The Critical Care Workforce and COVID-19: A State-by-State Analysis
The United States remains among the countries most severely impacted by the coronavirus pandemic, with reported COVID-19 cases rising again in many states. While much recent research and media reporting on the pandemic response has focused on the availability of hospital beds and medical equipment, there is also concern that the availability of medical personnel capable of providing intensive care could be a limiting factor in the care of COVID-19 patients. This is a particular challenge as cases and hospitalizations surge in hotspots across the country.
Using recent data from the National Plan and Provider Enumeration System (NPPES) National Provider Identifier (NPI) Registry, this Data Note reports baseline estimates of the number of active critical care physicians and nurses in each state relative to state population.
To date, much of the federal and state-level response to the COVID-19 pandemic in the United States has focused on the availability of hospital resources such as funding, beds, and personal protective equipment.1 However, some experts have signaled that personnel are also in short supply. Alarmingly, the Society for Critical Care Medicine (SCCM) reported that the number of providers trained in intensive care unit (ICU) care and mechanical ventilation could be a limiting factor in the care of COVID-19 patients, and has recommended that the pandemic response should place greater emphasis on increasing the number of available critical care professionals.2
However, quantifying the number of critical care providers in the U.S. has historically been difficult. On the one hand, some professional societies have argued that only “intensivist” physicians who have completed a formal fellowship in critical care medicine should lead critical care teams, and some research suggests that this may improve clinical outcomes in the ICU setting.3 On the other hand, many providers without formal critical care training regularly care for critically ill ICU patients, including substantial numbers of hospitalists, pulmonologists, and anesthesiologists. The issue is further complicated by variability in the proportion of duty hours that individual providers spend in the intensive care setting. Researchers writing in 2015 noted that, “our current supply of full-time intensivists is very low, as the vast majority of adult, board-certified intensivists are really part-time practitioners based in pulmonary medicine, operating rooms (surgeons/anesthesiologists), or emergency medicine”.4
Consequently, prior estimates have reflected these limitations. For example, an early landmark study by the Committee on Manpower for Pulmonary and Critical Care Societies in 2000 found that, of the 10,244 practicing U.S. physicians that classified themselves as critical care providers, nearly half did not hold a formal critical care certification.5 A 2013 study by the Health Resources and Services Administration (HRSA) took duty hour variation into account, reporting only 3,570 full-time equivalent intensivist physicians and 2,880 full-time equivalent critical care nurse practitioners.6 The most recent published estimates are based on data from 2015, though the ongoing COVID-19 pandemic response warrants further updates.7 Using data from the 2020 National Plan and Provider Enumeration System (NPPES) National Provider Identifier (NPI) Registry, this Data Note quantifies the availability of providers capable of providing critical care in each state relative to state-level population.
- Approximately 16,600 intensivists and 67,900 critical care nurses, including certified registered nurse anesthetists (CRNAs), were identified in the United States. At the state level, these counts correspond to an average of 0.62 intensivists and 2.54 critical care nurses per 10,000 adults.
- There are also nearly 116,000 second-line physicians—hospitalists, pulmonologists, and anesthesiologists—who do not have formal critical care training, but who may be caring for critically ill patients. Across the states, these providers average 4.32 per 10,000 adults.
- Individual state-level provider concentrations varied widely. Several states that have recently reported a surge in cases have per-population numbers of intensivists or critical care nurses that are substantially lower than national average ratios, such as California, Arizona and Texas. Estimates per 10,000 adults are reported in Table 1.
These estimates highlight several issues relevant to both the baseline critical care workforce in the U.S. and to the response to the coronavirus pandemic. Notably, the number of intensivist physicians is substantially smaller than that of “second-line” providers that sometimes provide critical care, such as hospitalists, pulmonologists, and anesthesiologists, lending credence to longstanding concerns that intensivists are in short supply in the U.S. at baseline. However, it is unclear how many of these second-line providers could be readily redirected into the ICU setting. Many hospitalists likely can be, since most practice in the hospital setting. However, significant numbers of anesthesiologists and pulmonologists may primarily practice in non-hospital settings such as ambulatory surgery centers and outpatient physician offices, and may have little experience providing ICU-level care. Similarly, the number of nurses specifically trained in critical care also appears relatively small compared to prior estimates, suggesting that the source data may lack comprehensive records for some categories of nurses that provide critical care.
Furthermore, recent increases in COVID-19 cases in several states may justify redirection of second-line providers into critical care roles, as well as recruitment of intensivists and critical care nurses from other regions, as the pandemic intensifies. Both approaches may be facilitated by volunteer programs and state government proposals similar to those that supported prior workforce expansions in New York.8
Finally, providers outside of the hospital setting will also play instrumental roles in the pandemic response, both by reducing strain on hospitals and by providing direct COVID-19 care. For example, long-term care and skilled nursing facilities are continuing to be disproportionately impacted, increasing their demand for additional personnel as well.9 Similarly, sufficient numbers of primary care physicians and other ambulatory care providers are vital, not only to help minimize avoidable hospitalizations through monitoring of their patients’ chronic conditions, but also to coordinate essential follow-up care for recovering COVID-19 patients after hospital discharge.
National and state leaders are facing challenging decisions about where to allocate limited resources, including critical care providers. Estimates of the current workforce size and distribution can help inform these decisions, though they must be interpreted in conjunction with local factors such as disease burden, health care infrastructure, workplace safety, and the availability of funding and medical resources. The interactions between these factors are complex and will require continuous re-evaluation in order to best protect both patients and health care personnel during the pandemic.
Eric John Lopez was a member of KFF’s ACA and Medicare Policy teams. He is a medical student at the University of California, San Francisco, and participated in a yearlong UCSF-KFF Health Policy Fellowship.
|State-level counts of active critical care providers were calculated based on May 2020 data from the National Plan and Provider Enumeration System (NPPES) National Provider Identifier (NPI) Registry (https://download.cms.gov/nppes/NPI_Files.html).10
NPPES specialty taxonomy codes used to calculate raw provider counts included: 207LC0200X (Anesthesiology – critical care medicine), 207RC0200X (Internal medicine – critical care medicine), 207VC0200X (Obstetrics & gynecology – critical care medicine), 2084A2900X (Neurocritical care), 2086S0102X (Surgical critical care), 163WC0200X (Registered nurse – critical care medicine), 364SC0200X (Clinical nurse specialist – critical care medicine), 363LC0200X (Nurse practitioner – critical care medicine). Certified Registered Nurse Anesthetists (CRNAs) are included in estimates of critical care nurses, as an American Association of Nurse Anesthetists (AANA) position statement on COVID-19 has stated that CRNAs can safely assume care of ICU patients, subject to the experience and judgment of individual clinicians (https://www.aana.com/docs/default-source/practice-aana-com-web-documents(all)/crnas_asked_to_assume_critical_care_responsibilities_during_ the_covid_19_pandemic .pdf? sfvrsn=ea3630e7_6).
Providers are assigned to their state of practice as reported the most recent version of the dataset. State-level ratios of providers per 10,000 adults were calculated by dividing the number of each critical care provider by the state-level population as reported in the 2019 U.S. Census Bureau projections.11 Providers specializing in pediatric and neonatal critical care are not included. The full list of taxonomy codes and definitions can be found at the Washington Publishing Company website (http://www.wpc-edi.com/reference/codelists/healthcare/health-care-provider-taxonomy-code-set/).