Critical (Re)thinking

By MELINDA BECK

It's 7 a.m. and attending physicians from seven of the 10 intensive-care units at Montefiore Medical Center in Bronx, N.Y., gather for their first daily triage session of the hospital's sickest patients. Residents, fellows, nurses and other specialists ring the conference table. More join in via video feed from ICUs at Montefiore's two remote campuses.

Bed by bed, unit by unit, they rapidly run through the multiple complex conditions each patient faces, each word telegraphing just how critical the patients are and how long they are likely to need ICU care.

"A 34-year-old man with catastrophic heart disease requiring ventricular assist device…a 50-year-old women with rare liver disease awaiting transplantation…an 86-year-old man with small-bowel resection, renal failure, ischemic heart disease…."

Some patients are improving and heading for a less-intensive step-down unit, opening up some beds. Three patients who had surgery overnight are waiting to take their places. Five more are expected to need ICU care after surgeries today—and that's just what's anticipated as of 7 a.m. Anywhere in the 1,491-bed hospital, a patient could suddenly suffer respiratory, heart or other organ failure and need critical care. And anything from gunshot wounds to auto accidents to a building collapse could bring more critically ill patients into Montefiore's emergency department, the second busiest in the nation.

As the triage sessions illustrate, handling the flow of patients in and out of the hospital's 78 adult medical and surgical ICU beds, and anticipating who else might need such high-level care on any given day, requires precision management. Many hospitals struggle to do it effectively, but Montefiore doesn't—thanks to several innovations spearheaded by Vladimir Kvetan, director of critical-care medicine, over the past decade.

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Montefiore Medical Center/Adi Talwar

Dr. Vladimir Kvetan (standing) with Dr. Graciela Soto and Dr. Andrew Lee at Montefiore Medical Center in New York

Among them: Teams of critical-care specialists are dispatched to the bedsides of potentially critical patients before they are brought to the ICU to determine what kind of care they really need and where in the hospital that can best be provided. An "ICU Without Walls" system can provide ICU-level care anywhere if a bed isn't immediately available. Terminally ill patients are offered palliative care instead of high-cost, high-tech interventions. And all of Montefiore's ICUs—for medical, surgical, neurosurgical and cardiothoracic patients—report to the critical-care department, not individual medical services, facilitating patient flow and minimizing turf wars.

Such changes in critical care have helped Montefiore reduce its overall mortality rate from 3.5% in 1997 to 1.8% in 2009. In its medical and surgical ICUs, the mortality rate fell from 36% in the 1980s to less than 8% in 2004—in part because many terminally ill patients are now offered palliative care elsewhere.

"Every four hours or so, we are asking, 'Is this patient benefiting from ICU care?' " says Dr. Kvetan. "It's all about using this precious resource as wisely as possible."

Preventing Bottlenecks

Many hospitals battle chronic capacity shortages in their ICUs, which are designed to provide constant monitoring and intervention for patients with life-threatening conditions. Many patients are on breathing machines, heart-pumping machines and kidney-dialysis machines. Some are awaiting organ transplants. Others are battling surgical complications, systemic infections or organ failures.

Demand for such care is growing with the aging population and the proliferation of technology that can prolong the lives of ever-sicker patients. But ICU care also is the most expensive in the hospital. Critical-care beds typically cost several times as much as a regular hospital bed—roughly $3,000 versus $1,500 per day at Montefiore—so most medical centers aren't eager to build more.

With rising demand and limited resources, there's a high potential for bottlenecks in many ICUs. And when they occur, they can cause backups throughout the hospital. Operating rooms may have to postpone elective surgeries, and emergency rooms may have to close to trauma if they have nowhere to send their most critical patients.

Dr. Kvetan, who joined Montefiore in 1983 and became head of critical care in 1999, began making changes about 10 years ago when he realized that many patients in the ICU didn't really need such intense care. They needed faster and better evaluation before they got there. So he devised a system to provide that, while keeping more ICU beds available for patients who could benefit most from them.

Part of that involved converting Montefiore from an "open" system, in which physicians admit their own patients to the ICU and continue overseeing them, to a "closed" system, where critical-care specialists decide which patients are treated in the ICU and assume responsibility for their care. About one-third of ICUs in the U.S. operate on the closed system, and debates continue over which is best. Studies have found that some patients in closed systems miss the familiarity of their own physicians, but survival rates are higher because the specialists have more training in critical situations.

