18. Haeuptle J, Zaborsky R, Fiumefreddo R, et al. Prognostic value of procalcitonin in Legionella pneumonia. Eur J Clin Microbiol Infect Dis. 2009;28(1):55-60. 19. Eryüksel E, Karakurt S, Balci M, Celikel T. Non-invasive positive pressure ventilation for a severe Legionella pneumonia case. Tuberk Toraks. 2009;57(3):348-351. 20. Bryner B, Miskulin J, Smith C, et al. Extracorporeal life support for acute respiratory distress syndrome due to severe Legionella pneumonia [published online ahead of print July 17, 2013]. Perfusion. doi:10.1177/0267659113497229. 21. Pedro-Botet L, Yu VL. Legionella: macrolides or quinolones? Clin Microbiol Infect. 2006;12(suppl 3):25-30. 22. Varner TR, Bookstaver PB, Rudisill CN, Albrecht H. Role of rifampin-based combination therapy for severe communityacquired Legionella pneumophila pneumonia. Ann Pharmacother. 2011;45(7-8):967-976. 23. Lettinga KD, Verbon A, Nieuwkerk PT, et al. Health-related quality of life and posttraumatic stress disorder among survivors of an outbreak of Legionnaires disease. Clin Infect Dis. 2002;35(1):11-17.
Evolution of ICU Design Smarter Is Better care medicine is commonly considered to Intensive originate with the systematic management of polio-
myelitis victims suffering from respiratory failure in the 1950s. Large numbers of patients had a lifethreatening medical problem: acute respiratory failure, for which there was a high tech treatment strategy— the iron lung respirator. By placing these patients in a common hospital setting—among the earliest ICUs— effective medical care could be administered more efficiently by experts using highly specialized equipment and providing comprehensive standardized care. Historical photographs of the expansive open wards that housed the many poliomyelitis patients and their ventilators illustrate the systematic approach applied to the problem but also underscore how little resemblance these early “ICUs” bear to modern ICUs. Beginning with this issue of CHEST (see page 399), Halpern1-3 provides an insightful and in-depth review of ICU structure and function in a series of three articles aptly titled “Innovative Designs for the Smart ICU.” He brings considerable first-hand experience to the task and is the recipient of awards related to exceptional ICU design. His reviews emphasize the many practical aspects of the process of ICU design and implementation and will be a valuable resource for all individuals who are contemplating new ICU construction or ICU renovation. Particularly noteworthy is the substantial emphasis on the increasingly important and complex issue of ICU informatics.3 Halpern1 frames the challenge of ICU design with the observation that, based upon 2005 data, there are at least 6,300 ICUs and 94,000 ICU beds in the United States,1 with the number continuing to rise despite
journal.publications.chestnet.org
a decline in total hospital beds.4 Indeed, the United States has far more ICU beds for its population (estimated to be about 25 per 100,000 people) than any other country, including roughly twice that for Canada, fourfold more than in the United Kingdom, eightfold more than in China, and 15-fold higher than in developing countries.5 In addition to differences in the number of beds per population around the world, there are dramatic differences in the facilities, technology, and staffing, typically driven by resource limitations and health-care spending.5 The number of ICU beds actually required to meet the needs of critically ill patients worldwide is not known. An argument can be made for expanding ICU bed numbers where shortages are present. Research shows that mortality is higher among patients who are refused ICU admission because of bed shortage6 and is lower for patients admitted directly to the ICU in a timely fashion rather than after a delay.7 On the other hand, there may be an excess number of US ICU beds, since as many as one-third of all ICU bed-hours in US ICUs were not occupied by a patient in an analysis of . 225,000 consecutive ICU admissions.8 It may be that ICU beds are not optimally distributed, since the mean hourly occupancy was significantly higher for academic hospitals, where particularly complex ICU care is often provided.8 Regardless of the ideal number of ICU beds, the upgrading of older ICUs to meet newer standards, whether by renovation of existing space or construction of a new ICU with closing of the old one, is a common occurrence. The basic tenet of the ICU, that of bringing together the personnel expertise and the necessary equipment to provide immediate care of the critically ill patient with particular emphasis on close monitoring and provision of support for failing organs, has not changed in many decades and remains at the core of ICU design. Earlier ICU design placed substantial emphasis on monitoring and direct observation of patients in all ICU beds from a central station. Indeed, placing an unstable patient into a low-visibility room has been linked to worse outcomes.9 However, ICU beds were often in open areas separated only by curtains to be drawn as needed to provide privacy. This approach had clear trade-offs with patient privacy, comfort, and infection control. Although there has long been concern for the high noise levels, this was generally accepted as part of the ICU setting—perhaps in part because patients who are mechanically ventilated in the ICU were routinely maintained in a state of deep sedation. Similarly, an open environment eliminated the natural barriers for hand hygiene, as a care provider often could merely turned 180 degrees and take one or two steps to attend to a second patient. Finally, family visitation was often brief and uncomfortable at the bedside. We have entered an era of critical care in which considerably CHEST / 145 / 2 / FEBRUARY 2014
