Critical Care for Patients With Cancer

Podcast Transcript

Raed Dweik, MD:

Hello, and welcome to the Respiratory Inspirations podcast. I'm Raed Dweik, MD, Chairman of the Respiratory Institute at the Cleveland Clinic. This podcast series of short, digestible episodes is intended for patients and families and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of yourself and your loved ones. I hope you enjoy today's episode.

Hassan Khouli, MD:

Hello, everyone, and welcome to the Respiratory Inspirations podcast. I am your guest host Hassan Khouli, MD, Chair of the Department of Critical Care Medicine in the Respiratory Institute at the Cleveland Clinic. My guests today are Humberto Choi, MD and Simon Mucha, MD.

Dr. Mucha is the Director of the Medical Oncology ICU and a physician staff in the Department of Critical Care Medicine in the Respiratory Institute. Humberto Choi, MD is the Associate Director of the Medical Oncology ICU and the Medical Director for the, uh, Critical Care Advanced Practice Providers in the Department of Critical Care Medicine in the Respiratory Institute.

We will be talking about oncology ICU today. Humberto and Simon, welcome to the program.

Simon Mucha, MD:

Thank you.

Humberto Choi, MD:

Thanks for having us.

Hassan Khouli, MD:

So, we're going to actually get into it and ask you to share with our audience here. What is a medical oncology ICU, Simon?

Simon Mucha, MD:

Yeah. So, our medical oncology ICU is a 13-bed ICU that is situated within our large ICU here at the Cleveland Clinic main campus. Our ICU has 65 beds and can flex up to more beds if necessary. But this is a 13-bed unit that is dedicated to patients with active cancer that need ICU care during any part of their journey for their cancer care. It is staffed by a core group of physicians, nurses, pharmacists, advanced practice providers who have additional training in taking care of patients with cancer.

Hassan Khouli, MD:

Thank you, Simon. That seems like a big team there that has been assembled to focus on the care of such patients there. So why take on all of these efforts to develop a program like this? Maybe you can share your thoughts about the why with our audience, please.

Simon Mucha, MD:

Of course. So, a large portion of all ICU patients may carry a diagnosis of cancer. And cancer, or patients with cancer, especially those undergoing active treatment, have complicated disease processes. Active cancer therapy is complex. It has complex complications. These patients require a dedicated team that really understand those unique care needs.

And we realized that with the number of patients that we see in our ICU, that number of patients who have very specific care needs related to their ongoing cancer care, it is about 20 percent of all the patients. So that's a high number of patients that would really benefit from a really specialized team.

Hassan Khouli, MD:

Thank you, Simon. So, what I heard from you, really, I mean, a couple interesting things about how patient centric this is. The patient is really in the front and the goals, the why behind it is how we can really take care of these patients in the best way we can, the most compassionate way, we can to deliver the desired outcome for them.

So maybe you can share with us what are the goals that you had in mind as you and the team worked on developing this unit?

Simon Mucha, MD:

The goals, as for every unit in the Cleveland Clinic, is to provide the best care possible. And we recognize that, you know, oncology care and oncology care in an ICU is complex. There are new treatments every day, and they make the field more effective, but also more complicated for those providers to turn around to provide the best care.

So, our goal is to provide the teams an opportunity to collaborate, the intensivists or the ICU doctors working very closely with the oncologist to develop expertise in our ICU that really our providers are at the forefront of what is medically possible in the realm of oncology and develop and follow protocols specific for those patient needs.

Hassan Khouli, MD:

Thank you. And you know, the other thing that I heard from you is how critical and important it is for the primary oncologist of the patient to continue to be engaged in their care, that physician or their partners to be a really part of that team, too. That is definitely reassuring to hear.

Dr. Choi maybe can share with us a bit of a history of how we came about to launch this program at the Cleveland Clinic. Humberto?

Humberto Choi, MD:

Yes. So, as Simon was saying, there's a high number of patients who have a diagnosis of cancer who become ill and need to be in the ICU. And taking care of these patients can be complex. And I'll say it in another way. It would be someone from oncology or the cancer team who'd work as a consultant and come into the ICU and talk to us. But there's a high volume of patients that were often admitted to different places in the ICU.

So actually, about two years ago or so, we started doing a meeting every day that we call huddle, that someone from our team, from the ICU would meet with one representative from the other teams, and then we would have a conversation and develop a common plan for our patients in the ICU. And I think we all saw the need for this to become one unit, one team to make it easier not only for the medical teams, but also for the patients.

So, then we developed this idea of having one dedicated unit, and we actually launched that in January this year, in 2023. And that's when we started putting the patients who have a history of cancer who need to be in the ICU in one space. So, they're taken care of by us. And when they need the expertise from the cancer team, the oncologist, or the hematologist, they come to our unit, and then we communicate, we talk, and we develop a common plan. And I think it's very important for the patient and for the family to see that the doctors are communicating, and they are on the same page on the issues. So, they see that they're getting the best care possible.

