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The Future of Critical Care


 

Critical care is starting to face some tough obstacles, and the ICU of the future will be shaped by these problems—namely an aging population and a shrinking field of expert critical care practitioners. Because of these impending changes, in 20 or 30 years your hospital’s ICU must look different and work differently in order to handle a steady influx of critically ill patients.

This installment of our “Hospital of the Future” series will examine how the hospital of the future will deal effectively with the supply-and-demand quandary that is already becoming apparent in the ICU. It will also examine future possibilities for staffing structure, introduction of critical care guidelines, and groundbreaking technical solutions. Prospects for critical care may look questionable now, but solutions are available. And the future just might be brighter than expected.

Supply and Demand of Critical Care Demands Change

Current trends in both the U.S. population and the demographics of critical care staff dictate that critical care must change—and fast. With millions of baby boomers aging, demand for critical care facilities within hospitals will increase.

“There’s little question that critical care is used disproportionately by the elderly,” says Timothy Buchman, MD, PhD, FACS, FCCM, past president of the Society of Critical Care Medicine (SCCM) and professor at Washington University School of Medicine, St. Louis. “The demand can only increase as the population ages.”

At the same time, there are already too few critical care providers in the United States. “If we designed an ideal ICU for every hospital in the country, we could only staff about one-third of them” right now, says Thomas Rainey, MD, FCCM, president, CriticalMed, Inc., Bethesda, Md.

Critical care experts are, of course, the key to quality care in the ICU. But the population of both specially trained intensivists and experienced ICU nurses is declining. The average age of an ICU nurse is now 47, and they are not replaced fast enough.

“Critical care nursing is brutally hard work; it’s physically, emotionally, and spiritually grueling,” points out Dr. Buchman. “The challenge is keeping experienced nurses from leaving because they’re burned out. We need to keep their knowledge and experience, possibly by creating new positions where their knowledge, experience, and accumulated wisdom can be used to benefit the next generations of patients and providers.”

As for physicians, fewer are choosing critical care, which will likely lead to significant staffing issues. “The number of doctors choosing a career in critical care is leveling off,” says Dr. Buchman. Part of the problem is an educational system that helps medical students choose a specialty.

“We have a direct training path to many specialties through residencies,” he says. “There is no residency in critical care medicine. Instead, we ask people to initially train as something else. We’ve created an educational barrier.”

The upshot of these trends, says Dr. Rainey, is that “the graying population and the loss of [critical care] staff is a collision waiting to happen.”

Dr. Buchman adds, “The question is: How do people organize themselves and leverage technology to address this gap and improve the quality of care?”

One solution to the staffing shortage is electronic ICUs—or eICUs, which allow an intensivist and ICU nurse to monitor and manage part or all of the patient population in their organization’s ICU from off-site.

How Technology Fits In

In 2001, Richard L. Craft, MSEE, wrote of “Trends in Technology and the Future Intensive Care Unit” ( . 2001;29[8 suppl]): “ … advances in networking are likely to redefine the physical and organizational boundaries of the critical care unit. No longer a self-contained entity … tomorrow’s critical care units are likely to regularly draw on resources—both human and technological—located outside the unit’s physical space.”

The solution to staffing shortages in ICUs lies in using technology that is already available to hospitals.

“Remote monitoring will help leverage existing manpower,” says Dr. Rainey. One option is electronic ICUs—or eICUs, which allow an intensivist and ICU nurse to monitor and manage part or all of the patient population in their organization’s ICU(s) from off-site, if applicable. This remote monitoring supplements on-site hospital staff, but allows fewer specialists access to more patients.

“eICU with smart alerts, physiologic status boards, [and] color-coded assessments of response to protocolized care may help hospitalists and intensivists on-site manage increasingly busy and acute ICUs,” says Dr. Buchman. “The greatest impact will be to facilitate the transformation of data into information and to highlight factors that are of greatest immediate importance.”

In addition to maximizing medical staff, eICU systems can also leverage technical support. Craft writes, “… it is easy to foresee a day when a network of hospitals might centralize its critical care application servers and patient record servers in one location to reduce IT staff overhead, standardize clinical protocols, and automate corporation-wide quality control mechanisms.”

With an eICU system, cameras, monitors, and communication devices provide information on each patient, and can even provide treatment recommendations or guidelines.

“eICU systems are evolving now,” says Dr. Buchman. “They synthesize data streams and allow us to stratify information with respect to how important it is. We’ve [already] had a few components, such as bedside hemodynamic monitors. For each individual patient, a sophisticated system should be able to take data from multiple systems, integrate it, and provide a snapshot of how that patient is doing. Take that throughout the entire ICU and have a display that presents instant pictures of how the ICU is doing. [Have] inventories presented in parallel to providers so they can see where problems are.”

