Limited communication among team members meant that quality of care was indeed often better when the chief physician was present than when he was not. In the past, the physician in charge of the ICU too often considered that his (more often a man than a woman) physical presence was essential if patients were to be treated "correctly", and equally that patient management would obviously be suboptimal in his absence. From a paternal "dictatorship" to more "democratic" teamwork Family visiting hours have been extended in many units, although this not yet a universal finding, or even suppressed completely, allowing relatives to visit at any time. Gowns and gloves are rarely seen except when performing sterile interventions. ICUs today are much more accessible and welcoming places for patients, staff, and visitors. Staff (and visitors) had to wear gowns and shoe covers to enter, and even sometimes ring a bell and provide their name through a voice system in order to gain access! Visiting hours were very strict and limited, children were generally not welcome, and in some ICUs family members could only view their relatives through a glass screen! These precautions were primarily "psychological", believing that patients needed to be kept quiet and undisturbed to recover, and also that patients needed to be protected from infections brought in by visitors (and vice versa), a theory based on little scientific evidence-indeed, resistant microorganisms are already present inside the ICU and do not really represent a threat outside, otherwise no-one would want to work in the ICU for fear of taking resistant infections home! The initial ICUs were small, restricted, closed units. But perhaps the biggest changes have been in the processes of care within the ICU.įull size table From small, closed units to larger, more open ICUs Information technology has seen similar expansions into the ICU as in other fields, and is now widely used to speed test requests and result availability and to help reduce errors, such as drug interactions. The small mobile respirators of today are unrecognizable compared with the early "tank ventilators" and "iron lungs", and most other forms of equipment have also become smaller and more mobile. Equipment and technology have of course changed considerably. The excitement over the results of activated protein C in sepsis was transient, and it was later withdrawn from the market. It is interesting to note that there have been no major advances in critical care therapeutics over the years despite many attempts. As such, and despite continuing advances in medicine, ICU mortality rates will probably remain fairly static: indeed, if mortality rates decreased, it would rather suggest that ICUs were no longer fulfilling their primary role and were admitting less severely ill patients they would need to be renamed "surveillance units" or "organ support" units! As medicine progresses, the ICU must continue to accommodate the very sickest patients, those who would not previously have survived long enough to benefit from intensive care. Because ICUs cater for the needs of the sickest hospital patients, it is not surprising that mortality rates are higher than on the general ward, averaging around 15% across the globe. ICUs are designed to care for critically ill patients, those requiring more support, attention, and surveillance than is available on the general floor. As critical care medicine continues to develop, further paradigm shifts in processes of care are inevitable and must be embraced if we are to continue to provide the best possible care for all critically ill patients. These and other paradigm shifts have resulted in improvements in the whole approach to patient management, leading to more holistic, humane care for patients and their families. Here, we will highlight just a few of the paradigm shifts we have seen in processes of critical care, including the move from small, closed units to larger, more open ICUs from a paternal "dictatorship" to more "democratic" team-work from intermittent to continuous, invasive to less-invasive monitoring from "more" interventions to "less" thus reducing iatrogenicity from consideration of critical illness as a single event to realization that it is just one part of a trajectory and from "four walls" to "no walls" as we take intensive care outside the physical ICU. There has, however, been a gradual, continuous improvement in the process of care over the years, which has resulted in improved patient outcomes. There have really been no single, major, advances in critical care medicine since the specialty came into existence.
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