Hassan Khouli, MD:

Thank you, Dr. Choi. Dr. Mucha, maybe you can expand a little bit on the team. Who's on that team, and what do they really represent in the minds of our audience?

Simon Mucha, MD:

Yeah. We really realize that the benefit of this team is really the strength of all of its members. Like Dr. Choi mentioned earlier, we started with a virtual huddle where we met daily between the two teams, the ICU team and the oncology team, to make sure the care plans are clear.

But it takes a team to translate this care plan into actual patient care. So, it requires the physicians, of course, to develop the care plan. It requires specially trained nurses to make sure the care is executed at the bedside. It requires pharmacists that make sure all medications are dosed correctly, timed correctly, and delivered on time. And it requires advanced practice providers, nurse practitioners, physician assistants to make sure we follow up on all orders and procedures et cetera.

It also requires coordination of extra services, such as the care coordination that our social workers provide for many cancer patients, start way before they ever require an admission to the hospital in the first place.

So, it really is a team of teams or, you know, takes a village to take care of complex patients. And we really learn that it takes coordination of everybody to get things done. So, it's a wide range of providers that we try to bring together at the same time.

Hassan Khouli, MD:

It is interesting how you described it, Simon, a team of teams, which is a concept we have here at the Cleveland Clinic and how this unit functions really and operates and has been developed to align with that vision and important piece of how we deliver care here at the Cleveland Clinic and certainly in this medical ICU and in this oncology ICU. Thank you for sharing that.

You know, Dr. Choi, you have faced a few challenges in, probably as you cared for some complex patients before. The way you and Dr. Mucha described how this unit has evolved and developed and launched earlier this year, are there certain challenges you'd like to share with our audience as a lesson learned or just to be aware of and maybe how we have been able to overcome some of these challenges, too?

Humberto Choi, MD:

Yeah. We were just talking about team of teams, and I think this is one of the challenges that it was not an ICU team and the cancer team. There are actually multiple teams that we were collaborating with. For example, in the oncologist side, we have more than one solid oncology team. And on the hematology team, we have teams who take care of people who suffer from leukemia, another team that works with patients with lymphoma, or another team, patients who had a bone marrow transplant, for example.

So, we are collaborating with all these different services. And on top of that, there are the subspecialties that collaborate with us. They have very extensive experience in providing for patients who are suffering from cancer. So, working with all these teams at the same time can be a challenge. But I think we are very fortunate that this is at the Cleveland Clinic, and this is a project that had in mind to improve patient care. So, we always have the mind, "Patients first."

And from the beginning, everyone was very interested and motivated. So, in the end, this was a challenge, but it was actually a very easy to overcome challenge, just because of how everyone collaborated and how everyone was motivated and interested to be part of this and to help out.

And another thing that comes to mind is really what we discussed before that now there are so many newer therapies for cancer and for other bone marrow or blood disorders. And sometimes, it can be difficult to stay up to date with all of those and understand what potential side effects someone can have from the therapies themselves.

And that's the perfect match between us in the ICU doing what we know how to do best, take care of someone who is very sick, and combine the expertise with the oncology and the hematology teams, because they are the ones who are working with these therapies and often prescribing them. So, they have that expertise. So, we combine those at the same time. And this is exactly one of the reasons why we developed this ICU, and we have a dedicated team that is committed to learning all of these new therapies and the best ways to take care of patients who are receiving the new treatments that are available nowadays.

Hassan Khouli, MD:

That's wonderful. You know, you re-leverage the strengths of the team and the concept of a team of teams at the Cleveland Clinic that is so embedded in what we do to overcome some of these challenges that face anyone. Thank you for sharing that, Humberto.

Let's maybe shift to talk a little bit more about some specific things related to what type of patients we see in this medical oncology ICU. Simon, we can start with you, and if you can share also, a unique example of a case that puts it in perspective for our audience here.

Simon Mucha, MD:

Yeah. We really see patients either with a known diagnosis of cancer who need to be, they're admitted to the ICU or the hospital for care that either is directly related to symptoms that stem from the cancer, or patients who are undergoing treatment and may experience toxicity or side effects from their treatment.

So, one example, for instance, would be someone who is diagnosed with leukemia, an aggressive form of blood cancer. They might receive chemotherapy that is designed to wipe out this cancer, but in the process, places the patient at risk to have infections. One of the common infections is called neutropenic fever. Those patients can become very sick very quickly and require ICU care that requires both treatment of the infection and ongoing care of their cancer.

