Philosophy of care, decision making, and ethical considerations

The very nature of critical care opens the door to controversy, for it is in the intensive care unit that staggering amounts of money and human resources are expended. The outcome is frequently suboptimal, and the feeling often persists that our patients, who should be the beneficiaries of our efforts, are paying a tremendous price in the form of isolation from loved ones, life-support systems that do not allow them to communicate with their families or caretakers, and the physical pain of multisystem failure. As Carlon has recently asked, are we allocating our limited resources inappropriately because we are unable to select patients who will not survive despite our intensive care units? This concern may be justified. However, the work we do in the intensive care unit has another, more positive intangible result. Many of the breakthroughs in medicine have been achieved by dedicated pioneers who tried to accomplish something that had not been accomplished before. At first their efforts were often challenged as being useless or overly extravagant or were even opposed as a violation of God's will or the laws of nature. Developing new forms of treatment, some of which can only be tested in an intensive care unit, is a challenge for all of us. We must, of course, balance what we are trying to accomplish with what we spend, since too much as well as too little emphasis on new techniques is suboptimal. If we persevere, some of what we find impossible to achieve today will become possible tomorrow, will become the norm of the future, and will, we hope, give way to still better innovations as medicine continues to evolve.     

Bilateral anterior superior iliac spine pressure ulcers: a case report

The most frequent sites for pressure ulcers are the occiput, sacrum, ischial tuberosities, trochanters, lateral malleoli, and posterior heels. A 27-year-old woman with Wegener's granulomatosis was admitted to our rehabilitation unit after spending 65 days in an intensive care unit and 40 days in an internal medicine ward. She required mechanical ventilation because of respiratory failure. Adequate oxygenation was only achieved in the prone position. As a result, she developed bilateral anterior superior iliac spine pressure ulcers. Pressure ulcers in this location have not been reported in the literature. Complicating factors included variable levels of oxygenation, malnutrition, anemia, and steroid therapy. Complete healing, documented with serial photographs, occurred over 9 months. Although prone positioning can improve pulmonary gas exchange, it exposes the patient to unique complications. When it is required, specific care should be directed to the unusual weight-bearing surfaces to avoid pressure ulcers.     

Telemedicine: a new dimension in the practice of medicine.

Telemedicine has drawn increasing attention as one of the emerging service delivery vehicles running on the information highway. Until recently, the adoption of telemedicine has been discouraged by the cost of telecommunications and equipment and by the lack of infrastructure, standards, and evidence of cost-effectiveness and cultural acceptance. Although there have been attempts to reduce costs by making use of computer communication networks, they were technically limited by slow network speed and the lack of real-time audio/video compression technology. Ongoing technologic advances in telecommunications, imaging, multimedia computers, and information systems are making interactive telemedicine increasingly possible as high-speed video, voice, and data services are brought to large segments of the general population. The current synergy between health reform initiatives, which are redefining how health care services are accessed and delivered, and advances in technologies that support telemedicine has resulted in a proliferation of telemedicine projects. However, there is still no proof that telemedicine is necessarily cost-effective for a broad set of applications. Each prospective application requires its own business case analysis. Within the current environment, the development of a telemedicine strategy should be based on a sound knowledge of the current and future potential of telemedicine to improve health care access and quality while containing and possibly reducing health care costs.     

Year in review 2006: Critical Care--Resource management

As health care resources become increasingly constrained, it is imperative that intensive care unit resources be optimized. In the years to come, a number of challenges to intensive care medicine will need to be addressed as society changes. Last year's Critical Care papers provided us with a number of interesting and highly accessed original papers dealing with health care resources. The information yielded by these studies can help us to deal with issues such as prognostication, early detection and treatment of delirium, prevention of medical errors and use of radiology resources in critically ill patients. Finally, several aspects of scientific research in critically ill patients were investigated, focusing on the possibility of obtaining informed consent and recall of having given informed consent.     

Communication skills and error in the intensive care unit

PURPOSE OF REVIEW: Poor communication in critical care teams has been frequently shown as a contributing factor to adverse events. There is now a strong emphasis on identifying the communication skills that can contribute to, or protect against, preventable medical errors. This review considers communication research recently conducted in the intensive care unit and other acute domains. RECENT FINDINGS: Error studies in the intensive care unit have shown good communication to be crucial for ensuring patient safety. Interventions to improve communication in the intensive care unit have resulted in reduced reports of adverse events, and simulated emergency scenarios have shown effective communication to be correlated with improved technical performance. In other medical domains where communication is crucial for safety, the relationship between communication skills and error has been examined more closely, with highly detailed teamwork assessment tools being developed. SUMMARY: Critical care teams perform many activities where effective communication is crucial for ensuring patient safety and reducing susceptibility to error. To develop valid team training and assessment tools for improving teamwork in the intensive care unit there is a requirement to better understand and identify the specific communication skills important for safety during the provision of intensive care medicine.     

