The Structure of Medical Intensive Care Units at Training Institutions

Abstract

Background

As a result of the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour guideline implementation, the structure of intensive care unit (ICU) teams at training institutions has been affected. The impact these changes have had on the current work environment has not been well described.

Methods

The authors conducted an online survey of internal medicine program directors in 2016. The survey investigated how training institutions structure their intensive care units in reference to volume, resident housestaff and alternative coverage options, with a focus on changes made after the implementation of the 2011 ACGME duty hour restrictions.

Results

Notable differences were found in program director responses to coverage of patients in the ICUs. A total of 62 of the 132 (48%) responding program directors describe coverage of all patients solely by resident housestaff. Since 2011, 54 (41%) programs have increased the number of resident physicians rotating in the ICU per month and initiated or increased the use of nonresident coverage of patients. Use of non-resident providers is not associated with a decrease in the number of total ICU months per resident or a decrease in educational value.

Conclusions

Since the 2011 ACGME duty hour implementation, there is wide variability in the learning environment of medical intensive care units in training institutions.

Introduction

The last several decades have seen a substantial increase in the number of intensive care unit (ICU) beds without a parallel increase in critical care staffing, creating a workforce shortage.1, 2, 3, 4 Contributing factors to the shortage include a decrease in the number of physicians pursuing pulmonary and critical care training out of residency and a reduction in the resident physician duty hours, potentially leading to direct care coverage solely by the attending physician.2, 5 This places significant burdens on critical care providers including increased patient census, decreased dedicated education time, decreased quality of care and increased burnout.² Training institutions are coping in different ways including adjusting resident involvement and adding nurse practitioners (NPs) and physician assistants (PAs), or advanced practice providers (APPs).² Such adaptations alter traditional ICU teams, and team structure plays a critical role in the delivery of patient care.⁶ Currently, there is limited data on how training institutions structure their intensive care teams in reference to volume, resident housestaff and alternative coverage options. The primary goal for this study is to explore the current learning environment of medical intensive care units (MICUs) at academic medical centers, focusing on structure and staffing of MICUs in relation to resident housestaff. The secondary intent is to explore how the learning environment has changed since the 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour guidelines and whether this affected the educational value.