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xxx Contributing Authors
Michael J. Schurr, MD
Professor of Surgery
University of Colorado School of Medicine
12631 E 17’th Avenue
Aurora, CO 80045
Email: Michael.j.schurr@ucdenver.edu
HYPOTHERMIA
Ryan Shelstad, MD
Cardiothoracic Surgery Fellow
University of Colorado School of Medicine
12605 E. 16th Avenue
Aurora, CO 80045
Email: ryan.shelstad@ucdenver.edu
CARDIOTHORACIC
Samuel E. Smith, MD
Orthopaedic Spine Surgeon
Denver Health Medical Center
777 Bannock St. MC 0188
Denver, CO 80204
Email: Samuel.Smith@dhha.org
SPINE TRAUMA: DIAGNOSIS, CLEARANCE, MOBILITY
Talia Sorrentino, MD
Surgical Resident
General Medical Student
University of Colorado School of Medicine
12631 E. 17th Ave. MC C302
Aurora, CO 80045
Email: Talia.sorrentino@ucdenver.edu
RENAL REPLACEMENT THERAPY
Contributing Authors xxxi
Philip F. Stahel, MD
Director of Orthopaedics,
Denver Health Medical Center
777 Bannock Street, MC 0188
Denver, CO 80204
Email: philip.stahel@dhha.org
SPINE TRAUMA: DIAGNOSIS, CLEARANCE, MOBILITY
Robert T. Stovall, MD
Assistant Professor of Surgery
University of Colorado School of Medicine
777 Bannock Street, MC0206
Denver, CO 80204
Email: robert.stovall@dhha.org
APPROACH TO THE OLIGURIC/ANURIC CRITICALLY ILL SURGICAL
PATIENT COLORECTAL
EVALUATION OF FEVER
URINARY TRACT INFECTION
BLOODSTREAM/CENTRAL VENOUS CATHETER-ASSOCIATED INFECTIONS
NECROTIZING SOFT TISSUE INFECTION
Molly E.W. Thiessen, MD
Assistant Professor of Emergency Medicine
University of Colorado School of Medicine
777 Bannock Street
Denver, CO 80204
Email: molly.thiessen@dhha.org
CENTRAL VENOUS CANNULATION
Nicole T. Townsend, MD
Surgical Resident
University of Colorado School of Medicine
12631 East 17th Ave, MS C313, Aurora CO 80045
Email: Nicole.Townsend@ucdenver.edu
GERIATRIC
xxxii Contributing Authors
Todd F. VanderHeiden, MD
Chief of Orthopaedic Spine Surgery
Denver Health Medical Center
777 Bannock St, MC 0188
Denver, CO 80204, USA
Email: Todd.VanderHeiden@DHHA.org
SPINE TRAUMA: DIAGNOSIS, CLEARANCE, MOBILITY
Michael J. Weyant, MD
Associate Professor of Surgery
University of Colorado School of Medicine
12631 East 17th Ave, MS 310
Aurora, CO 80045
Email: michael.weyant@ucdenver.edu
PLEURAL SPACE AND MEDIASTINUM
TUBE THORACOSTOMY
Cole A. Wiedel, MD
Urology Resident
University of Colorado School of Medicine
12631 East 17th Ave, MS C313, Aurora CO 80045
Email: Cole.Wiedel@ucdenver.edu
DIFFICULT URINARY CATHETERIZATION
Max Wohlauer, MD
Surgical Resident
University of Colorado School of Medicine
777 Bannock St
Denver, CO 80204
Email: Max.Wohlauer@dhha.org
ACUTE RENAL INSUFFICIENCY AND FAILURE
Heather Young, MD
Assistant Professor of Medicine
University of Colorado School of Medicine
777 Bannock Street, MC4000
Denver, CO 80204
Email: Heather.Young2@dhha.org
SEPSIS
I: Background
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Critical Care Responsibility in Healthcare Reform
Chapter 1
Ernest E. Moore, MD* and Hunter B. Moore, MD
*Professor of Surgery and Vice-Chair of Surgical Research, University of Colorado
School of Medicine
†
Surgical Resident, University of Colorado School of Medicine
Take Home Points
• Intensivists have a unique opportunity, and fundamental responsibility, in
healthcare reform in the United States (U.S.) The objective of this overview
is provide the rationale and mechanisms to provide cost-effective care in the
surgical intensive care unit (SICU).
Contact information: (Ernest E. Moore) 655 Broadway St. 365, Denver, CO 80203;
(Hunter B. Moore) 12631 E. 17
moore@dhha.org; Hunter.Moore@ucdenver.edu
th
Ave. MS C313, Aurora, CO 80045; Email: Ernest.
