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Updating the Leapfrog Group Intensive CareUnit Physician Staffing StandardMeredith B. Rockeymoore, MPH, Christine G. Holzmueller, BLA, Arnold Milstein, MD, MPH, Todd Dorman, MD,and Peter J. Pronovost, MD, PhD

AbstractThe Leapfrog Group, a consortium of large health carepurchasers representing 35 million employees, sup-ports the adoption of 3 proven standards to preventmedical mistakes in hospitals. In this paper, the authorsdescribe the process used to revise Leapfrog’s ICUphysician staffing standard, including a review of evi-dence supporting the standard. Primary or secondaryauthors who published studies that evaluated the effectof increased ICU physician staffing by intensivists onhospital mortality were surveyed. The 8-item telephonesurvey instrument evaluated hours of intensivist careon weekend and weekdays and pager response times.To revise the standard, comments were compiled,salient issues were identified, revisions were proposed,and evidence review was performed. National advisorypanel votes were collected and compiled. Of 19 hospi-tal studies, 100% reported responding to 95% of pageswithin 5 minutes. Hours of weekend coverage rangedfrom 1.5 to 24, with a mean of 8 hours. 84% of inten-sivists were present in the ICU 4 hours per day or moreon the weekends, and 42% of intensivists were present8 hours or more. Hours of weekday coverage rangedfrom 3 to 24, with a mean of 11 hours. 95% of inten-sivists were present in the ICU 4 hours or more on theweekday, and 74% of intensivists were present 8 hoursor more. Evidence was found in the literature to supportthe components of the Leapfrog ICU staffing standardand proposed revisions to the standard.

Medical mistakes are a significant public health prob-lem. The Institute of Medicine report released in1999 estimated that every year nearly 100,000 peo-

ple die from medical mistakes in U.S. hospitals [1]. Thesenumbers suggest that more Americans are accidentally killedin U.S. hospitals every 2 weeks than died in the September11th attacks.

Given the magnitude of this problem, it is not surprisingthat many organizations, including health care purchasers,

insurers, accreditors, and providers, are attempting to ad-dress the issue of patient safety. One such organization is theLeapfrog Group, a consortium of more than 100 Fortune 500companies and other large private and public-sector healthcare purchasers representing more than 35 million employ-ees. Leapfrog supports the adoption of 3 proven standards toprevent medical mistakes in hospitals [2]:

• Use of computerized physician order entry

• Selection of hospitals with the best results or exten-sive experience for certain high-risk conditions andprocedures (evidence-based hospital referral)

• Staffing intensive care units (ICUs) with ICUphysicians (intensivists)

Leapfrog members encourage their employees to use pro-viders who meet these standards. Collectively, the groupexercises significant purchasing power.

Leapfrog partnered with regulators, insurers, and pro-viders to roll out its initiatives last year in 6 geographic re-gions, and recently it expanded into 12 new regions. Urban,acute care hospitals in these areas are being urged to volun-tarily fill out an online survey to share their progress towardimplementing the standards. Survey information is availableto consumers, and consumers are encouraged to use this in-formation when choosing a hospital.

The current ICU physician staffing standard states thathospitals fulfilling this standard assure that all patients intheir adult general medical and surgical ICUs are managedor co-managed by physicians certified (or eligible for certifi-cation) in critical care medicine who:

1. Are present in the ICU during daytime hours aminimum of 8 hours per day, 7 days per week,and during this time provide clinical care exclu-sively in the ICU; and,

From The Johns Hopkins University School of Medicine and Bloomberg Schoolof Public Health, Baltimore, MD, and The Leapfrog Group, Washington, DC.

PATIENT SAFETYREPORTS FROM THE FIELD

2. At other times,

a. Return more than 95% of ICU pages within 5 minutes (excluding low-urgency pages, if thepaging system can designate low-urgencypages), and

b. Can rely on a physician or FCCS-certified non-physician “effector” who is in the hospital andable to reach ICU patients within 5 minutes inmore than 95% of cases.

In hospitals where scientifically rigorous risk-adjusted ICUoutcome comparisons are publicly reported, favorable risk-adjusted outcomes may replace the ICU staffing standard.

