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Journal ArticleDOI

The critical care cascade: a systems approach.

01 Aug 2009-Current Opinion in Critical Care (Lippincott Williams and Wilkins)-Vol. 15, Iss: 4, pp 279-283
TL;DR: The basis and rationale for the ‘critical care cascade’ concept, which contends that the optimal management of critically ill patients should be a continuum of care through the healthcare system, are discussed.
Abstract: Purpose of review To emphasize the evolving body of evidence that supports the need for a more seamless and interconnected continuum of patient care for a growing compendium of critical care conditions, starting in the prehospital and emergency department (ED) phases of management and continuing through ICU and rehabilitation services. Recent findings The care of critically ill and injured patients has become increasingly complex. It now has been demonstrated that, for a number of such critical care conditions, optimal management not only relies heavily on the talents of highly coordinated, multidisciplinary teams, but it also may require shared responsibilities across a continuum of longitudinal care involving numerous specialties and departments. This continuum usually needs to begin in the prehospital and ED settings with management extending through specialized in-hospital diagnostic and interventional suites to traditional ICU and rehabilitation programs. In recent years, examples of these conditions have included the development of systems of care for trauma, cardiac arrest, myocardial infarction, stroke, sepsis syndromes, toxicology and other critical illnesses. Although the widespread implementation of such multidisciplinary, multispecialty critical care cascades of care has been achieved most commonly in trauma care, current healthcare delivery systems generally tend to employ compartmentalized organization for the majority of other critical care patients. Accordingly, optimal systematic care often breaks down in the management of these complex patients due to barriers such as lack of interoperable communication between teams, disjointed transfers between services, unnecessary time-consuming, re-evaluations and transitional pauses in time-dependent circumstances, deficiencies in cross-disciplinary education and quality assurance loops, and significant variability in patient care practices. Such barriers can lead to adverse outcomes in this fragile patient population. Summary This article discusses the basis and rationale for the 'critical care cascade' concept, which contends that the optimal management of critically ill patients should be a continuum of care through the healthcare system. In the critical care cascade, each patient is enrolled on a 'pathway' of management based on their working diagnosis and each and every healthcare provider engaged along that continuum acts as part of a interconnected coordinated team that ensures a specific endpoint for these patients in a bundled manner that seamlessly extends from the prehospital and ED phases to the ICU and rehabilitation services.
Citations
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Journal ArticleDOI
TL;DR: Raising awareness of post–intensive care syndrome for the public and both critical care and non–critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness.
Abstract: Background Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post-intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. Objectives To report on engagement with non-critical care providers and survivors during the 2012 Society of Critical Care Medicine post-intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. Participants Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. Design Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. Meeting outcomes Future steps were planned regarding 1) recognizing, preventing, and treating post-intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post-intensive care syndrome across the continuum of care, including explicit "functional reconciliation" (assessing gaps between a patient's pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post-intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. Conclusions Raising awareness of post-intensive care syndrome for the public and both critical care and non-critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

318 citations


Cites background from "The critical care cascade: a system..."

  • ...As this work evolves, explicit documentation (“functional reconciliation”) and communication (“handoffs”) resources can be developed and evaluated in clinical practice, particularly during transitions of care (42), as an important patient care and safety issue for patients at risk of PICS....

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Journal ArticleDOI
TL;DR: The amount ofcritical care provided in U.S. EDs has increased substantially over the past decade, driven by increasing numbers of critical care ED visits and lengthening ED length of stay.
Abstract: The burden of caring for critically ill patients in the United States is massive, currently accounting for nearly 1% of the gross domestic product and affecting large sectors of the U.S. healthcare system including the emergency department (ED) (1–3). The majority of critical care in the United States are provided to patients over the age of 65, and this population is predicted to grow by 50% from 2000 to 2020 (4, 5). The rising demand for critical care in the face of already insufficient capacity has become an area of concern for clinicians, hospital administrators, and policymakers (6–9). In 2000, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine Committee on Manpower for Pulmonary and Critical Care Societies forecast large shortfalls in the critical care workforce. A 2006 Health Resources and Services Administration report to Congress not only confirmed the predicted shortages, but also projected worsening shortages into the future (4). There currently exist little data on how system-wide increases in the demand for critical care are affecting U.S. EDs. Most patients, critically ill patients in the United States are admitted from an ED (10). These patients typically require medically complex and resource intensive care often begins outside the ICU in the ED (2, 3, 10, 11). The provision of critical care in the ED is a potentially important factor in ED crowding. The Institute of Medicine report “Hospital-Based Emergency Care: At The Breaking Point” identified that the inability to promptly admit critically ill ED patients to inpatient beds can lead to boarding and contributes to ED crowding (12). Several studies suggest that the proportion of critically ill patients presenting to U.S. EDs is increasing (13–15). Additionally, other studies have questioned the ability of many EDs to provide optimal care for critically ill patients in crowded conditions and linked prolonged ED stays by critically ill patients with increased mortality (16–18). This study investigates changes in the total hours of ED care provided to patients ultimately admitted to an ICU from U.S. EDs between 2001 and 2009. To evaluate the hypothesis that EDs are providing an increasing amount of critical care, we examined both trends in ED visit ICU admissions and trends in the median ED length of stay (EDLOS) for these patients. Additionally, we analyzed trends in the national ED capacity to estimate changes in the average daily hours of care provided to patients admitted to an ICU at an average U.S. ED.

115 citations

Journal ArticleDOI
03 Jun 2013-PLOS ONE
TL;DR: Functional recovery may play an important role in explaining SES-mortality gradients following AMI, and the effects of functional recovery on S ES-m mortality associations were not explained by access inequities to physician specialists or cardiac rehabilitation.
Abstract: Objectives To examine the relationship between socio-economic status (SES), functional recovery and long-term mortality following acute myocardial infarction (AMI).

