NO. 3 1975
VOL. 51 MARCH Circu latlion
AN OFFICIAL JOlURNAL ofthe AMERICAN NEART ASSOCIATION
EDITORIAL
Optimal Cardiac Care: Achievable? To the hospital administrator this
Preamble In an editorial concerning goals for optimal care of patients with heart disease, one might take at least two approaches. The first is to catalogue some of the existing deficiencies that most of us have encountered in our experience as cardiologists. The second is to
involves
a
pursuit of excellence for the benefit of the patient.
What combination of circumstances is necessary for such care to be available to those who need it and achievable by those who provide it? Some of the components can be described in a series of C-letter words, such as: Care: Total care, intensive care, critical care, optimal care, the best care, and a companion word: Caring: Back in 1927 when Dr. Francis W. Peabody of Boston addressed a class of Harvard medical students on The Care of the Patient,' he began by stating that "The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine or, to put it more bluntly, they are too 'scientific' and do not know how to take care of patients." Perhaps such statements were made in ancient times as well. Certainly we hear them today. For instance, while most of us would list intensive care units and cardiopulmonary resuscitation as two major modern life-saving developments for patients with heart trouble, critics rightly deplore the dehumanization of some intensive care situations, or the injudicious application of cardiopulmonary massage to a patient with a medically hopeless condition who is about to die. In addition to scientific achievements and armamentaria, Peabody advised that "Time, sympathy and understanding must be lavishly dispensed," and he concluded "- the secret of the care of the patient is in caring for the patient." We too subscribe to the premise that: Caring is part of the Cure. Compassion is the es-
acknowledge that there are many problems that detract from excellence of care and to consider the ingredients necessary to relieve these difficulties and to optimize the total approach. Rather than a listing of what's wrong, I prefer to discuss what we might do to make the system right. HAT IS OPTIMAL CARDIAC CARE? To the symptomatic adult, optimal care is that management which is both expertly and kindly given and which restores him to good health and activity, or if that is not possible, helps him adjust to his limitations. To the parents of the breathless blue baby, it is the prompt recognition of the problem and its skillful relief that gives him a chance to grow up. To the family of the child that they see as normal but are told needs open-heart surgery, optimal care is the understanding and gentle treatment, not only by their cardiologist and surgeon but by the total team, that helps their child emerge from the experience with happy memories and a long lease on life. To the physician, optimal care is the culmination of learning experiences and problem-solving that enables him to help each of his patients to function securely at the peak of capacity through medical or surgical means. From the Division of Pediatric Cardiology, The New York Hospital-Cornell University Medical Center, New York, New York. Supported in part by NIH Training Grant, #IT01 HL 05989-03. Address for reprints: Dr. Mlary Allen Engle, Division of Pediatric Cardiology, The New! York Hospital-Cornell U niversit} Medical (Center, New York, New York 10021. Circulation, Volume 51. March 1975
care
juggling act, three components of which are keeping quality high, costs down, and bed occupancy up. To the medical center, optimal care translates into the
399
Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on March 28, 2015
EDITORIAL
400
sence of the healing art. Tender, loving care is not a requisite of infants alone. Pediatricians are accustomed to hearing their internist colleagues jokingly (?) refer to pediatric subjects as "just little adults." With respect to T.L.C., perhaps they will accept the judgment that "grown-ups are just big babies." Consumer: From the patient's point of view, his appreciation that the care is optimal and also the manner of his response to treatment are based in large measure on the Confidence he has in his doctor and in the establishment, in the esprit de Corps he perceives in the well-functioning team, and in the Courtesy extended him from arrival, as he is prepared for what is to happen next and helped along the way, to departure. Such confidence helps him to have the Courage for Compliance with recommendations for study or treatment that may be at least frightening and a bit uncomfortable. Captain: At any point in the cardiac patient's care there is only one physician ultimately responsible for making decisions, only one captain with clear lines of authority for those doctors, nurses, and paramedical personnel associated on the team. Leadership roles change according to circumstances. In the community, it is the personal physician; in the medical center it is the medical or pediatric cardiologist for medical aspects of care, but if cardiac surgery is involved, it is the cardiovascular surgeon who joins his medical colleague and is in charge in the operating room and surgical