Navigating the future of critical care.

According to veteran airline pilots, plane crashes do not usually occur because of a single malfunction. Rather, a series of ominous events occur that lead to a “perfect storm” scenario with tragic consequences. For example, weather is marginal, visibility is poor, the flight crew is inexperienced or communicates poorly, and a piece of navigational equipment malfunctions. None of these factors in and of themselves lead to a plane crash, but in combination they can converge to create a disaster. Many nurses and physicians working in critical care today are worried that a “perfect storm” is brewing on the horizon of our specialty. Although the forces pointing to a future system crash in critical care are many, we are going to focus on 3. These 3 forces have the potential to create a dramatic new demand for intensive care unit (ICU) services in the face of a decreasing ability to meet that demand. First, an aging society with multiple comorbidities is poised to require intensive care when hospitalized. The oldest baby boomers are 58 years old, and they are quickly coming to an age when their need for critical care services markedly rises. As an increasing percentage of people in the United States qualify for senior discount rates and enter their eighth and ninth decades of life, we can anticipate an explosion of demand for healthcare services. Second, we know from past research that between 13% and 35% of certain procedures are not indicated but are still performed. Some of these interventions are fueled by patients’ and families’ unrealistic expectations about what medical and nursing science can deliver. These unrealistic expectations can result in longer ICU stays or a reluctance on the part of physicians and nurses to transfer patients from the ICU to more appropriate settings (eg, hospice or skilled nursing units). As the gap between what is possible and what is appropriate widens (to say nothing of the gap between what is possible and what is affordable!), stress will occur in the relationships between patients, families, caregivers, and payers. One can foresee an increase in malpractice suits on the part of patients and families and denial of payment on the part of payers in this scenario, with patient and family satisfaction plummeting and nurses caught in the middle. It is a scenario that is played out every day in hospitals and will become even worse as the population ages and budget constraints continue to come into play. Third, the current shortages in critical care personnel, particularly in experienced nurses, physicians, and pharmacists, are projected to get far worse. The wave of retirements predicted to occur during the next decade will leave ICUs in dire straits, ill equipped to care for the increasing numbers of patients requiring critical care. Taking their cue from famous baseball manager and player Yogi Berra, representatives from 4 professional organizations—the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine—recently held a series of meetings to consider the future of critical care, focusing on the challenges that are converging to create a perfect storm in healthcare. The group developed a consensus document titled Framing Options for Critical Care in the United States that lays out arguments for rethinking how critical care is delivered and by whom. Since no clinical trial or consensus document can avoid being abbreviated in our acronym-filled clinical world, the document is referred to as FOCCUS.