Continuum of hospital care: the role of intensive care Ken Hillmana, Jack Chena and Anders Anemanb a The Simpson Centre for Health Services Research, The University of New South Wales and bThe University of New South Wales, Sydney, Australia Correspondence to Professor Ken Hillman, Professor of Intensive Care, Critical Care Services, Liverpool Hospital, Locked Mailbag 7103, Liverpool BC, NSW 1871, Australia Tel: +61 2 9828 3431; fax: +61 2 9828 3577; e-mail: k.hillman@unsw.edu.au Current Opinion in Critical Care 2010, 16:505–509 Purpose of review This review outlines the way the specialty of intensive care has expanded over the last decade in response to the changing population of hospital patients, being older with more comorbidities and having more complex interventions. The previous disjointed professional and geographical silos, providing patient care, are being challenged and a more patient focussed continuum of care is replacing it. Recent findings There have been many reports over the last few years, describing patient centred systems, constructed around the needs of the seriously ill, at-risk patient, including trauma systems and Medical Emergency Team-type systems. There is now general agreement that in most settings these systems are responsible for a significant reduction in mortality and serious adverse events such as cardiac arrest rates. Summary The implications for the move towards systems to improve patient outcome and decrease mortality in hospitals are having a significant impact on the way we practise medicine, resulting in an emphasis, among other things, of constructing our care around the needs of patients, rather than rigidly practice medicine from within our own tribal boundaries, for example professional boundaries, medical specialty boundaries and geographical boundaries. Keywords acute care systems, medical emergency teams, rapid response systems Curr Opin Crit Care 16:505–509 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 1070-5295 Introduction This article will describe the high mortality and incidence of serious adverse events as a result of a lack of continuity in patient care in acute hospitals. Although the individual skills of clinicians can be of a high calibre and the functioning of individual departments such as ICUs and emergency departments can be exemplary, patients can fall between the cracks. Their vital signs may not be accurately recorded and there may not be a systematic way of connecting the right skills to urgently attend the patient at risk. This review summarizes what we know about this problem and recent developments in how we solve it. Hospitals have been in existence for more than 1000 years [1]. They were initially charitable institutions caring mainly for the poor who had an illness. Hospitals resulted in the emergence of formal training for physicians and nurses and the science of medicine. Part of their strength has been the close doctor–patient relationship supported by nursing and allied health expertise. These relationships can also be a weakness. 1070-5295 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Care is often silo based – geographically and professionally. Grafted onto the ancient concept of general wards in a hospital have been the additions of emergency departments, operating suites, coronary care units, diagnostic services and ICUs. Within these silos, care is delivered by individuals and teams [2]. The advantages of this arrangement are that responsibility for patient care often ultimately rests with an individual, not an amorphous system and that the geographical silos have their own sense of quality and organization. Disadvantages include tight boundaries between sites of care, teams and individuals with often poor interaction and communication. The system is often centred around the sites of care and individuals rather than constructed around the needs of patients. It is often at the interfaces of hospital silos where care falls down. For example, patients in hospital are increasingly older with multiple chronic comorbidities often accumulated simply as a result of ageing [3,4]. These complex patients with multiorgan dysfunction are ironically coming under the care of physicians who are becoming increasingly specialized around a particular organ or disease state. This, combined with the tendency to decrease hospital DOI:10.1097/MCC.0b013e32833e11dc Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 506 Critical care outcomes length of stay has resulted in a population of patients who not only have more complex procedures and interventions but are more vulnerable to deterioration as a result of their chronic health status. The individual physician under whom the patient was admitted usually has skills and knowledge limited to their own specialty. Even if they had been trained and practised in acute care and resuscitation at one time in their career, one soon loses these skills if not currently practised and, of course, it is difficult to maintain continuing education in all areas of medicine. Thus, the at-risk patient is left to the existing hospital infrastructure, particularly after hours, this is often limited