Next Generation of Intensive Care
Since coming to Emory in 2009 as the founding director of Emory's Center for Critical Care, Dr. Timothy Buchman has spearheaded various initiatives to better integrate and streamline care in the ICUs throughout the Emory Healthcare system, such as making sure that every ICU had a medical director and was staffed 24/7 with a nurse practitioner or physician assistant specializing in critical care. Most recently, Dr. Buchman's team has begun building a next-generation ICU on 11-South at Emory University Hospital Midtown (EUHM) that will become the standard design for all Emory Healthcare ICUs.
In the new design, patient rooms will be 313 square feet each―a size that is 83% bigger than current ICU rooms―and will provide space for family members. Nursing workstations will be located between every two patient rooms with wide windows looking into the rooms. Each room will have a camera to send images to a team theater, where health care providers will develop a plan to ensure that each patient gets complete and consistent care. The team theater will have eight large screens, much like an air traffic control center, which will facilitate rapid identification of patient needs.
The new ICU will also feature quiet care. "Go into the average ICU today and the first thing you are assaulted by is noise," says Dr. Buchman. "Of course it is important to receive and respond to alerts. But why generate the alerts next to the patient? Let's send them directly to the caregiver." The monitoring instruments will send alerts to the workstations or to a "voice badge" that nurses can wear on their lanyards to help them monitor patients as they move about the unit.
These ideas will be incorporated in Emory University Hospital's new bed tower―more than half of the 210 beds will be for critical care―and EUHM's new 12-bed cardiothoracic ICU. A bridge will also be built at EUHM to connect the OR and the ICU so postoperative patients can travel from one to the other without having to enter an elevator.
Because his branch of medicine can be the most resource-intensive of all inpatient care, Dr. Buchman is developing an overall operational plan that details the processes that must take place when a critically ill or injured patient is admitted to an Emory Healthcare ICU. "Not all patients need care at the same level, but they all can be managed by the same processes," he says.
To address the fact that clinicians in Emory's ICUs come from such diverse professional backgrounds as pulmonary medicine and surgical intensive care, Dr. Buchman is underwriting interdisciplinary training sessions to improve communication and encourage team building. At one recent session, the team had to work through a hypothetical scenario that included rescuing medical professionals held hostage by foreign rebels. The participants had to develop a plan to get the hostages out of danger and home safely—much as they have to do with many of their patients.
Redesigning critical care now is of particular importance since Atlanta's population is aging. "We're on the cusp of not having enough critical care physicians," says Dr. Buchman. In metro Atlanta, the population of people 65 and older will increase by 38% between 2010 and 2015. As a result, demand for these physicians will outstrip supply by as early as next year.
In related news, Dr. Buchman and long-distance colleague Dr. Michael W. Deem, John W. Cox Professor in Biochemical and Genetic Engineering, Department of Bioengineering at Rice University in Houston, recently received funding from the NIH and NSF for "Predicting patient subpopulation dynamics from fluctuation theory." The grant is a product of a call the NIH and NSF initiated in 2007 for proposals that would operate at the juncture of mathematics and statistics on questions in the biological and biomedical sciences.
Drs. Buchman and Deem plan to advance the traditional framework of fluctuation-dissipation theory (FDT), which allows prediction of a stable system's response to external force and its subsequent return to equilibrium from the moment-to-moment spontaneous fluctuations of that system at rest. Recent advances in mathematical physics created an opportunity for the investigators to propose adapting the theorem to certain physiologic systems, which are open and maintained in a near steady state, yet far from equilibrium. The investigators will take advantage of standard perturbations in clinical care, such as the spontaneous breathing trial (SBT) that is part of routine critical care practice, to analyze and model responses of heart rate and blood pressure. Patient groups of representative ages, genders, and disease states will be observed at Emory University Hospital.
"Through this novel application of fluctuation theory, we aim to eventually predict the precise physiologic dynamics of patients in response to treatments, and from those predictions understand why clinicians remove or retain physiologic supports for their patients," says Dr. Buchman. "Such predictive ability could be expanded to encompass multiple physiological variables, assist in forecasting complications before they happen, and support individualized care."