INTENSIVE CARE - The specialty and its specialists

M McD Fisher MBChB MD FFICANZCA, FRCA
Head, Intensive Therapy Unit
Royal North Shore Hospital
St. Leonards NSW 2065
AUSTRALIA

Introduction:

Critical Care began in the 1950's polio epidemic. Simple hand ventilation, often performed by teams of medical students and 'iron lung' ventilators enabled survival of some patients if respiratory function was maintained. This lead to positive pressure ventilation which was applied to patients with drug overdoses, tetanus, and chest trauma with improvement in survival. The development of effective ventilators and improved circulatory support radically extended surgical possibilities and improved survival in diseases previously inoperable.

The evolution of the new speciality of Intensivist was usually lead by committed individuals who began intensive care units as solo practitioners and then attracted others.

The Intensivist lead the development of medical teams, who recognised the abilities and skills of one another, and coordinated their efforts. The team comprised nurses, scientists, nutritionists, pharmacologists, and physiotherapists all of whom had special training and expertise in, and dedication to the care of the critically ill.

As Intensive Care is multidisciplinary, and crosses the traditional boundaries of medical speciality groups, its practitioners must have a knowledge of some parts of these traditional specialities that is at least the equal of, and preferably superior to that of individuals from those specialities. There is also a major coordinating function to ensure that contributors to the care of the patient provide opinions and knowledge that are complementary and not contradictory. The volume of medical knowledge and diversity of medical skills today mean no individual can encompass the entire discipline. The Intensivist essentially looks after the patients of others, and crosses established frontiers of referral, responsibility, (which includes medicolegal responsibility) and ownership.

WHAT IS INTENSIVE CARE?

An Intensive Care Unit may be defined as 'a hospital area in which an increased concentration of specially trained staff and monitoring equipment allow more detailed and frequent monitoring and more frequent intervention in seriously ill patients.'

Critical Care is defined as 'the care of seriously ill patients from point of injury or illness until discharge from Intensive Care.' This latter definition encompasses Ambulance Services, Disaster Medicine, Emergency Medicine and Preventive Medicine.

An effective intensive care unit involves people from different disciplines; medical, nursing and allied health, providing the skills they have ownership of in a collaborative, cooperative, and coordinated fashion, with communication being of optimum importance.

Although the technology of intensive care is important an important USA study showed that management structure and relationships of staff to be more important than technology in determining outcomes. ⁽¹⁾

WHAT IS AN INTENSIVIST?

Pinsky⁽²⁾ describes the intensivist as providing the most efficient primary care for the critically ill, bringing some aspects of all specialties to the bedside and allowing titration of resources in a patient specific fashion; a primary generalist.

He also emphasises the major role such physicians must play in documenting the efficacy brought to patient care if intensive care is to receive continuing support from Government and third party payers.

The Society of Critical care Medicine in the USA defines the role of an intensivist thus - the qualified critical care practitioner is physically available without competing obligations and possesses knowledge, skill, judgement, attitude and compassion acquired through training, experience and focus to achieve the best outcome for patients suffering from critical illness and injury. Critical care practitioners plan and manage the environment in which critical care occurs. This environment includes physical plant, equipment, supplies, personnel and the organisation within which they function^.(3)

The evolution of the specialist intensivist posed problems. The speciality transgressed the traditional borders of medical specialities which were based on age (geriatrics) technique (anaesthetics), organ, (cardiology) or disease (oncology). Intensive Care took a different approach by basing patient selection on acuity, which challenged the traditional concepts of responsibility for (and ownership of) patients. Successful responses to these challenges resulted in the development of medical , nursing and support teams who recognised the abilities and skills of one another Unsuccessful responses lead to turf wars associated with a belief that excellent care of the critically ill could be delivered by doctors from the traditional specialty. The intensivist, with special training in and commitment to Intensive Care and overall responsibility for the running of an intensive care unit, is the norm in most developed countries outside the USA where, the turf wars continue.

It was inevitable that those who worked in intensive care would seek recognition as an independent specialty. The degree of success in this area varies between countries with critical care being a sub specialty of anaesthesia or internal medicine in most from which discipline the intensivist comes from is of little relevance if training, ethos, and commitment are adequate. In addition to the criteria for the intensivist described in the SCCM document, the intensivist interpersonal skills, and the ability to work on, and to lead, a team. The place of the intensivist is in the unit at the bedside. It is here the team is coordinated. It is here the right to care for others patients is earned.

