Navigating the Future of Critical Care

When looking at the problem on a national level, the solutions appear straightforward. The most obvious solutions are discussed at length in the original FOCCUS document: regionalize services and standardize ICU care. But both recommendations have their costs as well as barriers to implementation. For example, although regionalizing neonatal and pediatric ICUs has proven highly effective,^9,10 no data exist to support regionalizing adult critical care. Given the burden on families who must travel long distances to regional hospitals and the loss of jobs in a given community created by moving critical care units from local hospitals to new and distant regional centers, the need for supporting data is paramount. We can only imagine the intensity of the debate as people on the committee discussed whether it makes sense to have critically ill patients transported to distant regional centers. (Raising teenagers has taught both of us that debates are most contentious in the absence of data.)

Standardizing ICU care using current practice guidelines and the principles of evidence-based medicine can hardly appear controversial; however, such recommendations must be balanced with the recognition that every individual has unique needs and responses and with the knowledge that much of what we do every day in ICUs lacks definitive evidence. The importance of these caveats to guideline-driven care should not be lost in the enthusiasm for evidence-based medicine.

Perhaps more germane to the question of addressing future challenges is whether caregivers will implement the guidelines that do exist. Human barriers to changing behavior are vast. Much of the research to date suggests that it takes 5 to 10 years for evidence-based recommendations to move into common use; in critical care, that’s a lifetime.

We are in the midst of a national shortage of critical care nurses, intensivists, respiratory therapists, and pharmacists. The FOCCUS document has intriguing and dramatic recommendations. The panel reviewed the research to date on patient outcomes related to specialty care. It is clear that the outcomes for patients cared for by intensivists are better when compared with care delivered by generalists. These patients have less morbidity and mortality in the face of similar illness severity. Yet, only approximately one third of all patients are cared for by intensivists in the United States today and less than 1 out of 10 units are “closed” (meaning that care is delivered by a hospital-based intensivist rather than by the patient’s private physician). The call for encouraging specialization and restructuring hospital ICUs to be closed units is bold in the face of current shortages.

For us, some of the most intriguing parts of the document had to do with restructuring the work environment of nurses and physicians. The FOCCUS authors recognized that the way to attract and retain talented individuals to the field, particularly nurses, is to provide them with autonomy in their practice (both in clinical and financial arenas), to have a zero tolerance policy for disruptive behavior in the workplace, to promote interprofessional collaboration and communication, to use technology to organize data and minimize medical errors, and to provide appropriate compensation and opportunities for career growth. Although more can always be said about how the future could be different for critical care teams, the document provides a wonderful blueprint for any administrator or educator thinking about the future of critical care.

Critical care has faced daunting challenges in the past. In the early days of the specialty, visionary and forceful leaders dared colleagues to create a new way to provide care to the acutely ill. Nurses and physicians taught each other, and ICUs were created from regular patient rooms and supply closets. It is time to rethink the way we are currently doing business in our specialty and bring that same sense of boldness to today’s challenges.