Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
EXPERT COMMENTARY  
Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 154-155
Smooth transitions in critical care


Director, Critical Care Consult Service, Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA

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Date of Submission02-May-2017
Date of Acceptance20-May-2017
Date of Web Publication01-Oct-2018
 

How to cite this article:
Shiloh AL. Smooth transitions in critical care. J Emerg Trauma Shock 2018;11:154-5

How to cite this URL:
Shiloh AL. Smooth transitions in critical care. J Emerg Trauma Shock [serial online] 2018 [cited 2018 Dec 11];11:154-5. Available from: http://www.onlinejets.org/text.asp?2018/11/3/154/242529




In this issue of JETS, Savel et al describe the challenges that face the Intensive Care Unit (ICU) in an academic medical center pursuing a Level I trauma designation.[1] Numerous anecdotes of the experience are detailed within their manuscript. They have chosen to focus on the following major areas: leadership and strategy issues; intensivist staffing changes; integration and training of advanced practice practitioners; bed allocation and throughput preparation and challenges; educational issues, specifically as they relate to resident training; required training for nurses; and changes that may occur to the overall structure of the critical care service.


   What was Useful Top


This manuscript serves as a primer to members of the health-care team. Intensivists will find it of value to learn about some potential challenges that face them as they move forward with trauma designation. The detailed discussion of the changes in intensivist staffing when trauma surgeons engage in surgical ICU management will be of interest to multiple members of the health-care community. Physician and nursing leadership, as well as other hospital administrators, could use this manuscript to help decide if the challenges of pursing Level 1 trauma designation are worthwhile. Clinical educators will gain knowledge and understanding regarding graduate medical training and requirements.


   Structure of the Critical Care Service Line Top


The repercussions to the preexisting critical care service line are vividly detailed. A unified adult critical care service, as established at the authors' academic medical center, can be fraught with complex issues when transitioning to a trauma designation; the lack of such a unified service has the possibility of leading to a “siloed” approach to critical care.[2] One might ask “so what?” Does it really matter if a unified multidisciplinary critical care service gets fragmented back into the traditional “medical” and “surgical” services?[3] Although there are limited data to support the value added of a unified adult critical care service, there is significant evidence that substantial efficiencies can be achieved in terms of streamlined patient throughput, optimization of limited critical care bed resources, unification of equipment as well as enhanced implementation of evidence-based clinical protocols, bundles, and guidelines.[2],[4],[5]


   What Could be Better Top


Overall, we commend the authors for tackling an issue that is not particularly well covered in the critical care/trauma literature; we had some significant concerns regarding potential limitations in the manuscript. First, as valuable as the descriptions may be, ultimately they are a series of anecdotes of a single north-east urban academic medical center. Their experience with this unique transition may not be generalizable. Perhaps, their complex leadership, staffing, and training struggles are restricted to their medical center and that medical centers with a more robust administrative infrastructure would not have the same difficulties. Second, the readers are not given the opportunity to evaluate any significant follow-up with regard to training, educational, and throughput solutions proposed by the authors. The manuscript lacks a more robust discussion of diverse leadership styles, and how changes in this intangible element can lead to alterations in how the ICU infrastructure functions, and to what degree this can influence efficiency and overall morale of the unit.[6] Finally, a clearly delineated financial analysis of the risks and benefits to an organization moving forward with Level 1 trauma designation, both from the perspective of ICU personnel and the institution as a whole would be beneficial.[7],[8]


   Conclusions Top


The authors should be commended for constructing this manuscript and for detailing their experience, working through difficulties and differences that they may have had for the sake of their organization and more importantly, for their patients. This seems to be an overriding theme that the authors emphasize throughout their manuscript. Savel et al have demonstrated the importance of complex unforeseen downstream ripple effects when pursuing Level 1 trauma designation is being considered. A decision such as this should not be taken lightly, especially if a medical center may be in the relatively early stages of implementing a unified adult critical care service. An exceptionally functional ICU is the result of many highly qualified, talented, and educated members of the multiprofessional team working in a synchronized and synergistic fashion to help critically ill and injured patients recover; it may take significant strides to get a functioning nontrauma ICU to the same level of function it was at before its transition to a trauma ICU. Great caution must be taken so that patient care remains of the highest quality during this challenging time.



 
   References Top

1.
Savel RH, Cohen W, Borgia D, Simon RJ. The Intensive Care Unit Perspective of Becoming a Level I Trauma Center: Challenges of Strategy, Leadership, and Operations Management. J Emerg Trauma Shock 2018;11:65-70.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Gershengorn HB, Kocher R, Factor P. Management strategies to effect change in intensive care units: Lessons from the world of business. Part III. Effectively effecting and sustaining change. Ann Am Thorac Soc 2014;11:454-7.  Back to cited text no. 2
    
3.
Duane TM, Rao IR, Aboutanos MB, Wolfe LG, Malhotra AK. Are trauma patients better off in a trauma ICU? J Emerg Trauma Shock 2008;1:74-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Green SA, Bell D, Mays N. Identification of factors that support successful implementation of care bundles in the acute medical setting: A qualitative study. BMC Health Serv Res 2017;17:120.  Back to cited text no. 4
    
5.
Nguyen YL, Wunsch H, Angus DC. Critical care: The impact of organization and management on outcomes. Curr Opin Crit Care 2010;16:487-92.  Back to cited text no. 5
    
6.
Fassier T, Azoulay E. Conflicts and communication gaps in the intensive care unit. Curr Opin Crit Care 2010;16:654-65.  Back to cited text no. 6
    
7.
Maggio PM, Brundage SI, Hernandez-Boussard T, Spain DA. Commitment to COT verification improves patient outcomes and financial performance. J Trauma 2009;67:190-4.  Back to cited text no. 7
    
8.
DiRusso S, Holly C, Kamath R, Cuff S, Sullivan T, Scharf H, et al. Preparation and achievement of American College of Surgeons Level I trauma verification raises hospital performance and improves patient outcome. J Trauma 2001;51:294-9.  Back to cited text no. 8
    

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Correspondence Address:
Dr. Ariel L Shiloh
Director, Critical Care Consult Service, Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JETS.JETS_44_17

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