to doctors in training and nursing staff. Often the physicians providing this service have had relatively poor training in acute medicine [5,6]. Although there can be centres of excellence for the care of the seriously ill within a hospital, there can be many vulnerable areas as well. The continuum and standard of hospital care can be disjointed and often inadequate for the level of illness of the patient. In terms of the history of medicine, the specialty of intensive care is a relatively recent phenomenon. The concept probably had its beginnings in the early 1950s in Copenhagen, Denmark [7] in the middle of a poliomyelitis epidemic. Patients with respiratory failure were hand ventilated for varying lengths of time by medical students working around the clock. As a result, the mortality rate was reduced from approximately 80% to around 40% [7]. Soon, specific areas in the acute hospital were constructed in order to care for seriously ill patients who required temporary life support until either the disease ran its natural course or was abated by medical and surgical interventions. Doctors and nurses working these socalled ICUs soon developed the skills associated with sustaining life. Patients had the cardiorespiratory systems supported by drugs and technology. In doing this, unique skills were also acquired relating to caring for patients who were temporarily dependent on artificial support: pain relief and sedation was administered, fluids and nutrients were given, pressure areas were prevented and complications such as stress ulceration and venous thrombosis were prevented. As a result of learning these skills, separate medical and nursing specialties developed in many countries. Specific journals, textbooks and conferences were developed in order to share experiences and professional societies and bodies established. Initially, patients were referred to ICUs by colleagues who had been made aware of their existence and facilitated by someone within the hospital who had an interest in providing the service. Many of the early pioneers were anaesthetists because they had technical skills in intuba- tion, artificial ventilation and insertion of intravenous lines. Some of these early pioneers devoted more of their time to caring for patients in the ICU. Sometimes the referring clinician maintained control over the patient’s clinical course, utilizing the skills of the anaesthetists. The specialty of intensive care became routine for nursing staff before medical staff. However, it soon became obvious that the specialty of intensive care was not a parttime hobby and ICUs are now only rarely run by absentee landlords working in other specialties. Many countries now have formal training and accreditation in intensive care and most large hospitals have intensive care specialists. During this development, an interesting interaction occurred between other medical specialties and intensive care. The levels of intensive care provided in a hospital are determined by the need of other medical specialties. At the same time, the level of the ICU determines the nature of the hospital’s function. For example, many major surgical specialties such as cardiothoracic, neurosurgery and complex general surgery could not be performed without sophisticated intensive care services. Similarly, medical specialties such as neurology, cardiology, respiratory medicine and gastroenterology could only operate at limited levels without adequate intensive care services. Thus, the continuum of care in many larger acute hospitals is largely determined by its intensive care services. Open vs. closed units Some ICUs operate as so-called open units [8]. This generally infers that the admitting physicians remain in ‘control’ of their patients while they are in the ICU. They interact directly only with nursing staff in some lower level units and with medical clinicians of various skill levels in other cases. The demarcation of roles and responsibilities between the admitting clinician and the clinician working in the ICU varies between different units. A closed unit refers to the ‘control’ of the patient being the responsibility of physicians working in the ICU. In larger hospitals, these are often intensive care specialists. The continuum of care of patients across the hospital may be affected by this arrangement. The ease of admission or even the reluctance or otherwise of an admitting clinician to refer a patient to an ICU may vary according to who is in ‘control’ of the patient once they are admitted to the ICU. From the patient’s perspective Unfortunately, not every patient can be in an ICU under the watchful eye of physicians and nurses used to caring for the critically ill. Moreover, intensive care specialists Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Continuum of hospital care Hillman et al. 507 are trained in maintaining normal cardiorespiratory function, ensuring well oxygenated blood is provided to all tissues. However, the correction of hypoxia and ischaemia has often occurred elsewhere. In some situations such as the operating suite or emergency department, this usually involves clinicians who are also trained in the care