Critical Care Update 2009 Vineet Nayyar, JV Peter, Roop Kishen, S Srinivas
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Section A
Manpower

Manpower in Critical Care—Global IssuesOne

Roop Kishen
“Life is pleasant. Death is peaceful. It's the transition that is troublesome.”
—Isaac Asimov (1920–1992)
 
INTRODUCTION
Imagine the scene in Blegdams Hospital, Copenhagen on that August day in 1952.1 Polio has spread worldwide and in Denmark it is especially severe. Blegdams Hospital is admitting about 50 patients a day and they are dying of respiratory failure.2 Only one large and six smaller iron lung machines (negative pressure or cuirass ventilators) are available for respiratory support for these patients.1 The mortality is about 90%, even for those supported with the iron lungs. At the same time, patients, mostly children, seem to exhibit a metabolic alkalosis, as their serum bicarbonate (as dissolved total carbon dioxide, CO2) is observed to be high; this is thought to be due to decreased excretion of bicarbonate by failing kidneys.2 With encouragement from Dr Mogens Bjørneboe, a physician at Blegdams, a young anesthetist, Dr Bjørn Ibsen3 has the courage to suggest that this observed metabolic alkalosis in these patients is due to retained CO2 (because of respiratory failure) and that positive pressure ventilation utilising a tracheostomy and hand ventilation instead of iron lungs3 would not only cure this strange metabolic alkalosis but save lives as well.1–3 The chief hospital physician, Dr HAC Lassen is sceptical (anesthetists, in 1950s, were not considered proper doctors, but merely technicians).1 No other suggestions are forthcoming and Ibsen is allowed to carry out his plan. Ward 19 at Blegdams, with its entire complement of 70 beds, is converted into a polio ward1. Most patients (usually children) are now being hand ventilated with a bag attached to oxygen supply, via a tracheostomy by a relay of students, working in six hour shifts. By the end of the epidemic about 1500 students have written their way into history by bag squeezing for more than a staggering 165,000 hours1 and reducing the mortality from about 90% to below 30%.3 Although lessons are learned from Copenhagen experience, the message does not seem to travel very far, as in nearby Cork (Ireland), doctors have no means of treating patients struck by a 1956 polio epidemic.42
This story is told here for two important reasons. First, this was the birth of intensive care units (ICUs); the second, motivating a large number of students to take part in this kind of supportive therapy must have been a mammoth task. Ibsen and perhaps Lassen (as the chief) seemed to have no staffing problems in 1952. When Ibsen was later asked to organize intensive care services, opening such a unit in 1953, he only admitted one patient that year and 13 the next.5 He did not have any other colleagues to run such a unit and almost certainly had no junior or resident staff.2 From this rather sudden but timely beginning, Intensive Care Medicine has grown rapidly, mostly driven by clinical need, but also because of improvements in technology. Modern ICUs and other areas where the critically ill are looked after (now collectively known as critical care units) are as different from Ibsen's original attempt as modern surgery is from that which was practiced in the 19th century. Today, care of the critically ill is central to the practice of modern medicine and much as the budgetary considerations may want to do away with this speciality, modern health care cannot be delivered without ICUs. Taken together, coronary care units and ICUs account for >50% of hospital deaths and in financial terms alone, consume 1% of gross domestic product, at least in the USA.6,7
Medicine (primary—family medicine and secondary—hospital medicine), as practiced today, has expanded from its humble beginnings in late 19th and early 20th century because of changes in the way it is delivered. Today, health care delivery is highly organized and in most instances is run on business lines. Depending on the way health care is funded, delivery of care is largely dependent on the availability of qualified staff (both medical and nursing), service models as well as availability of resources. It may be thought that service delivery in critical care is no different from other medical services and manpower issues will be the same; however, a closer examination shows that delivery of critical care services involves a different philosophy that impacts on a completely different set of work force issues. This chapter will attempt to discuss some of the important manpower issues that face the specialty with some suggestions for the future staffing of critical care units.
