Indian Journal of Critical Care Medicine
Medknow Publications on behalf of the Indian Society of Critical Care Medicine
ISSN: 0972-5229 EISSN: 1998-359x
Vol. 10, Num. 1, 2006, pp. 53-63
Indian Journal of Critical Care Medicine, Vol. 10, No. 1, January-March, 2006, pp. 53-63
Critical care delivery in intensive care units in India: Defining the functions, roles and responsibilities of a consultant intensivist
Indian Society of Critical Care Medicine Committee
Recommendations of the Indian Society of Critical Care Medicine Committee
on Defining the Functions, Roles and Responsibilities of a Consultant
J. V. Divatia1, A. K. Baronia2, A. Bhagwati1,
R. Chawla3, S. Iyer4, C. K. Jani1, S. Joad5,
V. Kamat6, F. Kapadia1, Y. Mehta3,
S. N. Myatra1, S. Nagarkar1, V. Nayyar7*, S.
Padhy8, R. Rajagopalan6, N. Ramakrishnan6,
B. Ray9, S. Sahu10, S. Sampath11, S. Todi12
From: *(Formerly from Bangalore), 1Mumbai, 2Lucknow, 3Delhi, 4Pune, 5Jaipur, 6Chennai, 7Sydney, 8Indore, 9Jamshedpur, 10Bhubaneshwar, 11Bangalore, 12Kolkata
Code Number: cm06011
Over the last few years, there has been a tremendous increase in the knowledge, technology and skills required to treat critically ill patients. This has lead to the development of intensive care units (ICUs), which are essentially areas, where severely ill patients can be concentrated and looked after and provided with the infrastructure and expertise necessary to treat critical illness. Current ICU patterns result in the patient being admitted under a primary consultant, before admission to the ICU. Often this primary consultant is not an intensive care specialist and may not be conversant with the current critical care practices and guidelines. The presence of a consultant intensivist (critical care specialist) in this setting has been demonstrated, to greatly increase patient safety and to improve outcomes in terms of morbidity, mortality, length of stay and costs.
While the concept of the intensive care unit has gained widespread
acceptance amongst medical professionals, hospital administrators and
the general public, recognition of the need and role for doctors specialising
in intensive care medicine, has lagged behind. One of the reasons may
be that intensive care medicine is a relatively new speciality; social,
political and economic factors also undoubtedly play a role in preventing
wholehearted acceptance of a consultant intensivist in the hospital.
Nevertheless, it is becoming increasingly clear that the presence of
an intensive care medicine specialist working in the intensive care unit
improves outcomes, in terms of various previously mentioned quality indicators. In
the United States, the Leapfrog Group, a group of more than 170 companies
and organizations that buy health care and work together to reduce preventable
medical mistakes and improve the quality and affordability of health
care, mandates that hospitals fulfilling the ICU Physician Staffing standard
will operate adult and/or pediatric ICUs that are managed or co-managed
by intensivists .
A number of our members are practicing as consultant intensivists on
a part time or full time basis. Also, a number of trainees and graduates
of the Indian Society of Critical Care Medicine (ISCCM) Certificate
Course, the Post-Doctoral Fellowship programme of the National Board
of Examinations (NBE) and other critical care programmes are being
appointed as consultant intensivists in various hospitals throughout
the country and this trend is going to increase. It is essential that
the training, talent and services of trained consultant intensivists
be appropriately utilised in hospitals for the benefit of patients.
It is imperative that in this dual consultant model (involving the
primary consultant and the consultant intensivist in the ICU), the
relationship should be one that promotes an equal partnership and
This committee of the ISCCM was set up to formulate recommendations
on how consultant intensivists may be utilised in hospitals, so
that they give their best as intensive care specialists and receive due
recognition and acknowledgment of their efforts from patients and
health care professionals.In this document, the terms intensive
and critical care medicine and the terms consultant intensivist
and critical care specialist, have been used interchangeably.