†
3
4 E. E. Moore and H. B. Moore
Background
The U.S. healthcare crisis (Fig. 1)
Annual spending:
• 18% Gross domestic product
• $ 2.7 trillion
• $8000 Per capita
1
Health status ranking among 34 Organization for Economic and Development
(OECD) countries:
• Life expectancy: 78.2 years = 27
• Healthy life expectancy: 68.1 years = 26
2
th
th
Proposed solution: The Patient Protection and Affordable Care Act (HR
3590, Pub L 111-148).
3
Healthcare spending in the U.S.4 (Fig. 2)
Risk Factors for U.S. Burden of Health
(1) Dietary composition
(2) Tobacco smoking
(3) Hypertension
(4) High body mass index
(5) Physical inactivity
U.S. has highest obesity (BMI > 30) rate among all OECD countries.
Preventive measures are unlikely to solve the U.S. healthcare crisis in the
foreseeable future.
6
Consequently, physician’s decision-making has been recognized as the key
in controlling healthcare costs.
7
5
2
National Survey of Physicians’ View of Responsibility
(1) Trial lawyers
(2) Health insurance companies
(3) Hospitals and health systems
(4) Pharmaceutical and device manufacturers
(5) Patients
Critical Care Responsibility in Healthcare Reform 5
(6) Government
(7) Individual physicians
Only 11% of physicians strongly agreed, “Cost to society is important in my
decision to use or not use an intervention.”
8
U.S. healthcare system waste (Fig. 3)
It is estimated that more than
1
of U.S. health care expenditure is wasted.
3
9
Main Body
Balancing limited resources and care of the individual patient
• The emerging philosophy in confronting the inevitable limited resources and
care of the individual patient is generally referred to as value-based care.
• Academic health centers, charged with educating the next generation of
physicians, will face the greatest challenge. On the other hand, inculcating
this social obligation in these trainees is an undeniable responsibility.
• This is not a new concept. In 1977, Dr. Ben Eiseman admonished “The
science and technology of surgical care has clearly outgrown society’s ability
to afford it. Yet, like the financially irresponsible teenage son of a rich family,
we as a profession continue to spend as though our rich uncle will never tire
of providing us cash. Clearly, this is not so, and the day of reckoning will soon
be on us.”
12
10
11
Intensivists have a unique opportunity (Fig. 4)
• 10% of the sickest patients consume 65% of the annual healthcare
expenditure.
• Use of the ICU in the last month of life is estimated at 30%.
• 20% of Americans die during an ICU stay or immediately thereafter.
As our understanding of the basic mechanisms of disease and related organ
dysfunction have matured enormously, so have the sophistication and related
costs of diagnostic and treatment modalities. Evidence-based medicine (EBM)
with associated management guidelines and algorithms are an important process
for cost-effective care. But this represents only the surface, and we must achieve
more with appropriate point-of-care decision-making.
13
14
15
6 E. E. Moore and H. B. Moore
Reducing waste in the ICU
• Cost-effectiveness should be an integral component of our daily patient
management decisions.
• Critically analyze the necessity for diagnostic tests; i.e., how will the results
of this test change patient management?
• Uninformative MR studies and CT scans are conspicuous examples of wasted
resources but collectively “routine” CXRs and blood chemistry measurements are an enormous potential source of unnecessary healthcare expenditure.
• Critically evaluate the cost: benefit of therapeutic interventions. The intensity
of critical care is not generally maintained outside the SICU.
• Employ low cost technology for diagnosis and therapeutic interventions in the
ICU; e.g., ultrasound (US) evaluation of pericardial, pleural and peritoneal
fluid collections; US-assisted placement of vascular cannulae, pleural catheters, peritoneal drains, and IVC filters; and US-assessment of cardiovascular
performance. The availability of contrast enhanced US may further the ability
to identify organ specific disease and determine response to therapy.
Endoscopic-guided percutaneous tracheotomy and gastrostomy should now
be routine.
• Perhaps most contentious, is when to transfer to palliative care in the debili-
tated or terminally ill ICU patient. As intensivists, we know what to anticipate
with advanced, prolonged organ support and should sensitively introduce the
concept of futile care to the family, and alleviate their sense of guilt when
there is a decision to desist with heroic efforts. We should treat our patients
as how we would treat our families.
Critical Care Responsibility in Healthcare Reform 7
Practical Algorithms/Diagram
Fig. 1. U.S. healthcare crisis.
Fig. 2. U.S. healthcare expenditure by category.