 
WHAT DO WE MEAN BY CRITICAL CARE
As provision of critical care services varies throughout the world, it is important to describe in some detail what we mean by such services.8,9 No discussion on staffing issues in critical care is complete without an understanding of what is meant by the term ‘critical care’ or ‘critical care unit’ (referred to as ICUs in this paper). This is important as there are no uniform or universally acceptable definitions.8,9 Whereas an ICU in the USA may look nearly the same as in the UK or Western Europe, the services delivered may not function in the same way.10 Likewise, ICUs in other parts of the world differ in their set up, constitution, staffing, case mix and patient flow. Local geography, access to medical care, case mix and funding of health care are important factors that shape the kind of services delivered by hospitals. In many hospitals, an ICU may just be a small ward with some basic monitoring whereas in others, especially large teaching or corporate hospitals, one or many large ICUs may co-exist 3on a single campus. Thus, there is an enormous variation in the configuration of individual units and between units, such that one ICU may or may not resemble another in the same hospital, city, and country or health service.8,9
For the purposes of the present discussion on staffing, following definitions are pertinent and useful. Critical Care/Intensive Care is defined as that branch of medicine, which deals with the critically ill patients in an institution (usually a hospital). A critically ill patient is one who requires immediate assessment and resuscitation (when first seen) and/or continuous monitoring, frequent evaluation, frequent interventions and/or organ support in a controlled environment (after resuscitation and initial stabilization) that is usually not possible on an ordinary ward.11 The care provided to a critically ill patient in a specialized ward where all the necessary equipment and expertise is concentrated is called the Critical Care Unit (CCU) or Intensive Care Unit (ICU).
In 2000, UK Department of Health, UK (Ministry of Health) commissioned an expert group to look into the adult critical care services in the UK. The expert group's remit was to describe a service ‘which focuses on the needs of patients and how they can be met through partnership between professions and specialties’.12 The group also ‘considered that the service must be comprehensive–encompassing the whole of the patient's pathway through care, and inclusive—involving all professions and specialties caring for the critically ill’.12 These definitions were already operative in the UK and have subsequently been endorsed by the Intensive Care Society, UK.11 Table 1.1 describes these definitions in detail.
Table 1.1   Levels of care11
Level 0
Patients whose needs can be met through normal ward care in an acute hospital
Level 1
Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team.
Level 2
Patients requiring more detailed observation or intervention including support for a single failing organ system or postoperative care and those ‘stepping down’ from higher levels of care.
Level 3
Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.
Looking at Table 1.1, it is clear that different levels of staffing (both medical and nursing) are required for patients being cared for at different levels of care. Thus, patients being cared for at Levels 0 and 1 will not generate the same intensity of activity as those requiring Level 2 or Level 3 care. Level 3 care is the most intense and units providing this level of care are busy with a number of patients on mechanical ventilation and other organ specific support. This kind of ICU, referred to as high intensity ICU in the US,13 requires medical and nurse staffing at the highest level of any critical care unit. Although ICUs that provide only or mostly 4Level 3 care exist in large numbers, many have both Level 3 and Level 2 patients being cared for in the same location. Organizational factors may also dictate that Level 2 units (generally called high dependency units or intermediate level care units) are geographically, administratively and clinically managed as separate from Level 3 units. There are other definitions of ‘levels of care’ described as well (Levels III, II and I);14 they are essentially reworking of and combination of the definitions in Table 1.1; clinicians should note that a Level I care proposed by US definitions is the highest level of ICU care14 (cf definition in Table 1.1). Thus, staffing patters in any one ICU will depend upon the patient case mix, levels of care provided, number of beds as well as the model of care (see below).
