demand for healthcare reform, the shrinking continuing education dollar, the decreasing time and money available for travel, and other limiting factors have led to the development of this cooperative group. The critical care societies have come to the obvious conclusion that working together as much as possible to forge a single critical care voice is the best service we can provide to our collective membership.
Given the enormity of the issues that face our culture – specifically in regard to healthcare reform and particularly surrounding critical care costs, safety, quality improvement, and the inevitability of pay for performance – common ground has emerged that provides a clear understanding of the potential impact of collaboration. What has been the result of these collaborative efforts? In the last year, the Quad Societies has worked together to respond to multiple issues.
The Office for Human Research Protections’ (OHRP) decision to put a halt to ongoing improvement efforts in Michigan’s Keystone Project galvanized the group. In response to this decision, the Quad Societies met with the deputy secretary of Health and Human Services (HHS). This meeting at HHS headquarters came about as the result of a letter from the Quad Societies expressing concern about OHRP’s action. The rapid response from HHS was surprising, and the ultimate resolution has been gratifying. It also illustrates the power of speaking with one voice in a collaborative effort. Essentially, HHS agreed with most of the concerns raised by the Quad Societies both in the letter and the face-to-face meeting that ensued. Our actions served to inform the clarification that came from HHS to OHRP, which led to the ultimate resolution of this issue. In addition, the OHRP released a list of frequently asked questions regarding quality improvement activities, which was modeled after input from the societies. The information is available on the HHS Web site at
The Quad Societies also achieved success in its response to the proposal on hospital-acquired conditions issued by the Centers for Medicare and Medicaid Services (CMS). The Quad Societies was invited to participate (together) on a teleconference with CMS to define which conditions under consideration could truly be considered “never events.” This was an extremely important conversation that led to a reduction in the number of conditions ultimately identified as never events by CMS. Speaking as one voice to CMS was the key to being heard. Our voice continues to be prominent in the ongoing conversations on the evolution of ventilator-association pneumonia prevention measures. Our efforts related to this are highlighted in this issue of Critical Connections.
Finally, the Accreditation Council for Graduate Medical Education (ACGME) approached the Quad Societies for a formal response to the proposed changes in resident duty hours. The societies collaborated and sent a letter to the ACGME, outlining its concerns. The Quad Societies observed that if resident work hours were further restricted, efforts to train future intensivists would be hindered, as many added responsibilities would fall on attending physicians and fellowship supervisors. Further work restrictions also may impair training in professionalism and make it increasingly difficult to support the scholarly mission of subspecialty training. This is another partnership that likely will have a significant effect on not only the future of critical care, but also medical care in general.
This marks just the beginning of collaborative efforts among the North American critical care societies. The pressures that brought us together are likely to intensify, not diminish. I believe strongly that the successes already achieved through collaboration will enable us to respond to future challenges in a thoughtful and measured manner. To a certain extent, the competition among the groups is inevitable and likely to continue. Because of the varied critical care models that exist in the United States, each of the societies serves a different constituency. On the other hand – and I believe this is clear to the Quad Societies – we have more commonalities to bind us than differences to separate us. As we learn to appreciate and define these similarities, the subsequent collaborative efforts will enable us to remain a compelling, unified voice that advocates for patients while also shaping the future of critical care practice.
1. Joint Commission on Accreditation of Healthcare Organizations. Improving Care in the ICU: Improving Health Care Quality and Safety. Oakbrook Terrace, Illinois: Joint Commission Resources, Inc.; 2004.
2. Carmel S, Rowan K. Variation in intensive care unit outcomes: a search for the evidence on organizational factors. Curr Opin in Crit Care. 2001; 7:284-296
3. Levy, MM, et al. Association between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit. Annals Int Med. 2009; 418(11):801-809.
4. Gajic, O, Afessa, B. Physician Staffing Models and Patient Safety in the ICU. CHEST. 2009; 135(4):1038-1044.
5. Multz, AS et al. A "Closed" Medical Intensive Care Unit (MICU) Improves Resource Utilization When Compared with an "Open" MICU. Am J Respir Crit Care Med. 1998; 157(5):1468-1473