Critical Care Leadership in the Greater New York Area: A New Approach to Regionalization

Background
As the United States’ population ages and health-care technology prolongs life for increasingly sicker patients, the number of people treated in ICUs is growing. While the overall number of hospital beds is on the decline, critical care medicine beds are steadily increasing in number and represent about 15% of hospital beds in the country, as well as $82 billion annually of total hospital costs (Halpern and Pastores. Crit Care Med. 2010;38[1]:65).

Growing costs and complexity of critical care in an environment of diminishing health-care resources magnify the need to streamline care delivery and education related to critical care services. Regionalization—in which health-care resources are distributed geographically in a tiered system with referral centers—has been offered as a potential strategy to streamline and improve critical care (Thompson et al. Crit Care Med. 1994;22[8]:1306; Singh and MacDonald. Crit Care. 2009;13[4]:219). This approach requires planning, geographic organization of beds, and regulatory oversight so that patients are treated in the most appropriate setting.

In the New York metropolitan region, critical care leaders are testing an alternative approach to regionalization: clinical leaders in the region work collaboratively to drive standardization, share training resources, and measure outcomes. With operational support and facilitation from the Greater New York Hospital Association (GNYHA) and the United Hospital Fund (UHF), the Critical Care Leadership Network (CCLN) has convened critical care professionals to establish new evidence-based health-care processes for ICU care to improve outcomes, lower costs, increase care coordination, and enhance communication within all hospital areas and departments.

In 2006, the GNYHA partnered with UHF to establish the CCLN to “regionalize” the critical care services using a collaborative structure that coordinates efforts across participating hospitals. The CCLN effort differs from traditional “regionalization of health-care services,” where critical care medicine services are grouped together, redistributed, and sometimes eliminated. Instead, the GNYHA/UHF effort is driven by critical care clinicians practicing in the region who focus on continuous improvement, delineation of appropriate care delivery processes and methods to standardize and institute them, and innovative educational programming.

The CCLN comprises executive leadership and interdisciplinary hospital staff from GNYHA’s member hospitals spanning New York, New Jersey, Connecticut, Rhode Island, and Pennsylvania. Participants are local and national leaders in the fields of critical care medicine, emergency medicine, and trauma, surgery, and nursing.

Patient Care Initiatives
The CCLN pursues its mission through the development and implementation of strategic programs and initiatives guided by its steering committee, composed of 31 physicians and nurses representing 20 GNYHA-member hospitals. This group sets overall regional priorities and designs and plans targeted activities in educational and patient care interventions using regional expertise and measuring clinical outcomes. The following efforts are completed or underway:

•24-Hour ICU Survey. In 2006, and again in 2007, the CCLN developed and administered a standard ICU survey tool to profile the region’s critical care units over a single 24-h period. The survey was completed by 143 ICUs in 69 hospitals and captured de-identified data on 1,889 patients each year it was conducted. Data from the survey provided the CCLN and hospitals with insight into the areas of the ICU and hospital that need improvement, including information about resources and planning for surge capacity in emergencies, advance directives, patient throughput, and training and education needs.

•Project Hypothermia. The CCLN, along with medical staff from the Fire Department of New York City (FDNY), worked with directors of ICUs and EDs across New York City to develop a comprehensive, city-wide protocol for providing therapeutic hypothermia to eligible patients following cardiac arrest. The FDNY-launched NYC Project Hypothermia is entering a second phase in which Emergency Medical Services staff will induce hypothermia in the field. Participating hospitals submit data to FDNY to track the project’s outcomes.

•STOP Sepsis Collaborative. In October 2010, the CCLN launched the Strengthening Treatment and Outcomes for Patients (STOP) Sepsis Collaborative to reduce mortality associated with severe sepsis and septic shock at 55 participating hospitals. A CCLN steering committee developed standardized processes for early identification and treatment of patients with severe sepsis and septic shock. The STOP-Sepsis Collaborative’s 55 participating hospitals have approximately 22,000 acute care beds and more than 1 million annual discharges, making this initiative a significant opportunity to save lives, improve hospital processes and patient flow, and reduce costs associated with sepsis.