intensive care area. Ease of communication between these specialists facilitates the continuity of care of the patient and smooths the transition from one phase to the next. Commitment: It takes the dedication of a total team to provide Cardiac Care of high quality as a Continuum, with Collaboration and Communication being integral parts of the system of optimal care that links cardiologist, community hospital, and cardiac center. Recognition of the problem and longterm care (preventive, expectant, convalescent, chronic) are at one end of the continuum and are also the points of referral and of return of the patient should a critical or complex condition arise that calls for consultation and for the diagnostic and therapeutic capabilities concentrated in a cardiology center.2' 3 Cardiovascular centers, established on the basis of community need, provide a critical concentration of personnel and facilities with capability for the effective discharge of responsibilities of complete diagnosis and medical as well as surgical management. There is coverage 24 hours a day. The capacity of the facilities, the caseload and the staffing must mesh closely. Competition among centers is a positive feature, for there is no one way that is optimal, and the critical self-analysis and comparisons with other centers of ex-
cellence promote improvements in the system. Channels of communication are necessary for contact between physicians for referral and acceptance, recommendations, action and progress reports. Communication between members of the team in the center concerning the individual patient but also the program as a whole is necessary so that as different members (doctors, nurses, technicians and others) meet the patient, explain the plans, and answer questions, there are no discrepancies. Counseling of the patient concerning immediate management and long range goals of vocation, recreation, and occupation are forms of communication.2 In the broader sense and covering a wider area is communication of knowledge with exchange of ideas through presentations at conferences and meetings and through publication. This is essential to update information and translate new knowledge into application. Categorical and untargeted research into etiology, prevention, mechanisms, and treatment of cardiovascular diseases is an essential, ongoing component of the system of optimal care, as is: Career training for future clinical investigators, for those engaged in basic research and for those who practice cardiovascular medicine and surgery. Criteria for resources for optimal care have been established by commissions3 4 and committees5' 6 whose members have given considerable thought, individually and collectively, to promoting optimal care for cardiac patients of all age groups and in all categories of cardiovascular disorders. In these recommendations are two recurrent themes of cases and cost effectiveness, which emphasize that costly equipment and complete teams that are infrequently called upon function less well over-all than the equally well-equipped facilities and well-trained personnel that are continually utilized. These discussions led to definitions of minimal case loads, below which the team cannot be expected to maintain its skills, and maximal case loads, above which the capacity of facilities and personnel is overstrained and calibre of care deteriorates. Optimal, achievable numbers of cases have been suggested for cardiac catheterization with contrast visualization and for the different types of open heart surgery for congenital heart disease,3- 7 valvular heart disease,3 and coronary arterial disease.3'4 Regular reporting by centers of annual case loads and results will establish or refute the validity of these suggested numbers, but the rationale and the recommendations seem reasonable. Such a mechanism has proven its merit in New York City, where it has been effectively utilized for the last twenty years.8 Costs for the most complex forms of complete diagnosis and treatment continue to mount for institutions, individual patients, and insurance carriers. Circulation, Volume 51, March 1975
Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on March 28, 2015
EDITORIAL
401
Rather than deny an adult with heart disease the treatment that would promote his comfort and prevent premature death, or deny a baby or child with serious congenital heart disease the opportunity for surgical correction or amelioration of his condition so that he can look forward to many years of good health, it behooves each of us to become involved in making optimal cardiac care achievable. We doctors must enhance our individual capabilities to provide knowledgeable, comprehensive, compassionate cardiac care while the scientific community in tandem with private and governmental agencies seeks to continue and to promote a total stratified system of excellence for continued advances and improvements in cardiovascular research, training, and patient care. The total team approach with clear responsibilities in a system that has ready access, good communication, and flexibility functions well today in a number of regions so that one can say with conviction that optimal cardiac care is not only achievable but is being achieved.
