SCCM Resource Library-A Century of Critical Care From the Median Viewpoint

Video Transcription

Hello, my name is Rhonda D'Agostino, and I'm a critical care nurse practitioner at Garnett Health Medical Center, as well as faculty at Mount St. Mary College of Nursing.  I am honored to be here today to moderate this excellent session with two critical care giants, Dr. Timothy Buchman and Dr. Neil Halpern, the latter of whom I've had the pleasure of  working with for over a decade, and I miss him dearly. Had I lived in Georgia, I know I'd be saying the same thing of Dr. Buchman.  This session, A Century of Critical Care from the Media Viewpoint, is taking two interesting  perspectives describing the vision of SCCM's founding members that has helped shape critical care today, as well as ICU design in the era of our pandemic. Please enjoy. Good day.  My name is Neil Halpern. I'm director of critical care at Memorial Sloan Kettering Cancer Center in New York,  and it is my pleasure to speak about the future of ICU care delivery and design looking into the crystal ball.  I specifically want to thank the Society of Critical Care Medicine for the invitation to speak with you today, and for Rhonda D'Agostino for her introduction as well.  These are my disclosures, and nothing in this talk are impacted by these. So our agenda for today is we're going to look at a crystal ball, then we're going to  look at the evolution of a new care model, patient-centered care at the bedside versus a hybrid care.  We're going to look at acute expansion of ICU capacity at the local level and at larger levels, and finally, we're going to close with how we administer an acutely expanded  ICU bed capacity.  We'll start with our crystal ball, and that essentially focuses us on the status quo. For this talk, I have envisioned that we have a ship, the USS ICU Design and Bed Capacity  Ship, and it starts out in San Diego at what I call the ICU River. As we flow across the United States, we have periodic updating of ICU design, we have periodic  increasing of ICU beds, and as we finally get to New York City, where I am, we have an old but sturdy ship.  The trouble is in March, that old and sturdy ship hit a iceberg, the COVID iceberg. And in that iceberg, we found that the ICU design that worked for years did not work,  and we were losing patients. So what happened is we had to come up with an approach, and this happened in all the  pandemic areas, to save the ICU design and bed capacity, and rethink it, and steady the ship, rethink the ICU design, and figure out how to acutely increase ICU bed capacity.  So let's move into the evolution of a new care model. And typical ICU room has, of course, the bed, the patient, from left to right, the physiologic  monitor, infusion pumps, and a ventilator, and the room pressure is commonly set at neutral. And we may or may not have a nurse sitting outside the room, and the nurse, of course,  comes in the room to render care, and associates the physiologic monitor with the patient,  and the infusion pumps with the patient, respiratory therapists will come in and associate the  ventilator with the patient, and the MD or APP comes in, and together, we have patient-centered or focused bedside care. Now, what happened in the COVID pandemic?  The patient exploded and created a toxic bedside environment. It was toxic to everything in the room, both people and devices. And we then had to rethink the care model.  We had to move from patient-centered care, which is optimal, but we had to deal with staff safety, and that caused a dichotomy in the approach, and we had to clear out the  toxic bedside environment and figure out how to render care. So we had to move the staff outside the room, and we had to figure out a way to move the  toxic COVID outside the room, and for that, we converted rooms to negative pressure or placed HEPA filters to create a more safe bedside environment.  And now we moved into a hybrid bedside and remote care model. So in this model, we moved infusion pumps outside the room. We may or may not have moved ventilators outside the room.  We're going to spend more time about that. And we created some remote management, and we mirrored the physiologic monitor outside  the room and also had remote management of the monitor in the room. We hazmat suited up the staff, and they came in the room.  Of course, nurses also came in the room, and we linked the bedside care with nurses and nurses outside the room, and that created patient-centered but now hybrid bedside and  remote care. Now, I want to spend a moment on the ventilator in the room being managed by remote control.  To date, this has not been approved, but more recently, already in April and May, the FDA, under emergency use authorization, allowed for remote control ventilators.  So how did that happen? We have a ventilator in the room, so we could move the vent display outside the room, control the ventilator.  Or we can have a ventilator with two displays, both inside and outside. Or we could attach a robot to the ventilator and control the ventilator remotely, which  I'm going to show you. Or the ventilator has software that permits wired or wireless remote control from an outside PC, which I will show you as well.  Alternatively, we can have the ventilator placed outside the room altogether, and I'm going to show you that too.  So on the right, we see a robot placed on the face plate of the ventilator. And on the left, we see a laptop controlling the ventilator, and this was created down  in Hopkins in the biomedical engineering lab. Let me show you what we've done here at Memorial.  We're looking through a window into the patient, and here's the patient, and here's the ventilator.  And now we have software loaded on the ventilator and outside, and we mirror image the ventilator display, and we could control the ventilator from outside the room.  And we now have three patients on ventilators like that. This is approved just for COVID-19 patients. Let's shift over to acute expansion of ICU capacity.  We're going to look at it at two levels, the local hospital level and the networked city and state levels. So we're going to start with my two tower hospital.  On the left, we have a critical care tower. On the right, we have an acute hospital tower. We, of course, have a whole bunch of ICUs, and we expanded ICU bed capacity of existing  ICUs to deal with COVID and non-COVID. And in most large hospitals, these were managed together.  But we shift out of the ICUs, and we expanded into other areas, a step down unit to create an ICU.  