The Society of Critical Care Medicine at 50 Years: Interprofessional Practice in Critical Care: Looking Back and Forging Ahead

Abstract

OVERVIEW Interprofessional practice in the ICU has been embraced as a standard of care since the early origins of the Society of Critical Care Medicine (SCCM) (1,2).This focus has been instrumental in improving the care and outcomes of patients with life-threatening illness and injuries utilizing teams of critical care professionals (2). The ICU team is typically comprised of physicians, bedside nurses, nurse practitioners (NPs), physician assistants, clinical pharmacists, respiratory therapists (RTs), dieticians, physical/occupational therapists, case management and social work, dietician/nutritionists, spiritual support, as well as clinicians-in-training, among others. In the interprofessional team model, members of the ICU team communicate, collaborate, consult, and capitalize on the individual expertise of each team member (3). As highlighted by Dr. Max Harry Weil, the first president of SCCM, the ICU team is committed to bringing orderliness and expertise to the management of the critically ill patient (2). The coronavirus disease 2019 (COVID-19) pandemic and news reports of patients in the ICU during the pandemic served to raise the awareness of the general public of ICU care. More than ever, the importance of team-led care in the ICU became evident during the ongoing pandemic. In this article, part of a series on the 50th anniversary of SCCM in Critical Care Medicine, we review key aspects of interprofessional practice in critical care. Efforts to advance interprofessional team-based care in the ICU are essential for improving patient outcomes and ICU team performance (4). Evidence-based best practice for effective interprofessional team care has identified the importance of multidisciplinary rounds that include ICU patients and family members in the care discussions and decision-making, and uses communication strategies that foster inclusive and supportive behaviors to enhance interprofessional collaboration in the ICU (5). A review by the American College of Critical Care Medicine (ACCM) Task Force on Models of Critical Care highlighted the importance of multidisciplinary ICU rounds in reducing mortality independent of the care team structure (1). Additionally, optimal interprofessional team performance also appears contingent upon open communication, conflict resolution, cooperation, coordination, and coaching between individual team members (Table 1) (6). The frequent changing of individual ICU team members due to rotations and different schedules from day to day has been identified as a potential challenge in ICU team performance (7,8). However, ICU professionals function cohesively as a team, sharing their individual expertise and the perspectives of other team members day to day, as well as providing seamless continuity in patient care (9). Based on the COVID-19 pandemic, novel staffing models were developed to maximize critical care expertise to manage patient care needs and built new, nontraditional teams, with rapidly upskilled nurses and other staff (10,11). TABLE 1. - Key Qualities for Promoting Interprofessional Team-Based Care in the ICU Effective communication Mutual respect Collaboration Consultation Cooperation Cohesion Adaptability Coaching Strategic decision-making Defining expectations Resolving challenges Team identity Psychologic safety Stollings et al 2019 (5), Salas et al 2015 (6), and Durbin 2006 (3). In caring for the most critically ill patients, ICU team members often work in physically, emotionally, and ethically challenging environments. This can lead to provider burnout and dissatisfaction, which can be avoided with good team performance (Table 1). In a recent study examining the quality of interprofessional collaboration involving 2,992 clinicians working in 68 adult ICUs in 12 European countries, ICU and clinician characteristics that were associated with lower clinician “intent to leave” were mutual respect, open interdisciplinary reflection, and a direct approach to difficult decision-making including end-of-life decisions (12). INTENSIVIST-LED CARE IN THE ICU Intensivists are physicians who have completed training in one of several primary specialties (i.e., internal medicine, anesthesiology, emergency medicine, surgery, neurology, and pediatrics) who have additional subspecialty training in critical care medicine (13). Over the past several decades, ICU care evolved from managing critically ill patients in open units where multiple physicians were admitting and directing patient care without the presence of intensivists to a closed model of care, where a dedicated team or teams provide care. Intensivist-led care in the ICU care is now advocated for the care of critically ill patients (1,3), and SCCM outlines a number of key roles of the intensivist, including ICU team leadership, oversight of ICU care and decision-making, and coordination of care with specialists in management of the multiple health problems of ICU patients (Table 2) (14). TABLE 2. - Interprofessional Team Member Roles in the ICU Intensivists Provide leadership and oversight of ICU care Lead multidisciplinary rounds Oversee the many decisions involved in a critically ill patient’s care Coordinate other services the patient may need—including those from specialists Diagnose, manage, and deliver the care of critically ill patients Have the medical training and skills to manage multiple health problems, including but not limited to: Cardiovascular: shock, myocardial infarction, cardiac failure, and arrhythmias Respiratory: prevention and treatment of pneumonia, respiratory failure, acute respiratory distress syndrome, chest trauma, smoke inhalation, and burns Neurologic: stroke, traumatic brain injury, intracranial hypertension, seizures, and brain death evaluation Renal: insufficiency or failure, electrolyte and acid base disorders, and rhabdomyolysis Endocrine disorders: adrenal insufficiency, diabetic emergencies, and thyroid storm Gastrointestinal: pancreatitis, gastrointestinal bleeding, and hepatic failure Pharmacologic emergencies: overdose, drug reactions, and poison Hematologic: anemia, coagulation disorders, and thrombotic disorders Infectious disease: treatment of multiple infections and recognition of and treatment of sepsis Nutritional: prevention, recognition, and treatment of malnutrition Able to manage or perform certain unit-specific procedures, including but not limited to: Endotracheal intubation and mechanical ventilation Placement of intravascular catheters, including central venous catheters, pulmonary artery catheters, dialysis catheters, and arterial catheters Cardiac pacing device insertion and management Tube thoracostomy Pharmacists Assist healthcare team members in making informed decisions of pharmacotherapy options Provide clinical pharmacotherapeutic to the care team the to which be drug for and for drug Provide drug with the healthcare team to drug Provide and with rounds as member of a multidisciplinary critical care team Assist with the of ICU and patients and on in critical care independent patient Provide and services for in of with skills Provide drug consult, and on therapists or on medicine and of practice improving patient outcomes respiratory and as well as in the treatment and prevention of disease and of clinical and to respiratory care and Provide patient and family to advance their of the disease and of as well as to and disease patient care and pulmonary in to patient and advance the of respiratory care and prevention public training of the healthcare professionals Provide direct care or care for ill patients who are for or potential life-threatening health problems the critically ill patient including and and healthcare services for critically ill patients in where patients and and Lead and in interprofessional teams Provide critical care including oversight of mechanical and other to the needs of patients and with illness or and and for their in and end-of-life decisions the of and patient care to critically ill patients with interprofessional team and provide oversight of patient care and provide for care in the ICU nurse specialists Provide to nurses and other members of the ICU team to patient care needs and with the interdisciplinary team, and family Coordinate to treatment and the practice and for ICU and practice and and and and of and and and and and nurses and staff in practice Lead and in quality and safety on and evaluation the and with clinicians and the and and clinical expertise to and of best the bedside and of nurses and other staff Consultation and of quality and review and physician Assist in the care management of critically ill patients and perform and with and and with the interdisciplinary team, and family and family of care and practice for ICU patients central insertion procedures, prevention and and enhance communication with other ICU nurses, clinical nurse respiratory therapists, team, and services and as 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