Corrigendum for Intensive Care Society State of the Art 2017 Abstracts

The below abstracts were missing from Intensive Care Society State of the Art 2017 Abstracts supplement issue 19:2 of Journal of the Intensive Care Society.

Stop! Collaborate and listen …

Zoe Brummell

Abstract

‘Alone we can do so little, together we can do so much’. ¹

Collaborating in healthcare is what the best of us do well and the worst of us don’t do at all. Staff shortages in combination with a growing and ageing population and a rise in chronic disease make the long-term safety and sustainability of intensive care unfeasible. There is no single solution to this increased demand, no single randomised-controlled trial and certainly no single intensivist that will enable intensive care medicine (ICM) to cope with the increased pressures facing us.

ICM requires cooperation, connection, participation and team working.^2–4 As the UK population increases from an estimated 64.6 million in mid-2014 to 74.3 million by mid-2039, we will need to collaborate even more,⁵ not just with other intensivists, physicians, surgeons, nurses, therapists, dieticians and pharmacists within our trusts, but also with others in our regions, our networks, the rest of the country and beyond. How we form these connections and work together needs to be joined up and coordinated. ICM is leading the way with the formation of critical care networks and the formalisation of these into the Critical Care Operational Delivery Networks.⁶ Improving and increasing collaboration further is now easier with the advancement of technology, enabling us to better connect, communicate and share with others.

Critical care networks, ICM units and individual collaboration could be facilitated through the roll out of a secure online networking platform created and maintained by intensivists for all the multi-disciplines working in intensive care. I propose a platform, ‘ICM-SHARE’ (Intensive Care Medicine Sharing Hub for Academia, Research and Education) incorporates many features which will enable us to improve our practice and therefore make ICM more sustainable:

• A forum for meeting other ICM practitioners who can collaborate on projects, offer advice and knowledge to the wider community

• Database of quality improvement projects in progress nationwide

  • ○ Sharing ideas and good practice
  • ○ Audit calendar for ICM Units
• Database of anonymised morbidity and mortality data

  • ○ to improve patient safety by raising awareness and identifying trends early on
  • ○ to share good work and ethical dilemmas around end of life care

• Database of rota gaps within ICM units to raise awareness of the difficulties which we are all facing, alongside successfully utilised strategies to mitigate workforce problems

• Database of proposed and ongoing trials in the UK

  • ○ to enable interested parties to participate and facilitate the recruitment of patients
  • ○ to inform the wider community of both planned and work underway

• ○ Healthcare specific guidelines – doctors, dieticians, therapists, nurses, pharmacists

• ○ Portals to FICM, ICS, RCOA, RCP, SSQD, NELA and ICNARC websites

• ○ Portal to National Critical Care Dashboard and Critical Care bed state

• ○ Portals to Critical Care Operational Delivery Networks

ICM-SHARE will bring us closer, make us stronger and improve standards.⁷ It is through collaboration that we will reduce duplication, improve quality and outcomes, reduce costs and enable us to cope with what stands before us.^3,4

Ban anaesthetists from intensive care

Adam Young

Leeds Teaching Hospitals NHS Trust, UK

Abstract

The Dunning-Kruger effect is a concept in psychology that describes a cognitive bias of illusory superiority. An individual mistakenly overestimates their own ability at a task and cannot recognize their actual ineptitude.

It perfectly describes the anaesthetist in intensive care.

Intensive care has evolved. It is no longer simply a matter of tweaking the physiology, blanket bans on admitting the elderly and the satisfying yet frankly unchallenging insertion of myriad tubes and lines. Good intensive care requires consultants who dedicate their entire career to the speciality and not use it as a prolonged break between theatre cases. The scope of critical illness and the complexity of patients are rapidly growing along with our understanding of what can (and cannot) be achieved with limited resources. We should not be allowing part-timers to look after the sickest and most expensive patients in the hospital.

The history of the speciality is littered with dozens of failed ‘magic bullets’ that promised much but failed to revolutionize patient care. The lesson from these false hopes? Good intensive care comes in the form of marginal gains and paying attention to seemingly minor details. Thousands of journal articles on critical care are published each year.¹ An anaesthetist–intensivist, attempting to manage their ongoing learning in two specialities, cannot hope to keep up. The deficits in their knowledge – while apparently minor – will add up to have significant impact on patient outcomes over time. It takes approximately 17 years for clinical evidence to be fully implemented into clinical practice.² This lag time will only be prolonged if we continue to allow anaesthetists to run our intensive care units.