Year in review 2006: Critical Care – resource management

As health care resources become increasingly constrained, it is imperative that intensive care unit resources be optimized. In the years to come, a number of challenges to intensive care medicine will need to be addressed as society changes. Last year's Critical Care papers provided us with a number of interesting and highly accessed original papers dealing with health care resources. The information yielded by these studies can help us to deal with issues such as prognostication, early detection and treatment of delirium, prevention of medical errors and use of radiology resources in critically ill patients. Finally, several aspects of scientific research in critically ill patients were investigated, focusing on the possibility of obtaining informed consent and recall of having given informed consent.     

La réanimation dans les systèmes de santé à ressources limitées : expérience d’une coopération francopakistanaise en réanimation

Intensive care medicine is poorly recognized as a medical specialty in resource limited health sytems. Between 2000 and 2010 a French-Pakistani cooperation program in intensive care medicine was launched between the Pakistan Institute of Medical Sciences (Islamabad teaching Hospital, PIMS) and the medical intensive care unit (MICU) of Saint Antoine hospital in Paris. It allows understanding the different challenges created in Pakistan by patients requiring intensive care, the weaknesses of the public health system and the slow uprise of this medical specialty. The sociocultural context is an important factor to explain the failures and successes of this program. The interventions focused on the creation of a 9-bed medical intensive care unit organized in a closed system with a dedicated team, the advocacy for recognition of intensive care medicine as a medical specialty, the creation of one formal training program and writing of a medical department project submitted to the health ministry. Sustainability of the results achieved by this cooperation program is questionable, but we obtained the recognition of intensive care medicine as a medical specialty and young doctors are now joining specific training programs. In 2014, the MICU of PIMS still works as a closed unit.     

Telecardiology and the intensive care unit.

Technology continues to advance at a pace that produces a new innovation daily. To move forward, clinicians must assess these potential technological solutions adequately for their clinical, financial, and customer satisfaction efficacies. Whether the payers, the patients, or health care will find these systems acceptable has yet to be established completely. The preliminary data in the literature seem to point to physicians' trepidations as the limiting factor. More work is needed on the legal and ethical issues surrounding telemedicine. Telemedicine is progressing quickly from a strange rare subtype of medicine into something that is part and parcel of the practice of medicine in general. Cardiology and intensivist practices have been impacted directly by this technology. As it matures it will be intertwined with daily practice.     

Telemedicine: evolving technology in an e-health care world

This article provides an overview of telemedicine and its expanding capabilities to deliver health care services. Clinical applications, including home care, continue to evolve and expand as the technology improves and the experience of telemedicine service providers grows. As an emerging technology in a changing health care environment, implementation of telemedicine is not without its challenges. The future of telemedicine will be impacted by the emerging emphasis on e-health care.     

Family-physician interactions in the intensive care unit

Surrogate designation has the potential to represent the patient's wishes and promote successful family involvement in decision making when options exist as to the patient's medical management. In recent years, intensive care unit physicians and nurses have promoted family-centered care on the basis that adequate and effective communication with family members is the key to substitute decision making, thereby protecting patient autonomy. The two-step model for the family-physician relationship in the intensive care unit including early and effective provision of information to the family followed by family input into decision making is described as well as specific needs of the family members of dying patients. A research agenda is outlined for further investigating the family-physician relationship in the intensive care unit. This agenda includes a) improvement of communication skills for health care workers; b) research in the area of information and communication; c) interventions in non-intensive care unit areas to promote programs for teaching communication skills to all members of the medical profession; d) research on potential conflict between medical best interest and the ethics of autonomy; and e) publicity to enhance society's interest in advance care planning and surrogate designation amplified by debate in the media and other sounding boards. These studies should focus both on families and on intensive care unit workers. Assessments of postintervention outcomes in family members would provide insights into how well family-centered care matches family expectations and protects families from distress, not only during the intensive care unit stay but also during the ensuing weeks and months.     

Long-term follow-up of ICU patients.

Critical care medicine programs must provide outpatient experience for their fellowship trainees. We have developed an unusual follow-up plan allowing critical care fellows to contact their patients months after their intensive care unit stay. We evaluated responses of 46 patients after a mean interval of 8.6 months since their initial intensive care unit stay. Patients were stratified by severity of disease by using the APACHE scoring system. Diagnostically, the patients represented the typical medical-surgical intensive care unit population. Patients were asked 11 questions concerning their health and socio-emotional status as it related to their hospitalization and intensive care unit stay. Our results established a practical method of providing outpatient follow-up that may fulfill residency review requirements for critical care fellowships, confirmed previously speculative ideas about ICU experiences, and suggested future research opportunities to study intensive care unit patients following discharge.     