90 citations

Journal ArticleDOI
01 Sep 2017-Shock
TL;DR: EoT was present at the scene of injury and prehospital interventions aimed at endothelial restoration may represent a clinically meaningful target for prehospital resuscitation.
Abstract: Background:Trauma patients are vulnerable to coagulopathy and inflammatory dysfunction associated with endotheliopathy of trauma (EoT). In vitro evidence has suggested that tranexamic acid (TXA) may ameliorate endotheliopathy. We aimed to investigate how soon after injury EoT occurs, its ass

74 citations


Cites background from "The critical care cascade: a system..."

  • ...Rather than waiting until arrival in hospital to attempt to address pathological processes, there may be some justification for working toward earlier, and more bespoke, intervention for critically unwell patients (28)....

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Journal ArticleDOI
TL;DR: A multidisciplinary cardiogenic shock team is recommended to guide the rapid and efficient use of these available treatments, making time‐dependent decision‐making more challenging.
Abstract: Cardiogenic shock is a common clinical condition with high in-hospital mortality. Early application of appropriate interventions for cardiogenic shock-including medical therapies, revascularization, temporary hemodynamic support devices, and durable mechanical circulatory support-may improve outcomes. The number and complexity of therapies for cardiogenic shock are increasing, making time-dependent decision-making more challenging. A multidisciplinary cardiogenic shock team is recommended to guide the rapid and efficient use of these available treatments. © 2015 Wiley Periodicals, Inc.

72 citations


Cites background from "The critical care cascade: a system..."

  • ...Similar systems have been developed for care of stroke, sepsis, and acute poisoning [43]....

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References
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Journal ArticleDOI
TL;DR: This study randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit.
Abstract: Background Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit. Methods We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups. Results Of the 263 enrolled patients, 130 were ...

8,811 citations

Journal ArticleDOI
01 Apr 2003-Stroke
TL;DR: In this article, the authors provide updated recommendations that can be used by primary care physicians, emergency medicine physicians, neurologists, and other physicians who provide acute stroke care from admission to an emergency department through the first 24 to 48 hours of hospitalization by addressing the diagnosis and emergent treatment of the acute ischemic stroke in addition to the management of its acute and subacute neurological and medical complications.
Abstract: In 1994, a panel appointed by the Stroke Council of the American Heart Association authored guidelines for the management of patients with acute ischemic stroke.1 After the approval of the use of intravenous recombinant tissue plasminogen activator (rtPA) for treatment of acute ischemic stroke by the Food and Drug Administration, the guidelines were supplemented by a series of recommendations 2 years later.2 Several promising interventions for the treatment of acute ischemic stroke have subsequently been tested in clinical trials, and other components of acute management have been evaluated since the previous guidelines were published. These new data have prompted the present revision of the prior guideline statement. The goal of these guidelines is to provide updated recommendations that can be used by primary care physicians, emergency medicine physicians, neurologists, and other physicians who provide acute stroke care from admission to an emergency department through the first 24 to 48 hours of hospitalization by addressing the diagnosis and emergent treatment of the acute ischemic stroke in addition to the management of its acute and subacute neurological and medical complications. Several groups have now written statements about management of stroke.3–7 These statements also include recommendations about public educational programs, the organization of stroke resources, and other aspects of patient management. For example, the Brain Attack Coalition published recommendations for organizing stroke services in a community, and the recommendations of the American Heart Association Emergency Cardiovascular Care Committee provide an outline for emergency medical services.6 The current panel elected not to duplicate these recent efforts. Therapies to prevent recurrent stroke, also a component of acute management, are similar to prophylactic medical or surgical therapies used for patients with transient ischemic attacks and other high-risk patients. The reader is referred to relevant recent statements for additional information.8,9 In developing …

1,325 citations

Journal ArticleDOI
TL;DR: A detailed literature and historical record search for support of the "golden hour" concept is discussed, finding none is identified.
Abstract: The term “golden hour” is commonly used to characterize the urgent need for the care of trauma patients This term implies that morbidity and mortality are affected if care is not instituted within the first hour after injury This concept justifies much of our current trauma system However, definitive references are generally not provided when this concept is discussed It remains unclear whether objective data exist This article discusses a detailed literature and historical record search for support of the “golden hour” concept None is identified

429 citations

Journal ArticleDOI
TL;DR: These pilot data suggest that infusion of up to 2 L of 4°C normal saline in the field is feasible, safe, and effective in lowering temperature, and it is proposed that the effect of this cooling method on neurological outcome after cardiac arrest be studied in larger numbers of patients, especially those whose initial rhythm is ventricular fibrillation.
Abstract: Background— Although delayed hospital cooling has been demonstrated to improve outcome after cardiac arrest, in-field cooling started immediately after the return of spontaneous circulation may be more beneficial. The aims of the present pilot study were to assess the feasibility, safety, and effectiveness of in-field cooling. Methods and Results— We determined the effect on esophageal temperature, before hospital arrival, of infusing up to 2 L of 4°C normal saline as soon as possible after resuscitation from out-of-hospital cardiac arrest. A total of 125 such patients were randomized to receive standard care with or without intravenous cooling. Of the 63 patients randomized to cooling, 49 (78%) received an infusion of 500 to 2000 mL of 4°C normal saline before hospital arrival. These 63 patients experienced a mean temperature decrease of 1.24±1°C with a hospital arrival temperature of 34.7°C, whereas the 62 patients not randomized to cooling experienced a mean temperature increase of 0.10±0.94°C (P<0.000...

416 citations