What might ‘intensive care’ mean in 2035?
2020 was the tenth anniversary of the creation of the Faculty of Intensive Care
Medicine (FICM), and intensive care medicine (ICM) as a stand-alone medical
specialty in the UK. The COVID pandemic has been significantly disruptive and
there is no going back to how we were; NHS services such as critical care that
were so exposed must move forward. Two recent workstreams, Health Education
England’s ‘Future doctor’ project of 2019 [1] and the ‘Getting It Right First Time’
programme [2] provide pointers as to what might change. FICM is also shortly
due to release a suite of documents, ‘Critical Staffing’, that provide a best practice
framework for staffing critical care. This is my personal take on what these
developments might lead to.
Whilst there is always going to be a necessary relationship
between training in ICM and anaesthesia, more people with
medical and emergency medicine training will be working in
ICM alongside single ICM specialists. Future intensivists will be
more likely to see themselves at the heart of all acute hospital
care pathways, not just surgical ones, leading and contributing to
complex decision making. The Association of Anaesthetists has
a distinguished record of supporting self knowledge, leadership
training and development opportunities for trainees. These are
skills that will need to be embedded across the ICM workforce.
The growth of peri-operative medicine in anaesthesia will
redefine a large amount of elective patient work that currently
involves ICU. Many surgical patients will be managed exclusively
by anaesthetists and surgeons who have the skillset to lead
the whole elective pathway, including running enhanced care
facilities to ensure patients are kept safe and their surgery
takes place as planned. The phenomenal contribution to ICU
work made by many anaesthetic colleagues during the peaks
of COVID shows the benefits for patients. Greater separation
of elective and emergency pathways, with differing groups of
specialists managing them, will be cost effective as we finally
start to ‘get it right first time’ in improving patient outcomes.
ICUs will be managing a population that is older, with a higher
proportion of medical patients and those who had emergency
admission. More of the hospital day-to-day outpatient consulting
and care planning will be done off site or remotely, so those coming to hospital will be sicker or have more complex health
care needs. Intensivists will therefore be working more outside
the physical walls of their units. They will support planning and
delivery of patient care in clinics and MDT meetings, helping
ensure patients have early treatment escalation plans in place,
and working proactively to prevent or detect early deterioration
rather than the reactive responses we see currently.
Complex decision making
Doctors working in ICM will need to be highly skilled in complex
decision making, comfortable with making decisions with and
for patients whose problems do not fit neatly into care pathways
and opinions traditionally offered by single-organ specialists.
Intensivists will need to be holistic doctors with a strong
grounding in decision-making ethics and the scientific and data knowledge
skills to use information in a humane, patient centred
way. Helping patients to understand the limits of ICM and the
likelihood of achieving treatment goals will need to be built into
care pathways much earlier than at present, and intensivists will
be required to do this.
The future ICU team will still be medically led, but it will be a wider multidisciplinary team, supporting, teaching and training each other.
COVID has shown the need for widespread involvement in
research programmes. Intensivists have always been good at
converting research outside the ICM environment into their
working practices, but ICUs will also need to collect and review
more of their own data. Quality improvement skills, and the ability to contextualise research findings for individual patients,
will be necessary for all to ensure resources are used correctly
and fairly.
FICM will shortly be releasing a report ‘Life after critical illness’.
As intensivists undertake more of their own patient follow-up
and develop greater reach into community and secondary care
pathways, this will have a significant impact on future decision
making and planning. We will be much better prepared to ask
future patients “What matters to you?”, and help them achieve it.
The future ICU team will still be medically led, but it will be
a wider multidisciplinary team, supporting, teaching and
training each other. Doctors and nurses will work shoulder-to-shoulder
with advanced critical care practitioners, critical care
pharmacists will have a significant patient safety role, and many
other allied health professionals will be based in ICUs ensuring
patient rehabilitation and recovery is maximised from the point
of admission.
ICM has existed for longer than the FICM, but the recognition
of ICM training requires us to move further forwards. Recent
pandemic experience has shown what can be achieved by a
team working together in extremely challenging circumstances.
We should not accept that as evidence that what we have at
present is enough and resist change, but rather work towards
a service and specialty that capitalises on the best of recent
experience and welcomes what the future brings. I know the anaesthetist/intensivist of 2035 will not have trained or work as I
have, but she or he will hopefully still see those working in acute
services as valued colleagues, to whom they can turn to for
advice and support, irrespective of title.
Daniele Bryden
Vice Dean, FICM
Consultant in Intensive Care Medicine, Sheffield Teaching
Hospitals
Twitter: @DannytheBaker
References
- NHS Health Education England. Future doctor, 2021.
www.hee.nhs.uk/our-work/future-doctor (accessed
20/4/2021).
- Getting It Right First Time. Reports, 2021.
www.gettingitrightfirsttime.co.uk/girft-reports/ (accessed
20/4/2021).