Michael J. Murray, M.D., Ph.D.
Committee on Critical Care and Trauma Medicine

For most anesthesiologists who have not spent much time in an intensive care unit (ICU) since their training days, a cursory peek into their local hospital’s ICU will probably reveal that not much has changed. Nurses are overworked (and there are never enough of them), patients have the same problems caused by infections and cardiovascular disease as they had in olden days, and though the devices have more bells and whistles, they continue to be used to mechanically ventilate patients and monitor intravascular pressure. Although recent studies have shown the benefit of using small tidal volumes (6-8 mL/kg) when ventilating patients with acute lung injury and using an inhibitor of activated protein C in treating patients with sepsis, the treatment regimens in most ICUs in the United States do not include these therapies. Anticoagulation and sedation therapies comprise the largest items in the pharmaceutical budget of an ICU. The same drugs that we employed during our training 10 or 20 years ago — vasopressin for managing all kinds of hypotensive states, glucocorticoids for anyone with sepsis or acute lung injury (in fact any form of severe stress) who does not seem to be responding to treatment, and so forth — are now receiving a resurgence of interest.

Such a cursory look, however, would ignore the advances that we have recently achieved in managing the care of our critically ill patients: we more fully understand the signaling pathways that underlie the hypotension that develops in septic shock; we have greater insights into the genomic and proteomic pathways that make a person susceptible to disease; and through our understanding of those pathways, we better appreciate newly identified pharmacogenetics, thereby recognizing why some patients and not others respond to the use of a specific drug. We more aggressively manage diabetes, hyperglycemia, stroke, traumatic brain injury and ischemic heart disease; and the same technologies that are revolutionizing the electronics industry are expanding our options for managing the care of our patients.

Do you have a patient with a gastrointestinal bleed? A member of the bleeding team can “scope” and treat the patient on the spot. Is that patient in bed three having a myocardial tamponade? Looking at a pulmonary artery pressure tracing is obsolete when you can obtain a transesophageal echocardiogram right at the bedside. You say that you have a patient with renal dysfunction and fluid overload and you want to do what? Hemodialysis? Excuse me, but what century is this? Continuous veno-venous hemofiltration-hemodialysis is available right in the ICU.

Or what about this scenario: It is Saturday morning, and your daughter has an all-day soccer tournament, but you have to check Mrs. Jones’ laboratory report at 3 p.m. No problem. You head out and enjoy the day, fire up your hand-held computer at 2:58 p.m., log on to the hospital’s network and evaluate the lab results. You can even take the opportunity to hook up to the ICU’s video monitoring system and observe Mrs. Jones in real time — and you have spent the day bonding with the family. How is that for using technology?

So although much remains the same on the surface, our ability to diagnose diseases and treat patients in the ICU has changed dramatically. Unfortunately these advances have come at a huge cost, a cost that no one wants to discuss — certainly not when our legislators, members of the general public and the pharmaceutical industry are deeply enmeshed in developing a prescription drug program for Medicare beneficiaries and scrambling to find a way to pay for it. Because this benefit will be added to a relatively neutral Medicare budget, anesthesiologists are justifiably concerned that the reimbursement rate for their operating room-based services will decrease. How will we pay for the technologies that have enhanced the care we provide for our patients in the ICU? In addition to answering that burning question, we have to address the huge bulge in our population brought about by the baby boomer generation, which is crossing over from being middle-age wage earners to health care-consuming elderly and retirees who will place incredible demands on our health care system. How will we staff our ICUs when intensivists of all training backgrounds are already in short supply? Trauma units around the country are closing because funding mechanisms are insufficient to cover the costs of the technology and the liability incurred in delivering trauma care. Are ICUs next on the hatchet block?

The Leapfrog Group, a growing consortium of more than 140 Fortune 500 companies and other large private and public health care purchasers, has made recommendations that will affect us all but still seem to be blatantly out of step with the above observations. The Leapfrog Group has recommended that its beneficiaries (including hundreds of thousands of people nationwide) obtain their health care services at hospitals that have implemented three “leaps” that include 1) computer physician order entry (currently on hold), 2) evidence-based hospital referral (hospitals with proven outcomes or extensive experience with specific high-risk surgical procedures and conditions) and 3) an ICU physicians’ staffing model. This final staffing model requires that hospitals fulfilling the standard will operate adult or pediatric ICUs that are managed or comanaged by intensivists who 1) are present during daytime hours and who provide clinical care exclusively in the ICU and 2) who, during nondaytime hours, will (at least 95 percent of the time) return pages from the ICU within five minutes and will arrange for a Fundamental Critical Care Support-certified physician or physician extender to reach ICU patients within five minutes.

The data upon which the Leapfrog Group’s recommendations are based are not perfect, but they are at least as good as the data that these Fortune 500 companies use in making other billion-dollar decisions, and numerous studies are under way to validate the data. Recognizing that the Leapfrog Group’s decisions and recommendations may drive the hospital-based practice of medicine, the Joint Commission on Accreditation of Healthcare Organizations convened a task force to develop ICU practice recommendations that should be announced later this year.

The Accreditation Council for Graduate Medical Education also has taken up the task and, through the Residency Review Committee (RRC), is promulgating a revision of the anesthesiology residency requirements. The RRC is considering making changes to residency programs that would increase the amount of training in critical care medicine that anesthesiology residents receive over their four-year residency from its current two months to six months and also would increase the residents’ clinical responsibilities throughout the continuum. This education expansion could not come at a better time, when the practice of critical care medicine becomes more and more complex.

If the number of anesthesiologists who practice critical care medicine does not increase, however, all this effort is for naught. As anesthesiologists, and particularly as members of ASA, we are too often under-represented when outsiders make decisions about the practice of critical care and trauma care medicine. Although the Committee on Critical Care Medicine and Trauma Medicine represents ASA in a number of these venues, members of the committee are convinced that anesthesiologists must be more involved in determining the future of critical care medicine in the United States. The committee submitted a resolution to be considered by the House of Delegates at the ASA Annual Meeting in October asking that 1) ASA reaffirm its support that critical care medicine is part of the practice of anesthesiology and 2) the ASA President appoint a task force to both develop the Society’s strategy on the role of critical care medicine within our specialty and identify ways to improve that role.

Members of the committee are optimistic that we can continue to improve the care of critically ill patients and that anesthesiologists will not only continue to play a pivotal role in delivering that care but also develop mechanisms to advance the subspecialty of critical care medicine.

Michael J. Murray, M.D., Ph.D., is Professor and Chair, Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida.