Team Approaches to Hospital Care

Feb 26, 2010
Studies Examine Team Approaches to Hospital Care

Multidisciplinary care teams consisting of clinicians, nurses and other health care professionals appear to be associated with a lower risk of death among patients in the intensive care unit, according to a report in the February 22 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.1 A second report finds that an increasing number of surgical patients are being managed jointly by a surgeon and another clinician, such as a hospitalist or internal medicine sub-specialist.

More than 4 million patients are admitted to the intensive care unit (ICU) each year, according to background information in the first article. These patients are often at a high risk of death from conditions such as sepsis and acute lung injury. Studies have shown that the presence of trained intensivist physicians is associated with improved survival, but there are not enough of these clinicians to meet demand.

“A potential complement to intensivist staffing is a multidisciplinary care model in which physicians, nurses, respiratory therapists, clinical pharmacists and other staff members provide critical care as a team,” write Michelle M. Kim, M.Sc., of the University of Pennsylvania, Philadelphia, and colleagues.

The researchers analyzed data from 107,324 patients admitted to 112 acute care hospitals between 2004 and 2006. Daily rounds conducted by a multidisciplinary care team were independently associated with a lower risk of death among ICU patients. Of the hospitals, 22 (19.6 percent) had an intensivist either consulting on or managing all cases and also had daily rounds conducted by a multidisciplinary care team. Patients at these hospitals were least likely to die, followed by patients at facilities without intensivist care but with multidisciplinary care teams.

Several mechanisms could explain the association, they note. “Multidisciplinary rounds may facilitate implementation of best clinical practices such as evidence-based treatments for acute lung injury, sepsis and prevention of ICU complications. Pharmacist participation on rounds is associated with fewer adverse drug events and alone may be associated with lower mortality among ICU patients. Multidisciplinary rounds may also improve communication between health care providers.”

The findings have implications for organizing critical care services, the authors conclude. “Based on these results and expert opinion voiced in consensus guidelines, it is reasonable for hospitals to implement routine multidisciplinary rounds when staffing capabilities allow,” they write. “Our study shows that hospitals without the ability to implement high-intensity physician staffing can still achieve significant mortality reductions by implementing a multidisciplinary, team-based approach.”

In another report, Gulshan Sharma, M.D., M.P.H., and colleagues at the University of Texas Medical Branch, Galveston, conducted a study of 694,806 Medicare fee-for-service beneficiaries hospitalized for one of 15 inpatient surgical procedures between 1996 and 2006. The researchers calculated the proportion of these beneficiaries who were co-managed during their hospital stay. “Co-management of surgical patients refers to patient care in which the medicine physician (generalist physician or internal medicine subspecialist) daily assesses acute issues, addresses medical co-morbidities, communicates with surgeons and facilitates patient care transition from the acute care hospital setting,” the authors write.

Between 1996 and 2006, 35.2 percent of the patients hospitalized for a common surgical procedure were co-managed by non-surgical clinicians (23.7 percent by a generalist physician, 14 percent by an internal medicine subspecialist and 2.5 percent by both). The percentage of patients who were co-managed remained steady from 1996 to 2000 and then increased sharply, by 11.4 percent per year between 2001 and 2006.

Older patients, those with more co-occurring illnesses and those receiving care at mid-sized (200- to 499-bed), non-teaching or for-profit hospitals were more likely to be co-managed. “All of the growth in co-management was attributed to increased co-management by hospitalist physicians,” the authors write.
“In summary, co-management of surgical patients by medicine physicians is increasing,” they conclude. “To meet this need, training in internal medicine should include medical management of surgical patients.”

“These findings are important for both our patients and the specialty of critical care, published coincident with a national focus on comparative effectiveness research and wider recognition of the imperative to deliver high-quality care,” writes J. Perren Cobb, M.D., of Massachusetts General Hospital, Boston, in an accompanying commentary2.

Investigating effective models of care for hospital patients is difficult and requires collaboration between clinicians, administrators, systems engineers, informaticists, sociologists and business experts, Dr. Cobb writes. “I submit that health engineering is the application of systems science to study how staff, patient, data and equipment interactions can be engineered to optimize patient outcomes in the ICU. If the essential features of high-quality teams can be exported, or even automated, then care for those patients in low-intensity staffing ICUs without multidisciplinary teams (the current majority!) could be improved.”

1. Arch Intern Med. 2010;170[4]:369-376, 363-368.
2. Arch Intern Med. 2010;170[4]:319-320.