Asking the critical questions about critical care

New research for better patient outcomes in the ICU

Date published: 2022-04-06 12:00:00 PM

Caring for patients in the COVID-19 ICU at Sunnybrook Health Sciences Centre in Toronto, February 2021. (Dr. Wunsch is at the far right.)

Photo: Sunnybrook Health Sciences Centre

Over the last two years, the COVID-19 pandemic has raised a number of questions about intensive care units (ICUs). How should they be organized and staffed? What’s the best way to run them? Hannah Wunsch, Canada Research Chair in Critical Care Organization and Outcomes at the University of Toronto, has been studying these and other questions about ICUs since she was a medical student. Today, she’s aiming to create a clearer picture of the practices that produce the best outcomes during both normal times and periods of overwhelming demand, such as those caused by a global pandemic.

A field in its infancy

The world’s first ICU was created in the 1950s in response to the polio epidemic. Since then, there has been little research into best practices and models for intensive care, despite increasing pressures on hospitals and the health-care system. This leaves a lot of opportunity for research in this area that can have tangible, direct impacts on patient outcomes.

“Unlike in more established fields like cardiology, there are still some extremely basic questions about ICUs that haven’t been answered yet,” says Wunsch. “One of my first projects was simply finding out how many ICU beds per capita there were in eight countries, including Canada.”

Understanding the baseline to better respond to surges

Wunsch is currently preparing to survey hospitals in the United States and Canada to get a sense of how hospitals of different sizes and in different regions choose to staff their ICUs with intensivists (physicians who specialize in critical care) and other roles. Along with colleagues on both sides of the border, she plans to investigate practices such as intensivist-to-patient ratios as well as the proportions of intensivists, nurses and other care providers among ICU teams—and how the different approaches being used affect patient care and outcomes.

Caring for patients in the COVID-19 ICU at Sunnybrook Health Sciences Centre in Toronto, February 2021.

Photo: Kevin van Paassen / Sunnybrook Health Sciences Centre

This work will build on previous work she’s done with international colleagues that looked at ICU staffing in the United Kingdom and Australia. In the UK, she found a decrease in patient mortality when each intensivist was responsible for approximately eight or nine patients. But she cautions that the same ratio cannot be assumed for every jurisdiction. Because differences in populations, health-care systems and other factors all have a significant impact on patient outcomes, what works in the UK may or may not work well in a Canadian setting. That’s why it’s critical to look at each country separately.

Although Wunsch’s work is currently focused on pre-COVID ICU practices, it will have implications for future pandemics, offering a baseline to which data from the past two years can be compared.

“We’re going to have a lot of data to look at over the next few years,” she says. “This will help us understand what happened when we surged, what strategies helped when we were stretched thin, and what are the best options for staffing and providing care the next time it happens.”

Minimizing the harms of opioid use

Another branch of Wunsch’s work looks at how hospitals prescribe opioids during and after intensive care. While few ICU patients go on to misuse opioids after leaving the hospital, in the context of the ongoing opioid crisis, it’s important to understand the factors that might affect post-discharge use and outcomes.

One factor Wunsch is examining is whether different types of ICU-prescribed opioids are associated with different rates of misuse. This research is especially relevant now, as many COVID-19 patients have required significant amounts of sedation and pain medication—so it could help shed light on the long-term effects of prescribing practices in the ICU.

Supporting the evolution of the ICU

Although every ICU is a little different, the basic model hasn’t changed significantly since the earliest days of formalized intensive care—despite advances in nearly every other aspect of medicine. A lack of research on ICU structure and care delivery means there is little data available to guide new models. Wunsch hopes her work will change that, providing the evidence needed to support optimized resource allocation, decision-making and guidelines for running ICUs as effectively and safely as possible.

“My goal is to help people in Canada who are critically ill have better experiences and better outcomes.”

Want to learn more?

To learn more about Wunsch’s work, visit her website, follow her on twitter and visit the Acute and Intensive Care Outcomes Research Network.