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Model 'ICU WIthout Walls' Program At Montefiore Saves Lives of Critically Ill

NEW YORK CITY,NY (November 24, 2004) -- "It is well established in the medical world that rapid access to critical care saves lives," said Vladimir Kvetan, MD, Director of Critical Care Medicine (CCM) at Montefiore Medical Center. "We took that premise and ran with it to a degree most other hospitals have not. As a result, we are saving lives and reducing medical complications and costs in caring for the critically ill."

The crux of Montefiore's success is a rapid response team of 16 critical care medicine specialists, or ‘intensivists,' who are present and available 24/7 in the hospital to immediately treat the sickest patients whether they are in the emergency department (ED), in general medical surgical units, and in the intensive care units (ICUs). "A member of our team arrives, day or night, within 5 minutes of being called to any one of our 5 adult ICUs, and within 30 minutes when called to any other area in the hospital," said Kvetan.

The ICU Without Walls

"Most hospitals practice what I call 'silo' ICU medicine, with specialists practicing only in their own discipline in a specific type of unit and only during daytime hours," said Kvetan. "Montefiore, on the other hand, has an ICU without walls. Our ICU specialists, many of them triple boarded, are cross-trained to provide care in all critical care disciplines. And they are available immediately, round the clock in any department in the hospital. For example, a ‘medical care' ICU specialist on duty at night can provide critical care in a surgical ICU recovery room or in the ED."

The system is effective because the team of intensivists works directly with the administrative leadership of the hospital and has the collaboration of all departments and specialties. The CCM department also supervises a large post-graduate fellowship-training program for critical care specialists.

Program Results Lead to Fewer Deaths and Recognition by National Organizations

Through ongoing clinical and staffing improvements, Montefiore, which began its Critical Care Medicine Department in the mid-1980's, has reduced the mortality in its medical-surgical ICUs from 36% to under 8%. More recently, Montefiore has been singled out by several prominent, external organizations, who use risk-adjusted data, as providing exemplary critical care. For example, Solucient, the nation's leading source of healthcare business intelligence, picked Montefiore as having one of the nation's best ICUs, calling it a "benchmark" hospital (one of the top 100); the Alliance for Quality Health Care, a coalition of New York State insurance companies, lists Montefiore on its "honor role" of hospitals with superior care for a range of critical care diagnoses; and the Leapfrog Group, an influential national organization of health care buyers concerned with patient safety, also lauds Montefiore's programs.

Improving Care, Lowering Costs in ICU

"While we have been improving and expanding Critical Care Medicine for over two decades at Montefiore, it was in 1998 that we became a true service line, woven into the medical care and administrative fabric of the hospital," said Kvetan. "We now provide rapid resuscitation and stabilization to all Montefiore patients regardless of location and we have established a knowledgeable and humane system of palliative care for those patients who would not benefit from ICU interventions.

The Critical Care Medicine department receives more than 350 consult requests each month from the medical center's two campuses to take care of critically ill patients. Montefiore has 5 adult ICU units (a medical ICU, a cardiothoracic ICU and a surgical / neurosurgical ICU on the Moses campus; and a cardiothoracic ICU/CCU and a medical/surgical ICU on the Einstein campus). While the 56 beds in these adult units represent only 8 percent of the total beds at the two campuses, each bed costs up to four times a normal medical surgical bed.

"The United States has an exploding population of elderly patients who need increasing amounts of critical care. Our objective has been to improve the quality of care for these patients, to expand services to them, but not increase the number of ICU beds," said Kvetan. "Our system does this. Our rapid response program not only improves the quality of care, it reduces lengths of stay so that we can keep at a minimum the number of ICU beds we need." The Montefiore system has handled the impact of the national shortage of intensivists by maintaining its own large training program.

