Atrium Health Wake Forest Baptist in Winston-Salem, NC, has one of the few medical oncology ICUs in the U.S. From its inception in 2017, the oncologists, physicians, nurses, and other members of the team have worked to provide the best care for their patients-those with cancer diagnoses and hematologic disorders that require intensive care. Though unique challenges-including the crisis of COVID-19-have presented to the unit, the team has persevered. Now celebrating 5 years of outstanding care, Peter "PJ" J. Miller, MD, Medical Director of the Medical Oncology ICU, shares a look at the team's journey and its road to success.
"When looking at the data, it became apparent that increasing numbers of patients with cancer or hematologic disorders, such as sickle cell anemia or complex bleeding and clotting disorders, required ICU care," Miller said. "We found that this was reflective of improved survival with cancer or hematologic disorders, as opposed to patients getting sicker from chemotherapy or cancer-directed treatments.
"Patients that would typically have short survival times because of cancer were now surviving and developing not only complications of chemotherapy or cancer, but also complications from typical critical illness such as septic shock or pneumonia," he explained. "It was reassuring to see cancer patients now surviving longer, but it was a double-edged sword due to the large gaps of knowledge with current treatments not only in chemotherapy, but cellular-based treatments or study protocols being used in the cancer world that were unfamiliar to the typical critical care physician."
To bridge that gap, the medical oncology ICU was developed, led by Miller himself, who offered knowledge in both areas of medicine and could ensure patients were being provided with optimal care. Work to build the ICU was not simple-when the team began plans for its development, there were almost no background models that could be easily adopted and adapted without a significant amount of overhaul.
"So, we looked at several other co-management types of ICUs, some of which we have in our own institution, and picked apart what was working well, what was not working well, what would need to be shifted for cancer patients specifically, and how we could redefine what co-management meant," Miller said.
In some institutions, co-management referred to a practice where no one physician "owned" the patient, but instead every clinician was on equal footing in ordering labs, tests, and procedures for the patient. The Wake Forest Baptist team felt this wouldn't work due to the complexity of patients with cancer who are critically ill.
"Oncologists have relationships with patients sometimes extending over the course of a decade or longer, and we needed to respect those personal relationships," Miller said. Instead, the team chose to redefine the co-management model into what they call assisted management, a system that very distinctly defines the boundaries of what is managed by critical care teams versus oncology teams, leaving room open for areas of negotiation between the two groups to optimize patient care and ensure team members are functioning in the roles they are best suited for.
Building the Team
With the co-management model defined, the next step in building the medical oncology ICU-and perhaps the most critical-was to find the ideal team. "We had to identify physicians who had an academic and clinical interest in the management of cancer patients, as well as those who had excellent bedside manner, the ability to work in an interdisciplinary team, and those who were comfortable leaving the 'captain of the ship' approach of one physician leader and instead embrace the coordination of all members of the team," Miller said.
Finding that balance wasn't easy, but now, 5 years later, the medical oncology ICU employs a solid team using the advanced practice provider-driven model consisting of physician assistants and nurse practitioners that provide day-to-day beside care; physicians to handle management and oversight; nurses, respiratory therapists, CNAs, secretaries, an environmental services team (who Miller noted was especially key during the height of COVID-19); and plentiful opportunities for learners such as critical care fellows, hematology and oncology fellows, and practice provider students to supplement care and coordination.
"It took a little bit of time for everybody to get on board, but since we are all very invested in the unit's success, we were able to smooth out any issues pretty fast," Miller said. "For the most part, the ICU team manages all critical care aspects for the patients, including treatments for organ failures such as mechanical ventilation, renal replacement, and other ICU indications. The hematology team is responsible for all complex hematologic and oncologic orders and treatments, such as chemotherapy and specific labs that may be complex such as genetic testing. The oncology teams focus on oncology-specific care, ensuring they are first and most importantly involved with the patient to make determinations in regards to whether or not cancer-directed care continues."
Patient Services
The patient population in the medical oncology unit is quite wide, with many patients with cancer or hematologic disorders being admitted for common ICU issues that are often not directly related to cancer, including sepsis, pneumonia, and COVID-19, as well as common critical illnesses impacted by underlying immunosuppression or the cancer/hematologic disorder. These ICU issues are often more dire in the medical oncology ICU patient population, Miller noted.
"For example, septic shock in a patient with cancer can be far more aggressive and driven by underlying infections you would not see in ICU patients," he said. "Patients with both COVID and cancer sometimes require additional therapies or prolonged therapies and may need additional evaluations to see if the patient is infectious or not before they are released from isolation."
The major difference between the medical oncology ICU and general ICU, Miller explained, is the risk of procedures, including very common ICU procedures such as placing a central line. The patients they are treating have a platelet count of less than 10,000, putting them at a high risk for bleeding, "and no amount of transfusion will safely increase that number per any published guideline," he noted.
In addition, more and more patients of the medical oncology ICU are those in clinical therapy trials who need to be in the ICU as part of their care. "Some of these complex patients have multi-system organ failure while they undergo chemotherapy, requiring additional therapy for secondary disorders with a complication of underlying malignancy," Miller explained.
Meeting Unique Challenges
Because the management of hem/onc patients in the ICU has so many unique challenges requiring a tailored approach, the team developed numerous guidelines specific to the medical oncology ICU that differed from the general ICU patient population.
"We have different visitation rules for adolescents and young adults housed in the ICU, for example, because we recognize that just because someone is 17-19 years old and ends up in an adult ICU, they may need additional support from family, parents, and friends."
The team also implemented policies regarding pet therapy and exposure risk, and a practice referred to as Code Lavender, which is a care policy for staff when they become overwhelmed by the demands of the job.
"As one could imagine, the medical oncology ICU could at times have a higher mortality rate than the general ICU, and it can really impact staff," Miller said. "One of the big challenges we faced initially was how much the staff would be impacted by the deaths of patients. We had to ensure we worked hard on resiliency training and providing outlets for staff to grieve, such as taking time after a patient death to be released from clinical duties to refresh," he said.
"In that regard, we had to reframe our policies because, as the medical oncology ICU developed, the oncology teams wanted to transfer their sickest patients to us, which lead to us getting a high number of patients who would not benefit from ICU-level care-sadly, no amount of care at that point would impact their quality of life or survival. We had to develop different approaches to help identify patients that would most benefit from the ICU and redirect those who wouldn't benefit to other types of therapies, such as palliative care and hospice."
A Proud Foot Forward
Miller said he and the team are proud of how far they've come since the inception of the medical oncology ICU 5 years ago, and now that they have such a strong footing, the team is turning its sights to the future, where they hope to become leaders in this emerging field.
"With an estimated 25 percent of all ICU patients currently or previously having cancer, the time is now for education to increase," he said. "There are going to be more cancer patients in the future because newer treatments and therapies are improving survival. This will only increase demand in the ICU as patients develop other illnesses they never would have experienced if they had died from cancer."
Miller noted that the literature supports earlier ICU intervention as one of the biggest impacts on survival of patients with cancer, and that will mean a growing need for physicians and practitioners with a specialized knowledge of Medical Oncology ICU practices. "You can't take a cancer or hematologic patient and shove them into a protocol or guideline box that you may use for other critically ill patients," he said. "We need to have a patient-centered approached while developing newer guidelines that adjust for the specific patients we are dealing with. In this ever-growing field, our education needs to keep up with our patient demands."
If you're interested in starting your own medical oncology ICU, Miller is happy to share more details of Atrium Health Wake Forest Baptist's experience, troubleshoot problems, or just think things through. Email him at [email protected].
Kelly Wolfgang is a contributing writer.