205
more emphasis is placed on creating a healing environment of care.10,11 The ICU remains the hospital location of choice for rapid and coordinated resuscitation and stabilization. But now there is equal emphasis on creating an environment that is more attuned to patient privacy and comfort, support of visiting family and loved ones, and effective infection control. As discussed by Halpern,2 the form and function of the modern ICU room should be designed to meet the dual needs of effective patient care for life-threatening illness and injury and of a supportive environment for healing and well-being of patients, visitors, and staff. Perhaps the most substantial change in modern ICUs has been the progressive integration of information systems and the vast array of electronic devices. The goal is for comprehensive electronic integration of the patient with all aspects of care and transformation of patient-related data into useful and actionable information.3 Early efforts in informatics and electronic processes focused on computerized order entry and bedside physiologic monitoring. More recently there has been rapid expansion of electronic medical records into ICUs. This has been followed by development of systems for data management and decision support of electronic medical record data that enhance the quality and efficiency of patient care—an aspect of ICU design that holds great promise. Real-time data analysis can support “smart” alerts that identify patients at risk for clinical deterioration or for harm from preventable untoward events, such as a drug-drug interaction. Some proprietary systems integrate such alerts into dashboards and may be linked to telemedicine monitoring remotely.12 Other electronic advances that enhance patient safety include bar code scanners and infusion pump drug libraries and dosing limits. Although electronic integration of the many devices commonly used in ICU care, such as physiologic monitors, infusion pumps, mechanical ventilators, dialysis machines, and point-of-care testing instruments, has historically been challenging, interoperability can be enhanced through the use of “middleware,” as outlined by Halpern.3 In summary, creation of “smart” ICUs, including a logical structure of the entire ICU, well-conceived ICU room layouts and integrated electronic devices, and robust information systems leveraged to deliver useful and timely information, can contribute to the important goals of better patient outcomes, enhanced patient safety, and a supportive environment for patients, their loved ones, and health-care workers. Curtis N. Sessler, MD, FCCP Richmond, VA Affiliations: From the Center for Adult Critical Care, Medical Respiratory ICU, Medical College of Virginia Hospitals and Physicians, Virginia Commonwealth University Health System. 206
Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Curtis N. Sessler, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Box 980050, Richmond, VA 23298; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-2746
References 1. Halpern NA. Innovative designs for the smart ICU: part 1: from initial thoughts to occupancy. Chest. 2014;145(2):399-403. 2. Halpern NA. Innovative designs for the smart ICU: part 2: the ICU. Chest. In press. doi:10.1378/chest.13-0004. 3. Halpern NA. Innovative designs for the smart ICU: part 3: advanced ICU informatics. Chest. In press. doi:10.1378/ chest.13-0005. 4. Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38(1):65-71. 5. Prin M, Wunsch H. International comparisons of intensive care: informing outcomes and improving standards. Curr Opin Crit Care. 2012;18(6):700-706. 6. Robert R, Reignier J, Tournoux-Facon C, et al; Association des Réanimateurs du Centre Ouest Group. Refusal of intensive care unit admission due to a full unit: impact on mortality. Am J Respir Crit Care Med. 2012;185(10):1081-1087. 7. Simchen E, Sprung CL, Galai N, et al. Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds. Crit Care Med. 2004;32(8): 1654-1661. 8. Wunsch H, Wagner J, Herlim M, Chong DH, Kramer AA, Halpern SD. ICU occupancy and mechanical ventilator use in the United States. Crit Care Med. 2013;41(12):2712-2719. 9. Leaf DE, Homel P, Factor PH. Relationship between ICU design and mortality. Chest. 2010;137(5):1022-1027. 10. Bartley J, Streifel AJ. Design of the environment of care for safety of patients and personnel: does form follow function or vice versa in the intensive care unit? Crit Care Med. 2010; 38(suppl 8):S388-S398. 11. Kesecioglu J, Schneider MME, van der Kooi AW, Bion J. Structure and function: planning a new ICU to optimize patient care. Curr Opin Crit Care. 2012;18(6):688-692. 12. Lilly CM, Cody S, Zhao H, et al; University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175-2183.
