Carefully ramping up implementation of the multidisciplinary team model with an intensivist (the model) along with improving outcomes helped the team of dedicated experts at Newark, Delaware’s Christiana Hospital build a solid reputation and take charge of the surgical intensive care unit (SICU).

“Over the course of a decade, we were able to transition from an open surgical ICU to the intensivist-led multidisciplinary model promoted by the Society of Critical Care Medicine,” says Gerard J. Fulda, MD, FCCM, a leader of the Christiana transformation and an SCCM member. “The intensivist-led multidisciplinary team is now managing approximately 80% to 90% of the patients in the surgical unit.”

Christiana Hospital is a 700-bed community hospital with 22 surgical critical care beds functioning under the model. Patients in the cardiac surgical unit and medical cardiac unit continue to be cared for by the admitting physician and consultants. The neonatal unit is intensivist-led, and the medical intensive care unit (MICU) has followed the lead of the SICU.

Before the surgical ICU began its transition, the unit was an open ICU with little involvement from intensivists and no care oversight. If patients had difficulties on the ICU, the appropriate consultant was called.

“Our outcomes are quite good,” says Dr. Fulda, who is director of surgical critical care at Christiana Care Health System, a health network with several hospitals including Christiana. “We use several standard tracking systems to study our outcomes. Both APACHE data and Project IMPACT data suggest that we have better than expected outcomes for our patient population.”

Research from the ’80s and ’90s, which indicated that an intensivist-led model improved patient outcomes, decreased length of stay, and promoted better overall functioning, spurred the change. “With the help and encouragement of department chairman – one of SCCM’s early pioneers and members – Michael Rhodes, MD, FCCM, we began slowly implementing the intensivist model,” Dr. Fulda explains.

In 1993, Dr. Fulda and another intensivist began making unit rounds on a daily basis. The intensivists saw all patients regardless of whether or not they had been consulted on the patient. Today Christiana has five full-time intensivists staffing the surgical critical care unit. Dr. Fulda hopes to add a sixth.

According to Dr. Fulda, the most frustrating position for a bedside nurse is having a sick patient, not being able to contact the physician, and not having a plan to reference. “Having an intensivist available at all times and a multidisciplinary team that performs rounds in the unit daily and sets patient plans will provide a significant amount of job satisfaction,” he says.

“We were lucky to have a willing nursing staff that wanted to accompany us on patient rounds,” Dr. Fulda comments. “Once we started the daily rounds system, we expanded it to include our nutritionists, respiratory therapists, social workers and pharmacy personnel. Now we have an intensivist in the surgical ICU generally 90% of the time, including nights and weekends.”

During the transition to the model, the SICU team discussed every patient’s care and communicated suggestions to the attending physicians with the help of an involved and caring nursing staff. Attending physicians usually chose to act on these recommendations. Because of the intensivists’ good results, attending physicians began consulting the critical care team at the beginning of patient care instead of relying on a multiple phone call system. According to Dr. Fulda, the success of the model was what changed people’s behavior and resulted in consultations coming freely without being mandated.

As a community-based teaching hospital, Christiana has not mandated the transfer of patients to intensivist service. The SICU is still considered an open ICU environment. “Despite the fact that consultation and management by an intensivist is elective, physicians have really welcomed and embraced this service,” Dr. Fulda says.

The intensivists manage 90% of the SICU admissions. Of the exceptions, half are on the SICU for overnight observation and the half have a physician who has managed critically ill patients for a number of years and is comfortable with delivering critical care.“It is possible that the ‘observation’ patients do not require critical care and would do just as well outside the ICU,” says Dr. Fulda. “We are trying to shrink that population through education. With time, I think we will also have an impact on the attending physicians who are still caring for their critically ill patients.” Dr. Fulda says the next step is to provide complete SICU intensivist coverage — 24 hours, seven days per week. He also hopes to decrease the number of admissions that are for low-risk patients admitted for monitoring and to capture the last 5% of patients who are not under active intensivist management.

Gaining Acceptance in a Community Hospital

“I agree with the Advisory Board’s recent study that suggested mandating intensive care consultations in private practice hospitals would more likely result in staff physicians resistance rather than acceptance,” Dr. Fulda states. “Mandating critical care in a community practice based environment is more likely to result in rebellion and could cause attending physicians to threaten to take their patients elsewhere. On the other hand, I think if intensivists provide a good service, it will sell itself.”

In a community-based environment, the wishes and desires of the patient’s attending physician need to be respected, says Dr. Fulda. Having knowledge of the way each attending physician practices helped the Christiana intensivists modify treatment for patients.

“It’s been a gradual evolution at Christiana,” says Dr. Fulda. “The biggest change occurred as a result of the way physicians have historically decided to whom they are going to send their patients. We did not upset people with sudden change, because we slowly built our reputation.”

After the intensivists began consulting, attending physicians started to recognize value in the model. The number of consultants dropped significantly. Intensivists now manage almost all patients admitted to the ICU.

Dr. Fulda believes other Christiana ICUs may follow the SICU’s lead. The medical critical care service is already paralleling the SICU’s activities: “In my mind they are equally successful and are expanding their services as well. This is a model that works in an environment where things cannot be mandated as easily as perhaps you can in a university setting.”

Advice for Transitions

According to Dr. Fulda, several factors contributed to the success of the SICU’s transition to the multidisciplinary team model with an intensivist:

• Develop a multidisciplinary team that rounds on every patient whether consulted or not. The team should include physicians, nurses, respiratory care practitioners, pharmacists, nutritionists, social workers, and others.
• Relay suggestions to attending physicians
• Maintain 24 hour availability of an intensivist

Recruit team members with skills, expertise and diplomacy

“Once you build and implement the fundamental elements of the team, do not be frustrated if the patients do not come as quickly as you expect. Have patience and perseverance. It takes time for people to change their practice patterns, opinions and biases,” concludes Dr. Fulda.

Editor's note: The Society is seeking similar success stories about implementing the multidisciplinary team model by its members. Because implementing the model is often a challenging task, sharing your experience may help other intensivists overcome similar obstacles to the ones you faced. Your experience will also help SCCM highlight the fact that the multidisciplinary team model can work in any setting and that the intensivist can work effectively with other healthcare providers.

These stories will be collected and published by SCCM as a resource to its members and other healthcare practitioners. To contribute your story to this project, please contact mnielsen@sccm.org