Originally published in the June 2003 issue of Critical Connections,
Volume 2, Number 3.

Following a 10-year quest for change, Hoag Memorial Hospital Presbyterian now embraces the intensivist model after a successful 2002 transition to intensivist-led intensive care units (ICU). As a 400-bed, acute-care, not-for-profit community medical center in Newport Beach, Calif., Hoag has approximately 25,000 admissions and 260,000 outpatient/ ECU visits annually. Approximately 2,500 patients are treated in Hoag’s ICUs.

Hoag Hospital has only recently begun data collection, but the preliminary results are positive. “The data we have already seen shows a markedly diminished patient return rate to the ICU within 24 hours. Many physicians, particularly cardiovascular surgeons, tell us that ICU care has had a definite impact upon survival,” says Herbert Rogove, DO, FCCM, FACP, director of the department of critical care medicine at Hoag Hospital.

The catalyst behind the ICU transition to the intensivist model was Kris V. Iyer, MD, FACP, FACE, chief of staff and an endocrinologist at Hoag Hospital. He says that a senior cardiologist first asked for the intensivist model in a general staff meeting nearly 15 years ago.

“The first day I became vice chief of staff in October 1999, the then chairman of the Critical Care Committee presented a report which clearly demonstrated opportunities to improve patient care in critical care units and this report prompted the Medical Executive Committee to take charge of patient care,” Dr. Iyer explains.

Coincidentally, at approximately the same time, the Medical Executive Committee started pushing for the intensivist model, because the APACHE evaluation of critical care services reported that Hoag Hospital was using critical care beds inappropriately. The length of stay, cost and mortality were also high. “Objective quality indicators proved what we knew anecdotally,” remarks Dr. Iyer.

Hoag Hospital currently has a director of critical care with a staff of four intensivists who provide critical care 24 hours a day, seven days a week. Dr. Rogove states that one of the major aspects of the success of the program is attributed to the intensivists, Drs. O’Meeghan, Vovan and Singh. The intensivist program started in July 2001 with Dr. Rogove’s arrival as director. As he hired additional personnel, the intensivists were able to staff the ICUs from 7 a.m. to midnight. In October 2002, the ICUs at Hoag Hospital were able to switch to 24-hour intensivist care at all times. Dr. Iyer would like to further increase the staff to reduce the heavy workload experienced by the intensivists.

The intensivists cover three units with a total of 30 beds. Prior to the transition, Hoag’s ICUs were open with patients being admitted by their physician. Previously, specialists ran the ICU, which left the nurses with a tremendous amount of responsibility because care often was not well coordinated.

“I personally believe that the director of critical care services should be in charge of all critical beds with the ability to manage the flow of patients,” states Dr. Iyer. Critical care medicine is a freestanding department at Hoag Hospital. This is consistent with the Canadian and European model. Dr. Rogove says that as a department, critical care has political input into hospital policies. The critical care department has instituted performance improvements, including weaning protocols and continuous insulin infusion protocols, and is working on protocols to improve infection management.

“The administration also thinks this is one of the best things we have ever done,” Dr. Iyer notes. “The campaign to upgrade the ICU to the intensivist model was driven by the need and desire to provide the best possible care for critically ill patients in our hospital.”

“I think all institutions must try for this. It is a monumental effort; the intensivist-driven ICU has been one of the most important patient-centered projects we have done,” concludes Dr. Iyer.

Dr. Iyer observes that there was some initial resistance: “The most difficult part of the process was convincing my colleagues that an intensivist-model would result in better patient care and not an intolerable loss of control or income.”

“The neurosurgeons welcomed the change and the other specialists gradually started using the services of the intensivists. Deep inside, everyone knew this was the best way to care for the critically ill. I think that everyone is now happy. My colleagues told me that they have lost some income, but they are sleeping more,” Dr. Iyer continues.

The proposed ICU change had some strong proponents. According to Dr. Rogove, the critical care nurses were advocates for the intensivist model. “The critical care nurses focused a tremendous amount of energy on this project because they felt that care would significantly improve. Some of them worked at other institutions with intensivists.”

The hospital administration was receptive to the intensivist model because of the nurses’ support. They also felt the intensivist model would help with nurse recruitment.

Advice for Instituting Change
A new intensivist-led ICU needs at least two to three years before it becomes a well developed program, according to Dr. Rogove. He advises first building an infrastructure, then developing policies and procedures, and finally establishing relationships with everyone in the hospital—physicians, therapists and nurses.

Dr. Iyer says that the support of the entire medical staff is necessary to institute this kind of change. Dr. Iyer attended departmental meetings in all 22 hospital departments to personally ask for their support. The departments were given examples of what needed to change in patient care. In addition to the abstract examples, Dr. Iyer made these talks personal by asking the medical staff this direct question: “Would you put your mothers in our ICUs?”

Dr. Iyer shares his suggestions for physicians at other institutions considering a similar transition to an intensivist model ICU. He recommends clearly demonstrating the opportunities in patient care that can be improved by intensivists.

“When asked for recommendations about possible patient care improvements, the Medical Executive Committee appointed an ad hoc committee which included pulmonologists, neurosurgeons, surgeons, internists and cardiologists. We developed the criteria for the Critical Care Program and included the details for a bylaw change to create the department of critical care. The Medical Executive Committee and medical staff overwhelmingly supported the change,” Dr. Iyer asserts.

Editor's note: The Society is seeking similar success stories about implementing the multidisciplinary team model by its members. Because implementing the model is often a challenging task, sharing your experience may help other intensivists overcome similar obstacles to the ones you faced. Your experience will also help SCCM highlight the fact that the multidisciplinary team model can work in any setting and that the intensivist can work effectively with other healthcare providers.

These stories will be collected and published by SCCM as a resource to its members and other healthcare practitioners.