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Seminars in Anesthesia, Perioperative Medicine and Pain (2005) 24, 50-58

valuating the impact of the Leapfrog Group’s standardor Intensive Care Unit physician staffing

eter J. Pronovost, MD, PhD,a David A. Thompson, DNSc, MS, RN,a,b

hristine G. Holzmueller,a Todd Dorman, MD,a Barbara A. Rudolph, PhD, MSSWc

From the Johns Hopkins University School of Medicine; andJohns Hopkins University School of Nursing, Baltimore, MD
The Leapfrog Group, Washington, DC.
There is growing concern over the quality and escalating costs of health care in the US. This paperreviews the Leapfrog Group’s ICU Physician Staffing (IPS) standard, summarizes evidence supportingthe standard, reviews the cost of implementing the standard, and discusses the impact of the standardon critical care in the US. The IPS standard requires that all patients in adult or pediatric generalmedical and/or surgical ICUs be managed or co-managed by physicians certified in critical caremedicine. A systematic review of the literature demonstrated high intensity physician staffing (e.g.intensivists manage all patients) was associated with a 30% reduction in hospital mortality and a 40%reduction in ICU mortality. Interviews with authors from 19 studies demonstrated that the IPSrequirement for pager response and weekday and weekend hours were supported by the evidence. Costsavings estimates with IPS ranged from $510,000 to $3.3 million (greater savings in larger ICUs). Theimpact of the IPS is unknown, although most hospitals in the original 6 regional rollouts made effortsto implement IPS. Given the results from this study, if IPS were implemented nationally, up to 134,000lives could be saved annually with most hospitals incurring a net savings.© 2005 Elsevier Inc. All rights reserved.

KEYWORDS:ICU;Quality;Leapfrog;Physician staffing

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There is growing concern over the quality of healthare.1-3 It is estimated that between 44,000 and 98,000eople die each year in the United States, primarily fromistakes of commission, or things caregivers do to patients

hat should not be done. Mistakes of omission, or thingsaregivers should have but did not do, likely impart a fararger toll.4 On average for a diverse group of conditions,atients in the US receive half of the therapies they shouldeceive.5 There is also concern about escalating costs of carend poor correlation between the amount spent on health-are and the results achieved.6 Healthcare currently con-umes approximately 15% of our gross domestic product,7

Address reprint requests and correspondence: Peter Pronovost, MD,hD, 901 S. Bond Street, Suite 318, Baltimore, MD 21231.

tE-mail address: [email protected]

277-0326/$ -see front matter © 2005 Elsevier Inc. All rights reserved.oi:10.1053/j.sane.2004.11.001

r 4887 per capita,6 and is increasing nearly 10% eachear.5,8

ICU care is associated with significant morbidity, mor-ality and costs.4,9,10 The Leapfrog Group is a consortium ofver 159 Fortune 500 companies and other large private andublic healthcare purchasers focused on breakthrough im-rovements (leaps) in the safety, quality and affordability ofealthcare. Leapfrog Group members have agreed to baseheir purchase of care on a set of safety and quality stan-ards, which hospitals have been asked to report publicly tohe Leapfrog Group. These “leaps” or safety specificationsnclude staffing ICUs with intensive care physicians (IPStandard).11,12

Currently, only 10-20% of ICUs in the US are staffed byntensivists.13 Leapfrog implemented its IPS standard
hrough 23 active regional rollouts, which cover approxi-

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51Pronovost et al ICU Physician Staffing

ately 50% of Americans. Of the hospitals submitting in-ormation in Version 2.0 of the survey, 21% within theegional rollout areas had fully implemented the ICU stan-ard (www.leapfroggroup.org). Over 5 million patients aredmitted annually to ICUs in the US. Ten percent of theseatients die during their hospitalizations, and nearly alluffer preventable adverse events.10,13,14 ICU care in the USccounts for approximately 13% of acute hospital costs and55 billion annually.9 Both the number of ICU beds and theosts per bed day are increasing; in 2000, on average an ICUay cost $2674.9 If the ICU standard is fully implemented inon-rural US hospitals, it could prevent between 54,000 and34,000 deaths and save 5.4 billion dollars annually.4,15-17

Despite the magnitude of the Leapfrog Group’s initiativend the potential to improve quality of care, no one isvaluating the effects of these standards on hospitals, insur-rs and employers. There are political and economic barrierso implementing the ICU standard. Hospitals can selectarious strategies to meet the standard. However, little isnown about which strategies are being pursued, the factorsacilitating or hindering the implementation of the ICUtandard, or perceptions of the standard’s impact on patientsnd hospitals.

