Models of Staffing

  • Ruth KleinpellEmail author
  • Stephen M. Pastores


The high-acuity, fast-paced environment of the intensive care unit (ICU) mandates that adequate staffing is available to provide care for critically ill patients. It is widely recognized that patient care in the ICU is best provided by an integrated multiprofessional team of dedicated experts directed by a trained physician credentialed in critical care medicine (an intensivist). However, the shortage of full-time intensivists has necessitated that alternate models of staffing be utilized including the use of nurse practitioners and physician assistants, hospitalist physicians, and residents and fellows in academic centers to assist in the management of ICU patients. The use of telemedicine has become more widespread to provide care to critically ill patients by intensivists remotely in ICUs that lack intensivists on site. Adequate nurse staffing is also a requisite. Finally, care provided by other ICU team members including pharmacists, respiratory therapists, and other healthcare professionals, along with involvement of patients and their families, can help to ensure that the needs of critically ill patients are met to promote best care outcomes.


Intensivists Organization Staffing Models Advanced practice providers Nurses Physician trainees Hospitalists Telemedicine 


  1. 1.
    Nates JL, Nunnally M, Kleinpell R, et al. ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med. 2016;44:1553–602.CrossRefGoogle Scholar
  2. 2.
    Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151–62.PubMedPubMedCentralGoogle Scholar
  3. 3.
    Halpern NA, Pastores SM, Oropello JM, Kvetan V. Critical Care Medicine in the United States: Addressing the intensivist shortage and image of the specialty. Crit Care Med. 2013;41:2754–61.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Ward NS, Chong DH. Critical care beds and resource utilization: current trends and controversies. Semin Respir Crit Care Med. 2015;36:914–20.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Varelas PN, Conti MM, Spanaki MV, Potts E, Bradford D, Sunstrom C, Fedder W, Hacein Bey L, Jaradeh S, Gennarelli TA. The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit. Crit Care Med. 2004;32(11):2191–8.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Morrow DA, Fang JC, Fintel DJ, et al. American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Quality of Care and Outcomes Research. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation. 2012;126(11):1408–28.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Benoit MA, Bagshaw SM, Norris CM, Zibdawi M, Chin WD, Ross DB, van Diepen S. Postoperative complications and outcomes associated with a transition to 24/7 intensivist management of cardiac surgery patients. Crit Care Med. 2017;45(6):993–1000.CrossRefGoogle Scholar
  8. 8.
    Leapfrog Group. Hospital Survey. Factsheet: ICU Physician Staffing. Accessed 10 Jan 2019
  9. 9.
    Wilcox ME, Chong CA, Niven DJ, et al. Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses. Crit Care Med. 2013;41:2253–74.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Wallace DJ, Angus DC, Barnato AE, et al. Nighttime intensivist staffing and mortality among critically ill patients. N Engl J Med. 2012;366:2093–101.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Kahn JM, Brake H, Steinberg KP. Intensivist physician staffing and the process of care in academic medical centres. Qual Saf Health Care. 2007;16:329–33.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    Parikh A, Huang SA, Murthy P, Dombrovskiy V, Nolledo M, Lefton R, Scardella AT. Quality improvement and cost savings after implementation of the Leapfrog intensive care unit physician staffing standard at a community teaching hospital. Crit Care Med. 2012;40(10):2754–9.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Gajic O, Afessa B, Hanson AC, et al. Effect of 24-hour mandatory versus on-demand critical care specialist presence on quality of care and family and provider satisfaction in the intensive care unit of a teaching hospital. Crit Care Med. 2008;36:36–44.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Banerjee R, Naessens JM, Seferian EG, Gajic O, Moriarty JP, Johnson MG, Meltzer DO. Economic implications of nighttime attending intensivist coverage in a medical intensive care unit. Crit Care Med. 2011;39(6):1257–62.