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KEY POINTS

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KEY POINTS

  1. Critical care is not and cannot be completely standardized across all institutions; the local hospital and regional health care environment necessarily impacts the role of the ICU.

  2. Critical care administration is often siloed, but may benefit from centralization into a service line, division, department, or institute.

  3. Staffing of critically ill patients must be flexible and depend on the hospital environment; intensivists may be asked to care for patients outside of the ICU and physicians without traditional intensivist pedigrees may be trained and then appropriately tasked with caring for patients in the ICU.

  4. Critical care is not just care within the ICU; rapid response/medical emergency teams, telemedicine, and regionalization of critical care can be used to advantage in certain institutional settings.

  5. ICU resources—specifically, ICU beds—are limited; optimal use of this scarce resource in each hospital environment depends on understanding the capabilities outside of the ICU, both within an individual institution and regionally.

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INTRODUCTION

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While the “intensive care unit” (ICU) is a distinct location to which patients with critical illnesses are transferred, in order to optimally manage the ICU and care for the critically ill, it is important to understand the ICU as it functions within the global hospital environment. ICUs in the United States originated during the polio epidemic of the 1950s as a place to cohort patients in need of mechanical ventilation.1 Over time, however, patients classified as critically ill have become far more heterogeneous and the potential to care for them has increased dramatically.2 As a result, the role of the ICU in the hospital environment has necessarily changed. Currently, ICUs cannot be viewed as standalone units that operate in silos. Instead, they must be well integrated into the hospital system to maximize the benefit of what is often a sparse resource—the ICU bed.3,4,5

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In this chapter, four aspects of ICU management—(1) the administration of critical care, (2) staffing for critical care, (3) the structure of critical care, and (4) resource utilization for critical care—will be discussed. Some of these topics are addressed in detail in other chapters; herein, I will highlight how they are integral to situating the ICU well within the broader hospital environment.

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ADMINISTRATION OF CRITICAL CARE

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Critical care medicine has, traditionally, been a specialty without a home. ICU physicians have come from multiple backgrounds (eg, internal medicine, surgery, anesthesiology) and, in larger institutions, the units in which they work have, historically, been separately managed by their individual clinical departments.6 To make matters more complicated, the administration of nonphysician ICU staff (eg, nurses, respiratory therapists, nonphysician providers) is further fragmented. Instead of having a department unto themselves, critical care practitioners have been scattered throughout the organization. This type of fragmented or “siloed” structure has known drawbacks; silos can detract from teamwork and worsen communication with patients and families.7,...

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