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

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

ICU• So expensive

per patient

per time interval

We need data about the type and quality

provided in ICU

Two Questions

1. Role and practice of an intensivist

2. The best practice model in ICU

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

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

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

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

ICU Survey (1997)

ICU administrator– Anesthesia : 0.6%

– Medicine : 36.7%

– Surgery : 16%

– Free : 29.1%

– Others : 17.6%

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

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%

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

Full time intensivists

More common in

• Larger hospital

• Managed care penetration higher

• MICU

ICU physicians (1997)During office hours

• Full time in ICU : 27%

• Elsewhere in hospital : 44%

• Presence off site : 24%

• Unknown : 5%

ICU Resident (1997)

• Full time in ICU : 53%

• Cover (ICU & ward) : 42%

• Other : 5%

NP (nurse practitioner )

PA (physician assistant )

<10%

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

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

An Ideal ICU

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

Team Dynamics

• A multidisciplinary team to effectively attain specified objective

• Physician team leader & critical care nurse manager

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

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

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

Critical Care Practice Pattern

• Open

• Closed

• transitional

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

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

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

Advantages of Intensivists

• Morbidity (ICU, 30-day, hospital) • Cost • Length of stay (ICU, hospital) • Complication

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

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

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

Discussion

For NTUH SICU:

• Technician team complex treatment

• SICU CNS uncommon in USA

• Communication

• Team dynamics