On the right, we shifted to monitored settings, cardiac cath labs, GI labs, and so on, any place with all kinds of monitors and gases. Some hospitals have ICUs in the ED.  Those were included. We included PACUs, and wards were turned into ICUs, ORs, usually as a last resort, but many  of the large hospitals in New York and elsewhere that happened, and conference spaces were turned into ICUs, and we're going to show you that.  And parking garages were turned into ICUs, and we're going to show you that as well. In the middle of this cartoon, we see oxygen, vacuum, data cables, and power conduits,  and those are illustrated on the inner right and the inner left of the two towers. We're going to come back to that. So in our hospital, this was a typical ICU room pre-COVID.  There is nothing outside the room. Now we shift to COVID, and this is a COVID-managed bed, and what we see are infusion pump outside the room.  We have a remote control for the physiologic monitor. We have extension tubing and electrical power outside the room, extension tubing going to  the patient, and we have writing on the wall, on the glass, that was used as communication.  So this was the major conversion that we did and many others did to convert to hybrid care. What about in our step-down unit? So this was pre-COVID.  There was no glass window in the door, and there was nothing outside the room. So initially, no window in the door. Inside the room has all the elements to take care of the patient.  Now this is the post-COVID same step-down unit, and what we built is a remote nursing station.  Initially, windows were cut in the door to allow for direct line of sight of the patient and the monitor. The infusion pumps, of course, are outside. We have a remote workstation.  We have a barcode reader. We have a mirror image of the display in the room. The rooms were converted to negative pressure, or HEPA filters were put in, and the nurses  cared for the patients in full PPE outside the room. There was still a PC and the medical record inside the room, as well as outside the room.  So this is a major change in the pop-up or novel ICU area. This is in our regular ICU, a nurse wearing a PAPR, so-called hazmat, to go in the patient  room, and this is another picture illustration of communication from inside the room to outside the room with writing on the glass. What about the operating room?  An operating room has core services for only one patient.  In many of the large hospitals, those single-patient operating rooms were converted to multi-patient rooms, and this is a cartoon of what it looked like.  In order to convert from one patient to additional patients, power, data, gases, suction had to be added for each bed, and information had to be tracked in multiples in a one-bed  environment. Each of the beds had to have an assignment in the hospital's admission-discharge transfer system, as well as the electronic medical record.  The rooms commonly were also converted to negative pressure, where HEPA filters were put in.  Care was provided in these rooms in full PPEs, and in most of the ORs, it was very difficult to build an outside nursing station, as on a regular ward or a regular step-down area.  What about PACUs? PACUs were also converted to ICUs. Now in this PACU, the outside beds along the periphery, negative pressure was put in place,  and the inside central staffing area was wrapped in plexiglass. But this could be done two ways, there are two choices.  You could wrap the beds in plexiglass and apply negative pressure, and then you could work in regular clothing, of course with masks, in the central nursing station, or  you could wrap the central nursing staffing area in plexiglass. Two choices. Now, I'm going to shift over to the COVID-19 ICU Design Citation Award.  The Society of Critical Care, in conjunction with the American Association of Critical Care Nurses and the American Institute of Architects on Architecture for Healthcare,  they've had an ICU Design Citation Award. Because of the extenuating circumstances, these groups, led by the Society of Critical  Care, created the COVID-19 ICU Design Citation Award, and Holy Name Medical Center, located in Teaneck, actually near where I live, won the award.  So I'd like to take a minute and show you what they did. They took a conference center, which we're going to call generically a shell space, and  they converted it essentially overnight. They stripped it down. They put flooring in, and then they built multiple ICUs.  They ran gases and power and data in, and in between each of the ICUs, and this is what the ICU looked like, there was an alleyway to the left and to the right, and we see negative  pressure being put in, and we see the inside. There are conduits. There is power, gases, data, suction, and so on.  There are mirrors so the nurses outside of the plexiglass window in the alleyway could see the patient, and so on.  And all the patient heads were on the periphery of the created ICU, so all care was rendered through the plexiglass, through conduits, and the patient's head was here.  And this is what the alleyway looked like for each patient. Let's not focus on the letters. There is a conduit that takes all tubing inside the room.  There's plexiglass and a conduit in the plexiglass, and then we have infusion pumps, a ventilator, physiologic monitor, power, gases, and so on.  And then all care could be rendered from outside the ICU to inside the ICU, and they were facilitating  nurses inside the unit, but all of this monitoring, ventilation, and pumps was managed from outside in the alleyway.  Let's shift over to another kind of ICU, and this is a prefabbed ICU constructed in shipping containers.  It was known as the Cura, Connected Units for Respiratory Ailments, and it was designed and constructed by Carlo Ratti Associates in Torino, Italy.  What we're looking at on the right is the shipping container, and this is a standardized container used all over the world, and what they did is they inserted glass windows on  both sides for direct visualization. They added an anteroom that is inflated for donning and doffing and storage.  In fact, these anterooms were able to be connected so you could construct multi-bed ICU, and this is what the schematic looked like.  There were two beds in each of the shipping containers, and here we see a cartoon of the inflated anteroom area, and this is what it looked like inside.  You could purchase this with monitoring and all the accessories, or you just purchased it without anything and you added your own devices and beds.  