Introduction

One of the specialized areas of care for traumatically injured patients is the intensive care unit where continuity, communication, experience, and evidence-based protocols help to maximize critical care therapies and ultimately save lives. The multidisciplinary team consisting of registered nurses, physicians, nurse practitioners, physician assistants, respiratory therapists, pharmacologists, social workers, case managers, and often many other disciplines must not only strive to provide up-to-date care but must also employ meticulous communication skills. This ICU team succeeds when all members are contributing leaders within their fields of expertise and work together on ever-changing patient care challenges to optimize patient care and patient outcomes.

Traditional ICU Tasks

Continuity of Care

A primary critical care team in an academic institution generally consists of an attending faculty physician, a fellow, a resident, and an advanced practice provider. In a nonteaching institution, such as a community hospital the ICU team may consist of only the intensivist attending physician and a team of advanced practice providers (APPs). This team provides 24/7 coverage to meet the high demand for consistent, continuous monitoring and management of critically ill patients.

Many large academic trauma centers are utilizing APPs, made up of nurse practitioners (NPs) and physician assistants (PAs), to augment trauma care (Sherwood 2009). The number of APPs caring for traumatically injured patients has grown over the last several decades along with the scopes of practice for these clinicians. One of the driving factors for this demand-based growth in the United States was the 2003 national mandate to limit medical residents to an 80-h work week (Christmas 2005). Many trauma departments have successfully incorporated nurse practitioners and physician assistants into their trauma teams to effectively care for their injured patients. Often with trauma, ICU, military medic, or prehospital backgrounds, these specialized nonphysician providers have unique perspectives and experience and offer helpful contributions that are different than other medical team members. A small group of research studies looking at the ICU care provided by APPs find that these trauma and critical care specialized nonphysicians are a safe, effective, viable staffing option for maintaining trauma protocols and providing evidence-based ICU care in collaboration with other members of a critical care team.

Substantial evidence shows that continuity of care promotes better outcomes by decreasing medical errors and potentially preventing adverse events when patients are covered by a primary team (Howell 2012). Fragmentation of care has been associated with poor family satisfaction, providing strong evidence that care fragmentation affects an important aspect of the quality of overall care. Length of stay (LOS) increases with fragmentation of care, secondary to inconsistencies with patient management often because of frequently changing providers. ICU provider continuity has been recommended as a measure of high-quality end-of-life care by the Robert Wood Johnson Foundation of Critical Care End-of Life Peer Workgroup which states that “Continuity of care” was identified as one of the seven key domains as quality indicators for measuring end-of-life care in the ICU (Clarke 2003). This is important because the ICU has an average patient mortality rate of 10–29 % (SCCM 2012).

Coordination of Care

The general rule for coordination of care in an ICU primary team starts with providing 24/7 coverage. Team members generally work 12-h rotating shifts and are assigned dedicated patients for whom that team member is responsible for being the “first call” to address patient management issues and emergencies and update the patient or family on plan of care. Members of the team are then responsible to report and keep the attending physician updated with any patient status changes, new patient admissions, and ongoing patient care. The attending intensivist, who is responsible for the global care and management of all the ICU patients, is also responsible for educating the team and providing expert advice on patient care. This defined coordination of care goes hand in hand with continuity of care, promoting improved patient safety, better patient and family satisfaction, with overall care, and improved ICU team satisfaction and lessens the chances of medical error by providing a standardized practice paradigm.

Trauma patients often present challenging medical care situations, as severely injured patients usually have a constellation of injuries where creativity on the part of the ICU team is essential. This can involve patient positioning, transport, procedure prioritization, and challenges to preventing secondary injury, such as, the inability to safely anticoagulate a patient to prevent deep vein thromboses and subsequent pulmonary embolism.

Coordination of care specific to injured patients now most often includes the timely performance of a tertiary trauma survey – a complete head-to-toe physical exam of an injured patient as well as a review of all radiological studies in order to summarize and document all of the patient’s injuries. This process is often performed 12–24 h post-injury. Any physical or clinical findings suspicious for additional unknown injuries can be imaged at this time and included in the complete injury list. The tertiary trauma survey injury synopsis is then used as a communication piece for all care providers and most importantly is used to ensure that all necessary consulting services have been involved in the patient’s care. This process is the standard of care for not only decreasing missed injuries (Biffl 2003) but also serves as a type of checklist for complex and challenging trauma patients with a constellation of injuries.

Handoff Communication

Each member of the ICU medical team has an essential task of effective communication of all imperative medical information regarding each trauma patient. Throughout the day or night, the flow of communication is important to ensure the patient’s needs are being met. With a multidisciplinary team approach, each member of the team holds important information and must continuously evaluate which facts are passed off and to whom. During larger shift changes, this communication sharing becomes even more important as a shift’s worth of data must be distilled down to the critical information needed by the next team to effectively and safely care for the patient. Many trauma centers and ICU teams have protocolized ways in which ICU teams sign out to one another by creating a template to follow that helps to prevent error and streamline essential data points.

Another time when important handoff communication takes place is during patient transport into the care of other medical teams such as interventional radiology and the operating room or during transfer to a medical/surgical ward and trauma ward medical team. Trauma APPs, and other experienced providers, can act as communication hubs during these transfers out of, and back to, the ICU.

Debriefing

While nearly all communication in an ICU is critical, knowing how to succinctly describe a patient’s condition and plan of care to all participants in the ICU, from patients and their friends and family members to other members of the team, is vital. These members may include registered nurses, intensivists, resident or student physicians, respiratory therapists, physical or occupational therapists, dieticians, social workers, chaplains, and case managers to whom communicating patient status is a valuable skill that not only improves efficiency but is at the core of a unified patient care plan. This communication stream also prevents harmful misunderstandings, medical errors, and frustrating gaps in care.

