Future of critical care: a blueprint for building sustainable cardiac critical care capacity

Introduction

As large quaternary care hospitals establish heart and vascular institutes and cluster highly complex procedures such as heart and lung transplantation, congenital cardiac surgical procedures, and advanced interventional cardiology techniques, cardiac critical care programs are compelled to consider the future of advanced cardiac critical care medicine (1). Over the past 10 years, cardiac critical care medicine has become increasingly complex (2,3). As hospitals continue to face capacity challenges, many of these programs, like ours, have been forced to think creatively about the broader critical care footprint for all cardiac patients and where they can safely recover after cardiac procedures. This will likely continue for years to come, given the ever-growing patient population with heart failure and cardiac disease. To meet the needs of these new heart and vascular institutes, it was imperative that our program concentrated on the focused education of our faculty and, most importantly, communication as the key elements for the program’s success. We anchored this initiative around a predictable, high-volume practice and an opportunity to train and engage our housestaff, nurses, and others interested in cardiac critical care. The predictability of cases and volume allowed us to rotate learners around patients. This approach allowed us to maximize the use of available intensive care unit (ICU) beds in the hospital and earned our program the Capacity Champion Award from Massachusetts General Hospital (4).

Capacity

Over the past 12 months, our program has successfully recovered 2,100 patients after cardiac surgery, with 250 of those patients admitted outside of our traditional cardiac ICUs. These 250 patients recovered in the general surgical (non-cardiac) ICU under the management of non-cardiac intensivists. The program currently admits more than 15 patients per month (Figure 1). While many initially viewed this as a less-than-ideal alternative for a hospital with a heart center, we saw it as an opportunity to educate and equip non-cardiac staff with the skills to manage select cases and to build bridges across historically siloed ICUs. Throughout this program, there was an opportunity to redirect patients from the operating room to a cardiac ICU if their management required advanced therapies, such as mechanical circulatory support, including ventricular assist devices or extracorporeal membrane oxygenation. This process required intensive training, protocols, and guidelines, including a clear list of inclusion and exclusion criteria for patients eligible for direct transfer to the non-cardiac ICU from the operating room. We recognize that some criteria will need to be tailored to the capabilities of specific units, such as patient co-location based on patient and staffing ratios, indicating this is not a one-size-fits-all approach. For this specific program, we focused on coronary artery bypass graft surgery, single aortic or mitral valve replacements, atrial myxomas, atrial septal defect closures, and simple aortic procedures. We separated these procedures from more advanced cardiac procedures, which continued to recover in our cardiac ICUs. This list included procedures such as revision sternotomies, pulmonary thrombectomies, and heart and lung transplants.

Figure 1 This graph shows both the patient volume and intensive care unit LOS for patients admitted to the non-cardiac surgical intensive care unit over time. AVG, average length of stay; EL04, Ellison 4; LOS, length of stay.

Training

Effective management of cardiac patients in the ICU largely depends on staff training. This includes bedside nurses, residents and fellows, advanced practice providers, and general surgical intensivists. Proper education and dedicated time to thoroughly train the staff are likely the most vital components in caring for these patients in the general surgical ICU. Cardiac critical care medicine is a subspecialty within critical care, and educating the staff about this subspecialty is important (5). The fundamentals of critical care, including the management of respiratory failure, renal failure, liver failure, neurologic dysfunction, and delirium, are integral to general practice for intensivists. However, caring for patients recovering from cardiac surgery requires specialized training and a focused understanding of cardiac critical care, particularly in the early recognition and management of common postoperative complications (6,7). Recognizing and managing cardiac tamponade, dysrhythmias, and acute cardiogenic shock is crucial for this cardiac patient population. A deeper understanding of perioperative or rescue echocardiography, cardiac pacemakers, invasive hemodynamic monitoring [such as pulmonary artery (PA) catheters], resuscitation of patients after cardiac surgery, and, most importantly, the ability to communicate and escalate true emergencies in real time is vital.

Rescue echocardiography

The ability to perform rescue echocardiography for the early recognition of postoperative complications in the surgical ICU is perhaps the single most important technical skill in an intensivist’s toolkit. Proficiency in both transthoracic and focused transesophageal echocardiography is essential for the rapid and effective management of these patients. Rescue echocardiography enables clinicians to quickly diagnose conditions such as cardiac tamponade, left ventricular failure, right ventricular failure, hypovolemia, and more (8). The ability to identify and differentiate between various shock states, such as cardiogenic shock, obstructive shock, distributive (septic) shock, and hypovolemic shock, is crucial, as their management can vary significantly depending on the specific type of shock or mixed shock state. This determination can often be made using an echocardiogram. In our study of 189 rescue echocardiograms performed in our cardiac critical care units over 2 years, we found that 72% were conducted between 5 p.m. and 7 a.m., and/or on weekends and hospital holidays. Additionally, of the 189 total echocardiograms, 54% led to an intervention within 30 minutes, such as returning to the operating room for chest re-exploration or to the cardiac catheterization lab for an emergent coronary angiogram or advanced mechanical support therapies. One major limitation of relying solely on outpatient echocardiography labs to perform inpatient rescue echocardiograms is their restricted availability, which varies depending on the time of day and the specific institution. This underscores the importance of training our intensivists to perform rescue echocardiograms. Fortunately, the National Board of Echocardiography now offers the Examination of Special Competence in Critical Care Echocardiography (CCEeXAM) for intensivists who plan to manage both cardiac and non-cardiac patients. In our opinion, this certification should be considered mandatory for faculty members who intend to manage cardiac patients (9).

