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The CCU Director

While it is desirable for the CCU director to be a critical care medicine specialist, this is seldom the case. The NIH Conference Statement on Critical Care Medicine found that "the ICU should be directed by a physician with demonstrated competence in the areas necessary for provision of critical care. These areas generally include a broad base in physiology, pharmacology, the continuum of disease, cardiopulmonary function, and the associated intervention skills."

There should be one physician in charge of each CCU patient's care. This need not be the same physician throughout the patient's stay, but there should never be a time when the patient's care is being managed by a group rather than a single individual. The responsible physician may be part of a group, but he or she must have full responsibility for the patient's care. If the responsibility for the care is shared, conflicting orders may be given or situations may occur when care will not be rendered because each person assumed that the other took care of it.

The CCU attending physicians should have demonstrated skills in CCU practice and should regularly practice in the CCU. The attending must limit his or her practice (when on CCU duty) to one hospital. This physician must also have the authority to commit whatever resources are necessary for the patient's care. It is critical to avoid the teaching hospital problem where a resident is in charge of the patient's care but must have permission or a counter-signature to order needed care.

Many hospitals attempt to run their CCUs without sufficient physician coverage. Since CCU decisions must be made quickly, this means that the nursing staff is forced to make medical decisions. This is hidden by standing orders, whereby the fiction is created that the nurse is following a set protocol rather than making medical decisions. If a patient is injured, the jury will see the standing orders as a sham to allow nurses to substitute for physicians. If an institution cannot arrange for proper physician coverage in the CCU, it should reexamine whether it can justify having the CCU.

The physician coverage must also be arranged to ensure that there is a smooth transition between the different physicians who accept responsibility for a patient's care. This shifting of authority must be done in a formal manner, and it must ensure that there is reasonable continuity of care. At all times, the physician responsible for an individual patient should know the history of the patient's illness and all the care the patient has received. It is difficult to explain to a jury how a patient can walk into a hospital with an acute problem and end up viewed by the CCU staff as a long-term case with no hope of recovery.

The physician director of the CCU is often a member of the medical staff rather than a salaried administrative employee of the hospital. If this is the case, there should also be a single high-level administrator assigned to oversee the CCU. This administrator must act as a buffer between the CCU and the hospital, protecting the CCU from policies that would jeopardize patient care and monitoring the CCU to prevent it from becoming a financial burden on the hospital. To carry out these duties effectively, the administrator must be familiar with CCU activities and be available at all times to manage emergent situations. Most important, the administrator should have enough authority to act unilaterally if an administrative crisis develops. This authority must include hiring temporary personnel, bringing in outside equipment and technicians, and, in cooperation with the physician director, suspending personnel, both physician and nonphysician, from duty in the CCU until the normal hospital grievance or disciplinary process can review any questionable conduct.


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