The cherry blossoms were a riot of pink the week of March 29, 2004, the grass was green on the Mall, and that could mean only one thing: Congress was back in session. The Society of Critical Care Medicine (SCCM) took advantage of spring to head to Capitol Hill on behalf of critically ill and injured patients, just before National Critical Care Awareness Month (NCCAM) in May.

The Society, in partnership with other organizations with an interest in critical care, launched an extensive public relations campaign in May, including an electronic letter-writing initiative directed to Congress. To help instigate these efforts, SCCM planted a few seeds in March.

What Your Government Doesn’t Know

Society of Critical Care Medicine President, Margaret M. Parker, MD, FCCM, and Chair of the SCCM Advocacy Committee, Todd Dorman, MD, FCCM, joined Laura Loeb and Beth Roberts, SCCM’s Washington, D.C. counsel, and Eric Chandler, PhD, SCCM’s manager of professional affairs, in an ongoing effort to educate leaders on the issues facing critical care. The mission was clear: remind the U.S. government about the importance of critical care and the need to ensure access to quality care for its constituents. However, because members of Congress and other Washington decision makers are not always familiar with critical care, the mission would not be easy. To point out what needs to be done today and tomorrow, the SCCM advocacy team first had to educate the leaders on what has already taken place.

Capitol Hill visits in 2003 taught SCCM that the United States Congress truly does mirror the U.S. population in at least one respect: most cannot differentiate between the Emergency Department and the ICU and do not know about the current workforce crisis facing the critical care community. As the U.S. population ages and the supply of team professionals continues to decline, access to quality critical care continues to be under threat. The Society built upon the lessons of 2003 and came prepared with a focused message.

Drs. Parker and Dorman outlined the demand for critical care services and underlined the vital importance of the integrated team of dedicated critical care professionals. “The crisis we face stems from a collision of supply and demand,” explained Dr. Parker. “Two national trends are conspiring to deny access to quality care. These trends affect our parents, our critically ill children, and anyone else requiring our services – unless we act soon. First, it’s common knowledge that the U.S. population is aging, and that translates to increased demand since the elderly are disproportionate users of critical care services. Second, there are not enough dedicated teams to staff ICUs today, and the availability of the various team members is only getting worse!”

Society President Dr. Margaret Parker (Middle) met with Drs. Jim Kiley (Left) and Barbara Alving (Right) from the National Institutes of Health (NIH) met to discuss critical care research efforts.

SCCM’s Message

The multidisciplinary team model is present in fewer than 25% of ICUs nationwide, according to published estimates,(1) and the shortage of nurses, pharmacists, respiratory therapists, and even physicians is especially acute within critical care. During the two-day trip, the Society’s advocacy team met with 15 government officials and staff and emphasized this point to each of them.

With the groundwork laid regarding the role of critical care specialists, SCCM leaders outlined ways in which the U.S. government can help. Two related areas were emphasized, with a relevant message tailored to each decision maker:

• Confirming the team as the national standard of care
• Increasing the available workforce

Establishing a National Standard

The Society remains committed to promoting an integrated team of dedicated critical care experts to provide the standard of care. In addition, SCCM continues to demonstrate the effectiveness of the multidisciplinary team approach in literature and translate critical care research into bedside practice. But the critical care community continues to encounter resistance in recognizing this standard as an evidence-based approach that provides the highest level of care. The federal government’s prominent decision makers can help promote national recognition of that standard.

One key meeting during SCCM’s trip to Washington, D.C., involved the National Institutes of Health (NIH). The Society’s advocacy team spoke with two key officials at NIH, the acting director for NIH’s National Heart, Lung, and Blood Institute (NHLBI), Barbara Alving, MD, and NHLBI’s director of lung diseases, James Kiley, PhD. Dr. Parker made the point clear: “Research in critical care within NIH is vitally important, but it is not coordinated. In this respect it reflects the situation in 75% of adult ICUs in the United States today – there are talented individuals working very hard, but they are missing a key ingredient important to the standard of critical care. They are missing coordination of care, coordination that is best delivered by a dedicated team.”

