Organizational Structure, Staffing, Resources, and Educational Initiatives in Cardiac Intensive Care Units in the United States
2017; Lippincott Williams & Wilkins; Volume: 10; Issue: 8 Linguagem: Inglês
10.1161/circoutcomes.117.003864
ISSN1941-7705
AutoresSean van Diepen, Christopher B. Fordyce, Zachary K. Wegermann, Christopher B. Granger, Amanda Stebbins, David A. Morrow, Michael A. Solomon, Jeffrey S. Soble, Timothy D. Henry, Ian C. Gilchrist, Jason N. Katz, Mauricio G. Cohen, L. Kristin Newby,
Tópico(s)Mechanical Circulatory Support Devices
ResumoHomeCirculation: Cardiovascular Quality and OutcomesVol. 10, No. 8Organizational Structure, Staffing, Resources, and Educational Initiatives in Cardiac Intensive Care Units in the United States Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBOrganizational Structure, Staffing, Resources, and Educational Initiatives in Cardiac Intensive Care Units in the United StatesAn American Heart Association Acute Cardiac Care Committee and American College of Cardiology Critical Care Cardiology Working Group Cross-Sectional Survey Sean van Diepen, MD, MSc, Christopher B. Fordyce, MD, MHS, MSc, Zachary K. Wegermann, MD, Christopher B. Granger, MD, Amanda Stebbins, MSc, David A. Morrow, MD, MPH, Michael A. Solomon, MD, Jeffrey Soble, MD, Timothy D. Henry, MD, Ian C. Gilchrist, MD, Jason N. Katz, MD, MHS, Mauricio G. Cohen, MD and L. Kristin Newby, MD Sean van DiepenSean van Diepen From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , Christopher B. FordyceChristopher B. Fordyce From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , Zachary K. WegermannZachary K. Wegermann From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , Christopher B. GrangerChristopher B. Granger From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , Amanda StebbinsAmanda Stebbins From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , David A. MorrowDavid A. Morrow From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , Michael A. SolomonMichael A. Solomon From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , Jeffrey SobleJeffrey Soble From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , Timothy D. HenryTimothy D. Henry From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , Ian C. GilchristIan C. Gilchrist From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , Jason N. KatzJason N. Katz From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). , Mauricio G. CohenMauricio G. Cohen From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). and L. Kristin NewbyL. Kristin Newby From the Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Canada (S.v.D.); Division of Cardiology, University of British Columbia, Vancouver, Canada (C.B.F.); Duke Clinical Research Institute, Durham, NC (C.B.G., A.S., L.K.N.); Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.); National, Heart, Lung, and Blood Institute and Clinical Center, National Institutes of Health, Bethesda, MD (M.A.S.); Rush University Medical Center, Chicago, IL (J.S.); Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Milton S. Hershey Medical Center, Penn State University, Hershey, PA (I.C.G.); Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill (J.N.K.); and University of Miami Miller School of Medicine, FL (M.G.C.). Originally published9 Aug 2017https://doi.org/10.1161/CIRCOUTCOMES.117.003864Circulation: Cardiovascular Quality and Outcomes. 2017;10IntroductionContemporary cardiac intensive care units (CICU) have evolved into intensive care units for patients with a primary cardiovascular diagnosis.1,2 In response to this changing clinical environment, the American Heart Association (AHA) published a scientific statement advocating for organizational, staffing, and educational evolution in CICUs.3 The AHA statement also provided a roadmap for the future of acute cardiovascular care delivery, which included (1) CICU care delivery in advanced units with unit-based physician staffing (historically referred to as closed units), (2) dedicated cardiac intensivist training, and (3) a descriptive 3-tiered CICU categorization.3 Herein, we describe the current organizational structures, professional staffing, and medical and technological resources available in CICUs in the United States.Methods and ResultsA 16-question cross-sectional web-based survey (Methods in the Data Supplement; Qualtrics platform; Provo, UT) was first emailed to 542 Mission: Lifeline hospital coordinators with a request for the survey to be completed with help from the hospital's CICU medical director or unit manager between October 2015 and April 2016. The survey was subsequently emailed to 1389 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines CICU directors between May and November 2016. To preclude duplicate responses from hospitals present on both