Authors: Daniel Wu (1Division of Trauma and Acute Care Surgery, Penn Medicine — Lancaster General Health, Lancaster, PA.; 2Division of Trauma, Trinity Health — St Mary Medical Center, Langhorne, PA.), Amy L. Dzierba (3Department of Medicine, New York University Grossman School of Medicine, New York, NY.), Enyo A. Ablordeppey (4Department of Anesthesiology and Emergency Medicine, Washington University, St Louis, MO.), Todd Dorman (5Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.), Bin Du (6State Key Laboratory of Complex Severe and Rare Diseases, Beijing, China.; 7National Infrastructures for Translational Medicine, Institute of Clinical Medicine, Peking Union Medical College and Chinese Academy of Medical Sciences, Bejing, China.; 8Peking Union Medical College Hospital, Beijing, Beijing, China.), Alina O. Dulu (9Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.), Kyle Gunnerson (10Departments of Emergency Medicine, Anesthesiology, and Internal Medicine/Pulmonary Critical Care, University of Michigan, Ann Arbor, MI.), Pamela B. Holly (11Department of Respiratory Medicine, Atrium Health Carolinas Medical Center, Charlotte, NC.), Johannes Jansen van Rensburg (12Department of Pulmonology and Critical Care, Busamed Paardevlei Hospital, Somerset West Cape Town, South Africa.), Teresa B. Kortz (13Department of Pediatrics, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, CA.; 14Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA.), Sarah L. Livesay (15Adult and Gerontological Nursing, Rush University, College of Nursing, Chicago, IL.), Javier Lorenzo (16Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Medicine, Palo Alto, CA.), Maureen A. Madden (17Division of Pediatrics, Critical Care Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.), Piyush Mathur (18Department of Anesthesia, Cleveland Clinic, Cleveland, OH.), Sheila Nainan Myatra (19Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.), Kathryn E. Roberts (20Department of Nursing, Nemours Children’s Health, Wilmington, DE.), Gloria M. Rodríguez-Vega (21Division of Neurocritical Care Medicine, Hospital Menonita-Caguas, Puerto Rico.), Tamas Szakmany (22Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, United Kingdom.), Ahmed Taha (23Critical Care Development, Integrated Hospital Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.), Samuel A. Tisherman (24Department of Surgery and the Program in Trauma, University of Maryland School of Medicine, Baltimore, MD.)
Categories: Article, critical care specialist, intensive care physician, intensive care specialist critical care, intensivist
Source: Critical care medicine
Authors: Daniel Wu, Amy L. Dzierba, Enyo A. Ablordeppey, Todd Dorman, Bin Du, Alina O. Dulu, Kyle Gunnerson, Pamela B. Holly, Johannes Jansen van Rensburg, Teresa B. Kortz, Sarah L. Livesay, Javier Lorenzo, Maureen A. Madden, Piyush Mathur, Sheila Nainan Myatra, Kathryn E. Roberts, Gloria M. Rodríguez-Vega, Tamas Szakmany, Ahmed Taha, Samuel A. Tisherman
The goal of this task force was to examine the 1992 definition of the intensivist, identify gaps, and initiate a path forward to define a concise and practical definition that could be applied globally.
A modified Delphi technique was used to develop a revised definition and roles of the intensivist. We determined a priori that 75% or greater participant agreement for the definition and essential roles of the intensivist was required.
A task force consisting of physicians, a respiratory therapist, advanced practice providers, and a pharmacist that practice in critical/intensive care medicine, in various settings, was established with the goal of evaluating and revising the previous definition considering evolving healthcare.
The task force participated in online questionnaires related to the definition and roles of the intensivist.
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The task force agreed on the following definition of an “A physician who has successfully completed an accredited program or equivalent critical care/intensive care medicine training and maintains advanced certification (if available); and shows dedication to the area of critical/intensive care medicine in the way of professional work.” Additionally, the task force determined a list of essential roles of the intensivist categorized into Direct Clinical Care, Unit Management/Unit Involvement, Responsibility to the Community, and Administration and Leadership.
The revised definition of the intensivist seeks to integrate the intensivist in the current realm of team-based healthcare. The intensivist is a physician who provides care to critically ill patients in collaboration with an interprofessional team. Establishment of a single, revised definition is intended to render clarity of an intensivist’s role and responsibilities for patients, families, and the interprofessional team.
