Critical care medicine. Organizing and staffing intensive care units

[Aspects of intensive care medicine in emergency medicine]

Emergency medicine and intensive care medicine have many similarities. In this review, we will first discuss the terminology of emergency medicine in a hospital in terms of a uniform designation as a department for emergency medicine or emergency department. Emergency medicine and intensive care medicine are a location-independent concept of patient care in the sense of the recognition, treatment and diagnosis of acute health disorders. Emergency medicine covers the entire range of disease severity, while intensive care medicine focuses on organ replacement and organ preservation, uses highly specialized technology for this purpose and treats only the seriously ill. The treatment of seriously ill patients in the emergency departments requires special intensive care medical knowledge both by the physicians and nursing staff. In the medical field, the curriculum for the European emergency medicine specialist takes into account all aspects necessary for the diagnosis and treatment of critically ill patients. For the nursing sector, Germany has had its own recognized specialty training program in emergency medicine for several years. However, the treatment of critically ill patients in emergency departments also requires that the emergency departments be adequately equipped. In this regard, there is an urgent need for statutory quality criteria that are concrete and structured. We know from the literature that intensive care competence in emergency departments reduces the admission rate to intensive care units and the mortality of all emergency patients. The concept of intensive care units in the emergency department is gaining popularity in the USA and should also be evaluated for implementation in the German-speaking countries.

Anatomy of resuscitative care unit: expanding the borders of traditional intensive care units

Resuscitation lacks a place in the hospital to call its own. Specialised intensive care units, though excellent at providing longitudinal critical care, often lack the flexibility to adapt to fluctuating critical care needs. We offer the resuscitative care unit as a potential solution to ensure that patients receive appropriate care during the most critical hours of their illnesses. These units offer an infrastructure for resuscitation and can meet the changing needs of their institutions.

The history of neurocritical care

Critical care medicine came into sharp focus in the second part of the 20th century. The care of acutely ill neurologic patients in the USA may have originated in postoperative neurosurgical units, but for many years patients with neurocritical illness were admitted to intensive care units next to patients with general medical or surgical conditions. Neurologists may have had their first exposure to the complexity of neurocritical care during the poliomyelitis epidemics, but few were interested. Much later, the development of neurocritical care as a legitimate subspecialty was possible as a result of a new cadre of neurologists, with support by departments of neurosurgery and anesthesia, who appreciated their added knowledge and expertise in care of acute neurologic illness. Fellowship programs have matured in the US and training programs in certain European countries. Certification in the USA is possible through the American Academy of Neurology United Council of Neurologic Specialties. Most neurointensivists had a formal neurology training. This chapter is a brief analysis of the development of the specialty critical care neurology and how it gained strength, what it is to be a neurointensivist, what the future of care of these patients may hold, and what it takes for neurointensivists to stay exemplary. This chapter revisits some of the earlier known and previously unknown landmarks in the history of neurocritical care.

Do hospitals need oncological critical care units?

Since the inception of critical care as a formal discipline in the late 1950s, we have seen rapid specialization to many types of intensive care units (ICUs) to accommodate evolving life support technologies and novel therapies in various disciplines of medicine. Indeed, the field has expanded such that specialized ICUs currently exist to address critical care problems in medicine, cardiology, neurology and neurosurgery, trauma, burns, organ transplant and cardiothoracic surgeries. Specialization does not only need new infrastructure, but also training and staffing of health care providers, ancillary staff, and development and implementation of processes of care. Oncology is another branch of medicine with growing ICU needs. Given the rise in cancer incidence worldwide and better survival rates alongside advances in chemotherapeutic and surgical options, more cancer patients are nowadays requiring advanced life support for cancer-related complications, treatment-related toxicities and severe infections. Here we provide a brief summary of the current evidence supporting the specialization of critical care and explore three different models of care for critically ill cancer patients, including the development of a specialized oncological ICU. Finally, we also discuss recently published and future research related to the care of critically ill cancer patients.

