Where Are the Bounds of Critical Care?

2013 - 6 December - The ICU of the Future
Carol Thompson, PhD, CCRN, ACNP, FCCM
Society of Critical Care Medicine president, Carol Thompson, PhD, CCRN, ACNP, FCCM discusses the bounds of critical care and the intensive care unit (ICU).

Where are the bounds of critical care? Science has no bounds; any and all disciplines are encouraged to use it as a base of practice. But what about the bounds for patient care? If the name of the unit is intensive care, then certainly we intensivists have responsibilities there. Other disciplines may have responsibilities as well, and they contribute important members to the ICU team. 

When rapid response teams were developed, we took accountability for those as well. We saw those teams treating potential intensive care unit (ICU) admissions for whom early intervention could improve outcomes, and it has. This model has been widely adopted.
In recent years we have learned more about post-intensive care outcomes, driving us to say, “Can we improve these?” The science showed that for every day of delirium in the ICU, the mortality rate increased by 10%; thus, we have been making fundamental changes in care delivery to include mobility, reduce sedation, and more consistently address analgesia. Post-ICU cognitive impairment is related to delirium, so perhaps we can affect long-term outcomes with these measures; as yet, we don’t know if delirium is causal or just covariant.

Do the bounds of critical care extend beyond the days in the ICU? Certainly there are subpopulations where this is true, such as children with congenital defects who have surgical repair and spend some time in the ICU. Often there is follow-up by the cardiac surgeon. Should we provide routine follow-up of our ICU patients? If so, for how long or until what outcome? Is the handoff to the primary care provider or hospital service sufficient? We hear stories of patients, and some healthcare providers, who do not understand why lung function is reduced upon discharge, because the history of acute respiratory distress syndrome was not transmitted by the ICU. Or ICU psychosis episodes that are remembered but unexplained without the context of mechanical ventilation to provide insight into the events. Some matters may be helped by the medical records, but only if the primary care provider has time to sift through them for answers. As we all know, not everything is in the record, but perhaps some issues could be recalled if we provided ICU patients with routine follow-up. What in the healthcare delivery system would need to change for us to do routine follow-up?

Just as I am throwing up my hands and saying it would be impossible with our resources, I recall that we created rapid response teams because that was what was needed for patients. Surely the first step is deciding if our patients need post-ICU follow-up by intensivists.

The science about delirium tipped the scales for me to routinely include mobility as part of standard ICU care. The science of post-ICU outcomes may well drive further changes. I am not at this time performing post-ICU follow-up, but certainly the scope of reading in my field has expanded to post-ICU outcomes. Have the bounds of critical care expanded for you?