Now we talked about turning regular beds into ICU beds, and one may not have all the accessories,  so already years ago, the military, in conjunction with Thornhill Medical, a Toronto company, created a portable integrated ICU in a single device, which we see at the right.  These were deployed in 2017 by armed forces and used in transport and field hospitals. It was a single user interface physiologic monitor, and one of the main specifications  was no oxygen tanks, because as you can imagine, if you're using this in a military area, that would be quite detrimental.  So Thornhill created an O2 concentrator with an O2 conserving circle circuit, and that allowed invasive ventilation up to an FiO2 of 0.85.  It included a multimode ventilator and suction. So these could be deployed, and the company's actually looking to deploy these in California  at this point in civilian use as convention centers or wards and hospitals are deployed  or stood up as ICU beds, you would need additional devices, and this is what their device looks like in a simulation on a dummy. Let's get back to our two-tower hospital.  In normal circumstances, normal O2 flow, there is no problem supplying oxygen. However, in an environment where there's abnormally high demand, the oxygen systems on occasion  did not work, and they froze, and we had freezicles, and what happened? So we knew about this in March in Italy.  The experience had taught Italy that coronavirus patients, top left, are enormous consumers of oxygen, and that all of the compressed oxygen gas had led to tubes freezing.  So you can have a hospital full of reanimation or ICU beds, but if the tubes aren't adopted, everything freezes.  This subsequently happened in New York City in Queens, and we'll see later on, patients had to be moved.  This has happened currently at the end of December in Los Angeles, and these are three newspaper articles that talked about it, and the military finally came in and helped get  the oxygen going. What I want to now do is shift to ICU capacity and network city and state healthcare systems. In the middle, we have our hospital and network.  On the right, we have the governor and Department of Health. Another network left, another network on the right, a convention center, a warehouse  with prefab-stored ICUs, an empty hospital, LTAC. And the thermometer in the middle, space is still available, and networks are shifting  patients across hospitals of the network, and we see network one, two, and three shifting within the network's patients. But then what happens?  The governor, Department of Health says, let's move patients in between networks to better load, share, and balance.  And then we have patients moving across networks, and we'll come back to that. And then the census is full, the ICUs are full.  Let's activate the plan to acutely increase ICU bed capacity and open the hospital and the LTAC. And patients are then shifted to those areas.  Finally, we want to distribute the prefabbed ICU beds from the warehouse, get the cars out of the parking lots.  So the warehouse distributes on trucks or other ways prefabbed ICUs, and to the various  networks, and patients are put in those prefabbed ICUs, and then the convention center is also loaded with patients in their prefabbed ICUs.  And we have to make sure we staff these new beds, we'll come back to that, and engage the U.S. remote telemedicine system, and we'll come back to that.  And of course, when this is all over, we need to reimagine our approach to regionalization of ICU care.  And an example of load sharing in real life was when the New York hospitals in Queens had their O2 freezing, Albany Medical accepted patients transferred by helicopter from the  New York City area. And let's look at how a convention center could have been set up with regular hospital beds and prefabbed ICU beds under a single roof.  This is what was actually done in the conference center in Torino. So we had regular beds and the Roddy shipping container prefabbed ICU pods.  And of course, these could be set up in parking lots, and this is a cartoon of an ICU, all these prefabbed ICU beds linked together, and they're linked to the hospital for all  their data, power, and so on. Let's finish up with administering the acutely expanded ICU bed capacity.  So this is one of my favorite paintings, A Walk in the Park by Urbanikova, and this is a beautiful painting.  So the question is, is quickly expanding ICU bed capacity a walk in the park? It is not. So let's briefly deal with how we quickly expand ICU beds.  And this is what the COVID-19 epicenters had to do. So on the Y-axis, we have number of ICU beds, on the X, we have types of ICU beds created.  So the ICUs and specialty ICUs all have to have naming, governance, staffing, technologies, triage, management, logistics, and informatics. They have that all the time.  And we had to add step-down units. So these issues, these parameters had to be expanded to cover step-down units, doable.  But then we added monitored units, ORs, and PACUs, which never really function as ICUs. And you see as the arrow gets bigger, I'm indicating the difficulty in expanding typical  ICU parameters. And finally, when we add novel ICUs of all varieties, it is really a big deal.  So I want to share with you the tiered staffing strategy from Society of Critical Care. And we have four triangles here. We have a load of patients.  And what we do is we incorporate ICU staff with non-ICU staff. It's done with nurses, it's done with respiratory therapists, it's done with APPs, it's done with physicians.  And at the top of the triangle are critical care trained or experienced physicians to help force amplify the triangle itself.  This was done in many of the hospitals in all different configurations to allow redeployed non-ICU staff to function with ICU staff.  I want to mention in our closing minutes something called the NET-CCN, the National Emergency Telecritical Care Network.  This is currently being developed by the U.S. government, the military, the Army, in conjunction with academic medical centers and private vendors.  And the goal is to create virtual ICUs with mobile interfaces that link the patients, the local caregivers, and the remote experts, and integrate EMRs, devices, and other levels  of support. It is not looking to duplicate the hardware-intense current telemedicine, telecritical care systems.  It's looking to be able to deploy not just in COVID, but in many disaster areas where all the hardware wouldn't even be in existence, and it would be deployed in military tents  and conference centers and hospitals, certainly without critical care expertise. So we're going to see more about this in the coming months.  