And one of the newer groups of medications that we see quite frequently now in the ICU here, and they're often referred to us from other hospitals, are patients who are being treated with novel therapies that use the immune system. So, call it immunotherapy. Those are great medications that really revolutionized the world of oncology and changed the prognosis for many cancers, but they have unique side effects or toxicity, and they can sometimes be life-threatening. And they're new. We're learning how to recognize them and treat them. But they provide a unique challenge, and not everyone has a good understanding, like maybe our oncologists. So, we see a lot of patients who are referred to us for those kinds of admissions.

Hassan Khouli, MD:

That's great. Thank you for sharing that. You know, we'll go back to Dr. Choi. What's special about this unit? What's unique in your mind that differentiates it from maybe other just general medical ICU or even some oncology units that exist in some of these oncology hospitals in the United States? Humberto?

Humberto Choi, MD:

Yeah. So, I think the ICU care can be similar in many ways to the care that someone might get from a general ICU. I don't think we are saying that a general ICU is a place that a patient with cancer shouldn't go. But there's certainly benefits of this kind of unit, and it's really about the team having the experience and expertise of taking care of patients who have unique needs and, in this case, patients who have a history of cancer, receiving treatment for cancer, or have maybe a blood disorder that can be an emergency.

And when we are talking about experiences, really when there is a physician and a medical team that is seeing the same kind of cases all the time, and I think, I always say that we are good at the things that we do every day. So, when we have a team that is seeing this type of case every day, that's how we become good at it. This is how we build expertise, and this is how we are able to recognize certain patterns that sometimes may not be so obvious in other places. But because here we see each other every day, we see each other all the time at work, that becomes, I think, easier for us to recognize and to act on these things as soon as we find them.

And I think it's very important for the patients and their families to see that the doctors are talking to each other. They see that the ICU team is talking to their cancer doctors and having a plan together at the same time. So, they'll see that there is a collaboration among the medical teams.

And I think that one of the benefits of being here at the Cleveland Clinic is often when someone has a history of cancer, they might come to the ICU for something that is unrelated to that, might be something else. And then we have the resources of the entire Cleveland Clinic. So, we have expertise in so many areas. I'll risk saying that in every area. And we have everything available to us, all these resources to take care of the patients and provide the best care possible.

Hassan Khouli, MD:

Thank you, Humberto. You talked about experience and expertise and how important they are as a foundation to really provide success and really help patients, you know in such complex, challenging diseases that they may have in oncology too.

So, I'll, I'll shift back to Dr. Mucha on this. And as you think about these experiences and expertise, we look for success. We want to optimize and really give the patients the best outcomes that they have. To do that, we often think about, "Well, how do we measure what we do? How do we really learn from what we do, what data we collect around that so we can continue to improve and possibly share with the world?"

So, Simon, maybe you can share with us what this data or these measures would be like.

Simon Mucha, MD:

Absolutely. And, you know, I think one of the themes you've heard throughout the conversations today is this is a complex care with large teams that needs to be coordinated well and efficiently.

And as we set off with the birth of this unit in January of this year, this was our first sort of marker of success. Can we develop our protocols, find patients, move them into the ICU, and deliver cancer specific care safe and effectively for every single one of these patients? So, we're really looking at the sort of process of care.

Some examples of what we're monitoring and then seeing some early success is making sure that cancer therapy and chemotherapy, which are really high-risk therapies, there's really no room for error. We're really aiming that these therapies are administered on time every time without errors and out- complications. This is the first goal that we set for our team. And we're really excited to say that in the first six months, we've achieved that and made no errors, no complications. And we've really delivered as intended.

And then we want to make sure we deliver all this care that we know makes overall outcomes better, a particular focus for these patients. That includes hand hygiene for every provider who answers the door. Something as simple as washing your hands will prevent infections, preventing infections that are associated with catheters either, bladder catheters or central lines et cetera.

And I think in the next few months these short-term or process focused metrics will translate into outcomes that are, you know, important for patients. How long do I stay in the hospital? What's my functional status when I leave the ICU?

But for now, I think we're really focused on coordinating a large group of teams and providers and we've learned a lot and I think we've come a long way. And so far, I think, we're looking forward to a bright future.

Hassan Khouli, MD:

I'm looking forward to seeing you, too. You know, you shared no errors and no complications in a complex environment like this. I'm going to knock on some wood, you know, over here. But it's really not luck. It's that focus and delivery, teamwork that achieves this kind of impressive results as well. Congratulations to you and to the team.

So, as we talk about this, I'm sure there are a few cases that stand out in your mind. There are probably many of them. But both of you, I want to maybe ask you, can you think of a quick case that you can share with our audience over here? I’ll start with you, Dr. Mucha.