Strategic Procedures and Revisions for implementing Telemedicine and Telecare in Greece

The development of telemedicine and telecare has been changed all over the world the recent decades as practitioners and health care managers reached better understanding of the use of information and communication technologies to offer urgent and qualified medical services at a distance. Governments and health care providers have shown a large initial interest in the benefits of telemedicine services to reduce costs mostly for patient’s transfer to tertiary hospitals or for educational purposes but have been slow to provide strategic plans and procedures in order to proceed the projects into practice.The paper identifies the involvement of governments, healthcare management, healthcare professionals and IT suppliers in telemedicine policy development and reviews the experience of Greece in the specific field which seems that despite the enormous scientific interest for both medicine and health informatics, the practice until now has not gained the expected results. Furthermore, the analysis concerns the critical success factors that have to be revised simultaneously with the main managerial principles for the design and implementation of quality telemedicine and telecare services.     

Telemedicine and trauma care

Advances in technology have made it possible for telemedicine to be used in multiple areas of medicine, including trauma care. Teleradiology and teleconsultation are becoming standard operating procedure for many rural facilities. Future uses of telemedicine include teleproctoring and telepresence surgery. The medicolegal and financial impact of telemedicine remains to be determined. The potential influence of telemedicine in the care of future trauma patients will likely be important and may alter patterns of referral, consultation, and treatment.     

Telemedicine and Team-Based Care: The Perils and the Promise

The COVID-19 pandemic accelerated adoption of telemedicine visits into American medicine. It is commonly believed that, within a matter of weeks, telemedicine was widely and successfully implemented and that medicine is forever changed. The experience on the ground, however, is more nuanced, with both positive and negative experiences for patients and clinicians. Advanced models of team-based care with in-room support (aTBC) have developed over the past decade, with strategic delegation of tasks to uptrained support staff, allowing physicians to provide undivided attention to their patients and greater access to care for their populations. Herein, we describe our initial experiences with telemedicine in the context of many years practicing in aTBC models. Our experience demonstrates that when implementing telemedicine visits, it is important to avoid a reflex reversion to the outmoded model of the physician alone in the room with the patient and instead bring forth the safety, quality, and satisfaction advantages associated with aTBC. We provide a practical “how-to” guide for implementing telemedicine visits; outline logistical details of representative video and audio visits from our own practices; describe new opportunities for family engagement, care coordination, and comanagement across specialties; and outline a research agenda going forward to further knowledge of the risks and benefits and optimal application of health care on a telemedicine platform.     

End-of-life care in the critically ill geriatric population

As the geriatric population in the United States increases and better management of chronic diseases improves survival, more elderly will become critically ill and potentially require treatment in an intensive care unit (ICU). Dan Callahan has written, "... we will live longer lives, be better sustained by medical care, in return for which our deaths in old age are more likely to be drawn out and wild." Although no health care provider hopes for a drawn out and wild death for elderly patients, many geriatric persons will succumb to disease and die after having chosen and received ICU care. Recent data suggest that, on average, 11% of Medicare recipients spend more that 7 days in the ICU within 6 months before death.     

Clinician statements and family satisfaction with family conferences in the intensive care unit

OBJECTIVES: The quality of family-clinician communication in the intensive care unit is often inadequate, but little is known about specific clinician communication behaviors that might improve family satisfaction. In this exploratory analysis, we hypothesized that clinicians' communication behaviors providing emotional support to families during intensive care unit conferences would be associated with increased family satisfaction. DESIGN: We audiotaped 51 intensive care unit family conferences in which withholding or withdrawing life support was discussed or bad news was delivered. Emotional support techniques used by clinicians during each conference were identified and coded using grounded theory. SETTING: Four Seattle hospitals. SUBJECTS: Family members of critically ill patients. INTERVENTIONS: Questionnaires rating satisfaction with communication were completed by 169 family members. MEASUREMENTS AND MAIN RESULTS: Linear regression with generalized estimating equation methods was used to analyze the association between the frequency of clinicians' emotionally supportive statements and family satisfaction. Increasing frequency of three types of clinicians' statements during family conferences was associated with increased family satisfaction: a) assurances that the patient will not be abandoned before death (p=.015); b) assurances that the patient will be comfortable and will not suffer (p=.029); and c) support for family's decisions about end- of-life care, including support for family's decision to withdraw or not to withdraw life-support (p=.005). CONCLUSIONS: Most family members participating in this study were quite satisfied with the communication in the family conferences. Specific clinician communication behaviors are associated with increased family satisfaction during family conferences among family members who are willing to have a family conference recorded. Our results suggest that clinicians in the intensive care unit may improve the experiences of families of critically ill patients by providing explicit support for decisions made by a family with regard to end-of-life care and by assuring families continuity of high-quality care with particular attention to the patient's comfort.     