There has been an ongoing debate as to which model of care, if any, is best for clinical care of the critically ill. Early ICUs were run by amateur enthusiasts like Ibsen, who had little training in Intensive Care Medicine and hardly any understanding of the pathophysiology of critical illness.2 During these early days of development, ICUs were open where the primary clinicians, whose understanding of critical care pathophysiology was not optimal, retained the day-to-day control of clinical management whereas the amateur enthusiast usually helped in the clinical management in some minor capacity and generally helped to administratively manage the unit. Other specialists would be consulted when the primary clinicians ‘ran out of ideas’. Intensivists, have now replaced the amateur enthusiast in closed model of care, however, majority of ICUs in the US and India and many other countries are still working as open ICUs. In closed units, day-to-day management is vested in the hands of intensivists who remain in frequent contact with the primary clinician and seek advice of specialists when appropriate and necessary. It is now generally agreed that closed ICUs are cost effective, and have lower mortality and morbidity.10,15 These units are also more likely to use evidence based therapy and management protocols and use resources effectively.15,16 However, despite demonstrable improvements in the care of critically ill, closed units mostly exist in the UK, Western Europe and Australia whereas the ICUs in the rest of the world are still mostly open. It is suggested that a closed unit model of intensive care has been resisted, probably because the primary physicians’ reluctance to relinquishing authority for their patients to intensivists, but much more so because of the lack of enough intensivists to provide full-time staffing for all the units, at least in the US.10
A closed model of ICU care is accepted as cost-efficient, but the savings accruing from effective care may be offset by increased costs of staffing. There are no controlled studies to tell us what the intensity of staffing in any ICU should be? Although there is consensus that intensivists should provide care to the critically ill, the optimal intensivists-to-patient ratio is not known. There are many factors that affect this ratio, e.g. case-mix of admitted patients. In a study evaluating a medical ICU, it was found that a 1:15 intensivist-to-bed ratio compared to 1:12, 1:9.5 or 1:7.5 bed ratios led to increased length of ICU stay, although there were no adverse impact on mortality.17 This study was performed in a medical ICU, staffed with in-house critical care fellows and therefore, its findings may not be generalizable. However, with 5a uniform configuration of ICUs in the UK, it has been suggested that a 1:8 intensivist-to-bed ratio for all Level 3 ICUs is ideal.18 This may not work in all situations or other countries.
 
CONCERNS ABOUT STAFFING ISSUES IN ICUs
The need for qualified medical staff in ICUs and other acute medical specialties is a direct consequence of an aging population consuming an ever increasing share of health care funding.19–21 This coupled with an increase in complexity of surgical and medical procedures now on offer to a population with multiple comorbidities is another factor that is driving up the demand for intensive care services. Incidence of certain disease conditions like sepsis are also on the rise, with one study showing an yearly increase of 8.7% from 1979 to 2000.22 This increase in demand for critical care services comes at a time of unprecedented shortages in physician numbers all over the world.
Studies conducted in the USA about medical manpower predicted physician and specialist surplus from 1990s onwards.23,24 These conclusions were based on the assumption that an increasing number of patients in the USA will enter Health Management Organization's (HMO) managed care plans.19 However, as pay per item of service is still very much alive and thriving in the USA (part of the demand for health care is driven by physicians themselves),25,26 predictions about over supply of health care manpower were not realized. On the other hand, over last two decades, there has been a concern that medical staffing, particularly in specialties caring for the critically ill and with pulmonary diseases, will fall short in coming years (COMPACCS study).22 This forecast is especially valid for the USA, however, it is difficult to imagine the situation being different in other parts of the world (e.g. Australia).27
The remuneration for physician services is dependent on the economic development of a country and the model of health care funding. Economically challenged countries spend a smaller proportion of their per-capita income, on health care or health care infrastructure. So, although there has been substantial increase in medical manpower in some countries (e.g. USA, Australia) many other countries have shown little or no growth (Table 1.2).28
Table 1.2   Physician staffing in various countries*
Time period
USA
Philippines
Pakistan
India
1980s
180
10
30
40
1990s
270
10
60
40
*Physicians per 100,000 population.