of the seriously ill. However, there are many parts of the hospital where rapid resuscitation does not occur and where immediate care by staff trained in acute medicine is not available. Even small amounts of ischaemia and hypoxia can cause cellular dysfunction and damage that can eventually lead to organ dysfunction [9–13]. Long before overt signs of ischaemia and hypoxia are clinically noted, serious dysfunction can occur in the liver [14], splanchnic beds [15] and cerebral circulation [16]. The vital signs of these patients can remain normal. The problem seems to be more with patients being managed on the general wards of acute hospitals. There is an enormous gap between the standards of care provided for the seriously ill within the four walls of intensive care compared to the general wards of a hospital [2,17,18]. One of the early pioneers of intensive care medicine stated as long ago as the early 1980s that ‘the most sophisticated intensive care becomes unnecessarily expensive terminal care when the pre-ICU system fails’ [19] and fail it often can. Up to 80% of hospital cardiorespiratory arrests are preceded by a slow deterioration in vital signs [20]. Over half of all patients who die without a do-not-resuscitate order in hospitals also have a long period of slow deterioration [21]. Many admissions to the ICU could potentially be avoided [22]. An unacceptable number of patients have serious abnormalities before being admitted to an ICU [23–26]. This is in contrast to patients who are actually being managed within the ICU, where sudden, unexpected deterioration is rare. The majority of patients die as a result of planned withdrawing and/or withholding therapy [27,28]. From a patient’s perspective the general wards of an acute hospital can be dangerous environments. Systems to identify and respond to deterioration are often inadequate. They are designed around maintenance of care rather than acute resuscitation. Patients may have improved outcomes if, at the first sign of deterioration, they were admitted to the emergency department. The reasons for this are many and complex. We have already discussed the compartmentalization and lack of acute care expertise on general wards. There is often a hierarchical system in which nurses measure abnormalities in vital signs but are not empowered to act on them. Instead, they refer the problem up through a system which may not have the appropriate skills and knowledge to deal with the problem at any of its levels. Even vital signs and recording may be inadequate. It is surprising that what must be the most common procedure in medicine, the recording of vital signs, has been subject to so little research. From the limited information we have, we know that the recording and frequency of recording of respiratory rate, pulse rate, blood pressure and temperature varies widely within hospitals, between hospitals and between countries [29–31,32,33]. Thus, from a patient’s perspective, the potential complexity and level of their illness are often not met by systems designed to recognize and react to deterioration. This effectively limits the continuum of patient care. Systems to improve the continuum of hospital care As it would be impractical to transfer every deteriorating or at-risk patient in a hospital to the emergency department, there needs to be a different system for providing the appropriate level of care to the at-risk patient. The system of ideal trauma care provides a good model for patient centred care [34]. The continuum from the moment of trauma to final rehabilitation is designed around patient needs. A rapid response with appropriate personnel is quickly provided to the injured person; they are resuscitated and triaged to the most appropriate centre; further resuscitation occurs within the emergency department. The patient has more definitive procedures and investigations. Treatment in hospital is followed by an appropriate period of rehabilitation and community based care. A similar system for identifying and responding to the seriously ill within a hospital is now available in many hospitals. The system was first developed as the medical emergency team (MET) concept [35,36]. It is often organized and driven by intensive care staff but could involve any team trained in advanced resuscitation. At-risk patients are identified by serious abnormalities in vital signs such as respiratory rate, pulse rate and blood pressure as well as observational abnormalities such as seizures, loss of consciousness, airway obstruction and concern by staff – the so-called MET criteria [37]. Once identified, there is a rapid response by staff trained in advanced resuscitation. A meta-analysis has demonstrated a large reduction in cardiac arrests in adult and Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 508 Critical care outcomes paediatric hospital where the system is used [38] as well as a reduction in paediatric mortality rates. Further evidence comes from the demonstration of a reduction in mortality in hospitals using the MET system in the largest randomized control trial yet conducted [39,40]. The system provides a continuum of care for all at-risk and seriously ill patients and is now being increasingly employed in many parts of the world. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as:  of special interest  of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 522). 1 Nemes CN. The medical and surgical treatment of the pilgrims of the Jacobean Roads in medieval times. Part 1: The caminos and the role of St. Anthony’s order in curing ergotism. Int Congr Ser 2002; 1242:31–42. 2 Hillman K, Chen J, Aneman A. The ICU without walls. In: Flaatten H, Moreno R, Putensen C, Rhodes A, editors. Organisation management of intensive care. Berlin: MWW Medizinsch Wissenschaftliche Verlagsgesellschaft (in press). The other end of the spectrum in the continuum of patient care is when active treatment is no longer indicated. Intensive care specialists are becoming increasingly involved in managing end-of-life (EOL) challenges [41,42]. Most patients who die in ICU do so as a result of withdrawing and withholding treatment [43,44]. Dying is the most common illness in the ICU with a least 20% of Americans now dying in, or shortly after, having been in an ICU [43]. 3 Hillman KM. The changing role of acute care hospitals. Med J Aust 1999; 170:325–327. 4 Hillman KM. Restructuring hospital services. Med J Aust 1998; 169:239. 5 Hillman KM. Redefining preventing deaths and containing costs: the expanding role of intensive care medicine. Med J Aust 1996; 164:308–309. 6 Thwaites BC, Shankar S, Niblett D, Saunders J. Can consultants resuscitate? J Roy Coll Phys Lond 1992; 26:265–326. 7 Lassen HCA. A preliminary report on the 1952 epidemic of poliomyelitis in Copenhagen with special reference to the treatment of acute respiratory insufficiency. Lancet 1953; 1:37–41. 8 Pronovost PJ, Angus DC, Dorman T, et al. Physician staffing patterns and clinical outcomes in critically ill patients. JAMA 2002; 288:2151–2162. Managing EOL by intensivists has now moved outside the ICU. As a result of rapid response systems operating in many hospitals, intensive care staff are not only urgently called to seriously ill patients with a large potentially reversible component to their illness but also to those who are seriously ill as a result of a predictable and natural dying process [45]. For many reasons, there is a reluctance to make a diagnosis of dying in acute hospitals. One of the more important factors is related to our colleagues not understanding what intensive care may and, more importantly, may not be able to offer. The intensivist is increasingly playing the role of making the diagnosis of dying through discussions with their colleagues, patients and the relatives and friends of the patient. 9 Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalised patients. Results of the Harvard Medicine Practice Study I. N Engl J Med 1991; 324:370–376. Management of the end-of-life in hospitals Conclusion Intensive care has moved from delivering services within the four walls of the ICU to being involved in the continuum of care throughout the patient’s hospital journey. This involves participation in resuscitation in the emergency department; communicating and being consulted by colleagues throughout the hospital; providing early emergency resuscitation services throughout the hospital; and, increasingly, initiating and managing EOL care both within and outside the ICU. Many intensivists are also involved in prehospital emergency services and posthospital services, following up patients who have a high incidence of problems after discharge from the hospital. In a relatively short period of time, the specialty of intensive care has become crucial in the function of most acute hospitals and the expertise of those trained in the specialty are increasingly utilized in the continuum of care across the health system. 10 Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian Healthcare Study. Med J Aust 1995; 163:458–471. 11 Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalised patients. Results of the Harvard Medicine Practice Study II. M Eng J Med 1991; 324:377–384. 12 Deitch EA. Multiple organ failure: pathophysiology and potential future therapy. Ann Surg 1992; 216:117–134. 13 Alexander JW, Boyce ST, Babcock GF, et al. The process of microbial translocation. Ann Surg 1990; 212:496–510. 14 Gottlieb ME, Sarfeh IJ, Stratton H, et al. Hepatic perfusion and splanchnic oxygen consumption in patients post injury. J Trauma 1983; 23:836–843. 15 Price HL, Deutsch S, Marshall BE. Hemodynamic and metabolic effects of hemorrhage in man with particular reference to the splanchnic circulation. Cir Res 1966; 18:469–474. 16 Schmoker JD, Zhuang J, Shackford SR. Hemorrhagic hypotension after brain injury causes an early and sustained reduction in cerebral oxygen delivery despite normalization of systemic oxygen delivery. J Trauma 1992; 32:714– 720. 17 Hillman K. Critical care without walls. Curr Opin Crit Care 2002; 8:594– 599. 18 Hillman K, Bishop G, Bristow P. Expanding the role of intensive care medicine. In: Vincent J-L, editor. 1996 yearbook of intensive care and emergency medicine. Berlin: Springer-Verlag; 1996. pp. 833–841. 19 Safar P. Critical care medicine – Quo Vadis? Crit Care Med 1974; 2:1–5. 