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Integrating Subspecialty Expertise in the Intensive Care Unit

  • Nicole Tran
  • Jason N. Katz
Chapter
Part of the Respiratory Medicine book series (RM, volume 18)

Abstract

The integration of subspecialty expertise in the management of critically ill patients has become an area of both great interest and controversy. The past several decades have seen the emergence and rapid implementation of such subspecialty intensive care settings as the cardiac intensive care unit (ICU) and the neuroscience ICU. By pooling individuals with similar disease processes, and capitalizing on the expertise of specially trained nurses and physicians, many believe these units can provide more efficient and effective critical care delivery. Despite limited evidence to either support or refute their significance, these ICUs have become more commonplace, and their proliferation has brought to light important questions regarding optimal structure, staffing, and training. At the same time, the role of subspecialty consultants for an increasingly complex critical care population remains an important and evolving process.

Keywords

Intensive care unit Subspecialty Staffing Training Consultation Intensivist Critical Care Cardiac ICU Neuroscience ICU 

References

  1. 1.
    Groeger JS, Guntupalli KK, Strosberg M, et al. Descriptive analysis of critical care units in the United States: patient characteristics and intensive care unit utilization. Crit Care Med. 1993;21:279–91.PubMedCrossRefGoogle Scholar
  2. 2.
    Knaus WA, Wagner DP, Zimmerman JE, et al. Variations in mortality and length of stay in intensive care units. Ann Intern Med. 1993;118:753–61.PubMedCrossRefGoogle Scholar
  3. 3.
    Halpern NA, Pastores SM. Critical care medicine in the United States 2000–2005: an analysis of bed numbers, occupancy rates, payer mix and costs. Crit Care Med. 2010;38:65–71.PubMedCrossRefGoogle Scholar
  4. 4.
    Julian DG. Treatment of cardiac arrest in acute myocardial ischaemia and infarction. Lancet. 1961;2:840–4.PubMedCrossRefGoogle Scholar
  5. 5.
    Killip T, Kimball JT. Treatment of myocardial infarction in a coronary care unit. Two year experience with 250 patients. Am J Cardiol. 1967;20:457–64.PubMedCrossRefGoogle Scholar
  6. 6.
    Lown B, Fakhro AM, Hood WB, et al. The coronary care unit. New perspectives and directions. JAMA. 1967;199:188–98.PubMedCrossRefGoogle Scholar
  7. 7.
    Goldman L, Cook EF. The decline in ischemic heart disease mortality rates: an analysis of the comparative effects of medical interventions and changes in lifestyle. Ann Intern Med. 1984;101:825–36.PubMedCrossRefGoogle Scholar
  8. 8.
    Katz JN, Shah BR, Volz EM, et al. Evolution of the coronary care unit: clinical characteristics and temporal trends in healthcare delivery and outcomes. Crit Care Med. 2010;38:375–81.PubMedCrossRefGoogle Scholar
  9. 9.
    Wentworth DA, Atkinson RP. Implementation of an acute stroke program decreases hospitalization costs and length of stay. Stroke. 1996;27:1040–3.PubMedCrossRefGoogle Scholar
  10. 10.
    Webb DJ, Fayad PB, Wilbur C, et al. Effects of a specialized team on stroke care: the first two years of the Yale Stroke Program. Stroke. 1998;26:1353–7.CrossRefGoogle Scholar
  11. 11.
    Suarez JI, Zaidat OO, Suri MF, et al. Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team. Crit Care Med. 2004;32:2311–7.PubMedGoogle Scholar
  12. 12.
    Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med. 2001;29:635–40.PubMedCrossRefGoogle Scholar
  13. 13.
    Mirski MA, Chang CW, Cowan R. Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care: evidence-based support for an intensivist-directed specialty ICU model of care. J Neurosurg Anesthesiol. 2001;13:83–92.PubMedCrossRefGoogle Scholar
  14. 14.
    Markandaya M, Thomas KP, Jahromi B, et al. The role of neurocritical care: a brief report on the survey results of neurosciences and critical care specialists. Neurocrit Care. 2012;16:72–81.PubMedCrossRefGoogle Scholar
  15. 15.
    Stamou SC, Camp SL, Stiegel RM, et al. Quality improvement program decreases mortality after cardiac surgery. J Thorac Cardiovasc Surg. 2008;136:494–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Kumar K, Zarychanski R, Bell DD, et al. The impact of 24-hour in-house intensivists on a dedicated cardiac surgery intensive care unit. Ann Thorac Surg. 2009;88:1153–61.PubMedCrossRefGoogle Scholar
  17. 17.
    Whitman GJ, Haddad M, Hirose H, et al. Thoracic surgeons providing cardiac critical care improve patient management and decrease costs. Presented at the 46th Annual Meeting of the Society of Thoracic Surgeons, Fort Lauderdale, 2010.Google Scholar
  18. 18.
    Lott JP, Iwashyna TJ, Christie JD, Asch DA, Kramer AA, Kahn JM. Critical illness outcomes in specialty versus general intensive care units. Am J Respir Crit Care Med. 2009;179:676–83.PubMedCrossRefGoogle Scholar
  19. 19.
    Katz JN, Turer AT, Becker RC. Cardiology and the critical care crisis. A perspective. J Am Coll Cardiol. 2007;49:1279–82.PubMedCrossRefGoogle Scholar
  20. 20.
    Brown JJ, Sullivan G. Effect on ICU mortality of a full-time critical care specialist. Chest. 1989;96:127–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Reynolds HN, Haupt MT, Thill-Baharozian MC, et al. Impact of critical care physician staffing on patients with septic shock in a university hospital medicine intensive care unit. JAMA. 1988;260:3446–50.PubMedCrossRefGoogle Scholar