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Kerlin MP, Adhikari NK, Rose L, Wilcox ME, Bellamy CJ, Costa DK, Gershengorn HB, Halpern SD, Kahn JM, Lane-Fall MB, Wallace DJ, Weiss CH, Wunsch H, Cooke CR, ATS Ad Hoc Committee on ICU Organization. An Official American Thoracic Society Systematic Review: the Effect of Nighttime Intensivist Staffing on Mortality and Length of Stay among Intensive Care Unit Patients. Am J Respir Crit Care Med. 2017;195:383–93.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Levy MM, Rapoport J, Lemeshow S, et al. Association between critical care physician management and patient mortality in the intensive care unit. Ann Intern Med. 2008;148:801–9.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    van der Wilden GM, Schmidt U, Chang Y, et al. Implementation of 24/7 intensivist presence in the SICU: effect on processes of care. J Trauma Acute Care Surg. 2013;74:563–7.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Yoo EJ, Edwards DJ, Dean ML, Dudley RA. Multidisciplinary critical care and intensivist staffing: results of a statewide survey and association with mortality. J Intensive Care Med. 2016;31:325–32.CrossRefGoogle Scholar
  19. 19.
    Kelley MA, Angus D, Chalfin DB, et al. The critical care crisis in the United States: A report from the profession. Chest. 2004;125:1514–7.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    HRSA: The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians. Requested by: Senate Report 108–81. Rockville, MD, US Department of Health and Human Services; Health Resources and Services Administration. Report to Congress, 2006. Available at: Accessed 24 Jan 2019.
  21. 21.
    Kahn JM, Rubenfeld GD. The myth of the workforce crisis. Why the United States does not need more intensivist physicians. Am J Respir Crit Care Med. 2015;191:128–34.PubMedCrossRefGoogle Scholar
  22. 22.
    National Center for Health Workforce Analysis: Health Workforce Projections: Critical Care Physicians and Nurse Practitioners. 2016. Available at: Accessed 24 Jan 2019.
  23. 23.
    Pastores SM, Halpern NA, Oropello JM, Kvetan V. Intensivist workforce in the United States: the crisis is real, not imagined. Am J Respir Crit Care Med. 2015;191(6):718–9.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Halpern NA, Tan KS, DeWitt M, Pastores SM. Intensivists in US acute care hospitals. Crit Care Med. 2019;47(4):517–25.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Checkley W, Martin GS, Brown SM, et al. Structure, process and annual ICU mortality across 69 centers: United States critical illness and injury trials group critical illness outcomes study. Crit Care Med. 2014;42:344–56.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Sakr Y, Moreira CL, Rhodes ND, et al. The impact of hospital and ICU organizational factors on outcome in critically ill patients: results from the extended prevalence of infection in intensive care study. Crit Care Med. 2015;43:519–26.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    West E, Barron DN, Harrison D, Rafferty AM, Rowan K, Sanderson C. Nurse staffing, medical staffing and mortality in intensive care: an observational study. Int J Nurs Stud. 2014;51:781–94.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    McGahan M, Kucharski G, Coyer F. Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: a literature review. Aust Crit Care. 2012;25:64–77.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Penoyer DA. Nurse staffing and patient outcomes in critical care: a concise review. Crit Care Med. 2010;38:1521–8.CrossRefGoogle Scholar
  30. 30.
    Needleman J, Buerhaus P, Pankratz VS, et al. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011;364:1037–45.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Cho SH, Yun SC. Bed-to-nurse ratios, provision of basic nursing care, and in-hospital and 30-day mortality among acute stroke patients admitted to an intensive care unit: cross-sectional analysis of survey and administrative data. Int J Nurs Stud. 2009;46:1092–101.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Stone PW, Kunches L, Hirschhorn L. Cost of hospital-associated infections in Massachusetts. Am J Infect Control. 2009;37:210–4.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Schubert M, Clarke SP, Aiken LH, et al. Associations between rationing of nursing care and inpatient mortality in Swiss hospitals. Int J Qual Health Care. 2012;24:230–8.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Hickey PA, Gauvreau K, Curley MA, Connor JA. The effect of critical care nursing and organizational characteristics on pediatric cardiac surgery mortality in the United States. J Nurs Adm. 2014;44:S19–26.