Circ statement: Time to transform cardiac ICU setting

The increased use of advanced supportive technologies, both cardiovascular and non-cardiovascular, requires specialized expertise that is not in the realm of common experience for the general clinical cardiologist, stated several American Heart Association councils. “This transformation necessitates innovative approaches to the staffing, structure and training behind the contemporary cardiac ICU,” wrote the authors.

This according to a scientific statement from the AHA’s Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, the Council on Clinical Cardiology, the Council on Cardiovascular Nursing and the Council on Quality of Care and Outcomes Research, which they created “as a roadmap to meet the changing needs of the population with cardiovascular disease requiring critical care.”

The provision of optimal care in the contemporary cardiac ICU (CICU) presents a different set of challenges and requires an expanded set of skills compared with 10 years ago, according to the statement published Aug. 14 in Circulation. “Cardiovascular medicine has lagged behind other medical disciplines that have met the ‘critical care crisis’ with ICU-focused innovations in organization, training and quality improvement,” the study authors wrote.

Between 2000 and 2005, although the total number of hospital beds in the U.S. declined by 4.2 percent, the number of critical care beds increased by 6.5 percent and the annual costs attributed to critical care increased by 44 percent, representing 13.4 percent of hospital costs (Crit Care Med 2010;38:65-71). Projections for the next 15 years suggest that the need for critical care will increase markedly in the U.S. and globally (Lancet 2010;376:1339-1346).

First, the writing group, led by David A. Morrow, MD, director of the Levine cardiac unit at Brigham and Women’s Hospital in Boston, suggested that optimal care of patients with acute cardiovascular disease is best administered by healthcare professionals with expertise in cardiovascular diseases and critical care medicine.

“The evidence supports a closed structure with staffing by dedicated cardiac intensivists … as a preferred approach for the advanced CICU,” the authors wrote, but they acknowledged that this model is not currently common in the U.S. Until it becomes part of clinical practice, Morrow et al suggested a model with “shared responsibility with consulting intensivists,” in which cardiologists and a general intensivist co-manage each patient or selected patients in the CICU.

In addition to physicians and intensivists, specialized nursing is “a foundation of excellence in cardiology critical care … Advanced practice providers with specific training and experience in cardiac conditions contribute to cost-effective care, improved staffing and continuity of care.”

The writing group also defined three levels of CICUs, with a Level 1 unit being the most advanced:

• Level 1: Capable of management of all cardiovascular conditions and major non-cardiovascular comorbid conditions. The unit may contain advanced heart failure (HF) patients dependent on percutaneous ventricular assist devices (VADs) and some who have undergone surgical ventricular assist device placement or cardiac transplantation. Resident and/or fellow training programs would usually be present, along with a commitment to perform research. Physician leadership ideally would be provided by a cardiac intensivist or co-directorship with a cardiologist and general intensivist.
• Level 2: The level 2 CICU is capable of providing the initial evaluation and management of most acute cardiovascular conditions and medical comorbid conditions. Mechanical hemodynamic support is available but limited to non–VADs, including intra-aortic balloon counterpulsation. Physician staffing for these patients is generally by cardiologists, and intensivists are available for consultation or co-management of complex patients. The unit may be combined with a general medical or surgical ICU.
• Level 3: Should have the capacity to manage respiratory failure, administer vasopressors and inotropes for hypotension, and provide immediate resuscitation of cardiac arrest but may be focused on the care of patients with suspected acute coronary syndrome, HF without shock and hemodynamically stable arrhythmias. Cardiology service admission or consultation is expected for management of patients admitted with primary cardiac conditions. Critical care primary or consultative services are available. Nurse-to-patient ratios are usually 1:2 to 1:3.

Lastly, the group addressed training, especially considering the “obvious shortfall in intensivists available to meet the needs of staffing models.” The authors suggested combining the current training expectations of three years for cardiovascular disease and one year for critical care medicine to six months of cardiovascular clinical training that may be applied toward the critical care medicine training requirements. Therefore, the overall pathway for dual certification requires four years of fellowship with a minimum of 30 months of clinical training, of which six months of clinical training must be in critical care medicine within a critical care training program accredited by the Accreditation Council for Graduate Medical Education.

While the breadth and volume of cardiovascular research has outpaced many other medical specialties over the past decades, the authors said that “there has been relatively little research focusing on the evolution of critical care cardiology to include patients with multisystem organ dysfunction. There are also important opportunities to study how staffing models, provider training, team composition and electronic systems, including decision support, may impact process and outcomes.”

In addition, they recommended investigation of structured approaches to enhance communication and facilitate transitions between the CICU and external providers inside and outside the hospital.

“With an increasing proportion of healthcare dollars going into care during the last months of life, much of this in intensive care units, research into efficient use of resources is also warranted,” the authors noted.