contact lists, all responding Mission: Lifeline hospitals were removed from the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines contact list before circulation. The study was approved by the Duke Institutional Review Board. A description of study programs, registries, and statistical methods is provided in the Methods in the Data Supplement.A total of 612 sites (31.7% response rate) completed the survey, including 138 Mission: Lifeline and 474 Acute Coronary Treatment and Intervention Outcomes Network-Get with the Guidelines sites. CICU organization, staffing, and resource characteristics stratified by hospital type are presented in Table I in the Data Supplement. The distribution of academic, tertiary nonacademic, and community hospitals was 18.8%, 18.8%, and 62.4%, respectively (Figure A). CICUs most frequently (74.2%) had an open staffing model (Figure B), and only 8.2% of all centers had dedicated CICUs. There was joint physician leadership by a cardiologist and an intensivist in 34.8% of units, followed by general intensivists (25.9%) and cardiologists (19.3%). Dual-boarded cardiologist–intensivists were physician leaders in 8.5% of CICUs and practicing in 14.7% of units. A dedicated cardiac critical care training program was available in 33 (6.5%) centers. There were no differences between Mission: Lifeline and Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines respondents (Table II in the Data Supplement).Download figureDownload PowerPointFigure. Distribution of cardiac intensive care unit (CICU) survey responses by (A) hospital type and (B) organizational structure, leadership, and admission practices. CICU indicates cardiac intensive care unit; MICU, medical intensive care unit; NSTEMI, non–ST-segment–elevation myocardial infarction; and SICU, surgical intensive care unit.Differences by Hospital Type and CICU PopulationAcademic medical centers more frequently had a closed unit staffing model (37.4%), dedicated CICUs (23.6%; Table I in the Data Supplement), medical leadership by a cardiologist (32.3%) or dual-boarded cardiologist–intensivist (14.1%), an attending cardiologist–intensivist (25.3%), and plans to hire a cardiologist–intensivist (18.3%) compared with tertiary nonacademic and community hospitals. Trainee education (95.8%) and critical care cardiology subspecialty training programs (24.2%) were also more prevalent in academic centers.Differences between dedicated CICUs and mixed population intensive care units are provided in Figure I in the Data Supplement and Table IV in the Data Supplement. Compared with mixed units, dedicated CICUs more frequently were at academic centers; had closed staffing models, cardiology medical leadership, and plans to hire a cardiologist–intensivist; and had established critical care cardiology subspecialty training programs.CICU CategorizationOnly 11.3% of respondents were aware of the AHA position paper on transformation of CICU medical staffing and training models; among whom, 52.7% felt their unit currently met level 1 standards. The prevalence of recommended level 1 CICU therapeutic technologies, staffing, and education initiatives is presented in Table III in the Data Supplement. Overall, only 10.8% of units met level 1 criteria, including 26.1% of academic, 18.3% of tertiary nonacademic, and 3.9% of community sites. In a sensitivity analysis that included cardiologists with ≥10 years of intensive care unit focus as part of the medical leadership, the percentage of overall and academic units that met level 1 criteria rose to 13.2% and 34.8%, respectively.CommentIn medical and surgical intensive care, a meta-analysis of nonrandomized trials reported that high intensity staffing, defined as either mandatory intensivist consultation or closed units with all care primarily directed by an intensivist, was associated with reduced intensive care unit mortality.4 It is important to recognize the limitations of the studies within this meta-analysis, which included small sample sizes, noncontemporary cohorts, and nonrandomized design. However, based on the consistency of published evidence, the AHA and other national CICU practice statements recommend unit-based staffing models of CICU care delivery, wherein a single dedicated physician maintains primary responsibility for all patients in the unit, as the preferred approach for advanced CICUs.3,5,6 A recent single-center Korean study reported that a transition from an open to a closed model was associated with a reduction in mortality; however, the organizational change also included a staffing shift from general cardiologists to cardiologist-intensivists.7 In this survey, we observed that 74% of hospitals had open staffing models. This proportion is substantially lower than the 55% closed CICU unit structure reported by O'Malley