In 1992, the Society of Critical Care Medicine defined an intensivist focusing on physician qualifications, the role of inpatient care and unit management, and the practice of critical/intensive care medicine (CCM) in the United States (1). Globally, over the last 30 years the management of specialized care for critically ill and injured patients has evolved including advancement in knowledge and technology, the development of multiple, specialized training pathways, and the expansion of the team caring for patients in the ICU.
Variability in global definitions of an intensivist exists (2–10) due to differences in the scope of practice, training and certification requirements, regulatory oversight, and resource availability (Supplemental Table 1, http://links.lww.com/CCM/H669). A retrospective analysis of 105 published studies conducted in the United States found variability and inconsistencies in nomenclature when referring to an intensivist (11). While none of the studies referenced the 1992 intensivist definition (1), 60% of the studies defined an intensivist with at least one parameter (background and training, works in an ICU, staffing, and database-related) yielding 34 unique combinations (11). This variability suggests a lack of agreement on the definition of an intensivist and creates needless ambiguity, misunderstanding, and imprecision. As such, this may lead to obstacles in international research and benchmarking, and confusion in the medical field, in the press, and among laypersons. Therefore, a modern and comprehensive but nuanced “intensivist” definition would offer many benefits internationally. This would establish a denotation of intensivists providing standardization of terminology for future intensivist-based research, insight for administrators to help appreciate the myriad roles associated with intensivists, and recognition among the layperson (e.g., during the COVID-19 pandemic). A standardized term could, thus, potentially affect reimbursement systems, justification for regulatory agencies directing hospitals in credentialing and privileging intensivists, and guide educational curricula for fellowship programs toward real-world expectations.
A task force comprised of a diverse group of individuals practicing CCM in various specialties was established, ensuring a broad range of perspectives and expertise. The members of the task force included physicians, a respiratory therapist, advanced practice providers, and a pharmacist practicing in ICUs. The goal was to examine the 1992 definition of the intensivist, identify gaps, and initiate a path forward to define a concise and practical definition that could be applied internationally. The task force considered the evolution of CCM combined with contemporary, heterogeneous CCM practice environments.
A modified Delphi technique (12) was used to develop a definition and roles of the intensivist (Online Supplement, http://links.lww.com/CCM/H669). We determined a priori that 75% or greater participant agreement for the definition and essential roles of the intensivist was required. Data analysis was primarily descriptive.
Our Delphi consensus study did not seek full research permissions or ethical application. This decision was based on the established methodology of seeking expert consensus as described in the Ethical Delphi Manual (13) which, recognizes the absence of randomization of participants, no changes to any treatment or patient care, and the understanding that the findings would not be generalized outside of the identified population without additional research. Furthermore, no participant-identifiable data has been used within the analysis or article. All participants gave explicit consent for their anonymized opinions to be used in the process. Procedures were followed in accordance with the ethical standards of the Helsinki Declaration of 1975.
All members of the task force were invited for three rounds of voting on the definition of intensivist (Supplemental Table 2, http://links.lww.com/CCM/H669). Ninety-four percent of the task force participants in round three agreed on the following A physician who has successfully completed an accredited program or equivalent critical care/intensive care medicine training and maintains advanced certification (if available); and shows dedication to the area of critical/intensive care medicine in the way of professional work.
The task force agreed that the term “intensivist” refers specifically to an individual physician. In light of this, the task force acknowledged the importance of not minimizing the dedication, commitment, and contribution of nonphysician multidisciplinary members of the CCM team. All members of the CCM team contribute unique knowledge, skills, and expertise that improve care for critically ill patients. Nonetheless, the fundamental differences in undergraduate and postgraduate training pathways between physicians and other medical professionals would make the application of a single definition across all individuals of the CCM team impossible.
The task force also acknowledged that many physicians from a wide variety of specialty backgrounds caring for critically ill patients may have had training and expertise in the management of specific elements of CCM. The task force consensus was that training in an accredited or equivalent program dedicated to the management of critical care patients is essential to being an intensivist. Other nonintensivist specialists may not have specific training and certification in the holistic and integrated CCM approach to deal with the many potential interactions between one or more acutely impaired organ systems.