In countries like India, the apparent no growth in physician numbers may be the result of rapid increase in population or physician export; however, the net effect is no apparent change in physician numbers per unit of population. This situation is likely to change, as developing Indian economy and increasing disposable income will lead to (in fact has already led to) 6increasing demand for and access to health care. Thus, there seems to be a physician shortage looming on the horizon and estimates show that by 2020 this will be a real threat to health care delivery.20 In the meantime, because of the factors cited above, rising demand for Critical Care physicians is also a reality.20 This demand is rising despite increased intake of physicians.28
Current inadequacies in staffing of Critical Care services were highlighted only about a decade ago.20 For example, in a recent survey of ICUs in the US, a study by COMPACCS group29 found that only 4% of adult ICUs in the US are high intensity units with dedicated senior physician coverage during the day and a physician cover during the night. Half the ICUs (53%) have no intensivists coverage at all and a few ICUs have in-house physician cover only during office hours on weekdays only. To try and predict national staffing requirements for these different types of ICUs is virtually impossible.
Closed units will usually have intensivists staffing the unit every day and most often over the weekends and during the nights. Presence of intensivists in ICUs has been found to improve outcome;30 out-of-hours intensivists cover for ICUs is beneficial.31,32 Having intensivist cover in ICU is considered to be ‘the most effective intervention to improve the survival of the critically ill that has been devised in the last 30 years’.33 However for a closed model to work, special attention has to be paid to staffing numbers, both medical and nursing34 and such staffing patterns may not be easily sustainable due to the shortage of adequately qualified doctors.20 Other important factors also operate, and need to be considered.
 
FACTORS AFFECTING PHYSICIAN SUPPLY
 
Trainees’ Working Hours
Working hours of trainees in medicine has provoked much debate in Europe, Australia and USA. European Working Time Directive,35 which came into full effect in European Union on 1st August 2009, has restricted trainees working 48 hours per week. This legislation not only restricts trainees training time but also puts the burden of front-line care on the senior staff and consultants; indeed it is already doing so in the UK where ‘shift work’ by consultants is beginning to be the ‘norm’ in many institutions (ICUs).2 Consultant staff staying in hospitals overnight as ‘residents’ is another possibility and being considered by many hospitals in the UK.36 Given that most of the ICUs in the UK are closed units, this will place a great burden on senior ICU staff and will require reorganization of services and recruitment of more intensivists.
 
Burnout in Critical Care
Burnout within critical care environment remains a real issue, so far having been forgotten by many employers. Even Ibsen and Lassen faced this issue way back in 1952 when a number of students who could not stomach the plight of patients in their care and dropped out.1 This burnout has a serious impact on the supply-demand equilibrium.37 This topic has been covered in a separate chapter in this book.
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Changing Demography of Medical School Intake
Increasing numbers of women are entering medicine, at least in the UK and in many medical schools, female students already outnumber their male colleagues. Thus, in coming years, female workforce is going to be predominant in medicine. Medical profession as a whole and intensive care, in particular, will have to look at ways of improving retention of female doctors– especially making the workplace family friendly as most of our future young female (and male) colleagues contemplate parenthood and bringing up families.2 Although no reasons were specified, women in critical care worked fewer annual hours than their male colleagues in COMPACCS study.20
Along with increased female colleagues, many young doctors are seeking appropriate work-life balance. This factor has been identified as one of the significant barriers to increasing the number of practicing intensivists as well as a significant factor prompting many to leave the speciality.38 This is well recognized as an essential feature of future intensive care service setups2 and has been elegantly voiced in a short article by Peter Suter, when talking about a futuristic medical service in general and ICUs in particular.39
 
Quality and Safety
Leapfrog Group, a Fortune 500 company of health care providers, aiming to improve patient safety, has ICU physician staffing as one of its initiatives13,40 which sets out a standard for ICU staffing. It is a compromise between high intensity staffing of a closed model (intensivist staffing the ICU at all times; day and night) and no intensivist staffing the unit at all. Although, not all aspects of the standard are supported by robust data, it is believed that such a pattern of staffing could potentially save nearly 54,000 lives in the US.40 However, a recent publication noted that only 25% of ICUs that met the Leapfrog standards gave authority to intensivists to write orders on all patients.41 There are, therefore, poor incentives for intensivists to want to work in such units, where their hands are tied, so to speak! Poor motivation may also be created by low reimbursement for critical care as well as medical politics (with fear of loss of control by primary physician who is not qualified to provide care in the ICU but is not prepared to relinquish clinical control).42,43 These barriers need to be tackled with appropriate remuneration for the intensivists (in a fee per item of service culture) as well as a better political atmosphere where intensivists are allowed to do what they are employed for – care for the critically ill.