Rapid Response Reduces ED Overcrowding, Frees Up OR Rooms

"In the US, up to 10% of patients in the ED suffer from severe pneumonia, septic shock, kidney failure and the like, and they are responsible for a disproportionate amount of ED staffing time and costs. The prolonged stay of patients who require ICU care in the ED has negative impact of outcomes and the ability of the hospital to take care of more patients," said Kvetan. "Our consulting intensivists are called in to treat and triage this group of patients right away, and this frees up the ED staff to care for others."

The collaboration between ED and CCM consulting staff has allowed Montefiore to take care of a 45% increase in ED patients over the past 5 years. Even with the current 180,000 ED visits annually, the ED does not get overwhelmed.

"Another important benefit of our critical care service is that we treat continuously the most severely ill post-op neurosurgical, cardiothoracic, and general surgical patients who are severely ill after major surgery. Through our services, they get better care, sooner. This frees up OR more quickly for other patients," he said.

Plaudits from Outside Groups

Several outside groups have substantiated how the Montefiore's model team of intensivists can reduce mortality, complications and costs.

• Solucient, in its 2001 report on risk adjusted mortality, includes Montefiore as a "benchmark" hospital, where death rates were up to 26.1 percent lower than peer hospitals nationally for a range of critical care, high-risk procedures (such as brain hemorrhages, vascular and neurological surgery); 11.8 percent lower for critical care medicine admissions (such as gastrointestinal bleeding and sepsis); and 7.1 percent lower for patients with severe lung failure who required ventilator support.
• The New York State Hospital Report Card for 2004, developed by the Alliance for Quality Health Care, lists Montefiore as having a "significantly lower mortality rate" than the state's average for a broad range of critical illnesses including: coronary artery bypasses graft surgery and craniotomies, both of which are surgical ICU areas well-staffed by critical care, as well as the general acute diagnoses of heart attacks, congestive heart failure, acute stroke and pneumonia.
• In the just-released 2004 Leapfrog Group survey of hospitals nationwide, Montefiore meets or surpasses the quality and safety criteria for computerized physician order entry, ICU staffing, and the Leapfrog's "quality index" (27 individual safety and quality criteria). Montefiore also scores better than all other hospitals in the Bronx in terms of providing critical volumes of high-risk surgeries. (Note: these Metro NY data are limited to the 32 hospitals who responded to the Leapfrog Group's lengthy survey, whereas 146 hospitals were asked to participate in the survey).

The Montefiore model of critical care practice is based in complete integration of all specialized clinical and academic efforts in intensive care medicine. It provides a full range of 24/7 response from early intervention through highest intensity ICU medicine to comfort care. The high intensity staffing resulted in increased safety and better outcomes.

Montefiore Medical Center, The University Hospital and Academic Medical Center for the Albert Einstein College of Medicine, ranks among the top one percent of all US hospitals based on its investments in medical innovation and cutting-edge technology.

Montefiore invests more in order to enable compassionate, personalized care and the most positive outcomes for patients and their families in New York, the tri-state area and beyond.

Montefiore's unique combination of ‘state-of-the-art' technology with ‘state-of-the-heart' medical and nursing care in a teaching and research environment provides patients with access to world-class medical experts, the newest and most innovative treatments and the best medical center experience anywhere.

This 1,062 bed medical center includes the Henry and Lucy Moses Division, the Jack D. Weiler Hospital and The Children's Hospital at Montefiore, a large home healthcare agency and a 21-site medical group practice located throughout the Bronx and nearby Westchester.

Montefiore treats all major illnesses and has distinguished centers of excellence in cardiology and cardiac surgery, cancer care, tissue and organ transplantation, children's health, women's health, surgery and the surgical subspecialties. Montefiore Medical Center focuses on providing family-centered healthcare in a nurturing environment that extends well beyond hospital and clinic walls.

Steven M. Safyer, MD

President and CEO
Montefiore Medical Center

Whether you are a patient in one of our hospitals, visiting your healthcare team at our care centers throughout the Bronx and nearby Westchester, or have children receiving medical and dental care at our school-based health clinics, I know you will experience our dedication and professionalism as we work hard to support your healthcare needs.

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