History

The Intensive Care Unit (ICU) at the Winnipeg General Hospital first opened on 23 September 1966 on the seventh floor of the H Wing, and was part of a larger project H Wing expansion that had been approved in 1962. The new ICU replaced a smaller and insufficient ward that had been in operation on the E Wing since 1963. This space was used largely as a Cardio-respiratory unit, with Dr. Reuben M. Cherniack as the unit director. Critical care did not begin with the opening of the Intensive Care Unit on H7, however this Unit did create a designated space that was designed with all aspects of intensive care in mind. From the beginning, the Unit also prioritized securing specially trained medical staff by establishing educational programs and courses, and installed state-of-the-art technologies to provide the best possible care for critically ill patients.

When the ICU opened in 1966, it was one of the first and one of the most modern Intensive Care facilities in the world, and the only other operational ICU was at Johns Hopkins in Baltimore. The hospital newsletter, The Generator, reported that the ICU was “unequalled anywhere in the world, with the possible exception of Sweden”* and that it promised to “put the Winnipeg General Hospital on the map as a unique North American medical centre.” The Intensive Care Unit at the Winnipeg General Hospital was one of the first proper ICUs in North America. The ICU was so exceptional in large part because of the dedication and attention to detail of Dr. Cherniack, who served as the first Unit Director and was a pioneer in respiratory intensive care. Much the design of the Unit was inspired by the experience gained during the polio epidemic of the early 1950s, when hundreds of patients required constant care and monitoring.

*Note: The Generator likely meant Denmark; the first ICU is generally thought to have opened in Copenhagen in the 1950s.

Polio Epidemics of 1952 and 1953

In the summer of 1952, Manitoba experience a major outbreak of polio following approximately ten years of relative relief from the disease. To combat the problem, then Minister of Health, Ivan Shultz, formed a committee  of health authorities and specialists to coordinate a response to the epidemic. The King George Hospital in Winnipeg (demolished in 1999) served as a medical centre at this time for patients requiring respiratory care.

In 1953, another major polio epidemic occurred in Manitoba, with the total number of reported cases reaching 2,300 by October. Again, care and response was centralized at the King George Hospital under the direction of Dr. Jack Hildes. Immediately the experience and expertise gained during the previous year’s epidemic was put into action. Under Dr. Jack Hildes’ leadership, medical staff managed to provide constant, twenty-four hour care for as many as 93 respiratory patients simultaneously being ventilated in iron lungs at the King George Hospital.

As with treatment of critically ill patients in Intensive Care Units, the treatment of polio also requires specialized and expensive equipment, such as respirators, suction pumps, tracheotomy tubes, bronchoscopes, and physiotherapy equipment. Providing this equipment required that Manitoba health professionals be able to identify the necessary equipment and make arrangements for space, additional maintenance, and ensuring that there was adequate electrical power. Similar factors would be taken into consideration when designing the ICU.

Likewise, because the polio outbreak affected the entire province of Manitoba, transport services had to be arranged to bring critical patients to Winnipeg. Transport staff were trained to use specialized equipment like respirators and suction pumps and were made aware of medical complications that could occur during transport. Another vital aspect of their role was communicating knowledge of patients’ conditions to medical staff at the King George Hospital.

The polio epidemics of the early 1950s, while undoubtedly tragic, provided crucial learning experiences for handing a large number of patients requiring constant care in a designated area and inspired innovative solutions to complicated and frequently evolving health crises. These skills, expertise, experience, and appreciation of teamwork would prove invaluable when the ICU was been designed at the Winnipeg General Hospital.

Dr. Cherniack was in Winnipeg during the summer of 1953 and was involved in responding to the polio crisis. Shortly afterwards, he attended Johns Hopkins University in Baltimore, Maryland, to research respiratory physiology. When he returned to Winnipeg, he and Dr. Hildes provided care for patients with respiratory failure on F2 of the Winnipeg General Hospital in the late 1950s. By 1960, a four bed room on E3 was being used for this purpose, and Dr. Hildes and Dr. Cherniack served as “Attendings” by making rounds and providing instruction to interns and residents. Dr. Bryan Kirk credits this unit as being his first introduction to intensive care in 1960 when he was a rotating intern.