In this manuscript, we will review the Leapfrog Group’sCU Physician Staffing (IPS) standard, summarize the evi-ence supporting the standard, review data on the economicmpact of implementing the standard, and discuss the extento which the standard has influenced critical care in thenited States.

eapfrog Group ICU physician staffingtandard

he Leapfrog Group is focused on improving patient safetyor their members’ employees and as such has targetedpecific standards for patient safety and quality (www.leap-roggroup.org).11 Leapfrog is growing daily and now in-ludes over 34 million employees from US corporationsuch as General Electric, Ford, Verizon, as well as membersf the Buyers Healthcare Action Group and the Pacificusiness Group on Health. The Leapfrog Group has sought

o create a business case for quality by rewarding high-uality care and encouraging employees to use high-qualityroviders.

Leapfrog’s standards include the following: (1) creatingolume-based purchasing for five surgical procedures andeonatal care (EHR); (2) implementing computerized phy-ician order entry (CPOE); (3) implementing ICU physiciantaffing by intensive care physicians (IPS);11,12 and recentlydded the National Quality Forum Safe Practices (NQF-SP)s a fourth safety leap (The National Quality Forum Saferactices for Better Healthcare: A Consensus Report, 2003).o help increase the number of hospitals meeting these fourtandards, the Leapfrog Group worked over the past 2 years
ith a variety of employers and partnered with regulators,
nsurers and providers to support the implementation pro-ess and expanded the number of regional rollouts from 6 to3 regions. Leapfrog has also published information on theortality benefits associated with their first three leaps

CPOE, IPS, EHR). Most of the mortality benefits attributedo implementing these standards are derived from ICU phy-ician staffing.16 Below we describe the latest version of thePS standard.

he Leapfrog Group’s ICU patient safetytandard

004 ICU physician staffing (IPS) leap

A hospital fulfilling this leap assures that all patients in itsdult or pediatric general medical and/or surgical ICUs areanaged or co-managed by physicians certified in critical

are medicine who:

Are ordinarily present in the ICU (on-site, or via tele-medicine that meets Leapfrog specifications) during day-time hours a minimum of 8 hours per day, 7 days perweek, and during this time provide clinical care exclu-sively in the ICU; andAt other times:

Return more than 95% of ICU pages within 5 minutes,based on a quantified analysis of pager response time;*and

Can rely on a physician or FCCS-certified non-physician“effector” who is in the hospital and able to reach ICUpatients within 5 minutes in more than 95% of cases,based on a quantified hospital analysis of pager responsetime.*

This may exclude low-urgency pages, if the paging systeman designate low-urgency pages or if the hospital has anlternative scientific method for documenting non-return ofigh-urgency pages in 5 minutes.

otes

. When a hospital publicly documents favorable ICU per-formance via scientifically rigorous and comparable per-formance assessment systems endorsed by The LeapfrogGroup, favorable performance will replace or supple-ment the physician staffing leap. The Leapfrog Group iscurrently collaborating with JCAHO and operators ofICU performance measurement systems to specify theterms “favorable performance,” “scientifically rigorous,”“publicly document,” and “comparable.”

. Intensivist “presence” may be accomplished via tele-medicine per Leapfrog’s specifications.

. On an interim basis, other categories of physicians maybe considered by Leapfrog to be “certified in Critical
Care Medicine.”
http://www.leapfroggroup.org



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52 Seminars in Anesthesia, Perioperative Medicine and Pain, Vol 24, No 1, March 2005

efinitions for terms used in the IPStandard

anaged or co-managed

The intensivist, when present (whether on-site or viaelemedicine), is authorized to diagnose, treat and writerders for a patient in the ICU on his/her own authority.andatory consults or daily rounds by an intensivist are not

ufficient to meet the managed/co-managed requirement.owever, an ICU need not be “closed” (that is the inten-

ivist becomes the attending of record) to meet this require-ent.

ertified in critical care medicine

A physician who is “certified in Critical Care Medicine” isboard-certified physician who is also certified in the subspe-

ialty of Critical Care Medicine. Certification in Critical Careedicine is awarded by the American Boards of Internaledicine, Surgery, Anesthesiology and Pediatrics.Since subspecialty certification is not offered in emer-

ency medicine, emergency medicine physicians will beonsidered “certified in Critical Care Medicine” if they areoard-certified in emergency medicine and have also com-leted a critical care fellowship in an ACEP-accreditedrogram. On an interim basis, two other categories of phy-icians will be considered by Leapfrog to be “certified inritical Care Medicine”:

Physicians who completed training prior to availability ofsubspecialty certification in critical care in their specialty(1987 for Medicine, Anesthesiology, Pediatrics and Sur-gery), who are board-certified in one of these four spe-cialties, and who have provided at least 6 weeks of full-time ICU care annually since 1987. (The weeks need notbe consecutive weeks.)Physicians board-certified in Medicine, Anesthesiology, Pe-diatrics or Surgery who have completed training programsrequired for certification in the subspecialty of Critical CareMedicine but are not yet certified in this subspecialty.

rdinarily and exclusively present in the ICU

“Ordinarily present in the ICU” refers to direct presencen the ICU (or presence via telemedicine) of an intensivisturing the 8-hour period. While it need not be the samentensivist for the entire 8-hour duration, it is expected thathe ICU(s) are primarily staffed by dedicated ICU intensiv-sts who are ordinarily and exclusively present in theCU(s). “Presence” does not mean staffed part-time by mul-iple physicians who are not ordinarily and exclusivelyedicated to the ICU, nor does it mean the cumulative timehat one or more intensivists spend in the unit visiting,ounding, consulting, or responding to pages.

The standard allows for normally expected intensivist
ctivities outside of the ICU related to their responsibilities a
n the ICU (eg, evaluating patients proposed for ICU ad-ission), as long as intensivists are ordinarily present in the

CU and return immediately when paged. An intensivistresent in one ICU immediately adjacent to another can beonsidered present in both units as long as s/he can respondo demands in both units as if both units were one largernit. While tele-intensivists can be used to meet the pres-nce requirement, some on-site intensivist presence is stillecessary to meet the Leapfrog specifications.

“Exclusively” means that when the physician is in theCU, s/he has no concurrent clinical responsibilities to non-CU patients.

uantified analysis of pager response times

Providers can monitor pager response times in multipleays, as long as the data collection process is non-biased

nd scientific.For example, providers could maintain an exception log

n the ICU(s) on 6 randomly sampled days per year. Onhose days, ICU nurses would record:

the number of urgent pages made to intensivists whenthey are not present in the unit (whether on-site or viatelemedicine);the number of urgent pages made to other physicians orFCCS-certified effectors when no physician or FCCS-certified effector is physically present in the unit; andthe number of times that responses exceed 5 minutes forthose respective pages.

ospitals can then cost-effectively estimate whether theyeet the 95% timely response standards by dividing the

verage number of log exceptions per day by the averageumber of pages per day.

CCS-Certified “effector”

FCCS certificates are awarded to nurses and doctorspon their successful completion of a brief course devel-ped by the Society for Critical Care Medicine to improve/onfirm critical care knowledge and skills; for more infor-ation visit http://www.sccm.org/edu/fccscourses.html. At

resent, this is the only course recommended by the Leap-rog Group’s expert advisory panel. Intensivists or any otherhysicians who are certified in critical care medicine (orligible based on residency training or fellowship) need notlso be FCCS certified.

ntensivist presence via telemedicine

To meet the Leapfrog ICU requirement for intensivistresence in the ICU via telemonitoring, a hospital mustffirm that its telemonitoring intensivist presence fulfills theollowing 10 key features based on a modification of the
pproach reported in Critical Care Medicine.20,21 Note that,
http://www.sccm.org/edu/fccscourses.html

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s with other Leapfrog specifications, these features must beet under ordinary circumstances.

1. An intensivist who is physically present in the ICU(“on-site” intensivist) performs a comprehensive re-view of each ICU patient each day and establishesand/or revises the care plan. The tele-intensivist hasimmediate access to information regarding the on-siteintensivist’s care plan at the time monitoring responsi-bility is transferred to him or her by the on-site inten-sivist. When care is transferred back to the on-siteintensivist, the tele-intensivist communicates (rounds)with the on-site intensivist to review the patient’sprogress and set direction.

2. When an intensivist is not on-site in the ICU managing orco-managing all ICU patients, a tele-intensivist is moni-toring and able to manage all ICU patients for the remain-ing 24 hours per day, 7 days per week. “Monitoring”means the tele-intensivist has no other concurrent respon-sibilities, is immediately available to communicate withICU staff, and is in the physical presence of the tele-ICU’spatient monitoring and communications equipment.“Manage” means authorized to diagnose, treat, and writeorders for a patient in the ICU on his/her own authority.