And we need to rethink space and cost savings within the ICU design.  We purchase new devices, and we include trade-in or turning-in of old devices. They're good reasons to get rid of old equipment.  It decreases the cost of new device, we don't have to store, and it's difficult to maintain preventive maintenance if devices are no longer supported.  In COVID, it was impossible to get vents. So I do think it's important for us to rethink the trade-in and storage of mission-critical devices in the future. One last thing.  Much has been learned about configuring ICUs in the COVID-19 area. So I was privileged to co-author a piece known as Configuring ICUs in the COVID-19 Area,  and there were 16 epicenter hospitals, 40 participants, 10 health care disciplines, and it addressed all the elements I've spoken about in this talk.  So in conclusion, COVID-19 highlighted the deficiencies and lack of foresight in our ICU design approach, care delivery model, and ability to efficiently, acutely, and economically  expand ICU bed capacity locally or nationally. However, great successes were seen under awful conditions, certainly in the spring  and going into the summer in the first layer of the pandemic. Importantly, we cannot anticipate every ICU nightmare scenario or the Donald Rumsfeld  famous unknown unknowns, but there is no excuse if we do not incorporate COVID-19-induced lessons learned and innovations into future ICU and hospital design planning and acute  expansion of ICU bed capacity. Thank you very much for your attention. Have a good day. Hi, I'm Tim Buchman. I'm here to speak today on standing on the shoulders of giants.  I have no personal disclosures, although Emory University does receive a stipend from SCCM for my editor-in-chief services, and Emory University receives payment for my services  to the United States government. I do have to give some disclaimers. These remarks are purely personal, and they may not represent the views of Emory University,  the Society of Critical Care Medicine, Critical Care Medicine or Critical Care Explorations, the journal, the United States government, or the Santa Fe Institute.  Let's begin by traveling to France, just southwest of Paris, to the cathedral at Chartres. And here's a view from the south showing the spires and then the south transept.  And I call your attention to the south transept shown here. On the right, a view of the beautiful rose stained glass window above and the five lancet-shaped windows below.  And in those lancet-shaped windows, you'll find that four out of the five show pairs of men, one sitting on top of the other.  These are truly giants sitting on the shoulders of giants. We'll come back to this at the end of the talk.  With this notion of on the shoulders of giants, it's the original literary meme, perhaps. Who said it first?  Was it Pritian, who was a Latin grammarian of Caesarea and Mauritania, who taught Latin language in Constantinople in the sixth century?  Was it Bernard of Chartres, who was part of the beautiful cathedral that I just showed you? Was it John of Salisbury, Robert Burton?  There's the famous exchange between Isaac Newton and Robert Hooke. Hundreds of others have used the phrase, including Stephen Hawking. Yes, even I have used this phrase before.  But if you want to read more about it, pick up a copy of this book. This is Robert Merton's wonderful book on the history of the meme. As I said, I've used it before.  The three men shown in this picture, Will Shoemaker, Bart Schirna, Joe Perrillo, these are truly giants on whose shoulders I stand as the fourth editor-in-chief of the journal.  But for purposes of this talk, the giants that I want to focus on are Hal Weil, Max Harry Weil, Will Shoemaker, and Peter Saffer.  Now they would be the first to tell you that it's giants all the way down. They'll tell you that they never acted alone. They acted in partnership.  Will, who invented the first civilian trauma center, Hal, his classification of shock, Peter, who developed the modern ICU with on-site dedicated physicians, they'll tell you they  never worked alone. But importantly, I'll also tell you, they too stood on the shoulders of giants. I had the privilege of speaking with Hal in the last years of his life.  And I asked him what he thought might have been his most important contribution to the care of patients.  And he said it was the classification he developed with his partner, Schubert, the classification of shock, with special reference to distributive defects.  Shown here, the picture from the original article was published in 1971. But this is the way we learn it in the textbooks. Cardiogenic shock, hypovolemic shock, distributive shock,  obstructive shock, all with the causes that have become so familiar and that we treat every day in the ICU. How do we recognize these four classifications of shock?  From the physiology that Hal Weil taught us, examining cardiac output, filling pressures, vascular resistance, and venous oxygen saturation. With this grid of information, we're  able to make decisions about rapid treatment that has been shown to save lives, to provide the right care right now for every patient every time.  But Hal also reminded me that he wasn't the first to study this sort of classification. He pointed to Alfred Blaylock, surgeon at the Johns Hopkins Hospital.  You may remember Dr. Blaylock from the movie Something the Lord Made, the discussion of the Blue Baby Operation. But Dr. Blaylock, in his classic book on shock,  himself had a quadripartite division of shock causes. 1936, fully a third of a century before Hal Weil's work, Blaylock wrote of the hematogenic type of shock,  the neurogenic or distributive type of shock, vasogenic, another distributive type of shock, and cardiogenic shock. And when Blaylock was asked where he got his inspiration,  he pointed to Walter B. Cannon, the Harvard physiologist who described homeostasis and the wisdom of the body. But Cannon referred to Rudolph Mattis's work  on the importance of continuous IV infusions of solutions such as intravenous saline. And he pointed to the work of William T. Thomas.  So even in Hal Weil's classic description of shock states and their management, it was giants all the way down. I had the privilege of asking Peter Saffer, who  was nominated three times for his Nobel Prize in medicine and who did extraordinary work in cardiopulmonary resuscitation and brain resuscitation, what he thought  was his most important work. And he pointed to the creation of an ICU that was staffed by dedicated physicians and nurses.  