The Society of Critical Care Medicine at 50 Years: Interprofessional Practice in Critical Care: Looking Back and Forging Ahead

Field: Health Professions (Health Sciences)

OVERVIEW Interprofessional practice in the ICU has been embraced as a standard of care since the early origins of the Society of Critical Care Medicine (SCCM) (1,2).This focus has been instrumental in improving the care and outcomes of patients with life-threatening illness and injuries utilizing teams of critical care professionals (2). The ICU team is typically comprised of physicians, bedside nurses, nurse practitioners (NPs), physician assistants, clinical pharmacists, respiratory therapists (RTs), dieticians, physical/occupational therapists, case management and social work, dietician/nutritionists, spiritual support, as well as clinicians-in-training, among others. In the interprofessional team model, members of the ICU team communicate, collaborate, consult, and capitalize on the individual expertise of each team member (3). As highlighted by Dr. Max Harry Weil, the first president of SCCM, the ICU team is committed to bringing orderliness and expertise to the management of the critically ill patient (2). The coronavirus disease 2019 (COVID-19) pandemic and news reports of patients in the ICU during the pandemic served to raise the awareness of the general public of ICU care. More than ever, the importance of team-led care in the ICU became evident during the ongoing pandemic. In this article, part of a series on the 50th anniversary of SCCM in Critical Care Medicine, we review key aspects of interprofessional practice in critical care. Efforts to advance interprofessional team-based care in the ICU are essential for improving patient outcomes and ICU team performance (4). Evidence-based best practice for effective interprofessional team care has identified the importance of multidisciplinary rounds that include ICU patients and family members in the care discussions and decision-making, and uses communication strategies that foster inclusive and supportive behaviors to enhance interprofessional collaboration in the ICU (5). A review by the American College of Critical Care Medicine (ACCM) Task Force on Models of Critical Care highlighted the importance of multidisciplinary ICU rounds in reducing mortality independent of the care team structure (1). Additionally, optimal interprofessional team performance also appears contingent upon open communication, conflict resolution, cooperation, coordination, and coaching between individual team members (Table 1) (6). The frequent changing of individual ICU team members due to rotations and different schedules from day to day has been identified as a potential challenge in ICU team performance (7,8). However, ICU professionals function cohesively as a team, sharing their individual expertise and the perspectives of other team members day to day, as well as providing seamless continuity in patient care (9). Based on the COVID-19 pandemic, novel staffing models were developed to maximize critical care expertise to manage patient care needs and built new, nontraditional teams, with rapidly upskilled nurses and other staff (10,11). TABLE 1. - Key Qualities for Promoting Interprofessional Team-Based Care in the ICU Effective communication Mutual respect Collaboration Consultation Cooperation Cohesion Adaptability Coaching Strategic decision-making Defining expectations Resolving challenges Team identity Psychologic safety Stollings et al 2019 (5), Salas et al 2015 (6), and Durbin 2006 (3). In caring for the most critically ill patients, ICU team members often work in physically, emotionally, and ethically challenging environments. This can lead to provider burnout and dissatisfaction, which can be avoided with good team performance (Table 1). In a recent study examining the quality of interprofessional collaboration involving 2,992 clinicians working in 68 adult ICUs in 12 European countries, ICU and clinician characteristics that were associated with lower clinician "intent to leave" were mutual respect, open interdisciplinary reflection, and a direct approach to difficult decision-making including end-of-life decisions (12). INTENSIVIST-LED CARE IN THE ICU Intensivists are physicians who have completed training in one of several primary specialties (i.e., internal medicine, anesthesiology, emergency medicine, surgery, neurology, and pediatrics) who have additional subspecialty training in critical care medicine (13). Over the past several decades, ICU care evolved from managing critically ill patients in open units where multiple physicians were admitting and directing patient care without the presence of intensivists to a closed model of care, where a dedicated team or teams provide care. Intensivist-led care in the ICU care is now advocated for the care of critically ill patients (1,3), and SCCM outlines a number of key roles of the intensivist, including ICU team leadership, oversight of ICU care and decision-making, and coordination of care with specialists in management of the multiple health problems of