et al8 in a survey of 123 CICUs. We think this difference is likely largely because of differences in hospital mix; 78% of responders were from an academic center in the O'Malley et al's study.8 In this study, the relatively low prevalence of best-practice unit-based physician staffing in CICUs suggests a potential opportunity to improve care delivery and patient outcomes. However, as recognized in the AHA scientific statement, such efforts to improve care at hospital and systems levels must take into account the diversity of needs and resources across varied settings and should recognize that the organization and staffing of the CICU likely should be individualized to the care system.3The European Society of Cardiology was the first organization to advocate advanced training in general intensive care among CICU practitioners followed by the AHA's scientific statement on the evolution of critical care cardiology, and the American College of Cardiology's Core Training Statement-4, which outlined critical care cardiology training levels, but the proportion of hospitals with dual-trained practitioners has remained unclear.3,5,9 A 2012 American and a 2014 Canadian survey reported that 4% and 6.8% of centers, respectively, had an attending cardiologist–intensivist.3,6 Although the number of centers (14.7%) in our report exceeds these historical reports, the overall results may belie the impact the above-mentioned scientific and training statements have had on academic medical centers where 25% of CICUs had a dual-trained attending and 18% were planning to hire or recruit a dual-boarded physician. In addition, nearly one quarter of academic centers self-reported a critical care cardiology training program, and an additional 9.5% were contemplating or in the process of establishing a program. Taken together, our results suggest a potential early national shift in CICU staffing and hiring practices along with an increase in dedicated critical care training pathways in development. Follow-up studies are necessary to accurately evaluate temporal trends, determine the optimal balance between training capacity and workforce needs, and to evaluate whether training cardiology graduates to manage the growing complexity of noncardiovascular disease in contemporary CICUs can improve patient outcomes. The Discussion in the Data Supplement provides a commentary on the percentage of centers that met level 1 criteria and study limitations.ConclusionsIn a cross-sectional survey of CICUs in the United States, we observed that <10% of units had dedicated CICU populations, and the majority of units had an open staffing model. Only 10.8% of centers currently have the on-site resources, leadership, and staffing that meet level 1 CICU criteria. These results highlight that CICU administrators should assess the patient care needs within their communities and regions with the goal of potentially redesigning and improving care delivery. In academic centers, cardiologist–intensivists attending in the CICU and critical care training programs were high compared with historical studies and may signal a transition in national CICU staffing and training in academic centers.AcknowledgmentsWe gratefully acknowledge the survey support provided by Allison Groom from the American Heart Association (AHA) and Sarah Sears from the American College of Cardiology. We also acknowledge the organizational contributions of the AHA's science and medicine advisor, Anne Leonard. We thank L. Soulard for copy-editing this manuscript. All persons named in this section have provided the corresponding author with permission to be named in the manuscript.Sources of FundingThis survey was funded by the American Heart Association. This research was supported, in part, by the Intramural Research Program of the National Institutes of Health, Critical Care Medicine Department.DisclosuresDr Fordyce served as advisory board for Bayer Pharmaceuticals. The other authors report no conflicts.FootnotesThe Data Supplement is available at http://circoutcomes.ahajournals.org/lookup/suppl/doi:10.1161/CIRCOUTCOMES.117.003864/-/DC1.Correspondence to Sean van Diepen, MD, MSc, 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440-11 St, Edmonton, Alberta T6G 2B7, Canada. E-mail [email protected]References1. Katz JN, Minder M, Olenchock B, Price S, Goldfarb M, Washam JB, Barnett CF, Newby LK, van Diepen S. The genesis, maturation, and future of critical care cardiology.J Am Coll Cardiol. 2016; 68:67–79. doi: 10.1016/j.jacc.2016.04.036.CrossrefMedlineGoogle Scholar2. van Diepen S, Cook DJ, Jacka M, Granger CB. Critical care cardiology research: a call to action.Circ Cardiovasc Qual Outcomes. 2013; 6:237–242. doi: 10.1161/CIRCOUTCOMES.111.969501.LinkGoogle Scholar3. 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