SummaryAs part of Montefiore Medical Center’s “intensive care unit without walls,” critical care physicians (called intensivists) determine where critically ill patients can be most appropriately treated—the intensive care unit, an intermediate care unit, a floor unit, or a palliative care program—and provide needed consultations and interventions at any of these locations. Intensivists also serve on the hospital’s rapid response team and critical care consult teams, and hold daily huddles to manage intensive care unit capacity. The goal is to ensure that all critically ill patients receive care from a trained intensivist at the bedside at any time (24 hours a day, 7 days a week), while simultaneously ensuring that only appropriate patients get admitted to intensive care units so that bed shortages do not occur and cause bottlenecks elsewhere in the hospital. The program has contributed to a reduction in overall hospital and intensive care unit mortality, improved management of intensive care unit bed capacity (with no capacity increases even as emergency department patient volume has risen significantly), and led to below-average intensive care unit length of stay for patients benefiting more from high quality end-of-life comfort care services than aggressive intensive care.Moderate: The evidence consists of pre- and post-implementation comparisons of hospital-wide and ICU mortality rates, trends in ICU bed capacity and ED patient volume, and post-implementation comparisons of ICU LOS for terminally ill patients to that of similarly-sized hospitals.
Developing OrganizationsMontefiore Medical Center
Date First Implemented1995
Vulnerable Populations > Intensive care unit patients; Terminally ill; Urban populations
Problem AddressedManaging patient flow in and out of intensive care units (ICUs) is critical to ensuring that beds remain available for critically ill patients. However, the demand for ICU beds—particularly in large urban hospitals—can be highly variable and often exceeds supply, causing patient flow bottlenecks across the hospital, including diversions of emergency department (ED) patients, cancellations of elective surgery, and delays in care for critically ill patients.
- Frequent shortages in available ICU beds: The demand for ICU care can be highly variable, with the demand for beds frequently exceeding supply.1 Factors driving the high demand for critical care include an aging population, better (life-prolonging) technologies, and—in large urban hospitals—an influx of patients suffering from trauma.2 Given the wide variability in demand and high cost of adding beds, most medical centers prefer to closely manage ICU bed availability rather than expanding ICU capacity.
- Resulting in bottlenecks in care: ICUs operating at capacity can cause bottlenecks throughout the hospital,1 which in turn can have detrimental effects on efficiency, patient safety, patient and staff satisfaction, and revenues.1 For example, operating rooms (ORs) may have to postpone elective surgeries, and EDs may have to divert patients to other hospitals. Quality of care may also suffer, as patients requiring critical care remain on general units until ICU beds become available.2
Description of the Innovative ActivityMontefiore Medical Center’s “ICU without walls” allows intensivists to determine where critically ill patients can be most appropriately treated, and then provide needed interventions at any of these locations. Intensivists also serve on the hospital’s critical care consult and rapid response teams and lead daily huddles to manage ICU capacity. The goal is to ensure that all critically ill patients receive care from a trained intensivist, with only appropriate patients being admitted to the ICU so as to avoid bed shortages and associated bottlenecks elsewhere in the hospital. Key program elements include the following:
- Cross-trained intensivists who determine placement: The medical center's critical care service oversees all seven adult (noncardiology) ICUs. Critical care attending physicians, known as intensivists, determine the appropriate placement of all patients who are critically ill (e.g., the ICU, intermediate care unit, general floor unit, palliative care unit). Prior to establishing the critical care service line supported by the highest level of administration, any physician could admit his/her patients to an ICU and continue to monitor them. Under the current “closed” system, only intensivists may admit a patient to an ICU. While the adult ICUs consists of separate units (e.g., medical, surgical, neurosurgical, cardiothoracic, transplant, etc.) staffed by nurses with specialty-specific expertise, intensivists are cross-trained to manage both medical and surgical cases, allowing greater flexibility in intensivist assignments and patient placement.
- Critical care consult teams to evaluate potentially critical patients: Physicians, hospitalists, and nurses anywhere in the hospital can request a critical care consult at any time. A consult team consisting of an intensivist, critical care fellow, and respiratory therapist guarantees a 10-minute bedside response. The team evaluates potentially critical patients and decides the most appropriate care location. The team, which responds to more than 6,000 calls each year, is equipped with all necessary hardware and pharmaceutical agents, including difficult airway devices, and ultrasound and echocardiography machines.
- Intensive care activities provided in non-ICU settings: When intensivists determine that a critically ill patient does not require ICU admission, they still provide care and ongoing monitoring at the patient’s bedside. For example, intensivists can provide central venous access, fluid resuscitation and antibiotic administration for sepsis patients; initiate therapeutic hypothermia treatment after cardiac arrest; and provide ventilator support outside of the ICU.