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Boyle DK, Cramer E, Potter C, et al. The relationship between direct-care RN specialty certification and surgical patient outcomes. AORN J. 2014;100(5):511–28.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: a review. Surg Neurol Int. 2014;5:S295–303.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Messing J, Garces-King J, Taylor D, van Horn J, Sarani B, Christmas AB, Eastern Association for the Surgery of Trauma, the Society of Trauma Nurses, and the American Association of Surgical Physician Assistants. Eastern Association for the Surgery of Trauma and Society of Trauma Nurses advanced practitioner position paper: Optimizing the integration of advanced practitioners in trauma and critical care. J Trauma Acute Care Surg. 2017;83(1):190–6.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Paton A, Stein DE, D’Agostino R, Pastores SM, Halpern NA. Critical care medicine advanced practice provider model at a comprehensive cancer center: successes and challenges. Am J Crit Care. 2013;22(5):439–43.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Garland A, Gershengorn HB. Staffing in ICUs: physicians and alternative staffing models. Chest. 2013;143(1):214–21.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Kleinpell R, Buchman T, Boyle WA. Integrating Nurse Practitioners and Physician Assistants in the ICU: Strategies for Optimizing Contributions to Care. Mount Prospect: Society of Critical Care Medicine; 2009.Google Scholar
  41. 41.
    D’Agostino R, Pastores S, Halpern NA. The NP staffing model in the ICU at Memorial Sloan-Kettering cancer center. In: Kleinpell R, Buchman T, Boyle WA, editors. Integrating Nurse Practitioners and Physician Assistants in the ICU: Strategies for Optimizing Contributions to Care. Mount Prospect: Society of Critical Care Medicine; 2009. p. 18–25.Google Scholar
  42. 42.
    Joffe AM, Pastores SM, Maerz LL, et al. Utilization and impact on fellowship training of non-physician advanced practice providers in intensive care units of academic medical centers: a survey of critical care program directors. J Crit Care. 2014;29:112–5.PubMedCrossRefGoogle Scholar
  43. 43.
    Kleinpell RM, Grabenkort WR, Kapu AN, Constantine R, Sicoutris C. Nurse practitioners and physician assistants in acute and critical care: a concise review of the literature and data 2008–2018. Crit Care Med. 2019;47(10):1442.PubMedCrossRefGoogle Scholar
  44. 44.
    Pastores SM, O’Connor MF, Kleinpell RM, Napolitano L, Ward N, Bailey H, Mollenkopf FP Jr, Coopersmith CM. The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. Crit Care Med. 2011;39(11):2540–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Pastores SM, Kvetan V, Coopersmith CM, Academic Leaders in Critical Care Medicine (ALCCM) Task Force of the Society of Critical Care Medicine, et al. Workforce, workload, and burnout among intensivists and advanced practice providers: a narrative review. Crit Care Med. 2019;47(4):550–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Society of Hospital Medicine. State of Hospital Medicine Report. Philadelphia: Society of Hospital Medicine; 2016.Google Scholar
  47. 47.
    Hyzy RC, Flanders SA, Pronovost PJ, Berenholtz SM, Watson S, George C, Goeschel CA, Maselli J, Auerbach AD. Characteristics of intensive care units in Michigan: not an open and closed case. J Hosp Med. 2010;5(1):4–9.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Sweigart JR, Aymond D, Burger A, Kelly A, Marzano N, McIlraith T, Morris P, Williams MV, Siegal EM. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018;13(1):6–12.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Lilly CM, Zubrow MT, Kempner KM, et al.; Society of Critical Care Medicine Tele-ICU Committee. Critical care telemedicine: evolution and state of the art. Crit Care Med. 2014;42(11):2429–2436.Google Scholar
  50. 50.
    Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J, Chandler MW, Irwin RS, University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175–83.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Vranas KC, Slatore CG, Kerlin MP. Telemedicine coverage of intensive care units: a narrative review. Ann Am Thorac Soc. 2018;15(11):1256–64.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Vanderbilt University School of NursingNashvilleUSA
  2. 2.Critical Care Center, Department of Anesthesiology and Critical Care MedicineMemorial Sloan Kettering Cancer CenterNew YorkUSA

Personalised recommendations