  22. 22.
    Goh AY, Lum LC, Abdel-Latif ME. Impact of 24 hour critical care physician staffing on case-mix adjusted mortality in paediatric intensive care. Lancet. 2001;357:445–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Nathens AB, Rivara FP, MacKenzie EJ, et al. The impact of an intensivist-model ICU on trauma-related mortality. Ann Surg. 2006;244:545–54.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients. A systematic review. JAMA. 2002;288:2151–62.PubMedCrossRefGoogle Scholar
  25. 25.
    Angus DC, Shorr AF, White A, et al. Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med. 2006;34:1016–24.PubMedCrossRefGoogle Scholar
  26. 26.
    Chang SY, Multz AS, Hall JB. Critical care organization. Crit Care Clin. 2005;21:43–53.PubMedCrossRefGoogle Scholar
  27. 27.
    Mayer SA, Coplin WM, Chang C, et al. Core curriculum and competencies for advanced training in neurological intensive care: United Council for Neurologic Subspecialties guidelines. Neurocrit Care. 2006;5:159–65.PubMedCrossRefGoogle Scholar
  28. 28.
    Neurocritical care society education and training. http://www.neurocriticalcare.org/i4a/pages/index.cfm?pageid=3345. Accessed 26 Apr 2012.
  29. 29.
    Morrow DA, Fang JC, Fintel DJ, et al. on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation, Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Council on Quality of Care and Outcomes Research. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation. 2012;126:1408–28.PubMedCrossRefGoogle Scholar
  30. 30.
    European Board for the Specialty of Cardiology. Curriculum for acute cardiac care subspecialty training in Europe. www.escardio.org/communities/working-groups/acute-cardiac-care/documents/esc-curriculum-training-intensive-acc-europe.pdf. Accessed 16 Apr 2012.
  31. 31.
    Julian DG. The history of coronary care units. Br Heart J. 1987;57:497–502.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Tonnelier JM, Prat G, Le Gal G, et al. Impact of a nurses’ protocol-directed weaning procedure on outcomes in patients undergoing mechanical ventilation for longer than 48 hours: a prospective cohort study with a matched historical control group. Crit Care. 2005;9:R83–9.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Campbell J. The effect of nurse champions on compliance with Keystone Intensive Care Unit Sepsis-screening protocol. Crit Care Nurs Q. 2008;31:251–69.PubMedCrossRefGoogle Scholar
  34. 34.
    Gandhi PJ, Smith BS, Tataronis GR, Maas B. Impact of a pharmacist on drug costs in a coronary care unit. Am J Health Syst Pharm. 2001;58:497–503.PubMedGoogle Scholar
  35. 35.
    Carr DD. Building collaborative partnerships in critical care: the RN case manager/social work dyad in critical care. Prof Case Manag. 2009;14:121–32.PubMedCrossRefGoogle Scholar
  36. 36.
    The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT). JAMA. 1995;274:1592–8.Google Scholar
  37. 37.
    Bradley CT, Brasel KJ. Developing guidelines that identify patients who would benefit from palliative care services in the surgical intensive care unit. Crit Care Med. 2009;37:946–50.PubMedCrossRefGoogle Scholar
  38. 38.
    Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Buisson C. The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Am J Respir Crit Care Med. 1999;159:1249–56.PubMedCrossRefGoogle Scholar
  39. 39.
    Cm L, Aruj P, et al. Appropriateness and delay to initiate therapy in ventilator-associated pneumonia. Eur Respir J. 2006;27:158–64.CrossRefGoogle Scholar
  40. 40.
    Esposito S, Leone S. Antimicrobial treatment for Intensive Care Unit (ICU) infections including the role of the infectious disease specialist. Int J Antimicrob Agents. 2007;29:494–500.PubMedCrossRefGoogle Scholar
  41. 41.
    Classen DC, Burke JP, Wenzel RP. Infectious disease consultation: impact on outcomes for hospitalized patients and results of a preliminary study. Clin Infect Dis. 1997;24:468–70.PubMedCrossRefGoogle Scholar
  42. 42.
    Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. 2002;346:549–56.CrossRefGoogle Scholar
  43. 43.
    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;346:557–63.PubMedCrossRefGoogle Scholar
  44. 44.
    ECC Committee. Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112:1–203.CrossRefGoogle Scholar
  45. 45.
    Blondin NA, Greer DM. Neurologic prognosis in cardiac arrest patients treated with therapeutic hypothermia. Neurologist. 2011;17:241–8.PubMedCrossRefGoogle Scholar
  46. 46.
    Dumas F, Grimaldi D, Zuber B, et al. Is hypothermia after cardiac arrest effective in both shockable and nonshockable patients? Insights from a large registry. Circulation. 2011;123:877–86.PubMedCrossRefGoogle Scholar
  47. 47.
    Reader R. Why the decreasing morality from coronary heart disease in Australia? Circulation. 1978;58(Suppl II):32.Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Division of Cardiology, Department of MedicineUniversity of North CarolinaChapel HillUSA
  2. 2.Divisions of Cardiology and Pulmonary and Critical Care Medicine, Department of MedicineUniversity of North CarolinaChapel HillUSA
  3. 3.UNC Center for Heart and Vascular CareChapel HillUSA

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