ICU patients (Table 2) (14). TABLE 2. - Interprofessional Team Member Roles in the ICU Intensivists Provide leadership and oversight of ICU care Lead multidisciplinary rounds Oversee the many decisions involved in a critically ill patient's care Coordinate other services the patient may need—including those from specialists Diagnose, manage, and deliver the care of critically ill patients Have the medical training and skills to manage multiple health problems, including but not limited to: Cardiovascular: shock, myocardial infarction, cardiac failure, and arrhythmias Respiratory: prevention and treatment of pneumonia, respiratory failure, acute respiratory distress syndrome, chest trauma, smoke inhalation, and burns Neurologic: stroke, traumatic brain injury, intracranial hypertension, seizures, and brain death evaluation Renal: insufficiency or failure, electrolyte and acid base disorders, and rhabdomyolysis Endocrine disorders: adrenal insufficiency, diabetic emergencies, and thyroid storm Gastrointestinal: pancreatitis, gastrointestinal bleeding, and hepatic failure Pharmacologic emergencies: overdose, drug reactions, and poison Hematologic: anemia, coagulation disorders, and thrombotic disorders Infectious disease: treatment of multiple infections and recognition of and treatment of sepsis Nutritional: prevention, recognition, and treatment of malnutrition Able to manage or perform certain unit-specific procedures, including but not limited to: Endotracheal intubation and mechanical ventilation Placement of intravascular catheters, including central venous catheters, pulmonary artery catheters, dialysis catheters, and arterial catheters Cardiac pacing device insertion and management Tube thoracostomy Pharmacists Assist healthcare team members in making informed decisions of pharmacotherapy options Provide clinical pharmacotherapeutic consults to the care team Review the medication history to determine which maintenance medication should be used Prospectively evaluates all drug orders for appropriate indication, dose, interactions, allergies, and monitors for adverse drug events Provide pertinent, comprehensive drug information Collaborate with the healthcare team to prevent potentially inappropriate drug therapy Provide pharmacokinetic monitoring and therapeutic adjustments with targeted drugs Regularly attends rounds as member of a multidisciplinary critical care team Assist with medication reconciliation at the time of ICU admission and discharge Educate patients and caregivers on medications used in critical care Perform independent patient assessments Provide antimicrobial stewardship and monitoring services for anti-infective agents Participate in resuscitation of emergencies with advanced life support skills Provide drug therapy–related education Review, consult, and advise on nutrition therapy Respiratory therapists Use protocols or guidelines based on evidence-based medicine and standards of practice targeted at improving patient outcomes Implement respiratory therapy and diagnostic procedures as well as technology in the treatment and prevention of disease Patient observation and monitoring of clinical signs, symptoms, and physiologic changes related to respiratory care and diagnostic interventions Provide patient and family education to advance their knowledge of the disease process and understanding of prescribed therapy as well as resources available to assist them Develop and facilitate disease management, patient care plans, and pulmonary rehabilitation Participate in research to better understand current practice, improve patient outcomes, and advance the field of respiratory care Promote cardiopulmonary wellness and prevention through public education Facilitate training of the future healthcare professionals Nurses Provide direct care or influence care for acutely/critically ill patients who are at high risk for actual or potential life-threatening health problems Monitor the critically ill patient including vital signs and physical assessment findings Assess, plan, implement, and evaluate healthcare services for critically ill patients Practice in settings where patients require complex assessment and therapies, high-intensity interventions, and high-level, continuous nursing vigilance Lead and participate in collaborative interprofessional teams Provide critical care treatments including oversight of mechanical ventilation, invasive monitoring, and other life support equipment Respond to the unique needs of patients and families coping with unanticipated illness or injury and treatment, and advocate for their choices in quality-of-life and end-of-life decisions Ensure the delivery of safe and high-quality patient care to critically ill patients Collaborate with interprofessional team and provide oversight of patient care Communicate and provide for family-centered care in the ICU Clinical nurse specialists Provide expert specialty consultation to nurses and other members of the ICU team related to complex patient care needs Collaborate and consult with the interdisciplinary team, patient, and family