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ORGANIZATION AND MANAGEMENT OF THE ICUs. Arzu TOPELI-ISKIT,MD Hacettepe University Faculty of Medicine Medical Intensive Care Unit 22 April 2006.

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organization and management of the icus
ORGANIZATION AND MANAGEMENT OF THE ICUs

Arzu TOPELI-ISKIT,MD

Hacettepe University Faculty of Medicine

Medical Intensive Care Unit

22 April 2006

slide2

ICUs are specialized units where intensive monitorization and organ supportive therapies can be applied to patients with physiologic instability, continuously and with same standarts, i.e., 24 hours a day, 7 days a week and 365 days a year.

slide3

“Guidelines for intensive care unit design, 1992” www.sccm.org; Crit Care Med 1995;23:582-8.

‘’Recommendations on minimal requirements for intensive care departments’’ TASK FORCE of the ESICM. Intensive Care Med 1997;23:226-32.

‘’Intensive care unit design and environmental factors in the acquisition of infection’’ J Hosp Infect 2000;45:255-62.

‘’Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care’’ Crit Care Med 2003;31:2677-83.

‘’Guidelines for environmental infection control in health-care facilities, 2003’’. Recommendations of CDC and HICPAC. www.cdc.gov

Physical Design

slide4

Physical Design

  • Members to be present in ICU planning:
      • Medical director of the ICU
      • Director of the hospital
      • ICU chief nurse
      • Hospital architect and engineer
      • Other departments wrelated with the ICU
  • Points that have to be taken into consideration:
      • Patient population
      • Admission and discharge criteria
      • ICU occupancy
      • Tha status of the other hospitals
      • Categorization according to level of care
      • Staff and visitor number
      • Necessity of the other support units
slide5

Level of Care‘’Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care’’ Crit Care Med 2003;31:2677-83.

  • LEVEL I: Units having staff and technologic equipment so that every critically ill patient can be managed
  • LEVEL II: Units managing the critically ill patients but not in all fields (e.g., neurosurgery, transplantation, etc) and having protocols to transfer these patients to appropriate units
  • LEVEL III: Units where critically ill patients can be stabilized but can not be fully treated and having protocols to transfer these patients to appropriate units
slide6

Level of Care‘’Recommendations on minimal requirements for intensive care departments’’ TASK FORCE of the ESICM. Intensive Care Med 1997;23:226-32.

slide7

Level of Care‘’Recommendations on minimal requirements for intensive care departments’’ TASK FORCE of the ESICM. Intensive Care Med 1997;23:226-32.

N: Necessary

R: Required

O: Optional

physical design
Physical Design
  • SPESIFIC or GENERAL (Multi-diciplinary)
      • In intracranial bleeding, head trauma, follow up in the neurointensive care increases survival.
  • ICUs should be close to each other; far away from the main hospital traffic, close to ER, OR, lab, radiology department and elevators
  • 5-10% of hospital beds
  • Ideal bed no 8-12
physical design1
Physical Design
  • Beds: OPEN, SEPERATE (ISOLATED ROOMS), MODULAR (UNITS OF A COUPLE OF BEDS)
  • Bed no = Total area / 40
  • Support units (clean room, dirty room, etc) = Bed area
  • Open system 20 m2/bed; isolated rooms 25 m2/bed
  • In the open system beds should be seperated by 2.5 m from each other
  • Central monitorization (direct veya indirect)
physical design2
Physical Design
  • Other areas:
      • Rooms for staff (director, physicians, nurses, secretary, others; showers, meals, alarms, communication, etc)
      • Rooms for equipment, drugs, sinks, security...
      • Clean room (10-15 m2)
      • Dirty room (20 m2, seperate enterance and air conditionng, etc.)
      • Seminar room for education
      • Room for relatives (1-1.5 chair/bed; room for talk)
physical design3
Physical Design
  • For each bed: 2 O2 (5 bar), air (5 bar) and vacum (500 mmHg) source; lightning; 16 electrical socket; alarms
  • Water supply for dialysis
  • Clock, tv, radio
  • Beds, monitors
  • Natural lightning (window)
  • Chairs for relatives
  • Seperate enterance for staff, equipment, relative (seperate corridors for patient transport
  • < 8 persons / rounds
  • Material used for walls, floor should be cleaned easily, absorb noise (day 45 dB(A), night 20 dB(A))
physical design infection
Physical Design - Infection
  • More infection risk in ICU patients
  • Multi-drug resistant microorganisms
  • Min 1-2/10 isolation rooms (25 m2)
      • Antre for dressing, hand wash, etc
      • Sink and bathroom
  • Open sytem 1 sink/2 beds; isolated rooms 1 sink/bed; 2 sinks/each module
      • Operated by elbow, foot; deep and wide enough; easy to reach
      • Alcohol based disinfectants for each bed
  • Standarts for cleaning and disinfection
physical design infection1
Physical Design - Infection
  • Appropriate air flow and conditioning
      • Positive and negative pressure rooms
      • Filtration: 5 µm particulate, 99% efficient
      • Temp and humidity could be adjusted: 16-27°C, 30-60%, 6-15 cycles of air flow/hour
  • Dirty rooms (20 m2)
      • Seperate air flow
      • Seperate corridor for garbage
slide17
3.5 years; 18 ICU; ~ 23,000 admissions
  • Adjusted mortality:
      • Weekend vs. weekday admission: 1.20 (1.01 – 1.43)
      • Night vs. dayadmision: 6.89 (5.96 – 7.96)
slide18
7 years; single center (USA); ~ 29,000 admissions
  • Adjusted mortality:
      • SICU: Weekend vs. weekday 1.23 (1.03 – 1.48)
      • No difference in MICU and general ICU

