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Critical Care Delivery: The Importance of Process of Care and ICU Structure to Improved Outcomes An Update From the American College of Critical Care Medicine Task Force on Models of Critical Care

Weled, Barry J. MD, FCCM1; Adzhigirey, Lana A. RN, MN, CPHQ1; Hodgman, Tudy M. PharmD, BCPS, FCCM2; Brilli, Richard J. MD, FCCM3; Spevetz, Antoinette MD, FCCM4; Kline, Andrea M. MS, RN, FCCM5; Montgomery, Vicki L. MD, FCCM6; Puri, Nitin MD7; Tisherman, Samuel A. MD, FCCM8; Vespa, Paul M. MD, FCCM9; Pronovost, Peter J. MD, PhD, FCCM10; Rainey, Thomas G. MD, MCCM11; Patterson, Andrew J. MD, PhD, FCCM12; Wheeler, Derek S. MD, MMM, FCCM13

doi: 10.1097/CCM.0000000000000978
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In 2001, the Society of Critical Care Medicine published practice model guidelines that focused on the delivery of critical care and the roles of different ICU team members. An exhaustive review of the additional literature published since the last guideline has demonstrated that both the structure and process of care in the ICU are important for achieving optimal patient outcomes. Since the publication of the original guideline, several authorities have recognized that improvements in the processes of care, ICU structure, and the use of quality improvement science methodologies can beneficially impact patient outcomes and reduce costs. Herein, we summarize findings of the American College of Critical Care Medicine Task Force on Models of Critical Care: 1) An intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery; 2) Process improvement is the backbone of achieving high-quality ICU outcomes; 3) Standardized protocols including care bundles and order sets to facilitate measurable processes and outcomes should be used and further developed in the ICU setting; and 4) Institutional support for comprehensive quality improvement programs as well as tele-ICU programs should be provided.

1CHI Franciscan Health, Tacoma, WA.

2Northwest Community Hospital, Arlington Heights, IL.

3Nationwide Children’s Hospital, Columbus, OH.

4Cooper University Hospital, Oxford, PA.

5Rush University, Northville, MI.

6University of Louisville, Louisville, KY.

7INOVA Fairfax Hospital, Arlington, VA.

8University of Pittsburgh Medical Center, Pittsburgh, PA.

9UCLA Health Sciences Center, Los Angeles, CA.

10The Armstrong Institute, Johns Hopkins School of Medicine, Baltimore, MD.

11CriticalMed, Inc., Bethesda, MD.

12Stanford University, Stanford, CA.

13Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

This work was performed at Society of Critical Care Medicine.

Dr. Wheeler served as a board member for Springer Publishing (receives annual stipend for services as Editor-in-Chief for the Journal of Current Treatment Options in Pediatrics), has been provided expert testimony, and has received royalties from Springer Publishing (for serving as editor of Pediatric Critical Care Medicine: Basic Science and Clinical Evidence textbook). His institution received grant support from the Agency for Healthcare Research and Quality (AHRQ) (receives some salary support for two AHRQ grants on which he is co-investigator) and received support for travel from the American Academy of Pediatrics (Dr. Wheeler serves as the Associate Editor for PREP ICU and receives funds for travel to Editorial Board meetings). Dr. Adzhigirey is employed by the Franciscan Health System (FHS) and received support for travel from FHS (FHS reimbursed Annual Society of Critical Care Medicine [SCCM] Congress meeting fees, accommodation, travel). Dr. Kline is employed by Rush University and received support from WebMD (web-based presentation on RSV dz).

Dr. Montgomery’s institution received grant support from NIH (grant related to Epidemiology and Immune Response to Life-Threatening Influenza - site principal investigator [PI] and a grant related to improving safety and quality of tracheal intubation practice in PICUs - site PI). Dr. Vespa has stock options with INTOUCH HEALTH and received support for article research from the National Institutes of Health and the Department of Defense. Dr. Pronovost consulted for the Gordon and Betty Moore Foundation (strategic advisor), lectured for the Leigh Bureau (honoraria from various healthcare organizations for speaking on patient safety and quality), received royalties from the Penguin Group (co-author of the book, Safe Patients, Smart Hospitals), receives stock and fees to serve as a director for Cantel Medical, and is the Founder of Patient Doctor Technologies. His institution received grant support from the AHRQ, the NIH (acute lung injury research), the American Medical Association (AMA) (improve blood pressure control), and the Gordon and Betty Moore Foundation (research related to patient safety and quality of care). Dr. Patterson received support for travel from the Society of Critical Care Medicine; served as a board member for the American Board of Anesthesiology and the SCCM; is employed by Stanford University; lectured for the Massachusetts General Hospital, University of Nebraska, and California Society of Anesthesiologists (provided Grand Rounds presentations at the University of Nebraska and MGH - travel, hotel, and an honorarium); has stock options with Mag Array (consulted for the company and received stock options); and received support for travel from the SCCM, American Board of Anesthesiology, California Society of Anesthesiologists, ACGME, and the AMA. His institution received grant support from Stanford University. The remaining authors have disclosed that they do not have any potential conflicts of interest.

The American College of Critical Care Medicine (ACCM), which honors individuals for their achievements and contributions to multidisciplinary critical care medicine, is the consultative body of the Society of Critical Care Medicine (SCCM) that possesses recognized expertise in the practice of critical care. The College has developed administrative guidelines and clinical practice parameters for the critical care practitioner. New guidelines and practice parameters are continually developed, and current ones are systematically reviewed and revised.

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