Intensivist Time Allocation: Economic and Ethical Issues Surrounding How Intensivists Use Their Time

Michael D. Howell

doi:10.1055/s-0032-1322410

Seminars in Respiratory and Critical Care Medicine, Table of Contents

Semin Respir Crit Care Med 2012; 33(04): 401-412
DOI: 10.1055/s-0032-1322410

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Intensivist Time Allocation: Economic and Ethical Issues Surrounding How Intensivists Use Their Time

Michael D. Howell

¹Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts

²Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harvard Medical School, Boston, Massachusetts

› Author Affiliations

Abstract

Intensivists' time is a fundamentally constrained resource. Many factors can put intensivists under conditions in which demands for their time outstrip the amount of time available. The importance of intensivist time strain is increasing both because demand for intensivists exceeds supply and because the roles that intensivists are being asked to take on are constantly expanding. There is strong evidence that time strain affects the decisions that intensivists make; evidence about whether it impacts patient outcomes is mixed. In deciding how to allocate their time, intensivists face many challenges. This article highlights two of these challenges: (1) How should intensivists approach two common scheduling-related issues (24/7 intensive care unit coverage and long blocks of service time that promote continuity but sacrifice weekends off) and balance these issues with the very real workforce concern of accelerated professional burnout? (2) What are the hidden financial impacts of intensivist participation in quality improvement programs, given current reimbursement systems?

Keywords

intensive care - intensivist - workload - 24-hour intensivist - burnout - business case for quality improvement

