Name: John J. Brady M.D.
Age: 35
Position: Director of Critical Care Medicine and Kent Hospitalists program, Kent County Memorial Hospital
Education: Bachelor of Arts, Temple University, 1987; Doctor of Medicine, The George Washington University, 1991; Residency in Internal Medicine, The George Washington University Medical Center, 1994; Fellowship in Critical Care Medicine, University of Pittsburgh Medical Center, 1996
Residence: Warwick
BRADY: ‘We cut our costs in half. Our complications went down. So we actually improved the quality of care.’
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PBN: What makes intensive care medicine so different from regular hospital care?
BRADY: The intensive care unit is simply a nursing unit staffed differently than a regular medical floor. The ratio of nurses to patients is much higher and the expertise of the nurses is much higher. The ability to monitor a patient is much more sophisticated. Prior to my being here the ICU was an open intensive care unit. Any physician in the hospital could admit. What we have done is developed a semi-closed unit, which means that now, any physician on staff may have his or her patient in the ICU but they don’t have the control over the care of that patient the way it used to exist. Now we provide the same level of physician care to all the patients regardless of where they come from. The type of patient we see now is a much sicker patient, by and large. We’ve removed the patients that don’t need to be in the intensive care and we prevent those patients for the most part from coming in. And once they’re no longer in the state where they require that level of care, they’re transferred out.
People used to be admitted into intensive care that didn’t really need it?
Absolutely. We had a unit that was always full or near full. We had long delays waiting for an ICU bed. People would come in through the emergency room, the attending physician would write orders to go to the ICU, but there was no bed available. So these patients sat in the emergency room all night, or sometimes for a couple of days. There’d be people on the floor that would deteriorate but they couldn’t get in because there were no beds or there was a long wait. Post-op patients would stay in the recovery room for overnight or a day or two. We had logjams all over the place.
Kent Hospital participated in a national Adult ICU Collaborative through the Institute of Health Care Improvement a few years back. What did you learn?
People always thought that the more money you spend the better care you will get. [But] what they found was as you improve the quality of care, you reduce your costs because you standardize your level of care. And once you do that you’re able to find out better ways to do things. So people spend less time on the ventilator. They have less time in the ICU. A couple of years ago we formed a critical care task force. We decided we would go through our pre-established admissions criteria and figure out what percentage of patients in our ICU on any given day needed to be there. And we found that 30 to 40 percent of our ICU patients didn’t even meet the criteria. That’s why everything was backed up. Today, we pretty consistently have less than 5 percent of our ICU patient days being inappropriate days. And a fair number of those really have nothing to do with what we’re doing in the unit, they have to do with not being able to get the patient moved out to the floor because there’s no available bed.
How did you change staffing in the ICU?
It [used to be] completely up to the primary care physician or whoever was in charge of the case to get the people that he or she wanted involved. And it may or may not have been appropriate, the physician may or may not have been available, [or] have had the expertise to manage that patient. So you had just a free-for-all in terms of what level of care those individual patients [in the ICU] were getting. So it was oftentimes up to the nurses to try and manage the unit. They were making triage decisions. So we did several things. One, we had full presence of an intensivist in the ICU all the time. We developed a team, and we started making recommendations. We developed protocols for weaning people off the ventilator. The same way. So that the therapist knew how we did it, the nurses knew how we did it, the doctors knew how we did it. And when you have a system then it gives you a template. If it’s just random and haphazard, you have no way of doing it better.
So what’s been the bottom line?
We use antibiotics and medications differently. We tend to use less intravenous drugs, which cost a lot more money. We cut our costs practically in half. In 1997 to 1998 our average charge for taking care of patients that were on a ventilator was over $40,000. The following year after we made changes, our total costs were about $22,000. Interestingly our hospital mortality went down for patients coming through the ICU. Our complications actually went down. So we actually improved the quality of care. And the number of readmissions to the ICU didn’t change at all. If anything it went down. We didn’t go in there and say we want to cut the costs of caring for these patients in half. We just went in there and said how can we provide better care. And we provided better care and we cut the costs in half.
What’s your role as “intensivist”?
An intensivist is a specialist in critical care medicine, providing care in an intensive care unit. The biggest cause of cost in the ICU is physician variability. If you take 10 doctors, let them loose in an intensive care unit, you’re going to find 10 different ways of doing things. And if you have 10 different ways of doing things then the nurses don’t know what to do, the therapists don’t know what to do. What you have to do is you have to provide the same level of care, the same type of care to every patient. And what we have now is we have a new culture. Now all the nurses know how we do things. The doctors know how we do things. The respiratory therapists know how we do things. There’s a communication that requires very few words, because we’re speaking the same language. We already know what the plan is because we already talked about it.
Why did you choose intensive care?
Everywhere I trained, the physicians who staffed the intensive care unit were the physicians I was most impressed with. These people seemed to know how to deal with the worst possible cases. They just seemed to know how to get these people better. And I was always very impressed by the acuity, the pathology that they were taking care of, where you had to deal with on a minute by minute or hour by hour basis, some of the sickest people in the hospital. I wanted to be that type of physician.
What does it mean when a patient is in critical condition?
Critical illness is a disease state. It doesn’t matter whether you’re the victim of a motor vehicle accident, or you just had a lung removed or whether you have septic shock from a bad infection. The body responds to physical stress in a predictable way. Regardless of how you got to that state. We’re really more interested in stable or unstable. Stable to me means your condition’s not exactly changing. You’re in septic shock but I have a decent blood pressure, but you’re on a lot of medication to support your blood pressure. You’re on a ventilator and I’m able to oxygenate you but it’s requiring an oxygen level of 90 percent. You’re critically ill, but you’re stable. And I can go home tonight and handle questions and things over the phone. I don’t have to necessarily stand there at the patient’s bedside for the next 12 hours, whereas an unstable patient requires my presence.
What are some of the most difficult ICU cases you have experienced?
I think unexpected death is probably the most difficult thing for families to handle. And it is certainly the most difficult for me. It happens fortunately not that frequently. It’s very difficult to be at a patient’s bedside that just hours before or a day before you were actually talking to this individual, and had a very pleasant relationship or experience with them, and then have a catastrophic event occur and have to then personally experience that loss but then also have to experience it with the family.
How do you help family members deal with having a loved one critically ill?
Information. All families have anxiety. All people have anxiety. And the best way to alleviate that anxiety is to provide the information and the answers to their questions. And secondly, having them participate in the health care decisions. The worst thing to do is to be patronizing or paternalistic and just say everything will be okay. The most important thing is to be honest and say exactly what is happening, what the prognosis is, and explain what the options are. And then help them come to a decision that we feel is appropriate and that they feel is appropriate.
Caring for the most ill 1 percent of adults accounts for more than 20 percent of all health care costs. Do you ever feel a financial pressure to move patients through ICU quickly?
Yes, only in the sense that it’s a limited resource and we have to use that resource wisely, just like anything else. We don’t move people out of the ICU who still require the intensive care unit. We never make decisions solely on a financial basis, but we do manage the ICU with an eye to costs. Because we can’t afford to build another intensive care unit. So we have to make do with what we have.