Committee members were selected to represent a variety of intensive
care practices across the country. The experience of the committee member's
practice ranged from practice in open, transitional and closed ICUs;
senior, established consultant intensivists, to freshly qualified, young
consultant intensivists; practice in large multispeciality hospitals
to practice in nursing homes; practice in large cities to practice in
smaller towns; private hospitals to public hospitals and academic centres.
Individual committee members wrote of the systems they had adopted in
their ICUs and hospitals, successes and failures of their respective
systems of care and suggestions for improvement. The collective experiences
were pooled towards development of the recommendations.
tried to answer the following questions:
- Who is a consultant intensivist?
- Does a consultant intensivist make a difference to outcomes of critically
- What system of ICU care is best?
- What is the role of the consultant intensivist in a hospital? I.e. how
should the consultant intensivist function in the ICU in general
and his interaction and relationship with the primary consultant in particular.
- How can the services of the consultant intensivist be best utilised
for improved patient outcomes?
In order to answer the above questions, the Committee members reviewed
the relevant literature and also looked at guidelines of professional
organisations, including those of the ISCCM, Society
of Critical Care Medicine (USA) and
the Australia and New Zealand Joint Faculty of Intensive Care Medicine. Recommendations
are based on the interpretation of the literature as well as the expert
opinion of the committee, arrived at after mutual discussion, personally
and by email.
Levels of Evidence are graded as follows: Level I: Large, randomized
trials with clear-cut results; low risk of false-positive or false-negative
Level II: Small, randomized trials with uncertain results; moderate to
high risk of false-positive and/or false-negative error Level III: Nonrandomized,
concurrent cohort comparisons, contemporaneous controls Level IV: Nonrandomized,
historical cohort comparisons/controls and expert opinion Level V: Case
series, uncontrolled studies and expert opinion
Who is a consultant intensivist?
The ISCCM defines an intensivist as follows: The intensivist should
have a postgraduate qualificationFNx01 in Internal Medicine, Anaesthesia,
Pulmonary Medicine or Surgery and either a) An additional qualification
in Intensive Care such as DM, DNB Post Doctoral Fellowship, Certificate
Course of the ISCCM, or qualifications from abroad such as the European
Diploma in Intensive Care, American Board Certification, Australian or
New Zealand Fellowship (FANZCA or FFICANZCA). OR b) At least one-year's
training in a reputed ICU abroad.[FNx01: A few candidates of the ISCCM
Certificate Course who have been certified with a 3-year training programme
in Intensive Care after M.B.B.S, are also recognised as Intensivisits.
Since January 2003, M.B.B.S. graduates are no longer be eligible for
certification and only those with a postgraduate diploma or degree can
qualify for the
In addition, persons so qualified or trained must have at least two-years' experience in the ICU (at least 50% time
spent in the ICU), to work in a secondary level (Level 2) ICU and three-years
experience to work in a tertiary level (Level 3) ICU.
In case of doctors not having either of the above mentioned qualifications
or training, they should have extensive experience in intensive care
in India, quantified as at least three years' experience in the ICU (at least 50% time
spent in the ICU), for a Secondary level (Level 2) ICU and five years
experience for a Tertiary level (Level 3) ICU.
Does a Consultant intensivist make a difference to outcomes of critically ill patients?
A number of observational studies- suggest
that ICU mortality and costs are lower with a consultant intensivist
present in the ICU.
There are a number of small, nonrandomized studies primarily using
historical controls (level IV) that support the presence of a consultant
in the the ICU compared, with a prior model without a consultant intensivist.
These studies were usually done when there was a change in ICU organizational
structure, primarily the addition of a consultant intensivist. ICU outcome
data (usually mortality) from a time period before the addition of the
consultant intensivist are compared with data for a time period, after
the addition of the consultant intensivist care delivery.
