Our expert answers 3 Questions
As a pulmonary critical care physician, I spend a lot of time thinking about the decision making that happens in the intensive care setting. How do we identify which patients should be sent to the intensive care unit (ICU), and how long should they stay? When do the potential harms of ICU care outweigh the potential benefits, and for whom? The answers to these questions aren’t always obvious. In practice, clinicians lack precise guidelines to help identify which patients should go to the ICU. Their decisions can also be influenced by lots of other factors entirely unrelated to the patient, such as the availability of ICU beds, how sick the other patients are, and a variety of hospital-level factors. The goal of my research is to understand and improve decision-making in the ICU for providers, patients, and families to help ensure this care is the safest and most effective it can be. Part of this involves examining patterns from past decisions to improve upon future decision making and outcomes.
For some patients – such as those requiring ventilators or other types of life support, and who require close monitoring by specialists – the ICU is obviously where they need to be to recover. For other patients on the borderline of needing intensive care, the benefits of the ICU are less certain. There are also potential, often underrecognized harms involved with ICU care, such as increased risks for infection, complications, anxiety, pain and discomfort, and undergoing potentially unnecessary or harmful procedures.
The ICU also involves expensive and resource-intensive treatment (25% of patients in hospitals receive ICU care but account for 50% of all hospital costs), and on a healthcare systems level, putting people in the ICU unnecessarily contributes to excess costs and inefficiency. And with limited availability of ICU beds, having patients who don’t truly need to be there constricts options for others who do. We need to better enable clinicians to identify which patients are likely to benefit from ICU care.
In one study, we’re trying to help clinicians better identify the causes of acute respiratory failure, one of the major reasons someone can end up in the ICU. A variety of conditions can lead to acute respiratory failure, but determining the root of the problem and how to treat it efficiently can be extraordinarily difficult. We are developing a video game to help physicians hone their diagnostic abilities specifically for this illness; this will allow them to practice and receive feedback within a virtual training environment, with the added motivation of a gaming setting that goes beyond typical simulation exercises that have become more common in medical training.
Our team is also trying to understand ICU decisions at the organizational level through surveys, observation, and interviews with critical care, ER, and hospitalist physicians and nursing leaders in hospitals around the state. We know new strategies are needed to improve how we use ICUs and reduce associated healthcare costs, but we need to reassess the best ways to do that. All of this work is intended to find ways to use the ICU more efficiently while also ensuring that patients who need this kind of advanced care are not overlooked.