He first realized this dream at the Baltimore City Hospital in 1958, where the sickest patients, he realized, required the continuous attention of specialized nurses  and doctors skilled in recognizing and treating serious illness. But where did Peter get this idea? Well, lingering in his mind and in everyone else's  was the tragedy of the Coconut Grove fire. Now, in November of 1942, at a nightclub in Boston, a fire broke out, the exits were blocked, and 400 died. But some survived.  And they were taken to the Massachusetts General Hospital, where a young Oliver Cope, not as old as shown in this picture, was suddenly confronted  with dozens of survivors and realized that the only way he and his colleagues could effectively care for those patients was to initiate team-based care and protocolized care.  He rapidly prototyped and changed and revised, and then made sure that the skills would be passed on from one team member to the next,  to one team to the next, to ensure of diffusion. And he made sure that the care was consistent. He designed a strategy for mapping burns and for standardizing the fluid infusions  and for standardizing the changing of dressings for these patients. And among those patients, those who didn't die within the first hour, they all survived at least seven days,  a testament to his ability to construct a team-based and task-based approach to care, literally on the fly. Which brings us to a discussion of Will Shoemaker,  who was the first editor-in-chief of the journal that I publish, and the first editor-in-chief of the textbook of critical care. Now, Will was a polymath.  He didn't get a start in critical care. He got a start as a urologist, redesigning bladders that gave new hope to thousands of paraplegics,  winning the Society Award not once, but twice. But I had a chance to ask Will of what he thought was his most important achievement, what he was most proud of.  And he told me it was the design of the first trauma unit in the United States at Cook County Hospital in Chicago. Now, Will had been trained in surgical physiology  at the Peter Bent Brigham Hospital in Boston by Franny Moore, and in biochemistry by Barrett Hastings, who was the Harvard University giant of that field.  And in that setting, Will Shoemaker's interest included hemorrhagic shock and its complications, and the hemodynamic and metabolic consequences of injury.  He went on to write this paper with his successor, Robert Baker, on the evaluation and treatment of the patient in shock from trauma. Will was perhaps happiest in the laboratory,  shown here with his newly acquired amino acid analyzer, showing it to the board of visitors. But it was a family affair as well, because his wife, Mrs. Norma Shoemaker,  was one of the nurses who was involved at the opening of the trauma center with two other surgeons, Bob Friark and Bob Baker.  Now, where did Will get this idea to have a dedicated trauma center? We go back to the Coconut Grove fire. And again, at the MGH, on the spot in three hours,  an intensive care unit was created for 39 survivors of that fire. And that team and task-based care model  transferred within months to the European War Theater. By the end of 1944, it was the standard way of caring for patients. And it continued over into the Korea conflict.  The team-based, task-based unit had become the foundation of military trauma care. And Will certainly knew about it from his service to the Navy.  So we look, our founding fathers had many contributions, but many contributions that supported what the other was doing. Now, they weren't perfect.  The fact is there were some soft shoulders. Will was very proud of his attempt to show that delivery of supernormal levels of oxygen would improve outcomes.  And in fact, his early work suggested that establishing therapeutic goals increased cardiac index to four to five and a half liters per minute per meter square.  An increase of 30% to 80% above normal would actually help trauma victims survive. He did a prospective randomized study. And later on, that study was repeated.  And in the repeat shown here, it wasn't the treatment that mattered. It's what the patient was capable of accomplishing. In ACWA, treated or controls who  got to levels of 600 milliliters per minute per meter squared had mortalities of 14%. Treated or controls who could not achieve 600, mortalities between 53% and 58%.  And ultimately, it was shown that trying to drive higher levels in patients who were not responding was counterproductive. And Will was perfectly happy to set his idea aside  and recognize that this is the way science progresses, with a hypothesis, with a test, and frequently with failure.  But the question arises, what do we mean by standing on the shoulders? Hal Weil and Will Shoemaker would never have argued about who stood on whose shoulders.  They were the best of friends and partners in trying to make critical care safer for patients in their units and for the world. They wouldn't say standing on.  They wouldn't say standing by. They would say we stand with one another. And that really has been the tradition of leadership in the Society of Critical Care Medicine.  Here's Mitch Fink, who succeeded Will Shoemaker as the editor-in-chief of the fifth edition of the textbook of critical care. He wasn't just an editor.  He contributed a new theory to the development of shock and sepsis, that of cytopathic hypoxia due to mitochondrial factor, complementing the work that Hal Weil had done.  He followed Will Shoemaker as the editor of the textbook of critical care.  Here is Vlad Kovatin, who published his own textbook of critical care medicine. But Vlad was not just a textbook editor. He was the godfather of disaster medicine.  He led delivery of critical care medicine into war zones. He was the father of the ICU without walls that followed on to Peter Safra's concept  of on-site dedicated physician-to-physician on-site dedicated physicians and nurses, essentially moving Hal Weil's shock board anywhere it needed to move.  He was the motive force behind regional collaboratives. In fact, he was a strong proponent of institutions sharing their critical care resources, following on Mitch's idea of having  a dedicated department of critical care medicine that followed on Will Shoemaker's idea of having a multidisciplinary, multi-professional, international society of individuals.  These gentlemen didn't stand on each other's shoulders or stand on each other's toes or stand on ceremony. They stood with one another to drive the best care possible.  So we have many different types of giants. Whose shoulders actually matter? There are those, the relentless leaders, who devote their entire lives to a single-minded pursuit.  