Pronovost PJ, Jenckes MW, Dorman T, et al: Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA 1999; 281:1310-1317 (level III evidence)
This is a large observational, nonrandomized study, using contemporaneous
controls. The study was done using the Maryland Health Discharge Data
Set, with a focus on 2987 patients undergoing major abdominal aortic
The authors showed that daily rounds in the ICU by an ICU physician were
associated with reduced in-hospital mortality and specific postoperative
medical complications. The magnitude of this mortality reduction was
equivalent to that observed in other studies, that compared the skill
volume) of operating surgeons.
Hanson CW, Deutschman CS anderson HL, et al: Effects of an organized critical care service on outcomes and resource utilization: A cohort study. Crit
Care Med 1999; 27:270-274 (level III evidence)
This study compared two different concurrent care models of surgical
ICU patients. One group was managed exclusively by the critical care
attending service and the other by the general surgical faculty and house
Despite higher severity of illness scores, the critical care patient
group had shorter ICU lengths of stay, fewer days of mechanical ventilation,
fewer arterial blood gases, fewer consultations, fewer complications,
hospital lengths of stay and fewer Medicare-adjusted charges.
Pronovost PJ, Angus DC, Dorman T, et al: Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA . 2002; 288:2151-6
This systematic review of the available literature regarding ICU
physician staffing and outcomes, concluded that, there is a consistent
decreased mortality and length of stay with consultant intensivist presence.
Reynolds NH, Haupt MT, Thill-Baharozian MC, et al: Impact of critical care physician staffing with septic shock in a university hospital medical intensive care unit. JAMA 1988; 260:3446-3450 (Level IV evidence)
In a retrospective review of MICU records, two consecutive 12-month
periods of time were compared. During the first time period, the ICU
was without critical care-trained faculty and during the second time
the ICU was supervised by critical care-trained faculty. Severity of
illness scores were comparable during the two time periods. Mortality
decreased during the post critical care medicine time period.
Brown JJ, Sullivan G: Effect on ICU mortality of a full-time critical care specialist. Chest 1989; 96:127-129 (level IV evidence)
A retrospective review was conducted of two time periods (consecutive
years) in a MICU, before and after the addition of a trained critical
care specialist (consultant intensivist). Despite similar severity of
the mortality rate was significantly lower during the consultant intensivist
Manthous CA, Amoateng-Adjepong Y, Al-Kharrat T, et al: Effects of medical consultant intensivist on patient care in a community teaching hospital. Mayo
Clin Proc 1997; 72:391-399 (level IV evidence)
This was a retrospective review of MICU patient admissions comparing
two consecutive time periods before and after the addition of a medical
consultant intensivist. Patient severity of illness was similar during
the two time periods. Mortality for pneumonia, mean length of hospital
stay and MICU stay, were all reduced after the addition of the medical
Blunt MC, Burchett KR: Out-of-hours consultant cover and case-mix-adjusted mortality in intensive care. Lancet 2000; 356:735-736 (level IV evidence)
A historical case control study examined standardized mortality
ratios in 452 patients admitted to an ICU after a consultant intensivist
the staff, compared with 372 patients before the consultant intensivist's arrival. Severity of illness scores were comparable in both groups; however, the standardized mortality ratio improved significantly in the consultant intensivist group (0.81 vs. 1.11; ratio, 0.73 [95% confidence
What system of ICU care is best?
There is much debate on who should admit and manage critically ill
patients in the ICU. A Closed unit is one, where once a patient enters
the ICU, primary care of the patient is transferred to the consultant
intensivist. The consultant intensivist takes all the major decisions
in the ICU, including
admission to and discharge from the ICU. Once the patient goes out of
the ICU, care of the patient is transferred back to the primary consultant.
An Open ICU is one in which any consultant may admit a patient to the
ICU, with or without the knowledge or consent of the consultant intensivists.
Often, such ICUs may not even have a consultant intensivist on their
The primary consultant remains in charge, makes all decisions regarding
patient management, including whether or not a consultant intensivist's consultation is required. The consultant intensivist may be asked to look after only certain parts of patient management (e.g. ventilation). It is not uncommon to find such a patient being managed by a series of single-organ specialists (e.g. gastroenterologist, nephrologist, neurologist, cardiologist, etc). As with all other consultations, the consultant intensivist's
recommendations may not be accepted by the primary consultant. The junior
staff in the ICU (housemen, registrars) report on that patient to the
referring consultant and not to the consultant intensivist.
