Economically Practical and Critically Necessary? The Development of Intensive Care at Chestnut Hill Hospital

After prolonged debate Chestnut Hill Hospital, a small community facility in Chestnut Hill, Pennsylvania, opened a small room designated solely for the care of the critically ill in May 1954. The next intensive care unit to open in the Philadelphia area, at the Hospital of the University of Pennsylvania (HUP), debuted in February 1955. ¹ By 1961, 50 percent of the thirty-two hospitals in Philadelphia reported having intensive care units. ² The "acute room," as the new intensive care area at Chestnut Hill Hospital was first called, provided round-the-clock nursing service to critically ill patients and a "safety net" for postsurgical patients after the recovery room closed in the late afternoon.

As this case will show, the intensive care unit was not the only strategy the hospital could have chosen to provide care to its critically ill patients. It was, nonetheless, a strategy that initially fit the economic goals of the hospital, as it invested in both traditional and nontraditional patterns of rendering care to patients. In this paper, I explore the development of the intensive care unit at Chestnut Hill Hospital and examine the context in which this technologic system of caring for critically ill patients developed. ³ My analysis will provide a glimpse of the foundation of contemporary dilemmas surrounding this most expensive form of hospital care, as the meaning and substance of intensive care changed over time for its multiple participants.

Although intensive care has become the symbol of the highly technical aspects of contemporary health care and its associated dilemmas, I will argue that contrary to earlier accounts, neither machines nor new therapeutics drove the development of intensive care at Chestnut Hill. ⁴ The analysis of this case study will uncover the complex dimensionality and often contradictory nature of knowledge and practice as seen in the paradox of the daily clinical practices of nurses and physicians and the possibilities offered by new medical knowledge. In the process, heterogeneous factors such as economics, class, and gender become important parts of the story.

A local story of technology development can contain a narrative that bridges human experience with larger theoretical constructs. The illumination of the importance of daily realities provides an interesting counterpoint to the seemingly natural trajectories of technological change and the apparent superiority of one technology over another. The story becomes less linear, exposing the turbulence of the time and the difficulty of choosing a particular course of action. ⁵ Different kinds of questions may be raised that digress from the typical, although important, inquiries concerning successful models of development. In the case of intensive care, could the care of the critically ill have been structured in any other way? What would have happened if the hospital had hired more nurses for the general floors, or if it had paid private-duty nurses more money to care for more than one critically ill patient? Did intensive care, under the guidance of those who had an investment in the idea, engender a self-reinforcing belief that it was a "good" concept? By conducting the analysis in the light of these questions, I show that the development of a particular technology, intensive care, becomes less a story of its "intrinsic superiority" than a window through which to observe the interactions among knowledge development, the relationships of the actors within a particular system, and technology.

The intensive care unit, ⁶ a conceptual and spatial recategorization and reorganization of the care of critically ill hospital patients into architecturally discrete areas with a concentrated group of nurses providing continuous care, did not become institutionalized in hospitals until mid-century. Although the effectiveness of the triad of concentrated nursing care, triage, and vigilance in the care of critically ill patients was documented by nurses and physicians working in recovery rooms, field hospitals, and polio units, the required...