Although technological improvement for organ support and resuscitation is important, appropriate intensive care unit (ICU) organization and management are also crucial for improved outcomes in the ICU.[1,2] Much evidence suggests that key elements of ICU organization—including appropriate intensivist physician staffing (IPS), nurse-patient ratio, a high volume of critically ill patients, and a multidisciplinary care team—are associated with improved quality of care in the ICU and better outcomes.[3-6]

An intensivist is a certified critical care physician who provides clinical care exclusively in the ICU. The potential advantages of the presence of intensivists in ICUs have been reported; timely and frequent titration of therapy by being physically present in ICU, easier implementation of evidence-based protocols likely to benefit patients, enhanced communication and collaboration with other clinicians and medical specialists to provide optimum care, and the ability of the ICU manager to standardize care, discharge patients in a timely manner, and evaluate performance.[7] However, intensivist-staffing patterns in ICUs vary markedly. Although most European ICUs are fully staffed by intensivists, approximately one-third of ICUs in the USA are covered by an intensivist.[8] In Korea, a formal intensivist certification system was begun in 2009. The Korean Society of Critical Care Medicine (KSCCM) and the Korean government have made effort to improve the quality and safety of intensive care. A government regulation requiring intensivist staffing in tertiary hospitals in Korea has been in force since January 2015. As per the government regulation introduced, tertiary hospitals must have at least one full-time intensivist in the adult ICU. The intensivist is supposed to be present during the daytime and provide clinical care exclusively in the ICU, as suggested by the Leapfrog group IPS standards.[9] However, barriers to establishment of optimal IPS in adult ICUs of tertiary hospitals are expected under the current critical care medical environment in Korea. Furthermore, little information exists regarding the barriers related to IPS. To identify relevant barriers, we performed a questionnaire survey of critical care program directors regarding their perception of IPS.

Of the 42 critical care program directors of KSCCM critical care training hospitals, 28 directors (66.7%) responded to the e-mail survey. Organizational characteristics varied markedly among the responding hospitals. Table 1 lists the characteristics of the respondents, including hospital size, number of adult ICUs, ownership of the organization, presence of a rapid response system, and designation as a tertiary hospital. Most of the hospitals had 300–1000 beds (64.2%), 1–5 adult ICUs (85.7%), and operated privately (75%). Only four hospitals (14.3%) had a rapid response system for the acutely ill during their hospital stay. Twenty-one hospitals (75%) were accredited as tertiary hospitals at the time of the survey.

This study highlights the obstacles to optimal IPS under current medical practice in Korean adult ICUs. Although the overwhelming majority of critical care program directors in Korea believed that intensivists could improve the quality of critical care, they had both positive and negative opinions of intensivist staffing. Moreover, perceived current resources for optimal IPS seemed to be inadequate.

A previous study reported several obstacles to IPS in the USA.[11] Critical care program directors in Korea shared similar barriers to those in the USA in terms of structural and cultural challenges. However, the perceived barriers were somewhat different. The critical care program directors in Korea believed that the most significant barrier to IPS is the associated financial burden, followed by the concern of certain physician groups regarding loss of control of management of their patients in ICUs, whereas a loss of control of patients to certain physician groups in USA.[11]

As expected, the critical care program directors’ concern is based on our medical cost reimbursement system. Korea has a compulsory National Health Insurance (NHI) system. Thus, all health care services are mandatory NHI providers under the National Health Insurance Act. All services, including hospital and physician costs, are paid on a fee-for-service basis. A crucial problem in critical care delivery is that the reimbursement rate for critical care was ~46% of the actual expenditure in a 2004 NHI study.[12] Thus, hospital administrators were not motivated to adopt the intensivist model of critical care. Under the current payment system in Korea, an intensivist without general ward designation, outpatient clinic, or operation theatre responsibilities may not be able to make a profit for their institution. However, intensivist-led critical care can be cost saving by avoiding unnecessary admission to ICU, decreasing readmission after discharge and enhancing the efficiency of use of finite resources.[13]

Specialists working in hospitals are employed and paid using a performance based salary system in many hospitals, including academic hospitals, in Korea. About 74.2% of hospitals in Korea have introduced a performance based salary system.[14] Performance is determined by the volume of services provided by each specialist. Therefore, the attending physicians might be reluctant to relinquish control over their patient’s care in the ICU, which indirectly is an important source of income.[11] Due to the performance based salary system on a fee for services basis, admitting physicians tend to be resistant to hand over control of patients, which is also an important barrier to IPS adoption.

