The Lay of the Land The intensive care unit is the place where care is provided to the sickest patients in the hospital. When a patient’s condition is listed as ‘critical’, the intensive care unit is the place they will be in the hospital. It is the place where life-sustaining and life-saving care is provided. This can be in the form of a ventilator to help a patient whose has respiratory (lung) failure and in the powerful intravenous (IV) medicines that can be given to keep a patient’s blood pressure up and support the heart in providing the necessary circulation of blood and oxygen required for life. It is also the place where patient’s vital signs (blood pressure, temperature, breathing, and heart rate) are monitored more closely than any other place in the hospital*. It is the place where medical ‘miracles’ sometimes happen when a patient has an especially good recovery or survives against the bleakest of odds. It also can be a very overwhelming place for both patients and their families.
ICU care is complicated and can be extraordinarily so on multiple levels. This multilevel complexity extends from the care provided directly to the patient to all the support systems and staff that make up an ICU. The medical care to our patients will be the subject matter of multiple posts on this site. This post aims to give a brief description of the operation of the ICU.
An important aspect of the ICU that distinguishes it from the rest of the hospital is the staff. The patient to nurse ratios are the lowest in the hospital with a nurse typically responsible for caring for only 1 or 2 patients at a time. There is a physician specializing in the care of critical ill patients, called an intensivist, along multiple other physicians sometimes involved from different medical specialties. The patient’s primary care physician or another assigned primary care physician often called a hospitalist also typically follows patients in the ICU. Along with nurses and physicians are pharmacists, social and case workers, physical, occupational, speech and respiratory therapists. Pastoral care personnel round out the team and can provide invaluable services in helping patients and families cope with the catastrophic illness so often present in the ICU.
The intensivist should be coordinating the care among all the staff. This is no small task. One vexing issue in the ICU is the lack of communication among the staff and this also extends to the communication between the staff and the patients and their families. The intensivist should be responsible for the effective flow of information between all the parties whether that be between the staff themselves or between the staff and the patients and their families.
The intensivist should also be coordinating medical care often provided by multiple specialists. She or he should have excellent leadership and communication skills along with possessing the medical knowledge and skill set needed in the care of these very sick and complicated patients. One of the new trends in ICU care is a multidisciplinary team approach where each team member’s input is sought and valued so it is important for the intensivist to seek out and value everyone’s input and point of view.
The intensivist should be able to speak to patients and families in clear and understandable language. Often medical people slip into speaking with medical terms that are not understood and patients and families will not ask questions regarding such language. Within the emotionally charge atmosphere of an ICU, it is paramount that open communication occurs with clear understanding by all parties.
The intensivist should be readily available for ongoing and frequent discussions. Generally, it is best to designate one individual as the point person in these sometimes lengthy and detailed discussions who may then impart important information to other family and friends. It is not practical for the intensivist to have repeat discussions of repeated issues with multiple family members. At the same time, the patient, family and those close to the patient should be able to have their questions and issues addressed in timely manner without feeling they are imposing upon the staff. If there is an urgent or emergent issue which precludes a discussion at that moment than that should be made clear with the understanding that the discussion can occur at a later time. Again, communication is so key in the ICU that what may seem like time consuming and difficult discussions will in the end make for better care and actually save time by effectively addressing burdensome and difficult issues.
Surprisingly, less than half of all the patients in intensive care units in the United States at any given time are under the direct care of an intensivist.