3. A tele-intensivist has immediate access to key patientdata, including:a) physiologic bedside monitoring data (in real-time);b) laboratory orders and results;c) medications ordered and administered; and,d) notes, radiographs, ECGs, etc. on demand.

4. Data links between the ICU and the tele-intensivist arereliable (�98% of the time) and secure (HIPAA com-pliant).

5. Via A-V support, tele-intensivists are able to visualizepatients with sufficient clarity to assess breathing pat-tern, and communicate with on-site personnel at thebedside in real time.

6. Written standards for remote care are established andinclude, at a minimum:a) tele-intensivists are certified by a national medical

specialty board in critical care medicine;b) tele-intensivists are licensed to practice in the legal

jurisdiction in which the ICU is located;c) tele-intensivists are credentialed in each hospital to

which he/she provides remote care (can be specialtelemedicine credentialing);

d) activities of the tele-intensivist are reviewed withinthe hospital’s quality assurance committee structure;

e) there are explicit policies regarding roles and re-sponsibilities of both the on-site intensivist and thetele-intensivist; and,

f) there is a process for educating staff regarding thefunction, roles, and responsibilities of thetele-intensivist.

7. Tele-ICU care is proactive, with routine review of allpatients at a frequency appropriate to their severity of
illness. r
8. A tele-intensivist’s patient workload ordinarily permitshim or her to complete a comprehensive assessment ofany patient within 5 minutes of the request, with assis-tance being initiated by hospital staff.

9. There is an established written process to ensure effec-tive communication between the on-site care team andthe tele-intensivist.

0. The tele-intensivist documents patient care activities,with this documentation incorporated into the patientrecord.

ow does the Leapfrog Group evaluateompliance with the standard?

he Leapfrog Group conducts an annual voluntary survey ofospitals and, using the survey instrument in Table 1, evaluates thextent to which hospitals meet the standard. Local implementationf the hospital survey is handled by the 23 regional rollouts. Basedn responses to the survey, hospitals are scored into three imple-entation categories (Table 2): fully implemented, good progress,

nd good early stage effort. Hospitals are also given some creditor simply reporting their status to Leapfrog. The three implemen-ation scores are based on the extent to which intensivists manageatients in the ICU; these scores are made public for employees ofarticipating companies, and the general public on the Leapfrogroup Web site (www.leapfroggroup.org).

hat incentives does the Leapfrog Groupse?

he Leapfrog Group sought to increase the number ofmployees exposed to high quality care through two strat-gies. First, by educating consumers they sought to movearket share to high quality providers. Second, through

ewards, they sought to increase the number of high qualityroviders in the market.12 A number of Leapfrog employerembers are active or are in the process of activatingnancial and other types of incentives and rewards pro-rams. Some of the members involved in incentive pro-rams include Empire Blue Cross, IBM, Verizon, PepsiCO,erox (NY), General Electric, Boeing, UPS, Proctor andamble, and Group Insurance Commission (MA). The

ypes of programs vary, but they include performance oneapfrog standards, such as IPS. For more detail on theserograms, see the Leapfrog Group’s Web site mentionedbove.

ow does the Leapfrog Group update thetandard?

he Leapfrog Group recognizes that evidence is dynamic
ather than static and the standard must reflect the best

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vailable evidence. As such, each year, one of the authorsPP), the national medical director for the IPS standard,eads a national advisory panel to: (1) review new evi-

Table 1 Leapfrog Group’s hospital survey to evaluate complia

1) Does your hospital operate any adult or pediatric general mebeds

If ‘Yes’, continue:2) Are all patients in these ICUs managed or comanaged by one

who are certified in critical care medicine? (More Information

3) Is one or more of these physicians ordinarily present in eachduring daytime hours for at least 8 hours per day, 7 days perprovide clinical care exclusively in one ICU during these hourInformation)

4) When these physicians are not present in these ICUs on-sitedoes one of them return more than 95% of pages from theseminutes, based on a quantified analysis of pager response timmay exclude low-urgency pages, if the paging system can despages or if the hospital has an alternative scientific methodnon-return of high-urgency pages in 5 minutes.)