There may be local factors that determine how the staffing of ICUs evolves in the future. In the UK, acute and critical care was given prominence in a Department of Health (DH) report recently.44 Reorganization of these services as seen by this report is likely to result in increased need for manpower in intensive care.2 There may be issues in other countries that will affect intensive care and manpower in health services; the current health care reform bill in the US45 is a good example as is the present worldwide economic recession. These issues will need to be factored in any manpower plans for the future.
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Attrition
What about the attrition of the workforce? It has already been noted that burnout and poor work-life balance are two important factors that make the physicians leave ICM. Intensive care is a high intensity work environment and many physicians do not want to work under such conditions for long. This will cause a natural attrition. In an incomplete but significant manpower survey in the UK,2 it was noted that about 400 consultants will be required to fill positions vacated by retiring colleagues by 2015; this figure does not take into account attrition by burnout and early retirement nor does it take into account the expansion of services. Are there trainees out there who can fill these places? It has been noted that there are less graduates entering critical care training program, whereas more are entering other specialties; there was >50% decline in new certifications in Critical Care Medicine per examination cycle between 1995 and 2001 while there were more physicians entering Pulmonary Medicine.38
It is, therefore, evident that there is an ever increasing need for more intensivists despite shortage of physicians and it is suggested that this will yield a shortfall of intensivists hours equivalent to 22% of demand in 2020 and 35% by 2030 – at least in the US.20 The situation in other developed countries is not far from this scenario46 and one suspects not too different in developing countries.
 
FUTURE DIRECTIONS
Intensive care is one of the most difficult specialist workforces to examine.47 However, there seems to be a general agreement that supply of intensive care specialists, is limited in comparison to requirements.2,20,47 Fewer medical graduates are training in Intensive Care now than in other specialities. There are disincentives for specialists to who want to continue working in the specialty.
If, as is suggested, we want to improve care of the critically ill and improve mortality, we are going to have a look at how we can attract specialist to Intensive Care. At the very least, this would mean changing the way we work and provide a better work-life balance in addition to some thought to improving remuneration for intensivists. If we do not make the workplace attractive, we will not be able to attract or retain staff. Intensive care physicians, like any other valuable resource, are precious. They need to be husbanded, maintained at peak of their efficiency and occasionally rescued from themselves. Unless we do that, we are doomed to lose young, active and inquisitive minds to other specialties.
Looking for a universal solution to staffing problems in ICM is like looking for a needle in a haystack. However, anyone planning to set up standards for staffing in ICUs will do well to pay heed to the following points;
  • There are no universally accepted definitions of what constitutes an ICU.
  • Whereas, some countries have worked out the ideal physician intensivist-to-bed ratios, it is not possible to extrapolate these findings to all countries and all situations.
    9
  • There is a physician shortage in general and of intensivists in particular.
  • Changes in working conditions are needed to attract and retain specialists in ICU.
  • Most important of these changes involves making the work-place family friendly and stress free.
  • Given the nature of the specialty, this may very nearly be impossible.
So dream on Peter Suter; you have the right ideas and hopefully, the right recipe.39
 
 
Declaration
The author is the past (2005–2008) Chairman of the Manpower Committee of the Intensive Care Society, UK.
