ICU resources for Cardiac Surgery Patients
There have been a lot of discussions should all the ICU treatments be under same management control, or should we have highly spesified units (e.g. cardiac surgery icu)
We have clinical Expertise centers at our University Hospital. Our own unit is Heart and Lung center (others like e .g. Abdominal, Psychiatric, Cancer, Anesthesiology, intensive care and pain, Emergency, Children and Adolescents etc.). We have our own separate cardiac surgery ICU with eleven beds and we are performing annually 1200-1300 open heart cases; 1250 last year, this year at least 1350 cases. Problem is our cardiac surgery ICU capacity. I think that normal capacity resource should be at least 1-bed/ 100 cardiac surgery patients worldwide. Our national responsibility includes TX, VAD, PEA, and ACH surgery, there is no other hospital in our country performing these resources demanding surgery (TX, VAD, PEA, ACH, ECMO), but there are 4 other centers performing ”general” heart surgery. Our hospital has general ICU, which could take some of our easiest cases for postoperative treatment. But there are big differences in culture how to treat these patients. E.g. if 75-year-old patient has been operated for normal AVR, this patient would be extubated at our unit early after operation. In general ICU this patient is still on ventilator next day after operation. This causes increase in costs and also complications and morbidity. Also in hospital mortality is much higher in general ICU than cardiac surgery ICU for same kind of patients. I think that the process or patient care for cardiac surgery should be in same organization under our management. We should have more space for our cardiac surgery ICU patients. What are your recommendations? -should we hire more space from general ICU under our management policy? So that we would be in charge, when we are treating these patients. -or should we just buy these ICU nights from general ICU under their management? -Or should we build total new ICU? Hospitals 1-4 are other University Hospitals in our country. CSICU = cardiac surgery icu.
This is a challenge, but once an organization goes to subspecialty ICU care it is next to impossible to revert back. Closed units develop their own cultures and standards that the providers are comfortable with, so even if the actual outcomes would be the same, it is challenging to house patients in a different unit with different cultures. Once a certain volume is reached there are very clear benefits to a cardiac or other specialty ICU and you have certain reached that volume. Is it possible to have some patients in the other ICU, but that receive care from the cardiac surgery team or in conjunction with your team? Having them in the other unit not being cared for by the cardiac team is extremely challenging and unlikely to lead to good care and good relationships with the other unit. If you get better by doing a lot of something, it would be hard for a unit that only takes overflow volume to become good at caring for complex patients that they only see infrequently.
Our hospital provides for complex surgical cases that range from lung transplant surgeries to cardiac cases, covering less demanding general surgery patients as well.
We opted to go for a general 30 bed ICU, realizing that all these surgical cases shared an estimated 75-90% of the same resources; antibiotics, inotropic drugs, some sort of mechanical assistance …
However, we devised some critical functional units within the ICU to treat certain conditions that required special resources/knowledge.
As such, I was in charge of the postoperative management of all lung transplant cases; supervising my team, managing specific resources for this subset of patients, interacting with the thoracic surgeons and pulmonologists.
My other peers would be in charge of different surgical units.
However, we all shared the same space, shared most of the physical resources, performed our daily meetings – where we would share our patient´s status together – and we all benefited from this knowledge-sharing meetings.
We created a culture of synergistic cooperation while fostering subespecialization through the creation of functional work teams and avoided the duplication of activities and resources that would come along with the creation of separate ICUs in a general hospital such as ours.