Care at the end of life in critically ill patients: the European perspective

PURPOSE OF REVIEW: Care surrounding end-of-life has become a major topic in the intensive care medicine literature. Cultural and regional variations are associated with transatlantic debates about decisions to forego life-sustaining therapies and lead to recent international statements. The aim of this review is to provide insight into the decisions to forego life sustaining therapies and end-of-life care in Europe. RECENT FINDINGS: Although decisions to forego life-sustaining therapies are increasingly made in European countries, frequency and characteristics of end-of-life care are still heterogeneous. Moreover, even though many determinants of these variations have been identified, epidemiologic and interventional studies still provide additional information. In agreement with public opinions, recent European laws have emphasized the patient's autonomy. In real life, advance care planning is rarely used. Decisions are often made by caregivers (physicians and nurses) or families, these latter being less involved than in North America. Not only ethic divergences between physicians but also cultural variations account for this disparity. SUMMARY: To optimize end-of-life care in the intensive care unit, there is an urgent need for the development of palliative and multidisciplinary care in Europe. Furthermore, it highlights the need for culturally competent care, adapted to needs and values of every single patient and family. In addition, a lack of communication with families and within the medical team, an uninformed public about end-of-life issues, and insufficient training of intensive care unit staff are crucial barriers to end-of-life care development. Special awareness of professionals and innovative research are needed to promote a high-standard of end-of-life care in the intensive care unit.     

Relocating an intensive care unit: An exploratory qualitative study

BackgroundAs new hospitals are built to replace old and ageing facilities, intensive care units are being constructed with single patient rooms rather than open plan environments. While single rooms may limit hospital infections and promote patient privacy, their effect on patient safety and work processes in the intensive care unit requires greater understanding. Strategies to manage changes to a different physical environment are also unknown.ObjectivesThis study aimed to identify challenges and issues as perceived by staff related to relocating to a geographically and structurally new intensive care unit.MethodsThis exploratory ethnographic study, underpinned by Donabedian's structure, process and outcome framework, was conducted in an Australian tertiary hospital intensive care unit. A total of 55 participants including nurses, doctors, allied health professionals, and support staff participated in the study. We conducted 12 semi-structured focus group and eight individual interviews, and reviewed the hospital's documents specific to the relocation. After sorting the data deductively into structure, process and outcome domains, the data were then analysed inductively to identify themes.FindingsThree themes emerged: understanding of the relocation plan, preparing for the uncertainties and vulnerabilities of a new work environment, and acknowledging the need for change and engaging in the relocation process.Discussion and conclusionsA systematic change management strategy, dedicated change leadership and expertise, and an effective communication strategy are important factors to be considered in managing ICU relocation. Uncertainty and staff anxiety related to the relocation must be considered and supports put in place for a smooth transition. Work processes and model of care that are suited to the new single room environment should be developed, and patient safety issues in the single room setting should be considered and monitored. Future studies on managing multidisciplinary work processes during intensive care unit relocation will add to the learnings we report here.     

Avian Influenza: Are We Ready?

We cannot be certain when the next influenza pandemic will emerge, or even whether it will be caused by avian influenza (H5N1) or some unrelated virus. However, we can be certain that an influenza pandemic will occur. The United States is leading the scientific effort to contain the pandemic through vaccine studies and antiviral studies. The need for pandemic influenza preparedness is extensive and expensive. Planning entails increased development of antivirals and vaccines, effective surveillance systems not only for people, but in agriculture, effective communication systems, plans to continue essential services, identification of health care priorities, and thorough guidelines for care. Critical care nurses, as well as all health care professionals, need to consider where their personal and professional obligations meet and end. There should already be discussions of contingency plan of the institution in which they are employed and the community in which they live. Additionally, a personal plan for their families with regard to economics, safety, and optimizing personal health outcomes during such a crisis should be considered. As many have said, "It is not a matter of if, but rather of when." Although the pandemic might not be the avian flu, history has taught us that pandemics surface with little warning and can have devastating effects on human lives, and can over tax the already fragile health care system.     

How to Develop a Tele-ICU Model?

The concept of the tele-ICU (intensive care unit) is about 30 years old and more hospitals are utilizing it to cover multiple hospitals in their system or for hospitals that lack on-site critical care coverage such as in the rural setting. Doing a needs analysis, picking the appropriate committee to oversee development of the correct model, choosing quality metrics to measure, and designing an implementation plan that has a timeline is how the process should begin. Research including visitation to established programs and connecting with professional societies are helpful. Developing both a business and financial plan will optimize the value of a tele-ICU program. The innovative ICU nursing director will help to integrate a telemedicine program seamlessly with the on-site program to insure a successful program that benefits patients, their families, the ICU staff, and the hospital.