ICU physician staffing is an appropriate focus for a Leap-frog Group “safety leap.” Currently, intensivists staff only10% of U.S. ICUs [3]. Five million patients are admitted annu-ally to U.S. ICUs; 10% of these patients die during their hos-pitalizations, and nearly all suffer preventable adverse events[3–5]. ICU care in the U.S. accounts for approximately 30% ofacute hospital costs and $180 billion annually [6]. Severalstudies have shown that higher levels of intensivist staffingreduce costs per stay and improve patient health outcomes[7–10]. If the ICU standard is fully implemented in nonruralU.S. hospitals, it would prevent an estimated 54,000 deathsand 5.4 billion dollars in hospital costs annually [11]. Most ofthe mortality gains expected to result from the Leapfrog stan-dards are derived from ICU physician staffing [12].

To be of most benefit, the ICU physician staffing standardmust accurately reflect current evidence on the associationbetween ICU staffing and quality. To achieve this, the Leap-frog Group convened a national advisory panel comprisingclinicians and researchers active in ICU outcomes research.The panel was asked to re-review available empirical findingsand consider comments received in the Leapfrog Group’sannual public review and comment process. This paper de-scribes the process that was used for integrating evidence intorevisions of the ICU physician staffing standard.

MethodsEvidence Review We developed an 8-item telephone survey instrument toevaluate components of the ICU physician staffing standard.The survey evaluated hours of intensivist care on weekendand weekdays and pager response times. We selected theseitems because the level of support in the literature wasunknown and because suggested revisions to these aspects ofthe standard were received during public review and com-ment. The survey was pilot tested for consistency of respon-dent interpretation for each question’s intended meaningwith 3 intensive care physicians and was then revised.

The study sample was primary or secondary authorswho had published studies in peer-reviewed journals that

evaluated the effect of ICU physician staffing on hospitalmortality. To identify participants, we performed a system-atic review of the literature for studies and abstracts thatreported the effect of intensivist staffing in an ICU. Themethods for conducting the systematic review are publishedelsewhere [13]. Authors were traced through correspondingaddresses on published articles, institutional affiliations,medical colleagues, and internet searches.

We contacted the first or second author by phone and con-ducted a 6- to 8-minute interview. International authors weree-mailed the survey tool with text instructions. We informedthe authors that we were interested in the evidence support-ing the ICU staffing standard and instructed them to reflecton ICU physician staffing during the intervention period oftheir published study when answering the survey questions.To clarify the time period we were asking about, the inter-viewer cited the title, journal, and year of the published study.In the studies that included more than one ICU, the primaryauthor provided information, if available, about each of thehospitals in the study [14,15]. Responses for these studieswere classified according to the majority of the hospitals.

Process for Revising the StandardThe Leapfrog Group asked Peter Pronovost (one of theauthors of this paper) to chair a national advisory panel torevise the standard. The panel included critical care expertswho had published evaluations of ICU performance and 2 physicians from community hospitals. (Panel members arelisted at the end of this article.)

The chair instructed the advisory group that any new rec-ommendations to the standard should be short, self-evidentin their value, feasible, and easily ascertainable. To gain con-sensus on revisions to the standard, the national advisorypanel used the nominal group technique, a process thatsolicits comments from everyone. The nominal group tech-nique eliminates social and psychological dynamics ofgroup behavior, which tend to inhibit individual creativityand participation in group decisions [16,17]. An advantagefor using this technique over the committee approach is thatgroup consensus can be reached faster and everyone hasequal opportunity to present his or her ideas [18].

To revise the standard, the Leapfrog Group issued a callfor comments on its Web site. Individuals and organizationswere invited to e-mail or fax comments to the LeapfrogGroup. The chair compiled the comments, identified thesalient issues, and framed them into proposed revisions.These were then e-mailed to the members of the nationaladvisory panel in the form of a structured memorandum.Included in the memorandum for each issue was the recom-mendation, rationale, evidence supporting change, suggest-ed change to survey, and proposed alternative if the membersvoted the recommendation down. The results of the evidence

32 JCOM January 2003 Vol. 10, No. 1 www.turner-white.com

ICU PHYSICIAN STAFFING

review (once completed) were also sent to the advisory panel.Votes and comments were collected and compiled. Final revi-sions to the standard thus reflected known data and expertopinion. The panel had a conference call to gain consensus onthe final set of recommendations.

