To the Editor:
On the basis of the preponderance of published studies, professional organizations recommend that the care of critically ill or injured patients be supervised by clinicians with expertise in intensive care (1). In addition, recent studies indicate improved outcomes in intensive care units (ICUs) with lower patient-to-nurse ratios (2–4). Although several studies have reported on the daily work responsibilities of critical care physicians (3, 5), less is known about the cumulative work requirements and responsibilities of critical care physicians who care for these critically ill patients.
To better understand the amount of clinical time spent by a typical critical care physician, we surveyed physicians with the responsibility for setting schedules for ICUs serving adults at acute care hospitals in the United States, regarding the workload and responsibilities of clinicians who worked in their ICUs. Some of these results have been previously reported in the form of an abstract (6)
We surveyed individuals with the authority to schedule physicians on clinical services derived from two groups: the U.S. Critical Illness and Injury Trials Group, composed of clinical investigators across the United States whose expertise spans the spectrum of prehospital, in-hospital, and posthospital care, with a Listserv that included 230 people; and an ad hoc Ebola working group that includes 10 attending physician faculty members who work on staffing for patients with Ebola virus disease. The Institutional Review Board at Emory University evaluated the survey and did not consider this survey to be research.
We sent three e-mail messages to 240 candidates, including an initial invitation to participate and two reminders. Potential respondents were directed to an online link to a REDCAP database. The survey included questions on hospital characteristics, physician workload and training, and nonclinical responsibilities. No personal information was obtained. A full-time equivalent (FTE) critical care clinician was explicitly defined as a hypothetical physician employed full time who provides direct care to patients exclusively in ICUs and has no nonclinical responsibilities.
Data were described using means and standard deviations, medians and interquartile ranges (IQRs), and sample size and percentages, as appropriate. Data were analyzed using Student’s t test, Wilcoxon rank sum test, Pearson Chi-squared test, and Fisher’s exact test when appropriate. SPSS version 22 (IBM, Armonk, NY) was used for analysis.
We received a total of 68 responses (52 complete and 16 incomplete). The crude response rate was 28% (68/240). It is likely that some of the members of the Listserv did not fit the desired characteristics for survey respondents, which could raise the effective response rate.
The majority of the respondents worked in an urban setting (75%) and at private not-for-profit (63%) or teaching hospitals (96%). Medical ICUs made up the largest group of the types of ICUs surveyed (41%), and 66% of respondents practiced in a closed unit model ICU.
The median reported total ICU daily census was 18 (IQR, 14–23) (Table 1).
Table 1.
Hospital and attending physician characteristics
| All (n = 68) | Medical (n = 28) | Nonmedical (n = 40)* | P Value | |
|---|---|---|---|---|
| Hospital type, n (%) | 0.854 | |||
| Nonfederal public | 15 (22.1) | 7 (25.0) | 8 (20.0) | |
| Private for-profit | 4 (5.9) | 1 (3.6) | 3 (7.5) | |
| Federal | 6 (8.8) | 2 (7.1) | 4 (5.9) | |
| Private not-for-profit | 43 (63.2) | 18 (6.4) | 25 (62.5) | |
| Hospital locale, n (%) | 0.088 | |||
| Urban | 51 (75.0) | 24 (85.7) | 27 (67.5) | |
| Suburban/rural | 17 (25.0) | 4 (14.3) | 13 (32.5) | |
| Teaching, n (%) | 65 (95.6) | 28 (100) | 37 (92.5) | 0.138 |
| Critical care fellowship training program, n (%) | 54 (79.4) | 26 (92.9) | 28 (70.0) | 0.022 |
| 24 h in-house attending coverage, n (%) | 32 (47.1) | 13 (46.4) | 19 (47.5) | 0.931 |
| 24 h in-house fellow coverage, n (%) | 29 (42.7) | 12 (42.9) | 17 (42.5) | 0.977 |
| 24 h in-house resident coverage, n (%) | 60 (88.2) | 28 (100.0) | 32 (80.0) | 0.012 |
| 24 h in-house midlevel coverage, n (%) | 29 (42.7) | 13 (46.4) | 16 (40.0) | 0.598 |
| Telemedicine coverage, n (%) | 15 (22.1) | 5 (17.9) | 10 (25.0) | 0.484 |
| Staffing model, n (%) | 0.001 | |||
| Open | 8 (11.8) | 1 (3.6) | 7 (17.5) | |
| Closed | 45 (66.2) | 27 (96.4) | 18 (45.0) | |
| Mixed | 15 (22.0) | 0 (0.00) | 15 (37.5) |
Nonmedical intensive care units included all intensive care units that were not exclusively medical (i.e., surgical, mixed medical–surgical, cardiothoracic surgical, etc.).
