COMMENTARY

Today's Cardiac Intensive Care Unit--Not Your Mother's CCU

Gayatri Acharya, MD; Gregory Barsness, MD

Disclosures

November 27, 2017

Editorial Collaboration

Medscape &

Gayatri Acharya, MD: Greetings. I am Dr Gayatri Acharya, cardiology fellow at Mayo Clinic. Today we will be discussing critical care and the cardiac intensive care unit (CICU). I'm joined by my colleague, Dr Gregory Barsness, who specializes in this area. Welcome, Dr Barsness.

Gregory Barsness, MD: Thank you very much. It is great to be here.

Dr Acharya: Glad to have you. Dr Barsness, let's start with the history of the CICU. How does this play a role in the management of our patients?

History of the Cardiac Intensive Care Unit

Dr Barsness: That's a good question. It is a fascinating story. The histories of cardiology and cardiac intensive care move together. In the past century, cardiology itself has gone from an observational practice to one of invasive direct management. In the 1920s, when cardiologists were primarily performing observational duties with heart failure and congenital heart disease, technology had evolved to the point where they could monitor, make predictions, and [perform] resuscitation. By the 1950s and '60s, there was a push toward greater intensity of management. In fact, by 1961, a couple of abstracts described cardiology and coronary care units (CCUs) to better identify and support patients with acute coronary syndromes (ACS).

Dr Acharya: Since that time, how has cardiology intensive care evolved?

Dr Barsness: Again, a great topic. In 1961, this was first described by Morris Wilburne,[1] and that's an interesting story. Wilburne was a private-practice cardiologist in Los Angeles who submitted an abstract describing a nurse-led unit to support patients with ACS. His abstract was rejected by Circulation. For a couple years, Circulation would publish abstracts that were rejected, so his abstract was published, [albeit] somewhat forgotten. But in the coming years, this topic grew support, with Desmond Julian and others who also submitted this idea that a nursing-led unit—to support patients with ACS,[1] identify life-threatening arrhythmias, and treat them promptly—could save lives.

In fact, with the first CCU opening in Kansas City in 1962 and further innovations and new units opening over the coming years, by the late 1960s there were widely dispersed CCUs with data supporting the practice. Some data show up to 75% reduction in (in-hospital) mortality among ACS patients who are treated in a CCU, so it has had a major impact over a short time.

What Makes a CCU or ICU Successful?

Dr Acharya: That is fantastic. With how many CCUs we have across the United States and their varied practices, what are the models of care that make a CCU or an ICU successful?

Dr Barsness: There are as many different types of CCUs as there are hospitals and practices. What distinguishes various practices and CCUs is the staffing, available technology, and resources brought to bear.

What has been shown over many years by the medical ICU data is that with high-intensity care from intensivists and specialists who support multiorgan failure and other processes, patients do better and have [lower risk for] mortality than patients in less-intense care. That [applies to] the CICU as well.

Currently, we [aim] to have units based on local resources and expertise. One issue is whether a unit has cardiologists or intensivists. There are mixed units where patients are cared for by intensivists or anesthesiologists and/or cardiologists.

About two thirds of hospitals, academic centers, have a dedicated CICU, and about half of those [have] what we call a "closed system," where patients are admitted from their normal caregiver to a special team that practices intensive care at that hospital. It is a closed unit because a set group of people are caring for the patient, not just anyone with hospital-admitting privileges. Although only about half of the ICUs or CICUs in the country have a closed system, surveys have shown that most people feel that the system has some benefit. [However, closed systems] are associated with increased cost, staffing issues, and resource allocation challenges, so there are downsides as well.

Regardless of the specific type of model, adequate staffing is important. In the CICU world, which is no longer a CCU but a CICU, you really need the support of an intensivist. There are a lot of models for that intensive care support as well. We have combined cardiologist/critical care people, we have intensivists who support a cardiologist, and we have intensivists who are able to assist when needed.

The [CICUs] that work best have frequent and robust support from intensivists to provide care for these multidimensional patients. You also need access to the technologies that these very complicated patients may require.

Demographics in the CICU

Dr Acharya: We were talking about transitioning from a CCU to a CICU. What is the modern demographic of patients that we are caring for?