2016_107_001a The first intensive care unit on the E wing, 1960

2016_107_001a The first intensive care unit on the E wing, 1960

A five bed unit opened on E2 in 1963 and was designed according to many of Dr. Cherniack’s specifications. Down the hall from the unit was a research laboratory (on F2) that had equipment capable of of measuring oxygen and CO₂ the blood. Interns and residents received instruction here. Dr. Cuddy returned from his post-graduate training in Cardiology, and cardiac monitoring equipment, early defibrillators, and external pacemakers were also made available. Horst Friesen, a technician, maintained the ventilators and oxygen and suction equipment, and under his guidance, being able to disassemble and reassemble a Bird ventilator became a component of residents’ training. This unit and the adjacent lab proved to be a kind of trial run for the intensive care unit that would be built on H7, as well as the beginning of Respiratory Therapy in Manitoba.

Dr. Cherniack and Darlene Boucher of the nursing staff were instrumental in designing this unit. In addition to learning from the polio epidemic in the early 1950s, Dr. Cherniack also travelled to other hospitals and units throughout North America and Europe. Of particular influence was the very modern intensive care unit that opened in the 1950s at the Bispebjerg Hospital in Copenhagen following a polio outbreak in Denmark in 1952.

The ICU opened as a twenty-two bed unit and was adjacent to the Dialysis Unit, the Recovery Room, and the Operating Rooms on H7. There were six isolation rooms and one large ward with eight two-bed cubicles, as well as two nursing stations. Several auxiliary services also supported the Unit: there were two large supply areas and a small laboratory where measurements of arterial blood gas tensions and Ph, blood and urine electrolytes, serum osmolality and the blood volume could be determined. The Unit was staffed by a medical director and two assistant directors, as well as a team of nurses. There was to be one nurse in constant attendance of each isolation unit and one nurse for each two-person cubicles. The Unit opened on 23 September 1966 with Dr. Reuben M. Cherniack as Unit Director, Doctors Bryan W. Kirk, T.E. Cuddy, and A.R. Downs as Associate Directors, Enid Hassett as Unit Supervisor, and Judith Hindle and Gwen Galbraith as nursing instructors.

2016_107_008a. Responsibility flow chart, 1966.

2016_107_008b. Responsibility flow chart, 1966.

Every detail of patient care was taken into consideration when planning the space, right down to the window drapes, which were enclosed between two panes of glass to ensure that dust would not spray out and affect the patients when the drapes were opened or closed. Different air pressures were also used throughout the Unit in order to prevent cross-contamination: patient-care areas had higher air pressure than other spaces so that drafts would move outwards, and the six isolation rooms all had their own ventilation systems. The ICU was the last department to open following the renovations of the H Wing largely because of the level of detail put into its design.

Other functional design decisions included a raised nursing station in the centre of the Unit, which allowed nursing staff to survey the entire Unit from one centralized location. An electronic console was installed in the nursing station where information was fed from bedside monitors. This central station also benefited teaching because students could be instructed directly from the nursing station, rather than crowding around a patient’s bed.

“And that, by the way, was the philosophy of the time: you looked at clinical problems, you took them to the lab to sort out, you brought them back to the bedside, you went back to the lab. And you kept going through the improvemnet loop until you got it right. The setting was perfect, because you had the clinical experience, you had not only the lab there, but  also a very, very active Department of Biomedical Engineering, that was very innovative and developed many of the tools we needed, and a very active group of Respiratory Therapists that were very keen to come up with new things – and did.”

Dr. Luis Oppenheimer

During the Unit’s first 17 months of operation, 911 patients were admitted. Between September 1966 and September 1967, over 50% of patients were admitted for cardiac problems (Arrhythmia at 25.3%, Myocardial Infarction at 22.7%, and Cardiac Arrest at 7.5%). The remaining reasons for admission consisted of Dialysis, Overdose, and Respiratory Failure.

Improvements continued to be made to the unit throughout the following years. Heavy, transparent vinyl curtains were installed around beds to allow continued monitoring by staff while also providing privacy and reducing sound – especially the noise created by the gas-driven PR2 ventilators reverberating off of the metal cubicle walls! When the H7 ICU was first designed, airborn infections were believed to be the greatest risk to patients, which was guarded against with the installation of a ventilation system. Later, sinks were also installed in order to cut down on infections transmitted by hands, which proved to be the higher risk factor.

