Critical care is an enormously complex system of care to render. Its complexity is from how sick and complicated patients are but this complexity is also spread across all facets of care. One of the roots of this complexity is variability. This variability is harbored in great differences in how individual patients respond to severe illness both in how sick they get and in how they may or may not respond to treatment. There is also variability in how critical illness is treated and this in turn occurs at multiple levels starting with how such care is initiated, maintained, and ended. There are big differences in how individual critical care physicians practice. There are differences in how patients, once they are identified as critically ill are started on appropriate treatment.
One factor has emerged in the care of the critically ill is that time is of the utmost importance: it is manifestly essential that critical care be started as soon as possible. Delays in care are associated with more severe illness and increased mortality. It is imperative that we catch such patients early and indeed, delays in the identification of severe illness and the institution of definitive care is an area that needs particular focus.
It can be difficult to identify such patients early in their illness because key signs of how sick they are or may become are often subtle and can easily be overlooked. The failure to identify and act in a timely manner can be catastrophic. Critical care illness is an absolute emergency. This also fits into this idea of variability that results in differences in how such sick patients are treated. One physician or institution may be especially good at getting the critically care patients the quick and definitive care they need whereas another practitioner may miss some of the subtle findings that herald severe illness. An institution may not have fostered a good communication system between the emergency room staff and the critical care physicians so that there delays result in both the identification and treatment of a critically ill patient. Such delays in care can also happen in the hospital when a patient is on a general hospital floor and gets sicker. We all have heard horror stories of patients languishing on the hospital floor or in the emergency room.
The variability in the care provided between institutions can also be great. Most of the care in this country is provided by small to medium size community hospitals. Nearly all the research occurs at major university teaching hospitals which only account for about 10-15% of the care in this country. There is also a separation between practitioners at teaching institutions and those at community hospitals. Those at teaching institutions tend to forge their entire careers in academics whereas those in the community likewise forge theirs in smaller hospitals and private practices. Needless to say, there are also variations in the culture, philosophy of care, and availability of resources between these large academic institutions and smaller community health systems.
One review article published within the last few years in the New England Journal of Medicine by two pulmonary and critical care physicians outlined an aggressive program for removing patients off of ventilators (McConville JF, Kress, JP. NEJM. 2012) . For patients in the intensive care unit on ventilators, half or more of their intensive care stay is spent trying to get them off ventilators. So this is an important issue in our field. These academic authors advocated a program in which they were very aggressive in removing the ventilator. For one thing, they took patients off of the ventilators during the night as long as certain parameters were met. This practice likely results in higher than expected failure rates with more patients having to be put back on ventilators, which the authors openly point out. They justified the suspected higher failure rate surmising that this offset the risk of further and worsening illness associated with continued ventilator support.
There are several points that merit consideration. One is that there is medical literature supporting that those patients who fail being removed off ventilator successfully not only do worse but this worsening is associated with a failure to be removed from the ventilator and having to be put back on. Getting this right makes them better, getting this wrong can make them worse. Another point is that these practitioners are at an institution in where there is ample support to deal with a patient who had failed to be removed from the ventilator and has to be put back on even if this is in the middle of the night. This typically involves an anesthesiologist or a healthcare professional with anesthesiology skills re-inserting a breathing tube. Many community hospitals do not have that same degree of support as larger teaching institutions especially at night.
There is medical literature supporting that there higher success rates of patients being removed off of ventilators when this process is started so that the tube can be removed early in the day. At smaller community hospitals, there are more available staff around during the day to closely follow the patient and act to maybe avert having to place a patient back on the ventilator and if when the patient does need to be placed back on the ventilator, then someone is around to do it. There is much less staff around in the middle of the night immediately available.
The feasibility of such a program in a community hospital is suspect from a logistical perspective where there is not the resources or support that a big university system has. The application of such a program whole scale would probably be disastrous with many patients failing and having to be put back on ventilators. It’s not that such a program is untenable. At large academic teaching institutions where there are residents, fellows, and even attending physicians available even in the middle of the night, it may be feasible. Whether this actually would result in better care presumably offsetting the increased risk of getting sicker the longer otherwise patients would need to be on the ventilator would to be studied. The point is that there are large differences in how medical care is delivered across the healthcare spectrum and this variability is a barrier developing and initiating performance improvement initiatives that can successfully undergo wide scale implementation.
I will go further and say that much of the research in our field is severely hampered by all of this variability. In medical statistics, this variability is more commonly referred to as heterogeneity. It is difficult, if not impossible, to find out what works and doesn’t when the care is all over the map. There needs to be more consistency in our system care for us to optimally find ways to improve it. How to go about reducing this variability is also very complicated. One obvious place is to start with physicians and from the most rudimentary perspective: the processes of how we see and treat patients and this is a whole other topic.