Full Text

References

References
1 Ward NS, Teno JM, Curtis JR, Rubenfeld GD, Levy MM. Perceptions of cost constraints, resource limitations, and rationing in United States intensive care units: results of a national survey. Crit Care Med 2008; 36 (2) 471-476
2 Truog RD, Brock DW, Cook DJ , et al; for the Task Force on Values, Ethics, and Rationing in Critical Care (VERICC). Rationing in the intensive care unit. Crit Care Med 2006; 34 (4) 958-963 , quiz 971
3 Sinuff T, Kahnamoui K, Cook DJ, Luce JM, Levy MM ; Values Ethics and Rationing in Critical Care Task Force. Rationing critical care beds: a systematic review. Crit Care Med 2004; 32 (7) 1588-1597
4 Strauss MJ, LoGerfo JP, Yeltatzie JA, Temkin N, Hudson LD. Rationing of intensive care unit services: an everyday occurrence. JAMA 1986; 255 (9) 1143-1146
5 Singer DE, Carr PL, Mulley AG, Thibault GE. Rationing intensive care—physician responses to a resource shortage. N Engl J Med 1983; 309 (19) 1155-1160
6 Angus DC, Kelley MA, Schmitz RJ, White A, Popovich Jr J ; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population?. JAMA 2000; 284 (21) 2762-2770
7 Krell K. Critical care workforce. Crit Care Med 2008; 36 (4) 1350-1353
8 Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 2010; 38 (1) 65-71
9 Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Crit Care Med 2004; 32 (6) 1254-1259
10 Walter KL, Siegler M, Hall JB. How decisions are made to admit patients to medical intensive care units (MICUs): a survey of MICU directors at academic medical centers across the United States. Crit Care Med 2008; 36 (2) 414-420
11 Mallick R, Strosberg M, Lambrinos J, Groeger JS. The intensive care unit medical director as manager. Impact on performance. Med Care 1995; 33 (6) 611-624
12 ACGME Program Requirements for Graduate Medical Education in Pulmonary Critical Care 2011. http://www.acgme.org/acWebsite/downloads/RRC_progReq/156pr707_ims.pdf . Accessed September 5, 2011
13 ACGME Program Requirements for Graduate Medical Education in Surgical Critical Care. 2011. http://www.acgme.org/acWebsite/downloads/RRC_progReq/442_critical_care_surgery_01012009.pdf . Accessed September 5, 2011
14 ACGME Program Requirements for Graduate Medical Education in Anesthesiology Critical Care Medicine. 2011. http://www.acgme.org/acWebsite/downloads/RRC_progReq/045pr101.pdf . Accessed September 5, 2011
15 Talmor D, Greenberg D, Howell MD, Lisbon A, Novack V, Shapiro N. The costs and cost-effectiveness of an integrated sepsis treatment protocol. Crit Care Med 2008; 36 (4) 1168-1174
16 Angus DC, Linde-Zwirble WT, Clermont G , et al; PROWESS Investigators. Cost-effectiveness of drotrecogin alfa (activated) in the treatment of severe sepsis. Crit Care Med 2003; 31 (1) 1-11
17 Understanding costs and cost-effectiveness in critical care: report from the second American Thoracic Society workshop on outcomes research. Am J Respir Crit Care Med 2002; 165 (4) 540-550
18 Siegel JE, Weinstein MC, Russell LB, Gold MR ; Panel on Cost-Effectiveness in Health and Medicine. Recommendations for reporting cost-effectiveness analyses. JAMA 1996; 276 (16) 1339-1341
19 Ward N, Afessa B, Read R, Kahn JM. Effects of attending physician workload in academic intensive care units: a national survey of training program directors [conference abstract]. Am J Respir Crit Care Med 2011; 183: A1022
20 Guntupalli KK, Fromm Jr RE. Burnout in the internist—intensivist. Intensive Care Med 1996; 22 (7) 625-630
21 Curtis JR, Patrick DL, Shannon SE, Treece PD, Engelberg RA, Rubenfeld GD. The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement. Crit Care Med 2001; 29 (2, Suppl) N26-N33
22 Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest 2008; 134 (4) 835-843
23 Solomon AW, Kirwan CJ, Alexander ND , et al; Prospective Analysis of Renal Compensation for Hypohydration in Exhausted Doctors (PARCHED) Investigators. Urine output on an intensive care unit: case-control study. BMJ 2010; 341: c6761
24 Profit J, McCormick MC, Escobar GJ , et al. Neonatal intensive care unit census influences discharge of moderately preterm infants. Pediatrics 2007; 119 (2) 314-319
25 Mountain SA, Hameed SM, Ayas NT , et al. Effect of ambient workload in the intensive care unit on mortality and time to discharge alive. Healthc Q 2009; 12 Spec No Patient: 8-14
26 Dara SI, Afessa B. Intensivist-to-bed ratio: association with outcomes in the medical ICU. Chest 2005; 128 (2) 567-572
27 Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 2000; 356 (9225) 185-189
28 Iwashyna TJ, Kramer AA, Kahn JM. Intensive care unit occupancy and patient outcomes. Crit Care Med 2009; 37 (5) 1545-1557
