Smooth Transitions in Critical Care.

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

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

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.[245]

WHAT COULD BE BETTER

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.[78]

CONCLUSIONS

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.