Chest 2004;126:1292-8

hacettepe micu ankara arzu topeli n defne alt nta melda aybar toraks dergisi 2004 5 ek 1 83
Hacettepe MICU, AnkaraArzu Topeli, N. Defne Altıntaş, Melda Aybar. Toraks Dergisi 2004;5 (Ek 1):83
  • 20 month period, single center, prospective; 331 pts hospitalized for >24 hours
  • Adjusted mortality
      • Holiday admissions (including weekend and holidays): 2.0 (1.0 – 4.1)
icu team
ICU team

Intensivist

“Director”

Physicians

Nurses

Resp

therapists

Clinical

Pharmacist

Others

slide22
Workload  occupancy + nursing care (1.3 nurses / pt)
  • Adjusted mortality
      • Increased workload: 3.1 (1.9 – 5.0)

Lancet 2000;356:185-9

hacettpe micu
Hacettpe MICU
  • 30.3 – 5.4.2006 (1 week); 9 beds
  • 100% occupancy
  • Mean TISS 28: (11-39)
  • 40 hours/shift
  • 5 nurses (4-6) /shift are required
slide25

Aust J Physioth 2004;50:67-73

  • Randomized prospective study
  • Acute hypercapnic resp failure + NIMV
  • 17 pts no physiotherapy: Length of NIMV 6.7 days
  • 17 pts physiotherpy: Length of NIMV 5.0 days

p=0.03

slide26

JAMA 1999;282:267-70

  • MICU + CCU
  • Clin Pharmacist rounding with ICU staff everyday, consultation is asked at other times
  • 66%  in medication errors (10.4/1000  3.5/1000 pt day, p<0.001)
hacettepe micu deniz y lmaz arzu topeli skit kutay demirkan yo un bak m derg 2005 5 ek 1
Hacettepe, MICUDeniz Yılmaz, Arzu Topeli İskit, Kutay Demirkan. Yoğun Bakım Derg 2005;5 (Ek 1)
  • Seminar to the physicians was given by the pharmacist about blood level monitorization and drug application accordingly
  • Prior to education 110 (30 pts), after education 90 (21 pts) blood level monitorization
  • Prior to education 39 (35.5%) levels, After education 15 (16.7%) levels were monitored in a wrong way (p<0.05).
definition of an intensivist
Definition of an Intensivist
  • Education in the main specialty and then education in Critical Care Medicine
  • Spending 50 – 75% of his/her professional time in the ICU

[SCCM 1992]

[ICM 1997]

slide29
USA

Pulmonary

Anestesiology

Medicine

CCM

(1-3 yrs)

Pediatrics

Surgery

europe
Europe

Anestesiology

Medicine

CCM

(1-2 yrs)