A Semiclosed or Transitional unit is one which lies in between. There
is a mandatory consult and daily rounds by the consultant intensivist,
all patients admitted in the ICU. The primary consultant as well as the
consultant intensivist play a significant role in patient care. Orders
are written by consultant intensivist or by primary team, in consultation
with consultant intensivist. A large proportion of care is provided by
the consultant intensivist and his team, in consultation with the primary
consultant. There is now an increasing body of literature supporting
the closed ICU systems, over open ICUs.-
Topeli A, Laghi F, Tobin MJ. Effect of closed unit policy and appointing an intensivist in a developing country. Crit
Care Med . 2005; 33:299-306
This study from Turkey looked at the effect of changing over to
a closed system in a medical ICU of a university hospital. Data were
collected over 5 months before the policy change (open policy) and over
an initial 6 months (early closed policy) and subsequent 12 months (late
closed policy) after the policy change. Instituting a closed policy and
simultaneously appointing a critical care specialist was associated with
the admission of sicker patients and more frequent use of invasive procedures.
Compared with open policy, patients were approximately 4.5 times more
likely to survive their hospital stay during early closed policy ( P < 0.001)
and approximately five times more likely during late closed policy ( P < 0.0001). Among patients receiving mechanical ventilation, hospital mortality was lower during the early (57%) and late closed periods (59%), than during open period (91%; P < 0.01).
The authors concluded that the dual strategy of closed policy and simultaneously
appointing an intensivist fostered admission of sicker patients and improved
the survival of patients requiring admission to an ICU of a developing
Carson SS, Stocking C, Podsadecki T, et al: Effects of organizational
change in the medical intensive care unit of a teaching hospital: A comparison
of 'open' and 'closed'formats. JAMA 1996; 276:322-328 (level III evidence)
This was a prospective cohort study which compared two consecutive
time periods of ICU care. In the first period, there was an open ICU
organizational structure, wherein critical care specialists consulted
on all ICU patients
and made recommendations, but the admitting attending physician retained
primary responsibility for patient care. The second period had a closed
format. The critical care attending physician assumed primary responsibility
for all patient care and the admitting physician was a consultant. Despite
significantly higher severity of illness scores during the closed ICU
organization, the risk-adjusted mortality score was 0.78, compared with
0.90 in the open
ICU organization. Resource utilization did not increase during the closed
unit structure, despite higher severity of illness.
Multz, AS, Chalfin DB, Samson IM, et al: A closed medical intensive care unit (MICU) improves resource utilization when compared with an open MICU. Am
J Respir Crit Care Med 1998; 157:1468-1473 (level IV evidence)
A retrospective analysis of two time periods in one hospital was
compared, as the ICU administrative structure changed from an open organizational
structure to a closed one. In addition, another cohort of patients was
prospectively analyzed, wherein one group from one hospital managed in
an open ICU organizational structure, was compared with another group
another hospital managed in a closed ICU organizational structure (prospective
analysis). Illness severity and primary diagnostic categories between
groups, were comparable. ICU and hospital length of stay was less in
An open ICU format was associated with greater mortality prediction.
Ghorra S, Reinert SE, Cioffi W, et al: Analysis of the effect of conversion from open to closed surgical intensive care unit. Ann
Surg 1999; 229:163-171 (level IV evidence)
This is a retrospective review comparing two time periods (open
unit vs. closed unit) in a surgical ICU. Mortality and overall complications
were significantly higher in the open-unit group, compared with the closed-unit
Cole L, Bellomo R, Silvester W, et al: A prospective, multicenter
study of the epidemiology, management and outcome of severe acute renal
in a "closed" ICU system. Am J Respir Crit Care Med 2000; 162:191-196 (level III evidence)
This was a prospective, observational study examining the outcome
of acute renal failure requiring replacement therapy (severe acute renal
failure), within closed ICU systems in Australia. The study was conducted
over a 3-month period in all nephrology units and ICUs in the state of
Victoria, Australia. By using the SAPS II score or a recently validated
renal-failure specific score, the predicted mortality for these patients
was shown to be 59%. Actual mortality was 49.2%. The authors
concluded that patients with renal failure managed in closed ICU systems
in Australia, had favorable outcomes compared with predicted mortality.