20 Schein RM, Hazday N, Pena M, et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest 1990; 98:1388–1392. 21 Hillman KM, Bristow PJ, Chey T, et al. Antecedents to hospital deaths. Internal Med J 2001; 31:343–348. 22 McQuillan P, Pilkington S, Allan A, et al. Confidential inquiry into quality of care before admission to intensive care. Br Med J 1998; 316:1853–1858. 23 Garrad C, Young D. Suboptimal care of patients before admission to intensive care. Is caused by a failure to appreciate or apply the ABCs of life support? Br Med J 1998; 316:1841–1842. 24 Goldhill DR, Sumner A. Outcome of intensive care patients in a group of British intensive care units. Crit Care Med 1998; 26:1337–1345. 25 McGloin H, Adams S, Singer M. The quality of pre-ICU care influences outcome of patients admitted from the ward. Clin Intensive Care 1997; 8:104. 26 Hillman KM, Bristow PJ, Chey T, et al. Duration of life-threatening antecedents prior to intensive care admission. Intensive Care Med 2002; 28:1629–1634. 27 Manara AR, Pittman JAL, Braddon FEM. Reasons for withdrawing treatment in patients receiving intensive care. Anaesthesia 1998; 53:523–528. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Continuum of hospital care Hillman et al. 509 28 Keenan SP, Busche KD, Chen LM, et al. A retrospective review of a large cohort of patients undergoing the process of withholding or withdrawal of life support. Crit Care Med 1997; 25:1324–1331. 29 Dobbs P, Stubbins K, Leggott S, Adsetts D. A prospective audit of the incidence of physiologic monitoring in the 24 h before a cardiac arrest in a district general hospital. Br J Anaesth 2002; 89:353. 30 Zeitz K, McCutcheon H. Observations and vital signs: ritual or vital for the monitoring of postoperative patients? Appl Nurs Res 2006; 19:204–211. 31 Hillman K, Chen J, Cretikos M, et al., MERIT Study Investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005; 365:2091–2097. 32 Chen J, Hillman K, Bellomo R, et al., the MERIT Study Investigators for the  Simpson Centre and the ANZICS Clinical Trials Group. The impact of introducing medical emergency team system on the documentations of vital signs. Resuscitation 2009; 80:35–43. This is one of the first papers to examine, probably for one of the first times, the recording of vital signs. It documents the lack of standardization and inaccuracy in the recording of vital signs. This has important implications for the detection and response to the seriously ill in the continuum of patient care. 33 Cretikos MA, Bellomo R, Hillman K, et al. Respiratory rate: the neglected vital sign. Med J Aust 2008; 188:657–659. 38 Chan PS, Jain R, Nallmothu K, et al. Rapid response teams. A systematic  review and meta-analysis. Arch Intern Med 2010; 170:18–26. This article is the largest meta-analysis describing the effect of a medical emergency team concept, demonstrating a one-third reduction in cardiac arrest rates in both adult and paediatric hospitals as well as a significant reduction in paediatric mortality. The question of adult mortality is addressed in [37]. 39 Chen J, Bellomo R, Flabouris A, et al., the MERIT Study Investigators for the  Simpson Centre and the ANZICS Clinical Trials Group. The relationship between early emergency team calls and serious adverse events. Crit Care Med 2009; 37:148–153. This study, the largest conducted on the effectiveness of medical emergency teams, shows a significant reduction in mortality in hospitals with a Medical Emergency Team system. It also demonstrated a significant relationship between the dose (number of urgent calls) and effect (reduction in deaths and cardiac arrests). This is important when tracking the effectiveness of the implementation of the system. 40 Priestley G, Watson W, Rashidian A, et al. Introducing critical care outreach: a ward randomised trial of phased introduction in a general hospital. Intensive Care Med 2004; 30:1398–1404. 41 Sprung CL, Cohen SL, Sjokvist P, et al. End-of-life practices in European intensive care units. The ethicus study. JAMA 2003; 290:790–797. 34 West JG, Williams MJ, Trunkey DD, Woferth CC. Trauma systems. Current status: future challenges. JAMA 1998; 259:3597–3600. 42 Prendergast TJ, Luce JM. Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med 1997; 155:15–20. 35 Lee A, Bishop G, Hillman KM, Daffurn K. The medical emergency team. Anaesth Intensive Care 1995; 23:183–186. 43 Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med 1998; 158:1163–1167. 36 Hourihan F, Bishop G, Hillman KM, et al. The medical emergency team: a new strategy to identify and intervene in high risk patients. Clin Intensive Care 1995; 6:269–272. 44 Hillman K. Dying in intensive care [editorial]. Care Crit Ill 2006; 22:1. 37 Hillman KM, Bishop G, Lee A, et al. Identifying the general ward patient at high risk of cardiac arrest. Clin Intensive Care 1996; 7:242–243. 45 Chen J, Flabouris A, Bellomo R, et al., the MERIT Study Investigators for the Simpson Centre and the ANZICS Clinical Trials Group. The medical emergency team system and not-for-resuscitation orders: results from the MERIT study. Resuscitation 2008; 79:391–397. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.