critical care delivery in icu
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critical care delivery in icuTRANSCRIPT
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Critical Care Delivery in ICU
Defining the clinical roles and the best practice model
From: Crit Care Med 2001:29:2007 -2019
Dr. Abdul-Monim BatihaDr. Abdul-Monim Batiha
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Economic Impact of ICU (1994)
* <10% of hospital beds
* 30% of acute care hospital cost
* >20% of hospital budget
* 1% of GNP expended for ICU care
With aging of the population
Demand for critical care service will increase
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ICU• So expensive
per patient
per time interval
We need data about the type and quality
provided in ICU
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Two Questions
1. Role and practice of an intensivist
2. The best practice model in ICU
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USA vs Taiwan
• 現在的美國就是 10 年後的台灣• 10-15 年前的美國就是現在的台灣
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1991 Survey in USA• 8% of hospital beds in USA are ICU beds• 10-12 beds per unit for adult ICU 21 beds per unit for neonatal ICU• Occupancy rate : 84%• Category of ICU
– MICU: 36%– mixed: 22%
• ICU directors : internist : 63% of all ICU
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1991 Survey in USA
ICU directors :
61% : part time
50% : unpaid
56% : not certified in critical care medicine
In 1991, full time intensivists were still not
common in USA
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ICU director authorized admission to ICU
• Pediatric: 31%
• Neonatal: 30%
• Surgical: 20%
• Medical: 2%
• <100 beds: 9%
• >500 beds: 56%
In general, not in charge of ICU admission
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ICU Survey (1997)
ICU administrator– Anesthesia : 0.6%
– Medicine : 36.7%
– Surgery : 16%
– Free : 29.1%
– Others : 17.6%
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ICU Model Care• Full-time intensivist model :
– patient care is provided by an intensivist
• Consultant intensivist model :– an intensivist consults for another physician to coordinate
or assist in critical care, but dose not have primary responsibility for care
• Multiple consultant model:– multiple specialists are involved in the patient care, (esp.
R/T doctors for ventilators), but none is designated especially as the consultant intensivist
• Single physician model :– primary physician provides all ICU care
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ICU Survey (1997)
For all ICU patients in 1997, cared by
• Full time intensivist : 23.1%
• Consultant intensivist : 13.7%
• Multiple consultant : 45.6%
• Single physician : 14.2%
• Others : 3.4%
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Full-time
intensivist
Consultant intensivist
Consultant sprcialist
Single physician
Hospital size
small 12 7 50 30 medium 9 14 55 20 large 40 14 37 4 very large 36 19 34 10Type of ICU
general 19 13 46 17 MICU 47 17 33 3 SICU 21 18 45 14 specialty 21 13 52 14
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Full time intensivists
More common in
• Larger hospital
• Managed care penetration higher
• MICU
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ICU physicians (1997)During office hours
• Full time in ICU : 27%
• Elsewhere in hospital : 44%
• Presence off site : 24%
• Unknown : 5%
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ICU Resident (1997)
• Full time in ICU : 53%
• Cover (ICU & ward) : 42%
• Other : 5%
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NP (nurse practitioner )
PA (physician assistant )
<10%
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19911997 consistent patterns
1. 1/3 ICU administered by medicine department
2. 60% ICU patients are in general ICU
3. Full time intensives treated 23% of all ICU patients, esp. in larger hospital, MICU
4. resident: 44% , fellow: 21% of all ICU
5. ICU coverage by non-physician: very uncommon
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預測台灣未來 5–10 年的 ICU
• 除了 medical center‚ sub special ICU not common– MICU, Vs SICU 區域醫院– General ICU 地區醫院
但台灣的醫院普遍床位較多• Full-time intensivist, closed unit 比例可占多少
?• Resident 不會是 ICU care 主力• Vs + NSP, not NSP alone
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An Ideal ICU
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Multidisciplinary& Collaborative approach to ICU care
• Medical & nursing directors : co-responsibility for ICU management• a team approach : doctors, nurses, R/T, pharmacist• use of standard, protocol, guideline consistent approach to all issues• dedication to coordination and communication for
all aspects of ICU management• emphasis on practitioner certification, research,
education, ethical issues, patient advocacy
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Team Dynamics
• A multidisciplinary team to effectively attain specified objective
• Physician team leader & critical care nurse manager
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IntensivistsDefinitions :• coordinators and leader of the multidisiplinary app
roach to the care of critically ill patients
Requirements :• trained and certified• immediately and physically available to ICU patie
nts• no competing priority that would interfere with pro
mpt delivery of critical care during scheduled interval
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Jobs of Intensivits• Coordinating and providing integrated critical care• Patient triage admission/discharge bed allocation discharge planning• development and enforcement of clinical &
administrative protocol• coordination and assistance in the implementation
of quality improvement activities within ICU
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Administrative Duties of Intensivits
• Admission/discharge criteria• Protocol development and implementation• Superving and directing performance improving a
ctivities • Maintain up-to-date equipment and techniques • Data collection• Link to other related departments• Approval of unit-based budget
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Critical Care Practice Pattern
• Open
• Closed
• transitional
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Open Units
Definition : any attending physician with hospital admitting
privileges can be the physician of record and direct ICU care. (All other physicians are consultants)
Disadvantage :• lack of a cohesive plan• Inconsistent night coverage• Duplication of services
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Closed Units• Definition: An intensivist is the physician of record for
ICU patients. (other physicians are consultants), All orders & procedures carried out by ICU staff
• advantage: • improved efficiency • standardized protocol for care• disadvantage: • potential to lock out private physician • increase physician conflict
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Transitional UnitsDefinition: intensives are locally present shared co-managed
care between ICU staff and private physician ICU staff is a final common pathway for orders
and proceduresAdvantage: reduce physician conflict, standard policies and
procedures usually presentDisadvantage: confusion and conflict regarding final authority &
responsibilities for patient care decision
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Advantages of Intensivists
• Morbidity (ICU, 30-day, hospital) • Cost • Length of stay (ICU, hospital) • Complication
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A Good ICU
• Well organized
trust
coordinated care
• Full-time intensivist: daily round
• protocol & policies (eg: how to DC elective operation when bed not available)
• bedside nurses (master degree)• no intern
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A Good ICU
• A team:
doctors, nurses, R/T, pharmacists
• led by full time intensivists
critical care trained
available in a timely fashion (24hr/day)
no competiting clinical responsibilities
during duty
• closed units, if resources allow
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Full time Intensivists
Timely & personal intervention by an intensivist
No difference from existing literature
• 24hr full time
• 8-12hr /day
• access in a timely period
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Discussion
For NTUH SICU:
• Technician team complex treatment
• SICU CNS uncommon in USA
• Communication
• Team dynamics