Knaus WA, Draper EA, Wagner DP, et al: An evaluation of outcome from intensive care in major medical centers. Ann
Intern Med 1986; 104:410-418 (level III evidence)
This study is the post hoc analysis of the original Acute
Physiology and Chronic Health Evaluation (APACHE) II database. This study
was a large, nonrandomized observational study. There were 13 hospitals
and 5,030 patients used to develop the APACHE II severity of illness
system. The authors ranked ICUs by the actual or observed mortality and
hospital deaths (standardized mortality ratio, SMR). When stratified
by SMR, it was demonstrated that the best ICU was well organized, with
and policies including the canceling of elective operating room cases,
if no beds were available. There were also a high proportion of bedside
nurses who had master's degree. In addition, there were no interns
(postgraduate year-1) in this unit. The lowest-ranked hospital did not
have an organized medical program and had a substantial shortage of nursing.
There was an atmosphere of distrust and there was no coordination of
care. It is concluded that organized ICUs as defined in this review,
There is increasing evidence that closed- or
transitional models- have
better outcomes and resource utilisation, than open ICUs. The ISCCM
discourages the adoption or continuance of open ICUs. Our preference
is for the closed
model to be adopted in general medical-surgical, as well as speciality
ICUs; however the transitional model is acceptable till closed units
Executive Summary of Recommendations
Defining the functions, role and responsibilities of the consultant intensivist
Admissions to and discharges from the ICU
The consultant intensivist must be informed of all admissions to the ICU. Preferably, no ICU admission should take place without the prior knowledge of the consultant intensivist and the decision to transfer the patient to the ICU should be taken after consultation with the consultant intensivist, or a designated member of the critical care team.
Discharge of a patient from the ICU should be with the knowledge of
the consultant intensivist. The consultant intensivist should have the
authority to discharge patients from the ICU, in order to accommodate
Overall co-ordination about admissions to and discharges from the ICU,
should be done by the intensive care medical team.
It is essential to prioritise admissions. The consultant intensivist
is ideally placed to triage patients, prioritise admissions and maintain
a waiting list. He / she is also best placed to select the patients most
suitable for early discharge, to make a bed available for admitting a
new critically ill patient. This will ensure that intensive care will
be available to patients who most deserve and are most likely to benefit
from intensive care.
Responsibility of the consultant intensivist
The consultant intensivist must communicate with the referring
consultants and explain the priority for admission, in a logical and scientific
manner. The presence of written protocols outlining how patient admissions
will be prioritised, is helpful. When discharging a patient from the ICU,
the consultant intensivist should be satisfied that the patient is suitable
for transfer out of the ICU and should communicate with the referring consultant,
the reasons for an early discharge, as well as any special instructions
to be followed on the wards.
All patients admitted to the ICU must be seen by a consultant intensivist.
- It is mandatory to have a critical care consult, once the
patient is in the ICU.
- Except in a closed ICU where the consultant intensivist
and his team takes over care of the patient, the responsibility for
patient management is
shared between the consultant intensivist and the primary consultant.
It is mandatory that the relation between ICU and external consultants
one of an equal partnership.
- The consultant intensivist must do daily rounds on all ICU patients. It is desirable to get radiology, microbiology, pharmacy and input from other disciplines, during these rounds. It is helpful if members from the primary consultant's
team are present during the ICU rounds. During these rounds, the consultant
intensivist needs to do the following.
- Be familiar with all relevant clinical aspects of the history
- Do a focused and relevant clinical examination.