ResultsEvidence ReviewOur systematic review identified 25 studies published by 23 authors who investigated the effect of intensivist

staffing in the ICU setting [7,9,14,15,19–38]. We conduct-ed telephone interviews with authors from the 19 studiesfor which ICU staffing was associated with a reduction inhospital or ICU mortality [7,9,10,14,15,29–38]. Four ofthese studies were from international hospitals [19–24].One author who published 2 separate studies reported“not measuring” weekday hours, weekend hours, andpager response time [27,28]. A summary of the studies isshown in Table 1 and responses to the survey are shownin Table 2.



Table 1. Reviewed Studies on ICU Physician Staffing and Outcomes

First Author Study Year Origin

Al-Asadi [26]* 1996 U.S.

Baldock [19] 2001 International

Blunt [20] 2000 International

Brown [23] 1989 International

Carson [9] 1996 U.S.

Multz [25] 1998 U.S.

DiCosmo [29]* 1999 U.S.

Dimick I [14] 2001 U.S.

Dimick II [15]* 2000 U.S.

Diringer [30] 2000 U.S.

Ghorra [34] 1999 U.S.

Goh [21] 2001 International

Hanson [31] 1999 U.S.

Jacobs [32]* 1998 U.S.

Kuo [22] 2000 International

Li [35] 1984 U.S.

Manthous [10] 1997 U.S.

Marini [36]* 1995 U.S.

Pollack [27] 1988 U.S.

Pollack [28] 1994 U.S.

Pronovost [7] 1999 U.S.

Reich [37]* 1997 U.S.

Reynolds [33] 1988 U.S.

Rosenfeld [38] 2000 U.S.

Tai [24] 1998 International

*Abstract only.

Clinical impact of closed versus open provider care in a medical intensive care unit

The impact of organisational change on outcome in an intensive care unit in the UnitedKingdom

Out-of-hours consultant cover and case-mix-adjusted mortality in intensive care

Effect on ICU mortality of a full-time critical care specialist

Effects of organizational change in the medical intensive care unit of a teaching hospital.A comparison of ‘open’ and ‘closed’ formats

A “closed” medical intensive care unit (MICU) improves resource utilization when com-pared with an “open” MICU

Addition of an intensivist improves ICU outcomes in a non-teaching community hospital

Intensive care unit physician staffing is associated with decreased length of stay, hospitalcost, and complications after esophageal resection

The effect of ICU physician staffing and hospital volume on outcomes after hepatic resection

Admission to a neurologic/neurosurgical intensive care unit is associated with reducedmortality rate after intracerebral hemorrhage

Analysis of the effect of conversion from open to closed surgical intensive care unit

Impact of 24-hour critical care physician staffing on case-mix adjusted mortality in paediatric intensive care

Effects of an organized critical care service on outcomes and resource utilization: acohort study

Improving the outcome and efficiency of surgical intensive care: the impact of full timemedical intensivists

Changing ICU mortality in a decade—effect of full-time intensivist

On-site physician staffing in a community hospital intensive care unit. Impact on test andprocedure use and on patient outcome

Effects of a medical intensivist on patient care in a community teaching hospital

The impact of full-time surgical intensivists on ICU utilization and mortality

Improving the outcome and efficiency of intensive care: the impact of an intensivist

Impact of quality-of-care factors on pediatric intensive care unit mortality

Organizational characteristics of intensive care units related to outcomes of abdominalaortic surgery

Saving lives in the community. Impact of intensive care leadership

Impact of critical care physician staffing on patients with septic shock in a university hos-pital medical intensive care unit

Intensive care unit telemedicine: Alternate paradigm for providing continuous intensivist care

Impact on quality of patient care and procedure use in the medical intensive care unit(MICU) following reorganisation

U.S. and international studies. Of 19 hospital studies com-pleting our telephone interview, 19 (100%) reported re-sponding to 95% of pages within 5 minutes. Hours of week-end coverage ranged from 1.5 to 24, with a mean of 8 hours.In 16 hospitals (84%), intensivists were present in the ICU 4 hours per day or more on the weekends, and in 8 hospitals(42%), intensivists were present 8 hours or more. Hours ofweekday coverage ranged from 3 to 24, with a mean of 11 hours. In 18 hospitals (94%), intensivists were present inthe ICU 4 hours or more on the weekday, and in 14 hospitals(74%), intensivists were present 8 hours or more.

U.S. studies only. All 15 U.S. studies (100%) reported respond-ing to 95% of pages within 5 minutes. Hours of weekend cov-erage ranged from 2 to 24, with a mean of 10 hours. In 13 hos-pitals (87%), intensivists were present in the ICU 4 hours ormore per day on the weekend, and in 8 hospitals (53%), inten-sivists were present 8 hours or more. Hours of weekday cov-erage ranged from 4 to 24, with a mean of 12 hours. In 15 hos-pitals (100%), intensivists were present in the ICU 4 hours ormore per day on weekdays and in 11 hospitals (73%), inten-sivists were present 8 hours or more.

Comments ReceivedThe Leapfrog Group Web site received 5 comments—fromprofessional societies, hospital associations, and health sys-tems. In addition, the chair of the advisory panel received 3 direct comments.

RevisionsBased on results from our nominal group technique and con-ference call, the panel gained consensus on the recommen-dations. Table 3 summarizes the issues and recommendedchanges.

DiscussionIn this manuscript, we present our review of the evidencesupporting components of the Leapfrog ICU staffing stan-dard and the process for revising this standard. Our reviewof the evidence supports keeping weekend and weekdayhour requirements and pager response time in the standard.The national advisory panel elected to maintain the majorityof the original standard. The main changes to the standardare expanding the standard to pediatric ICUs, consideringexperienced ICU physicians who meet specific criteria asequivalent to board-eligible, and adding several bases ofadditional credit. The panel also reaffirmed the use of out-come measures as an alternative to staffing. The NationalQuality Forum [39] and the Joint Commission on Accredita-tion of Healthcare Organizations [40] are attempting to de-velop such measures. Until these measures are developed,the panel recommended that the Leapfrog Group identify agroup of vendors who could provide risk-adjusted mortali-ty data for ICUs.

There are limitations to our review of the evidence andrevision process. For our review, we were not able to iden-tify 4 authors, and one did not record coverage of weekendand weekday hours or pager response time. Of the 4 wecould not identify, 2 were international studies; the gener-alizability of these studies to U.S. hospitals is unclear.Survey responses may have been inaccurate since subjectswere asked to recall hours of intensivist care on weekendand weekdays and pager response times during the inter-vention period of their study. The revision process hadlimitations. First, many stakeholders did not submit com-ments to the Leapfrog Group for consideration. Secondly,the national advisory panel is mainly composed of physi-cians who have published on ICU physician staffing.While they have the best knowledge of the evidence sup-porting the staffing standard, they may not fully graspbarriers faced by other hospitals attempting to implementthe standard.

In conclusion, we found evidence to support the compo-nents of the Leapfrog ICU physician staffing standard andproposed revisions to the standard.



Table 2. Pager Response Time and Weekday/WeekendCoverage

Mean Mean Returns Hours/d Hours/d

Pages Within Intensivist Intensivist 5 Minutes Present, Present,

Study 95% of Time? Weekdays Weekend

Baldock Yes 08 4

Blunt Yes 08 4

Carson Yes 012.5 008.5

DiCosmo Yes 04 2

Dimick I Yes 12 6

Dimick II Yes 12 6

Diringer Yes 11 5

Ghorra Yes 05 3

Goh Yes 10 004.5

Hanson Yes 10 005.5

Jacobs *Yes* 24 24

Kuo Yes 03 001.5

Li *Yes* 24 24

Manthous Yes 04 04

Marini Yes 07 07

Pronovost Yes 12 06

Reich Yes 08 06

Reynolds Yes 12 08

Rosenfeld Yes 12 06

*An intensivist was present 24/7.

