Critical Care Workforce
While it has been generally acknowledged and widely appreciated that the shortages in nursing, respiratory care practitioners and pharmacists have already reached crisis levels, there had been conflicting forecasts of the adequacy of the present and future physician labor market throughout the 1990s. Because of this, the ATS, CHEST and SCCM formed the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS) in 1995 and commissioned a study with the following goals: (1) determine current patterns of care for the critically ill and patients with pulmonary disease, (2) anticipate how demand for care might change in the future, and (3) project supply based on the current workforce and training. The COMPACCS study, published in JAMA in 2000, has convincingly predicted that the aging of the population of the United States will create a demand for care that will outpace the future supply of critical care medicine specialists, and that the effects of this shortfall in manpower will be significant after 2007.
Shortly after the COMPACCS study was published, the Collaborative became actively engaged in trying to help solve the issues within their power. In 2001 the CCSC formed the Critical Care Workforce Partnership task force that set out to accomplish two goals. The first was to analyze the current models of how critical care medicine was being delivered in the United States and what the four societies could do together to help alleviate the pressures that the manpower shortages were creating for their patients and their members. The results of this analysis and recommendations for action are the subject of the FOCCUS (Framing Options for Critical Care in the United States) Task Force report issued in 2003.
The second goal was to develop strategies to work with public policy makers to make short-term and long-term changes at the federal level that would favorably impact the reduced critical care provider workforce. The results of this effort are the subject of the 2004 report entitled “The Critical Care Medicine Crisis: A Call For Federal Action”. During the writing of this white paper, representatives of the CCSC had the opportunity to consult with members of Congress and share with them the results of the COMPACCS study as well as early drafts of the white paper. Shortly afterwards, the US Senate passed the FY03 Appropriations Bill. In that legislation, the Senate made clear that it appreciated that there was an impending crisis in health care due to manpower shortages in critical care specialists and requested that the Department of Health and Human Services, through the work of the Health Resources Services Administration, address this issue. The legislative history accompanying the FY03 Appropriations Bill for the Department of Health and Human Services states: “…the Committee remains concerned about the widening gap between the size of the nation’s aging baby boom population and the number of pulmonary/critical care physicians. Given the current funding trends for graduate medical education, we can expect a severe shortage of these specialists by 2007. The Committee therefore urges the Administrator of the Health Resources and Services Administration to consult with the American College of Chest Physicians and the members of the Critical Care Workforce Partnership to develop a comprehensive action plan to address this pending crisis.”
These workforce reports were the first initiatives of the CCSC, and they offer potential solutions to manpower shortages in critical care. The recommendations of the FOCCUS group address what the critical care societies can do, while the white paper is a call for federal action. These reports provide us with hope that the manpower shortage crisis can be avoided. They not only present sensible recommendations for viable solutions but also demonstrate that the four major critical care professional societies are willing and able to work together on common goals. The CCSC remains committed to moving forward with the recommendations and the action items in the white paper.
Subsequently in 2005 the CCSC successfully persuaded Congress to request a report on intensivist workforce by the Health Resources and Services Agency (HRSA), and the HRSA report was released in May 2006. The HRSA report is key in that it provides independent confirmation of the CCSC’s claims regarding the shortage.
A parallel effort addressed the American Medical Association (AMA). By lobbying the AMA’s House of Delegates in 2003, the Workforce Partnership successfully reversed AMA policy asserting a workforce surplus. The Partnerhip’s AMA delegates followed up with a presentation of data on the critical care shortage as part of a multispecialty panel in 2004. As a result of these efforts, the Partnership was invited to a special Work Group on Emergency Medicine and Trauma Workforce in 2005, convened by the AMA and the American College of Surgeons (ACS). This effort built on a series of reports on emergency care released by the Institutes of Medicine in June 2006. The IOM reports highlight the important link between emergency care and critical care, and noted the threat presented by the shortage of intensivists. The Work Group ultimately presented a report to the AMA’s House of Delegates, and helped prioritize current AMA policy on workforce advocacy.
As the next step in this process, the CCSC organized the PrOMIS Conference (Prioritizing the organization and management of intesnive care services in the United States) which published its recommendations in Critical Care Medicine (Crit Care Med. 2007 Apr;35(4):1193-4. )
PrOMIS Objective: Adult critical care services are a large, expensive part of U.S. health care. The current agenda for response to workforce shortages and rising costs has largely been determined by members of the critical care profession without input from other stakeholders. We sought to elicit the perceived problems and solutions to the delivery of critical care services from a broad set of U.S. stakeholders. We identified 39 stakeholders for the field of critical care medicine. Thirty-six (92%) completed the pre-conference survey and 37 (95%) attended the conference.
Participants expressed moderate to strong agreement with the concerns identified by the critical care professionals and additionally expressed consternation that the critical care delivery system was fragmented, variable, and not patient-centered. Recommended solutions included regionalizing the adult critical care system into “tiers” defined by explicit triage criteria and professional competencies, achieved through voluntary hospital accreditation, supported through an expanded process of competency certification, and monitored through process and outcome surveillance; implementing mechanisms for improved communication across providers and settings and between providers and patients/families; and conducting market research and a public education campaign regarding critical care’s promises and limitations.
This consensus conference confirmed that agreement on solutions to complex healthcare delivery problems can be achieved and that problem and solution frames expand with broader stakeholder participation. This process can be used as a model by other specialties to address priority setting in an era of shifting demographics and increasing resource constraints.
In 2007 the CCSC also endorsed the Patient-Focused Critical Care Enhancement Act. This legislation raises awareness among members of Congress and the general public about the importance of optimizing the delivery of critical care medicine and expanding the critical care workforce. The Patient-Focused Critical Care Enhancement Act was introduced in the US Senate by Senator Richard Durbin (D-IL) and Senator Mike Crapo (R-ID) and is based on the May 2006 Department of Health & Human Services, Health Resources and Services Administration (HRSA) report that confirms the increased demand for current and future critical care services will be exacerbated by an imminent shortage of critical care providers. The proposed legislation requested authorization of $9 million in appropriations for research and projects that would begin to address the current and future burden imposed by the critical care workforce shortage. The legislation was not adopted. However, the CCSC continues to support the legislation and work to have it adopted to reduce the critical care workforce shortage.
The CCSC continues to monitor the workforce situation and stands ready to take definitive action as may be necessary to both better understand workforce issues as well as working with federal agencies, legislators and training centers. Our goal is to ensure a well-prepared workforce in all professions that practice critical care to enhance patient outcomes.