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Demands for the Critical Care.

Demands for the Critical Care.

 

Abstract

Purpose of review: Interest in the global burden of critical illness is growing, but comprehensive data to describe this burden and the resources available to provide care for critically ill patients are lacking.

Recent findings: Challenges to obtaining population-based global estimates of critical illness and resources to treat it include the syndrome-based definitions of critical illness, incorrect equating of ‘critical illness’ with ‘admission to an intensive care unit’, lack of reliable case ascertainment in administrative data, and short prodrome and high mortality of critical illness, limiting the number of prevalent cases. Modeling techniques will be required to estimate the burden of critical illness and disparities in access to critical care using existing data sources. Demand for critical care is likely to increase, related to urbanization, an aging demographic, and the ongoing wars, disasters, and pandemics, whereas economic crises will likely decrease the ability to pay for it. Demands for the Critical Care.

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Summary: Major unexplored research and public health questions remain unanswered regarding the worldwide burden of critical illness, variation in resources available for treatment, and strategies to prevent and treat critical illness that are broadly effective and feasible.

Supply and Demand of Critical Care Demands Change

Current trends in both the U.S. population and the demographics of critical care staff dictate that critical care must change—and fast. With millions of baby boomers aging, demand for critical care facilities within hospitals will increase. Demands for the Critical Care.

“There’s little question that critical care is used disproportionately by the elderly,” says Timothy Buchman, MD, PhD, FACS, FCCM, past president of the Society of Critical Care Medicine (SCCM) and professor at Washington University School of Medicine, St. Louis. “The demand can only increase as the population ages.”

At the same time, there are already too few critical care providers in the United States. “If we designed an ideal ICU for every hospital in the country, we could only staff about one-third of them” right now, says Thomas Rainey, MD, FCCM, president, CriticalMed, Inc., Bethesda, Md. Demands for the Critical Care.

Critical care experts are, of course, the key to quality care in the ICU. But the population of both specially trained intensivists and experienced ICU nurses is declining. The average age of an ICU nurse is now 47, and they are not replaced fast enough.

“Critical care nursing is brutally hard work; it’s physically, emotionally, and spiritually grueling,” points out Dr. Buchman. “The challenge is keeping experienced nurses from leaving because they’re burned out. We need to keep their knowledge and experience, possibly by creating new positions where their knowledge, experience, and accumulated wisdom can be used to benefit the next generations of patients and providers.” Demands for the Critical Care.

As for physicians, fewer are choosing critical care, which will likely lead to significant staffing issues. “The number of doctors choosing a career in critical care is leveling off,” says Dr. Buchman. Part of the problem is an educational system that helps medical students choose a specialty.

“We have a direct training path to many specialties through residencies,” he says. “There is no residency in critical care medicine. Instead, we ask people to initially train as something else. We’ve created an educational barrier.”

The upshot of these trends, says Dr. Rainey, is that “the graying population and the loss of [critical care] staff is a collision waiting to happen.” Demands for the Critical Care.

Dr. Buchman adds, “The question is: How do people organize themselves and leverage technology to address this gap and improve the quality of care?”

One solution to the staffing shortage is electronic ICUs—or eICUs, which allow an intensivist and ICU nurse to monitor and manage part or all of the patient population in their organization’s ICU from off-site. Demands for the Critical Care.
How Technology Fits In

In 2001, Richard L. Craft, MSEE, wrote of “Trends in Technology and the Future Intensive Care Unit” ( . 2001;29[8 suppl]): ” … advances in networking are likely to redefine the physical and organizational boundaries of the critical care unit. No longer a self-contained entity … tomorrow’s critical care units are likely to regularly draw on resources—both human and technological—located outside the unit’s physical space.”

The solution to staffing shortages in ICUs lies in using technology that is already available to hospitals. Demands for the Critical Care.

“Remote monitoring will help leverage existing manpower,” says Dr. Rainey. One option is electronic ICUs—or eICUs, which allow an intensivist and ICU nurse to monitor and manage part or all of the patient population in their organization’s ICU(s) from off-site, if applicable. This remote monitoring supplements on-site hospital staff, but allows fewer specialists access to more patients.

“eICU with smart alerts, physiologic status boards, [and] color-coded assessments of response to protocolized care may help hospitalists and intensivists on-site manage increasingly busy and acute ICUs,” says Dr. Buchman. “The greatest impact will be to facilitate the transformation of data into information and to highlight factors that are of greatest immediate importance.” Demands for the Critical Care.

In addition to maximizing medical staff, eICU systems can also leverage technical support. Craft writes, “… it is easy to foresee a day when a network of hospitals might centralize its critical care application servers and patient record servers in one location to reduce IT staff overhead, standardize clinical protocols, and automate corporation-wide quality control mechanisms.”

With an eICU system, cameras, monitors, and communication devices provide information on each patient, and can even provide treatment recommendations or guidelines. Demands for the Critical Care.

“eICU systems are evolving now,” says Dr. Buchman. “They synthesize data streams and allow us to stratify information with respect to how important it is. We’ve [already] had a few components, such as bedside hemodynamic monitors. For each individual patient, a sophisticated system should be able to take data from multiple systems, integrate it, and provide a snapshot of how that patient is doing. Take that throughout the entire ICU and have a display that presents instant pictures of how the ICU is doing. [Have] inventories presented in parallel to providers so they can see where problems are.”

Dr. Buchman predicts that in the future ICU care providers will take on more duties as managers of care. Demands for the Critical Care.

“ICU providers will go through an evolution like airline pilots did,” he says. “These days, airline transport pilots don’t spend a lot of time actually flying the plane. There are plenty of autopilots and subsystems that do that. The pilot now spends most of her time managing the system, and intervenes as necessary to bring everything into harmony. I think this same type of sophisticated presentation will evolve in the ICU to provide a safer environment that uses the available human resource most efficiently. It won’t save on manpower, but it will greatly increase patient safety.”

J. Christopher Farmer, MD, FCCM, Division of Pulmonary and Critical Care, Mayo Clinic College of Medicine, Rochester, Minn., agrees—especially as relates to disaster response. Demands for the Critical Care.

“We need technology that doesn’t rely on human factors,” says Dr. Farmer. During a hospital’s disaster response, “we miss things because we don’t notice them. We need automation of systems that will push information to us as computerized analysis; systems that look at everything, including lab results, and postulate on that information. This would help in critical care and could be used in disaster settings as well.” Demands for the Critical Care.

Dr. Farmer’s vision includes automatic monitoring. “Ideally, I’d like to see every patient have a patch that reads their heart rate, oxygen levels, etc.,” he says. “This 100% monitoring of every patient is applicable in disaster medicine because otherwise you need a person to manually hook up monitors and check vitals on each patient.”

The evolution of ICU technology must focus on bridging the gap between limited staff and growing patient population as well as the gap between adequate care and excellent care. Demands for the Critical Care.

“Technology is there to serve the patient first, but most importantly, to serve the care alliance of patients and practitioners,” says Dr. Buchman “I think some [advancements] are simply technical toys that are replacing what humans can already do.” Technology can help identify a disease outbreak or other disaster faster than humans can. Some hospital systems are using surveillance systems that link across their facilities to find patterns. These systems can be used to find medical errors, but they can also act as bio-disease surveillance systems, which can be used to identify a sudden outbreak. “Say three different hospitals each admit one patient with diarrhea,” says Dr. Farmer. “What if this is the beginning of an outbreak of something? A system that links across hospitals can find these patterns.” Demands for the Critical Care.

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