Members of the National Advisory Panel were Peter Pronovost, MD,PhD, Johns Hopkins Medical Institutions, Baltimore, MD (chair); DerekAngus, MD, MPH, University of Pittsburgh School of Medicine, PA;William Bornstein, MD, PhD, Emory Hospitals, Emory Healthcare,Atlanta, GA; Todd Dorman, MD, Johns Hopkins Medical Institutions,Baltimore, MD; John Hoyt, MD, St. Francis Medical Center,Pittsburgh, PA; Mitchell Jacobs, MD, Northshore University Hospital,Manhasset, NY; Murray Pollack, MD, MBA, Children’s NationalMedical Center, Washington, DC; Thomas Rainey, MD, SuburbanHospital, Bethesda, MD and President, CriticalMed, Inc.; Mukesh Shah,MD, Presbyterian Intercommunity Hospital, Whittier, CA; AnnThompson, MD, Children’s Hospital of Pittsburgh, PA; JaniceZimmerman, MD, Baylor College of Medicine, Houston, TX; ChristineHolzmueller, BLA, Johns Hopkins Medical Institutions, Baltimore, MD(research coordinator).

Corresponding author: Peter Pronovost, MD, PhD, The JohnsHopkins Hospital, Dept. of Anesthesiology/Critical Care Medicine,600 N. Wolfe St., Meyer 295, Baltimore, MD 21287.

Funding/support: Financial support provided in part by the Agencyfor Healthcare Research and Quality (U18 HS11902-02) and in partby the Leapfrog Group.

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Table 3. Summary of Recommendations

Issue Recommendation

Expand ICU standard to pediatric ICUs

Reduce required hours for weekend coverage

Allow experienced ICU providers to be considered as board-certified or board-eligible intensivists

Exempt cardiac surgery patients in ICUs from the standard

Add other ICU organizational factors such as ICU nurse staffing, safety climate, and team performance into the standard

The requirement for pager response time and Fundamentals of Critical Care Skills(FCCS) training are not evidence-based and should be deleted

Measure quality of ICU care based on risk-adjusted outcomes and process measures rather than staffing

Limit the number of patients an intensivist can care for, and these patients should be located in 2 or fewer ICUs in a single hospital

Add a question that asks “What percent-age of adult med/surg ICU patients are managed or co-managed by physicians who meet the above standards for certifi-cation/eligibility, adult med/surg ICU presence, and exclusive focus on adult med/surg ICU patient?”

Expand standard to include pediatric ICUs

Maintain weekend coverage as written in standard (“minimum of 8 hours per day”)

Physicians who meet the following criteria may be considered board-certified:(1) obtained board certification in anesthesiology, internal medicine, or surgery;(2) completed training prior to availability of subspecialty certification in critical care intheir field (1987 for medicine, anesthesiology, pediatrics, and surgery); (3) provide atleast 6 weeks per year of dedicated ICU time, where they make daily rounds and provide complete care for all ICU patients.

Continue to include cardiac surgery patients

Forward information regarding additional ICU safety factors to the Joint Commission onAccreditation of Healthcare Organizations (JCAHO) and the National Quality Forum

Continue the requirement for pager response time and FCCS training

Hospitals can substitute risk-adjusted measures of quality of ICU care for the staffingstandard given the measures are reliable, valid, independently risk adjusted, and arepart of a publicly reported system that provides benchmark data. Efforts by JCAHO todevelop measures of ICU quality should provide hospitals with tools to measure ICUquality that meets these specifications. Because these measures may take at least36 months to develop, the Leapfrog Group will create a committee to identify andapprove vendors that provide measures of ICU quality on which a “superior perfor-mance” rating can be established in the interim.

To meet the Leapfrog ICU standard, intensivists can provide care in a single ICU

Add question to the survey to evaluate the number of patients an intensivist cares for

Add this question to the survey

Provide hospitals with one-quarter credit increase in their ICU score for up to 1 yearfrom the initial hospital survey when at least half of all ICU patients are cared for by anintensivist. This recommendation is made for hospitals where some but not all patientsare cared for by an intensivist. Because of the inequity in a system where intensivistscare for some but not all ICU patients, hospitals should strive to ensure that all ICUpatients are cared for by an intensivist. No credit increase will be given beyond 1 yearfrom initial survey.

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For an industry perspective on the Leapfrog standards, see page 56.



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