Organisation and resource management in the intensive care unit: A critical review

Background/Aim:

Patients are admitted to an intensive care unit (ICU) for critical care not available to patients in the general wards, with the potential for reversible organ failure as a key admission criterion. The objective of this integrative review was to examine and discuss the literature pertaining to the environment of the ICU, including unit organisation, staffing and equipment, that underpins the provision of ICU services. This review also aimed to discuss current perspectives on ICU resources and utilisation.

Methods:

To prepare this integrated literature review, computer-assisted searches were conducted using the PubMed/Medline, CINAHL and EMBASE databases. An extensive search of library databases was undertaken using relevant keywords and related article searches. Studies were included if they were rated by a single investigator to have relevant content in these areas. Due to the breadth of the review, a structured approach was taken to integrate the relevant findings.

Results:

There was limited literature examining the relationships between these important areas. There was some evidence that a closed model of ICU care is associated with improved outcomes and less resource utilisation compared with an open model of ICU, although there was conflicting evidence for critical care delivered outside of the ICU. Critical care may be most effectively provided via a team model. The heterogeneity of the ICU setting, in particular the unique aspects of the delivery of ICU care in the Australasian model, hampered the ability to draw broad and clinically meaningful conclusions.

Conclusions:

Due to the increased demand for ICU services, ongoing evaluation of the long-term outcomes of ICU on the efficient use of resources to optimise patient outcomes is imperative. Results from the current evidence base suggest that rather than broad-based adjunctive services, refinement and subsequent evaluation of intensive care services in targeted and specific populations may be required, and that empirical evidence for the support of many organisational, structural, equipment and staffing aspects of ICU service delivery is lacking. Further research is needed to investigate the relationships between existing and conceptual models of care and direct patient outcomes.

MORE for multiple organ dysfunction syndrome: Multiple Organ REanimation, REgeneration, and REprogramming

Those who care for the critically ill and injured rightfully celebrate the advances made by our field over its first 50 yrs. Advances in systems, tissue, and molecular engineering, together defined as "health engineering," will provide unprecedented opportunities to treat multiple organ dysfunction syndrome in the 21st century. In the future, Multiple Organ REanimation, REgeneration, and REprogramming will be responsible for new treatment approaches for those with multiple organ dysfunction syndrome; several examples are presented here. Thus, as we spent the first 50 yrs of care for the critical ill and injured learning how best to hook humans up to machines, we will spend the next 50 yrs understanding better how to liberate patients from mechanical support. It is difficult to know when these advances will be realized given that the rate of change continues to increase and the seemingly impossible goal of reprogramming fully differentiated cells was accomplished recently by manipulating a few transcription factors. It is not unrealistic to expect that in the next couple of decades that it will be possible to dedifferentiate dysfunctional somatic cells in vivo to a more robust, resistant cell phenotype. Our future should be aimed in part at refining our skill sets and refocusing (even rebranding) critical care as health engineering aimed at Multiple Organ REanimation, REgeneration, and REprogramming.

Evolution of the intensive care unit as a clinical center and critical care medicine as a discipline

This article discusses the history of the ICU and critical care medicine (CCM). It also discusses the certification of critical care nurses and allied health professionals, as well as CCM societies and congresses, education and board certification, evidence-based CCM, research and publications, and future challenges to the field.

The effect of prompt physician visits on intensive care unit mortality and cost

OBJECTIVE

To determine the effect on mortality, length of stay, and direct variable cost of physician response time to seeing patients after intensive care unit admission.

DESIGN

Retrospective analysis of the intensive care unit database.

SETTING

Medical center.