Options for coordinating communications among the many sources of critical care research at NIH were discussed during the meeting. Dr. Kiley was enthusiastic about the possibility of establishing a “virtual center” at NIH, which would focus less on bureaucratic reorganization (likely to create another “silo” within the NIH structure), and more on linking those important efforts already underway. One possibility would involve a stakeholder conference held at NIH in Washington, D.C., identifying players and the gaps that need to be filled in critical care
research.

Separate conversations with staff from Sen. Paul Sarbanes’ office, D-Md., and Rep. Michael Bilirakis, R-Fla., of the Committee on Energy and Commerce reinforced this message. Both were interested in ways NIH could be used to expand the standard. They also noted that once established, critical care grants could help attract students into the profession, and help address the shrinking workforce.

Drs. Parker and Dorman met with Rep. Tim Bishop, D-N.Y., and health policy advisors to the Senate Finance Committee (Chaired by Sen. Chuck Grassley, R-Iowa) and a House Ways & Means Committee Minority Chair staff representative. The common denominator was the necessity to create a team dedicated to patients receiving critical care, and how efforts such as Leapfrog standards and the Society’s multiprofessional membership are key to maintaining that team presence. The Society’s mission impressed even those few Congressional staff familiar with the work of intensivists and the multiprofessional team. Dr. Dorman pointed out, “SCCM is the only society representing not physicians, not nurses, but the entire team. We represent the critically ill or injured patient.”

In this context, SCCM raised the possibility of demonstration projects to confirm the value of the multiprofessional team. Congress is not expecting to fund new projects in 2004, but MedPAC could be approached as a way to add the project to the upcoming legislative agenda. In the meantime, it is possible that some federal agencies, such as the Centers for Medicare and Medicaid Services (CMS), Administrative Resource Center (ARC), Health Resources and Services Administration (HRSA), might show interest in such initiatives, and SCCM is considering follow-up efforts with each organization.

Team Reinforcements

With some legislators and Congressional committees, the most relevant need involves quality of care. Other committees and members of Congress direct their efforts toward workforce and education issues. For these members, the workforce crisis resonated more than research indicating the team’s accomplishments. Even this message, so closely related to ongoing efforts, was not always immediately apparent. While looking over SCCM’s talking points, more than one person said, “I’m surprised not to see anything here about tort reform.”

The Society’s advocacy team emphasized the importance of its stance. For example, in speaking with staff members of the Senate Health, Education, Labor and Pensions (HELP) Committee, Dr. Dorman remarked,“We’re not here today speaking about Malpractice Reform, or even Patient Safety or the new Trauma Bill – though we support each of these efforts and expressed our support along with our sister organizations within organized medicine. Today, we’re here to ask for your help in working out solutions to the workforce crisis within the critical care team.”

Because of legislation already passed in 2003, including the Medicare and Modernization Act (MMA), SCCM has limited opportunities to address the critical care workforce shortage in 2004. Consequently, Drs. Parker and Dorman placed the workforce issues on the legislative agenda for 2005 and beyond. Rhonda Richards, working with Sen. Barbara Mikulski, D-Md., on the Senate Subcommittee on Aging, noted the Senator was closely involved in past legislation addressing the nursing and pharmacist shortages. The advocacy team discussed the possibility of SCCM members addressing legislators in 2005 hearings and coordinating with Finance Committee efforts in the same arena.

Another possibility piquing Congressional interest involves the use of telemedicine, specifically its inpatient role in the ICU. While government demonstration projects using telemedicine have been funded in the past, they were exclusively outpatient. The promise of the “electronic ICU” was discussed as a way to help fill the gap while the workforce shortage is addressed over the long term. The legislative correspondent for Sen. Bill Frist, R-Tenn., Jennifer Romans, also expressed an interest in this aspect of the workforce problem and asked for additional information to pass along to the Majority Leader.

Following Up

While Drs. Parker and Dorman engaged in productive conversations on the Hill this spring, the efforts of two SCCM members cannot resolve all of the problems facing critical care. The opportunities for following up on loan forgiveness, expanded graduate medical education (GME) payments for fellowship programs, and demonstration projects will be evaluated by the Advocacy Committee, the Research Committee, and others within the Society. In addition, every SCCM member has a role to play.

Like the cherry blossoms, there is a perennial truth regarding trips to Capitol Hill: the efforts of the critical care community must be one persistent message. Such efforts require every team member’s contribution so that the critical care community can speak with one voice.