What giant comes to mind when you reflect on patient safety or on antibiotic therapy or on the management of a particular organ failure, maybe with a particular device?  Which giant shoulders matter when you think about institutional leadership, those individuals who connect individuals into teams and then into teams of teams,  aggregating them into mighty structures serving critical care? Who comes to mind when you think about the organization of symposia or study groups or departments  or centers of critical care excellence worldwide?  What about the frontline giants, many of you listening today who devote yourself to lifelong learning and excellence in the practice in your own ICUs?  Who comes to your mind when you reflect on the excellence in day-to-day care delivered in your own institution? Who are your giants? I would say those who matter most,  the shoulders who matter most, shoulders who matter most, those are those restless leaders. They are the rarest of all. Of the five that I've spoken about,  each I've mentioned was happiest, imagining what no one else had thought, building what others said was impossible, attracting others to the effort,  and then most importantly, giving it away, giving away whatever each had most recently built to somebody else so they could take on the next challenge.  Well, none of those five men are still with us. And there are other giants who are coming up. So on this 50th anniversary of the Society of Critical Care  and Medicine's founding, we commissioned for the journal a series to recount the challenges faced by the founders and their contemporaries,  to trace their explorations and achievements in the various topic areas to arrive at present day and to enumerate the core challenges  that our current care community leaves to the next generations. Each of the 23 articles that we've commissioned will be, to a greater or lesser extent,  a hero's and heroine's quest tale, well told. And the topic areas were selected not to be comprehensive because that is, after all, the province of textbooks,  but rather because these areas were felt to embody those quests and to have met with some success.  So from the February 2021 issue of Critical Care and Medicine that has already been published, and for the balance of the year you'll see articles like these.  On the left, co-evolutions of pediatric and adult critical care, showing how leaders in both our pediatric environments and our adult environments  work together, sharing progress, sharing ideas. On the right, a piece on nosocomial infection, recognizing that our invasive techniques  of endotracheal intubation, vascular cannulation, and so forth carry the risk of infection for our patients. And all of the efforts and progress  that have been made to reduce that risk as low as possible. They're wonderful stories, but still, the stories are about people. Father's story gets told.  Every other founding father gets to grow old. When you're gone, who remembers your name? Who keeps your flame? Who tells your story? Who tells your story?  Occasionally, an editor gets to tell their stories. Here are a couple of pieces I've written, one on Mitch Fink, one on Vlad Kovatin.  It's a responsibility that I don't look forward to, but one that I embrace. We do have a history in our Society of Critical Care and Medicine and in the discipline of Critical Care  and Medicine, and it's important that we continue to recognize the giants on whose shoulders all of us stand. Let me close by taking you back to that cathedral at Chartres  and telling you who was in those four lancet-shaped windows.  On the bottom, we have the four prophets of the Old Testament, Jeremiah, Isaiah, Ezekiel, and Daniel, sitting on their shoulders, Luke, Matthew, John, and Mark,  the author of the Gospels. For each of those men and for each of our founders and for each of our giants, everything they've done  has always been about something greater than themselves.  Thank you so much for your attention today. It's been a pleasure delivering this lecture at the 50th anniversary of the founding of our Society of Critical Care and Medicine. ♪♪♪  Christina, can you hear me? I can hear you. I couldn't hear Rhonda. I cannot hear. I'm just... I can hear you. I cannot hear Rhonda. Rhonda, can you talk?  Can you hear me? We can now. Now? Yes. So weird. Sometimes my ear buds. Okay. Welcome, everybody, to the live discussion forum. We have a number of questions.  So, first one for Dr. Halpern, based on the previous SCCM discussion about regionalization of care, what will be the optimal way to redesign for a future pandemic?  I think that's a great question. So, the good news is we've already had a pandemic, and I don't think the United States or any region,  well, maybe small regions in the United States, if the big hurricanes, but not on a national basis, certainly not in a worldwide pandemic,  have we ever seen such a thing in the modern era. So, there's a massive experience and literature about how this pandemic was handled in the winter and spring and again now.  So, I think there will be far better warehousing of supplies around the country. I have a bias towards purchasing nationally or regionally prefabricated ICUs,  having a massive amount of technologies available to be shipped where they're needed, and having groups like the society, in conjunction with other governmental,  national, and regional agencies, be able to plan and deliver support, whether it's personnel, technology, staffing, tele-staffing, wherever it's needed.  So, I think the old ideas of regionalization, like, for example, at Memorial, we send our ECMO patients to Presbyterian up to Adam and Adam, that's lovely,  but that has nothing to do with a real pandemic like we experienced. Additionally, in New York State now, really on the down low, the governor has set up  a whole bunch of COVID-specific centers. You cannot read about this in the media. It's not written about. But hospitals through agencies, like the meeting I just got off,  Haney's Healthcare Association of New York State knows about this, and there's a phone number. So, I'm hoping other states pick up on this,  and based on what went on here and what's ongoing, we'll create centers for certain types of pandemic-type illnesses beyond what local hospitals can deliver.  Next, Rhonda. I was having issues with, I can't hear anybody, but now, can everyone hear me?  Okay, thank you. Excuse me. So, Dr. Halpern, what do you think should be the priorities for SCCM to ensure an appropriate incorporation of any type of technology  in a critical care provider skill set? It's another very challenging question. SCCM has to have a lot of priorities because we are a very multidisciplinary organization.  