Worth the Cost?

Nationwide, such critical-care specialists, also known as intensivists, are in short supply. Only 46% of U.S. hospitals have a board-certified intensivist available round the clock. But Montefiore has 28 of them who can both staff the ICU and bring their expertise wherever it's needed in the hospital through the ICU Without Walls.

One arm of that program is the rapid-response team, which can be summoned by any hospital staffer who thinks a patient's condition is deteriorating. That can happen in the ER, the OR or anywhere else in the hospital. The goal of the team, which includes an intensivist, a critical-care fellow and a nurse, is to intervene early and prevent cardiac arrests. Most big hospitals now have some kind of rapid-response team, a concept pioneered in Australia around 2000.

Montefiore also has critical-care consult teams that can be summoned by any physician who wants a potentially critical patient evaluated. The team helps determine what kind of care the patient needs and where that can best be provided, whether it's in the ICU, in an intermediate unit, on a regular floor or in a palliative-care program.

In other hospitals, that evaluation might not happen until the patient is brought to the ICU, and then not until a critical-care specialist is summoned, often from outside the hospital.

"We can get to any patient with the risk of death within 10 minutes to evaluate and properly stabilize them and assess their benefit from the intensive-care resources," says Dr. Kvetan. The guiding principle, he says, is "to have the most experienced and highest-trained physicians available around the clock."

Montefiore is the university hospital for Albert Einstein College of Medicine, which has one of the nation's largest training programs for critical-care specialists. More than 250 critical-care attending physicians and ICU directors have studied there.

Having so many intensivists on staff is an added cost, "but the payoff in the quality of care is clear to us," says Gary Kalkut, a senior vice president and chief medical officer at Montefiore.

Montefiore has been able to keep its actual ICU beds—78 total, with 15 more in step-down units—relatively small for such a large hospital system. Its emergency department has seen a 45% increase in traffic since 2000, to over 300,000 visits annually, without encountering critical-care backups.

Moreover, the quality of care is very high, according to a national ICU database: In 2009, the in-hospital mortality rate for patients who stayed in a Montefiore ICU was 33% lower than expected for patients around the country with the same severity of symptoms.

Discussing end-of-life care with terminally ill patients and their families is a delicate but important part of Montefiore's critical-care consult teams. Nationwide, about 20% of ICU patients have very little hope of recovery, yet are undergoing costly life-sustaining interventions, according to a study in Critical Care Medicine last year.

Many are in ICUs because they can't communicate and haven't specified the kind of end-of-life care they want. Only 26% of New York-area hospital patients have filled out such advanced directives, according to the Greater New York Hospital Association, or GNYHA.

"Sometimes it's much kinder to say to family members, 'Your father really will not benefit from this kind of care,' " says Dr. Kvetan. "What he needs is to be made comfortable and have his family around him, rather than be subjected to the thermonuclear attack of technology and manpower that is typical in an ICU."

Thanks to such efforts, Montefiore patients who are in their last six months of life spend, on average, just 3.6 days in the ICU, less than half of that at some comparably sized medical centers, according to the 2009 Dartmouth Atlas of Health Care.

Combining all the medical, surgical, cardiothoracic and neurosurgical ICUs into a central critical-care department is still unusual among hospitals of Montefiore's size. Both Drs. Kvetan and Kalkut credit that move with making many of the other innovations possible.

Removing the silos is "a good idea," says Pamela Lipsett, president of the Society of Critical Care Medicine and co-director of the surgical ICU at Johns Hopkins University School of Medicine. "The foundational problems that bring patients into the ICUs are more similar than dissimilar, and with specialized units, efficiency goes down substantially."

Zeynep Sumer, the GNYHA's vice president for regulatory and professional affairs, says Dr. Kvetan is an icon in the critical-care world. She recalls that when the U.S. Airways jet made an emergency landing in the Hudson River in 2009, Dr. Kvetan called her within 20 minutes to say he could make 25 ICU beds at Montefiore available for the injured.

"He is constantly thinking of how things could be run more efficiently," she says. "That's why his ICUs work so well."

Ms. Beck is a senior editor at The Wall Street Journal and writes the weekly Health Journal column. She can be reached at HealthJournal@wsj.com.