Critical care is the care provided for patients with the most serious, life-threatening illnesses or injuries. These patients are often treated in the intensive care unit (ICU), where they are monitored around the clock, and are cared for by critical care doctors.
Critical care has changed a lot since its inception, and has been revolutionized even further in light of the COVID-19 pandemic. Let’s explore the history of critical care as well as what it may look like today and going forward.
The Beginning of Critical Care Medicine
The use of the term “critical care medicine” in the United States dates back to the 1950s. It was first used at the University of Southern California (USC), and according to a review published in Critical Care, “In 1958, Dr Max Harry Weil and Dr Hebert Shubin opened a four-bed shock ward in LA County – USC Medical Center, Los Angeles, CA, USA to improve the recognition and treatment of serious complications in critically ill patients. That same year, Dr Peter Safar opened a multidisciplinary ICU at Baltimore City Hospital.”
The same review notes that ICUs were initially “rather frightening,” adding that visitors were not always allowed and staff frequently wore masks (which, during today’s COVID-19 pandemic, would perhaps not be regarded as quite as frightening), gowns, and shoe covers; visitors also had to cover up in order to enter, and were only permitted to do so during very limited hours. Physicians who staffed the early ICUs often specialized in anesthesiology or internal medicine.
Early ICUs were not necessarily team environments, as another Critical Care article describes: “In the past, the physician in charge of the ICU too often considered that his (more often a man than a woman) physical presence was essential if patients were to be treated ‘correctly’, and equally that patient management would obviously be suboptimal in his absence. Limited communication among team members meant that quality of care was indeed often better when the chief physician was present than when he was not. The chain of hierarchy meant that other members of the ICU staff were generally there just to follow his orders, and rounds were often punctuated by verbal criticism of more junior doctors.”
Where We Are Today: A Team Effort
Today, critical care is widely regarded as a team effort, with critical care doctors (also called intensivists) working hand-in-hand with other specialists. Mayo Clinic notes that their critical care doctors frequently partner with specialists in anesthesiology, internal medicine, pulmonary medicine, cardiovascular medicine, cardiovascular surgery, neurosurgery, neurology, nephrology, pediatrics, surgery and transplant medicine. According to the American Medical Association (AMA), physicians working in critical care may also have the opportunity to team up with nurses, pharmacists, respiratory therapists, dieticians, social workers, and medical students.
While the team approach is certainly widely used today, having a dedicated intensivist on staff in the ICU has also been shown to improve ICU length of stay and resource utilization, according to the American Society of Anesthesiologists (ASA). But the team model has certainly benefited patients as well, per the ASA: “Further analyses of data suggest that it is not just the presence of a physician intensivist, but also comprehensive multidisciplinary care and an established leadership presence that may be important factors. As experts in coordinating care across specialties and providers, anesthesia physician intensivists are uniquely qualified to fill a leadership role on a multidisciplinary team.”
Critical Care ‘Areas of Excellence’
Regarding specializations, according to the AMA, “While nearly all ICUs are capable of providing a spectrum of care, many have developed a focused area of excellence: care of premature or critically ill newborns in the neonatal ICU (NICU); care of critically ill and injured children in the pediatric ICU (PICU); care of adult cardiac diseases in the coronary care unit (CCU); perioperative care, trauma care and care of multiple organ dysfunction in the surgical ICU (SICU); and care of neurological and neurosurgical patients in the neuroscience ICU (neuro ICU).”
According to Stanford Children’s Health, the NICU largely consists of babies born preterm, at a low birth weight, or with health conditions such as difficulty breathing, heart issues, infections, or birth defects. The NICU team may include a neonatologist, neonatal resident, pediatric fellow, and neonatal nurse practitioner, as well as respiratory, physical, occupational, and speech therapists, among others. The PICU, like the ICU, allows for children who need high-level medical care to be continuously monitored. Children may spend some time in the PICU after undergoing surgery or if they have a serious illness, heart condition, or infection.
Remote Patient Monitoring: Could The Tele-ICU Be Part of the Future?
The COVID-19 pandemic shed an enormous light on the far-reaching possibilities afforded by telemedicine. Many COVID-19 patients were admitted to the ICU, and the extreme need for ICU beds has also affected non-COVID-19 patients who required ICU admission.
The idea of integrating telemedicine and ICU care is actually not new. In fact, a study published in the Journal of the American College of Emergency Physicians in 1977 found that telemedicine was a viable strategy to fill the need for intensivists at smaller medical centers. In this study, an intensivist at a large university medical center communicated daily with a small private hospital by way of a two-way audiovisual link. After roughly six months of this intervention, the researchers made seven key observations. Among their findings, the study authors stated that regular critical care consultations were possible through telemedicine, and while the technology at the time was adequate to bridge the gap between specialized critical care medicine and small medical centers, it was notably expensive. Still, also among their findings, the researchers stated, “telemedicine can influence the process and probably the outcome of patient care.”
If the technology of 1977 was advanced enough to implement telemedicine in the critical care sphere, it would stand to reason that the technology exists to provide that same care today. A 2018 review published in Methodist DeBakey Cardiovascular Journal examined available data on telemedicine in the ICU, or tele-ICUs.
But how would tele-ICU work today? According to the researchers, “Tele-ICU delivers technology-enabled care from a remote command center. At its simplest, mobile platforms provide on-demand, two-way, audiovisual (AV) communication between ICUs and the tele-ICU center. Typical infrastructure is more complex and involves a tiered system of fixed AV communication, access to EMRs, telemetry, and imaging systems for data retrieval and documentation, plus risk stratification and decision support.”
Upon their review, the researchers found that using tele-ICU as part of a hybrid model—in conjunction with in-person support—is increasingly gaining popularity. They noted high levels of heterogeneity among the studies they analyzed but regardless stated “tele-ICU is associated with benefits including improved ICU mortality and decreased length of stay.” Tele-ICUs appear to be cost-effective, although they do come with high price tags for implementation.
The researchers called for continued research into the costs, impact, and associated outcomes for tele-ICUs. As appears to be the case with telemedicine as a whole in light of the COVID-19 pandemic, it’s likely that this area of medicine will continue to be investigated and utilized further throughout the pandemic and beyond.