Chapter 152: Organization of Intensive Care Units and Long-Term Acute Care Hospitals

Introduction

The birth of modern day critical care is traditionally ascribed to Bjorn Ibsen, a Harvard-trained Danish anesthesiologist, who led the efforts to combat the poliomyelitis epidemic in Copenhagen in 1952.¹ By relying on the manual power of volunteers to ventilate the critically ill for extended periods of time, respiratory failure-related mortality declined precipitously. From these humble beginnings, the growth of critical care medicine over the ensuing years has been exponential.

The tenets of 21st century critical care include the provision of care by professionals with diverse yet complementary experience and expertise that is delivered across the continuum of care. The nexus of critical care is the Intensive Care Unit (ICU), where critically ill patients are brought to be resuscitated and managed. It is estimated that there are in excess of 5.7 million annual ICU admissions in the United States, and the numbers continue to increase.^2,3 The costs attributed to the care of the critically ill continue to increase dramatically and currently exceed $80 billion, 13% of hospital costs, 4% of the United States healthcare expenditures, and approximately 1% of the gross domestic product.⁴ Approximately 500,000 patients admitted to an ICU die.² However, as a result of advances in the field, mortality is decreasing and the vast majority of critically ill patients survive. The direct result is that coordinated care is required following discharge from the ICU for these complex patients who have often sustained significant morbidity (e.g., postintensive care syndrome).^5,6

Structural Organization

The administrative and functional organization of critical care has evolved over decades. Selected aspects of this organization are discussed in the following sections.

The Continuum of Critical Care

The care of the critically ill patient begins at first recognition of physiologic derangement. The opportunity to alter the patient's course begins with the initial encounter with the healthcare system. Across the continuum of care (Fig. 152-1), this encounter may occur in the prehospital environment, outpatient clinic, or emergency department (ED). For the hospitalized patient, deterioration may occur on the medical or surgical inpatient unit. Evidence suggests that outcomes are significantly worse in patients admitted to the ICU from the general inpatient unit, in comparison to patients admitted through the ED or postoperatively.⁷ Once critical illness has been recognized, the tenets of care include resuscitation and stabilization and efficient and safe transport to the ICU. Traditionally, efforts to optimize care of the critically ill patient were focused on management provided in the ICU. One of the greatest advances in critical care medicine has been the recognition that the structure and processes of care in locations outside of the ICU (prehospital environment, ED, inpatient unit) are of paramount importance in optimizing care for these vulnerable patients.