WHAT IS A SPECIALITY?

In medicine a specialty has the following characteristics:

¨ A group of doctors with an interest in a particular patient group who regulate the intake into that group and provides educational training and clinical standards.
¨ award certification qualifications
¨ are recognised by other specialities as having the major expertise in the area of which the speciality has ownership
¨ have a share of the medical undergraduate curriculum.
¨ have their own journals
¨ deal with of Government and Professional bodies with respect to matters pertaining to the speciality

In many countries the speciality of intensive care fulfils these criteria and is well established. But a specialty is more than just the above.

1. A relevant specialty must have

Training Programs - In Australia, training through the internal medicine and anaesthesia colleges has been established since 1979. The graduates came when many units were established and the practitioners in the units had been 'Grandfathered' to receive the diplomas. The spread of trained intensivists into rural and suburban hospitals may well be an important factor in the low range of mortality ratios in NSW. Many of the hospitals in the Australian outcome studies are not entirely run by full time intensivists. They are, however, usually run by people who have specific intensive care training.

2. Acceptance by peers and government

It is my belief that this acceptance is won by demonstrating a commitment to providing clinical excellence on the floor of the unit. Efforts to legislate the role for the intensivist without the intensivists convincing the referring doctor that they provide a better service for the patient are doomed to failure. It is an interesting characteristic of the acceptance of the speciality in Australia that it was based on clinical performance, and few of our pioneers had any time for anything else. The initial acceptance of intensive care was in the hospitals and it has only been recently that Government has sought the views of the intensivists through there own organisations, rather than the colleges.

3. A place in the undergraduate curriculum

We must now approach undergraduate education as a priority. Medical specialities are taught to students. New graduates are equipped with poor skills in determining who needs urgent interventions, the interventions that will keep a patient alive until the cavalry arrive, and when to call the cavalry. The proportion of the curriculum a speciality has reflects its power in the University. It is another area in which legislation or impressive documents will enable little progress but cause conflict. It is another war to be won by demonstrating expertise, enthusiasm and value at a local level. The intensive care unit is a useful place to teach students about ethics, care of the dying, distributive justice and appropriateness.

4. A solid research basis to its clinical activities and an active ongoing research focus.

The growth of evidence based medicine has lead us to the appreciation that many of our activities and beliefs were based on experience and anecdote and may not stand scientific scrutiny.

Indeed, the application of evidence based medicine to both the time honoured and innovative techniques and therapies used in intensive care is a major challenge for the future as inappropriate therapies applied in intensive care units prolong dying and suffering are expensive and may deny access to the unit to more appropriate patients. Because of unresolved issues regarding whether patients in trials should be grouped by basic disease or intensive care syndromes of for example Multi-system Organ Failure or Acute lung injury, and what outcomes other than survival are valid, intensive care research is difficult. The complex and varied nature of critically ill patients means that large multicenter studies will be needed to address our questions and our Canadian, Spanish and Italian colleagues have shown admirable leadership in the establishment of trial groups effectively performing multicenter studies.

WHAT IS AN INTENSIVE CARE UNIT?

The Intensive Care Unit or Critical Care unit is the dedicated area where the critically ill are cared for Such units may be 'open' in which care is carried out by the primary team in consultation with the 'intensivist' ,or 'closed' where the 'intensivist' becomes the primary care physician.

IS INTENSIVE CARE A LOGICAL SPECIALTY?

Intensive Care as a speciality or sub speciality is multidisciplinary, and therefore crosses the traditional frontiers of medical specialist groupings. The intensivists must have knowledge of some parts of these traditional specialities that is at least the equal of, and preferably superior to the individuals from those specialities, and this must be reflected in appropriate training programmes. This is not to say that the intensivist does not need the information and skills of others: an important function of the intensivist is coordination of the skills of others. The volume of medical knowledge and diversity of medical skills today mean no individual can encompass the entire discipline. In most units the intensivist looks after the patients of others, and to effectively cross established frontiers of referral and, responsibility, (including medicolegal responsibility) is a privilege best earned at the bedside.

A key role of the intensivist is coordinating the efforts and management plans of the practitioners of other specialities; the quantity of knowledge needed to practice a medical speciality is so vast today I believe it impossible for most practitioners to stay current in several specialities.