Dr. Buchman predicts that in the future ICU care providers will take on more duties as managers of care.

“ICU providers will go through an evolution like airline pilots did,” he says. “These days, airline transport pilots don’t spend a lot of time actually flying the plane. There are plenty of autopilots and subsystems that do that. The pilot now spends most of her time managing the system, and intervenes as necessary to bring everything into harmony. I think this same type of sophisticated presentation will evolve in the ICU to provide a safer environment that uses the available human resource most efficiently. It won’t save on manpower, but it will greatly increase patient safety.”

J. Christopher Farmer, MD, FCCM, Division of Pulmonary and Critical Care, Mayo Clinic College of Medicine, Rochester, Minn., agrees—especially as relates to disaster response.

“We need technology that doesn’t rely on human factors,” says Dr. Farmer. During a hospital’s disaster response, “we miss things because we don’t notice them. We need automation of systems that will push information to us as computerized analysis; systems that look at everything, including lab results, and postulate on that information. This would help in critical care and could be used in disaster settings as well.”

Dr. Farmer’s vision includes automatic monitoring. “Ideally, I’d like to see every patient have a patch that reads their heart rate, oxygen levels, etc.,” he says. “This 100% monitoring of every patient is applicable in disaster medicine because otherwise you need a person to manually hook up monitors and check vitals on each patient.”

The evolution of ICU technology must focus on bridging the gap between limited staff and growing patient population as well as the gap between adequate care and excellent care.

“Technology is there to serve the patient first, but most importantly, to serve the care alliance of patients and practitioners,” says Dr. Buchman “I think some [advancements] are simply technical toys that are replacing what humans can already do.”

Technology can help identify a disease outbreak or other disaster faster than humans can. Some hospital systems are using surveillance systems that link across their facilities to find patterns. These systems can be used to find medical errors, but they can also act as bio-disease surveillance systems, which can be used to identify a sudden outbreak.

“Say three different hospitals each admit one patient with diarrhea,” says Dr. Farmer. “What if this is the beginning of an outbreak of something? A system that links across hospitals can find these patterns.”

The Critical Care Team of the Future

Today’s most highly developed ICUs are utilizing trained critical care teams to ensure the best possible care. In the future, all ICUs will follow this model in order to improve patient safety and efficiency of care.

These teams can include “not only physicians and nurses, but also respiratory therapists, nutritional support staff, and pharmacists, who collectively function as a highly integrated team, following protocols,” says Dr. Buchman. “This team formulates a patient plan together and evaluates the impact of that plan. I think we’re seeing more of that now, and we’re going to see a lot more of it. It’s a continuum; a growth process.

“This is not restricted to medical care; it will include social and spiritual care as well, with a team of case managers, social workers, and chaplains,” he continues. “These professionals contribute to the integrated care plans.”

Dr. Rainey agrees. “We’ll see a reorganization of physician services into an intensivist team model,” he predicts. “The development we’ve seen over the last 20 years is that outcomes are better with a unit-based special team that manages patients in cooperation with the primary care physician. In fact, this approach has shown something like a 30% decrease in risk for mortality.”

This team approach also applies to hospital disaster preparedness. In his white paper “Hospital Disaster Medical Response: Aligning Everyday Requirements with Emergency Casualty Care,” Dr. Farmer says, “ … we are witnessing the rapid development and emergence of medical emergency teams, or rapid response teams within the hospital. … These teams are intended to monitor inpatients and intervene before physiological deterioration supervenes. One might ask, in the event of a medical disaster, could these teams be repurposed for sophisticated casualty care and ICU expansion? We think it is logical that these types of critical care ‘outreach’ teams, in conjunction with noncritical care hospital personnel, could be leveraged as an effective strategy to extend ICU capabilities during a disaster.”

Having a complete team of ICU providers address each patient’s needs will vastly improve quality of care, but these teams must have some guidelines to follow in order to ensure that they work at maximum efficiency.

Critical Care Guidelines: An Integral Component

Critical care experts shy away from such buzzwords and phrases as “standardization of care” in regard to ICU practices, but they do agree that universal guidelines will be the norm in the future.

“We’ll see the development of drastically improved outcomes, and reduction in harm through reliable processes,” says Dr. Rainey. “We can see, for example, that five things need to be done to every ventilated patient. With development of reliable processes in place, we can see that we will close the gap between intent and actual execution.”

Dr. Farmer agrees. “We do clinical guidelines for everyday issues, so I don’t see why we can’t do the same thing” for critical care and disaster preparedness.

Critical care is ripe for integrating clinical practice guidelines. “There are certain types of interventions that are near universal in ICUs,” says Dr. Buchman. “How we sedate patients, how we relieve pain, how we liberate someone from mechanical support … having touchstones or guidelines for these interventions will help. This is complementary to standardization of care.