REFERENCES
  1. Le Fanu J. Rise and Fall of Modern Medicine. Little Brown and Co.,  London  1999; 72–81.
  1. Kishen R. Manpower in intensive care: Back to the future. J Intensive Care Soc 2008;9:218–9.
  1. Zorab J. The resuscitation greats. Bjørn Ibsen. Resuscitation 2003;57:3–9.
  1. Neal Ascherson. Lust for Leaks. London Review of Books, 2005;27:3–6.
  1. Richmond C. Obituaries; Bjørn Ibsen. BMJ 2007;335:674.
  1. Halpern NA, Bettes I, Greenstein R. Fedral and nationwide intensive care units and healthcare costs: 1986–1992. Crit Care Med 1994;22:2001–7.
  1. Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiological study. Crit Care Med 2004;32:638–43.
  1. Teres D, Rapoport J. Cost Containment: Perspectives from our Global Villages. (Preface). New Horizons 1994;2:273–4.
  1. Edbrooke D, Hibbert C, Corcoran M. Review for the NHS Executive of Adult Critical Care Services: An International Perspective – Research report. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006766; access checked - Dec 21, 2009.
  1. Burchardi H, Moerer O. Twenty-four hour presence of physicians in ICU. Crit Care 2001;5:131–7.
  1. Eddleston J, Goldhill D, Morris J. Standards and Guidelines. Levels of Critical Care for Adult Patients. 2009. Available at: http://www.ics.ac.uk/intensive_care_professional/levels_of_critical_care_for_adult_ patients_2008 Access checked - Dec 21, 2009.
  1. Day V and Department of Health Expert Group. Comprehensive Critical Care – A review of Adult Critical Care Services. 2001; Department of Health, England. 2000. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006585; access checked - Dec 21, 2009.
  1. Leapfrog Group. To hospital. Available at http://www.leapfroggroup.org Access checked December 22, 2009.
  1. Haupt MT, Bekes CE, Brilli RJ, et al. Guidelines on critical care services and personnel: recommendations based on a system categorisation of three levels of care. Crit Care Med 2003;31:2677–83.
  1. Carson SS, Stocking C, Podsadecki T, et al. Effects of organisational change in the medical intensive care unit of a teaching hospital: A comparison of ‘open’ and ‘closed’ formats. JAMA 1996;276(4): 322–8.
  1. Kahn JM, Brake H, Steinberg KP. Intensivist physician staffing and process of care in academic medical centres. Qual Saf Health Care 2007;16:329–33.
  1. Dara SI, Afessa B. Intensivist-to-bed ratio: Association with outcome in medical ICU. Chest 2005;128:567–72.
  1. Gunning K, Gillbe C. Standards for consultant staffing of intensive care units. The Intensive Care Society Standards Committee and Intercollegiate Board for Training in Intensive Care Medicine 2006. (Currently 10under review) Available at http://www.ics.ac.uk/intensive_care_professional/standards_for_consultant_ staffing_2007 Access checked - Dec 26, 2009.
  1. Weiner JP. Forecasting the effects of health reform on US physician workforce requirement: evidence from HMO staffing patterns. JAMA 1994;272:222–30.
  1. Angus DC, Kelley MA, Schmitz RJ, et al. Current and projected workforce requirements for the care of the critically ill and patients with pulmonary disease: Can we meet the requirements of an aging population? JAMA 2000;284:2762–70.
  1. Iglehart JK. The American health care system: Medicare. New Eng J Med 1999;340:327:32
  1. Martin GS, Mannino DM, Eaton S, et al. The epidemiology of sepsis in the United States from 1979 through 2000. New Eng J Med 2003;384:1546–54.
  1. Graduate Medical Education Advisory Committee. Report of the Graduate Medical Education National Advisory Committee: summary report. Washington DC; US Department of Health and Human Services. 1981. HAS 81–651. www.hrsa.gov/
  1. Council on Graduate Medical Education Recommendation to improve access to health care through physician workforce reform. Washington DC; US Department of Health and Human Services. 1994. www.hrsa.gov/
  1. Schroeder SA, Sandy LG. Speciality distribution of US physicians: the invisible driver of health care costs. N Eng J Med 1993;328:961–3.