Cardiac pacing and invasive monitoring

Understanding postoperative cardiac pacing is crucial for effectively managing this patient population. Our program has invested in a pacing simulator to train bedside staff and providers on the appropriate use of pacemakers. This investment has allowed us to prepare for low-frequency but high-impact complications that traditionally require years of management experience. These scenarios often include high-grade atrioventricular (AV) block, ventricular tachycardia, and sinus bradycardia, among others (10). Although the use of PA catheters has declined in general ICUs, it remains important for staff to understand how to interpret key hemodynamic values in these patients. This includes cardiac filling pressures, mixed venous oxygen saturation, and critical measurements such as cardiac output, systemic and pulmonary vascular resistance, among others, obtained from the PA catheter. The goal is to utilize this data to manage patients who rapidly deteriorate due to conditions such as cardiogenic shock, distributive shock, hypovolemic shock, and similar conditions (11). Also, while most critical care units are familiar with managing septic shock, cardiac patients require the staff are comfortable managing patients in a low-cardiac-output state. This necessitates an understanding of cardiac physiology and inotropic medications, including both the initiation and appropriate weaning of these medications post-cardiac surgery, such as dobutamine, milrinone, epinephrine, etc. Again, this is a patient population that is not frequently managed outside of the traditional cardiac ICU. Additionally, it is important that intensivists be proficient and obtain hospital privileges to safely place PA catheters at the bedside, as this is a skill set that needs to be continually honed and improved. Bedside placement of PA catheters is also continuing to evolve from exclusively using invasive pressure monitoring for placement to bedside fluoroscopy (12) and also bedside echocardiography (13) in the ICU.

Resuscitation post-cardiac surgery

Although every ICU routinely manages its own cardiac arrests and is experienced in handling hemodynamically unstable patients, special considerations are required for cardiac surgery patients who suffer a cardiac arrest. These cases necessitate a different resuscitation algorithm. In 2017, the Society of Thoracic Surgeons published an expert consensus statement on the resuscitation of patients who arrest after cardiac surgery, highlighting specific considerations for this patient population (14). Key differences include a low threshold for emergency resternotomy, multiple sequential defibrillation attempts for ventricular fibrillation before initiating external cardiac massage, and efforts at cardiac pacing for severe bradycardia or asystole using epicardial wires. The general principle of early recognition and immediate management of postoperative complications certainly applies to this patient population. The consensus statement also highlights the importance of a well-coordinated team of providers and clearly identifying key roles within the resuscitation team. Principles of teamwork and advanced life support, such as airway management, breathing, and circulation, remain essential. Medications like epinephrine and amiodarone continue to be the cornerstones of pharmacologic management.

Communication, cooperation, and collaboration

One of the biggest challenges, and perhaps the most important area of focus, for any ICU, especially units managing cardiac surgery patients, is communication. Cardiac critical care is incredibly complex and requires continuous communication, coordination, and collaboration with multiple stakeholders (15). Our program has established and utilizes rules to foster communication and connect providers in specific high-risk scenarios. By admitting cardiac surgery patients to a general surgical ICU, rather than a cardiac ICU, nurses and providers may not be accustomed to collaborating with the same cardiac surgeons daily. To reduce initial communication barriers and escalate concerns effectively, our program employs a set of rules designed to encourage the discussion of important clinical issues. While these rules are based on specific clinical scenarios and may be program-specific rather than universal across all service lines, the conversations they prompt are mandatory within our program. Additionally, documentation of these discussions in the electronic medical record is required. We rely heavily on this form of communication to ensure that all providers, including bedside nurses, are heard and aligned (Figure 2). In addition to these rules, our team mandates that all patients be discussed during a morning huddle. This huddle specifically reviews overnight imaging and events with providers from multiple role groups, including attending physicians, residents, fellows, and advanced practice providers.

Figure 2 This is the list of rules currently used for cardiac patients to promote communication among the providers and attending physicians managing these patients. *, the lactate acid level >10 mmol/L as a trigger for notification is currently under review at Mass General Brigham.

Conclusions

We are pleased to report that, upon follow-up of all patients enrolled in this program, all 250 successfully enrolled patients survived beyond hospital discharge, resulting in a 0% mortality rate. The overall mortality rate for all patients in our cardiac critical care program is approximately 5.6%. The median ICU length of stay (LOS) for patients enrolled in this program was 1.0 day, which is lower than the median ICU LOS of 1.6 days for all patients in our cardiac critical care ICU. The management of cardiac critical care has become increasingly complex, particularly within centers associated with heart and vascular institutes. On one hand, cardiac-specific units, managed by cardiac intensivists with extensive specialized training, are absolutely essential to handle the nation’s most complex patients. However, there may be a place for other intensivists and ICUs that do not traditionally manage cardiac patients to effectively care for more straightforward cardiac cases when appropriate. The key to achieving success in this endeavor lies in providing faculty with proper education, training, and communication tools to promptly escalate and manage postoperative complications.

Acknowledgments

The authors would like to specifically thank the following staff members for their invaluable support throughout this project. It would not have been possible without their dedication and contributions: Theresa Mills, Krystina Miller, Amanda Bourgeois, Laura Prout, Corey French, Vivian Donahue, Nancy Derosa, Jackie Kennedy-Harte, and Laurie Pidgeon.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://atm.amegroups.com/article/view/10.21037/atm-25-67/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-25-67/coif). A.B. reports grants from the National Institutes of Health, American Heart Association and Internal MGH sources. D.D.A. reports disclosures for Abiomed through a speaker’s bureau, equity in Paragonix, and departmental funding for other research projects not applicable to this project. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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