“One of the things that was a unique idea – unique for the time, anyway – that had been brought by Hildes from the polio epidemic was that you couldn’t look after sick patients unless you worked together as a team. So, when you made rounds there would be the attending physicians – whoever was on-call at that time – there’d be the residents who were assigned to the unit, there would be a physiotherapist, a pharmacist, a respiratory therapist. And this team would go around, and of course a really important part of it was the nurses because when you went to the bedside the drill was that if the patient had just been admitted or if there were things that happened overnight, the resident would present that part of  story – you know, ‘This is mister so-and-so, a 66 year-old man, et cetera, et cetera.’ And then the bedside nurse would present the findings, you know, what was happening with blood pressure, et cetera, et cetera. So we worked as a team, and this was quite unique, so we got to know each other pretty well through all of this. At that time, my nickname became ‘Captain Kirk’ – Star Trek was on TV at that time, so it was kind of a natural thing.”

Dr. Bryan Kirk

Although instrumental in the establishment of the ICU at Winnipeg General Hospital, Dr. Reuben Cherniack was appointed as Associate Dean of the University of Manitoba’s Faculty of Medicine shortly after the ICU opened; Dr. Bryan Kirk replaced him as Director of the ICU and Dr. T.E. Cuddy and Dr. A.R. Downs stayed on as Associate Directors. Dr. Kirk served as Director until 1982, and under his leadership the ICU continued to grow and refine, and education and research activities were also expanded. One such improvement was the acquisition and installation of new monitoring equipment. The sophisticated new monitoring system was designed onsite under the guidance of Monte Raber, Head of the Biomedical Engineering Department. You can read more about this monitoring system and other technologies here.

Dr. Reuben Cherniack, 1967

Dr. Bryan Kirk, no date

Dr. T.E. Cuddy, 1969

Dr. A. Downs, 1966

In 1971, renovations were approved to convert four of the isolation rooms into a six-bed Coronary Care Unit (CCU) area, which was opened in December 1971. The CCU specialized in caring for people that have acute myocardial infarction, cardiac arrhythmia, or unstable angina, and the separation from the ICU provided increased comfort to patients. One of the original isolation rooms remained as Kevin Keough‘s private room and another was converted into staff space.

By the mid-1970s, it was clear that the ICU and and CCU were experiencing a severe bed shortage; on several occasions throughout 1976 there were no beds available in either the ICU or the CCU. One of the major causes of this bed shortage was the lack of alternate care facilities, resulting in a backup of chronic care in the Units. In 1977, the hospital newsletter, CentreScope, reported that the ICU and CCU operate at a 98% occupancy rate and the bed shortage reached record levels in 1977. On a typical day, two beds might be available in the ICU and one available in the CCU, however it was often the case that no beds were available. The ICU was hit particularly hard by the bed shortage, and in 1977 on at least ten occasions, patients slated for elective surgery had to be canceled. The creation of specialized ICUs have helped to alleviate this problem and encourage patient flow.

In spite of these problems, the Intensive Care Units and services remained one of the best recognized programs in North America and offered invaluable training for postgraduate residents from Medicine, Surgery, and Anaesthesia specialties. Many of the doctors that worked as residents in the ICU went on to start or run intensive care units at other hospitals across Canada. By this time, the ICU at the Health Sciences Centre was no longer one of only a few intensive care units in the world, but one of many across Canada.

“Well, I think it was better in the old days [laughs]. My favourite thing about [working in MICU] – and I don’t think this changed much – is that it’s a place of learning. Even after thirty-five years there was not a single day that goes by in that place that you don’t learn something. And you learn something, you share it – that’s the way it is with everybody there.”

– Elizabeth Cohoe, former MICU nurse

During this time, the nurse-to-patient ratio varied from 2:1 to 1:4 according to the needs of each assessed patient, and nurses worked a 12 hour shift. In addition to exemplary care and technologies, the ICU was also supported by a wide range of services, including Dietary, Physiotherapy, Chaplaincy, and Social Work.

In the 1970s, the Recovery Room, which was also located on the 7th floor next to the Operating Room, formally split and formed the Surgical ICU and the Post-Anaesthesia Care Unit (PACU). At this time, the unit on H7, initially known as the Intensive Care Unit, came to be called the Medical Intensive Care Unit in order to be more specific.

 Adult ICU Pharmacy

HSC has the oldest operating 24-hour Adult Critical Care pharmacy in Canada. The pharmacy opened on 12 January 1982 in the Medical ICU on GH7.

