By Doug Kaufman, MD Consult, August 30, 2006

With an aging population, planning is crucial to handle the increased demand on critical care units, according to a trauma expert.

"Critical care has saved and extended the lives of a very large number of people," said Dr Timothy Buchman, chief of burn, trauma, and surgical critical care at Washington University School of Medicine in St. Louis. "As our populations nationally and internationally age, and as [these] populations become progressively more ill, the demand on critical care services is going to continue to rise. It will probably rise faster than we can build additional ICUs [intensive care units] or train additional personnel."

Dr Buchman, who also serves as medical director of the trauma center at Barnes-Jewish Hospital in St. Louis, said a proactive approach is necessary.

"It is going to be incumbent on all of us, as health care professionals, to deploy and use critical care resources as wisely as we can," he said.

Dr Buchman''s recommendations include the following:

"First, it means that the right patients get to the ICU," he said. "That means patients who truly do have an illness that will benefit from critical care. In general, that means a patient with an acute and potentially reversible problem. It generally means that we should consider how we use critical care resources on behalf of patients who stand to benefit less.

"Either those patients who simply need high-intensity monitoring, or alternatively, those patients whose illness is so far advanced that critical care cannot return them to a state of health."

"The second thing I think is important for health care professionals to grasp is the importance of providing critical care as effectively and efficiently as we can. For patients to benefit from critical care, it''s important that we identify the life-threatening processes, stabilize them as quickly as possible, and prevent further complications that can occur in the critical care environment—such as catheter-related infections, ventilator-associated pneumonias, pulmonary emboli.

"The point being that we in the critical care environment have just as strong a stake in patient safety as any other realm in healthcare, perhaps more so, because of the highly technical and highly invasive nature of critical care."

Critical care is crucial to a hospital''s success in dealing with an aging population, Dr Buchman said.

"It increasingly is going to become the core of what the hospital does as the nation ages and accumulates more and more illnesses," he said.

Dr Buchman compared the need for an efficient critical care unit with a healthy person who lifts weights to build up the arms, legs, and chest while neglecting the core.

"If the muscles of the core and trunk can''t support the rest of the activity, none of that focused muscle development does any good," he said. "Similarly, as we transition from hospitals being more or less acute care of otherwise healthy people to seeing increasing numbers of older and sicker patients, the critical care activities are going to move more and more to center stage as the core of the hospital activity. We will need ICUs to help manage trauma care in an increasingly older population that is more frail.

"We are going to need critical care to help support advanced operations and advanced non-operative but highly technical care such as chemotherapy for cancer. We are going to need critical care to continue to care for patients who must remain in the hospital, while a lot of traditional hospital care gets migrated out to either skilled nursing facilities, or even into the home," he said. "... One solution to managing the aging population is to ask families to become more and more involved in the care of their loved ones."

Older patients can be cared for at home, in an environment they find most comfortable, he said.

"The consequence of taking those relatively simpler problems out of the hospital is that you concentrate more complicated and acute problems inside the hospital," Dr Buchman said. "That requires, de facto, the hospital to have more critical care as its core activity."

Intensivists—specialists in critical care medicine—are playing a bigger role in seeing the whole picture.

The goal of critical care is to "deliver the right care, right now," Dr Buchman said. "Generally we''re talking about really sick folks with not one, but a whole series of problems. All of which have to be managed in parallel, understanding that each of the treatments probably affects more than one body system."

Each of the treatments also involves a trade-off, he said.

"There is no such thing as a treatment that is only good, and is good generally, for the entire patient and every body system. Every time we do something that tries to help a patient heal, there is at least the potential for adverse effects," Dr Buchman said. "It''s important that there be someone who is the patient''s advocate, who is looking at the entire patient as a whole, as these multiple parallel problems and multiple parallel treatments are being applied and managed.

"The persons who are in the best position to manage these multiple parallel processes are the intensive care physician and the intensive care nurse," he said. "Each of these individuals has received basic training in medical and nursing skills. Each of them has received additional training and certification in the management of this complex physiologic process and intervention that we call critical care."

In the past, the traditional model involved a nurse assigned to the ICU and a doctor who came in for short periods each day to check on ICU patients.

"The aging and complexity of the population now demands that we have people who are really focused on managing the collection of problems as a whole," Dr Buchman said.

This means, he continued, "that the right care—meaning the care that will do the greatest good for the greatest number of systems—can be delivered right now when it''s needed, rather than 6 hours, or 2 days from now, when the patient has further deteriorated. So the core idea is that we have a geographically dedicated team ... who are focused on the patient as a whole."

None of which actually cures the patient, he said.

"What we do in the intensive care unit is to set the stage for healing," he said. "To try to give the patient protected space—for example, unloading the lungs by means of a mechanical ventilator. And adequate time to emerge from their current illness—which typically requires a lot of life and systems support—to a point where they can get along on their own."

Nationwide, there is a growing awareness of the need to offer top-notch critical care.

"Hospital communities are truly aware of the importance of high-quality critical care as a key component of any acute care hospital," Dr Buchman said. "They are trying to find different solutions that are best suited to local needs. In a large teaching hospital such as Barnes-Jewish Hospital, there has been a turn toward full-time intensive care physicians.

"In some smaller, more rural hospitals, great advances are being made with remote critical care using electronic ICUs that allows local providers the support of expert intensive care physicians and intensive care nurses who can monitor the patient''s ... physiologic systems and medical conditions and provide 24-by-7 advice and support."

The support system appears to be solid, with good growth potential.

"We are seeing a proliferation of advance practice nurses who are receiving additional training in acute and critical care to try to support the population of physicians and critical care nurses that presently exists," he said. "So I think it''s fair to say that all of our partners in health—the administrators of the nation''s hospitals—recognize the need to provide round-the-clock high-quality critical care services. They are all trying to meet the challenge, in the context of local needs, with a wide variety of resources and solutions."

Still, Dr Buchman and other experts foresee a "significant shortfall" of physicians to staff critical care facilities. A joint effort will be necessary among health care providers to ensure the availability of critical care services.

"To be direct, [patients] lives may depend on it," he said.