Whether a Bill Becomes a Law of us remember the classic Saturday morning MostSchool House Rock segment, “I’m Just a Bill,”
which taught us the steps on how a bill becomes a law. While entertaining and informative, it did not address the many other factors that often determine whether a bill makes it into law. Before identifying those factors, I want to discuss challenges and opportunities regarding the future of the Medicare program. Medicare is critically important,
Editorials
Evolution of ICU Design Smarter Is Better care medicine is commonly considered to Intensive originate with the systematic management of polio-
myelitis victims suffering from respiratory failure in the 1950s. Large numbers of patients had a lifethreatening medical problem: acute respiratory failure, for which there was a high tech treatment strategy— the iron lung respirator. By placing these patients in a common hospital setting—among the earliest ICUs— effective medical care could be administered more efficiently by experts using highly specialized equipment and providing comprehensive standardized care. Historical photographs of the expansive open wards that housed the many poliomyelitis patients and their ventilators illustrate the systematic approach applied to the problem but also underscore how little resemblance these early “ICUs” bear to modern ICUs. Beginning with this issue of CHEST (see page 399), Halpern1-3 provides an insightful and in-depth review of ICU structure and function in a series of three articles aptly titled “Innovative Designs for the Smart ICU.” He brings considerable first-hand experience to the task and is the recipient of awards related to exceptional ICU design. His reviews emphasize the many practical aspects of the process of ICU design and implementation and will be a valuable resource for all individuals who are contemplating new ICU construction or ICU renovation. Particularly noteworthy is the substantial emphasis on the increasingly important and complex issue of ICU informatics.3 Halpern1 frames the challenge of ICU design with the observation that, based upon 2005 data, there are at least 6,300 ICUs and 94,000 ICU beds in the United States,1 with the number continuing to rise despite
journal.publications.chestnet.org
a decline in total hospital beds.4 Indeed, the United States has far more ICU beds for its population (estimated to be about 25 per 100,000 people) than any other country, including roughly twice that for Canada, fourfold more than in the United Kingdom, eightfold more than in China, and 15-fold higher than in developing countries.5 In addition to differences in the number of beds per population around the world, there are dramatic differences in the facilities, technology, and staffing, typically driven by resource limitations and health-care spending.5 The number of ICU beds actually required to meet the needs of critically ill patients worldwide is not known. An argument can be made for expanding ICU bed numbers where shortages are present. Research shows that mortality is higher among patients who are refused ICU admission because of bed shortage6 and is lower for patients admitted directly to the ICU in a timely fashion rather than after a delay.7 On the other hand, there may be an excess number of US ICU beds, since as many as one-third of all ICU bed-hours in US ICUs were not occupied by a patient in an analysis of . 225,000 consecutive ICU admissions.8 It may be that ICU beds are not optimally distributed, since the mean hourly occupancy was significantly higher for academic hospitals, where particularly complex ICU care is often provided.8 Regardless of the ideal number of ICU beds, the upgrading of older ICUs to meet newer standards, whether by renovation of existing space or construction of a new ICU with closing of the old one, is a common occurrence. The basic tenet of the ICU, that of bringing together the personnel expertise and the necessary equipment to provide immediate care of the critically ill patient with particular emphasis on close monitoring and provision of support for failing organs, has not changed in many decades and remains at the core of ICU design. Earlier ICU design placed substantial emphasis on monitoring and direct observation of patients in all ICU beds from a central station. Indeed, placing an unstable patient into a low-visibility room has been linked to worse outcomes.9 However, ICU beds were often in open areas separated only by curtains to be drawn as needed to provide privacy. This approach had clear trade-offs with patient privacy, comfort, and infection control. Although there has long been concern for the high noise levels, this was generally accepted as part of the ICU setting—perhaps in part because patients who are mechanically ventilated in the ICU were routinely maintained in a state of deep sedation. Similarly, an open environment eliminated the natural barriers for hand hygiene, as a care provider often could merely turned 180 degrees and take one or two steps to attend to a second patient. Finally, family visitation was often brief and uncomfortable at the bedside. We have entered an era of critical care in which considerably CHEST / 145 / 2 / FEBRUARY 2014
205