The respondents considered to overcome these barriers by appropriate reimbursement of required medical costs together with legislation requiring intensivists in adult ICUs in Korea. At present, legal regulation of intensive care is truly far below the global standard.[12] In contrast to neonatal ICUs, there is no obligation to have a full-time intensivist in adult ICUs, as indicated in a medical regulation (enforcement rule article 28, paragraph 8). Of the critical care program directors, 71.4% agreed legal revision to be a potential solution to issues preventing IPS implementation.

The solutions suggested by the respondents should be addressed to enhance critical care in our society, because a qualified intensivist, defined as a physician certified in critical care medicine, is a crucial element of the organizational structure of the ICU. The current requirement for at least one intensivist for tertiary hospitals should be urgently revised, because intensivist/patient ratios impact patient care, education of trainees, and wellbeing of staff.[15] To relieve conflicts between general physicians and intensivists in the same hospital, the role of intensivists should be clearly defined in Korean hospitals by legislation regarding critical care. Mandating semi-closed ICU or closed ICU can be one of the legislative mean to clarify the role of intensivists. Regular auditing of ICU care performance through the Health Insurance Review and Assessment Service will facilitate optimal IPS.

In this study, most respondents did not agree with public reporting of the HSMR and severity adjusted ICU mortality as a solution. Public reporting and performance-based pay have been considered potential solutions to the crisis in quality in US health care, despite conflicting results.[16-19] While an assessment of the performance of each hospital and ICU in Korea is currently underway, further valid tools for assessing quality of care are required.

Despite these barriers, similar to a previous US study,[20] some organizations are performing intensivist-led critical care. These “pioneers” have demonstrated the benefits of the intensivist model of critical care during the H1N1 pandemic, severe sepsis, major trauma, and surgical critical care in Korea.[21-24] These motivated intensivists and institutions have generated support for system-level change in critical care in Korea. In our study, the expectations of intensivist-led critical care and perceived resources differed according to hospital size, although all physicians stated that intensivist-led critical care would improve the overall quality of intensive care. For wider adoption of intensivist-led critical care and improvement of the quality of critical care nationwide, more support for smaller hospitals is needed.

In a recent OECD health-care quality review,[25] Korea faces looming challenges—an ageing population, growing chronic disease burden and rising medical costs. Concerns regarding quality of care and patient safety are growing, necessitating a strengthened focus on governance. Intensivist staffing in ICUs is a potential solution to these challenges. Intensivists, hospital leaders, and policy makers should build the best model of critical care and disseminate it across the Korean health system.

This study has several limitations that might impact interpretation of the data. First, our sample size was small and the response rate was 66.7%, which limited generalization of findings. However, the nation has 42 critical care program directors, and their overall response rate was similar to surveys of physician groups.[26] Second, we did not survey other stakeholders in the IPS, including hospital administrators, non-intensivist physicians, and policymakers. We believe that critical care program directors have seniority and clinical leadership in their organization; therefore, they have the greatest insight into the barriers and potential solutions under the current circumstances in Korea. Third, ICU staffing may depend on ICU characteristics, which necessitates an individual approach including alternative staffing models.[27] Further research is needed to develop the optimum model for each hospital.

In conclusion, there are several obstacles to intensivist physician staffing in Korean ICUs. An intensivist is a key player in an ICU organization, who should provide best practice on the frontline. Introduction of a sustainable and solid structure of intensivist staffing requires partnership among hospital leaders, policy makers, and physicians. Further research is warranted to define the best model of critical care delivery, which will further improve outcomes among the critically ill in Korea.