Key Point

According to one expert, the future of critical care medicine will be shaped by factors such as radical shifts in diseases treated in the hospital, disruptive technologies and clinical practices, and improvements in operations and staffing both in the ICU and throughout the health care enterprise.

SAN FRANCISCO—At a presentation given during the Society of Critical Care Medicine’s 35th Critical Care Congress, Brian Silverstein, MD, discussed both the current and future challenges facing clinicians in providing care for critically ill patients.¹ Dr. Silverstein is a Vice President at Sg2, a health care research, consulting, and education company in Skokie, Illinois.

CRITICAL CARE TODAY

"In clinical care today, we’re not offering a lot of cures, which creates a situation that puts an inherent strain on our system and presents a lot of challenges," remarked Dr. Silverstein. According to a 2004 survey published by the Society of Critical Care Medicine, the top three issues in critical care today are quality of care, staffing shortages, and bed shortages.

"Capacity over the past couple of years has been growing—hospital capacity, as well as critical care capacity," Dr. Silverstein said. A key question is: Do we need more capacity, or do we need improvements in staffing, technology, and operations? In some cases, "we do not have appropriate staffing on the floor." He explained that a physician who is normally comfortable having a patient monitored on the floor might opt to increase the acuity level of the patient’s care to ensure that the patient is placed in a unit where he or she can receive extra attention. Dr. Silverstein also noted that "85% to 90% of hospitals don’t have 24-hour intensivist coverage.... Only about 40% of patients are getting an intensivist when they’re in the hospital." Staffing shortages do not apply only to intensivists; respiratory therapists, nurses, and pharmacists are in short supply as well. "All of these reasons explain why we’re out of beds today," he said.

Other challenges for clinicians include increased workload, lack of electronic records, non–user-friendly equipment, and distance between lab and pharmacy.

"When you think about those issues today, it might seem as though the solution is simply to add more beds," he said. "However, just adding capacity is likely not the only solution. The true answers are multifactorial and will vary by market. Smart care is going to require new clinical practices and technologies, changes in operations, and creative staffing models."

CRITICAL CARE IN THE FUTURE

Dr. Silverstein asserted that in reality, "we don’t need more beds. I know this sounds fairly controversial, but you should resist the temptation to just add beds." Instead, "think about staffing, technology, clinical practices, and new ways of managing the patient mix.... We’re facing a lot of challenges today, and adding capacity doesn’t necessarily mean adding beds. There are different ways that we can be creative with adding capacity to be able to take care of these patients."

At Sg2, Dr. Silverstein and his colleagues analyze factors that influence critical care, such as population, technology, economics, and social and cultural dynamics. "Using this analytical framework, putting in place both qualitative and quantitative inputs, what we’re able to do ... is come up with outputs that are going to be able to predict what is going to take place," he explained.

According to Dr. Silverstein, the emergence of disruptive technologies—a term coined by Clayton Christensen to describe innovations that eventually overturn existing, dominant technology in the marketplace—will facilitate changes in clinical care. An example of a disruptive technology that has recently become fairly popular in the press is personalized medicine. Dr. Silverstein explained that with the use of personalized medicine, clinicians will be able to determine which patients will benefit from which treatment and at what specific time they will derive the most benefit. Genetic and molecular testing will become a standard of care for treating and preventing illness. "Chronic diseases of today—congestive heart failure, asthma, diabetes—are going to move outside of the hospital. That’s not saying there’s not going to be chronic disease going forward, but the diseases of today won’t be the diseases of tomorrow," said Dr. Silverstein.

He also postulated that the future would yield an increase in multiorgan dysfunction and a reduction in hospital postsurgical care. However, acute trauma will remain somewhat constant, he said.

There are many technologies, procedures, and treatments outside the intensive care unit that will alter clinical practice, said Dr. Silverstein. Examples include minimally invasive procedures, inpatient procedures that are becoming feasible in ambulatory care settings, targeted drugs, disease management, molecular medicine, remote monitoring, and protein-based therapies. There will also be changes in facility design and organizational structure. These changes will not only alter clinical practice but will reduce costs substantially, he said.

"Critical care tomorrow is going to be located everywhere," predicted Dr. Silverstein. "It’s going to be across an enterprise. It’s not going to be in one location." He noted that the EKGuard Remote EKG is an example of how this is already occurring. This FDA-approved device records a full 12-lead EKG and transfers the data through any telephone to a cardiologist. Currently, more than 120,000 people worldwide own this device. The EKGuard Remote EKG system has reduced emergency department business by 30% and decreased time from onset of symptoms to initiation of treatment from four hours to 40 minutes, said Dr. Silverstein. "Everyone knows that time is muscle, and so those patients are getting better care."

THE EVOLUTION OF HEALTH CARE

Dr. Silverstein pointed out that "a lot of what we do today is still reactionary.... We’re still not being proactive." He continued, "It’s hard to imagine a world tomorrow that is going to be different than the world today." However, health care is continually evolving and changing over time. For example, he said, "Think about the world of 1955, with polio, with the iron lungs. At that time, people had a hard time imagining that the world would be different today—yet it is.... The polio vaccine came out, and that vaccine just revolutionized the need for care overnight," though not many people recognized this change until years later. "This example highlights the opportunity that exists in identifying and forecasting health and wellness proactively," he said.

A recent example is the advancement in imaging abilities. Today, "we can see inside the body in ways that were unprecedented years ago," said Dr. Silverstein. "This breakthrough is evidenced by the power of noninvasive coronary angiography and virtual colonoscopy to visualize pathology that, in the past, required invasive diagnostic tests." Views on the use of laparoscopic surgery have changed as well. "Prior to last summer, doing a laparoscopic colectomy for cancer was heresy in most communities. How in the world could you give someone a substandard operation and leave behind disease? The community now knows ... that is a safe and effective surgery," he pointed out.

"It’s hard to imagine how things will be different when we are living the reality of a critical care crisis today," said Dr. Silverstein. He urged health care professionals to take a proactive, comprehensive approach to critical care medicine in the future. "We must look outside as well as inside the ICU to identify opportunities to improve care." Using of improved diagnostics with molecular medicine, utilizing interventions such as CT-guided biopsies and minimally invasive endovascular approaches, and changing operations with tools such as daily checklists "will make a difference in how health care is delivered tomorrow," he said. "There are also many new approaches yet to come. It is incumbent upon each and every member of the health care community to be a vector for change. These are all things that in the future, we’re going to have to think about."

—Karen L. Spittler

Reference
1. Silverstein B. Caring for tomorrow’s critically ill patients. Presented at: Society of Critical Care Medicine’s 35th Critical Care Congress; January 10, 2006; San Francisco, Calif.

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