CCLN Training/Educational Programs
The CCLN offers extensive education programs to critical care clinicians that promote medical knowledge and procedural skills, while facilitating collaboration among critical care fellowship program directors in developing standardized curricula. All programs offered to date have been free for staff from GNYHA’s nearly 150 member-hospitals. These programs included the following:

•Critical Care Ultrasound Training. The CCLN hosts an annual, intensive 3-day training program to teach first-year pulmonary and critical care fellows the use of ultrasonography in the care of critically ill patients. With hands-on training on volunteer subjects, participants develop skills in ultrasound imaging for vascular access; diagnosing lung, pleural, and abdominal disorders; and using basic echocardiography for critical care applications. Each volunteer faculty member works with only two fellows, and training is offered at no cost to participants. Faculty are on staff at GNYHA member hospitals, active in the CCLN, and many serve in national courses sponsored by the American College of Chest Physicians. A goal of the program is to create a cadre of fellows who go on to practice their skills throughout their careers and to pass on their expertise to their peers and, later, to their own trainees. Nearly 170 first-year fellows have participated to date. A comprehensive evaluation is carried out immediately after the program, along with ongoing follow-up to assess how the participants improved their skills and applied them to clinical practice.

•Postoperative Care of the Cardiac Surgical Patient. For the past 3 years, the CCLN hosted an annual daylong educational program for ICU staff, fellows, and referring physicians on caring for cardiac surgery patients in the ICU.

•Emergency Preparedness. The CCLN is involved in regional planning for catastrophic events, such as pandemic influenza or mass casualty. The CCLN also works with local agencies to determine the surge capabilities of hospital ICUs during various types of emergencies. Most recently, the CCLN participated in a program to train critical care clinicians to respond to major explosive events. As part of this initiative, the CCLN will also identify when and how to deliver critical care services outside the ICU.

•End-of-Life and Palliative Care in the ICU. The CCLN held a daylong educational program focused on addressing palliative and end-of-life care in the ICU. Regional experts shared their palliative care models and conducted a hands-on training workshop using real-life scenarios to improve communication skills and approach difficult decisions with families of critically ill patients.

•Annual Symposium on Critical Care Controversies. The CCLN hosts a daylong pro-con program on controversial issues in critical care, featuring experts from the New York region. Speakers examine the evidence behind practice recommendations, clinical guidelines, and ICU operations in a lively, debate-style format to encourage thoughtful discussion among the region’s critical care providers.

Looking to the Future
The CCLN has firmly established itself as a resource for critical care professionals to improve patient care in the greater New York area. Participants in the CCLN’s activities report enhanced improvement activities in their own institutions, greater collaboration within their hospitals and across departments, and increased collaboration and networking across the region on research, education, quality improvement, and emergency preparedness efforts. As such, the CCLN will continue to develop and pursue opportunities to improve quality and efficiency in the ICU. Future efforts will address the use of health information technology in critical care, optimal ICU staffing, and organizational configurations.

Dr. Mark J. Rosen, FCCP
Division of Pulmonary, Critical Care and
Sleep Medicine, North Shore-Long Island
Jewish Health System; and
Professor of Medicine,
Hofstra University North Shore-Long
Island Jewish School of Medicine
New Hyde Park, NY

Dr. David H. Chong
Hospital Director, Critical Care Services,
New York-Presbyterian
Hospital/Columbia; and
Assistant Professor of Medicine,
Columbia University College of Physicians and Surgeons
New York, NY

Dr. Vladimir Kvetan
Director, Jay B. Langner Critical Care
System, and Director, Division of Critical
Care Medicine, Department of Medicine
Montefiore Medical Center;
Professor of Anesthesiology and Clinical
Medicine; and
Associate Professor of Surgery
Albert Einstein College of Medicine of Yeshiva University
New York, NY