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August 1998
Volume 62 |
Number 8
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| The Value of an
Intensivist in the Management of Critically Ill Patients and
Critical Care Units |
Neal H. Cohen, M.D.
A. Sue Carlisle, M.D., Ph.D.
Management of the critically ill patient is a challenge. As
a result of greater diagnostic and therapeutic options, the clinical
complexities of care have increased. With improved capabilities,
the percentage of hospital beds devoted to intensive care is also
expanding. In order to utilize the intensive care unit (ICU) efficiently,
physicians caring for critically ill patients must be knowledgeable
about a wide variety of pathophysiologic abnormalities. More importantly,
the most effective critical care physicians are able to identify
patients at risk and intervene early enough to prevent complications
or development of clinical problems that necessitate prolonged
ICU care. They must also have the administrative skills to manage
the personnel and utilize resources effectively. The critical
care anesthesiologist who has been trained in anesthesia and critical
care medicine is particularly well-suited for this intensivist
role.
The Intensivist
One of the most important determinants of effective ICU care
is the availability of a dedicated intensivist to coordinate clinical
care and manage the ICU staff and resources.1,2
The intensivist assumes a number of roles that contribute
to improved patient care. The critical care physician provides
continuous clinical assessment and is able to address subtle changes
in clinical condition early enough to prevent complications that
would necessitate additional, often more expensive ICU care. The
critical care physician also has the skills and experience necessary
to ensure the timely institution of diagnostic and therapeutic
interventions. When clinical problems arise, the intensivist is
immediately available to intervene.
The specific clinical responsibilities assumed by the
critical care physician vary from one ICU to another.3
The most common models for ICU care include the "open" ICU and
the "closed" ICU. In an open unit, the physician who has been
caring for the patient prior to ICU admission continues to do
so after transfer to the ICU. For those open units that have critical
care physicians, the intensivist serves as a consultant to the
admitting physician. In most cases, the ICU physician provides
all emergency and resuscitative care and may be responsible for
airway management and ventilatory support. In the closed ICU,
the critical care physician provides or coordinates all patient
care. Although both models have been employed successfully,4
many studies have documented that the closed unit is associated
with improved patient outcome.5,6
The availability of intensivists also has impact on resource
utilization in the ICU. The use of tests and monitoring technologies
is often greater in units staffed with intensivists than in those
that are not.6-8 The increased use
of diagnostic studies has been associated with improved mortality6,7
and the allocation of resources to the patients most likely to
survive.8 At the same time, the intensivist
is also responsible for appropriate utilization of ICU beds. Those
ICUs staffed by an intensivist are often able to restrict admissions
to those patients most likely to benefit from ICU care and to
improve the efficiency of bed utilization.8
The intensivist also assumes many administrative responsibilities
for the ICU. An intensivist usually serves as the medical director,
coordinating the care provided by physicians, nurses, respiratory
therapists and others. The coordination and communication between
the providers is essential to ensure that care is optimized, particularly
for open ICUs. The ICU medical director can also facilitate development
of clinical protocols based on clinical outcome data to minimize
variability in patient care and improve resource utilization.4
The Critical Care Anesthesiologist
Although physicians from a number of medical specialties
can effectively fulfill the role of the intensivist, the critical
care anesthesiologist is particularly well-qualified to care for
critically ill patients and to manage the intensive care unit.
Anesthesiologists have the knowledge, skills and orientation essential
to the effective care of the ICU patient. They have extensive
knowledge of pharmacology, cardiac, hepatic, renal and pulmonary
physiology that is mandatory for the care of the complex ICU patient.
They also have the required technical skills to electively or
emergently manage the airway of patients with both normal and
abnormal anatomy. Based on anesthesiologists' experiences in the
operating room, they understand the indications for and value
of invasive and noninvasive monitors. Anesthesiologists are skilled
in the placement of arterial and central venous access, pulmonary
artery catheters and transesophageal echocardiography. With the
additional training obtained during the critical care fellowship,
they are able to ensure appropriate mechanical ventilator management
and use of circulatory assist devices and other therapies such
as continuous renal replacement therapy.
The roles and responsibilities assumed by the anesthesiologist
in the operating room provide a sound foundation for ICU management.
The experiences in the operating room ensure that the critical
care anesthesiologist is able to set appropriate priorities for
emergent interventions and to differentiate important, life-threatening
issues from health care maintenance issues. Anesthesiologists
are particularly well-suited to provide proactive care, identifying
trends and intervening to prevent, rather than treat, complications.
They try to anticipate potential problems in the operating room,
carefully assessing physiologic parameters that suggest possible
problems. For example, anesthesiologists continuously monitor
oxygen saturation and modify therapy to prevent complications
of hypoxemia, rather than waiting for signs of hemodynamic instability.
