Page 27 - Delaware Medical Journal - February 2016
P. 27
OPINION
multidisciplinary unit that manages a very broad array of patients.
dedicated cardiac intensivists. The third model is simply a unit in which cardiologists and a general intensivist co-manage each patient or selected patients in the CICU.4
care. It would be commonly used in smaller hospitals where specialty ICU bed availability does not allow appropriate triage of patients to particular ICUs. However, it is unclear whether this model will provide a real solution for the problem. The second model requires full-time potential expansion of critical care training for cardiologist, the current trend shows that only a limited number of physicians are pursuing
the training and therefore this model is likely to be suitable only for a small percentage of the large tertiary referral centers, and would not be optimal for the majority of community-based hospitals.
The co-management model is the most adaptable for CICU care
for patients with both higher and lower severity of illness and Integrating an intensivist in a multidisciplinary team approach will allow for well-coordinated care, better physician communication, and coordination of care. Intensivists will offer help in managing many of the complex medical co-morbidities. This includes the use and managing complications of many emerging advanced medical technologies, including noninvasive and invasive hemodynamic monitoring tools, complex modes of mechanical ventilation, renal replacement therapies, therapeutic hypothermia, and mechanical circulatory support. They may also facilitate with their expertise in many end-of-life decisions and family discussions. That will offer the cardiologist the chance to concentrate on providing the appropriate cardiac care, including those related to advanced mechanical support therapy, without worrying about the management of potential medical complexities resulting from the interventions.
REFERENCES
1. Julian DG. The history of coronary care units. Br Heart J. 1987;57:497-502.
2. Katz JN, Shah BR, Volz EM, et al. Evolution of the coronary care unit: clinical characteristics and temporal trends in healthcare delivery and outcomes. Crit Care Med. 2010;38:375-381.
3. Quinn T, Weston C, Birkhead J, Walker L, Norris R, MINAP Steering Group. Redefining the coronary care unit: an observational study of patients admitted to hospital in England and Wales in 2003. QJM. 2005;98:797-802.
4. Morrow DA, Fang JC, Fintel DJ, et al. Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: A scientific statement from the American Heart Association. Circulation. 2012;126:1408-1428.
Furthermore, applying this co-management model in hospitals with a cardiology training program may offer the chance to naturally train cardiology fellows in critical care by offering dual teaching from cardiologists and intensivists during multidisciplinary rounds and allowing them to be involved in many cardiac and critical
care procedures under the appropriate supervision.4 Such dual training in the CICU would offer the majority of future early career cardiologists a basic knowledge in managing such complexity if they have to work in an underserved area with limited availability to critical care consultation without prolonging their training or affecting their competency in other disciplines.
This newly proposed co-management model would face few
each team member, the decision about who would lead the rounds, and moving from a consultant role for the intensivist to a fully integrated team member in a collaborative multidisciplinary team are important steps that need a continuous team effort. Despite these challenges,
a partnership between cardiologists and critical care specialists
may offer a better roadmap to deal with cardiac critical care crisis, provide better care for our patients, and prepare the next generation of
CONTRIBUTING AUTHORS
■ ZAHER FANARI, MD is a Cardiology Fellow at Christiana Care Health System in Newark, Del.
■ SUMAYA HAMMAMI, MD, MPH is associated with the Department of Cardiology at Christiana Care Health System in Newark, Del.
■ ARMIN BAREKATAIN, MD, MSc is a Cardiology Fellow at Christiana Care Health System in Newark, Del.
5. Brown JJ, Sullivan G. Effect on ICU mortality of a full-time critical care specialist. Chest. 1989;96:127-129.
6. Pollack MM, Katz RW, Ruttimann UE, Getson PR. Improving the outcome and efficiency of intensive care: the impact of an intensivist. Crit Care Med. 1988;16:11-17.
7. Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288:2151-2162.
8. Kim MM, Barnato AE, Angus DC, Fleisher LA, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010;170:369-376.
9. Katz JN, Turer AT, Becker RC. Cardiology and the critical care crisis: a perspective. J Am Coll Cardiol. 2007;49:1279-1282.
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