Ms. C. was a pleasant, 70ish-year-old woman on my general medicine ward service. The last time I spoke with her, we chatted amiably as she awaited a scheduled procedure. But she acutely decompensated that night—she became dyspneic, hypoxemic, tachycardic, and hypotensive and, by the wee hours of the morning, was bound for the intensive care unit (ICU).
The following morning, as our ward team was organizing its usual rounds around the hospital, we planned our route to take us past the ICU. First, we stopped outside the unit for a few minutes to speak with Ms. C.'s husband and daughter. Then, we went into the unit to see Ms. C. The ICU attending paused briefly in his rounds to give us a quick update. As we were leaving, he casually commented, “You're the only floor attending who keeps rounding on patients once they go to the ICU.”
Could he be right? Should he be right? Since I (like most of my coattendings) virtually never round with other general medicine attendings, I had to resort to an informal survey of colleagues to answer the two questions. The results suggest that while “only” may have been well-intentioned hyperbole, the ICU attending was not far wrong—it is indeed unusual for general medicine services to visit the ICU to see their transferred patients. And that's too bad: There are some very good reasons why ward teams should continue to round on established patients, even when they are being cared for by another group of physicians after being moved to the ICU.
Let me be clear: I am not referring to the patient who is inappropriately admitted to the floor and quickly transferred to the ICU, nor does what I am saying apply to “open” ICUs, where the same physicians continue to care for their patients in and out of the unit. I am talking about “closed” ICUs and “established” floor patients, meaning patients with whom we have established some sort of a relationship on the general medicine ward service before they are moved to the ICU.
Why should we follow these patients? For one, we can learn. Acutely decompensated patients offer a dramatic lesson about the natural history of their disease process. It's one thing to talk about abstract mechanisms of pathophysiology in a lecture hall, but it's a far more powerful lesson to understand disease mechanisms as experienced by individual, specific, real patients.
An ICU transfer also provides an opportunity to ask other questions, not only about the disease but also about the medical system. What happened on the floor last night? What were the first signs of distress? Who noticed? The family may have detected some subtle signs but not felt comfortable (or encouraged) to bring them to the attention of the staff.
Or perhaps it was a nurse who saw the strained breathing, or the subtle deterioration of mental status. Who was first to the bedside? Did nursing staff (or perhaps the family) call the rapid-response team? What did they do? When? Did they accurately assess the problem, or in retrospect were there therapeutic steps that were missed? Exactly when did Ms. C.'s decompensation cross the “point of no return” and it became inevitable that she would need to be moved to the ICU? Should we have planned sooner for an ICU transfer? Most important: What could we have done differently to prevent the need for an urgent ICU transfer? The answer may well be “nothing,” but it's a question worth asking.
But, one might reason, such learning need not require visiting the ICU—it need not even have to be done immediately, although one could argue that salience and immediacy make all learning more meaningful. Is there any value in real time to such rounding? Yes, if we think about not only what we do but how we do it.
First, consider caring. It's one thing to care about our patients. It's another to let them and their families know that we care. The family of the patient whisked to the ICU is deathly afraid—usually with good reason. Perhaps they received a call at 3 a.m. They rushed back to the hospital in the predawn darkness. As the sun is coming up outside, they are sitting in a strange, windowless waiting area. Medical staff they have never seen before come in briefly to offer ominous-sounding prognoses before hustling back behind closed doors that say “no admittance.”
Once they enter the world of the ICU, families treasure the familiar faces they have grown accustomed to on the floor. Sometimes they fear that the ICU team doesn't appreciate how vibrant and alive their loved one was before “something happened.” The ICU team has only seen their loved one intubated and sedated—how can they realize that only yesterday Mom was alert, conversant, knitting, looking forward to the holidays? It means a great deal to them to know that the ward physicians who “know” Mom are still there and that they are talking to the ICU team. Such reassurance and comfort can be more powerfully provided by people already known and trusted by a patient's loved ones—and that often means the ward team.
It can be difficult for intensivists and hospitalists to find the time to demonstrate caring to the family—to answer questions (and follow-up questions) patiently, clearly, and compassionately, and thus to offer consolation during an incredibly stressful time. Working together as collaborative colleagues, the ward and intensive care teams can share their combined experiences, expertise, and compassion and offer more to the family than either team could separately.
Moreover, the patient's and family's perceptions define their reality. Even when the ward team is tracking the patient's clinical course through conversations with the ICU team and regular checks of the electronic medical record, if the family and patient do not see them, they do not know that the team is following the patient and that they care. It's one thing to care about our patients; it's another to provide visible evidence of this caring, and that's exactly what is accomplished by the ward team's physical presence in the ICU.
Next, consider continuity. In this age of time-limited shifts, we constantly think about continuity, talk about continuity, and try to practice continuity. But most of that continuity takes place behind the closed doors of the staff room or over the ubiquitous electronic terminals. How often do we enact continuity in ways that are visible to patients and families?
An emergency patient transfer from the floor to the ICU is one of the more jarring and dangerous discontinuities that patients and families can experience. As a result, these patients and families may be the very people most likely to benefit from continuity of care. Actually seeing the ward team in the ICU can be incredibly comforting to the family—it shows them that the two hospital teams are talking to one other and thus working as a team in ways that do not treat physical distance as an impenetrable barrier. Even more than comforting the family, conversations between the two teams can lead to a greater understanding than is provided by chart notations alone.
Some might argue that having the ward team physically present confuses families about who has primary responsibility for patient care. However, that isn't a problem if the ward team makes it clear at the outset that they are there to visit, not to take charge. Others might say it takes too much time, or is yet another expectation that cannot be converted into relative value units. But realistically, emergency transfers to the ICU are not a frequent occurrence (one hopes!), and the sort of interaction described here rarely takes more than 10 to 15 minutes.
Another argument might be to point out that hospitalists usually don't follow patients into the outpatient setting. True. But transfer to the ICU is different. For one, it's an inpatient setting. And it's an unexpected, unplanned transfer—the sort of event most in need of analysis. A similar argument might be made for the reverse transfer: That much could be gained if at least one member of the ICU team continued to follow patients for a few days once they are transferred back to the floor (although, at least in theory, such transfers can be planned, unlike the emergent floor-to-ICU transfer).
But perhaps there are other, less-often articulated reasons why ward attendings hesitate before going to the ICU. That Ms. C. was transferred at all could be perceived as an error on the part of the inpatient ward team, an error that some attendings might not wish to highlight by their presence. Some may choose to see an implicit hierarchy between the two sets of attendings. There may be a fear of moving out of one's comfort zone, into a space where learners might ask technical questions that the ward attending is ill-prepared to answer. Or, ward attendings may simply feel that they have nothing more to offer once the patient has moved into the ICU, although nothing could be further from the truth.
Finally, consider the implicit message for trainees: Following patients into the ICU models professionalism. It demonstrates the highest ideals of medicine, that we are focused not on defined areas of turf but on the good of the patient. It shows that we are not merely doing narrowly defined “shift work” in the hospital, but that we truly care about our patients. It helps to forge informal bonds between groups of physicians who are too often separated by hospital geography and allows trainees to see the attending physicians interacting to provide compassionate patient care.
Rounding on established patients in the ICU is the sort of behavior that undergirds the fundamental bases of professionalism. It takes a few minutes from a busy day, but can be incredibly beneficial for families, patients and the ideals of medicine.