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Correspondence |

Physician Staffing Models and Patient Safety in the ICU FREE TO VIEW

L. Marjon Dijkema, MD; Jack J. M. Ligtenberg, PhD; Jan G. Zijlstra, PhD; Armand R. J. Girbes, MD, PhD
Author and Funding Information

Affiliations: Drs. Dijkema, Ligtenberg, and Zijlstra are affiliated with the Department of Critical Care, University Medical Center Groningen, University of Groningen. Dr. Girbes is affiliated with the Free University Medical Center.

Correspondence to: Jan G. Zijlstra, PhD, University Medical Center Groningen, Intensive and Respiratory Care, PO 30.001, Groningen 9700 RB, the Netherlands; e-mail: j.g.zijlstra@int.umcg.nl


Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(5):1443. doi:10.1378/chest.09-0922
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To the Editor:

Staffing, as discussed by Gajic and Afessa1 in CHEST (April 2009), is a determining factor of outcomes in the ICU. The most ideal solutions, however, might not be feasible in the future because of anticipated staff shortages and staff exhaustion if we go on in the same way.1 As suggested in the editorial by Dunn and Murphy2 in the same issue, the ICU does not function in a vacuum. There are many outside influences. Most are uncontrollable by those working in the ICU. However, some are.

Two important influences are the societal expectations about ICU care and, related to that, the way we in the ICU use our resources. There are large cultural differences between countries. Without judging these differences, a comparison might indicate the direction to look for solutions. In the United States, > 50% of all hospital deaths occur in the ICU.3 This figure probably means that too many patients with an incurable disease are admitted to the ICU. There might be several reasons for that. Expectations by patients and families that are too high, pressure by colleagues, and uncertainty by the intensivist all can lead to ICU admissions with an unreachable target. Changing this figure for ICU deaths might have considerable impact.

In our view, patients do not necessarily need to die in the ICU while receiving mechanical ventilation.4,5 In our hospital with 50,247 acute care admissions in 2008, 2,905 of these admissions were to our high-intensity staffed ICU. In the hospital, 705 patients died in 2008, and 255 of these patients (36% of total hospital mortality) died in the ICU. Within 3 months after ICU admission, 125 patients had died, 52 patients in hospital wards and 73 patients at home. It seems that we have fewer ICU admissions and less ICU mortality as a percentage of hospital admissions and mortality; perhaps more patients are dying at home. Cure is the primary goal of ICU admission. Patients who cannot be cured will almost always suffer in this context, as the ICU is not a department that focuses on palliation. That is what makes Asimov's transition from life to death even more troublesome.2

Education of the society and of colleagues, and better education for intensivists to handle expectations that are too high might help to solve these problems. Fewer patients will suffer unnecessarily, less ICU care will be required, and intensivists will be confronted less often with hopeless cases, leading to less burnout among physicians. More and better trained intensivists might help break the spiral of staff shortages and too great a demand for ICU services.

Gajic O, Afessa B. Physician staffing models and patient safety in the ICU. Chest. 2009;135:1038-1044. [PubMed] [CrossRef]
 
Dunn W, Murphy J. Should intensive care medicine itself be on the critical list? Chest. 2009;135:892-894. [PubMed]
 
Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32:638-643. [PubMed]
 
Girbes AR. Dying at the end of your life. Intensive Care Med. 2004;30:2143-2144. [PubMed]
 
Beuks BC, Nijhof AC, Meertens JH, et al. A good death. Intensive Care Med. 2006;32:752-753. [PubMed]
 

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References

Gajic O, Afessa B. Physician staffing models and patient safety in the ICU. Chest. 2009;135:1038-1044. [PubMed] [CrossRef]
 
Dunn W, Murphy J. Should intensive care medicine itself be on the critical list? Chest. 2009;135:892-894. [PubMed]
 
Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32:638-643. [PubMed]
 
Girbes AR. Dying at the end of your life. Intensive Care Med. 2004;30:2143-2144. [PubMed]
 
Beuks BC, Nijhof AC, Meertens JH, et al. A good death. Intensive Care Med. 2006;32:752-753. [PubMed]
 
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