- Review all the radiology, laboratory and microbiology data.
At this point, he/she needs to ensure that all recent test reports
have been collected,
seen and appropriate action has been taken.
- Review the input by all the specialists involved in the
care of the patient. If needed, further opinions may be sought.
- Make a clear plan for the next 12-24 hours. This should
include all aspects of management including, but not limited to major
organ support, fluid
therapy, nutrition and antibiotics. It should also specify the
appropriate preventive measures including, but not limited to prevention
sores and appropriate DVT and stress ulcer prophylaxis.
- Check that all prior jobs generated by previous rounds
and by other consultants have been completed.
- Ensure clear documentation of Consultant and junior medical
- It is desirable that all orders are written by the intensive
care medical team.
- The consultant intensivist should periodically review the patient's
progress and may make necessary changes in patient management.
- A member of the ICU team should accompany the primary consultant
on his rounds, to facilitate co-ordination between the consultant intensivist
and the primary consultant.
- Any change in patient management desired by the primary
consultant, should take place after discussion and consultation with
the consultant intensivist.
All new orders should then be written by the intensive care medical
- Progress notes should be written by the intensive care medical team, as well as the primary consultant's and other consultants'teams.
- Common ICU procedures should be performed by the consultant
intensivist,or by personnel designated by the consultant intensivist
under his / her supervision.
- The consultant intensivist must be informed of any change in the
This information should also be communicated to the primary
consultant. Any emergency intervention should be performed by the intensive
- The consultant intensivist or referring consultant may
seek specialist consultations for the ICU patient,when required. The
must co-ordinate the advice of various consultants and devise
a plan of management for the patient as a whole.
- The decision to transport a patient within the hospital
or outside the hospital must be taken by the consultant intensivist,
in consultation with
the primary consultant. The risks and benefits of transport must be
- It is the responsibility of the intensive care team to
organise safe transport of the patient from the ICU and back to the
ICU. The ISCCM guidelines
transport of the critically ill patient (under preparation) may be
Responsibility of the consultant intensivist
of the consultant intensivist
ensure that any conflict
is avoided, without compromising
and by ensuring that standard practice guidelines and protocols
in the care of the patient. This necessitates adequate communication
between ICU and external consultants. The consultant needs to
procedures are done safely and competently. Teaching and training
of junior medical staff is the responsibility of the consultant
Communication with patients and their families
- The consultant intensivist must communicate with the patients
and / or their family members, the nature and seriousness
of the illness, the plan of management and the progress of the patient.
The consultant intensivist should discuss the patient's
progress with the primary consultant and ensure that the patient
and family are
given accurate and uniform information by all medical and nursing
End of life decisions
care may be futile in certain situations and initiate
with the family, in co-ordination with the primary consultant.
intensivist must ensure that the primary consultant and
nursing staff are in broad agreement, that an end-of-life
- The consultant intensivist should identify brain-dead patients
and liase with the transplant co-ordinators where appropriate.
Responsibility of the consultant intensivist
illness is not given by different medical teams. This creates
and is the basis
action. In the Indian multicultural context, the intensivist
should be sensitive
to social and
issues. The consultant
advised to read the end-of-life position statement published
by the ISCCM.19
Time Commitment to the ICU
- The consultant intensivist must either be present in the
ICU during daytime working hours or in the hospital and rapidly available
to the ICU when required.
- n a department with more than one consultant, cross cover
between consultants should be ensured. A consultant roster may be made
for ICU rounds and cover,
procedure supervision, CPR and Medical Emergency Team (MET) and out
of hours telephonic consultation and cover.
- It is not mandatory for the consultant intensivist to be
present in the ICU at night. However junior medical staff that can
with the consultant and carry out orders, must be present in the ICU.
The consultant intensivist must be continuously available for consultation
on phone and come into the ICU if needed.
- Hospital managements should ensure that adequate number
of consultant intensivists are appointed to provide coverage at all
times, while making provision
for leave, conferences, illness and vacations.