PATIENTS

Subjects were 840 patients who had complete direct variable cost data and a subset of 316 patients who were matched by propensity scores.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Median time to first visit by a physician was 6 hrs. One hundred thirty-five patients (16.1%) died in hospital compared with 25.0% predicted by Acute Physiology and Chronic Health Evaluation risk (p < .001). Higher Acute Physiology and Chronic Health Evaluation risk, older age, mechanical ventilation on arrival in the intensive care unit, and longer time until seen by a physician were predictors of hospital mortality. Each 1-hr delay in seeing the patient was associated with a 1.6% increased risk of hospital death, which further increased to 2.1% after including propensity score. However, patients seen more promptly (<6 vs. >6 hrs) had greater hospital direct variable cost ($11,992 +/- $12,043 vs. $10,355 +/- $10,368, p = .04), before controlling for acuity of illness and other factors that may have affected time to evaluation. In the subpopulation of propensity-matched patients, patients seen promptly (<6 vs. >6 hrs) had shorter hospital length of stays (11 +/- 11 vs. 13 +/- 14 days, p = .03) but similar direct variable costs ($10,963 +/- 10,778 vs. $13,016 +/- 13,006, p = .16) and similar mortality rates (24 vs. 30, p = .46).

CONCLUSIONS

In the total patient population, delay in seeing patients was associated with an increased risk of death. In the propensity-matched patients, promptly seen patients had shorter hospital stays but similar direct variable costs.

Critical care medicine in the 21st century: from CPR to PCR

As in other areas of medicine, the specialty of critical care medicine, which has made important contributions in the pathophysiology of critical illness, is facing challenges that must be recognized and addressed in the current century. In this review, we argue that the skill set required to adequately treat critically ill patients will also require knowledge of molecular biology for better diagnosis and treatment. The foundations of molecular biology and genetics are essential for the understanding of the mechanisms of disease. Incorporating molecular biology techniques in the research arsenal of the intensivist will provide the opportunity to dissect out and define the reversible and irreversible intracellular processes giving rise to the major causes of mortality in intensive care units. Two historical paradigms, the cardiopulmonary resuscitation and polymerase chain reaction, summarize how critical care medicine began, and how it could mature in the years to come.

A unique academic approach to critical care-emergency medicine training

The four-year program for training physicians in critical care-emergency medicine at Sacramento Medical Center, University of California, Davis School of Medicine is described. Its purpose is to train the physician in resuscitation, emergency care for life-threatening conditions, and intensive care, so that the graduate can staff community hospital emergency departments and intensive care units, be director of an emergency department or intensive care unit, or pursue an academic career in emergency medicine.

The role of an intensive care unit in a cancer center. An analysis of 1035 critically ill patients treated for life-threatening complications editorial

Life-threatening complications of cancer therapy often involve multiple organ systems and offer a therapeutic challenge which can be met with efficiency and success by concentrating personnel and equipment in a facility devoted to these problems. Three years ago, an Intensive Care Unit was created at Memorial Cancer Center to offer such patients the benefit of highly skilled nursing, advanced monitoring and supportive techniques, and full-time attendance by physicians and surgeons with a particular interest in Critical Care Medicine. Since then, 1035 patients have been admitted to the eight-bed unit with a mortality rate of 22.3%, which compares favorably with those reported from other institutions. Analysis of this experience has revealed that an average of 16% of those who survived their acute problems after considerable effort and expense, subsequently died of their underlying disease within 2 months. This experience has suggested the need for prognostic criteria to facilitate recognition of those patients for whom intensive supportive measures offer a reasonable chance of worthwhile palliation.

A paediatric respiratory intensive care unit in Lagos

The respiratory Intensive Care Unit was created at the Lagos University Teaching Hospital in 1963. Experience shows that mortality has been highest in neonates who had congenital anomalies, as well as in children under 2 years of age. The predominant cause of death was preventable respiratory failure. The incidence of mortality was 43 percent. This was related to several factors: (i) the severity of illness, types of illness and antecedent period of neglect; (ii) lack of a critical care medicine programme; (iii) insufficient skilled full-time intensive care personnel, including physicians, nurses, physiotherapists and paramedical specialists; (iv) the high incidence of infection in the Intensive Care Unit.

A review of 460 patients admitted to the intensive-therapy unit of a general hospital between 1965 and 1969

Four hundred and sixty patients with various severe disease processes were admitted to the intensive-therapy unit of a general hospital under the care of the anaesthetic and surgical staff in the 5-year period 1965-9 inclusive. The problems presented by these cases, their prognosis, and the lessons learnt in their management are reported, and the implications for similar units in the future are discussed.