Given staffing issues, is the idea of intensive care being staffed by pure intensivists sustainable for small units? No. They will have to close. The postcode lottery of patients having access to cutting-edge therapies and being cared for by dedicated intensivists rather than best-guessers will end. The volume-outcome relationship, proven to greatly improve the results of our surgical colleagues, will finally be embraced.³ Large integrated intensive care units will abolish the arbitrary, anaesthetist-driven divisions of ‘neuro ICU’ and ‘cardiac ICU’ along with the pretence that the modern critically ill patient only has a problem with one organ.

Many will disagree with this view. They will argue that, as anaesthetist-intensivists, they add valuable skills to the intensive care unit and have the ability to keep up with the huge volume of research advancing the field. Such is the essence of the Dunning-Kruger effect. Intensive care has evolved; anaesthetist–intensivists are holding the speciality back and harming our patients. In future, anaesthetists should only step foot into the intensive care unit when transporting the perioperative patient.

Overcoming obsolescence

Chris Tomlinson

Abstract

A growing, increasingly comorbid population, living longer and undergoing ever expansive procedures and treatments provides a burgeoning demand for critical care. A demand that can only be expected to increase. As a new and progressive specialty, much has been made of technological advancements in powering our collective ability to cope with such challenges.

With big data analytics and artificial intelligence already providing the minority report-esque ability to predict crime ‘before it happens’, one can imagine it will be not long until these technologies are re-purposed, providing advanced Early Warning Systems and illness modelling. Breaking down institutional boundaries, uniting hospitals, regions, even entire countries, serves to create a pool of data infinitely surpassing the darkest recesses of even the most experienced professor’s mind. Each and every intervention becomes a trial, constantly refining the predictive capabilities of the AI system.

Such developments may provide coping strategies on a system level – but what about for individual doctors? With AI able to predict when (or perhaps more pertinently, when not) to intervene, with what intervention and in whom, one may begin to question what will be the role for the intensivists of the future?

Acute proceduralists inserting lines, performing scans and managing airways? Perhaps roles that could be better served by dedicated technicians, other specialties, or the growing number of Advanced Critical Care Practitioners? Data gatherers and sign hunters meticulously taking histories and elucidating examination findings only to present them to an online data collection form? Perhaps as diplomats, updating patients and relatives, translating the system’s probabilistic prognoses into plain English and providing that often cited ‘human touch’?

Undoubtedly these elements are all encompassed within the intensivist’s current role, providing their own synergistic satisfaction. It is hard to imagine that they would have the same appeal when performed in isolation, with integrative decision-making surrendered to the system. Clearly, then, our role must be updated and redefined, abreast of technological advances.

In such an exciting era of change, rhetoric ought not to centre on the adequacy of coping, but have more aspirational aims of capitalising on opportunities to thrive. Engagement in the process of progression, be it through research, at an organisational level, through education or diversification and sub-specialisation, could allow us to seize control of our professional destiny and create a system in which we not only cope, but may thrive.

I’m an elective post-surgical patient – Get me out of here!

P Nandhabalan

Abstract

Elective surgery is increasingly offered to an ageing population with extensive co-morbidities and rising expectations. Consequently, utilisation of post-operative critical care has increased dramatically; patients undergoing elective surgery now account for 34% of all admissions to critical care.¹ This burden likely extends further in terms of critical care bed occupancy and exacerbates existing deficiencies in staffing and capacity.

The rationale is simple. The patient is admitted to critical care after high-risk surgery and undergoes extensive assessment by an ICU doctor followed by a consultant intensivist. Organ support is provided where needed, resuscitation is optimised with flow-guided fluid and inotrope therapy. The patient is regularly reviewed over several days, with any physiological disturbance rapidly detected and remedied. Consequently, they are prevented from developing a myriad of complications that would otherwise cause significant morbidity. However, reality paints a different picture. The patient arrives in ICU at the busiest time of the day, and is seen by the most junior team member. If fortunate, they are eye-balled briefly by a consultant intensivist. Overnight, any vasopressor support is weaned off as rapidly as blood pressure permits. Fluid boluses are given to correct hypotension or oliguria. Following a brief review in the morning, their discharge to the ward is expedited in order to free up beds for the next elective surgical admission later on.

