Looking After Their Own: Surgeons May Provide Better Care Than Intensivists in ICU

Reed Miller

January 29, 2010

January 29, 2010 (Fort Lauderdale, Florida) Thoracic surgeons can provide better care to critical cardiac patients in the ICU than intensivists not board-certified in thoracic surgery, a new study suggests [1]. Researchers say there are multiple possible explanations for the differences between specialists' outcomes beyond their different medical skills.

Here at the Society for Thoracic Surgeons (STS) 2010 Annual Meeting on January 26, Dr Glenn Whitman (Jefferson Medical College, Philadelphia) presented data from his institution's investigation conducted to determine if the quality of ICU care provided by thoracic surgeons was different than that given by intensivists not board-certified in thoracic surgery. Whitman cited research by the Institute for Healthcare Improvement showing that if all ICU patients in the US were cared for by trained intensivists, more than 200 000 lives per year would be saved.

Given the potential of high-quality ICU care to save lives, this study was intended to determine whether "all intensivists are created equal," Whitman explained. "By virtue of their operative and nonoperative training, specifically concentrating on cardiac surgical diseases, we speculate that thoracic surgeons may be uniquely qualified to provide critical care to postoperative cardiac-surgery patients."

The study found that, in populations with similar postoperative risks, thoracic surgeons provided postoperative critical care that shortened patients' hospital stays and decreased drug costs, compared with the care provided by nonsurgeon intensivists, without sacrificing quality.

The study retrospectively compared outcomes of similar patients treated in the ICU during two different periods. The populations were matched for STS operative risk scores. In the first period, which lasted about nine months, cardiac intensive care for 168 patients was overseen by nonthoracic intensivists without specific credentials in cardiac surgery. These intensivists were trained in either pulmonary critical care or trauma critical care. During the second period, which lasted about 16 months, care for 272 patients was managed by board-certified thoracic surgeons who were totally committed to the ICU for that period and who had no other surgical or consulting responsibilities.

The variables measured included mortality, central-line infections, ventilator-acquired pneumonias per 1000 device-days, percentage of patients with red blood cell exposure (PRBC), percent of patients with low blood sugar one and two days after cardiac surgery, postoperative and total length of hospital stay, and ICU pharmacy costs per patient.

Comparison of Outcomes for ICU Care by Intensivists and Surgeons

Measurement Intensivist care (168 patients) Surgeon care 272 patients) p
Mortality rate 3.1% 2.5% 0.15
No. of central-line infection 1.3 1.6 0.81
No. of ventilator-acquired pneumonias per 1000 device-days 7.6 4.2 0.19
PRBC exposure 46% 57% 0.28
Blood sugar compliance 83% 88% 0.19
Average postoperative length of stay (days) 9.8 8.3 0.04
Average time from admission to discharge (days) 13.4 11.2 0.01
Average ICU drug costs $4300 $1800 0.001

The reduction in patients' time in the hospital created an additional "600 opportunity days" for the hospital, which could potentially allow the hospital to admit an additional 100 patients and increase its revenues by $750 000. The direct cost savings from decreased ICU pharmacy expenditures was $680 000.

What Caused the Improvements?

While the hospital was shifting the care of cardiac critical-care patients from nonsurgeon intensivists to intensivists trained as surgeons, it implemented a new ICU quality-improvement initiative, which included the creation of multidisciplinary committees to provide input into ICU patient-care decisions. The initiative also created a list of quality metrics that were tracked and reported back to the caregivers every month. Also, every bedside nurse was given a checklist of steps to take every morning to improve on the quality measures.

At the STS meeting, Dr Jonathan Haft (University of Michigan, Ann Arbor) suggested that the improvements in efficiency seen during the period when surgeons were managing the patients could have been the result of the quality-improvement initiative and not the difference in the training of the physicians.

Whitman responded that it is impossible to know how many of the improvements were due to the change in physicians and how many were due to the quality-improvement initiative, but he believes that the difference in the intensivists' training did make a difference, because the surgeon-intensivists were better able to work closely with the surgeons who operated on the patients than the nonsurgeon intensivists.

"It's tempting to speculate that, by virtue of specific operative and nonoperative training, cardiothoracic surgeons may be uniquely qualified to provide postoperative cardiac critical care. The improvements may have been facilitated by a 'sense of team' that enabled implementation of an array of quality and performance improvements," Whitman suggested. "The improved efficiency of care may not have been solely due to the expertise of the caring physicians, but may have also been facilitated by the comfort level of the [surgeon-intensivist] and the [operating surgeon.]

He pointed out that surgeons managing the postoperative care usually had an easier time than their nonsurgeon colleagues in getting the surgeon who operated on the patient to go along with suggested changes in medication. "I don't think the kind of changes that we made, in terms of the way we cared for the patients, would have gone over well with the surgeons if those who were asking for the changes were not also thoracic surgeons," he said. "It's a very sociology-related issue. I don't know how to address that scientifically, but having worked in a few ICUs, I know it's certainly palpable."

Citing test-score data that showed that surgical residents often score below average on subjects specific to intensive care, Whitman agreed that "if we would like to have cardiac surgeons take care of their own patients in the intensive care unit, we are going to have to do a better job training our residents in critical care.

"Nevertheless, I think the commonality associated with having thoracic surgeons care for their own patients and working with the surgeons who operate on them is an extremely important aspect of cardiac critical care. We should take it into consideration and, in many respects, not abrogate the responsibility of the care of our patients to nonthoracic intensivists," he concluded.