- Intensivist participation on rapid response team: The rapid response team includes an intensivist, critical care fellow, and nurse. Any member of the hospital staff can summon this team when a patient’s condition deteriorates. The goal is to intervene early to prevent further deterioration and/or cardiac arrest, and in the context of the ICU without walls program, the rapid response team functions as a continuum of critical care.
- Daily triage sessions to manage ICU and critical care consult patients: Each morning at 7:00 a.m. every day of the year, the director of critical care runs a video teleconference with all critical care clinicians working that day. The intensivists lead a discussion of all ICU and intermediate care unit patients, including daily care goals and appropriate disposition (i.e., whether the patient should remain on the unit, be transferred, or be discharged). The huddle also includes discussion of all critical care team consults conducted over the past 24 hours (usually about 20 patients). Following the meeting, the director of critical care meets with the directors of logistics and admitting, who uses a computerized system to assign the beds of current ICU patients who will soon be discharged to other units.
- Discussions about appropriate end-of-life care: As appropriate, intensivists discuss end-of-life care and medical directives with patients and families to ensure that patients do not receive unwanted or unwarranted interventions. Intensivists arrange palliative care referrals as needed.
References/Related ArticlesBeck M. Critical (Re)thinking: How ICUs are getting a much-needed makeover. The Wall Street Journal. March 28, 2011. Available at: http://online.wsj.com/article/SB10001424052748704132204576190632996146752.html.
Contact the InnovatorVladimir Kvetan, MD
Director, Jay B. Langner Critical Care System
Montefiore Medical Center
111 East 210 Street
Moses Division, Gold Zone Main Floor
Bronx, NY 10467
Phone: (718) 920-5440
Innovator DisclosuresDr. Kvetan has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe program has contributed to a reduction in overall hospital and ICU mortality, improved management of ICU bed capacity, and generated below-average ICU length of stay (LOS) for terminally ill patients.
Moderate: The evidence consists of pre- and post-implementation comparisons of hospital-wide and ICU mortality rates, trends in ICU bed capacity and ED patient volume, and post-implementation comparisons of ICU LOS for terminally ill patients to that of similarly-sized hospitals.
- Fewer deaths: The program's ICU capacity management activities have contributed to a reduction in the hospital’s overall mortality rate (from 3.5 percent in 1997 to 1.8 percent in 2009) and mortality in both medical and surgical ICUs (from 36 percent in the early 1980s to less than 8 percent in 2004). In 2009, Montefiore’s inhospital mortality rate for ICU patients was 33 percent lower than that for similar patients nationally.2
- Better management of ICU bed capacity: Since program implementation, the medical center has not added any ICU beds, maintaining a relatively low ICU bed capacity for an institution of its size, even as its EDs experienced a 45-percent increase in patient volume (to 310,000 visits annually) between 2000 and 2011, representing the largest emergency medicine volume in New York State. During this time, ED diversion was essentially eliminated, partially by allowing all ICUs to share their capacity and prohibiting cancellations of major OR cases despite drastic increases in heart and liver transplants, neurosurgery cases, and the use of ventricular-assist devices.
- Low ICU LOS for terminally ill patients: Montefiore ICU patients in their last 6 months of life spend an average of 3.6 days in the ICU, less than half the average at other comparably sized medical centers.2 Furthermore, anecdotal reports indicate improved use of ICU resources and better early implementation of comfort and palliative care in patients with diffuse neoplastic disease in the last month of their lives.
Context of the InnovationThe largest health care organization in the Bronx, NY, Montefiore Medical Center has three hospital campuses with a total of 1,491 beds, four EDs (including three adult and one pediatric ED) that handle more than 310,000 visits annually, and 23 community clinics. The critical care service is responsible for all adult intensive care, which includes three medical ICUs, one surgical/neurosurgical ICU, and two cardiothoracic surgery ICUs, totaling 78 Level-I ICU beds. The service is also responsible for two Level-II progressive care units with a total of 21 beds, which serves the surgical and medical populations. The medical center serves as the major teaching hospital of Albert Einstein College of Medicine and has one of the country’s largest intensivist training programs. The impetus for this program came from the head of critical care and the medical center’s senior administrative leaders, who all wanted to ensure efficient patient flow so that patients would not be turned away from the ED or OR due to a shortage of available ICU beds. They felt that using intensivists to assess and manage critically ill patients could help to ensure that only appropriate patients received ICU care while simultaneously improving care for all critically ill patients, thus improving patient outcomes and patient flow throughout the hospital. The redesign of the critical care service over the past 25 years has been utilized as a major institutional tool for improvement in patient safety and quality of care.
