An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine.

RATIONALE: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs. OBJECTIVES: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting. METHODS: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law. MAIN RESULTS: The policy recommendations are based on the dual goals of protecting patients' access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a "shield" to protect individual clinicians' moral integrity rather than as a "sword" to impose clinicians' judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient's or surrogate's timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician's CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting. CONCLUSIONS: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians' COs in the critical care setting.

Quality improvement and cost savings after implementation of the Leapfrog intensive care unit physician staffing standard at a community teaching hospital.

BACKGROUND: Prior studies have shown that implementation of the Leapfrog intensive care unit physician staffing standard of dedicated intensivists providing 24-hr intensive care unit coverage reduces length of stay and in-hospital mortality. A theoretical model of the cost-effectiveness of intensive care unit physician staffing patterns has also been published, but no study has examined the actual cost vs. cost savings of such a program. OBJECTIVE: To determine whether improved outcomes in specific quality measures would result in an overall cost savings in patient care DESIGN: Retrospective, 1 yr before-after cohort study SETTING: A 15-bed mixed medical-surgical community intensive care unit PATIENTS: A total of 2,181 patients: 1,113 patients preimplementation and 1,068 patients postimplementation. INTERVENTION: Leapfrog intensive care unit physician staffing standard MEASUREMENTS: Intensive care unit and hospital length of stay, rates for ventilator-associated pneumonia and central venous access device infection, and cost of care. RESULTS: Following institution of the intensive care unit physician staffing, the mean intensive care unit length of stay decreased significantly from 3.5±8.9 days to 2.7±4.7 days, (p<.002). The frequency of ventilator-associated pneumonia fell from 8.1% to 1.3% (p<.0002) after intervention. Ventilator-associated pneumonia rate per 100 ventilator days decreased from 1.03 to 0.38 (p<.0002). After intervention, the frequency of the central venous access device infection events fell from 9.4% to 1.1% (p<.0002). Central venous access device infection rate per 1000 line days decreased from 8.49 to 1.69. The net savings for the hospital were $744,001. The 1-yr institutional return on investment from intensive care unit physician staffing was 105%. CONCLUSIONS: Implementation of the Leapfrog intensive care unit physician staffing standard significantly reduced intensive care unit length of stay and lowered the prevalence of ventilator-associated pneumonia and central venous access device infection. A cost analysis yielded a 1-yr institutional return on investment of 105%. Our study confirms that implementation of the Leapfrog intensive care unit physician staffing model in the community hospital setting improves quality measures and is economically feasible.