It was inevitable therefore that special units to concentrate equipment and medical and nursing expertise would be formed.

The management of intensive Care patients by doctors who consider their primary function as intensivists and who are recognised as such by their colleagues, favourably influences survival. The study of Knaus and colleagues study showed a Standard Mortality Ratio, a calculation measurement based on observed survival/predicted survival ranged between 0.65 to 1.81 (which was highly significant. (p=0.0001)) in a number of US ICUs. The best of the units studied relied on clinical protocol rather than technology, and on carefully designed protocols implemented by in-unit specialists. It also had the most comprehensive nursing education support, independent nursing responsibilities and excellent nurse/ physician communication. ⁽¹⁾

Fisher and Herkes⁽⁴⁾ analysed collected data from the USA and Australia and suggested that while the use of technology and patient characteristics were similar, an apparent improvement in Apache II outcomes could be related to the acceptance of the speciality as expressed by the number of full time directors of ICU with right of admission and discharge in Australia being 3-4 times greater than in ICU. The presence of a full time director and staff interaction had been suggested earlier by Knaus’s group ⁽¹⁾.

Rogers⁽⁵⁾ first showed improved survival in patients cared for intensive care units as opposed to wards in 1972. Subsequent evidence suggests that critically ill patients have improved survival in closed units run by intensivists. Safar and Grenvik.⁽⁶⁾ first showed an intensivist led to improved outcomes, particularly in patients in a middle range of severity. When on site physicians were employed in a community hospital ICU Li et al showed an improved survival rate in patients with intermediate risk of death⁽⁷⁾. However, Hainer & Lawler ⁽⁸⁾ suggested that a difference in survival did not occur when patients were cared for by a family physician or general internist, implying that both were as good, but perhaps suggesting that both were as bad^.(8) Reynolds et al^.(9) showed that providing intensive care trained doctors in a medical intensive care unit had a favourable impact on outcome in septic shock9, and Brown and Sullivan⁽¹⁰⁾ showed a full time intensivist produced a significant reduction in mortality in a general intensive care unit. Pollack et al showed improved outcomes in children after the arrival of a paediatric intensivist and in paediatric units run by intensivists compared to “open” units^.(11,12). A more recent study compared 200 randomised surgical patients managed by the general surgeon or the dedicated critical care service and showed in the intensivist treated group, who had significantly higher Apache II scores had fewer ICU days, ventilated days, equipment days, blood products, blood gases, and had one third the number of complications^.(13). Similar studies have been reported from Hong Kong^.(14) and Germany. ⁽¹⁵⁾

Other recent US studies have shown advantages in cost and outcomes with closed units in the USA^{(16,17,18,19)} In a large study of 3000 patients having aortic surgery regular bedside rounds by intensivists reduced complications, length of stay and outcome^.(20) Most recently Blunt and Burchett in the UK showed the coverage of ICUs by trained dedicated intensivists at nights and weekends improved outcomes as well as by day^.(21)

These studies often elicit impassioned responses⁽²²⁾ but to this author the outcomes of the studies are what would be expected.

The factors identified are presence, experience, technical skill, training, and knowledge. It would be surprising if an intensivist, from whatever discipline who has these factors, did not improve outcomes. The qualities needed in an intensivist are no different from other specialities, although frequency of consultation and coal face presence are probably more important .

What has not been sufficiently explored yet in my opinion is that the accumulated data puts the Speciality of Intensive Care in a unique position in that it is better validated than any other. The argument about who best should care for the critically ill patient is over. It is time to go forward.

Jean Louis Vincent ⁽²³⁾ writes that with the establishment of the speciality and the outcome data available patients should no longer be denied the services of specialist
intensivists.

There remains one place in which it is likely the part the intensivist or specialist with an interest in intensive care has a role. In small hospitals or rural hospitals there is a need for intensive care services, but to organise a roster with a reasonable life outside hospital means a group of doctors with intensive care interests are needed. Even in these circumstances it is unlikely that an open unit is likely to be safe and effective. Commitment to unit is also a factor inherent in the studies of intensive care unit efficiency.

The 'open' intensive care unit should rapidly vanish.

Intensive Care is a logical specialty.