Planning and Development ProcessSelected steps included the following:
- Obtaining approval to consolidate ICU oversight: The director of critical care obtained approval from hospital leaders to consolidate all ICUs under the critical care service, rather than having each ICU under the purview of a separate department (e.g., general medicine, surgery, neurosurgery). Critical care medicine is now an established independent interdepartmental academic division at Albert Einstein College of Medicine, and an independently-funded service at Montefiore, established and endowed by the previous chairman of the board of trustees.
- Setting ICU admission and discharge criteria: The critical care department standardized criteria for appropriate admission to and safe discharge from the ICU.
- Training intensivists and teams: Intensivists received training on how to handle the critical care needs of both medical and surgical patients. The hospital also used a simulation education module to train critical care teams. This simulation program also delivers training on ultrasound and echocardiography skills to 80 critical care medicine fellows from New York City.
- Purchasing portable diagnostic equipment: As technology improved over time, the medical center periodically purchased portable equipment, such as ultrasound and echocardiography devices, to allow the provision of services to critically ill patients outside the ICU.
- Communicating with non-ICU clinicians: The director of critical care communicated the principles of the ICU without walls to physicians and nurses at staff meetings, emphasizing the benefits of timely critical care consults and around-the-clock availability of critical care experts.
Resources Used and Skills Needed
- Staffing: While hard data are not available due to frequent staffing adjustments, total staffing with the program is likely lower than if each ICU were staffed independently. Montefiore Medical Center employs 28 full-time attending intensivists, who include cardiac surgeons, liver transplant surgeons, anesthesiologists, and specialty internists. The team also trains 17 critical care fellows and maintains 27 physician assistants, some of whom attend a new critical care residency program.
- Costs: Data on program-related costs are not available (although, as noted, the program likely requires less staff than if each ICU were staffed separately). Costs include the purchase of portable diagnostic equipment.
Funding SourcesMontefiore Medical Center
Getting Started with This Innovation
- Emphasize quality benefits when seeking clinician buy-in: Emphasize the program's potential quality benefits when describing the required organizational changes to physicians and staff. These benefits include having a trained critical care physician on site at all times to consult on patient care, something that will likely be recognized and appreciated by most if not all clinical staff. Sharing data on the program's potential impact on mortality can also be helpful in securing clinician buy-in and support.
- Highlight benefits to other departments: Position the program as an interdepartmental institutional service benefiting all. Since the integrated critical care service is responsible for all adult critical care both inside and outside of the ICUs, this approach can eliminate ED diversion, facilitate ED growth, prevent cancellation of major OR cases, and allow an appropriate level of care to be delivered rapidly at all times. Additionally, the critical care service benefits from managing a large critical care fellowship program and a team of physician assistants, all of whom are required to cross-train and rotate in all medical and surgical ICUs.
Sustaining This Innovation
- Recognize the personal sacrifice required: Ensuring 24/7 critical care staffing requires ongoing personal sacrifice on the part of intensivists and the director of critical care, who commits to being at the hospital every morning for daily huddles and regularly communicating with other department leaders regarding bed capacity and patient flow.
- Share data on program's impact: Track and regularly share data on the program's impact on mortality and other key indicators, including ICU bed availability and the frequency of bottlenecks due to ICU bed shortages (e.g., ED diversions, canceled surgeries). Sharing such information can serve to keep both clinicians and administrators enthusiastic about and supportive of the program.
Additional Considerations and LessonsMontefiore critical care has been selected to head the regional Critical Care Leadership Network under the auspices of the Greater New York Hospital Association-United Hospital Fund since 2006. Supported by an AHRQ conference grant, New York metropolitan area intensivists conduct a comprehensive annual survey of more than 140 ICUs, host a quarterly symposium on major areas of concern to regional leaders, and operate a large training program for all critical care fellows in ultrasound and echocardiography skills. The Montefiore critical care management structure is acting as a template for a successful integrated system.
Ryckman FC, Yelton PA, Anneken AM, et al. Redesigning intensive care unit flow using variability management to improve access and safety. Jt Comm J Qual Patient Saf. 2009 Nov;35(11):535-43. [PubMed]
2 Beck M. Critical (Re)thinking: How ICUs are getting a much-needed makeover. The Wall Street Journal. March 28, 2011. Available at: http://online.wsj.com/article/SB10001424052748704132204576190632996146752.html.
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Service Delivery Innovation Profile
Original publication: February 29, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: February 13, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: August 17, 2011.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.