Dr. Ranieri is the Chair of the Department of Anaesthesia and Intensive Care at Molinette Hospital in Turin, Italy; Professor at the University of Turin and the current President of the European Society of Intensive Care Medicine (ESICM). In this interview with Sherry Scharff, Dr. Ranieri reflects on the difficulties of applying business principles to critical care management and outlines his vision for ICU and emergency rooms of the future.
Can You Briefly Describe
Your Professional History?
I graduated from University of Bari, Italy with a specialisation in Anaesthesia and Intensive Care medicine. I completed a two to three year fellowship at McGill University in Montreal, Canada before returning to Italy in 1992. Subsequently, I was an Assistant Professor in the Anaesthesia and Intensive Care Department at the University of Bari until 1998. I spent the two years following as a visiting Professor at Mount Sinai Hospital, in the University of Toronto’s Critical Care Department. Upon returning to Italy I worked as an Associate Professor in Anaesthesia and Intensive Care at the University of Pisa. In 2001, I became a full Professor at the University of Turin in the Anaesthesia and Intensive Care department. I took on the Presidency of ESICM in 2006 and my term ends in 2008.
What does a Typical Day
I would say an average day is divided between the administration and maintenance of a busy ICU and research. The first order of business when I reach the department in the morning is to meet with attending doctors. I do rounds of the ward as well as the lab, and attend meetings with hospital officials and others, depending on the day. The rest of the day consists of administration of the department until the afternoon when the doctors arrive and I am able to focus on writing and reviewing research papers and preparing presentations for upcoming conferences.
Which Management and
Personnel Issues Take up Most of Your Time?
In my roles in both ICU and anaesthesia departments, the central management issue is always allocation of resources. I deal with this continuously, in direct cooperation with the hospital CEO. It often becomes a factor with personnel. Resources are not infinite, and an important part of my role as a manager is to make sure that limited resources are being used in the most efficient manner. Flexibility is the absolute key to success. Presently in Italian hospitals, I see this as our primary issue. There is a lack of flexibility in terms of personnel, structure and organisation, which prevents the most efficient use of resources. Anaesthetists, for example, are assigned to one operating room as opposed to transferring from varying theatres based on need. As some personnel are underutilised and others over-utilised, there is a danger not only of wasting resources, but also burnout syndrome.
What are Your Goals
for Your ICU/Emergency Department?
We must reach a gold standard of treatment means that we are providing the best possible medicine with the knowledge that resources are limited. This is the challenge of the new millennium, and we must learn to evolve rapidly and remain flexible. In many ways we need to think of ourselves as an efficient service, like that of an airline. We must adopt the same criteria in our system. The best way to organise our services more efficiently and fairly, in my view, would be by utilising a system of classification such as an updated Diagnosis Related Group (DRG). Patients can be assigned a group based on ICD diagnoses, procedures, age, sex, and the presence of complications or co-morbidities. This can help managers and intensivists, among others, to determine how much time, personnel, and resources to devote to each case, since patients within each category are similar clinically and are expected to use the same level of hospital resources.
Are there Particular
Areas in Which You Feel Your Department Excels?
Management of acute respiratory failure, specifically mechanical ventilation and extra-corporeal lung assistance is our speciality.
What has been Your Most
Satisfying Experience in Your Professional Life?
There are several pinnacle moments thus far in my career in general, and specific high points in both my physician and managerial roles.
As a doctor, absolutely the most rewarding experience to date occurred just over a year ago, and involved a patient who was a 15 year-old girl. She desperately needed a new lung and while awaiting a transplant, we used extra capillary support as a bridge and mechanical support to buy her time. The fact that we were able to save her life through our efforts was incredibly gratifying.
As a manager, running all institutional activities – within budget, while making some relevant savings last year was a success, easily measurable in business terms, and also satisfying in a goal-meeting sense. Of course, having my article published in JAMA was also deeply fulfilling on a professional level and was perhaps most beneficial in regards to my ego.
What is the Hardest
Decision You have had to Make as an ICU/Emergency Department Manager?
The choice to close an ICU (6 beds) because it ceased to be cost effective, and the medical personnel issues that resulted was clearly a difficult, albeit, necessary decision I was forced to make. As a manager, there is a fragile balance between maintaining personnel levels and overall satisfaction amongst ICU staff, and creating a good, efficient general system of care. Ultimately, in the case of this ICU closure, the personnel were reallocated, and, after a necessary transitional period, satisfaction returned and efficiency improved.
What Sorts of Issues
do You Feel the ICU Community Needs to Address to Prepare for the Future?
At the root of ICU organisation and management, there lies an inherent contradiction. On one hand, there is a drive for research and all that connects to it, in terms of new medications, updated tools and equipment to improve response and diagnosis time; while on the other hand, there are limited resources, and a push to tighten budgets and rein in spiralling expenditures. The challenge remains how to cope with this continual debate – on a daily basis, within our own ICU’s, as well as how to face these issues on a grander scale; in terms of whether we should be spending a million dollars in technological advances to save 10 lives in our own developed world, or the same amount for a continental vaccination program for Africa – where it could save thousands. These are the kinds of questions we need to ask ourselves within the intensive and emergency care communities and the broader issues we must deal with in the coming decade.
What are Your Feelings
as You Near the End of Your Term as President of ESICM?
Well, I hold enormous pride in the fact that I was able to oversee ESICM during such a momentous period. We celebrated our 25th Anniversary and held a successful 20th Annual Conference over the past year. I think as a relatively young society, and in so few years, ESICM has managed to reach the same level of accreditation, professional and clinical status that other societies have attained in a much longer period of time. I think it is a sign of how prevalent critical care has become and a clear signal of its’ importance in the future.