References 1. PEABOD'E FW: The Care of the Patient. JAMA 88: 877, 1927 2. EMGLE MA: Pediatric cardiology and the pediatrician. Pediatric Annals 3: 10, 1974 3. Cardiovascular Diseases. Guidelines for Prevention and Care. Reports of the Inter-Society Commission for Heart Disease Resources. Edited by WRIGHT IS and FRE1DRICKSON DT. Inter-Society Commission for Heart Disease Resources, New York, 1971 4. Optimal Criteria for Care of Heart Disease Patients. Heart Disease Advisory Committee. JAMA 226: 1340, 1973 5. Standards for Cardiac Diagnostic and Surgical Centers. American Heart Association, 1974 6. BLOOxI BS, PETERSON OL: Patient Needs and Medical-Care Planning. The Coronary-Care Unit as a Model. N Engl J Med 290: 1171, 1974 7. ENGLE MA, ADA.ois FH, BETSON R, DUSHANE J, ELLIOTT L, MNA\IARA DG, RASHKIND WJ, TALNER NS: Resources for the Optimal Acute Care of Patients with Congenital Heart Disease. Circulation 43: A-123, 1971 8. SC\NNFLL JG, Bno's,-\ GE, ELLISON RG, GROVES LK, LALU SIAN H, SABISTON DC, SLO.AN HE, WHEAT MW: Optimal Resources for Cardiac Surgery. Surgery Study Group. Report of Inter-Society Commission for Heart Disease Resources. Circulation 44: A-221, 1971
MARY ALLE.N E.NGLE, M.D.
Circulation, Volume 51, March 1975 Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on March 28, 2015
Optimal cardiac care: achievable. M A Engle Circulation. 1975;51:399-401 doi: 10.1161/01.CIR.51.3.399 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1975 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/51/3/399.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on March 28, 2015
VOL. 51 MARCH Circu latlion
AN OFFICIAL JOlURNAL ofthe AMERICAN NEART ASSOCIATION
EDITORIAL
Optimal Cardiac Care: Achievable? To the hospital administrator this
Preamble In an editorial concerning goals for optimal care of patients with heart disease, one might take at least two approaches. The first is to catalogue some of the existing deficiencies that most of us have encountered in our experience as cardiologists. The second is to
involves
a
pursuit of excellence for the benefit of the patient.
What combination of circumstances is necessary for such care to be available to those who need it and achievable by those who provide it? Some of the components can be described in a series of C-letter words, such as: Care: Total care, intensive care, critical care, optimal care, the best care, and a companion word: Caring: Back in 1927 when Dr. Francis W. Peabody of Boston addressed a class of Harvard medical students on The Care of the Patient,' he began by stating that "The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine or, to put it more bluntly, they are too 'scientific' and do not know how to take care of patients." Perhaps such statements were made in ancient times as well. Certainly we hear them today. For instance, while most of us would list intensive care units and cardiopulmonary resuscitation as two major modern life-saving developments for patients with heart trouble, critics rightly deplore the dehumanization of some intensive care situations, or the injudicious application of cardiopulmonary massage to a patient with a medically hopeless condition who is about to die. In addition to scientific achievements and armamentaria, Peabody advised that "Time, sympathy and understanding must be lavishly dispensed," and he concluded "- the secret of the care of the patient is in caring for the patient." We too subscribe to the premise that: Caring is part of the Cure. Compassion is the es-
acknowledge that there are many problems that detract from excellence of care and to consider the ingredients necessary to relieve these difficulties and to optimize the total approach. Rather than a listing of what's wrong, I prefer to discuss what we might do to make the system right. HAT IS OPTIMAL CARDIAC CARE? To the symptomatic adult, optimal care is that management which is both expertly and kindly given and which restores him to good health and activity, or if that is not possible, helps him adjust to his limitations. To the parents of the breathless blue baby, it is the prompt recognition of the problem and its skillful relief that gives him a chance to grow up. To the family of the child that they see as normal but are told needs open-heart surgery, optimal care is the understanding and gentle treatment, not only by their cardiologist and surgeon but by the total team, that helps their child emerge from the experience with happy memories and a long lease on life. To the physician, optimal care is the culmination of learning experiences and problem-solving that enables him to help each of his patients to function securely at the peak of capacity through medical or surgical means. From the Division of Pediatric Cardiology, The New York Hospital-Cornell University Medical Center, New York, New York. Supported in part by NIH Training Grant, #IT01 HL 05989-03. Address for reprints: Dr. Mlary Allen Engle, Division of Pediatric Cardiology, The New! York Hospital-Cornell U niversit} Medical (Center, New York, New York 10021. Circulation, Volume 51. March 1975
