Having already overwhelming approved the PAHPA reauthorizing legislation in both the House and Senate, Congress’ last remaining step before bringing the bill to the president’s desk for his signature is to put the bill to a final vote before the end of the year. Beyond representing one of the few pieces of legislation with strong bicameral bipartisan support in an otherwise staunchly partisan Congress, what is notable about this reauthorization is the addition — included in both the House- and Senate-passed versions of the legislation—of the critical care system to the National Health Security Strategy’s medical preparedness goals, thereby prioritizing the critical care system in federal disaster planning.
Critical care medicine is primary care for the critically ill patient, whose illnesses or injuries present a significant danger to life, limb, or organ function. Traditional, surgical, pediatric, or neo-natal intensive care units (ICUs) admit over five million Americans each year. Notwithstanding the prevalence and impact of critical care, remarkably, this PAHPA reauthorization is historic in recognizing the importance of strengthening the U.S. critical care infrastructure as an essential factor in enhancing our nation’s medical preparedness for a health emergency. This is important because, despite the significant role critical care plays in providing high quality health care for the critically ill and injured—a system whose capacity is put to the test and often stretched beyond its limits in the event of a wide-spread health emergency — critical care is not understood as distinct within the continuum of health care delivery, or for that matter, in the context of public health preparedness.
When a disaster strikes, critical care providers will always be on the front lines. Efficient disaster response depends on the existence of a highly competent critical care workforce, yet the supply of critical care clinicians is grossly inadequate to meet our population needs. The need for critical care today is outpacing the numbers of qualified clinicians in this field, and the gap between supply and demand will only continue to widen further — by one account, the expected demand for intensivists (providers of critical care with specialized training) will outstrip supply by 22 percent in 2020. Other estimates are even more sobering: a 2006 report to Congress showed this gap widening to 35 percent to if the proportion of ICU patients receiving care directed by an intensivist were to increase to more optimal levels.
Moreover, the majority of our nation’s ICUs operate at near capacity on a daily basis. One strategy for amplifying ICU availability during a disaster is to increase capacity by transferring patients out of the ICU sooner than is currently done. Such transfers, however, present significant risks under normal conditions. The risk is greater yet for patients in the ICU, who typically receive multiple medications and treatments that require constant monitoring and depend on highly specialized equipment, including ventilators and IV pumps. In a disaster, this risk of losing a patient during a transfer increases exponentially due to limitations in equipment, communication breakdowns, or shortages of specialized practitioners involved in patient transport — a reality that we saw unfold during Hurricane Sandy as NICU nurses, physicians and other clinicians harrowingly worked in the dark to take critically ill infants down multiple flights of stairs so they could be transferred to other facilities after power was knocked out and backup generators failed.
As a nation, we have faced many notable and severe health emergencies, and disasters and health emergencies will continue to test the United States and our public health system. Congress’ reauthorization of the PAHPA legislation will represent one of the many important steps forward towards addressing the unique challenges and needs of our critical care infrastructure to ensure our preparation for a national health emergency, because we know that at any time a disaster can strike.
Poss is chairman of the Board of Directors, the Roundtable on Critical Care Policy; professor of Pediatrics, Division of Pediatric Critical Care, University of Utah School of Medicine; PICU Medical Director, Primary Children’s Medical Center.