Responsibility of the consultant intensivist
There is a need for the presence of trained intensive care medical
staff round the clock. It is the duty of the consultant intensivist to
appoint, train and teach junior medical staff and roster them so that
the ICU is staffed by competent personnel, especially outside routine
hours. Written protocols should be available for patient management,
including but not limited to patient assessment, procedures, management
of common emergencies and transport.
Privileges Outside the ICU
The consultant intensivist may undertake commitments outside the ICU (e.g. clinics, admission privileges in the ICU and wards), but must ensure that he / she is readily available to the ICU at all times. Services outside the ICU - The consultant intensivist may also provide services such as but
not limited to
- Management of patients in the high-dependency unit Medical Emergency Team:Emergency department, including the Trauma teamCPR teamArtificial airway management
- Invasive procedures outside the ICU (e.g, Central Line, PICC lines,
Lumbar puncture, Insertion of feeding tubes etc)
A consultant intensivist may act as a consultant for the ICU Outreach
Services. The outreach services of critical care medicine plays a pivotal
role in improving patient care, in wards by providing all logistic
support for early recognition of acute life threatening events and treatment
interventions to stabilize sick patients who are at the risk of developing
life threatening events. The concept of the medical emergency team
is gaining wide acceptance.
Follow-up of patients outside the ICU
- Once a patient has been discharged from the ICU, the consultant
intensivist must transfer care to the primary consultant.The consultant intensivist may continue to provide care
to the patient on the wards, if requested to do so by the primary consultant
- If the consultant intensivist is the primary consultant
of the patient, then the above do not apply.
Maintaining standards of intensive care practice
- One of the major roles of the consultant intensivist
is to ensure that adequate medical and safety standards
are maintained throughout
the patients stay. This is best done by the creation and
implementation of appropriate protocols and practice guidelines. These
but are not limited to, protocols for Performance of standard ICU procedures Mechanical ventilation, renal replacement therapy and other major
life support Care of the airwaySedation and analgesiaInfection control Transport of the ICU patientIt is the duty of the consultant intensivist to ensure that the nursing,
technical and junior medical staff,are aware of the
protocols and comply with their implementation.
- Maintenance of a clear chain of command is essential for
optimal patient care. It is the duty of the consultant intensivist
major decisions are not made independently by junior medical staff.
Its is equally the duty of the consultant intensivist to ensure that
major decisions are not unduly delayed, due to inability to contact
Protocolized care and availability of second on call consultant intensivists
ensure that safety standards are not compromised.
- When more than one consultant intensivist is appointed in
the ICU, it is highly desirable that that they function as a department,
rather than autonomous individuals. In such a department, one of the consultant intensivists should function
as the ICU Director.The consultant intensivist should co-ordinate with other departments
in the hospital, to ensure that their services are delivered to the
ICU in an efficient and timely manner, whenever required. The consultant intensivist must play a key role in the design, maintenance
and upgradation of the ICU, including the physical structure and equipment
in the ICU.The consultant intensivist should have a clear role in the choice of
equipment, drugs and other consumables like catheters, filters etc.
He / she must firmly veto the purchase and use of substandard products,
in an attempt at cost saving or profit maximizing.The consultant intensivist should interact with the hospital administration
to ensure that the ICU is staffed with adequate number of appropriately
qualified staff, including junior medical staff, nurses and other paramedical
staff.The consultant intensivist should maintain unit statistics and run
regular audits and quality assurance and quality improvement programmes
for the ICU.
- The consultant intensivist must be member of the hospital infection
control committee, purchase committee and play a role in the formulation
of antibiotic policies, transport policies, admission and discharge
- In the interest of transparency and justice, all payments
should be documented and be of a rationalized structureThese should be in accordance with hospital policy and in accordance
with the underlying principle of an at par relationship with other
consultants. The consultant intensivist may receive a fixed salary,
or a fee for service. If fee is for service, the fees include consultation charges, which
may be more than one in a day and procedure charges.