Coordinate patient/family education related to illness/disease, treatment plan, and medications (family-centered care) Assess the nursing practice environment and processes for improvement opportunities Incorporate national guidelines into ICU protocols and practice (e.g., Pain Agitation Delirium, Immobility, and Sleep Disruption and Nutritional Support Guidelines, Assess, Prevent, and Manage Pain, Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT), Choice of analgesia and sedation, Delirium: Assess, Prevent, and Manage, Early mobility and Exercise, and Family engagement and empowerment Bundle, Surviving Sepsis Campaign, Healthy Work Environment Standards) Mentor nurses and nursing staff in using evidence-based practice principles Lead and participate in systematic quality improvement and safety initiatives based on precise problem/etiology identification, gap analysis, and process evaluation at the unit and system level Interface with clinicians and leaders across the continuum, leading system-wide initiatives and using research and clinical expertise to guide implementation and adoption of best practices at the bedside Competency development and education of nurses and other frontline staff Consultation and research support of quality improvement and institutional review board activities Nurse practitioner and physician assistants Assist in the care management of critically ill patients Prescribe and perform diagnostic, pharmacologic, and therapeutic interventions consistent with education, practice, and state regulations Collaborate and consult with the interdisciplinary team, patient, and family Patient and family education regarding anticipated plan of care Lead, monitor, and reinforce practice guidelines for ICU patients (e.g., central line insertion procedures, infection prevention measures, and stress ulcer prophylaxis) Promote and enhance communication with other ICU professionals: registered nurses, clinical nurse specialists, registered respiratory therapists, nutritional support team, and consulting services Perform procedures (as credentialed and privileged, such as arterial line insertion, suturing, and chest tube insertion) Transfer and referral consultations Serve on rapid response and post-ICU discharge follow-up teams to coordinate care Lead quality-assurance initiatives such as ventilator-associated pneumonia bundle, sepsis bundle, and rapid response team References: SCCM (14), American Association of Critical Care Nurses (22), Kleinpell et al (30), Lat et al (60), and American Association of Respiratory Care (62). Intensivist staffing models vary somewhat to meet the around-the-clock care demands in the ICU, although 24 × 7 intensivist staffing has not been consistently associated with significant decreases in ICU mortality to justify the cost of nighttime intensivists when a high-intensity staffing models are employed (1,15–17). In one recent meta-analysis, high-intensity intensivist staffing (mandatory consults or transfer of care to the intensivist-led ICU team) was associated with improved mortality when compared with low-intensity staffing (no mandatory intensivist involvement); however, the addition of nighttime intensivist coverage did not result in improved mortality over that produced by high-intensity daytime staffing alone (15). Similarly, in another study of 49 ICUs in 25 hospitals using the Acute Physiology and Chronic Health Evaluation database and a questionnaire to assess intensivist staffing, nighttime intensivist staffing again failed to show an effect on mortality in the units with high-intensity daytime intensivist staffing, although nighttime intensivist staffing did improve mortality in ICUs with low-intensity daytime staffing (16). This lead to the suggestion that 24 × 7 intensivist staffing models may not be an effective use of intensivist resources in units with high-intensity staffing models (16,17). Interestingly, however, in another recent study, implementation of nighttime coverage with in-house nonintensivist ("nocturnist") physicians in a unit with a high-intensity staffing model did result in significant decreases in ICU length of stay (18). Independent of the coverage model employed to meet 24 × 7 demands in the ICU, intensivist-led multidisciplinary team models of ICU care are associated with decreased mortality risk for critically ill and injured patients (1,19). HISTORY AND ROLES OF NURSES IN THE ICU ICU nursing has evolved considerably since its early origins in the time of Florence Nightingale, when injured British soldiers in the Crimean War of the 1850s were segregated based on acuity to provide more intensive care by special-duty nurses (20,21). During the latter 19th century, intensive nursing care of acute hospitalized patients was provided by locating the sickest patients closest to the nursing stations. With advancements in technology in the 20th century, including continuous monitoring and the development of life support devices such as ventilators and newborn incubators, intensive care nursing evolved rapidly (21). The American Association of Cardiovascular