Simon Mucha, MD:

Yeah. As you said, there are many cases that are certainly memorable. And one just stands out from last week when I was in the ICU, was a patient that was transferred to us from another surgical ICU that was initially admitted, was thought to be a routine case of colon cancer that required a simple surgery. After surgery, I had a lot of challenges and abnormal blood work that is not really explained by the initial diagnosis of colon cancer. And then we quickly learned that it wasn't colon cancer. It was a rare type of lymphoma.

The patient was transferred to us for ongoing care and was critically ill and really multisystem organ failure. But we were able to get the correct diagnosis. And although the patient was critically ill, our oncologists were able to develop a chemotherapy regime that we were able to administer in the ICU. And while the patient was still quite ill, I'm happy to say that they're now off the ventilator, breathing on their own and talking, and they're off all medications. I think the next step is trying to go on to rehab to regain some strength to go on with their cancer care, hopefully as an outpatient.

Hassan Khouli, MD:

That's great. You know, as you tell this story, a bit of a chill goes through of the outcome of this patient and how, you know, amazing the team. Congratulations to you and to the team for making a difference and influencing the outcome of this patient in a positive way, too.

So, Dr. Choi, any case that you can really share with our audience, too?

Humberto Choi, MD:

Yeah. I recall a case that we worked on in the beginning when we were putting the dedicated unit together. So here at main campus, we often get transfers from other hospitals because some resources may not be available. So, we received a call, someone who was in a different hospital, and they were suspecting that this patient to have a blood disorder that is often an emergency because of the complications that it can have.

And this is something that, as I said, can be an emergency. So, time is important. And making the diagnosis rapidly and giving the treatment as soon as possible is certainly important. So, we certainly accepted the patient. And as we knew that a patient was coming in, we started contacting the blood bank, the hematologist, our procedure team to place a special catheter for the patient.

So, we did all that leg work before the patient got to us. And once the patient arrived, it was so beautiful to see that there was already a line of people outside the patient room just waiting to talk to him. It was the first, the nurses to make their assessment, the ICU medical team, you know, waiting to see them, and behind them, the procedure team was already setting up the ultrasounds and getting ready to do a procedure for the patients. And the blood specialist, the hematologist, was already there as well, ready to talk to the patient as soon as everybody else was done.

So, it was just amazing to see that everything that we worked on was really happening live in front of us, that all that dedication and all that hard work paid off. You know, if it was just for one case, it was already all worth it.

So, I think it's a case that sticks to my mind just to see all the workflow. Everything that we worked on, it had, worked so well for that patient.

Hassan Khouli, MD:

Yeah. This is certainly beautiful. As you mentioned, you know, Humberto, and you can think about a patient, or a family who have gone through an experience like this and how, you know, when they see a team that is so organized and with all the expertise that they have, how reassuring it is when you are in the middle of a really high intensity, critical situation, it is. So, congratulations to you and to the team on really work well done here.

You know, let's conclude at this point and maybe both of you can share with us, if I am a patient, or a family who comes to our ICU, the oncology ICU, what to expect if you or your loved one come to such an ICU. So, I'm going to start with you, Simon.

Simon Mucha, MD:

Yeah. I mean, I would say I would expect high class care by compassionate experts. And I think if your care would require treatment in the ICU, I think that should go on be a seamless part of the continuum of the oncology care that you receive at the Cleveland Clinic and a seamless experience where everyone collaborates effectively together as one team.

Hassan Khouli, MD:

Great. Thank you, Simon. And Humberto?

Humberto Choi, MD:

Yeah. You know, I think a lot of people, if not most people, know someone who has suffered from cancer. I certainly had my personal experience in my own family of someone being treated for cancer, and I know it can be a very scary moment. And because of the diagnosis, we always want everything to go well. We always want ourselves or our loved ones to receive the best treatment possible.

And when someone comes to the ICU, it means that something happened, that something that was unexpected happened. And that can be even more scary in addition to the cancer itself. So I think what I would say that I think as a unit, that we thrive to understand what the unique needs of our patients are as a team that is dedicated to do the best they can and I think reassure if someone or their loved one is in this ICU, that they are getting the best care possible.

Hassan Khouli, MD:

This concludes our program today. Thank you, Dr. Mucha and Dr. Choi, and thank you, everyone, for listening to our podcast. I am your guest host Hassan Khouli, MD, Chair of the Department of Critical Care Medicine in the Cleveland Clinic. And my guests today were Simon Mucha, MD, our Director of the Medical ICU Oncology ICU and Humberto Choi, MD, the Associate Director of the Oncology ICU and the Medical Director of the Critical Care Advanced Practice Providers.

Today, we talked about our medical oncology ICU. Thank you both.

Simon Mucha, MD:

Thanks for having us.

Humberto Choi, MD:

Thank you.

Raed Dweik, MD:

Thank you for listening to this episode of the Respiratory Inspirations podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @RaedDweikMD.