  1. Reinhardt UE. The economist's model of physician behaviour. JAMA 1999;281:462–5.
  1. Scott IA. Health care workforce crisis in Australia: too few or too disabled? Med J Aust 2009;190:689–92.
  1. Biviano M, Makarehchi F. Globalisation and the physician workforce in the United Sates. Sixth Medical Workforce Conference, Ottawa, Canada, 2002. Report of the Health Resources and Services Administration. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/physicianworkforce/default.htm Access checked Dec 24, 2009.
  1. Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systemic review. JAMA 2002;288:2151–62.
  1. Pronovost PJ, Jenckes MW, Dorman T, et al. Organisational characteristics of intensive care units related to outcomes of abdominal aneurysm surgery. JAMA 1999;281:1310–7.
  1. Blunt MC, Burchett KR. Out-of-hours consultant cover and case-mix-adjusted mortality in intensive care. Lancet 2000;356:735–6.
  1. Gajic O, Afessa B. Physician staffing models and patient safety in the ICU. Chest 2009;135:1038–44.
  1. Dubin CG. Team model: advocating for the optimal method of care delivery in the intensive care unit. Crit Care Med 2006;34:S12–7.
  1. Coombs M, Lattimer V. Safety, effectiveness and costs of different models of organising care for critically ill patients: literature review. Int J Nursing Studies 2007;44:115–29.
  1. Department of Health. European Working Time Directive. Available at: http://www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraining/Modernisingworkforceplanninghome/Europeanworkingtimedirective/index.htm Access checked Dec 26, 2009.
  1. Royal College of Surgeons and Royal College of Anaesthetists WTD Report. Available at: http://www.healthcareworkforce.nhs.uk/working_time_directive/calling_time/royal_college_of_surgeons_and_royal_college_of_anaesthetists_wtd_report_calling_time_12.html Access checked Dec 26, 2009.
  1. Dunn W. Murphy J. Should intensive care medicine itself be on the critical list? Chest 2009; 892–4. DOI: 10.1378/chest. 09–0038.
  1. US Department of Health and Human Services. Health Resources and Service Administration. Report to Congress: the critical care work force: a study of supply and demand for critical care physicians. Available at: ftp://ftp.hrsa.gov/bhpr/nationalcenter/criticalcare.pdf Access checked Dec 26, 2009.
  1. Suter PM. From 2009 to 2019: what a change! Crit Care 2009;13:153 (doi: 10.1186/cc7895).
  1. FACTSHEET: ICU Physician Staffing (IPS). Available at: http://www.leapfroggroup.org/for_hospitals/leapfrog_hospital_survey_copy/leapfrog_safety_practices/icu_physician_staffing Access checked Dec 26, 2009.
  1. 11 Pronovost PJ, Thompson DA, Holzmueller CG, et al. The organisation of intensive care unit physician services. Crit Care Med 2007;35:2256–61.
  1. Pronovost PJ, Holzmueller CG, Clattenberg L, et al. Team care: Beyond open and closed intensive care units. Curr Opin Crit Care 2006;12:604–8.
  1. Kahn JM, Matthews FA, Angus DC, et al. Barriers to implementing the Leapfrog Group recommendations for intensivist physician staffing: A survey of intensive care unit directors. J Crit Care 2007;22:97–103.
  1. Darzi A. Our NHS, our future: NHS next stage review, interim report. October 2007. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079077 Access checked Dec 27, 2009.
  1. http://www.cnn.com/video/#/video/politics/2009/12/24/bts.senate.healthcare.senate?iref=allsearch
  1. Victoria Critical Care Services: Strategic Directions 2007–2012. 2006.
  1. Australian Medical Workforce Advisory Committee (1999). The Intensive Care Workforce in Australia, AMWAC Report 1999. 1, Sydney