CV fellow Travis Moss, MD
Cardiovascular third-year fellow Travis Moss, MD, and second-year internal medicine resident Eric Holland, MD, published a paper in the April 25th issue of the Journal of the American College of Cardiology (JACC) that may have important implications for how Cardiac Intensive Care Units are staffed and run.
Holland and Moss examined 1,042 admissions to UVA Hospital’s Cardiac Intensive Care Unit (CICU) over a 13-month period, performing multivariate statistical analyses to determine the association of acute noncardiovascular illnesses with outcomes such as length of stay, hospital readmission and mortality. They found that one-half of all cases were marked by physiological failure of noncardiac organs (particularly lungs and kidneys), the most common diagnoses being acute respiratory failure, acute kidney injury, and sepsis. They were key contributors to prolonged length of stay and higher mortality.
Internal Medicine Resident Eric Holland, MD. Eric won an award for best publication by a resident at DOM’s annual Research & Scholars Day in May.
In an editorial in the same issue of JACC, authors Dudzinski and Januzzi remark that the Holland-Moss study “confirms what is widely known: CICU patients are a vulnerable lot, with poor physiological and cardiac reserve, and numerous comorbidities, and thus are less able to tolerate critical illness.”
CICUs — or coronary care units, as they were then called — were established in the early 1960s to treat “post-heart attack complications, particularly arrhythmias,” says Eric Holland in an interview with the on-line journal TCTMD. “Now,” Holland says, “you have a completely different dynamic. [Today’s CICU] patients are riddled with comorbidities and [are] very complex.”
What are the implications of these findings? Holland and Moss write: “The extent of comorbidities demands that clinicians caring for patients in the CICU have the competencies necessary to manage patients with both cardiovascular and noncardiovascular conditions.”
Dudzinski and Januzzi agree, arguing that the study’s findings support the need for changes in the content of cardiovascular medical education. Currently, there is “limited emphasis on critical care training” in general cardiovascular fellowships, under the standards set by the Accreditation Council for Graduate Medical Education (ACGME). “This gap has been recognized,” they write, “and there are growing movements to embed more critical care training into the general cardiovascular fellowship, and to create a new accreditation for level III critical care cardiology, involving a separate year of dedicated critical care training.”
Dudzinski and Januzzi also argue that the research points to the need for “more integrated [CICU] management with critical care specialists (‘intensivists’)” as the new standard of practice in CICUs. “The CICU will benefit not only from the medical knowledge input from an intensivist perspective, but also from the culture of quality improvement and focus on prevention of iatrogenic harms (e.g., ventilator-associated pneumonia, catheter-related bloodstream infection) central to management in a modern medical ICU.” Currently, most CICUs at academic medical centers — including UVA’s — are staffed by a general cardiology fellow under the supervision of an attending cardiologist; critical care consultation is usually available, but not required.
References:
Holland EM, Moss TJ. Acute Noncardiovascular Illness in the Cardiac Intensive Care Unit. Journal of the American College of Cardiology 2017 (Apr 25);69(16):1999-2007.
Dudzinski DM, Januzzi Jr. JL. The Evolving Medical Complexity of the Modern Cardiac Intensive Care Unit. Journal of the American College of Cardiology 2017 (Apr 25); 69(16): 2008–10.
Cox CE. Cardiac Intensive Care Units Face an Ever More Complex Patient Population. TCTMD, April 28, 2017. At: https://www.tctmd.com/news/cardiac-intensive-care-units-face-ever-more-complex-patient-population.
Filed Under: Publications
Tags: Cardiology, Education, Publications, Research, Residents