Think outside the ICU, physician leader urges

Sick ICU patients outnumber the people allocated to care for them, notes J. Christopher Farmer, MD, FACP.

New Society of Critical Care Medicine (SCCM) president J. Christopher Farmer, MD, FACP, urged his colleagues to think beyond the ICU in caring for patients, and to have an open mind about clinicians from other disciplines providing critical care, in a speech at the SCCM Annual Congress in San Francisco in January.

“Yes, we still need ICUs. Yes, we still need to cluster the sickest patients around our teams with advanced, highly developed critical care skill sets,” said Dr. Farmer, professor and chair of the department of critical care medicine at the Mayo Clinic in Scottsdale, Ariz. “But...our future is bigger than the ICU.”

One of the biggest challenges now facing critical care physicians is that sick ICU patients outnumber the people allocated to care for them, Dr. Farmer said. The solution isn't to build more ICU beds and staff them with traditional critical care teams; it is to ensure other clinicians are trained to provide quality care for critical care patients, he said.

“Many U.S. hospital-based providers who are not formally trained in critical care provide a large volume of critical care services today and every day. Given these realities, how should we define and measure our critical care competencies?” Dr. Farmer said.

Another challenge is ensuring someone in each facility takes the role of “critical care band director”—i.e., takes responsibility for linking team members from different disciplines, Dr. Farmer said.

“Primary care physicians, nonhospital providers, even family members and the patients themselves: how do we ensure that these vital people are fully integrated team members as well?” he said.

Critical care physicians also must increasingly involve themselves in prevention, Dr. Farmer noted.

“Critical care prevention is not just for patients peering into the abyss; this is not just-in-time rescue. In fact, these responsibilities extend well beyond our current concepts of rapid response teams and the like. Some of these patients are right under our noses in our ICUs. They have delirium, they are weak, they are bedbound. Other patients who need critical care prevention are not in an ICU; in fact, some are not even in the hospital—patients at risk of deterioration, patients predisposed to sepsis or other catastrophic conditions. Some patients have these predilections encoded in their genes. Others teeter precariously every day with multiple disease comorbidities and chronic critical illness,” Dr. Farmer said. “How do we actively help to sustain their tenuous equilibrium and prevent the need for ICU readmission?”

The society president also warned his colleagues about the mentality of “building works of art” in the ICU, where the most complex patients are seen as masterpiece paintings that require enormous resources and individualized attention.

“All of our [patients] are resource intensive. [But some] patients would benefit from us powerfully shifting our focus away from unique creativity and more to predictability. So what are the boundaries between individualized masterpiece care provided by a team of many and predictable high-reliability care provided efficiently and with fewer resources?,” Dr. Farmer said.

To address these and other issues in critical care practice, physicians and facilities need to be willing to tear down walls between disciplines, Dr. Farmer noted. “Critical care must work across boundaries,” he said. “This is our inflection point.”