Getting out of the 1950s: rethinking old priorities for staffing in critical care
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EDITORIAL
Getting out of the 1950s: rethinking old priorities for staffing in critical care Hannah Wunsch1,2,3,4*
Medicine as we practice it is shaped by routines from decades ago; the attending physician on morning rounds, trailed by nurses, residents, and medical students. In those earlier days, there was little that could be done for someone who was struggling to breathe except perhaps get a chest x-ray and give them oxygen. Heart attacks in the 1950s were treated with bedrest [1], and a description by an intern in 1951 describes routinely finding cardiology patients dead in the morning when coming to draw blood [2]. The physician “on service” in the intensive care unit (ICU) well into the 1990s (and into the new millennium in some places) was often attending in the unit for a month at a stretch. Once rounding finished, the attending would usually leave, to reappear again the next morning. At least in many US academic centers, attendings were never or rarely called for deaths, deteriorations, or difficult families, and certainly not at night. The continuity of daily rounds by the same physician was prized above all else. A culture developed that hand-offs spelled death, and that continuity of care was to be maintained at all cost. But the modern critically ill patient may have blood drawn every 4–6 h or even more frequently, continuous monitoring, 20 different medications, as well as mechanical ventilation, dialysis, and possibly extracorporeal life support. Families expect to be updated for all critical events; consent must be obtained for every procedure. With the ability to provide endless unnatural
*Correspondence: [email protected] 1 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Rm D108, Toronto, ON, ON M5R 3B2, Canada Full list of author information is available at the end of the article
prolongation of life, family meetings about preferences for care are essential and complex. Deaths, deteriorations and families with conflict all (often) require involvement of an experienced physician. To deal with these demands, we have seen a gradual change in the approach to staffing by intensivists. First, the month became 2 weeks and then 1 week. In a recent survey of 23 North American critical care organizations, the range of consecutive shifts allowed was 1–14, with a median of 7, suggesting that the “norm” is now a week at a time [3]. In a survey of Australian ICUs (n = 109), 43 (39.4%) had intensivists scheduled to work for 7 or more consecutive days, with a median of 5 days [4]. The specialty has evolved to meet these challenges of twentyfirst-century critical care, but the optimal model is very unclear. There will always be large benefits of continuity, if for no other reason than the reassurance it provides to patients and families to feel known in a foreign environment; the importance of this aspect of care cannot be over-emphasized and also provides satisfaction to clinicians. But continuity with such complex patients also presents chal
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