Pediatrics

Surgery

duties of the director
Duties of the Director
  • Communication, coodination, Primary responsibility in pt care
  • Responsibility in admission, discharge, triage
  • Role in physical design, supplying equipments etc.
  • Continuous education
icu admission and discharge criteria crit care med 1999 27 633
ICU Admission and Discharge CriteriaCrit Care Med 1999;27:633
  • Critically ill pts with reversible underlying condition or having a reasonable life expectancy should be admitted.
  • Terminally ill pts or pts too good to be followed in a ward should not be admitted.
  • If pt becomes terminally ill after admission to an ICU limited/no support should be given or the pt should be transferred outside.
admission and discharge criteria crit care med 1999 27 633
Admission and Discharge CriteriaCrit Care Med 1999;27:633
  • Priority system:
    • 1.priority:Pt in need of full ICU care (MV,vasopressor treatment, etc)
    • 2. priority:Pts who who will get benefit from ICU care (acute problems in pts with comorbidities)
    • 3.priority:Pts with a low expectation of prolonged life but in need of ICU care for acut problems (acute problems in metastatic malignancy). Treatment might be limited.
    • 4. priority:Pts with no indication
slide34

ICU

Intermediary Care Unit

Ward

23-33% unnecessarily prolonged hospitalizations

icu management policies
ICU management policies
  • Open: Primary physicians are responsible from the pts
  • Closed: Intensivist is the responsible physician.
  • Semi closed: Primary physician and the intensivist sharing the decisions.
best management system
Best management system?
  • Presence of a responsible physician (director)
  • Presence of an intensivist director
  • Presence of an intensivist director + closed system policy
  • Presence of an intensivist in the ICU 24 hrs a day
slide37

JAMA 2002;288:2151-62

  • 26 studies
  • High density ICU care (mandatory intensivist consultation or closed system)
  • Low density ICU care (no intensivist or elective intensivist consultation)
  • Adjusted hospital mortality: HD vs LD 0.71 (0.62 - 0.82)
  • Adjusted hospital mortality: HD vs LD 0.61 (0.50 – 0.75)
  • Shorter ICU and hospital LOS in HD group
why closed system intensivist director
Why closed system/intensivist director?
  • Patient care is not like a standart round and ordering treatment, it is rather like titration.
  • ICU physician, not the primary doctor, is near the patient all the time.
  • Uncoordinated patient care by unnecessarily high amounts physicians is not good.

[Safar & Grenvik. Anesthesiology 1977]

slide39
21% decrease in ICU mortality, 10% decrease in hospital mortality
  • 17% decrease in LOS (3.5  2.9 days)

Crit Care Med 2004;32:2191-8

apache ii acute physiology and chronic health evaluation
Physiological parameters

Lab parameters

GCS

Age

Chronic health status

APACHE II(Acute Physiology and Chronic Health Evaluation)

Gerçek ölüm oranı

Beklenen ölüm oranı

 1

slide44
1/3–1/2 of Americans spend their last year of life in an ICU, 1/5 of them lose their lives in the ICU.

With the presence of an intensivist director, 54,000 lives could be saved each year in USA where 3.5 million pts are admitted to ICUs.

slide45

USA

  • 1% of national gross product for ICUs
  • 8% of hospital beds
  • Mean bed no: 10-12
  • Bed occupancy: 84%
  • In ~35% medical director
  • 1 out of 3 pts cared by an intensivist; intensivist crisis in 2007
  • Closed system: 22% (big hospitals, MICU)
  • Continuous respiratory therapist : 48%
  • Nurse/pt ratio: 1/2
  • Presence of educated intensivists in ICUs is considered to be a marker for quality of health care
europe1
Europe
  • 75% medical + surgical pts (general ICU)
  • 25% >10 beds; 57% 6-10 beds; 18% <6 beds (UK)
  • 72% continuous physician coverage; 67% medical director (intensivist)
  • Bed occupancy: 78%
respiratory icu italy
Respiratory ICU: Italy
  • RICU: Units between ICU and ward (intermediary care units) where pts with single organ failure (resp failure) can be followed
  • Nurse/pt: 1/2.5 – 1/4; continuous sufficient non-invasive monitorization; sufficient experience in NIMV and intubation in case of NIMV failure; presence of a physician 24 hrs a day
  • Results:
    • 26 RICU
    • Nurse/pt: 1/2 - 1/3 (36%: 1/4)
    • 756 pts; age: 68; APACHE 18 (expected mortality 22%; observed mortality 16%); length of stay: 12 days
    • 96% resp failure (COPD)
    • 30% monitorization; 62% MV; 8% weaning
    • 73% NIMV

Confalonieri. Thorax 2001;56:373

slide48

TURKEY ?

  • 1978: Society of Intensive Care
  • 1992: Turkish Thoracic Society Respiratory Intensive Care Working Group
  • Education of CCM subspecialty after education in main specialties (Medicine, Anestesiology, Pulm Medicine and Pediatrics) is being prepared
  • 8 March 2005: Society of Medical and Surgical Sciences Intensive Care Medicine
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