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Specialists reduce risks for ICU patients

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By Chris Van Ormer

When a patient wakes up in a hospital’s intensive care unit connected to a bank of bleeping monitors, answers and assurances are wanted.

That job falls to the intensivist.

“We try to pull everything together,” said Dr. Justin Gisel, a program director with ICC Healthcare (Intensive Care Consortium). “We try to promote communication; we try to open communication up.”

ICC Healthcare is an intensivist group now providing its program at Oak Hill Hospital in Spring Hill. In its new $2 million North Tower, Oak Hill has dedicated the second floor to a 36-bed intensive care unit (ICU). A hospital’s ICU treats patients with the most severe and life-threatening illnesses and injuries that require constant, close monitoring and support from specialist equipment and medication to return 

the patient’s health to stability.

“What our role as an intensivist is, we direct and manage the care of the patients that are in the ICU,” Gisel told the Chronicle on Thursday. “Essentially, we as intensivists will have a 24/7 presence in the ICU.”

Intensivist sounds like a new medical specialism, but the concept has been around for a while.

“It’s actually been a separate fellowship since 1985,” Gisel explained.

The fellowship started with a consortium looking for a way to improve ICU patient care.

“What the studies have shown by having an intensivist who specializes in critical care taking care of those patients in the ICU, you’re able to implement a decrease in mortality of upwards of 30 percent,” Gisel said. “You save lives.”

An intensivist always is present in the ICU to work with associates, physicians, patients and their family members. They provide face-to-face communication with the patient’s family and can react immediately to the patient’s changing circumstances for better health outcomes.

In the past, a pulmonary critical care physician or a hospitalist — a physician whose primary professional focus is the general medical care of hospitalized patients — might not be able to focus on a critical care patient because of other duties. 

“If you think about it from the aspect of the pulmonary critical care doctor, I have my outpatient pulmonary clinic, I have patients in the hospital and I have patients in the ICU,” Gisel said. “It’s difficult to be in three places at once.”

Since Feb. 24, Oak Hill has employed five intensivists in the ICU. They are Dr. Sava Necic, Dr. John Malcynski, Dr. Ariosto Rosado, Dr. Adrian Salmon and Dr. Omid Zad. They concentrate on ICU patients without distraction.

“If I have a patient that’s not doing so well in the ICU say at 1 o’clock in the afternoon and I’ve got a full bevy of patients in my clinic, it’s sometimes very difficult to pull myself away and get back to the hospital,” Gisel explained. “In addition, that’s going to take time. Time, when you’re dealing with a critically ill, sometimes unstable patient, means life.”

Another advantage is that intensivists decrease a patient’s time on a ventilator.

“Any time somebody has a mechanical device or is on a machine, there is potential for complications,” Gisel said. 

With a ventilator to assist a patient’s breathing, the tube put in the patient’s airway can allow bacteria to enter the lungs, which can cause ventilator-associated pneumonia.

“How many patients are actually liberated from a ventilator during morning hours or in the evening hours or weekends, sometimes, for that matter in a community hospital? The answer is: Very few, if any at all,” Gisel said. “There’s a good reason for that. If I am following a patient as a pulmonary critical care doctor and I’m at home and they get better at, say, 10 o’clock at night, what is my comfort level in relaying to the nurses and the respiratory therapist there to go ahead and take them off the ventilator, understanding that there may be a fairly good chance that they deteriorate through the next few hours and require reintubation? My inclination would be to err on the side of safety if you will, be a bit more conservative and just say, well, look, just resedate the patient. I’d like to lay eyes on them myself in the morning.”

But with a round-the-clock presence, an intensivist can monitor the patient taken off the ventilator.

“This leads to decreased days on the ventilator, decreased amount of sedation, which leads directly to delirium that has been associated with increased morbidity and mortality and of course decreased complications from these devices,” Gisel said.

The intensivist acts as the director of the care as co-manager with the hospitalist.

“What we really try to promote is a team-based approach,” Gisel said. “We assist in the coordination of the care. The coordinator lets the right hand know what the left hand is doing. We act as a bridge to improving communications.” 

Intensivists, according to Gisel, are in short supply in the nation’s hospitals, and he complimented Oak Hill for its program.

“Not every hospital is able to do this,” Gisel said.  “This is definitely a huge service that we’re here to provide. The metrics to improving outcomes is undeniable, scientifically.” 

 

Contact Chronicle reporter Chris Van Ormer at 352-564-2916 or cvanormer@chronicleonline.com.