The Intensivist Book
Cherly Fleitas
An intensivist, also known as a critical care doctor, is a medical practitioner who specializes in the care of critically ill patients, most often in the intensive care unit (ICU).[1][2] Intensivists can be internists or internal medicine sub-specialists (most often pulmonologists), anaesthesiologists, emergency medicine physicians, paediatricians (including neonatologists), or surgeons who have completed a fellowship in critical care medicine. The intensivist must be competent not only in a broad spectrum of conditions among critically ill patients but also with the technical procedures and equipment used in the intensive care setting such as airway management, rapid sequence induction of anaesthesia, maintenance and weaning of sedation, central venous and arterial catheterisation, renal replacement therapy and management of mechanical ventilators.[3]
Training in the medical speciality of intensive care medicine is facilitated and managed by the College of Intensive Care Medicine of Australia and New Zealand. Training takes a minimum of six years to complete after internship and involves a dedicated 12 months of clinical medicine training and 12 months of anaesthesia training in addition to training in the intensive care unit.[4] Trainees also complete a first part exam in the relevant basic sciences and a second part 'Fellowship' exam towards the end of training. Doctors who complete training are awarded Fellowship of the College of Intensive Care Medicine of Australia and New Zealand (FCICM) and are eligible to practice as a consultant Intensivist.
In Sweden, one speciality entails both anaesthesiology and intensive care, i.e., one cannot become an anaesthetist without also becoming an intensivist and vice versa. The Swedish Board of Health and Welfare regulates specialization for medical doctors in the country and defines the speciality of anaesthesiology and intensive care as being:
A medical doctor can enter training as a resident in anaesthesiology and intensive care after obtaining a license to practice medicine, following an 18-24 month internship. The residency program then lasts at least five years, not including the internship. See also Residency (medicine), Sweden.
After medical school there are several different routes to becoming an intensivist. One can do a three-year internal medicine residency, and then a three-year pulmonology/critical care fellowship, or a two-year critical care fellowship. Also, if starting with internal medicine, it is possible to do a different specialty fellowship entirely, such as three years of cardiology or gastroenterology, and then an additional one-year fellowship in critical care medicine.[6] It is also possible to complete a residency first in general surgery, anaesthesiology, and emergency medicine before applying for a one- to two-year fellowship in critical care.[7]
Intensivists most often work in the intensive care unit. These physicians oversee the majority of care of these patients and make decisions about treatment, testing, procedures, consultations, etc. Majority of the patients that are admitted to the ICU are severely ill, and these physicians are experts at managing their complex challenges including multiple organ failure, life-threatening infections, trauma victims, and more. They must work with a large number of other professionals including physician assistants/nurse practitioner, registered nurses, pharmacists, respiratory therapists, and more.[8]
Intensivists often man interhospital transfers of critically ill patients, both on short range helicopter[9][10] or ground based missions,[11] as well as longer range national transports[12] to specialized centra or international missions to retrieve citizens injured abroad.[13][14] Ambulance services employ units staffed by intensivists that can be called out to provide advanced airway management, blood transfusion, thoracotomy, ECMO, and ultrasound capabilities outside the hospital.[15] Intensivists often (along with general surgeons and orthopaedic surgeons) make up part of military medical teams to provide anaesthesia and intensive care to trauma victims during armed conflicts.[16]
Traditionally, primary care physicians maintain chief responsibility for treating their critically ill patients. They often bring in specialists as needed. There are clear drawbacks to this approach. For example, primary care doctors often have little experience treating critically ill patients, and they have time constraints because they must care for other hospitalized and office patients. This can result in poorly coordinated care with outcomes often less than optimal. An intensivist is a medical doctor who possesses special training and experience in treating critically ill patients. Less than 20 percent of hospitals in the United States have intensivist coverage. About 160,000 lives could be saved each year if critical care was delivered by intensivist-directed, multi-professional teams, according to the Society of Critical Care Medicine. The mortality rate for intensive care units with intensivist staffing is 6 percent, compared to 14.4 percent where attending physicians provide ICU care.
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Noncommercial use of original content on www.aha.org is granted to AHA Institutional Members, their employees and State, Regional and Metro Hospital Associations unless otherwise indicated. AHA does not claim ownership of any content, including content incorporated by permission into AHA produced materials, created by any third party and cannot grant permission to use, distribute or otherwise reproduce such third party content. Request permission to reproduce AHA content.
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Importance: The patient-to-intensivist ratio (PIR) across intensive care units (ICUs) is not standardized and the association of PIR with patient outcome is not well established. Understanding the impact of PIR on outcomes is necessary to optimize senior medical staffing and deliver high-quality care.
Main outcomes and measures: Using standard summary statistics, we evaluated PIR variation across ICUs. We used multivariable, mixed-effect, logistic regression analysis to evaluate the association between PIR and hospital mortality at ultimate discharge from acute hospital (primary outcome) and at ICU discharge.
Conclusions and relevance: PIR varied across UK ICUs. The optimal PIR in this cohort of UK ICU patients was 7.5, with significantly increased ICU and hospital mortality above and below this ratio. The number of patients cared for by 1 intensivist may impact patient outcomes.
Introduction: Without specific strategies to address tracheostomy care on the wards, patients discharged from the intensive care unit (ICU) with a tracheostomy may receive suboptimal care. We formed an intensivist-led multidisciplinary team to oversee ward management of such patients. To evaluate the service, we compared outcomes for the first 3 years of the service with those in the year preceding the service.
Methods: Data were prospectively collected over the course of 3 years on ICU patients not under the care of the ear, nose, and throat unit who were discharged to the ward with a tracheostomy and compared with outcomes in the year preceding the introduction of the service. Principal outcomes were decannulation time, length of stay after ICU discharge, and stay of less than 43 days (upper trim point for the disease-related group [DRG] for tracheostomy). Analysis included trend by year and multivariable analysis using a Cox proportional hazards model. P values of less than 0.05 were assumed to indicate statistical significance. As this was a quality assurance project, ethics approval was not required.
The AG-ACNP Intensivist subspecialty builds upon knowledge gained within the Adult-Gerontology Acute Care Nurse Practitioner (AG-ACNP) program by providing didactic and clinical training focused on comprehensive care delivery to critically ill patients. Our graduates are prepared to practice as leading members of multidisciplinary critical care teams like those found in tertiary care centers.
The number of admissions into the AG-ACNP Intensivist subspecialty varies annually and is subject to change. In previous admission cycles, 8 to 12 students have been admitted into the focus area. During fall semester, faculty will call for the submission of new goal statements from all interested students, and final admission decisions will be made at that time.
No. While some of the AG-ACNP core courses may be taken in a modified distance format, the AG-ACNP Intensivist focus clinical rotations and simulation training are completed on Vanderbilt campus during weekly sessions. Students who wish to participate in the AG-ACNP Intensivist focus will need to live in or near the Nashville area during their clinical and simulation training courses.
Yes. Distance students accepted to the AG-ACNP intensivist focus generally complete the fall semester at a distance, and later relocate to the Nashville area prior to the start of spring semester clinical rotations.
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