So, the skill set that was needed to take care of critically ill patients in COVID is massive, and all types from the bedside to telecritical care.  So, I think there's going to have to be programs that exist that can enable those delivering care to have very easy access to live help.  I know that SCCM, with the military and others and technology leaders, are trying to develop programs like that today, and I mentioned that in one of my slides in this talk.  But I think it's hard to answer, really, at this point, except to say we can identify the groups of healthcare providers that were necessary,  and we need to rethink the type of training that doctors and others have to have as they go through training and as their skill sets are further developed in real life.  And I think SCCM has a lot of information to put forth to work groups to further develop that.  Great. Thank you. Okay. Next question from Lillian. Staffing is an even more precious commodity. Are regional teams of nurses and RTs being considered?  Currently, resourcing of shortages due to illness is reliant on our locum staffing groups with high cost.  Tim, I don't want to deprive you from taking one of these tough questions, if you want to do it, because I think you can expand to the telecritical. Please carry on, Neil.  I love listening to you.  Regional teams of nurses and RTs being considered. Let me jump over to RTs for one second. The idea that the United States was unprepared for this is true.  The idea that the United States wasn't notified through a series of publications in the 2000s and studies of what was going on in states, especially towards ventilator support  and more than just having the technology of ventilators, the lack of enough respiratory therapists available to manage all the ventilators, that was also published, well-described,  and unfortunately, nobody really did anything about it. So certainly, I think there should be a push for more training of respiratory therapists.  Short of that, more cross-training of anesthesiologists, not just to use the ventilators that they're most comfortable with in the operating rooms,  but what they're comfortable with in PACUs to expand to other areas of the hospital or other kind of facilities. One other element I touched on briefly in my talk  is the emergency use authorization for remote control of ventilators. Now, we've been doing this at Memorial, controlling ventilators from outside the room using computer link.  There are various ways to do this. So it may just be that this is a once-in-a-lifetime horror that'll go one or two years, and I don't know if we could change our whole world  of educating people and training them and having them available for a once-in-a-lifetime horror, but certainly there could be the use of teletechnologies  which allow regional telecritical care setups to better deploy the knowledge of respiratory therapists  or others from central locations to work with hospitals in a much better way than we can do today based on the experiences we've had specifically with ventilator management,  which has been very challenging. In terms of regional teams of nurses, oh, that's a huge issue. I don't know really what to do with it  except to say locums companies may have to work with groups like the Society of Critical Care, like FEMA, and figure out how to rapidly deploy people. Certainly in New York State,  when we taxed the locum nurses with New York State taxes for coming and helping out New York State pandemic hospitals in the spring wasn't a great thing to do,  so there should be a better purpose nationally of how we reward or not tax people that come to help us.  Thank you, Dr. Halpern.  Dr. Buckman, thank you for the wonderful lecture. It appears that most of the ideas of today have been thought about in the past. Should we read and seriously consider the papers  of 50 years ago to find some answer to today's questions?  There's an old saying that if you want a new idea, you should read an old book. One of the things that I'll riff on what Dr. Halpern has mentioned  is this notion of task reallocation. This is something that Hal Weil and Peter Saffer understood that they had to change the way  the tasks of care in the 1950s and 60s and 70s needed to be redistributed.  I think we have to do the same.  I'm gonna push Dr. Halpern and suggest that the concept of the ICU and many of our practices are probably outmoded the notion of rounds. We can reallocate people,  provide enormous number of these tasks at a distance,  huge amount of what we do can be closed loop artificial intelligence. We can have robots, there are companies that produce these things  that can manipulate an ultrasound probe at a distance. It's not just the in your pocket model now, it's the fact that a robot can be placed  at a patient's bedside and manipulated at a distance. So in my view, we have to use the pandemic as an opportunity to reimagine what critical care is about.  And I go back to the Society of Critical Care and Medicine's tagline, Right Care Right Now, and ask what happens when instead of thinking  about liberating the patient from the ventilator, we begin to think about liberating the personnel from the bedside. How does this create new opportunities  to move expertise where needed and when needed? Dr. Halperin spoke of the Netson Project, which is really very much a stripped down in a cell phone level of critical care.  But how can we use that idea  and take the care that we provide today and mobilize it throughout the United States tomorrow and for that matter, the globe?  I agree 100%. But even locally within the hospital, we have to reimagine how we design hospitals in the future. The stresses that hospitals will put under  to move care just outside the room, the bed of the ICU and to put it up elsewhere in the building speaks to that we need power and data and better wireless communication,  even in the local ICU or in areas of the hospital that should be able to be converted to ICUs almost at the drop of a hat. And in Memorial, I've gotten support  and we've taken two floors that we have put in all the elements needed to convert those floors to ICUs almost literally at the drop of a hat.  So locally and nationally, and I agree very much.  Our focus at the bedside really was forced to be changed to a different type of focus.  Great, I think that's it for time. I wanna thank Dr. Buckman and Dr. Halpern for their excellent presentations. Thank you SCCM for this great content.  And with that, I bid you all adieu.  Thank you.

