EDITORIAL STEVEN R. INSLER, DO Medical Director, Cardiothoracic Intensive Care Unit and Respiratory , Department of Cardiothoracic , Anesthesiology Institute, Cleveland Clinic

Critical care : An ongoing journey

y introduction to critical care medi- personnel is invaluable, as these providers are M cine came about during the summer responsible for executing management proto- between my third and fourth years of medical cols such as weaning sedation and mechanical school. During that brief break, I, like most of ventilation, nutrition, glucose control, vaso- my classmates, was drawn to the classic medi- pressor and electrolyte titration, positioning, cal satire The House of God by Samuel Shem,1 and early ambulation. which had become a cult classic in the medical Unfortunately, as an increasing number of fi eld for its ghoulish medical wisdom and dark patients are being discharged from the ICU, humor. In “the house,” the intensive care unit evidence is accumulating that ICU survivors (ICU) is “that mausoleum down the hall,” its may develop persistent re- patients “perched precariously on the edge of quiring prolonged stays in the ICU and result- that slick bobsled ride down to death.”1 This ing in chronic critical illness. A 2015 study sentiment persisted even as I began my critical estimated 380,000 cases of chronic critical ill- care medicine fellowship in the mid-1990s. ness annually, particularly among the elderly population, with attendant hospital costs of up Although 70% See related article, page 523 6 to $26 billion. While 70% of these patients of ICU patients The science and practice of critical care may survive their hospitalization, the Society medicine have changed, evolved, and ad- of Critical Care Medicine (SCCM) estimates survive vanced over the past several decades re- that the 1-year post-discharge mortality rate hospitalization, fl ecting newer technology, but also an aging may exceed 50%.7 population with higher acuity.2 Critical care We can take pride and comfort in knowing the 1-year medicine has established itself as a specialty that the past several decades have seen growth postdischarge in its own right, and the importance of the in critical care training, more engaged prac- mortality rate intensivist-led multidisciplinary tice, and heightened communication resulting care teams in optimizing outcome has been in lower mortality rates.8 However, a major- may exceed 50% demonstrated.3,4 These teams have been asso- ity of survivors suffer signifi cant morbidities ciated with improved quality of care, reduced that may be severe and persist for a prolonged length of stay, improved resource utilization, period after hospital discharge. These worsen- and reduced rates of complications, morbidity, ing impairments after discharge are termed and death. postintensive care syndrome (PICS), which While there have been few medical mira- manifests as a new or worsening mental, cog- cles and limited advances in therapeutics over nitive, and physical condition and may affect the last 30 years, advances in patient manage- up to 50% of ICU survivors.6 ment, adherence to processes of care, better The impact on daily functioning and qual- use of technology, and more timely diagnosis ity of life can be devastating, and primary care and treatment have facilitated improved out- will be increasingly called on to comes.5 Collaboration with nurses, respiratory diagnose and participate in ongoing post-dis- therapists, pharmacists, and other healthcare charge management. Additionally, the impact of critical illness on relatives and informal doi:10.3949/ccjm.85a.18015 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 7 JULY 2018 527

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caregivers can be long-lasting and profound, into quality improvement, THRIVE may help increasing their own risk of depression, post- to reduce readmissions and improve quality of traumatic stress disorder, and fi nancial hard- life for critical care survivors and their loved ship. ones. In this issue of the Journal, Golovyan and Things have changed since the days of colleagues identify several potential complica- The House of God. Critical care medicine has tions and sequelae of critical illness after dis- become a vibrant and an charge from the ICU.9 Primary care providers integral part of our healthcare system. Dedi- will see these patients in outpatient settings cated critical care physicians and the multi- and need to be prepared to triage and treat the disciplinary teams they lead have improved new-onset and chronic conditions for which outcomes and resource utilization.2–5 these patients are at high risk. The demand for ICU care will continue to In addition, as the authors point out, fam- increase as our population ages and the need ily members and informal caregivers need to for medical and surgical services increases be counseled about the proper care of these commensurately. The ratio of ICU beds to patients as well as themselves. hospital beds continues to escalate, and it is The current healthcare system does not feared that the demand for critical care profes- appropriately address these survivors and sionals may outstrip the supply. their families. In 2015, the Society of Criti- While we no longer see that mournful cal Care Medicine announced the THRIVE shaking of the head when a patient is admit- initiative, designed to improve support for the ted to the ICU, we need to have the proper patient and family after critical illness. Given vision and use the most up-to-date scientifi c the many survivors and caregivers touched knowledge and research in treating underly- by critical illness, the Society has invested in ing illness to ensure that once these patients THRIVE with the intent of helping those af- are discharged, communication continues be- fected to work together with clinicians to ad- tween critical care and primary care providers. vance recovery. Through peer support groups, This ongoing support will ensure these patients post-ICU clinics, and continuing research the best possible quality of life. ■ ■ REFERENCES 6. Iwashyna TJ, Cooke CR, Wunsch H, Kahn JM. Population burden of 1. Shem S. The House of God: A Novel. New York: R. Marek Publishers, long term survivorship after severe in older Americans. J Am 1978; chapter 18. Geriatr Soc 2012; 60(6):1070–1077. doi:10.1111/j.1532-5415.2012.03989.x 2. Lilly CM, Swami S, Liu X, Riker RR, Badawi O. Five year trends of 7. Kahn JM, Le T, Angus DC, et al; ProVent Study Group Investigators. critical care practice and outcomes. Chest 2017; 152(4):723–735. The epidemiology of chronic critical illness in the United States. Crit doi:10.1016/j.chest.2017.06.050 Care Med 2015; 43(2):282–287. doi:10.1097/CCM.0000000000000710 3. Yoo EJ, Edwards JD, Dean ML, Dudley RA. Multidisciplinary critical 8. Kahn JM, Benson NM, Appleby D, Carson SS, Iwashyna TJ. Long care and intensivist staffi ng: results of a statewide survey and as- term acute care hospital utilization after critical illness. JAMA 2010; sociation with mortality. J Intensive Care Med 2016; 31(5):325–332. 303(22):2253–2259. doi:10.1001/jama.2010.761 doi:10.1177/0885066614534605 9. Golovyan DM, Khan SH, Wang S, Khan BA. What should I address 4. Levy MM, Rapoport J, Lemeshow S, Chalfi n DB, Phillips G, Danis at follow-up of patients who survive critical illness? Cleve Clin J Med M. Association between critical care physician management and 2018; 85(7):523–526. doi:10.3949/ccjm.85a.17104 patient mortality in the intensive care unit. Ann Intern Med 2008; 148(11):801–809. pmid:18519926 ADDRESS: Steven R. Insler, DO, Anesthesiology Institute, Cardiothoracic 5. Vincent JL, Singer M, Marini JJ, et al. Thirty years of critical care Anesthesia and Critical Care Medicine, J4-331, Cleveland Clinic, 9500 medicine. Crit Care 2010; 14(3):311. doi:10.1186/cc8979 Euclid Avenue, Cleveland, OH 44195; [email protected]

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