more emphasis is placed on creating a healing environment of care.10,11 The ICU remains the hospital location of choice for rapid and coordinated resuscitation and stabilization. But now there is equal emphasis on creating an environment that is more attuned to patient privacy and comfort, support of visiting family and loved ones, and effective infection control. As discussed by Halpern,2 the form and function of the modern ICU room should be designed to meet the dual needs of effective patient care for life-threatening illness and injury and of a supportive environment for healing and well-being of patients, visitors, and staff. Perhaps the most substantial change in modern ICUs has been the progressive integration of information systems and the vast array of electronic devices. The goal is for comprehensive electronic integration of the patient with all aspects of care and transformation of patient-related data into useful and actionable information.3 Early efforts in informatics and electronic processes focused on computerized order entry and bedside physiologic monitoring. More recently there has been rapid expansion of electronic medical records into ICUs. This has been followed by development of systems for data management and decision support of electronic medical record data that enhance the quality and efficiency of patient care—an aspect of ICU design that holds great promise. Real-time data analysis can support “smart” alerts that identify patients at risk for clinical deterioration or for harm from preventable untoward events, such as a drug-drug interaction. Some proprietary systems integrate such alerts into dashboards and may be linked to telemedicine monitoring remotely.12 Other electronic advances that enhance patient safety include bar code scanners and infusion pump drug libraries and dosing limits. Although electronic integration of the many devices commonly used in ICU care, such as physiologic monitors, infusion pumps, mechanical ventilators, dialysis machines, and point-of-care testing instruments, has historically been challenging, interoperability can be enhanced through the use of “middleware,” as outlined by Halpern.3 In summary, creation of “smart” ICUs, including a logical structure of the entire ICU, well-conceived ICU room layouts and integrated electronic devices, and robust information systems leveraged to deliver useful and timely information, can contribute to the important goals of better patient outcomes, enhanced patient safety, and a supportive environment for patients, their loved ones, and health-care workers. Curtis N. Sessler, MD, FCCP Richmond, VA Affiliations: From the Center for Adult Critical Care, Medical Respiratory ICU, Medical College of Virginia Hospitals and Physicians, Virginia Commonwealth University Health System. 206
Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Curtis N. Sessler, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Health System, Box 980050, Richmond, VA 23298; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-2746
References 1. Halpern NA. Innovative designs for the smart ICU: part 1: from initial thoughts to occupancy. Chest. 2014;145(2):399-403. 2. Halpern NA. Innovative designs for the smart ICU: part 2: the ICU. Chest. In press. doi:10.1378/chest.13-0004. 3. Halpern NA. Innovative designs for the smart ICU: part 3: advanced ICU informatics. Chest. In press. doi:10.1378/ chest.13-0005. 4. Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med. 2010;38(1):65-71. 5. Prin M, Wunsch H. International comparisons of intensive care: informing outcomes and improving standards. Curr Opin Crit Care. 2012;18(6):700-706. 6. Robert R, Reignier J, Tournoux-Facon C, et al; Association des Réanimateurs du Centre Ouest Group. Refusal of intensive care unit admission due to a full unit: impact on mortality. Am J Respir Crit Care Med. 2012;185(10):1081-1087. 7. Simchen E, Sprung CL, Galai N, et al. Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds. Crit Care Med. 2004;32(8): 1654-1661. 8. Wunsch H, Wagner J, Herlim M, Chong DH, Kramer AA, Halpern SD. ICU occupancy and mechanical ventilator use in the United States. Crit Care Med. 2013;41(12):2712-2719. 9. Leaf DE, Homel P, Factor PH. Relationship between ICU design and mortality. Chest. 2010;137(5):1022-1027. 10. Bartley J, Streifel AJ. Design of the environment of care for safety of patients and personnel: does form follow function or vice versa in the intensive care unit? Crit Care Med. 2010; 38(suppl 8):S388-S398. 11. Kesecioglu J, Schneider MME, van der Kooi AW, Bion J. Structure and function: planning a new ICU to optimize patient care. Curr Opin Crit Care. 2012;18(6):688-692. 12. Lilly CM, Cody S, Zhao H, et al; University of Massachusetts Memorial Critical Care Operations Group. Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011;305(21):2175-2183.
Whether a Bill Becomes a Law of us remember the classic Saturday morning MostSchool House Rock segment, “I’m Just a Bill,”
which taught us the steps on how a bill becomes a law. While entertaining and informative, it did not address the many other factors that often determine whether a bill makes it into law. Before identifying those factors, I want to discuss challenges and opportunities regarding the future of the Medicare program. Medicare is critically important,
Editorials