Dr Barsness: This is not just in a name. [We used to have] the CCU. Now, we no longer even see patients with coronary-specific problems although they have coronary disease—that's the foundation. The CICU is a system of care for multidimensional patients with dramatic comorbidities and disease risk

Our group, Dr Courtney Bennett and others, has demonstrated fairly consistent mortality rates or survival rates in the past decade.[2,3] The in-hospital, in-unit survival has actually been maintained despite a twofold increase in diabetes, twofold increase in chronic kidney disease, cancer, established coronary disease, and ventilator management (noninvasive or invasive ventilatory support). The patients we are seeing are much sicker—their SOFA (Sequential Organ Failure Assessment) scores and APACHE (Acute Physiology and Chronic Health Evaluation) scores are much higher—and their age is much greater. We no longer see the 60-year-old with a myocardial infarction. It's very often elderly patients, which necessitates a different type of thought process and a different type of team and management strategy to deal with these comorbidities.

Training Cardiologists for the CICU

Dr Acharya: You mentioned Dr Courtney Bennett, one of our new cardiac intensivists. How are we training our cardiologists to become cardiac intensive care physicians?

Dr Barsness: We're very fortunate at Mayo Clinic. We have a dedicated training program to develop a career pathway for people who are interested in doing cardiac intensive care. These are dual-trained cardiologists and critical care physicians who develop the skills necessary to have a lifelong dedication to cardiac critical care: expertise in team management, quality, and research involved with intensive care. It's a long road. It's a difficult road. But it is quite rewarding.

Areas for Future Development

Dr Acharya: Our cardiac intensivists, especially our new faculty, are very involved in research. What are some areas of research that will continue to [advance] the intensive care unit?

Dr Barsness: Cardiology critical care is wide open as far as research. Brandon Wiley is spearheading innovations in our patient care algorithms, team composition, how we collaborate, what the communication patterns ought to be, and [necessary] staffing patterns. Research in that area is critical.

Quality remains wide open. Aspects of general ICU care—including critical care, delirium management, ventilatory management, and sepsis management—may or may not [apply to] the cardiac intensive care population. Transfusion thresholds, ventilatory management, length of support, and VADs [ventricular assist devices] are wide open for research. We have ample opportunity to develop protocols and explore algorithms.

All of this would be impossible as an individual center or practitioner. Fortunately, more collaborative groups, regionally and nationally, have formed in recent years. Sharing best practices and developing registries to track progress in the field are essential.

Dr Acharya: Absolutely, and quality measures and tracking quality are so important for advancing how we care for our patients. What are some other areas that are ripe for future development?

Dr Barsness: Certainly, quality is important; it permeates every aspect of care. From our rounding patterns to our mortality reviews to our collaboration/communication efforts, we have many quality-improvement projects. It speaks to how exciting and novel the area is.

We can also consider expanding our reach to [help improve] quality at other institutions. With more input into the electronic ICU (eICU) realm, [we will be able to] assist other centers in the care of complex patients. Resource allocation is an essential component of best practices for what we do, so by expanding our reach we can make a tremendous impact. Better prognostication will help determine whether a patient may be best cared for locally, at a specialized center, or with palliative or other available resources.

Dr Acharya: Are there any challenges that, as a group, cardiac intensivists face that would be [important considerations] as we go forward?

Dr Barsness: I have a few concerns. As old guys (laughs) we have developed our cardiology practice in a specific manner that suits us. With the new practitioners, critical care cardiologists, it's a very challenging job. Job satisfaction is high but burnout is high. I worry about avenues for growth in the field, avoiding burnout, and maintaining a sane practice. We're working to determine how to evolve the practice to maintain skills while maintaining sanity.

There are the personal aspects of the caregivers themselves. The team also needs nourishment. There is a lot of excitement and difficulty in the critical care world. Maintaining adequate collaboration, communication, and a well-functioning team requires more [effort] than just assembling a group and letting them go. It requires some oversight; organizational efforts are critical.

Dr Acharya: As a member of that team, I can speak to that as well. It is good when the team can communicate. Good infrastructure certainly helps. Have we seen a benefit in how we communicate with our surgical colleagues because of the infrastructure of the CICU?

Dr Barsness: That's a great topic and so we've been trying to facilitate that. We're lucky, again, because we've always had fairly robust communication lines here at our institution. But I think having the critical care cardiologists who can speak the language of intensive critical care with the VAD surgeon, transplant surgeon, and cardiac surgeon [is important].

As an interventional cardiologist, I'm more versed in speaking with somebody who is going to do bypass. Having that background and being able to work in the different hospital units and develop relationships have brought us closer as a critical care community here at our institution, globally, and nationally.

Dr Acharya: Dr Barsness, thank you very much for these very important insights, and thank you for joining us on theheart.org | Medscape Cardiology.

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