Eighteenth century mindsets , twenty-first century challenges : The physician as team player *

Monday, March 30, 1981 was the last day of my week on clinical call. It had been a busy weekend and all the intensive care unit (ICU) beds were full. Because three patients were ready for floor transfer and only two patients were scheduled for admission, one bed would be available later in the day. Monday’s normal routine was suddenly interrupted by a TV news announcement—President Ronald Reagan had been shot at 2:30 PM. We soon heard that the President, his Press secretary, James Brady, and a Secret Service agent, Tim McCarthy, were in our emergency department. Even with no clinical information, it never occurred to me that they would not be coming to the ICU. A discussion with the ICU nurse manager and Associate Director of Critical Care Nursing led to a list of potential ICU admissions and discharges. We also made arrangements for the care of patients who would be admitted, remain in ICU, or be discharged with special care needs. Under these circumstances, the efficiency of ICU discharge was unprecedented and our terrific staff ensured that nursing resources were practically unlimited. Agent McCarthy was admitted to the ICU in stable condition after successful repair of a liver injury at 7:30 PM, but we heard nothing about the President. I called the recovery room and was told that the President had been there for an hour and had some disturbing blood gas results. I spent the night there providing him with respiratory care, while my colleague Bill Knaus cared for James Brady in the ICU, who had undergone a surgery for severe brain injury. The President’s low PaO2 was due to blood in his airways and loss of lung volume, which quickly responded to suctioning and lung reexpansion. He was extubated at 2:30 AM, transferred to ICU at 6:15 AM, and was stable throughout his 12-hour ICU stay. ICU clinicians know it is not unusual for a day to begin at full unit capacity and end with even higher occupancy. Beyond caring for the President, his Press secretary, and a Secret Service agent, what was unusual about the events described earlier was having practically unlimited nursing resources and an extremely efficient discharge process. In my 30 years in intensive care, I was more accustomed to begging nurses to work overtime, to perform a discharge process more difficult than “pulling teeth,” and to stretching assignments to care for more patients. Sometimes we had to “board” patients in alternative locations, and occasionally requested that ambulances be rerouted or surgery cancelled because there were no more beds and nurses. An increased patient load was a major cause of anxiety. Could we obtain sufficient resources to care for more patients? Will staff “burnout” be aggravated by the increased workload? Will admitting more patients compromise the quality of care? In this issue of Critical Care Medicine, Iwashyna et al (1) provide a reassuring answer to the latter question. In 108 ICUs at 46 hospitals, consistent patient mortality was maintained, despite an unusually high census on the day of admission. These ICUs were able to cope with a census that ranged from 65% to 147% of their mean daily census for a single day or as long as 2 weeks. They also found that census fluctuations had little impact on ICU stay and the rate of transfer to other hospitals. It is comforting to know we are likely to maintain consistent outcomes when we “play musical beds” or “stretch the staff” or stated more politely, safely scale up operations to meet operating conditions. The scaling up of care capabilities in preparation for admitting President Regan, Press secretary Brady, and Agent McCarthy represents an extreme example, and I had never thought of this often painful process as the functioning of a “high-reliability organization. ” But I do feel that ICU physicians and nurses are often negatively impacted when workload is markedly increased and sustained. The literature on ICU burnout supports this opinion (2–4). Iwashyna et al (1) state that their study “implies, but does not prove, the viability of regionalization strategies. ” The authors of the study have previously published convincing evidence about the potential value of regionalization and improved outcomes in association with concentrating patients in high-volume hospitals (5–7). I urge caution, however, in using this study to support regionalization. There are several reasons why this study might not support regionalization: First, the study hospitals and ICUs are probably not representative of US ICUs. In addition, the study included nonteaching (34%) and small teaching hospitals (28%), institutions that are unlikely to be high-volume centers of excellence or referral hospitals. Second, the ability to successfully adjust to high occupancy for 1–14 days does not mean that caregivers could do this permanently. Third, the study did not address the ability to respond to the demands of regionalization. Additional ICU beds, professional staff, and financial resources might not be available to meet the demands of increased patient referral. Finally, the authors provide no data that identify the structural and managerial mechanisms used by these ICUs to meet these temporary increases in care demand. All studies have limitations, but the take-home message of this one is pleasing. When faced with the need to scale up operations to meet increased patient demands, ICUs maintain consistent patient mortality and operate as high-reliability organizations. This conclusion is well supported and is good news. Jack E. Zimmerman, MD, FCCM Department of Anesthesia and Critical Care Medicine The George Washington University Washington, DC Cerner Corporation Vienna, VA *See also p. 1545.