President's Message - The Evolution of Critical Care

2015 - 1 February – Team Science
Craig M. Coopersmith, MD, FCCM
Society of Critical Care Medicine President Craig M. Coopersmith, MD, FCCM, discusses the Society’s commitment to patients both during and after their ICU stay.

 

Defining our role as critical care professionals is more challenging than ever before. Historically, critical care has been about a place—the intensive care unit (ICU)—and we have been tasked with delivering the Right Care, Right Now™ to the patient in the bed in front of us. Yet, last year, when he was the Society of Critical Care Medicine (SCCM) president, Chris Farmer challenged all of us to embrace the concept of critical care without walls. While the ICU is obviously incredibly important, critical care can happen anywhere. There should not be geographic boundaries on the care we provide. The concept of tearing down walls together is imperative to the growth of our specialty.

This year, I encourage each of you to broaden your definition of critical care even more. Our focus must continue to be on the patient in front of us and how we can work together as a team to give them the best possible outcome. But what happens to patients who survive critical illness and leave the ICU? And how do we care for patients who, despite our best efforts, are unable to return to their premorbid state and who are left with physical, cognitive and mental impairments?

Unfortunately, life is never simple. While we all wish that we could cure every patient we see and restore them back to their baseline quality of life in a rapid fashion, we also recognize that this is impossible. A significant number of patients will develop chronic critical illness. A groundbreaking study presented at our 2015 Critical Care Congress estimates an annual total of 380,000 cases of chronic critical illness in the United States at an annual cost of $26 billion.(1) Although 70% of this population survives the ICU stay, what happens to them afterwards? Most of us do not see our patients after ICU discharge, but their outcomes are sobering, at best. Patients on mechanical ventilation while in the ICU have an additional 30% mortality six months following discharge and 57% mortality three years later.(2) Over one-third are rehospitalized at least once within six months.(2) For patients transferred to long-term acute care hospitals after ICU discharge, the numbers are even scarier. One-year mortality in this patient population is greater than 50%.(3) Indeed, mortality reaches an astonishing 69% at one year for Medicare patients who receive mechanical ventilation in both the ICU and long-term acute care hospital.(3)

While these survival data may cause many of us to pause in reflection, we also recognize that mortality is not the only outcome metric that matters. Survivors of ICU stays are at risk for the post-intensive care syndrome (PICS).(4,5) PICS describes a wide range of new or worsening impairments in physical, cognitive and mental health after critical illness and persisting beyond acute care hospitalization. Importantly, PICS affects both survivors and their family members.

While I wish it were otherwise, the concept of PICS is essentially unknown in society as a whole. Critical care providers are well aware that the impact of an ICU stay continues long after discharge from the ICU, but there have not been ways to address PICS in a comprehensive fashion (although assuredly outstanding efforts have been made in multiple countries). Now, based upon the remarkable enthusiasm of a committed group of  SCCM volunteers, potential solutions to the challenges posed by PICS are emerging.

At the opening ceremony of our 2015 Congress, I was privileged to announce a new  program called THRIVE! Over the next three years, SCCM will invest $1 million to directly impact patients and their families suffering from PICS. Although still in its early stages, the THRIVE! Initiative is designed to help survivors of critical illness and their families work together with clinicians to advance recovery. This will take the form of a network of in-person support groups and an online community for peer support for survivors after they leave the ICU. In addition, SCCM will take a leading role in integrating PICS-related activities into the wide range of educational opportunities the Society offers. We will also fund a grant specifically for research into PICS. This is an ambitious agenda to be sure, but one that we are excited to pursue.

Currently, no single specialty or profession is equipped to handle the elements of PICS, and as such, there is often no place for patients and family members to turn to. As critical care professionals, we understand the importance of a team approach in tackling a multifactorial problem. We therefore believe SCCM is uniquely suited to catalyze action that will improve PICS awareness, care and outcomes. The THRIVE! Initiative represents a step in the evolution of critical care. It is important to emphasize that the core mission of SCCM remains focused on the patient in front of us. However, we are expanding the scope of commitment to our patients, acknowledging that critical illness does not end with ICU discharge. I look forward to the start of this exciting journey on behalf of our patients. Together, we can care for our patients today and in the weeks and months to come for an outcome that all of us want—one  in which our patients and their families truly thrive!

References:

1. Kahn JM, Le T, Angus DC, et al. The epidemiology of chronic critical illness in the United States. Crit Care Med. 2015;43(2):282-287.  http://journals.lww.com/ccmjournal/Fulltext/2015/02000/The_Epidemiology_of_Chronic_Critical_Illness_in.4.aspx.
2. Wunsch H, Guerra C, Barnato AE, Angus DC, Li G, Linde-Zwirble WT. Three-year outcomes for Medicare beneficiaries who survive intensive care. JAMA. 2010;303(9):849-856.  http://www.ncbi.nlm.nih.gov/pubmed/20197531.
3. Kahn JM, Benson NM, Appleby D, Carson SS, Iwashyna TJ. Long-term acute care hospital utilization after critical illness. JAMA. 2010;303(22):2253-2259.  http://jama.jamanetwork.com/article.aspx?articleid=186010.
4. Elliott D, Davidson JE, Harvey MA, et al. Exploring the scope of post-intensive care syndrome therapy and care: engagement of noncritical care providers and survivors in a second stakeholders meeting. Crit Care Med. 2014;42(12):2518-2526. http://journals.lww.com/ccmjournal/Fulltext/2014/12000/Exploring_the_Scope_of_Post_Intensive_Care.7.aspx.
5. Needham DM, Wunsch H,  Harvey MA. Postintensive care syndrome, need for recognition, treatment, research, and expansion of included symptoms [letter]. Crit Care Med. 2012;40(9):2743. http://journals.lww.com/ccmjournal/Fulltext/2012/09000/Postintensive_care_syndrome,_need_for_recognition,.54.aspx.