Survey respondents reported that attending critical care physicians were assigned a median of 169 total days (24.1 wk) per FTE (IQR, 136–198), including 24 weekend days (IQR, 18–30) and zero nights in-house (IQR, 0–32) (Table 2).
Table 2.
Attending workflow characteristics
| All | Medical | Nonmedical* | P Value | |
|---|---|---|---|---|
| Number of beds in hospital, median (IQR) | 532 (350–850) | 726 (500–950) | 400 (255–748) | 0.001 |
| Number of adult beds in study intensive care unit, median (IQR) | 22 (17–30) | 24 (18–31) | 20 (16–30) | 0.222 |
| Total number of adult intensive care unit beds in hospital, median (IQR) | 80 (39–207) | 102 (50–130) | 66 (28–100) | 0.014 |
| Total number of physicians who work in your intensive care unit, median (IQR) | 11 (6–18) | 16 (10–20) | 8 (5–14) | 0.001 |
| Total number of physicians who exclusively work in your intensive care unit, median (IQR) | 2 (0–5) | 1 (0–5) | 2 (0–6) | 0.384 |
| Average daily census, median (IQR) | 18 (14–23) | 20 (18–24) | 15 (12–22) | 0.018 |
| Number of physicians on clinical service at one time, median (IQR) | 2 (1–2) | 2 (2–3) | 2 (1–2) | 0.061 |
| Total number of days per full-time employee, median (IQR) | 169 (136–199) | 160 (140–200) | 170 (125–210) | 0.719 |
| Total number of weekend days, median (IQR) | 24 (18–30) | 20 (16–28) | 24 (18–36) | 0.115 |
| Total number of nights in-house, median (IQR) | 0 (0–33) | 0 (0–24) | 14 (0–42) | 0.117 |
Definition of abbreviations: IQR = interquartile range.
Nonmedical intensive care units included all intensive care units that were not exclusively medical (i.e., surgical, mixed medical–surgical, cardiothoracic surgical, etc.).
In addition to their clinical responsibilities in the ICU, ICU physicians were responsible for ICU triage (69%), code response (61%), rapid response calls (54%), and stepdown or intermediate care units (50%). Most surveyed physicians reported involvement with research (85%), training program administration (81%), and/or hospital committees (94%). Critical care physicians in medical ICUs, compared with those of nonmedical ICUs, had similar numbers of days and weekends worked, but were more likely to have 24-hour resident coverage (100% vs. 80%; P = 0.012) (Table 2)
The median annual number of expected direct patient care work days in an ICU per 1.0 critical care physician FTE reported by survey respondents was 169 (24.1 wk), including weekend days but no nights. Our survey results demonstrate no reported difference between medical and nonmedical ICUs in clinical workload, as defined by number of days and weekends required to work to support a FTE critical care physician. Of note, most of the clinicians had clinical responsibilities outside of ICU and did not work exclusively as critical care physicians.
A recent society consensus statement and opinion paper provided recommendations regarding the number of ICU patients that a critical care physician should see in a day (5, 7). However, these recommendations reflect daily practice, rather than yearly job responsibilities. Our survey results provide current experiential context for determining how many days a critical care physician should work in an ICU in a year.
Our survey has important limitations, including the unknown denominator of critical care clinicians with scheduling authority, which made it impossible to calculate an exact percentage response rate, and the use of survey responses that may not more accurately reflect actual scheduling. In addition, the survey respondents were primarily from academic urban centers, and thus may not reflect work performed in other types of institutions or provided by physicians without critical care training, such as hospitalists and those from other disciplines (8–10). In nonurban ICUs, critical care is often delivered by physicians without critical care training (9, 11).
We are also unable to comment about the economic or clinical outcomes associated with the various staffing models covered in our survey. Of note, recent studies of nighttime coverage and closed staffing models in ICUs have not consistently demonstrated improved clinical outcomes (12, 13). Finally, we relied on the respondent’s determination of what would constitute adequate work to cover a clinician’s salary without additional information about departmental or institutional support.
In summary, this report provides information on physician staff composition, annual work load, and attending critical care physician responsibilities in ICUs at largely urban academic acute care hospitals in the United States. Further steps should be taken to assess how these factors may affect clinical outcomes.
Footnotes
The authors are supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000454. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Author Contributions: J.E.S., Z.J.C., G.A.C., J.P.C., and S.M.P., involvement in the conception, hypothesis delineation, and design of the study; J.E.S., Z.J.C., G.A.C., J.P.C., and S.M.P., acquisition of the data or the analysis and interpretation of such information; and J.E.S., Z.J.C., G.A.C., J.P.C., and S.M.P., writing the article or substantial involvement in its revision before submission.
Author disclosures are available with the text of this letter at www.atsjournals.org.
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