They closely monitor the electrocardiogram to look for evidence
of myocardial ischemia and intervene to prevent further compromise
in myocardial function. This anticipatory approach to care is
also essential for the ICU patient.
Critical care anesthesiologists also have the knowledge
and skills necessary to facilitate development of clinical protocols
or pathways related to perioperative care as well as disease management.9,10
They have a particular advantage over other critical care providers
with respect to the care of the surgical patient. Because anesthetic
management has such a significant impact on perioperative care,
anesthesiologists are able to understand the implications of changes
in intraoperative management on postoperative care. They have
been able to identify more cost-effective approaches to clinical
care for surgical patients,11 facilitating
implementation of fast-track programs and assisting in the creation
of alternative sites of care such as transitional care units.
The same approaches have been successfully employed for other
critically ill patient populations. For example, many critical
care anesthesiologists have helped develop evidence-based clinical
pathways for management of diabetic ketoacidosis, community acquired
pneumonia and anticoagulation for deep vein thrombosis and pulmonary
emboli.
Finally, the successful functioning of an ICU requires
both a medical director and a clearly defined administrative structure
to ensure appropriate accountability for clinical care, to fulfill
institutional requirements and to assure that external regulatory
requirements are met. The role of the medical director requires
good administrative skills. However, the role of the medical director
also requires the ability to work cooperatively with a wide variety
of providers, each with different capabilities and responsibilities.
The anesthesiologist-intensivist can very effectively assume this
responsibility, since it is similar to the role assumed by the
anesthesiologist in the operating room.
Conclusion
The opportunities for physicians trained in critical care
medicine are increasing. As the percentage of hospitalized patients
who are critically ill increases and more beds are devoted to
ICUs, the roles for the critical care physician will continue
to expand. The intensivist will be expected to have a broad-based
fund of knowledge about critical illness, extensive procedural
skills and the ability to coordinate care provided by a wide variety
of clinicians. These expectations can easily be fulfilled by the
critical care anesthesiologist, if we are willing to accept the
responsibilities. As we address the many challenges that face
our specialty, we should accept these challenges and continue
to expand our role in critical care medicine, just as we do in
pain medicine and other subspecialties.
References:
- Manthous CA, Amoateng-Adjepong Y, Al-Kharrat
T, et al. Effects of a medical intensivist on patient care in
a community hospital. Mayo Clin Proc. 1997; 72:391-399.
- Marini JJ. Streamlining critical care: Responsibilities
and cost-effectiveness in intensive care unit organization.
Mayo Clin Proc. 1997; 72:483-485.
- Groeger JS, Strosberg MA, Halpern NA, et
al. Descriptive analysis of critical care units in the United
States. Crit Care Med. 1992; 20:846-863.
- Brown JJ, Sullivan G. Effect on ICU mortality
of a full-time critical care specialist. Chest. 1989;
96:127-129.
- Carson SS, Stocking C, Podsadecki T, et al.
Effects of organizational change in the medical intensive care
unit of a teaching hospital: A comparison of "open" and "closed"
formats. JAMA. 1996; 276:322-328.
- Reynolds HN, Haupt MT, Thill-Baharozian MC,
Carlson RW. Impact of critical care physician staffing on patients
with septic shock in a university hospital medical intensive
care unit. JAMA. 1988; 260:3446-3450.
- Li TCM, Phillips MC, Shaw L, et al. On-site
physician staffing in a community hospital intensive care unit:
Impact on test and procedure use and on patient outcome. JAMA.
1984; 252:2023-2027.
- Pollack MM, Katz RW, Ruttimann UE, Getson
PR. Improving the outcome and efficiency of intensive care:
The impact of an intensivist. Crit Care Med. 1988; 16:11-17.
- Hadorn DC. Who really needs to be in the
intensive care unit: Using clinical guidelines to define healthcare
needs. Crit Care Med. 1994; 22:1679-1682.
- Snider GL. Allocation of intensive care:
The physician's role. Am J Respir Crit Care Med. 1994;
150:575-580.
- Buist M. Intensive care resource utilization.
Anaesth Intens Care. 1994; 22:46-60.
Neal H. Cohen, M.D., is Professor and
Vice-Chair, Anesthesia Department, Professor of Medicine and Director,
Critical Care Medicine, University of California, San Francisco,
California. He is a member of the Board of Directors of the American
Society of Critical Care Anesthesiologists.
E-mail the author.
A. Sue Carlisle, M.D., Ph.D., is Professor
of Anesthesia and Medicine, University of California, San Francisco,
California.
E-mail the author.
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