29 Laupland KB, Shahpori R, Kirkpatrick AW, Stelfox HT. Hospital mortality among adults admitted to and discharged from intensive care on weekends and evenings. J Crit Care 2008; 23 (3) 317-324
30 Kuijsten HA, Brinkman S, Meynaar IA , et al. Hospital mortality is associated with ICU admission time. Intensive Care Med 2010; 36 (10) 1765-1771
31 Bhonagiri D, Pilcher DV, Bailey MJ. Increased mortality associated with after-hours and weekend admission to the intensive care unit: a retrospective analysis. Med J Aust 2011; 194 (6) 287-292
32 Barnett MJ, Kaboli PJ, Sirio CA, Rosenthal GE. Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation. Med Care 2002; 40 (6) 530-539
33 Meynaar IA, van der Spoel JI, Rommes JH, van Spreuwel-Verheijen M, Bosman RJ, Spronk PE. Off hour admission to an intensivist-led ICU is not associated with increased mortality. Crit Care 2009; 13 (3) R84
34 Morales IJ, Peters SG, Afessa B. Hospital mortality rate and length of stay in patients admitted at night to the intensive care unit. Crit Care Med 2003; 31 (3) 858-863
35 Luyt CE, Combes A, Aegerter P , et al. Mortality among patients admitted to intensive care units during weekday day shifts compared with “off” hours. Crit Care Med 2007; 35 (1) 3-11
36 Wunsch H, Mapstone J, Brady T, Hanks R, Rowan K. Hospital mortality associated with day and time of admission to intensive care units. Intensive Care Med 2004; 30 (5) 895-901
37 Afessa B, Gajic O, Morales IJ, Keegan MT, Peters SG, Hubmayr RD. Association between ICU admission during morning rounds and mortality. Chest 2009; 136 (6) 1489-1495
38 Howell MD. A 37-year-old man trying to choose a high-quality hospital: review of hospital quality indicators. JAMA 2009; 302 (21) 2353-2360
39 Wasson JH, Sauvigne AE, Mogielnicki RP , et al. Continuity of outpatient medical care in elderly men: a randomized trial. JAMA 1984; 252 (17) 2413-2417
40 Cabana MD, Jee SH. Does continuity of care improve patient outcomes?. J Fam Pract 2004; 53 (12) 974-980
41 Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events?. Ann Intern Med 1994; 121 (11) 866-872
42 Gray JE, Davis DA, Pursley DM, Smallcomb JE, Geva A, Chawla NV. Network analysis of team structure in the neonatal intensive care unit. Pediatrics 2010; 125 (6) e1460-e1467
43 Smith ME, Desai SS, Allen ES, Saha S, Hunter AJ. Impact of shorter inpatient faculty rotations on resident learning experience. Am J Med 2009; 122 (1) 96-100
44 Epstein K, Juarez E, Epstein A, Loya K, Singer A. The impact of fragmentation of hospitalist care on length of stay. J Hosp Med 2010; 5 (6) 335-338
45 Clarke EB, Curtis JR, Luce JM , et al; Robert Wood Johnson Foundation Critical Care End-Of-Life Peer Workgroup Members. Quality indicators for end-of-life care in the intensive care unit. Crit Care Med 2003; 31 (9) 2255-2262
46 Gajic O, Afessa B, Hanson AC , et al. Effect of 24-hour mandatory versus on-demand critical care specialist presence on quality of care and family and provider satisfaction in the intensive care unit of a teaching hospital. Crit Care Med 2008; 36 (1) 36-44
47 Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med 2005; 33 (6) 1266-1271
48 Kahn JM, Rubenfeld GD, Rohrbach J, Fuchs BD. Cost savings attributable to reductions in intensive care unit length of stay for mechanically ventilated patients. Med Care 2008; 46 (12) 1226-1233
49 Banerjee R, Naessens JM, Seferian EG , et al. Economic implications of nighttime attending intensivist coverage in a medical intensive care unit. Crit Care Med 2011; 39 (6) 1257-1262
50 Auerbach AD, Landefeld CS, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med 2007; 357 (6) 608-613
51 Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff (Millwood) 2005; 24 (1) 138-150
52 Embriaco N, Azoulay E, Barrau K , et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med 2007; 175 (7) 686-692
53 Azoulay E, Timsit JF, Sprung CL , et al; Conflicus Study Investigators and for the Ethics Section of the European Society of Intensive Care Medicine. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med 2009; 180 (9) 853-860
54 Kohn R, Rubenfeld GD, Levy MM, Ubel PA, Halpern SD. Rule of rescue or the good of the many? An analysis of physicians' and nurses' preferences for allocating ICU beds. Intensive Care Med 2011; 37 (7) 1210-1217
55 Cookson R, McCabe C, Tsuchiya A. Public healthcare resource allocation and the Rule of Rescue. J Med Ethics 2008; 34 (7) 540-544
56 Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA ; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med 2006; 34 (4) 1016-1024
57 Pronovost PJ, Thompson DA, Holzmueller CG, Dorman T, Morlock LL. The organization of intensive care unit physician services. Crit Care Med 2007; 35 (10) 2256-2261