More formal types of debriefing may include reviews of trauma resuscitations, codes or other unexpected emergencies in the ICU, and formal morbidity and mortality sessions involving traumatically injured ICU patients. Participation by each member of the involved ICU team in these debriefings, whether informal or formal, is important and helps troubleshoot system weaknesses and areas of strength among the team.

Patient Flow

It is important to facilitate patient flow both into and out of the ICU by prioritization of the patient’s medical care needs balanced by resource availability. Traumatically injured patients requiring ICU level care can be identified early on by trauma team members. When a patient meets ICU admission criteria by either life-threatening diagnosis such as intracerebral hemorrhage, unstable organ laceration, critically abnormal lab work such as perturbed coagulation studies, clinical or diagnostic signs of hemorrhage, intubation requiring ventilator management, or the need for close observation, notification of hospital staff involved in triaging ICU beds can occur. With earliest notification to nursing managers and by ICU bed reservation, the patient’s arrival to the ICU can be expedited, thereby facilitating optimal medical management of critically injured patients when timing is of the essence. Timely identification of patients who no longer meet ICU level criteria by the ICU team allows them to initiate transfer protocols out of the ICU. This criteria to transfer out of the ICU may include being stabilized, no longer requiring ICU level observation, or by extubation (as examples). Patients may transfer to either a step-down ICU ward or to a medical/surgical trauma care ward.

Transfer Times

Facilitating efficient patient transfers out of the ICU by completing transfer order sets, writing transfer orders, and communicating plans to transfer patients to appropriate staff members in a timely fashion is important. By notifying the bedside nurse, patient, and their family members of the transfer plan, the members of the ICU team can also answer questions and concerns regarding the transfer and proactively address issues (medical, psychosocial, logistical) that may delay the transfer (Christmas 2005).

Impacting Length of Stay

One of the most pervasive ongoing hospital and healthcare initiatives is to decrease all patient’s hospital LOS when medically appropriate. This in turn frees up beds and staff to care for other patients, optimizes resource allocation, and reduces healthcare costs to the patient and society as a whole. Decreasing the LOS in an ICU setting also potentially prevents hospital-acquired infections patients may get if they stay longer than what is medically necessary. Many researchers have studied factors that contribute to decreasing LOS and have found that there are staffing, preventative protocols, and goals-of-care decision measures that can positively contribute to patient’s efficient ICU stay.

Several studies have found that physician and nursing staff attention and ratios optimize ICU patient care and decrease ICU LOS (Gruenberg 2006). Practices including daily rounding by a full-time intensivist or ICU-trained physician reduce complications and decrease LOS (Gruenberg 2006). Research has also shown that higher registered nurse (RN)-to-patient ratios decreased ICU length of stays and reduced adverse events in the ICU (Thungjaroenkul 2007).

Many ICU working groups have created procedure or care bundles that are evidenced based and have been shown to help prevent the common nosocomial or hospital-acquired infections that increase patient’s LOS. These protocols may include sepsis identification and early treatment therapies, ventilator-associated pneumonia (VAP) prevention with oral care policies and protocolized ventilator weaning order sets, sedation and analgesia practices that allow for sedation vacations to decrease prolonged sedation, gastric ulcer prevention, delirium prevention and early identification, aggressive skin care and skin breakdown prevention, and identification and treatment to name a few. Frequently, trauma patients specifically are immobilized and need deep vein thrombosis (DVT) prevention within a specific time frame, and protocols help guide the details of this therapy. These protocols are the onus of all members of the ICU team and often are labor and resource intensive. They involve cost, education, and frequent revisions to remain evidence based and to provide state-of-the-art care.

Finally, communication around the patient’s desired medical care and appropriate medical care between ICU teams, patients, and their family members can decrease LOS by clarifying goals of care. When patients have determined their medical directives prior to hospital admission, their care can be aligned with their wishes. This may mean that if a patient or their designated advocate has deemed them do not resuscitate (DNR) or similarly, their care needs may be met more closely on a unit other than the ICU. Palliative care teams and ethics committees can help with challenging patient care scenarios to efficiently determine goals of care for a critical and dying patient, and get them to the most appropriate setting, which may be home with hospice or a hospice care facility.

Improving Hospital Readmission

Readmission into the hospital closely following a hospitalization for a traumatic injury is costly and is often preventable. While some trauma readmissions are planned, for example, to reverse temporary ostomies, to replace bone flaps, or to finalize orthopedic procedures, most are caused by postoperative wound infections and pain (Esposito 2012). Preventing readmissions is a standard of hospital objectives and is the responsibility of the entire healthcare team. By studying institution-specific trends in readmission causes, relevant performance improvement projects can be initiated. The multidisciplinary team can follow a systematic approach to planning an initial hospital discharge by attending to the patient’s unique needs of injury-specific education, wound, spine or extremity care, pain management, and, if applicable, anticoagulation therapy. The appropriate discharge destination is critical in ensuring a safe and successful discharge. Case managers and/or social workers can help to match patients with the options open to them in regard to finances, insurance coverage, and area-specific offerings. There is evidence that patients who are discharged home when they cannot afford the medically recommended supervised care such as in a subacute rehab facility are over-represented in readmission groups (Esposito 2012). Creative resource solutions can prevent these readmissions along with possibly allowing this cohort of patients to remain inpatient slightly beyond the usual pathway to provide them the supervision and care needed in those temperamental early days post-acute injury.