Satellite pharmacies were also opened in the Neonatal ICU and the Pediatric ICU, and the Medical ICU Pharmacy eventually expanded its services to also provide support for the Coronary Care Unit and the Surgical ICU.

Satellite pharmacies allowed trained and knowledgeable pharmacists to quickly meet the needs of patients in critical care by shortening the turnaround time for medication orders and to manage the increasing complexities of drugs and their preparation in critical care areas.

In the 1980s and 1990s in particular, a dedicated effort was made to dispel some misconceptions about working in the ICU. Intensive Care Units are often thought of as being high-stress environments where staff quickly burn out. Undoubtedly, many life-or-death decisions are made in the ICU, however it is also a well-supported unit: physicians are readily available, respiratory therapists assist with the respiratory equipment, and there is a pharmacy on-site. Many nurses also claimed that although the patients are critically ill, it is actually less stressful to have only one or two patients to focus on, rather than six or seven on another unit.

ICUs also have the reputation of being cold and impersonal units where there is a greater focus on technology than on the patients. However, the ICU has always prioritized patient care, and the one-to-one nurse patient ratio means that nurses often develop close relationships with the patients and their families. Technology is an important way that the ICU prioritizes and improves patient care.

 “Probably the best part of my job that I remember was providing direct patient care: working with the patients, working with their families. I think I have my fondest memories from that, I certainly enjoyed that interaction – not that I didn’t enjoy other parts of my work, but I look back on that and really feel as if I achieved something.”

– Alice Dyna, former ICU nurse and educator

An important aspect of how technology and research improves patient care is the Winnipeg ICU Database (WICUDB) developed by Dr. Dan Roberts in 1988 – three years after he became the Director of the Intensive Care Unit. The database, which was the first of its kind in Canada, initially included only the Medical and Surgical ICUs at the Health Sciences Centre. The database was expanded in 1999 to include all Adult ICUs within the Winnipeg Regional Health Authority, which consists of the Health Sciences Centre, St. Boniface General Hospital, Seven Oaks General Hospital, Concordia Hospital, Victoria General Hospital, and the Grace Hospital. The WICUDB links detailed information about adult ICU admissions in Winnipeg with provincial administrative data, which consists of  information about Manitoba residents including vital status, all hospitalizations, outpatient visits, prescription pharmaceuticals, home care, and use of chronic care facilities. Combined, these two datasets provide robust data and enables a wide range of original research on ICU epidemiology. Conducting research is a mandate of the Critical Care Section at the University of Manitoba, and to this end, the WICUDB is an invaluable resource and is routinely used for quality and patient care improvement.

As of 1998, all hospitals in Winnipeg coordinated under the Winnipeg Regional Health Authority. Adult critical care is jointly administered by the WRHA and the University of Manitoba Section of Critical Care Medicine, which oversees the academic aspects of critical care, including residency placements. Likewise, all adult intensive care units in Winnipeg now make up one integrated system. Within this system, the ICUs have all become “closed” units, meaning that there is a single attending physician in charge of care.

After more than forty years on H7, in 2007 the Medical ICU prepared to moved into a new space on the third floor of the Ann Thomas building. The expanded space also came with new equipment to help meet the demands of critical care. Today, MICU/CCU, SICU, and IICU are all located in the Ann Thomas building.

F3/P3/013 Floor plans of the new CSRP/Ann Thomas building, showing SICU on the second floor.

F3/P3/013 Floor plans of the new CSRP/Ann Thomas building, showing MICU/CCU and PICU on the thid floor.

H1N1 and Critical Care

In April 2009, an illness similar to influenza began to spread in Mexico, and particularly among young people. On April 22, samples were sent to the National Microbiology Lab in Winnipeg, which identified the virus as a new Influenza A H1N1 which appeared to have originated from pigs (hence “Swine Flu”). By late April, the virus had spread to Canada, the United States, Europe, and Asia, and because of this intercontinental reach, the World Health Organization declared it a pandemic on June 11, 2009.

The first positive specimen was identified in Manitoba on May 2. The outbreak peaked in mid-June and stretched critical care in Manitoba to its limits as every regional ICU bed was occupied. By August 31, a total of 889 cases had been reported in Manitoba and there had been seven deaths. Forty-four critically ill patients were cared for in the intensive care units, as well as many other unconfirmed but probable cases. Those admitted to the ICU often experienced severe hypoexmic (drop in oxygen carried in the blood) respiratory failure and required prolonged mechanical ventilation. However, it was found that this was a very successful technique for treating patients through critical illness.

