The Critical Care Crisis in the United States: A Report From the Profession

Abstract

T he care of the critically ill patients accounts for 1% of the gross domestic product in the United States. 1 The aging of the American population in the next 2 decades will increase the burden of acute and chronic illness and the demand for critical care services. 2 The Leapfrog Group, a consortium of Fortune 500 companies, has identified critical care as a major factor in health-care quality. 3 Leapfrog has promoted wider use of critical care physicians because such staffing improves patient outcome. 4 These imperatives come at a time when the resources supporting critical care services are strained. Most alarming is the impending shortage of the critical care professional. Based on current practice, a shortfall of critical care physician specialists will occur within the next 10 years. 2 If Leapfrog recommendations are implemented, the physician shortage will be immediate, highlighting the vulnerability of the system that also has a shortage of pharmacists and declining number of critical care nurses. This article describes these challenges and recommends steps to prevent a crisis in the delivery of critical care services. Impending Crisis in Critical Care Delivery The physician staffing of the ICU influences patient outcome. Staffing ICUs with physicians skilled in treating critical illness (“intensivists”) can reduce morbidity and mortality and the cost of care. 5 Intensivists currently provide care to only 37% of all ICU patients in the United States. These physicians are more likely to practice in larger hospitals and teaching institutions. 2 Intensivist staffing may yield benefits through a leadership role in organizing ICU care. A wellcoordinated ICU team promotes standardized care, more timely intervention, and appropriate use of resources. 5 More intense ICU physician staffing improves mortality and length of stay both in the ICU and the hospital. 4 Because most ICUs in the United States have low-intensity staffing, a major shift by hospitals toward high-intensity staffing could improve clinical outcomes and efficiency. In other developed countries, this approach has already been adopted. 6,7 In the United States, increasing intensivist staffing appears unrealistic because even the current level of subspecialty critical care appears unsustainable. As the nation ages, a larger number of elderly patients will require ICU care, thereby sharply increasing the demand for ICU services. 2 With current staffing and numbers of trainees, the demand for intensivist services will exceed the supply by the year 2007, and the imbalance will worsen dramatically thereafter. 2 This phenomenon may signal the beginning of a national shortage of all physicians. 8 The crisis is even more immediate for other health-care professionals. Vacancy rates for hospital nurses have risen because the growth in the nursing work force has not kept pace with the population growth. A projected 6% growth in the supply of nurses will not match a projected 40% increase in demand by the year 2020. 9 The situation is more problematic in critical care with nurse vacancy rates at 20% and rising. 10 In clinical pharmacy, the situation is equally grim. 11