Video Summary

In this video, Dr. Timothy Buchman and Dr. Neil Halpern discuss the future of critical care. Dr. Halpern focuses on the evolution of a new care model in the ICU, discussing the challenges that the COVID-19 pandemic has presented and the need to rethink ICU design and care delivery. He explains how the pandemic has required a shift towards a hybrid model of care that combines bedside and remote care, with the use of technologies such as remote control ventilators. Dr. Halpern also discusses the acute expansion of ICU capacity, both at the local level and at larger levels, such as regional or national. He highlights the need for a reimagining of ICU design and the incorporation of lessons learned from the pandemic in order to better prepare for future emergencies. Additionally, he emphasizes the importance of incorporating technology into critical care provider skill sets and the need to prioritize resourcing and staffing needs, including the consideration of regional teams of healthcare providers. In conclusion, Dr. Halpern emphasizes the importance of standing on the shoulders of the giants who have come before us and the need for ongoing collaboration and innovation in order to provide the best possible care for critical care patients. Dr. Buckman adds that it is important to revisit and consider the ideas of the past to find answers to today's questions. He also highlights the need for task reallocation and the reimagining of critical care delivery, emphasizing the importance of leveraging technology to provide care more efficiently and effectively.

Asset Subtitle

Professional Development and Education, Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Describe how the vision of SCCM's founding members helped shape our ICU of today and tomorrow
Contemplate the future of ICU design and patient care delivery
Analyze the importance of a multiprofessional staff in finding solutions

The Future of ICU Care Delivery and Design: Looking Into the Crystal Ball
Neil A. Halpern

Standing on the Shoulders of Giants
Timothy G. Buchman

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Area Crisis Management

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Healthcare Delivery

Tag Resource Allocation

Year 2021

Keywords

future of critical care

care model in the ICU

rethinking ICU design

hybrid model of care

remote control ventilators

expansion of ICU capacity

lessons learned from the pandemic

technology in critical care

efficient critical care delivery

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