For consistency, the task force recommended restricting the term “intensivist” to physicians who complete an accredited CCM training specialty program or equivalent if the former is not available in their setting, who hold advanced certification including, but not limited to a dedicated postgraduate, board certification or been given rights via a practice pathway by their regulatory or licensing body in CCM medicine. The task force recognized that multiple pathways exist for attaining advanced certification globally. For example, these pathways include subspecialty certification by multiple boards and organizations based upon primary specialty choice in the United States, as well as a single subspecialty certification regardless of primary specialty or a primary specialty of CCM in many other countries (14). The new definition applies to any physician who has obtained these certifications, regardless of the path taken (Fig. 1).
The task force extensively discussed that commitment to CCM extends beyond clinical practice to include research, administrative duties, and related responsibilities within CCM. The new definition does not specify a particular allocation of time for clinical activities, as regulatory bodies and professional organizations in each jurisdiction are best suited to determine these standards.
There are limitations to this definition. Given the diversity and subspecialization of the field coupled with a variety of pathways to CCM training diverse health policies and the diversity in practice environments, the global definition will require external validation. Additionally, while the definition has been developed by a modified Delphi consensus process with a wide representation of healthcare providers across the globe and aimed to be inclusive, the very nature of defining a specialist will mean that some physicians, who self-define as intensivists, will be excluded. The term “intensivist” is simply defined for reasons of consistency for CCM research reporting, regulatory agencies, reimbursement systems, and hospital administration.
All members of the task force were invited for two rounds of voting on the roles of the intensivist (Supplemental Table 3, http://links.lww.com/CCM/H669). The intensivist role has evolved over recent decades. The essential roles are those that any intensivist practicing in diverse settings is expected to perform when necessary (Fig. 2). The task force acknowledged that these roles may be performed by other members of the interprofessional critical care team. An intensivist can serve as the team leader or member of an interprofessional team, coordinating and guiding healthcare professionals to provide specialized care for critically ill patients. The intensivist manages and resuscitates patients with, or at risk for, critical illness and organ failure and initiates interventions to prevent imminent deterioration. This may include directing the safe and timely performance of common CCM procedures. The role of the intensivist in the delivery of patient care has evolved from providing care to patients within the designated units to now including triage, management of, and consultation for, critically ill patients outside of designated ICUs, including telehealth, and postintensive care recovery clinics.
Working with a well-integrated, interprofessional team, the intensivist supports and promotes equitable, ethical, efficient, and high-quality CCM. This includes, but is not limited to, direct patient care, adherence to best practices with interventions that minimize iatrogenic complications, particularly bundles of care, and participation in quality improvement and patient safety initiatives.
The intensivist in the role of ICU Medical Director is responsible for working with the interprofessional team to establish policies and guidelines for care. The Medical Director should participate in the regular review of unit outcomes that guide quality improvement initiatives, promote safety huddles and interprofessional rounds, and assure compliance with hospital policies and national regulatory bodies. The Medical Director is responsible for representing the ICU to institutional administration.
There are limitations to these roles. The intensivist roles presented here are not meant to be fundamental activities or services deemed essential to CCM practice in every setting; rather they are meant to be activities or services that will elevate the practice of CCM. Local culture or regulations may limit these roles. Additionally, intensivists practicing in resource-limited areas may not be able to fulfill all these roles due to the scarcity of technology, facilities, and personnel.
The 1992 intensivist definition (1) defined multiple aspects of the intensivists’ roles and responsibilities but did not specifically address their role as a team member in the expanding critical care milieu. The evolution of technology and patient complexity prompted the development of interprofessional teams in CCM. Studies in CCM confirm that well-integrated team-based healthcare is critical to the delivery of high-quality patient care (15). Like the intensivist, each member of the CCM team takes an active role in patient care and may participate in unit management/involvement, system-based practice and community participation, and unit administration and leadership. The skills and competencies of each team member to provide CCM are dictated by their respective profession and role on the CCM team. Depending on the circumstance, any team member may take a team lead role depending on the task and situation, and all should function as members of the interprofessional team.
Intensivists are part of the interprofessional team of professionals providing extensive perspectives and skills to deliver holistic care to critically ill patients. Using a modified Delphi technique, a diverse group of individuals practicing CCM revised the definition and roles of the intensivist for international application. The establishment of a single, revised definition is intended to render clarity of an intensivist’s role and responsibilities for patients, families, and the interprofessional team. Furthermore, this definition provides a foundation for future research in CCM. As the landscape of CCM changes, the role of the intensivist will continue to evolve. The intensivist, alongside a highly integrated and collaborative interprofessional team, will lead these changes.
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