Jeff Zilberstein – Community ICU Admin is Freaking Hard, But You Can Make a World of Difference

Sweet!  You just graduated from your Critical Care fellowship and landed a great job in the community.  No more PGY paychecks or 80+ hour work weeks.  Things are looking up!  But after showing up for your first day, you quickly realize things are MUCH different than when you worked at that massive tertiary care hospital just a month ago.

Is your cardiology, nephrology, or podiatry consultant really blocking your ICU patient from being transferred out of the unit?  Dr. Jeff Zilberstein is here this week to discuss the trials and tribulations of managing critically ill patients in the community, as well as talk about his experiences and success as a community ICU director.

ICU Directorship in the Community

  • A majority of community ICU’s are open units with multiple consultants that “co-manage” admitted patients.
  • Beware of malaligned incentives that can affect the ICU triage process
  • Standardization is CRITICAL, it’s important that your ICU as a consistent structure and flow
    • ICU note standardization
    • Development multidisciplinary care protocols
    • Need to continuously reinforce protocol utilization

Gaining the trust of referring physicians, surgeons, and administration was probably the biggest hurdle in developing a new ICU program.

Developing a new culture

  • Placing the intensivist as the lead physician in patient care is critical.
  • Triage: Have the intensivist decide on ICU appropriate admissions
  • Aggressive patient transfers out of ICU
  • Monitor the results of your interventions.  If you don’t keep track of your changes, you’re just a cowboy.

The Zilberstein Experience at Northwest Community Hospital ICU

  • Severity of illness increased, while admissions and length of stay decreased
  • No change in the readmission rate
  • Decrease in unplanned extubations
  • Increased cost savings

Resource Utilization

  • Intensivist led, team-based ICU care appears to improve outcomes
  • Intensivist led, team-based ICU care improves resource utilization – Most hospitals do not have too few ICU beds, but rather:
    • Too many inappropriate admissions
    • Excessive lengths of stay
    • Ineffective bed turnover
  • In an ideal world, maybe this should be our admission algorithm
    Gooch RA, Kahn JM. ICU bed supply, utilization, and health care spending: an example of demand elasticity. JAMA. 2014;311(6):567-8.

    Gooch RA, Kahn JM. ICU bed supply, utilization, and health care spending: an example of demand elasticity. JAMA. 2014;311(6):567-8.

 

Suggested Readings

  1. Parikh A, Huang SA, Murthy P, et al. Quality improvement and cost savings after implementation of the Leapfrog intensive care unit physician staffing standard at a community teaching hospital. Crit Care Med. 2012;40(10):2754-9. [PubMed]
  2. Krell K. Critical care workforce. Crit Care Med. 2008;36(4):1350-3. [PubMed]
  3. Keegan MT, Gajic O, Afessa B. Severity of illness scoring systems in the intensive care unit. Crit Care Med. 2011;39(1):163-9. [PubMed]
  4. Gooch RA, Kahn JM. ICU bed supply, utilization, and health care spending: an example of demand elasticity. JAMA. 2014;311(6):567-8. [PubMed]

Share this Post

Comments

  1. Jenny

    Dr. Zilberstein, Would you be able to share your new four page resident note format, so that residents can learn from it for their ICU rotations?
    Also, thanks for making such a difference in one of the community hospitals in chicago. I hope that other hospitals can learn and adopt your model.

Leave a Comment