Evolution of Critical Care Cardiology: Transformation of the Cardiovascular Intensive Care Unit and the Emerging Need for New Medical Staffing and Training Models

Morrow, David A.; Fang, James C.; Fintel, Dan J.; Granger, Christopher B.; Katz, Jason N.; Kushner, Frederick G.; Kuvin, Jeffrey T.; López‐Sendón, José; McAreavey, Dorothea; Nallamothu, Brahmajee K.; Page, Robert L.; Parrillo, Joseph E.; Peterson, Pamela N.; Winkelman, Chris

doi:10.1161/cir.0b013e31826890b0

Cited by 252 publications

(218 citation statements)

References 169 publications

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“…This variability makes sense and is not intrinsically adverse. 1 In a simplistic view, communities do not need an extracorporeal life…”

Section: Implications For the Road Aheadmentioning

confidence: 99%

“…1 Forged by a common clinical experience, recognition of this evolution by practitioners in the CICU preceded data that have quantified this transition. 2 A series of single center and small multicenter studies, mostly in academic hospitals, have started to detail the progression of demographics, comorbid conditions, and procedures that characterize the contemporary CICU environment.…”

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confidence: 99%

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Trends in Cardiac Critical Care

Morrow

2017

Circ: Cardiovascular Quality and Outcomes

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C oronary care units originated for the singular purpose of rapidly resuscitating patients from arrhythmic complications of acute myocardial infarction (MI) but have transformed into cardiac intensive care units (CICUs) that deliver comprehensive critical care for patients with cardiovascular diseases.1 Forged by a common clinical experience, recognition of this evolution by practitioners in the CICU preceded data that have quantified this transition.2 A series of single center and small multicenter studies, mostly in academic hospitals, have started to detail the progression of demographics, comorbid conditions, and procedures that characterize the contemporary CICU environment.3-6 Now, in this issue of Circulation: Cardiovascular Quality and Outcomes, Sinha et al 7 extend this investigation to a national level. Their study contributes meaningfully to an expanding database that will facilitate evidence-based redesign of the structure, staffing, and organization of our CICUs. See Article by Sinha et al Transformation of the CICUAt its core, this transformation of the CICU has been marked by a progressive decline in the need for critical care among patients with acute MI and expansion of other patient populations requiring cardiac critical care ( Figure). Quinn et al 3 first called attention to the diminishing role of the CICU in the care of ST-segment-elevation MI (STEMI) and quantified a shift in early resuscitation and reperfusion from the CICU to the Emergency Department in the United Kingdom. Katz et al 4 then described associated changes in CICU practice with substantially more granularity in a retrospective examination of 29 275 patients admitted between 1989 and 2006 to the CICU at Duke University Medical Center. By the end of this period, although the median age remained 63 years, the demographics had swung toward greater representation of women (41%) and minorities (38%). Key findings were a decline in admissions for STEMI, from ≈40% of admissions in 1989 to ≈20% in 2006, and increases in admissions with sepsis (≈8% in 2006), acute kidney injury, liver failure, and other noncardiac conditions. The median Charlson Comorbidity Index increased from ≈1.7 to ≈2.2. Although coronary angiography and pulmonary artery catheterization (≈3% in 2006) decreased, mechanical ventilation and bronchoscopy increased. Notably, the unadjusted CICU mortality rate remained stable during this period (7.4% in 2004-2006). A subsequent multicenter study of all admissions in 2011 to multiple academic CICUs in New York reinforced the diminished contribution of STEMI.5 In a population with a median age of 67 years and 42% women, 26.3% of admissions were for STEMI. The CICU mortality rate across 6 hospitals was 5.6%, with a range from 2.2% to 9.2%. In a single center study of 1042 admissions in 2013 to 2014 to the CICU at University of Virginia, only 11% of admissions were for STEMI. 6 In contrast, 50% of patients had presentations that included acute kidney injury, respiratory failure, or sepsis, each of which were independently as...

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“…This variability makes sense and is not intrinsically adverse. 1 In a simplistic view, communities do not need an extracorporeal life…”

Section: Implications For the Road Aheadmentioning

confidence: 99%

mentioning

confidence: 99%

Trends in Cardiac Critical Care

Morrow

2017

Circ: Cardiovascular Quality and Outcomes

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“…One major reason for that was the foundation of coronary care and stroke units led by qualified staff and doctors, and offering standardised treatment approaches. For both units a dramatic improvement with regard to a number of outcome measures could be shown [8,9]. Meanwhile, this type of unity has been established nationwide in nearly all devolped countries.…”

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confidence: 99%

Acute exacerbation in COPD: we must do more

Welte

2015

Eur Respir J

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“…We had been witnessing evolution of CICU from point of rapid resuscitation to intervention, and finally compendious critical care. 1 Authors analyze organization of CICU on national level in Croatia and compare it with economically more developed countries. Croatian GDP per capita is 35-40% of European (EU-28) average, which groups us among economically less developed European countries.…”

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confidence: 99%

“…2 Data were collected from thirty-four Croatian hospitals, and analyzed during September and October 2016. 1 Croatia has 5 CICU per million inhabitants with mostly 5-6 beds (range of 1-9), on average one nurse on 2.7 patients (significant variation according to hospital size) and less than 4 beds per one physician (mostly cardiologists, lesser extent during night shifts). In addition, 76.5% of ICUs had 24/7 transthoracic echocardiography, 26.5% 24/7 transesophageal echocardiography, one third without therapeutic hypothermia, and 23.5% without ECMO as available treatment.…”

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confidence: 99%