Buchman- The next generation of critical care

Clinical Pearls– Assisted by Dr. Tony Basel

• “Change is the only constant”
  • 50-60 years ago: upright patients + lots of nurses and no doctors
  • 1958: Peter Safar (of Baltimore City Hospital) proposed senior physicians (i.e. intensivists) should staff ICUs
• Manpower: what are the nation’s physician manpower needs?
  • Conventional wisdom of 1990-2000 (especially managed care) said “we have too many MDs”
  • Pronovost, JAMA 2002, proposed change: “An intensivist in every ICU”
  • Angus JAMA: “Can we meet the requirements of an aging population?” then HRSA 2006 confirmed there is an MD shortfall
    • PrOMIS conference was held in 2007 showing that “some critical care services will be provided by non-critical-care-boarded-physicians”
  • What about APPs?
    • CHEST 1991: concluded that properly trained physician extenders could work in ICUs with no increase in adverse events
      • 2008 CCM article shows that midlevel numbers continue to rise
      • Meanwhile, ICU fellowships were going unfilled (and some continue to go unfilled)
  • Currently estimated ~10k practicing, board certified intensivists
    • Versus the estimated numbers of APPs in critical care = 2600 PAs + 7150 NPs
    • So the number of doctors and APPs are nearly equal 
      • The time to develop competency may be key (takes 2/3 less time to be an APP)
  • How short are we?
    • View 1: Leapfrog – very short depending where you are in the US (some better staffed than others) (i.e: numbers are good, just not distributed well)
    • View 2: ICUs are full of patients that don’t need to be there, so we may not really be that short (i.e.: we don’t need more ICU doctors because there are few real ICU patients)
    • View 3: The workforce has responded; the production number is increasing considerably so we don’t know what it will look like in a few years (i.e.: be patient, the doctors are coming… just stuck in training)
• Technology: CCM 2004 – remote critical care
  • Mid-1970s: Cleveland, OH conducted a small study and concluded that they could provide medical care remotely
  • Today, there are about 50 eICU programs in the USA
    • Cover around 15.5% of ICU beds
  • What are we really doing with the eICU?
    • Trying to detect and track problems → just providing coverage during “off” hours
    • JAMA 2011: better mortality and LOS with eICU
  • Cost effectiveness
    • Fairly expensive to start (Yoo 2016)
    • Have to evaluate per-case revenue and per-case cost to see cost savings → it does take time (Lilly 2017)
• Sidebar on relational coordination
  • Between the APPs and teleICU, now re-engineering the social relationships in the ICU
  • Emory ICU with doctors/nurses in teleICU with APPs at bedside
    • LOS (both ICU and hospital) improved (saved ~21k ICU days!)

• ICU mortality also improved (Ratio dropped below 1.0)

• Day/Night teams
  • Traveling around the world: cover overnight shifts while working in local daylight hours (Australia vs. USA)
    • Better for clinicians → shift work has multiple health risks
    • Better for patients→ nights tend to be the most “active” times
  • Training for teamwork and focus on communication
• Technology: Mica Endley’s situational awareness
  • Situational awareness requires perception, comprehension, and projection
    • At bedside: information for “next best decision” + someone with the big picture for “population management”
  • We need an EMR with one screen with all the data in one screen in the same place every time → we’re not yet at that level of simplification
• Putting it all together
  • Tech is refining and redefining how we approach our tasks
  • High risk situations demand high-reliability approaches
    • High-reliability approaches need not have all participants co-located; the division of labor may favor that the participants be separated in space (but not in time)
  • The 4 Vs of data
    • Volume: LOTS of data
    • Velocity: coming at a high rate
    • Variety: in many forms
    • Veracity: data in doubt
    • And possibly a 5th: Value