The Increased Use of the ICU

We are using our ICU's more often than we have in the past, according to a new study. As published in the Academy of Emergency Medicine, George Washington University researchers found a 50 percent increase in Intensive Care Unit admissions between 2002 and 2009. 

As the patient's get older, we are utilizing intensive care more often. The group with the largest jump in ICU admission was those over the age of 85 years. That isn't likely to surprise, given the aging population in the United States.

Yet, the recent study that highlights an increase in hospice admissions only after intensive  and expensive ICU care in the last few days of life highlights the fact that we are still aggressively treating patients in the last chapter of their lives. That Journal of the American Medical Association study appeared with an editorial calling for an end to aggressive hospitalization in end of life care by increasing planning and communication between patients, families and doctors prior those final days. 

The article also notes that patient's also spent up to 5 hours in the Emergency Department waiting to get into the ICU. 

 "Studies have shown that the longer ICU patients stay in the emergency department, the more likely they are to die in the hospital," Pines said. "Better coordination between the emergency department and ICU staff might help speed transfers and prevent complications caused by long emergency department waits," he said.

Ummmmm ... I don't think it is interdepartmental coordination and ED wait time that is increasing these critically ill patient's mortality rate. Might have something to do with the fact that they are sick. 

Patient's are often stabilized the ED prior to transfer to the unit. Often times our ICU won't even take the patient until they are stable for transfer, have all their drips hanging and they have a tube in every orifice. Moreover, with increased admissions, there are increased demands on staffing the ICU. We retain core staffing in the Emergency Department even when our census is low because our patient population in the Emergency Department can change in a heartbeat. Many times we've seen the ER go from empty to full in just a matter of minutes. 

ICU's however, often call off staff when their population is low. Therefore, we are often waiting for a nurse to come in to take our patient. That doesn't mean that there couldn't be better coordination between the Emergency Department and the ICU. Those two departments attract very different personality types.

However, I doubt that lack of coordination between the ICU and the ED that is the primary reason for the increased mortality of patient's needing intensive care in the last years of their life. It may have more to do with the need for better communication between providers and patients and families before those days arrive. 

Damage Control - Keep Them From Sinking

When it comes to major trauma, often the role of the trauma team is Damage Control.

We are not attempting to fix all the problems a patient has at the time of presentation -- we may not even have time to identify all the damage suffered -- our primary goal is to stabilize the patient to allow for difinative treatment down the road.

"The concept of Damage Control came from the Navy," explained Dr. John Mayberry. "The idea was to keep a ship in combat from sinking, not to try and make all the repairs needed, just to try and get out of open water and get to port." Once safe at port, full repairs can be initiated.

This concept has long applied to trauma as well. Our job is to get the patient out of open water (the emergency department) and into port (the ICU) without sinking.

At last week's Northwest States Trauma Conference, two different approaches to damage control were presented. Mayberry - a professor of surgery at Oregon Health Science University - looked at 30 years of applying the damage control model to open abdominal wounds.  When a patient comes complex abdominal injuries and blood loss, they are often not stable enough to withstand the additional stresses of a long surgical proceedure to address every point of injury.

"Instead of definitive repair of multiple intra-abdominal injuries, the focus of damage control laparotomy is rapid control of hemorrhage, restitution of vital organ blood flow with temporary shunts, and closure of hollow viscus lacerations without anastomosis."

If major bleeding is the overriding problem, skin or fascia is closed tightly to produce tamponade. However, when tamponade  of bleeding is not vital, the belly is left open and and a Temporary Abdominal Closure (TAC) is used. As the patient is stabilized a series of operations are performed to repair injuries and remove packing, slowly closing the abdomen while attempting to avoid Intra-Abdominal Hypertension, he explained.

Temporary closure -- whether it be with a the good old Bogata Bag or the increasingly popular vacuum packs -- seems to yield good outcomes as far as recovery from injury and eventual return to work.

Measuring Intra-Abdominal pressures has been found to be beneficial to patients, increasing survival from 50 % to 72 % in one study while actually decreasing resource utilization.

Overall Mayberry's review concluded that the Damage Control approach to abdominal surgery is well worth it. Aggressive management of intra-abdominal hypertension and decompression is beneficial. Early progression to fascial closure prevents complications and long term outcomes are usually good.