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Critical Care Delivery in ICU

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Critical Care Delivery in ICU

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  1. 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 Batiha

  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. ICU • So expensive per patient per time interval We need data about the type and quality provided in ICU

  4. Two Questions 1. Role and practice of an intensivist 2. The best practice model in ICU

  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. 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. 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. Pediatric: 31% Neonatal: 30% Surgical: 20% Medical: 2% <100 beds: 9% >500 beds: 56% ICU director authorized admission to ICU In general, not in charge of ICU admission

  9. ICU Survey (1997) ICU administrator • Anesthesia : 0.6% • Medicine : 36.7% • Surgery : 16% • Free : 29.1% • Others : 17.6%

  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. 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. Full time intensivists More common in • Larger hospital • Managed care penetration higher • MICU

  13. ICU physicians (1997)During office hours • Full time in ICU : 27% • Elsewhere in hospital : 44% • Presence off site : 24% • Unknown : 5%

  14. ICU Resident (1997) • Full time in ICU : 53% • Cover (ICU & ward) : 42% • Other : 5%

  15. NP (nurse practitioner ) PA (physician assistant ) <10%

  16. 19911997 consistent patterns • 1/3 ICU administered by medicine department • 60% ICU patients are in general ICU • Full time intensives treated 23% of all ICU patients, esp. in larger hospital, MICU • resident: 44% , fellow: 21% of all ICU • ICU coverage by non-physician: very uncommon

  17. 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

  18. An Ideal ICU

  19. 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

  20. Team Dynamics • A multidisciplinary team to effectively attain specified objective • Physician team leader & critical care nurse manager

  21. 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

  22. 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

  23. 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

  24. Critical Care Practice Pattern • Open • Closed • transitional

  25. 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

  26. 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

  27. 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

  28. Advantages of Intensivists • Morbidity (ICU, 30-day, hospital)  • Cost  • Length of stay (ICU, hospital) • Complication 

  29. 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

  30. 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

  31. 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

  32. Discussion For NTUH SICU: • Technician team  complex treatment • SICU CNS  uncommon in USA • Communication • Team dynamics