Originally published in the December 2002 issue of Critical Connections, Volume 1, Number 5.

Society of Critical Care Medicine member Jay Cowen, MD, has seen both the good and the bad when it comes to implementing the intensivist model. In one instance, he and his colleagues were embraced and immediately able to integrate themselves with the hospital staff, but in another, they found the climate less than hospitable. Despite a track record of success and support from the hospital administration, many intensivists may find themselves facing an uphill battle.

On November 6, 2002, The Journal of the American Medical Association (www.jama.ama-assn.org) published "Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients," an article authored by Peter J. Pronovost, MD, PhD; Derek C. Angus, MB, ChB, FCCM; Todd Dorman, MD, FCCM, et al, that stressed the effectiveness of the intensivist model. This study, one of numerous studies on this subject, reinforces the basic premise that the intensivist-directed ICU saves lives and money, with no sacrifice to quality of care.

Each year, more than four million people are admitted to the ICU. Of those, approximately 500,000 will die in the ICU. However, this mortality rate drops significantly in intensivist-directed ICUs. Apart from saving lives, the intensivist model also may reduce lengths of stay and the number of unnecessary hospital admissions.

Despite the impressive statistics and the endorsement of the Leapfrog Group, fewer than 25 percent of all American hospitals are currently using the model. And, putting the intensivist model into practice can be a challenge. In many cases, even if the hospital administration is fully on board, it can be difficult to convince family physicians and other specialists of the value of the model and win their cooperation.

Dr. Cowen successfully implemented the intensivist model at two very different institutions: at Lehigh Valley Hospital in Allentown, Pennsylvania, a large tertiary care teaching hospital with a very sick patient population and, in contrast, at Northwest Community Hospital in Arlington Heights, Illinois, a non-tertiary care community hospital.

"What we did at Lehigh Valley Hospital was apply industrial quality management principles to the critical care program we began there," said Dr. Cowen. "We standardized care protocols which resulted in a shorter length of stay and the use of fewer resources than in a traditional ICU. Most importantly, quality improved as costs went down."

Because Dr. Cowen's group was developing a new program at the request of the hospital's medical staff and administration, they faced very little resistance at Lehigh. The group was able to exhibit outstanding statistics, decreasing the standard mortality rate more than 25 percent in a few years. When these results were presented to the medical staff, they were eager to buy into the intensivist model.

Three years ago, Dr. Cowen was recruited by Northwest Community Hospital (NWCH) to develop a similar critical care medicine program there. This time, however, the environment was far different.

"Even though we had been invited to come to NWCH and the hospital administration believed in our worth, there was tremendous resistance from other physicians," Dr. Cowen recalled. "No one knew what an intensivist was. The rest of the medical staff actually held meetings to see if they could force us out."

Early on in the program, the medical staff was suspicious. At their insistence, nurses were forbidden to directly contact an intensivist when patients were in trouble. At times, Dr. Cowen had to wait until a patient coded before he could go into the room.

Change, however, has come at NWCH. While there are occasional disputes, Dr. Cowen and his group now see virtually all critically ill patients. They have been open with other physicians about their care protocols and win support on a case-by-case basis.

"Compared to my experience at Lehigh Valley, here we have had to slowly establish our credibility with other healthcare providers," Dr. Cowen said. "We've been able to do this through educating the medical and nursing staffs, and most importantly, by providing immediate state of the art critical care to our patients. Being successful here has required a lot of patience, but it is well worth it."

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.