In spite of evidence that an intensivist and fulltime staff carry benefits this is not the way that intensive care units are likely to be run outside major centres. While the cost of fulltime medical staff is less than part time staff in a large unit, a small unit may not have sufficient work by day to occupy one doctor fully. Further, a fulltime doctor working in intensive care needs relief for nights, weekends and leave. Thus smaller units evolve under the care of specialists from other disciplines. Data from Australia suggests that if appropriate liaison, triage and transport facilities are in place, such units are associated with less ill patients but not adverse outcomes^.(7)

FUTURE CHALLENGES

a) Nursing

The nurses are key players in the Intensive Care Unit. Indeed with many diseases the nursing aspects of care play an equal or greater role in determining outcome than the medical input. Collaboration and integration of medical and nursing staff must be optimal. Indeed the intensive care unit often becomes a very tribal place where nurses and doctors see each other as professional colleagues more so that members of their specialty who work outside the unit. Changes in the role of women and nurses make the old patronising and controlling roles are no longer valid. Nurses solve nursing problems best, and the role of a medical unit leader is to facilitate and assist when requested. Nursing staff should be fully integrated into the scientific, quality, planning, educational and management activities of the unit.

In many countries the availability of nurses, especially those with post-graduate training, is the limiting factor in the ability of hospitals to provide health care. A major rethink of the role, the recruitment and the retention of ICU nursing staff is one of the major challenges facing Intensive and Critical Care.

b) Research

There is a need to re-evaluate many of the standard techniques and therapies of intensive care and to develop the facilities for National multicenter studies.

c) Appropriateness and distributive justice

The main challenge for the future in intensive care units throughout the world is in providing care that is appropriate. While the place of the new technology used in intensive care was being established it became apparent that it was possible to keep many patients alive almost indefinitely, often when there was no hope of a survival that the patient would find acceptable. Much of the new technology changes the cause of death but not the outcome. Each new drug or technical improvement is associated with diminishing returns and reduced cost benefit.

Critical Care has opened an ethical Pandora’s box which is about how much of a health care budget does one individual have a right to, and who has ownership of the decision to proceed with or withdraw active treatment.

Western societies accept largely that withdrawal of artificial forms of life support even when it will be followed by certain death, does not equate with murder. The ownership of the decision making prior to this act ,particularly when a patient is not competent to make decisions for himself, is a current area of debate. Whether such decision making should be carried out by lawyers, governments, health care workers or families is a major societal issue in which medical involvement in, if not leadership of the debate is mandatory.

In developing countries what is appropriate intensive care is an even more complex issue. In poor countries the life expectancy and quality of life of the population are far more likely to be influenced by water management, agriculture, birth control, vaccination, education, hygiene, peace, and removal of landmines than the provision of intensive care units. In the USA heart transplantation is performed in people with muscular dystrophy, while in poorer countries infectious diseases, many easily treatable, and starvation are the dominant causes of death. Fifty Three million people die each year. A third die of infectious diseases. Four million children die of lung infections and three million people die of gastroenteritis and TB. ⁽²⁴⁾

And yet in developing countries there are numbers of identifiable young people who could be returned to a productive life with simple intensive care.

The factor most likely to lead to improved survival in developing counties returns us to where intensive care began; mechanical ventilation. The ability to manage a ventilated patient is the one technique most likely to save lives. The use of oxygen compressors has extended the range of areas where mechanical ventilation may be used. There is a need for much simpler ventilators for such areas. Technical support and repairs may be virtually impossible.

An even more difficult question arises in countries with a small wealthy population and a large poor population. It is difficult from a 'Western' perspective to understand the fairness of the wealthy having access to high cost medicine in their own or other countries when the incidence of poverty is high. However those who provide such services defend them on the basis that it is better to provide access for the wealthy in their own country and develop those facilities to be more encompassing.

Intensive care aid must be appropriate. Maintenance of the unit should be within the financial, medical, and nursing resources of the country and reflect the ethnic, social and religious mores of the country.

Society will increasingly place the intensivist in the role of patient advocate. And yet there has been no real change since Dunstan wrote in 1985 - “The success of intensive care is not to be measured only by the statistics of survival, as though each death were a medical failure. It is to be measured by the quality of lives preserved or restored, the quality of the dying of those in whose interest it is to die and by the quality of relationships involved in each death" ⁽²⁵⁾ .