care
juggling act, three components of which are keeping quality high, costs down, and bed occupancy up. To the medical center, optimal care translates into the
399
Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on March 28, 2015
EDITORIAL
400
sence of the healing art. Tender, loving care is not a requisite of infants alone. Pediatricians are accustomed to hearing their internist colleagues jokingly (?) refer to pediatric subjects as "just little adults." With respect to T.L.C., perhaps they will accept the judgment that "grown-ups are just big babies." Consumer: From the patient's point of view, his appreciation that the care is optimal and also the manner of his response to treatment are based in large measure on the Confidence he has in his doctor and in the establishment, in the esprit de Corps he perceives in the well-functioning team, and in the Courtesy extended him from arrival, as he is prepared for what is to happen next and helped along the way, to departure. Such confidence helps him to have the Courage for Compliance with recommendations for study or treatment that may be at least frightening and a bit uncomfortable. Captain: At any point in the cardiac patient's care there is only one physician ultimately responsible for making decisions, only one captain with clear lines of authority for those doctors, nurses, and paramedical personnel associated on the team. Leadership roles change according to circumstances. In the community, it is the personal physician; in the medical center it is the medical or pediatric cardiologist for medical aspects of care, but if cardiac surgery is involved, it is the cardiovascular surgeon who joins his medical colleague and is in charge in the operating room and surgical intensive care area. Ease of communication between these specialists facilitates the continuity of care of the patient and smooths the transition from one phase to the next. Commitment: It takes the dedication of a total team to provide Cardiac Care of high quality as a Continuum, with Collaboration and Communication being integral parts of the system of optimal care that links cardiologist, community hospital, and cardiac center. Recognition of the problem and longterm care (preventive, expectant, convalescent, chronic) are at one end of the continuum and are also the points of referral and of return of the patient should a critical or complex condition arise that calls for consultation and for the diagnostic and therapeutic capabilities concentrated in a cardiology center.2' 3 Cardiovascular centers, established on the basis of community need, provide a critical concentration of personnel and facilities with capability for the effective discharge of responsibilities of complete diagnosis and medical as well as surgical management. There is coverage 24 hours a day. The capacity of the facilities, the caseload and the staffing must mesh closely. Competition among centers is a positive feature, for there is no one way that is optimal, and the critical self-analysis and comparisons with other centers of ex-
cellence promote improvements in the system. Channels of communication are necessary for contact between physicians for referral and acceptance, recommendations, action and progress reports. Communication between members of the team in the center concerning the individual patient but also the program as a whole is necessary so that as different members (doctors, nurses, technicians and others) meet the patient, explain the plans, and answer questions, there are no discrepancies. Counseling of the patient concerning immediate management and long range goals of vocation, recreation, and occupation are forms of communication.2 In the broader sense and covering a wider area is communication of knowledge with exchange of ideas through presentations at conferences and meetings and through publication. This is essential to update information and translate new knowledge into application. Categorical and untargeted research into etiology, prevention, mechanisms, and treatment of cardiovascular diseases is an