Critical Care Delivery in ICU

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Critical Care Delivery in ICU

  1. 1. Critical Care Delivery in ICU Defining the clinical roles and the best practice model From: Crit Care Med 2001:29:2007 -2019
  2. 2. 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
  3. 3. ICU • So expensive per patient per time interval We need data about the type and quality provided in ICU
  4. 4. Two Questions 1. Role and practice of an intensivist 2. The best practice model in ICU
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. ICU director authorized admission to ICU • Pediatric: 31% • <100 beds: 9% • Neonatal: 30% • >500 beds: 56% • Surgical: 20% • Medical: 2% In general, not in charge of ICU admission
  9. 9. ICU Survey (1997) ICU administrator – Anesthesia : 0.6% – Medicine : 36.7% – Surgery : 16% – Free : 29.1% – Others : 17.6%
  10. 10. 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
  11. 11. 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%
  12. 12. Full-time Consultant Consultant Single intensivist intensivist sprcialist physician Hospital size small 12 7 50 30 medium 9 14 55 20 large 40 14 37 4 very large 36 19 34 10 Type of ICU general 19 13 46 17 MICU 47 17 33 3 SICU 21 18 45 14 specialty 21 13 52 14
  13. 13. Full time intensivists More common in • Larger hospital • Managed care penetration higher • MICU
  14. 14. ICU physicians (1997) During office hours • Full time in ICU : 27% • Elsewhere in hospital : 44% • Presence off site : 24% • Unknown : 5%
  15. 15. ICU Resident (1997) • Full time in ICU : 53% • Cover (ICU & ward) : 42% • Other : 5%
  16. 16. NP (nurse practitioner ) PA (physician assistant ) <10%
  17. 17. 19911997 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
  18. 18. 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
  19. 19. An Ideal ICU
  20. 20. 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
  21. 21. Team Dynamics • A multidisciplinary team to effectively attain specified objective • Physician team leader & critical care nurse manager
  22. 22. Intensivists Definitions : • coordinators and leader of the multidisiplinary approach to the care of critically ill patients Requirements : • trained and certified • immediately and physically available to ICU patients • no competing priority that would interfere with prompt delivery of critical care during scheduled interval
  23. 23. 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
  24. 24. Administrative Duties of Intensivits • Admission/discharge criteria • Protocol development and implementation • Superving and directing performance improving activities • Maintain up-to-date equipment and techniques • Data collection • Link to other related departments • Approval of unit-based budget
  25. 25. Critical Care Practice Pattern • Open • Closed • transitional
  26. 26. 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
  27. 27. 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
  28. 28. Transitional Units Definition: intensives are locally present shared co-managed care between ICU staff and private physician ICU staff is a final common pathway for orders and procedures Advantage: reduce physician conflict, standard policies and procedures usually present Disadvantage: confusion and conflict regarding final authority & responsibilities for patient care decision
  29. 29. Advantages of Intensivists • Morbidity (ICU, 30-day, hospital)  • Cost  • Length of stay (ICU, hospital)  • Complication 
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. Discussion For NTUH SICU: • Technician team  complex treatment • SICU CNS  uncommon in USA • Communication • Team dynamics

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