Arthur St. Andre

Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model

Patients receiving medical care in intensive care units (ICUs) account for nearly 30% of acute care hospital costs, yet these patients occupy only 10% of inpatient beds (1, 2). In 1984, the Office of Technology Assessment concluded that 80% of hospitals in the United States had ICUs, >20% of hospital budgets were expended on the care of intensive care patients, and approximately 1% of the gross national product was expended for intensive care services (3). With the aging of the U.S. population, greater demand for critical care services will occur. At the same time, market forces are evolving that may constrain both hospitals’ and practitioners’ abilities to provide this increasing need for critical care services. In addition, managed care organizations are requesting justification for services provided in the ICU and for demonstration of both efficiency and efficacy. Hospital administrators are continually seeking methods to provide effective and efficient care to their ICU patients. As a result of these social and economic pressures, there is a need to provide more data about the type and quality of clinical care provided in the ICU. In response, two task forces were convened by the Society of Critical Care Medicine leadership. One task force (models task force) was asked to review available information on critical care delivery in the ICU and to ascertain, if possible, a “best” practice model. The other task force was asked to define the role and practice of an intensivist. The task force memberships were diverse, representing all the disciplines that actively participate in the delivery of health care to patients in the ICU. The models task force membership consisted of 31 healthcare professionals and practitioners, including statisticians and representatives from industry, pharmacy, nursing, respiratory care, and physicians from the specialties of surgery, internal medicine, pediatrics, and anesthesia. These healthcare professionals represented the practice of critical care medicine in multiple settings, including nonteaching community hospitals, community hospitals with teaching programs, academic institutions, military hospitals, critical care medicine private practice, full-time academic practice, and consultative critical care practice. This article is the consensus report of the two task forces. The objectives of this report include the following: (1) to describe the types and settings of critical care practice (2); to describe the clinical roles of members of the ICU healthcare team (3); to examine available outcome data pertaining to the types of critical care practice (4); to attempt to define a “best” practice model; and (5) to propose additional research that should be undertaken to answer important questions regarding the practice of critical care medicine. The data and recommendations contained within this report are sometimes based on consensus expert opinion; however, where possible, recommendations are promulgated based on levels of evidence as outlined by Sacket in 1989 (4) and further modified by Taylor in 1997 (5) (see Appendix 1).

Guidelines for intensive care unit design.

Objective: To develop a guideline to help guide healthcare professionals participate effectively in the design, construction, and occupancy of a new or renovated intensive care unit. Participants: A group of multidisciplinary professionals, designers, and architects with expertise in critical care, under the direction of the American College of Critical Care Medicine, met over several years, reviewed the available literature, and collated their expert opinions on recommendations for the optimal design of an intensive care unit. Scope: The design of a new or renovated intensive care unit is frequently a once- or twice-in-a-lifetime occurrence for most critical care professionals. Healthcare architects have experience in this process that most healthcare professionals do not. While there are regulatory documents, such as the Guidelines for the Design and Construction of Health Care Facilities, these represent minimal guidelines. The intent was to develop recommendations for a more optimal approach for a healing environment. Data Sources and Synthesis: Relevant literature was accessed and reviewed, and expert opinion was sought from the committee members and outside experts. Evidence-based architecture is just in its beginning, which made the grading of literature difficult, and so it was not attempted. The previous designs of the winners of the American Institute of Architects, American Association of Critical Care Nurses, and Society of Critical Care Medicine Intensive Care Unit Design Award were used as a reference. Collaboratively and meeting repeatedly, both in person and by teleconference, the task force met to construct these recommendations. Conclusions: Recommendations for the design of intensive care units, expanding on regulatory guidelines and providing the best possible healing environment, and an efficient and cost-effective workplace. (Crit Care Med 2012; 40:–16)

THE IMPACT OF IMPLEMENTATION OF NEUROMUSCULAR BLOCKADE MONITORING STANDARDS IN A SURGICAL INTENSIVE CARE UNIT

The purpose was to determine whether implementation of standards for peripheral nerve monitoring could decrease the incidence of neuromuscular dysfunction related to the administration of paralytic agents. Over a 2-year period, consecutive patients admitted to a surgical intensive care unit who received continuously-infused or >6 daily doses of neuromuscular blocking agents were subjected to train-of-four (TOF) monitoring of the adductor pollicis. Therapy was titrated to the maintenance of one to two twitches at all times. The incidence of prolonged (>12 h) paralysis after drug discontinuation was documented in these patients and compared to that in patients treated in the previous 12 months. The presence of electrolyte abnormalities, organ dysfunction, and concomitant medications was also recorded. Chi-square analysis with Yates correction was employed. Before implementation of routine TOF monitoring, there were five instances of paralytic-associated neuromuscular dysfunction (5/43). After implementation of the TOF protocol, no instances of paralytic-associated neuromuscular dysfunction occurred (0/90), despite the same incidence of risk factors (100%) (P < 0.05). A protocol for neuromuscular blockade monitoring is efficacious in preventing paralytic-associated neuromuscular dysfunction. This can be a cost-effective measure, minimizing the prolonged mechanical ventilation and intensive rehabilitation required secondary to unmonitored use of neuromuscular blocking agents.

Contemplating the Pentagon attack after five years of space and time: unheard voices from the ramparts of our burn center.

Marking the fifth year after the attack on the Pentagon, staff at the burn center in Washington, DC, memorialize in a contemplative frame of mind. These reflections are drawn from members of the extended burn team and render an interwoven sketch in prose that previously has not been heard.

The formation, elements of success, and challenges in managing a critical care program: Part I.

Leaders of critical care programs have significant responsibility to develop and maintain a system of intensive care. At inception, those clinician resources necessary to provide and be available for the expected range of patient illness and injury and throughput are determined. Simultaneously, non-ICU clinical responsibilities and other expectations, such as education of trainees and participation in hospital operations, must be understood. To meet these responsibilities, physicians must be recruited, mentored, and retained. The physician leader may have similar responsibilities for nonphysician practitioners. In concert with other critical care leaders, the service adopts a model of care and assembles an ICU team of physicians, nurses, nonphysician providers, respiratory therapists, and others to provide clinical services. Besides clinician resources, leaders must assure that services such as radiology, pharmacy, the laboratory, and information services are positioned to support the complexities of ICU care. Metrics are developed to report success in meeting process and outcomes goals. Leaders evolve the system of care by reassessing and modifying practice patterns to continually improve safety, efficacy, and efficiency. Major emphasis is placed on the importance of continuity, consistency, and communication by expecting practitioners to adopt similar practices and patterns. Services anticipate and adapt to evolving expectations and resource availability. Effective services will result when skilled practitioners support one another and ascribe to a service philosophy of care.Leaders of critical care programs have significant responsibility to develop and maintain a system of intensive care. At inception, those clinician resources necessary to provide and be available for the expected range of patient illness and injury and throughput are determined. Simultaneously, non-ICU clinical responsibilities and other expectations, such as education of trainees and participation in hospital operations, must be understood. To meet these responsibilities, physicians must be recruited, mentored, and retained. The physician leader may have similar responsibilities for nonphysician practitioners. In concert with other critical care leaders, the service adopts a model of care and assembles an ICU team of physicians, nurses, nonphysician providers, respiratory therapists, and others to provide clinical services. Besides clinician resources, leaders must assure that services such as radiology, pharmacy, the laboratory, and information services are positioned to support the complexities of ICU care. Metrics are developed to report success in meeting process and outcomes goals. Leaders evolve the system of care by reassessing and modifying practice patterns to continually improve safety, efficacy, and efficiency. Major emphasis is placed on the importance of continuity, consistency, and communication by expecting practitioners to adopt similar practices and patterns. Services anticipate and adapt to evolving expectations and resource availability. Effective services will result when skilled practitioners support one another and ascribe to a service philosophy of care.

Defining surgical critical care as an integrated specialty

Abstract Purpose Among general surgeons, resistance to incorporating critical care specialists into the mainstream of surgical critical care is well documented. Loss of control, fragmentation of care, added cost, and the abdication of expertise are frequently cited as objections to this approach. In 1992, we began to explore the feasibility of developing a fully integrated, multidisciplinary surgical critical care program, structured to avoid these pitfalls. The conversion from a traditional nonintegrated surgical model was completed in 1993. This report summarizes the structural changes and results of this effort. Methods The Surgical Critical Care Service was converted from a combined trauma/critical care service into a multidisciplinary section of the Department of Surgery, composed of 12 full-time faculty (7 surgeons, 5 nonsurgeons). All (surgeons and nonsurgeons) are active full-time members of the department with a director (nonsurgeon) and a residency program director (surgeon) who report to the chairman of the department. Patient care is both vertically (surgical team) and horizontally (intensive-care-unit team) integrated with a surgical/critical care resident functioning as the key crossover member of both teams. Educational programs are organized and administered by the residency program director with faculty choice based on ability rather than training background. A work group composed of the chairman, key section directors (anesthesiology, critical care, trauma, burns, and cardiac surgery), and the assistant vice president of nursing meet monthly to provide global direction and resolve differences of opinion. Results Tension between general surgeons and critical care specialists has been eliminated. Objective performance parameters have significantly improved since the conversion. Resident evaluations and American Board of Surgery In-Service Training Examination (ABSITE) performance remained constant or improved after conversion. Conclusion The development of a multidisciplinary critical care program based in the Department of Surgery relieves professional tensions, improves the quality of care, and enhances educational and research opportunities for both critical care and general surgery residents.

RADIOGRAPHIC DETECTION OF MOBILIZABLE LUNG WATER: THE GRAVITATIONAL SHIFT TEST

A radiographic method for detecting excessive lung water in patients with pulmonary infiltrates of uncertain cause is described. The gravitational shift test uses bedside frontal films before and after prolonged lateral decubitus positioning. Excess lung water is identified by detecting a shift in infiltrate to the dependent lung while the opposite side clears or remains stable. The test was evaluated in 33 patients with infiltrates of well defined etiology. Twelve patients had heart failure or fluid overload (edema): 14 had pulmonary infection or parenchymal damage (inflammation); and seven had inflammation plus edema. Infiltrates shifted to the dependent lung in 85% of patients with lung edema, but did not shift in 78% of patients with inflammatory disease. The test also detected excess lung water in six of seven patients with underlying inflammatory disease. Each patient with a positive test showed clinical, physiologic, and radiographic improvement after therapy directed at mobilizing excessive lung water. When the differential diagnosis of a diffuse infiltrate is in question, a positive test represents a strong indication for a trial of diuretic therapy.