Even in larger units, there may be problems in providing a balance between sufficient specialist staff to provide a reasonable lifestyle in terms of nights, weekends, and leave, and the number necessary to run the unit during the week. The traditional large consultant ward round is an inefficient way of running the ward although the benefit of the input of others in important, particularly with respect to decisions regarding outcome and appropriateness. In our unit, we restrict such rounds to twice a week and put a time limit on them.

INTENSIVE CARE AND OTHER SPECIALITIES

In the context of providing a continuum of care, the speciality of intensive care needs to interact effectively with a number of other recognised and emerging specialities. The intensive care unit must not be isolationist but participate fully in the activities of other hospital groups and be represented in their clinical, administrative, research, and teaching activities. Similarly, it may be advantageous for the administrative structure of the unit to contain a forum or committee to which users have input.

The consolidation of the speciality will increasingly place the intensivist in the role of patient advocate.

References
1. Knaus WA, Wagner PP, Zimmerman JE, Draper EA. Variations in mortality and length of stay in Intensive Care Unit. Ann Int Med 1986: 103;410-418.
2. Pinsky MR. Changes in attitude, changes in latitude. J Crit Care. 1995:10;151-153.
3. Editorial. Society of Critical Care Medicine’s vision for critical care. Crit Care Med 1994: 22;1713.
4. Fisher MMcD and Herkes RG. Intensive Care: Speciality without Frontiers. In: Critical Care: State of the Art. Society of Critical Care Medicine, Anaheim, California. Margaret M Parker, Marc J Shapiro, David T Porembka Eds. Volume 15, January 1995, pp 9-27.
5. Rogers RM, Weiler C, Ruppenthal B: Impact of respiratory intensive care unit on survival of patients with acute respiratory failure. Chest 1972; 62:94-97
6. Safar P, Grenvik A. Organization and physician education in critical care medicine. Anaesthesiology 1977: 47; 82-95.
7. Li TCM, Phillips MC, Show L et al. On site physician staffing in a community hospital intensive care unit. JAMA 1984: 252; 2023-2027.
8 Hainer BL, Lawler FM. Comparison of critical care provided by family physicians and general intensivists. JAMA 1988: 260; 354-358.
9. Reynolds N, 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.
10.Brown JJ, Sullivan G. Effect on ICU mortality of a full time critical care specialist. Chest 1989: 96; 127-129.
11.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.
12.Pollack MM, Cuerdon TT, Patel KM, Ruttimann UE, Getson PR, Levetown M. Impact of quality-of-care factors on pediatric intensive care unit mortality. JAMA 1994: 272; 941-946.
13 Hanson et al "Effects of an organised critical care service on outcomes and resource utilisation :A cohort study" Crit Care Med 1999 27:270-274
14.Tan IKS. Closed intensive care units and intensivists: the solution to cost and quality for intensive care in developing countries. Crit Care Shock 2000; 1: 1-3.
!5. Kern H, Kox WJ "Impact of standard procedures and clinical standards on cost effectiveness and and Intensive Care Unit performance in adult patients after cardiac surgery. Intensive Care Med 1999 25:1367-1373.
16. Multz AS, Chaflin DB, Samson IM et al. A "closed" medical intensive care unit (MICU) improves resource utilization when compared with an "open" MICU. Am J Respir Crit Care Med 1998; 157: 1468-73.
17. 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: 322-28
18. Ghorra S, Reindert SE, Cioffi W, Buczko G, Simms HH. Analysis of the effect of conversion from open to closed surgical intensive care unit. Ann Surg 1999; 229: 163-71.
19. Bach PB, Carson SS, Leff A. Outcomes and resource utilization for patients with prolonged critical illness managed by university-based or community-based subspecialists. Am J Respir Crit Care Med 1998; 158: 1410-15
20.Pronovost PJ, Jenckes MW, Dorman T, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA 1999; 281: 1310-17.
21.Blunt B, Burchett K. Out-of-hours consultant cover and case-mix-adjusted mortality in intensive care. Lancet 2000;365:735-736
22. Trunkey DD. An unacceptable concept. Ann Surg 1999; 229 171-173.
23. I. Vincent JL. Need for intensivists in intensive care units. Lancet 2000 356;695-696
24 McGregor, A. Fatal complacency over health says WHO. Lancet, 1996,347:1478.
25 Dunstan GR. Hard questions in intensive care. Anaesthesia 1985; 40:479-482.