President's Message - Continuum of Care

Heatherlee Bailey, MD, FCCM

The concept of the continuum of care in medicine has been around for many years but until recently its significance has not been universally embraced. The passage of the Patient Protection and Affordable Care Act in 2010 created a renewed focus in this area. The driving principle of this act is better care for patients at lower costs leading to, in theory, an overall healthier population. The principle involves seven basic categories of service areas: extended care, acute hospital care, ambulatory care, home care, outreach, wellness, and housing.1 This framework and concept to improve care has been used for a wide variety of medical populations such as newborn care and growth, patients with HIV and its sequelae, and elderly patients with hip fractures.

The Society of Critical Care Medicine (SCCM) has embraced the importance of the continuum of care for patients since the Society’s formation. In 1974 Peter Safar, MD, MCCM, one of SCCM’s founders, stated, “Critical care is a continuum that begins with prehospital care, continues with ED intervention and culminates with ICU admission and management.”2 As evidenced by Dr. Safar’s statement, the focus in the field of critical care and other hospital-based teams has traditionally been on the category of acute hospital care. The importance of early and appropriate care at all stages of hospitalization has also been part of SCCM from its beginning. Dr. Safar commented on the importance of finding missed opportunities and correcting inadequate care before patients arrive in the intensive care unit (ICU). He stated that “the most sophisticated intensive care often becomes unnecessary expensive terminal care when the pre-ICU system fails,”3 thus identifying early on that care rendered in one area of medicine has downstream effects on patients and their outcomes.

The continuum of critical care now extends outside the hospital’s physical walls. Prehospital care providers identify and initiate critical therapy for patients. These early interventions are bringing critical treatments into the field. For years, prehospital care providers have been identifying ST elevation myocardial infarctions and cerebrovascular accidents, initiating treatment, and transporting patients to the most appropriate facility in their region. Emergency medical services have been providing therapeutic hypothermia for patients after cardiac arrest.4 These efforts have led to improved patient outcomes and survival. The emergency department (ED) is also an important aspect of the early identification and care of the critically ill and injured patient. Depending on the hospital system, up to 50% of patients admitted to an ICU were admitted from the ED.5

The SCCM Fundamentals family of courses supports the continuum of care by educating providers of varying backgrounds on many topics such as early recognition of sepsis, tropical diseases, and most recently, obstetric care. These courses provide knowledge and skills that contribute to improved care worldwide; they are taught around the world to help improve the identification, early treatment, and management of critically ill patients.

SCCM has been pushing the envelope and extending the borders of the continuum beyond the ICU in an effort to ensure that our patients and their families receive the best possible care while attempting to mitigate some of the long-term consequences of ICU care. Several recent SCCM projects have promoted expanding the continuum via the inclusion of patients and families. These projects include the ICU Liberation ABCDEF bundle, the Patient-Centered Outcomes Research – ICU (PCOR-ICU) Collaborative, and THRIVE.

ICU Liberation Collaborative
The SCCM ICU Liberation evidence-based ABCDEF bundle is aimed at improving the quality and safety of care delivered to ICU patients. Poorly managed pain, agitation, and delirium (PAD) leads to longer ICU and hospital stays, increased healthcare costs, and patients with higher incidences of long-term physical and cognitive dysfunction.

The ICU Liberation Collaborative is a project that allowed adult and pediatric ICUs work together to implement elements of the ABCDEF bundle. This project was supported by a grant from the Gordon and Betty Moore Foundation. The collaborative focused on implementing the bundle components to improve patients’ outcomes and also sharing experiences with other teams. Barnes-Daly et al, in a study of over 6,000 patients in a California health system, found that, for every 10% improvement in bundle compliance in the ICU, patients had a 15% higher odds of survival.6​

Patient-Centered Outcomes Research (PCOR) – ICU Collaborative
SCCM launched the PCOR-ICU collaborative in 2016, aimed at implementing patient and family engagement programs. Over 60 teams participated in a 10-month project that was funded through a PatientCentered Outcomes Research Institute (PCORI) Eugene Washington PCORI Engagement Award. Teams focused on one of several initiatives aimed at improving patient and family engagement. The collaborative, led by a ninemember advisory group, shared strategies to promote family-focused care in the ICU.

THRIVE Initiative
One of Merriam-Webster’s definitions of thrive is “to progress toward or realize a goal despite or because of circumstances.” This definition encompasses the focus of the SCCM THRIVE program—to try to find ways to help our patients not just survive their ICU experience but to thrive afterward. One of the key areas of focus is to help overcome the many issues faced by both patients and families after an ICU stay. Many of these challenges are caused by post-intensive care syndrome (PICS), a collection of symptoms that includes chronic pain, cognitive dysfunction, posttraumatic stress disorder, depression, and anxiety. The peer support aspect of THRIVE allows patients and families to connect with others who have similar experiences. The knowledge that they are not alone, that others have been through similar experiences, will hopefully be beneficial to all parties. Additional information on these initiatives is available in this issue of Critical Connections.

A wonderful example of the importance and successful implementation of the continuum of care in critical care is the ICU Heroes Award, established by the Society in 2016. This award is given annually to both an adult and a pediatric patient and their ICU teams. It recognizes the importance of patient and family input into their own care and highlights the significant contribution they add as team members.

The continuum of care would not be possible without good collaboration. Not only is collaboration required at the patient’s transitions of care (i.e., from the prehospital arena to the ED to the ICU) but among the team members of each unit.

Another SCCM founder, Ake Grenvik, MD, PhD, MCCM, stated, “The best possible care of the critically ill can be rendered when physicians of various specialties, nurses and allied professionals join forces and treat problems together.”7 This is one of many ways that the multiprofessional nature of our Society contributes to the continuum of care. The best possible critical care delivery for a patient is administered by an appropriately trained and comprehensive team.

Our members and our Society programs are drivers of change in expanding the field of critical care. All of these courses and initiatives have come from our members’ creative ideas. These projects were conceived and developed by the hard work of our volunteer members in conjunction with our dedicated SCCM staff. I encourage everyone who has a novel idea that may improve the care of our patients to explore it—be the ripple effect of change in your community. You never know the difference that you may make in your patients’ lives and ultimately in the field of critical care. Thank you for your ongoing commitment to providing excellent care to the critically ill and injured patient.

References:

  1. Evashwick CJ. Creating a continuum. The goal is to provide an integrated system of care. Health Progress. 1989 Jun;70(5):36-9, 56.
  2. Safar P. Critical care medicine—quo vadis? Crit Care Med. 1974 Jan-Feb;2(1):1-5.
  3. Abramson NS, Levine R, Safar P. Physician education in emergency and critical-care medicine: a continuum? Amer J Emerg Med. 1985 Nov;3(6):569-571.
  4. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. 2002 Feb 21;346(8):557-563.
  5. Rose L, Scales DC, Atzema C, et al. Emergency department length of stay for critical care admissions. A population-based study. Ann Am Thorac Soc. 2016 Aug;13(8): 1324-1332.
  6. Barnes-Daly MA, Phillips G, Ely W. Improving hospital survival and reducing brain dysfunction at seven California community hospitals: implementing PAD guidelines via the ABCDEF bundle in 6,064 patients.  Crit Care Med. 2017 Feb;45(2):171-178.
  7. Grenvik A. Role of allied health professionals in critical care medicine. Crit Care Med. 1974 Jan-Feb;2(1):6-10.