5) When these physicians are not present on-site in the ICU orICU patient within 5 minutes, can they rely on a physician ophysician “effector” who is in the hospital and able to reachwithin five minutes in more than 95% of the cases, based onanalysis of pager response time? (This percentage may excludpages, if the paging system can designate low-urgency pageshas an alternative scientific method for documenting non-retpages in 5 minutes.)

If you answered “No” to any of questions #2-5 in this section,medical and/or surgical ICUs.

6) Are all patients in these ICUs managed or co-managed by oncertified in critical care medicine who are either:● ordinarily present on-site in these units;● for at least 8 hours per day, 4 days per week, and● providing clinical care exclusively in one ICU during theseOR● present via telemedicine for 24 hours per day, 7 days per wintensivist is not present on-site,● meeting the other Leapfrog ICU requirements for intensivisICU via telemedicine,● with an intensivist on-site at least 4 days per week to estacare plans for each ICU patient?

(More Information)7) If not all patients are managed or co-managed by physicians

care medicine, are some patients managed by these physician8) What is the date, if any, by which your hospital commits to

IPS Leap fully?9) Does your hospital have a board-approved budget that is ade

commitment?10) Does a clinical pharmacist make daily rounds on patients in

11) Does a physician certified in critical care medicine lead dairounds on-site on all patients in these ICUs?

12) When certified physicians are on-site in these ICUs, do theyfor all ICU admission and discharge decisions?

*Source: www.leapfroggroup.org

ence that would require updating the standard, (2) re- a

iew comments provided to the Leapfrog Group regard-ng IPS, and (3) make recommendations to the Leapfrogroup regarding the standard, the survey and the scoring

th IPS standard*

urgical ICU YesNo

re physicians Yes, all are certified in criticalcare

Yes, based on expandeddefinition of certified

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YesNo

telemedicine,within fiveis percentagelow-urgency

umenting

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le to reach ancertified non-ICU patientsntifiedurgencyhe hospitalhigh-urgency

YesNo

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vidence supporting the Leapfrog Group IPS

vidence to support the standard is perhaps best summa-ized in a systematic review published by our researcheams.20 In that study, we grouped ICU physician staffingnto high intensity staffing, such as a closed ICU orandatory consult where intensivists manage all patients,

ersus low intensity staffing, such as an elective consultodel or no intensivist model in which intensivists man-

ge some or none of the patients. We found that highntensity staffing was associated with a reduction in hos-ital mortality in 16 of 17 studies (94%) and a 0.71ooled relative risk for hospital mortality, suggesting thatigh intensity staffing is associated with an approximate0% reduction in hospital mortality (Figure 1). We alsoound that high intensity staffing was associated witheduced ICU mortality in 14 of 15 studies (93%), with a

Table 2 Scoring algorithm for IPS*

Fully implemented means:1. All patients in adult and pediatric general medical and sur

who are certified in critical care medicine (intensivists) (a2. One or more intensivist(s) is/are present in each ICU durin

week or via telemedicine 24 hours per day, 7 days per weehours (answered “Yes” to #3); and

3. When intensivists are not present (on-site or via telemedicfrom these units within five minutes. (answered “Yes” to #

4. When an intensivist is not present (on-site or via telemed“effector” is on-site at the hospital and able to reach ICU(answered “Yes” to #5).

5. Use of telemedicine requires that additional Leapfrog specGood progress means:

1. All patients in adult/pediatric medical ICU(s) are managedcritical care medicine (intensivists) when those physicians#2); and

2. The hospital commits to meet the Leapfrog IPS standard fu3. The hospital has a board-approved budget that is adequate4. The hospital has implemented either of the following prac

a) Intensivists are present and manage or co-manage all pweek or via telemedicine 24 hours per day, 4 days per w(answered “Yes” to #6); use of telemedicine requires th

b) Clinical pharmacists make daily rounds on adult medicaland

5. An intensivist:a) leads daily, multi-disciplinary team rounds on-site (answb) makes admission and discharge decisions when on-site

Good early stage effort means:1. The hospital commits to meet the Leapfrog IPS standard fu2. The hospital has a board-approved budget that is adequate3. Some patients in the ICU(s) are managed or co-managed b

“Yes” to #6 or Yes to #7). Use of telemedicine requires thWilling to report publicly means:The hospital responded to all the Leapfrog survey questions, buDid not disclose this information means:The hospital did not respond to this section of the survey, or th

one.N/A Standard does not apply means:The hospital does not operate an adult or pediatric general med*Source: www.leapfroggroup.org