How does this help? Post-operative complications rarely occur within the first 24 h. Furthermore, the ability of critical care interventions to prevent such complications is unclear; even goal-directed therapy has demonstrated inconsistent results. Perhaps this may explain why several large observational studies have failed to identify a survival benefit from routine critical care admission following high-risk elective surgery.^2–4 While such studies may suffer methodological weaknesses, the recurrent theme challenging our current practice cannot simply be ignored.

In addition, there are several ethical issues to consider. The ICU is a precious resource where demand already exceeds capacity. To prioritise a clinically stable patient over one who has already suffered, an acute pathophysiological insult appears morally questionable. Few would argue that the greatest resources should be reserved for those with the greatest need. Every day, intensive care physicians are asked to balance the needs of acutely unwell patients referred for critical care admission, those patients who may be suitable for discharge from ICU, and those scheduled for elective surgery with planned post-operative admission. Delayed admission to critical care is associated with considerable morbidity and mortality.⁵ Premature discharge from critical care puts the patient at risk of deterioration. And there is significant harm from cancelling operations and delaying treatment for those patients who cannot be accommodated due to bed capacity.

It is standard practice to separate emergency and elective treatment – such that one fails to adversely impact the other. Yet where the stakes are highest and the patients are sickest, we abandon these principles and risk compromising the interests of those most vulnerable. The ICU of the future has no place for the elective post-surgical patient. It’s time to get them out of here.

A new paradigm for ICU care: Taking the intubated patient to the wards

Elspeth J Hulse

Royal Infirmary of Edinburgh, Edinburgh, UK

Abstract

There are simply not enough beds on ICU for all the people that require them. Increasing ICU bed numbers requires more money, real estate, infrastructure and staff. I believe that the answer is to re-define ICU care into ICU light (ICU-L) and ICU heavy (ICU-H) care packages.

The concept of ‘light’ and ‘heavy’ capability comes from the military and defines the amount of equipment and staff a team take into the area to which they are deploying. This concept could be applied to NHS ICU care with the creation of a two-tiered ICU capability within the hospital. ICU-H would offer traditional ICU care with all organ support in the ICU, while ICU-L would be leaner and available elsewhere in the hospital.

ICU-L beds would have one-to-one nurse care and involve heart and lung support only with an agreed ceiling of care. Treatments available would include: intubation and ventilation, invasive blood pressure monitoring with vasopressor support, central venous access, pneumonia prevention strategies, antibiotics and thrombosis prophylaxis. Exclusion criteria would include invasive renal support, escalating cardiac (e.g. inotropes), or respiratory (e.g. ECMO) support.

Crucially, these ICU-L beds would be available outside the ICU. Suitable areas might include level 1 areas in medicine, surgical, emergency department and geriatric wards. ICU-L beds would only give care for up to 72 h at which point the decision to de-escalate care or transfer to an ICU-H bed would be made.

Patients that might benefit from this service would include those suffering from drug overdose, alcohol excess, post-seizure and simple surgical cases that may require overnight ventilation (e.g. laparotomy). The elderly population might also benefit from the availability of ICU-L beds. Some elderly patients may be declined an ICU bed based on their age and co-morbidities. This approach offers an ICU bed but with restrictions and a clearly defined exit strategy for the patient’s care.

Who is going to look after these ICU-L patients? The on-call ICU/HDU consultant would have outreach input and perform daily ward rounds for these ICU-L patients. Airway emergencies such as unexpected extubations could be managed by the on-call anaesthetic or ICU registrar. Many ICUs don’t have an intensivist consultant in their unit overnight and yet patient care is not diminished.¹ Advanced ICU nurse practitioners are also finding their place within the ICU and could ‘run’ these ICU-L beds overnight providing care, decision making and arterial and central venous access expertise if required.²

The funding for these extra ICU-L beds, equipment and nurses could come from the money saved by not admitting patients to ICU-H beds.

The ICU-L bed concept is one which will test the current doctrine on how ICU patients should be cared for, but it is a solution which could free up ICU-H beds for those who really need them. Gone are the days where level 3 care is confined to the ICU. The concept of critical care must evolve if we are to adapt to the nation’s ageing demographic and forecasted medical requirements.