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President’s Message: Hot Topics in Critical Care

Regardless of where you practice, you are likely to discover a Society of Critical Care Medicine (SCCM) member as part of your team. SCCM presently has over 16,000 multidisciplinary, multiprofessional members. In this issue, we will explore pressing topics that impact us all, including critical care organizations, SCCM’s partnership in the Critical Care Societies Collaborative (CCSC), emerging collaboration with the European Society of Intensive Care Medicine (ESICM), forthcoming guidelines that inform care, and post-intensive care syndrome (PICS).
Critical Care Organizations
You have no doubt noticed the coalescence of individual hospitals into the structure of much larger health systems. This phenomenon helps explain, at least in part, the observation that the total numbers of hospitals and hospital beds appear to be decreasing in the United States at the same time that the number of intensive care unit (ICU) beds appears to be increasing at tertiary and quaternary centers. Such changes support the flow of complex patients from less well-resourced facilities into robustly resourced hub facilities. This activity is termed horizontal integration. Both horizontal and vertical (within a service line) integration have been well explored by SCCM’s Academic Leaders in Critical Care Medicine Task Force.1 This accomplished group of critical care leaders has also assessed the number and location of intensivists to help better understand the intensivist shortage. They have also articulated the benefits that accrue when smaller facilities join larger ones as part of a health network. This process is similar to membership in SCCM, as the larger organization, and our specialty sections as individual entities. Only one-third of members currently designate a specialty section, so opportunity for membership, collaboration, and leadership skill development is readily available. Of course, SCCM is a member of a larger organization as well—the CCSC.
Critical Care Societies Collaborative
The CCSC is composed of the American Association of Critical-Care Nurses, American College of Chest Physicians, American Thoracic Society, and SCCM. Together we represent over 200,000 critical care clinicians. The CCSC’s initial foray into burnout syndrome in critical care is well chronicled across a call for action, a summit, and ongoing efforts within the National Academy of Medicine.2 A flexible organization, the CCSC is exploring how best to address a variety of relevant critical care topics, including workplace violence and ICU conflict. The CCSC has also offered to serve as a resource for the Joint Commission as it explores its critical care infusion titration measure. Being a member of the CCSC allows SCCM to leverage the benefits of belonging to a larger organization, just as we have done with the ESICM as our partner in the Surviving Sepsis Campaign (SSC).
European Society of Intensive Care Medicine
Multiple synergistic, mutually beneficial, and goal-oriented meetings have been held with ESICM leadership during the past year. As a reflection of that leadership synergy, we are moving ahead with partnerships with ESICM in areas other than the SSC. For instance, the ESICM-SCCM joint session at the upcoming ESICM Annual Congress (LIVES) to be held in Berlin, Germany, will focus on Controversies in Disaster Planning and Management. Our 2020 Congress (Critical Care Week) in Orlando, Florida, USA, will feature a joint Data Science session. In fact, we will also hold our first-ever Datathon as a pre-Congress course, in which data science and clinical experts will use an established database to search for novel approaches to answer clinically relevant questions. Each of these data-driven activities will rely on data science expertise that is shared between SCCM and ESICM.
Since such inquiry relies on sharing a common set of definitions, SCCM and ESICM leadership are working on a comprehensive project to establish common working definitions that could be deployed around the globe to allow anyone to understand an episode of critical care for research, clinical inquiry, or quality improvement. Stay tuned for ongoing updates as this project evolves. Data lie at the heart of scientific inquiry and, as such, also inform the development of guidelines to help direct bedside care.
Guidelines rely on close collaboration and dedication. This approach has supported the SSC as it generates the first-ever guideline addressing the care of the pediatric patient with sepsis. This guideline is scheduled to debut during Critical Care Week 2020. The next version of the adult SSC guideline is actively underway, with a planned release date in 2021. Not all clinical conditions require a guideline, but those that directly impact clinicians, patients, families, and patient- and family-centered care benefit from focused inquiry. One such entity is PICS.
Post-Intensive Care Syndrome
In 2013, the SCCM Council recognized PICS as an emerging condition that deserved intense focus. Almost six million people require critical care in the United States every year, of which about 15% require mechanical ventilation.3 The cohort requiring mechanical ventilation is at high risk of developing PICS. Any patient or family member who spends time in the ICU is also at potential risk. PICS is thought to be quite common; it is estimated that between 1 in 10 and 1 in 100 patients have some element of PICS.4 Family members may also have the psychosocial aspect of PICS. In this case, it is referred to as PICS-family (PICS-F).
Data such as these help identify the at-risk population. However, since the penetrance of PICS is not necessarily predictable, clinical efforts also support prevention. At present, most activity around prevention stems from the highly successful ICU Liberation bundle (A-F) approach that improves outcomes and reduces ICU length of stay, delirium, and ventilator duration.5,6 While ICU Liberation helps those requiring acute care, it does not help those who have been discharged.
Post-hospital activities instead revolve around the use of collaboratives such as those developed and deployed by SCCM’s THRIVE initiative, the establishment of post-ICU clinics, and enhancing recognition of patients and family members whose syndromes have not been recognized before discharge.7 In particular, patients who have been funneled into a central hub facility for specialty care or those who were subsequently transferred to a long-term acute care hospital or rehabilitation facility as they improve and ultimately repatriated to their home community may be an especially vulnerable population. SCCM is developing materials to help improve PCIS screening and recognition in such patients.
When PICS is recognized, a variety of therapies may be helpful in speeding recovery to the patient’s prior baseline. Cognitive, behavioral, and physical therapy all seem to play a role in improving health and quality of life.8 Understanding how patients and family members both perceive and receive care is essential in improving care delivery. This is one of the key lessons learned from the THRIVE Collaborative. In fact, understanding these facets can also help improve the ICU environment by engaging more clinicians, family members, and recovered patients in the process. As a result, facilities may discover improved staff morale, and a decreased prevalence of burnout syndrome. In this way, helping patients and families is a unique way of helping the bedside clinician.9 Importantly, improving how the ICU performs engages every member of your team—some of whom may be your newest section member!