.61 pooled relative risk for ICU mortality, suggesting a

hat high intensity staffing is associated with a 40%eduction in ICU mortality (Figure 1). If ICU physiciantaffing is viewed as an intervention, it is among the mostotent interventions, comparable to or exceeding suchritical care blockbuster therapies as glucose control, lowidal volume in ARDS, steroids in septic shock and ac-ivated protein C.21-24

We also evaluated the evidence regarding 8 hours peray and pager response time. We called the primary authorsor each of the US studies in our systematic review thatvaluated the affect of ICU physician staffing on mortalityo evaluate the components of IPS. All 19 US studies100%) reported responding to 95% of pages within 5 min-tes. Hours of weekend coverage ranged from 2 to 24, withmean of 8 hours. Eighty-four percent of intensivists wereresent in the ICU 4 hours or more per day on the weekend,

CU(s) are managed or co-managed by one or more physiciansd “Yes” to # 2); andime hours on-site for at least 8 hours per day, 7 days perprovide(s) clinical care exclusively in this ICU during these

these ICUs, one of them returns more than 95% of pagesdin the ICU, another physician or FCCS-certified non-physiciants within five minutes in more than 95% of the cases

ns are met.

managed by one or more physicians who are certified inesent, whether on-site or via telemedicine (answered “Yes” to

12/31/2004 (answered � 2005 for #8); andeet the IPS commitment (answered “Yes” to #9); and

in all ICUs either on-site at least 8 hours per day, 4 days perith on-site daily care planning at least 4 days per weektional Leapfrog telemedicine specifications are met; oral ICU patients (answered “Yes” to #10).

Yes” to #11), orred “Yes” to #12).

12/31/2005 (answered � 2006 for #8); andeet the IPS commitment (answered “Yes” to #9); andntensivist when present on-site or via telemedicine (answeredtional Leapfrog telemedicine specifications are met.

es not yet meet the criteria for a good early stage effort.

pital was asked to complete the survey but has not submitted

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f weekday coverage ranged from 3 to 24, with a mean of1 hours. Ninety-five percent of intensivists were present inhe ICU 4 hours or more per day every weekday and 73%ere present 8 hours or more.25 Though indirect, there is

vidence to support the hours and pager response timeomponents of IPS. There is no evidence in the publishediterature to support FCCS certification, although there iseason to believe that patients may benefit from havingualified caregivers.

We also evaluated the economic impact of the IPS standardn hospitals.18 From a hospital perspective, we estimated theosts and savings over a 1-year period, from implementing theeapfrog Group’s IPS standard compared with the existingtandard of non-intensivist staffing in adult ICUs. Using pub-ished data, primarily from our systematic review,20 we devel-ped a financial model of costs and savings for 6-, 12- and8-bed ICUs using conservative estimates for all variables. Welso conducted sensitivity analyses, including a best-case andorst-case scenario, to evaluate the impact of changing as-

umptions on the outcome of the model.In these models, we assumed the hospital was paying

or the intensivists and nurse practitioners who woulderve as the effector. Using conservative estimates for allariables, cost savings ranged from $510,000 to $3.3illion with greater savings achieved in larger ICUs

Table 3). One-way sensitivity analysis revealed that the

igure 1 Unadjusted hospital mortality with low and high inten88:2151-2162, 2002. Copyright © 2002, American Medical Asso

ariables affecting financial results the most were related a

o the ICU [number of beds, length of stay (LOS), occu-ancy and cost of bed day] and the benefits derived fromPS implementation (reductions in ICU admissions, ICUOS and hospital LOS). Assumptions regarding hospital-

elated variables and salary costs for intensivists andhysician extenders had less of an impact on the results.

Break-even analysis revealed that, using conservativessumptions for a 12-bed ICU, implementation of IPSeed only reduce hospital LOS by 5% without any con-omitant reduction in ICU admission or ICU LOS toesult in no net cost or savings to hospitals. Simulta-eously changing all variables in the model to reflect aest-case scenario demonstrated savings of approxi-ately $4.2, $8.8 and $13 million for 6-, 12-, and 18-bed

CUs, respectively. Only under a worst-case scenario washere a potential cost associated with implementing thePS standard. These costs ranged from $890,000 to $1.3illion, based on ICU bed size.This financial analysis has demonstrated that under

onservative assumptions, implementation of the Leap-rog Group’s IPS standard is associated with an annualnancial savings of $510,000 to $3.3 million for hospi-

als, with larger savings being realized as ICU size in-reases from 6 to 18 beds. Even hospitals with a 6-bedCU may see an important benefit. Given these savingsnd the potential to save up to 134,000 lives annually

f ICU physician staffing. Reprinted with permission from JAMA. All rights reserved.

