A. Joseph Layon

Critical Care Organizations: Business of Critical Care and Value/performance Building*

Objective: New, value-based regulations and reimbursement structures are creating historic care management challenges, thinning the margins and threatening the viability of hospitals and health systems. The Society of Critical Care Medicine convened a taskforce of Academic Leaders in Critical Care Medicine on February 22, 2016, during the 45th Critical Care Congress to develop a toolkit drawing on the experience of successful leaders of critical care organizations in North America for advancing critical care organizations (Appendix 1). The goal of this article was to provide a roadmap and call attention to key factors that adult critical care medicine leadership in both academic and nonacademic setting should consider when planning for value-based care. Design: Relevant medical literature was accessed through a literature search. Material published by federal health agencies and other specialty organizations was also reviewed. Collaboratively and iteratively, taskforce members corresponded by electronic mail and held monthly conference calls to finalize this report. Setting: The business and value/performance critical care organization building section comprised of leaders of critical care organizations with expertise in critical care administration, healthcare management, and clinical practice. Measurements and Main Results: Two phases of critical care organizations care integration are described: “horizontal,” within the system and regionalization of care as an initial phase, and “vertical,” with a post-ICU and postacute care continuum as a succeeding phase. The tools required for the clinical and financial transformation are provided, including the essential prerequisites of forming a critical care organization; the manner in which a critical care organization can help manage transformational domains is considered. Lastly, how to achieve organizational health system support for critical care organization implementation is discussed. Conclusions: A critical care organization that incorporates functional clinical horizontal and vertical integration for ICU patients and survivors, aligns strategy and operations with those of the parent health system, and encompasses knowledge on finance and risk will be better positioned to succeed in the value-based world.

Ethics, Morality, and Consulting: The Moral Problem of the Commons

We read with great dismay the review article published in The American Journal of Medicine under the name of Leonard Fromer. Dismay that this respected source of medical and social information, by publishing the aforementioned piece, has done a disservice to its readers and our country. The authors of this piece frontally attack the “Fiscal Commons” of the United States, and indirectly, the pocketbooks of our citizens. The Former article notes in the acknowledgements:

Nutrition in the Neurointensive Care Unit

Approximately 30–50 % of hospitalized patients worldwide suffer from malnutrition, making the importance of maintaining adequate nutritional support crucial to critically ill patients. Achieving an adequate level of nutritional support revolves around counteracting hypermetabolic effects of injury or illness by reducing the severity of malnutrition and preventing complications such as overfeeding. Early recognition, prevention, and appropriate initiation of supplemental nutrition will aid in optimizing nutritional status. Patients able to reach and maintain an optimal level of nutritional status will benefit from faster recovery, improved wound healing, and an increase in rehabilitative efforts. Likewise, a decrease in hospital length of stay, complication rates, morbidity, and mortality will occur.

Brain Death and Management of the Potential Organ Donor

A structured and standardized approach to the diagnosis of brain death is essential to ensure that patients are appropriately classified. This involves a physical exam to establish coma and exclude reversible causes of coma, a comprehensive evaluation of the cranial nerves, and an apnea test. The inability to perform any of the physical exam elements necessitates the use of confirmatory studies. Management of the potential organ donor commences after the diagnosis of brain death is established. Donation after cardiac death should be considered in patients whose prognosis is futile and in whom care is to be withdrawn. Specific donor management goals have been established and have been associated with greater organ procurement. Hemodynamic management forms the cornerstone of brain-dead donor management. Echocardiography should be performed in all potential donors to evaluate cardiac function. Fluid resuscitation is frequently necessary as potential donors tend to be intravascularly volume depleted. Vasopressors should be used to support acceptable blood pressure and hemodynamic profiles. Donor lung management should utilize a lung protective strategy with ventilatory manipulations undertaken to ensure adequate systemic oxygenation and lung expansion. A coordinated donor management approach utilizing intensivists and OPO coordinators has been shown to more effectively manage the donation process, resulting in more organs procured and transplanted.