“Here’s an example: A patient is admitted with a myocardial infarction. We would treat him with beta-blockers, nitrates, heparin, and aspirin. We don’t think of a standard dose of beta-blockers because the dose must be titrated to [have an] effect on the individual patient,” he continues. “How this individualization is done safely involves organizational guidelines. Systematic implementation of such guidelines will be the difference between good ICUs and great ICUs. The implementation is a continuous four-step process—learn the recommendations, deliver the care, measure the outcomes, and find ways to improve.”

Hospitalists and Critical Care

In concert with technologic advancement and improved guidelines, one major solution to the staffing shortage is hospitalists. According to Dr. Farmer, a large portion of critical care services across the country is provided by family practitioners and general internists. The demographics of the population, combined with the current system of training, ensure inadequate staffing. That shortage could be filled by hospitalists. For many hospitalists ICU care is already an important and satisfying arm of their practice. It may become necessary in the future to define skill sets to work in critical care areas. Hospitalists are well positioned to fill that need.

Looking Ahead

The area of critical care may be moving more quickly toward the future than other hospital functions because it must do so in order to continue to work at all. The success of achieving a future of quality care, patient safety, and adequate staffing rests on a different approach with providers and technology.

“We have to learn to work smarter to leverage new technology and the expertise of all other experts in other fields,” says Dr. Buchman of the future of critical care.TH

Chicago-based Jane Jerrard will write future installments of this series.

FLASHBACK:

An Ill Wind

An 1883 tornado strikes a familiar chord in today’s hurricane-ridden times

Rochester after the tornado of 1883.

Rochester after the tornado of 1883.

“An ill wind”—these were the opening words spoken by William Worrall, MD, at the official opening ceremony for St. Mary’s Hospital in Rochester, Minn. The hospital had been conceived following the destruction wrought on Rochester by a tornado that had left 37 dead and more than 200 injured six years earlier.

Aug. 12, 1883, was a particularly hot day, and many residents must have been hopeful of relief as they saw black clouds looming to the west late that evening. That evening Dr. William Mayo’s sons, Will and Charlie, were headed to the slaughterhouse northwest of town in the part of Rochester then known as the Lower Town to purchase a sheep’s head for eye dissections. The butchers had closed early because of the impending storm and advised the young Mayos to head back posthaste.

The cyclone descended just as they crossed a bridge, which was torn loose of its moorings, over the Zumbro River. They witnessed buildings smashed to bits, a grain elevator toppled, and railroad cars wrecked by the destructive force. They were almost killed by a heavy cornice that had ripped off the Cook House and smashed into their buggy. The Cook House was adjacent to the Cook Block that housed the offices of the Doctors Mayo. Though their buggy was destroyed, they survived and took shelter with their horse in a blacksmith’s shop.

They survived the storm, but others were not so lucky. One-third of the buildings in town were destroyed or damaged with more than half in Lower Town, a predominantly working class neighborhood. They immediately began to care for the wounded brought to the clinic offices. Their father had taken charge of relief efforts in Lower Town, the worst hit part of the city. Victims were brought to a local hotel, where they were quickly triaged and treated according to need.

The physicians in town shared a common goal though they were not always united in their methods. The routine use of an emetic for all trauma patients was advocated by one physician to the opprobrium of the elder Dr. Mayo, who quickly insisted on establishment of clear leadership. He also recruited the assistance of Sister Alfred Moes, who had offered her convent to shelter the sick and homeless and her nuns as nurses for the injured.

The anti-Catholic prejudices of the day necessitated Dr. W. Mayo asking that it be announced that Sister Alfred was offering shelter in her “house” and not in a convent. Other relief efforts such as offering food and provisions to the needy were established in available rooms across town. Recovery of bodies, funeral services, and burials were quickly conducted. Rebuilding efforts were speedily begun with fundraising activities bringing in enough funds to feed and clothe hundreds, rebuild more than 100 houses, and provide money for furniture.

The tornado had highlighted the need for a hospital in Rochester and Sister Alfred ultimately requested that Dr. W. Mayo assist in this venture. The Sisters of Saint Francis raised money and built Saint Mary’s Hospital—the first in Rochester.

The destruction and chaos caused by Hurricane Katrina has brought much pain to our nation. In the early aftermath there appeared to be a dearth of leadership, and questions arose regarding an apparent lack of preparedness and poor response to the carnage caused by the storm. Undoubtedly there will be many investigations into what went wrong. History may help answer these questions, but should also provide reassurance that good can come out of the debris of an ill wind.

—Jamie Newman, MD, FACP, and Adeboye B. Ogunseitan, MD

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