sity o

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PS implementation. Given the magnitude of its clinicalnd financial impact, hospital leaders should be askinghow to,” rather than “whether to” implement the Leap-rog Group’s ICU Physician Staffing standard.

hat is the impact of the Leapfrog Group’sPS standard in the US

elatively little is know regarding the impact of the IPS stan-ard. The Leapfrog Group initially implemented roll-outs in 6egions of the country, specifically California, Atlanta, East/

iddle Tennessee, Minnesota, Seattle and St. Louis; since thennother 17 regions have been rolled out. On average about0% of hospitals in these areas meet the standard (www.leap-roggroup.org). We recently conducted a survey of Chief Med-cal Officers (CMOs) and ICU directors (ICUD) in the original

roll-out regions. Interestingly, most hospitals are making

Table 3 Hospital costs and savings of the Leapfrog Group’s IP

Intensive Care Unit (ICU) Bed Days & AdmissionsAnnual number of ICU bed days (80% occupancya)Annual number of ICU admissions (5 day mean length of staya)I. COSTS1. Intensivists’ annual salary and benefitsa

LESS additional hospital income from:-displacement of non-intensivistsa

-intensivist billingsa

Net Annual Cost for Intensivist2. Physician extenders’ annual salary and benefitsa

TOTAL COSTSII. SAVINGSCost of ward bed daya

Savings from substituting ward for ICU bed ($2,300a-$805)1. Improved ICU Utilization

a) Reduced ambulance by-passa

b) Reduced ICU admissions:ICU admissions prevented (@ 15% of all admissionsa)ICU bed days saved (@ 3 day length of stay)

Savings from substitution of ward for ICU bed2. Reduced ICU Length of Stay (LOS) Savings

Decrease in ICU LOS (18% of 5 day LOSa)Savings per ICU patient admitted (substitution of ward bed)Annual savings across all ICU patients admitted

3. Reduced Hospital Length of StayDecrease in hospital LOSa

Savings in ward bed day costsAnnual savings across all ICU patients admitted

4. Reduced ICU Ancillary costsSavings per ICU admissiona

Annual savings in ICU ancillary costsTOTAL SAVINGSNET SAVINGS*Adopted with permission from Pronovost et al: Intensive care unit p32:1247-1253, 2004.

fforts to implement the standard. c

onclusion

here is growing concern about the poor quality and risingosts of healthcare and the poor relationship between what wepend on healthcare and the results achieved. The Leapfrogroup, a consortium of 159 large healthcare purchasers,

reated purchasing standards. One standard is that ICUsught to be staffed by ICU physicians. Evidence support-ng this standard and its impact on improvements inlinical and economic outcomes is strong. If the standardere implemented nationally, up to 134,000 lives coulde saved annually. In addition, most hospitals, even smallnes with 6-bed ICUs, would realize a net savings bymplementing IPS standard.

Given the evidence for improved clinical and eco-omic outcomes with IPS, further research is needed toetter understand what hospitals are doing in response tohe standard, what the barriers are to implementing thetandard, and what factors facilitate implementation. Be-

dard*

Number of ICU Beds

6 12 18

1,752 3,504 5,256350 701 1,051

592,800 592,800 592,800

60,000 120,000 180,00070,080 140,160 210,240

462,720 332,640 202,560312,000 312,000 312,000774,720 644,640 514,560

805 805 8051,495 1,495 1,495

18,000 18,000 18,000

53 105 158159 315 474

237,705 470,925 708,630

0.9 0.9 0.91,346 1,346 1,346

471,463 942,926 1,414,390

1.43 1.43 1.431,151 1,151 1,151

402,850 806,851 1,209,701

450 450 450157,500 315,450 472,950

1,287,518 2,554,152 3,823,671512,798 1,909,512 3,309,111

staffing: financial modeling of the Leapfrog standard. Crit Care Med

S Stan

hysician

ause healthcare costs continue to rise, purchasers are



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ikely to continue to search for strategies that improveuality and reduce costs; the call from the bull frogs isikely to grow louder.

cknowledgments

Support for this manuscript was provided by a grant fromhe Commonwealth Fund (Grant No. 20020637).