58 Hyzy RC, Flanders SA, Pronovost PJ , et al. Characteristics of intensive care units in Michigan: not an open and closed case. J Hosp Med 2010; 5 (1) 4-9
59 Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit. Ann Intern Med 2008; 148 (11) 801-809
60 Kim MM, Barnato AE, Angus DC, Fleisher LA, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med 2010; 170 (4) 369-376
61 Kahn JM, Brake H, Steinberg KP. Intensivist physician staffing and the process of care in academic medical centres. Qual Saf Health Care 2007; 16 (5) 329-333
62 Treggiari MM, Martin DP, Yanez ND, Caldwell E, Hudson LD, Rubenfeld GD. Effect of intensive care unit organizational model and structure on outcomes in patients with acute lung injury. Am J Respir Crit Care Med 2007; 176 (7) 685-690
63 Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002; 288 (17) 2151-2162
64 Pronovost PJ, Needham DM, Waters H , et al. Intensive care unit physician staffing: financial modeling of the Leapfrog standard. Crit Care Med 2006; 34 (3, Suppl) S18-S24
65 Kahn JM, Hall JB. More doctors to the rescue in the intensive care unit: a cautionary note. Am J Respir Crit Care Med 2010; 181 (11) 1160-1161
66 Young LB, Chan PS, Lu X, Nallamothu BK, Sasson C, Cram PM. Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis. Arch Intern Med 2011; 171 (6) 498-506
67 Lilly CM, Cody S, Zhao H , et al; University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA 2011; 305 (21) 2175-2183
68 Pronovost PJ, Goeschel CA. Time to take health delivery research seriously. JAMA 2011; 306 (3) 310-311
69 McGuire KJ. Health care delivery science. Spine (Phila Pa 1976) 2011; 36 (6) 417-418
70 Ali NA, Hammersley J, Hoffmann SP , et al; Midwest Critical Care Consortium. Continuity of care in intensive care units: a cluster-randomized trial of intensivist staffing. Am J Respir Crit Care Med 2011; 184 (7) 803-808
71 Klevens RM, Edwards JR, Richards Jr CL , et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007; 122 (2) 160-166
72 Pronovost P, Needham D, Berenholtz S , et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355 (26) 2725-2732
73 Taitz JM, Lee TH, Sequist TD. A framework for engaging physicians in quality and safety. BMJ Qual Saf 2011; Jul 14. [Epub ahead of print]
74 Flanagan ME, Welsh CA, Kiess C, Hoke S, Doebbeling BN ; Agency for Healthcare Research and Quality Hospital-Acquired Infections Collaborative. A national collaborative for reducing health care–associated infections: current initiatives, challenges, and opportunities. Am J Infect Control 2011; 39 (8) 685-689
75 Snell AJ, Briscoe D, Dickson G. From the inside out: the engagement of physicians as leaders in health care settings. Qual Health Res 2011; 21 (7) 952-967
76 Walsh KE, Ettinger WH, Klugman RA. Physician quality officer: a new model for engaging physicians in quality improvement. Am J Med Qual 2009; 24 (4) 295-301
77 Gosfield AG, Reinertsen JL. Finding common cause in quality: confronting the physician engagement challenge. Physician Exec 2008; 34 (2) 26-28 , 30–31
78 Frakt AB. How much do hospitals cost shift? A review of the evidence. Milbank Q 2011; 89 (1) 90-130
79 Medicare Physician Payment Schedule. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-medicare-physician-payment-schedule.page . Accessed September 5, 2011
80 Goodson JD. Unintended consequences of resource-based relative value scale reimbursement. JAMA 2007; 298 (19) 2308-2310
81 Physician Fee Schedule Search. 2011. http://www.cms.gov/apps/physician-fee-schedule/ . Accessed September 7, 2011
82 Girard TD, Kress JP, Fuchs BD , et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371 (9607) 126-134
83 Howell MD. Managing ICU throughput and understanding ICU census. Curr Opin Crit Care 2011; 17 (6) 626-633
84 McManus ML, Long MC, Cooper A, Litvak E. Queuing theory accurately models the need for critical care resources. Anesthesiology 2004; 100 (5) 1271-1276
85 Pastores SM, O'Connor MF, Kleinpell RM , et al. The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. Crit Care Med 2011; 39 (11) 2540-2549
86 Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med 2008; 36 (10) 2888-2897
87 Lindenauer PK, Pantilat SZ, Katz PP, Wachter RM. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med 1999; 130 (4 Pt 2) 343-349
88 Wellikson L. Care critical: hospitalists can—and will—help solve ICU workforce issues. The Hospitalist 2010; June. Available at: http://www.thehospitalist.org/details/article/704941/Care_Critical.html . Accessed July 17, 2012
89 Berwick DM. Launching accountable care organizations—the proposed rule for the Medicare Shared Savings Program. N Engl J Med 2011; 364 (16) e32
