Working in North Vietnam with Doctors without Borders prompted Derek C. Angus, MD, MPH, to think about how acute care systems respond to crisis. Now at the University of Pittsburgh Medical Center, where he is chair of the department of critical care medicine, Angus says, "I'm always thinking about the marriage between the care for the critically ill and the 50,000-foot public health view."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Derek Angus, MD.
This profile was published in the December, 2014 issue of HealthLeaders magazine.
"It's not every patient, but some patients who develop ICU psychosis never return to baseline, and even six months later have attention-, memory-, and other deficit disorders."
Sepsis expert Derek C. Angus, MD, MPH, acquired what he calls "my public health bug" in the late 1980s while working with Doctors Without Borders. He'd been asked to set up a healthcare delivery system for North Vietnamese refugees know as boat people who were fleeing to temporary camps set up in Hong Kong, a designated "first asylum" destination.
"Essentially, I was the only doctor on the ground and I had to design a mini system, ranging from assigning everyone a health record ID to setting up hepatitis, malaria, and TB clinics, and so forth" for thousands of refugees, Angus recalls. "It was very politically charged, and you had to balance immediate needs—women giving birth and terrible fights breaking out—with getting some sort of plan and order in place."
The experience prompted him to "think about healthcare as a system," specifically about how acute care systems respond to crises. And when the Scottish national came to the United States in 1989 for fellowship training in critical care medicine at the University of Pittsburgh, he got his master's degree in public health, specifically studying how acute care systems respond to disasters.
"I'm always thinking about the marriage between the care for the critically ill and the 50,000-foot public health view," Angus says.
Now chair of critical care medicine at the University of Pittsburgh Medical Center, Angus directs CRISMA, Clinical Research, Investigation, and Systems Modeling of Acute Illness, a research group he formed two decades ago, funded primarily with about $5 million a year from the National Institutes of Health. Since its inception, it has grown to about 60 people, including 20 faculty.
Through his nearly 300 articles in peer-reviewed journals, along with 103 books, chapters, and monographs, Angus has distinguished himself as an expert in the operations, cost, and efficiency of the ICU, especially in its care for patients with sepsis and septic shock, which strikes more than a million Americans a year and kills between 28% and 50%.
"Sepsis is a huge public health problem, a sleeping giant because people don't even hear the word. It's essentially what kills you from bacterial infections," he says.
Earlier this year, the results of his 31-hospital project concluded that use of an expensive and invasive catheter, which has been inculcated in guidelines for septic shock adopted by as many as half the hospitals in the nation and endorsed by the international Surviving Sepsis Campaign, was "overly aggressive" and "did not improve outcomes" compared with not using the catheter. That prompted many hospitals, including the Kaiser Permanente system, to revise their practices and the National Quality Forum to remove the catheter from its proposed sepsis quality measure.
"I'm so glad the NQF was adequately fleet of foot and nimble enough that they were prepared to modify the proposed measure based on new evidence," Angus says.
Angus' research has highlighted the frequency with which U.S. patients are cared for in the ICU, the most expensive part of a hospital. It pointedly notes that far too many patients get that level of care when they could be adequately cared for in less intense settings.
"Five to six million Americans get cared for in the ICU every year, which is staggering," he says. "What's more, the decision to admit to the ICU is incredibly variable from hospital to hospital, which is equally concerning. The overall use of the ICU is far higher here than in other Western countries. In other words, we spend a huge amount of money admitting patients to the ICU, often with no obvious benefit and in a very variable way."
Angus says his research finds ICU patients are about 10%–15% of all hospitalized patients, but when the ICU and non-ICU portions of their stay are added together, these patients comprise 40% of a hospital's expenditures. "These are clearly the most expensive patients in the hospital," he notes.
For every 10-bed ICU, he says, there is a 150-person staff, "a little business unit." Some are highly functional, others less so. But this wide variation in safety and practice behaviors can exist even between ICUs in the same hospital. "How you take a highly dysfunctional ICU and get it to learn the habits of a functional ICU is a big research interest of ours."
Among the findings of papers he's coauthored is the fact that, for hospitals in eight states, low-volume facilities have higher mortality rates among patients requiring mechanical ventilation than high-volume hospitals. His research team concluded that 4,720 lives per year could potentially be saved if those low-volume hospitals transferred their patients to high-volume hospitals. The median distance between low- and high-volume hospitals in the eight states is only 8.5 miles."
Another emerging topic of Angus' team research is ICU psychosis, the phenomenon of hallucinations and delirium that mysteriously affects some ICU patients, usually those with longer lengths of stay. "They often have vivid nightmares about the terrible things happening to the people in the beds next to them," Angus says. It's a frightening experience for everyone, and it wears down the doctors and staff who try to reassure and explain the symptoms to these patients and their families.
The cause is poorly understood, but Angus believes the condition stems from the underlying disease process, or from sedation and other drugs administered to the patient. Or it could be an interaction of the two combined with days spent in one room. What predisposes it, and whether it goes away after discharge or leads to neurocognitive decline, is unclear.
But Angus believes sepsis plays a role in the phenomenon, including the actual biologic process of brain inflammation. "It steepens your subsequent rate of cognitive decline." He notes, "It's not every patient, but some patients who develop ICU psychosis never return to baseline, and even six months later have attention-, memory-, and other deficit disorders."
The severity of disease should, of course, be part of any discussion with patients and family members about whether to be admitted or to prolong ICU care, and that's another area of Angus' research. What he and his colleagues have found is a huge disconnect. "The disconnect is not just a lack of information exchange," he says, though he acknowledges that can be a big issue. There also is an "optimism bias" at work on the part of the patient and family, meaning they may not hear what clinicians are telling them.
On the other side of the coin, intensivist teams must be realistic and learn how to communicate, he says. "Some people say, 'Well, we did save this person's life.' And you say, 'Yes, but it would be good to also have them not to have something resembling early-grade Alzheimer's.' A lot of the time, patients end up going through just a huge amount of suffering and long-protracted ICU periods, after which people then say, 'Gosh, if I'd known then what I know now, I don't think I would have ever wanted to see my grandmother go through all this.' "
Despite all of the issues, the fact remains that across the country, ICUs are saving lives with dramatic improvement in survival from classic ICU conditions, like septic shock. "In hospitals that have lower thresholds for admitting patients, the mortality rate is about 5%. In hospitals that only admit critically ill patients to their ICUs, as many as 75% are getting out alive, although by six months the mortality rate is 50%," he says.
Angus says he is on "my third green card," and intends to obtain U.S. citizenship eventually. He has five daughters and says he's a "good Steelers fan." When he's not doing research or spending time with his wife, he's skiing, biking, windsurfing, or playing his saxophone or guitar. But with the research and running his department, he says, "The reality is that I don't have that much spare time."