Inside the ICU

Care Around the Clock

In the simplest terms, critical care is focused on caring for the sickest of the sick. 

We’re talking about patients with life-threatening and frequently complex medical conditions, often involving vital organs such as the heart, lungs or liver. These patients typically find themselves in an intensive care unit, where they’re closely monitored and looked after around the clock by a multidisciplinary team of caregivers well-versed in specialized care and various modes of life support. 

Critical care began to come into its own in the 1950s, when the modern ICU was developed amid the polio epidemic. Seven decades later, in the throes of another global health crisis, critical care is arguably more critical than ever. 

“Because of the pandemic, people today are more familiar with critical care,” says Hassan Khouli, MD, Chair of the Department of Critical Care Medicine within Cleveland Clinic’s Respiratory Institute. 

“It’s a relatively young specialty,” Dr. Khouli says. “It’s constantly evolving, too. At its foundation, you have dedicated caregivers from different disciplines working together to coordinate the care of critically ill patients 24/7.” 

Across Cleveland Clinic’s health system as well as at other hospitals, separate intensive care units are dedicated to various subspecialties, including medical ICUs (MICUs), cardiovascular ICUs, neurological ICUs, neonatal ICUs, pediatric ICUs and surgical ICUs. 

As Raed Dweik, MD, Chair of Cleveland Clinic’s Respiratory Institute, puts it: “Critical care comes in different flavors.” 

With 64 beds across five nursing units, the MICU on Cleveland Clinic’s main campus is one of the largest and busiest in the United States. It has more than 4,500 admissions per year. Approximately 40% of patients arrive by way of the Emergency Department. Others come from other areas within Cleveland Clinic or via transfers from other hospitals across the region, from coast to coast and around the world. 

“At Cleveland Clinic, our systemness is one of our greatest strengths,” Dr. Khouli says. “Our ICUs don’t operate in a silo or in a vacuum. We have the ability to coordinate across our different ICUs, leverage their strengths and share resources and best practices. We can move critically ill patients based on the ability of an ICU to meet their particular needs or — as we’ve seen with patients with COVID-19 — based on ICU capacity.” 

The Covid Years 

Roughly two-thirds of the beds in Cleveland Clinic’s MICU are reserved for patients with COVID. At the height of the recent omicron surge, there were six straight weeks when every one of those beds was filled. 

“It’s tough on us as caregivers,” says Dr. Mireles-Cabodevila. “Some people think, ‘Oh, they see this all the time; it doesn’t hurt.’ But it does. It takes a toll.” 

Amid the pandemic, the sickest of the sick have become even sicker — and caring for them has become even more complicated, according to Smith. 

“Before, if a patient hit their call button because they wanted their shoulder scratched, I could simply put foam on my hand, go in the room, scratch their shoulder, put foam on my hand and go back out,” she says. “Now, I have to do this whole routine and put on a mask and a gown whenever I enter the room, even if it’s just to scratch someone’s shoulder. I feel bad because I can’t always do the little things that I used to be able to do.” 

How has COVID affected critical care? A better question might be: How hasn’t it? 

“Early in the pandemic, there was a lot of information floating around, good, bad and everything in between,” Dr. Dweik says. “We focused on best practices — what to do, what not to do. We worked with the Education Institute to create COVID e-learning modules, which were viewed hundreds of thousands of times.” 

Adi Gerblich, MD, of the Department of Critical Care Medicine developed an innovative platform that allows family members of patients to participate virtually in rounding (the ICU team’s daily check-in with patients) via video conference. “With limited visitation during the pandemic, patients can feel isolated,” Dr. Dweik says. “Families are an integral part of the care team, too, and this is a way to keep patients and families connected.” 

More recently, critical care experts from Cleveland Clinic locations in the U.S. and abroad shared pandemic learnings in a virtual conference presented by Cleveland Clinic London. 

“As a global health system, Cleveland Clinic has a big advantage,” Dr. Khouli says. “We can learn from our colleagues around the globe, and share our knowledge and best practices with them. The more data you have, the better you can identify trends and make adjustments that will help patients, whether they’re in Ohio or Florida or Abu Dhabi or the United Kingdom.”

The Shape of Critical Care to Come 

Critical care leaders at Cleveland Clinic have seen the future of the ICU, and it’s less invasive and more data-driven. 

“The trend in our intensive care units is moving toward less invasive interventions,” Dr. Khouli says. “In some cases, that means no more breathing tube down the throat. When appropriate, we can deliver breathing support from the same machine with a face mask, without making the patient uncomfortable.” 

Another case in point: point-of-care ultrasound. Advances in this technology have been a game-changer in hemodynamic monitoring, which charts the flow of blood through the cardiovascular system. Previously, this entailed inserting a catheter into a patient’s heart and arteries. With the high-resolution imaging provided by point-of-care ultrasound, caregivers can have a proverbial look inside, noninvasively. 

“Every intervention that we do has potential side effects,” Dr. Dweik says, “which we like to avoid if we don’t have to put the patient through it.” 

Big data also promises to play an increasingly crucial role in the ICU. 

“The proliferation of electronic health records has generated a massive amount of data,” Dr. Khouli says. “It’s somewhat unstructured, and our teams have to navigate all this data on a daily basis. Where we’re heading is more toward artificial intelligence, informatics and machine learning, to leverage the data and structure it in a way that provides real-time information that we can act on.” 

He adds: “These will be valuable tools, but they’ll never replace the brains of our multidisciplinary teams — or their human touch.” 

Smith started her career as a critical care nurse in the MICU at Cleveland Clinic. Twelve years later, she’s still there. At the intersection of Life and Death, she knows that even the littlest acts of kindness go a long way. 

“Any person in any one of those beds could be one of my family members — and how would I want my family member treated?” she says. 

“You might not know anything about them. Perhaps they have no visitors. But they’re still a person; they’re very sick; and they need someone to provide some comfort. What draws me to this job is being able to brush their hair or brush their teeth or wash their face, things I can do for them that they can’t do for themselves. Make them look nice, even if they’re unconscious, because if they look nice, maybe they feel a little better. The sicker the patient is, the more they need those things. 

“We’re their spokesperson when they can’t speak. We’re their advocate when they can’t advocate for themselves. We’re here to take care of everything.”