90 Song Z, Safran DG, Landon BE , et al. Health care spending and quality in year 1 of the alternative quality contract. N Engl J Med 2011; 365 (10) 909-918
91 Jones DA, DeVita MA, Bellomo R. Rapid-response teams. N Engl J Med 2011; 365 (2) 139-146
92 Offner PJ, Heit J, Roberts R. Implementation of a rapid response team decreases cardiac arrest outside of the intensive care unit. J Trauma 2007; 62 (5) 1223-1227 , discussion 1227–1228
93 DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, Foraida M, Simmons RL ; Medical Emergency Response Improvement Team (MERIT). Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Qual Saf Health Care 2004; 13 (4) 251-254
94 Numa A, Williams G, Awad J, Duffy B. After-hours admissions are not associated with increased risk-adjusted mortality in pediatric intensive care. Intensive Care Med 2008; 34 (1) 148-151
95 Burchardi H, Moerer O. Twenty-four hour presence of physicians in the ICU. Crit Care 2001; 5 (3) 131-137
96 Carlson RW, Weiland DE, Srivathsan K. Does a full-time, 24-hour intensivist improve care and efficiency?. Crit Care Clin 1996; 12 (3) 525-551
97 Groves Jr RH, Holcomb Jr BW, Smith ML. Intensive care telemedicine: evaluating a model for proactive remote monitoring and intervention in the critical care setting. Stud Health Technol Inform 2008; 131: 131-146
98 Rosenfeld BA, Dorman T, Breslow MJ , et al. Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care. Crit Care Med 2000; 28 (12) 3925-3931
99 Crippen D. The dilemma of full-time ICU physician coverage. Cost Qual Q J 1997; 3 (2) 38-39
100 Khan BA, Hui KY, Hui SL , et al. Time-motion analysis of health care workers' contact with patients and workers' hand hygiene: open vs closed units. Am J Crit Care 2011; 20 (3) e75-e79
101 Weiss CH, Moazed F, McEvoy CA , et al. Prompting physicians to address a daily checklist and process of care and clinical outcomes: a single-site study. Am J Respir Crit Care Med 2011; 184 (6) 680-686
102 Neziraj M, Sarac Kart N, Samuelson K. The intensive care delirium screening checklist: translation and reliability testing in a Swedish ICU. Acta Anaesthesiol Scand 2011; 55 (7) 819-826
103 Mayo PH, Hegde A, Eisen LA, Kory P, Doelken P. A program to improve the quality of emergency endotracheal intubation. J Intensive Care Med 2011; 26 (1) 50-56
104 Ko HC, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness. BMC Health Serv Res 2011; 11: 211
105 Cheema AA, Scott AM, Shambaugh KJ , et al. Rebound in ventilator-associated pneumonia rates during a prevention checklist washout period. BMJ Qual Saf 2011; 20 (9) 811-817
106 Stahl K, Palileo A, Schulman CI , et al. Enhancing patient safety in the trauma/surgical intensive care unit. J Trauma 2009; 67 (3) 430-433 , discussion 433–435
107 Piotrowski MM, Hinshaw DB. The safety checklist program: creating a culture of safety in intensive care units. Jt Comm J Qual Improv 2002; 28 (6) 306-315
108 Papadimos TJ, Hensely SJ, Duggan JM , et al. Intensivist supervision of resident-placed central venous catheters decreases the incidence of catheter-related blood stream infections. Patient Saf Surg 2008; 2: 11
109 Smith CC, Gordon CE, Feller-Kopman D , et al. Creation of an innovative inpatient medical procedure service and a method to evaluate house staff competency. J Gen Intern Med 2004; 19 (5 Pt 2) 510-513
110 Seppelt IM. All intensivists need echocardiography skills in the 21st century. Crit Care Resusc 2007; 9 (3) 286-288
111 Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW. Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest 2009; 135 (6) 1416-1420
112 Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest 2011; 139 (3) 538-542
113 Matsushima K, Frankel HL. Bedside ultrasound can safely eliminate the need for chest radiographs after central venous catheter placement: CVC sono in the surgical ICU (SICU). J Surg Res 2010; 163 (1) 155-161
114 Welpe P, Frutiger A, Vanek P, Kleger GR. Jejunal feeding tubes can be efficiently and independently placed by intensive care unit teams. JPEN J Parenter Enteral Nutr 2010; 34 (2) 121-124
115 Sanchez de Toledo J, Munoz R, Landsittel D , et al. Diagnosis of abnormal diaphragm motion after cardiothoracic surgery: ultrasound performed by a cardiac intensivist vs. fluoroscopy. Congenit Heart Dis 2010; 5 (6) 565-572
116 Bellomo R, Cole L, Reeves J, Silvester W. Who should manage CRRT in the ICU? The intensivist's viewpoint. Am J Kidney Dis 1997; 30 (5, Suppl 4) S109-S111
117 Tobin AE, Santamaria JD. An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a prospective cohort study. Crit Care 2008; 12 (2) R48