Dr. Anand Kumar and Dr. Ryan Zarychanski, both at HSC, completed an in-depth study on critically ill patients with influenza A(H1N1) across Canada. This study helped prepare for the second wave of infections and  was meant to aid in the diagnosis and clinical treatment of future infected patients.

The second wave of infections began in October 2009 and lasted until mid-January 2010. As expected, more people were effected during this second wave, however the mortality rate was lower. 1,773 people were infected during this three and a half month period in Manitoba and four people died.

Critical Care at HSC continues to prioritize patient care and innovation. Some of the recent projects being implemented by Adult Intensive Care Units include:

• Cherry Blossoms: This initiative was introduced at the Victoria Hospital (Winnipeg) Intensive Care Unit in 2014 as a subtle way to indicate end-of-life care for a patient. This symbols helps to ensure that staff and others remain sensitive to their surroundings and treat patients with dignity and respect. The symbol has since been introduced at all intensive care units within the WRHA.

• Family Presence: This initiative, which has gained national recognition in Canada, aims to improve communication between critical care staff and families and to address any environmental issues, such as physical surroundings, comfort, and noise. Specifically, the Family Presence during Rounds ensures that family members are included in the critical care process. Rounds refers to the daily procedure in which an interdisciplinary critical care team discusses the patient’s plan of care. Prior to 2014, families were asked to leave the ICU when rounds began and these conversations were held privately among medical staff. However, the results of a 2011 Family Satisfaction survey indicated that families did not feel as though they were being involved in the treatment process and that they did not have adequate access to their loved one in the ICU. Families are now invited to participate in daily rounds or to receive verbal/written information about the daily rounds.

• “My Patient Story”: This project, for which IICU won the best regional critical care improvement project, encourages staff to get to know their patients on a personal level. Dr. Oppenheimer describes the importance of such a project in the following way:
  “You need to have incentives to recover. And bringing back what is important to you, what is important to the patient, and say ‘Okay, we can do this. This is the path to this.’ An analogy that I give them is that it is like training for the Olympics: it is a longer period of time, but there is a definite goal. The definite goal is to go back to what you like, to the extent possible. And that motivates the patients, it motivates the families, motivates the staff: they see the patient not as somebody with a lung problem, but as Mr. Smith who is a gardener.”
  

• Bed Bike: In 2016, the Medicial ICU introduced the Bed Bike program into their Early Mobility activities; MICU achieved the highest number of activity events across the WRHA.

• Bedside Carts (Lean Project): Surgical ICU introduced the Bedside Carts Lean Project in 2016, which was developed to assist new staff with bedside activities.

The following tables show the number of admissions to critical care units at HSC between 1996 – 2015 (Table 1) and the primary reasons for admissions for the years 2011 – 2015.

Table 1: Critical Care Admissions

Table 2: Primary Reasons for Admission

Specialized Intensive Care at HSC

There are currently three Intensive Care Units in operation at the Health Sciences Centre: the Medical Intensive Care Unit/Coronary Care Unit (MICU/CCU), the Surgical Intensive Care Unit (SICU), and the Intermediate Intensive Care Unit (IICU). MICU/CCU contains 16 beds and focuses on patients with multi-organ failure, cardiac failure, respiratory failure, spsis, overdoses, and renal failure requiring dialysis or continuous renal replacement therapy. SICU consists of 11 beds and handles multi-system trauma, high-risk elective or emergency surgery, emergent neurosurgery and neurotrauma, burns, and lung transplants. The IICU, a 6 bed unit, cares for patients from ICUs across the city who are medically stable, but still require additional care.

Additionally, the Children’s Hospital also opened its first Intensive Care Unit in 1966, and it currently operates a Neonatal Intensive Care Unit (NICU) and a Pediatric Intensive Care Unit (PICU). NICU treats approximately 700 patients each year from Manitoba, Nunavut, and Northwestern Ontario. PICU consists of a 10 bed unit and each year handles approximately 500 critically ill children from Manitoba, Nunavut, Northwestern Ontario, and Eastern Saskatchewan each year.

You can read more about these specialized units by clicking on the links above.