essential, ongoing component of the system of optimal care, as is: Career training for future clinical investigators, for those engaged in basic research and for those who practice cardiovascular medicine and surgery. Criteria for resources for optimal care have been established by commissions3 4 and committees5' 6 whose members have given considerable thought, individually and collectively, to promoting optimal care for cardiac patients of all age groups and in all categories of cardiovascular disorders. In these recommendations are two recurrent themes of cases and cost effectiveness, which emphasize that costly equipment and complete teams that are infrequently called upon function less well over-all than the equally well-equipped facilities and well-trained personnel that are continually utilized. These discussions led to definitions of minimal case loads, below which the team cannot be expected to maintain its skills, and maximal case loads, above which the capacity of facilities and personnel is overstrained and calibre of care deteriorates. Optimal, achievable numbers of cases have been suggested for cardiac catheterization with contrast visualization and for the different types of open heart surgery for congenital heart disease,3- 7 valvular heart disease,3 and coronary arterial disease.3'4 Regular reporting by centers of annual case loads and results will establish or refute the validity of these suggested numbers, but the rationale and the recommendations seem reasonable. Such a mechanism has proven its merit in New York City, where it has been effectively utilized for the last twenty years.8 Costs for the most complex forms of complete diagnosis and treatment continue to mount for institutions, individual patients, and insurance carriers. Circulation, Volume 51, March 1975
Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on March 28, 2015
EDITORIAL
401
Rather than deny an adult with heart disease the treatment that would promote his comfort and prevent premature death, or deny a baby or child with serious congenital heart disease the opportunity for surgical correction or amelioration of his condition so that he can look forward to many years of good health, it behooves each of us to become involved in making optimal cardiac care achievable. We doctors must enhance our individual capabilities to provide knowledgeable, comprehensive, compassionate cardiac care while the scientific community in tandem with private and governmental agencies seeks to continue and to promote a total stratified system of excellence for continued advances and improvements in cardiovascular research, training, and patient care. The total team approach with clear responsibilities in a system that has ready access, good communication, and flexibility functions well today in a number of regions so that one can say with conviction that optimal cardiac care is not only achievable but is being achieved.
References 1. PEABOD'E FW: The Care of the Patient. JAMA 88: 877, 1927 2. EMGLE MA: Pediatric cardiology and the pediatrician. Pediatric Annals 3: 10, 1974 3. Cardiovascular Diseases. Guidelines for Prevention and Care. Reports of the Inter-Society Commission for Heart Disease Resources. Edited by WRIGHT IS and FRE1DRICKSON DT. Inter-Society Commission for Heart Disease Resources, New York, 1971 4. Optimal Criteria for Care of Heart Disease Patients. Heart Disease Advisory Committee. JAMA 226: 1340, 1973 5. Standards for Cardiac Diagnostic and Surgical Centers. American Heart Association, 1974 6. BLOOxI BS, PETERSON OL: Patient Needs and Medical-Care Planning. The Coronary-Care Unit as a Model. N Engl J Med 290: 1171, 1974 7. ENGLE MA, ADA.ois FH, BETSON R, DUSHANE J, ELLIOTT L, MNA\IARA DG, RASHKIND WJ, TALNER NS: Resources for the Optimal Acute Care of Patients with Congenital Heart Disease. Circulation 43: A-123, 1971 8. SC\NNFLL JG, Bno's,-\ GE, ELLISON RG, GROVES LK, LALU SIAN H, SABISTON DC, SLO.AN HE, WHEAT MW: Optimal Resources for Cardiac Surgery. Surgery Study Group. Report of Inter-Society Commission for Heart Disease Resources. Circulation 44: A-221, 1971
MARY ALLE.N E.NGLE, M.D.
Circulation, Volume 51, March 1975 Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on March 28, 2015
Optimal cardiac care: achievable. M A Engle Circulation. 1975;51:399-401 doi: 10.1161/01.CIR.51.3.399 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1975 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/51/3/399.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
Downloaded from http://circ.ahajournals.org/ at CONS CALIFORNIA DIG LIB on March 28, 2015