- Charges for procedures performed by the ICU team in the ICU should
be billed to the consultant intensivist. All charges should be at
par with similar services provided by other speciality consultants,
- Teaching forms a vital component of the consultant intensivist's
workload. Even in units that do not have formal training programmes,
it is essential that junior medical staff is taught the basics of
intensive care. This is because medical graduates have had little or
to intensive care during their undergraduate or postgraduate training.
Junior medical staff should be taught and encouraged to attend courses
including, but not limited to Basic and Advanced Cardiac Life Support,
Acute Trauma Life Support and Fundamentals of Critical Care Support.
They should be made familiar with management guidelines for common
problems, including but not limited to management of acute myocardial
infarction and the Surviving sepsis guidelines. Procedures should
be taught and supervised and emphasis must be laid on infection control
measures, including handwashing, aseptic techniques and rational
programmes and protocols for nurses should be developed.
- It is also useful to conduct symposia and case discussions in the
hospital to increase awareness and confidence in the capabilities of
Role of the Consultant Intensivist in a Teaching Hospitals
- Although true for almost all clinical specialties, a teaching
ICU more than any other, requires an environment where a teacher assumes
responsibility of role modelling. This is especially important not only in
how their ICU
trainees are moulded, but also how other residents training in
other specialities look at consultant intensivists and ICUs.Teaching hospitals should follow as much of a closed model as possible.Courses covering concepts of intensive care medicine may be offered
to postgraduate students of various faculties. The courses can teachCardiopulmonary resuscitationAirway obstruction: Early recognition and interventionCirculatory instability: Early recognition and interventionGeneral Principals of Mechanical Lung Ventilation o General Principals
of Intensive Care
- Prevention of Acute Life Threatening Events in patients admitted in
- Consultant intensivists are encouraged to conduct research,
especially in topics relevant to IndiaConsultant intensivists should also participate in acquisition of
Indian data relating to global issues in critical care.Research may take the form of audits, observational studies and randomised
clinical trialsAudits are valuable for both quality improvement, as well as research
projects. Consultant intensivists should follow standard ethical and regulatory
guidelines in the conduct of research.There is paucity of data with the ISCCM on the current models of
delivery of intensive care and the current role and status of intensivists
across the country. The committee recommends that the ISCCM should
maintain a database of ICU's
and survey delivery models and intensive care practice every year. This
will not only provide invaluable epidemiological data, but will help
track the changing patterns of intensive care delivery in India.
- The ISCCM should consider evolving a mechanism by which patient data
(including progress notes and ICU flow-charts) are recorded in a standardised
uniform format. All ICUs should also be encouraged to maintain data
on admissions and have some scoring system in place. This will facilitate
capturing of data on admissions diagnoses, disease patterns, case-mix
and epidemiology of intensive care medicine in India. In the long-term,
this will help in planning future multi-centre trials in Indian ICUs.
General Responsibilities of the Consultant Intensivist
- In the hospital, the consultant intensivist must demonstrate
ethical values, expertise and professionalism, in day-to-day work.
The consultant intensivist must put the patient at the centre of
all decisions and actions. The consultant intensivist should promote the culture of competent,
compassionate and cost-effective care of the critically ill patient The consultant intensivist should develop and maintain excellent rapport,
co-ordination and communication with various colleagues, administrators
and other hospital personnel to facilitate high quality patient care. The consultant intensivist should evolve a work culture that promotes
relationships and avoids conflict. The consultant intensivist should continuously upgrade his / her knowledge,
competence and skills. This will not only benefit patient care, but
also improve confidence in the consultant intensivist and the ICU
- The consultant intensivist should work towards creating awareness of
the speciality of intensive care medicine amongst the medical profession,
as well as the general public.
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|2.||The Leapfrog Group for patient safety. Factsheet: ICU Physician Staffing. accessed from "http://www.leapfroggroup.org/media/file/Leapfrog-ICU_Physician_Staffing_Fact_Sheet.pdf Accessed on06/07/2005. Back to cited text no. 2 |
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