Nurses was founded in 1969 to help educate nurses in the care of critically ill patients, and shortly thereafter, in 1971, the organization became known as the American Association of Critical Care Nurses (AACN). According to the AACN definition, "the scope of critical care nursing is defined by the dynamic interaction of the critically ill patient, the critical care nurse, and the critical care environment" (22). ICU nursing is distinguished from general care nursing by the severity of patient illness, the skill set of the nurse, and the setting where care is provided (20). The roles and scope of practice for ICU nurses specifically involve providing direct and comprehensive care for acutely or critically ill patients including critical care treatments, oversight of life support equipment and invasive monitoring devices, support for patient- and family-centered care in the ICU, and overall assurance of the delivery of safe and high-quality patient care in collaboration with the interprofessional ICU team (Table 2). By the late 1960s, the majority of U.S. hospitals with 500 or more beds had an ICU (20). Similar to the nurse-anesthetist and nurse-midwife programs that had provided specialty education and training for several decades, critical-care education programs in schools of nursing were also developed to support intensive care as a specialty area of nursing practice. Master's degree programs for clinical nurse specialists (CNSs) began in the late 1940s, and the first NP program was opened at the University of Colorado in 1965 (20). Soon thereafter, specialty-focused NP programs evolved and national certification for nurses working in acute and critical care—acute care NPs—began in 1995. More recently, certifications for acute care pediatric NPs and for CNSs working in the ICU have also became available. The use of NPs in the ICU is now a well-established model for providing care for acute and critically ill patients, and the integration of NPs as part of the medical team in acute, emergent, and intensive care has grown significantly in recent years. This was initially due in some large part to increased demands imposed by the aging population and increasing numbers of complex care patients coincident with work hour restrictions for physician trainees and, more recently, by increased availability of NPs, and continued demonstration of their contributions and value (23,24). The important role of NPs as alternate providers in the management of critically ill patients has also been recognized and included in the LeapFrog Group ICU physician staffing guidelines (25), and a number of workforce documents have similarly identified NP integration into ICU care models as an important solution to meet qualified professional staffing needs in the ICU (15,27). There are now nearly 250,000 NPs nationally, with more than 20,000 certified as adult or pediatric acute care providers (28). Twenty-eight percent of NPs work in hospital settings, with 5.8% working in emergency rooms or urgent care settings and 12% working in critical care (28). Similarly, CNSs, who are also advanced practice nurses, play a significant role in the ICU through their roles in supporting patient care and nursing practice, and influencing organizational change through quality improvement initiatives, promoting evidence-based practice, staff nurse education and competency assessment, consultation, and research (Table 2). Studies related to bedside clinical nursing care in the ICU have identified an association between nurse staffing and patient outcomes, with higher nurse-to-patient staffing ratios being associated with lower rates of infectious and postoperative complications, fewer unplanned extubations, and lower mortality (29). A growing number of studies have also demonstrated the positive impact of NPs and CNSs on outcomes in acute and critical care settings (30–33). Together these studies identify the value of advanced practice registered nurses in patient care management, continuity of care, improved safety and quality, increased patient, staff and family satisfaction, enhanced educational experiences of resident and fellow physician trainees, and decreased resource use and costs of care. Collectively, ICU nurses, NPs, and CNSs are essential members of the ICU interprofessional team who collaborate to provide patient care and management, promote implementation of evidence-based best practices, and ensure safety and continuity of care. HISTORY AND ROLES OF PHYSICIAN ASSISTANTS IN THE ICU The first Physician Assistant (PAs) training program was created at Duke University in the mid-1960s because of a perceived shortage of primary care physicians. Former military corpsmen were given advanced training using an abbreviated medical school curriculum based on general medical practice that was originally designed for WW II military physicians (34). The early PA graduates were typically placed in underserved rural healthcare settings as primary care providers. Now 50-plus years later, PAs can be found in virtually every medical specialty (35). With their general