eferences

1. Institute of Medicine: Crossing the Quality Chasm: A New Health Systemfor the 21st Century. Washington, DC, National Academy Press, 2001

2. McGlynn EA, Asch SM, Adams J, et al: The quality of health care deliveredto adults in the United States. N Engl J Med 348:2635-2645, 2003

3. Schuster M, McGlynn E, Brook R: How good is the quality of healthcare in the United States? Milbank Quarterly 76:517-563, 1998

4. Pronovost PJ, Rinke M, Emery K, et al: Interventions to reduce mortalityamong patients treated in Intensive Care Units. J Crit Care 19(3):158-164,2004

5. McGlynn E: There is no perfect health system. Health Aff 23:100-102,2004

6. Reinhardt U, Hussey P, Anderson G: U.S. health care spending in aninternational context: why is U.S. spending so high and can we affordit? Health Aff 23:10-25, 2004

7. Levit K, Smith C, Cowan C, et al: The Health Accounts Team. Healthspending rebound continues in 2002. Health Aff 23:147-159, 2004

8. Hussey P, Anderson G, Osborn R, et al: How does the quality of carecompare in five countries. Health Aff 23:89-98, 2004

9. Halpern N, Pastores S, Greenstein R: Critical care medicine in theUnited States 1985-2000: an analysis of bed numbers, use and costs.Crit Care Med 32:1254-1259, 2004

0. Andrews L, Stocking C, Krizek T, et al: An alternative strategy forstudying adverse events in medical care. Lancet 349:309-313, 1997

1. Milstein A, Galvin R, Delbanco SF, et al: Improving the safety of
health care: the leapfrog initiative. Eff Clin Pract 3:313-316, 2000
2. Eikel C, Delbanco S: The Leapfrog Group for patient safety: reward-ing higher standards. Jt Comm J Qual Saf 29:634-639, 2003

3. Angus D, Kelley M, Schmitz R, et al: Caring for the critically illpatient. Current and projected workforce requirements for care ofthe critically ill and patients with pulmonary disease: can we meetthe requirements of an aging population? JAMA 284:2762-2770,2000

4. Lipsett P, Swoboda S, Dickerson J, et al: Survival and functional outcomeafter prolonged intensive care unit stay. Ann Surg 23:262-268, 2000

5. Birkmeyer JD, Birkmeyer CM, Wennberg DE, et al: Leapfrog patientsafety standards: the potential benefits of universal adoption. Wash-ington, DC, The Leapfrog Group, 2000

6. Birkmeyer JD, Dimick JB: Leapfrog safety standards: potential bene-fits of universal adoption. Washington, DC, The Leapfrog Group, 2004

7. Pronovost PJ, Needham D, Waters H, et al: Intensive care unit phy-sician staffing: financial modeling of the Leapfrog standard. Crit CareMed 32:1247-1253, 2004

8. Rosenfeld B, Dorman T, Breslow M, et al: Intensive care unit tele-medicine: alternate paradigm for providing continuous intensivist care.Crit Care Med 28:3925-3931, 2000

9. Breslow MJ: Effect of a multiple-site intensive care unit telemedicineprogram on clinical and economic outcomes: an alternative paradigmfor intensivist staffing. Crit Care Med 32:31-38, 2004

0. Pronovost PJ, Angus DC, Dorman T, et al: Physician staffing patternsand clinical outcomes in critically ill patients: a systematic review.JAMA 288:2151-2162, 2002

1. Annane D, Sebille V, Charpentier C, et al: Effect of treatment with lowdoses of hydrocortisone and fludrocortisone on mortality in patientswith septic shock. JAMA 288:862-871, 2002

2. The Acute Respiratory Distress Syndrome Network: Ventilation withlower tidal volumes as compared with traditional tidal volumes foracute lung injury and the acute respiratory distress syndrome. N EnglJ Med 342:1301-1308, 2000

3. Van Den Berghe G, Wouters P, Weekers F, et al: Intensive insulintherapy in critically ill patients. N Engl J Med 345:1359-1367, 2001

4. Bernard G, Vincent J, Laterre P, et al: Efficacy and safety of recom-binant human activated protein C for severe sepsis. N Engl J Med344:699-709, 2001

5. Rockeymoore M, Holzmueller C, Milstein A, et al: Updating theLeapfrog Group intensive care unit physician staffing standard. J Clin
Outcomes Manag 10:31-38, 2003

evaluating the impact of the leapfrog group’s standard for intensive care unit physician staffing

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