medical training and background and a master's degree, nationally certified PAs have adapted to specialty practice, including critical care, through orientation and on-the-job training with consulting physicians or experienced PAs who have practiced in the specialty. Commonly, the clinical time of PAs is divided with other responsibilities including in or other patients in the or on the hospital In the ICU, an intensivist or other appropriate physicians are for complex problems such as with management or programs have PAs in a number of clinical including of anesthesiology, and critical care of these programs did not over time (e.g., and developed national (e.g., several (e.g., University and PAs were given critical care specialty training to practice in the ICU and were used for ICU typically to support coverage provided by physician There was of PAs contributions in the critical care when et al their on-the-job training program and use of PAs in a medical ICU, and demonstrated outcomes when care was provided by the PAs physician trainees over a A in in early provided additional support for PA practice in the ICU and PA and clinical The of the Group ICU physician staffing guidelines in which a role for PAs and NPs as to help provide intensivist-led care in the ICU to mortality and cost of care, in a for ICU A of that has has the roles of PAs and NPs as critical care providers in the ICU This has included recent reports in which PA and their clinical roles and in the ICU (Table 2) A recent by the on of PAs the number of PAs in acute and critical care practice Medicine and Critical Care (35). However, this PA contingent in critical care has demonstrated their by their in activities and in In the early PAs in critical care often the Society using an alternate professional and early SCCM had a PA members in However, since of the PA of the Society in PA in critical care has increased and in the PA has grown to now more than members over the past As has and educational from the PAs in the including collaboration with their NP in a number of on of mutual clinical and importance to the and of a to provide and mutual The also to the SCCM for PAs with research and PAs and NPs are involved in of the SCCM on the integration of PAs and NPs into critical care practice In recent PAs have to leadership in SCCM, with PAs as and of SCCM including and Strategic and SCCM PAs have been as in In addition to their increasing role in critical care delivery and Society PAs have a number of important leadership their individual healthcare as well as in and national healthcare PAs can now be found in roles of institutional of Practice in critical care, for quality and for the on and College of of Critical Care Medicine and of Clinical and of SCCM PAs in critical care medicine are growing in number and The perceived for advanced training has given to the of clinical training programs nationally providing of critical care training and an process has been developed to quality for these educational experiences to PAs into critical care practice are ongoing in the and the HISTORY AND ROLES OF IN THE ICU are reports of working in direct patient care settings as early as the the of this practice to the The most of the clinical is now to as a clinical is the that began in at the University of College of and This the of was initially as a with the primary function of the leadership of and this evolved to an part of providing regarding medication management as well as monitoring for adverse The role to include and support during emergencies and development of a drug for these in nutrition and 12 later, were to the for in was now the Over the developed to advance the clinical in and schools of and health across the and were a number of other demonstration of clinical services and the critical care were a number of highlighted the importance of drug in critically ill in the and for in patients This provided an for clinical to and discussions of using such as of and and with their physician and nurse was the most significant impact of this was the rapid of clinical services to include a pharmacokinetic for of and other therapeutic drugs based on pharmacokinetic This became the of the in the ICU, and the unique skill of the to and drug using them professional and a in the support provided to other health professionals at the bedside in the of the first on implementation of critical care services was found in The Practice of by in In the on ICU care, was a of critical care at the time and an for services implementation in the In the were also for training critical care advocated not for a background in drug but that critical care also be in several of the for critical care physician training including emergency medical care, cardiopulmonary respiratory care, infection and management of have served as the of critical care During the and the specialty of critical care as did the role of the as a member of the ICU multidisciplinary team of this role in the ICU has continued to now include in and critical care. In a was with the of the first standard for training in