بسم الله الرحمن الرحیم

The importance of

medical care in ICUBy:Dr.RoushanfekrAnesthesiologist2015

The relative risk for hospital mortality was reduced by 29% and for ICU mortality was reduced by 39% with high-intensity staffing.

By the year 2030,only 30% of the intesivists needed will be available to staff ICUs.

0.5% to 1% of the U.S. gross domestic product is spent on critical care, and patients 65 years of age and older make up over 50% of all ICU admissions.

INTRUDACTION(1)

Considering the magnitude of this expense, extensive research has focused on how the most cost-effective care can be delivered.

With an aging population and increasing availability of medical technology, ICUs have become a critical component of modern hospital care.

INTRUDACTION(2)

The practice of critical care medicine, which originated in the 1940s with anesthesiologists providing life support to patients with poliomyelitis, has undergone revolutionary changes.

The development of new equipment, procedures, and medications has enabled intensivists to treat critically ill patients and support them through increasingly invasive procedures.

ORIGINATION & DEVELOPMENT

In the past decade, another revolution has taken place, the introduction of evidence-based medicine into (ICU) practice.

intensivist staffing might lead to improved outcomes, specifically through the implementation of evidence-based practices.

Particular attention is paid to the implementation and cost-effectiveness of new clinical practices.

ORIGINATION & DEVELOPMENT

Considering the magnitude of expense, extensive research has focused on how the most cost-effective care can be delivered.

ICUs as open wards : where any physician could admit patients.

ICUs as closed wards : Most ICUs now have a designated medical

director who is responsible for the overall management of patient care and policies.

ICU ORGANIZATION

1. Open ICU versus closed ICU2. Medical ICU & Surgical ICU3. Full-time intensivist4. The consultant intensivist5. Multiple consultants6. The single-physician without intensivist7. Larger hospitals versus smaller hospitals8. Economic inasmuch & quality & mortality

Structure

Care of critically ill patients has been revolutionized by technology and drug development and the application of evidence-based medicine to critical care practice.

ARDS are mechanically ventilated with larger-smaller TV (12 ↔ 6 mL/kg IBW)→

improve oxygenation ratio↔significantly higher mortality rates

→ randomized, prospective trials

QUALITY MEASUREMENT IN CRITICAL CARE:

Each ICU should have a physician who is board certified or board eligible in critical care medicine.

to ensure the quality and safety of patient care in the ICU:

1- patient triage decisions2- education of house staff members3- development of clinical protocols4- and improvement of performance

Anesthesiologists for surgical&Internist for medical ICUs

Salary support by hospital

ROLE OF THE MEDICAL DIRECTOR

1. Triage of admissions and discharges2. Development of treatment protocols or

guidelines3. Collection of data4. Involvement in unit budget approval5. Updating of equipment and unit practices6. Promotion of efficient use of material and

personnel resources7. Responsibility for coordination and

dissemination of continuing education of hospital- and ICU-based personnel

organizational duties of an ICU administrator:

intensivists will continue to direct the care of only one third of critically ill patients.

the proportion of patients in the ICU whose care is directed by an intensivist were to increase to two thirds, then the large potential growth in utilization of intensivist services represents a shortage of 1500 critical care providers.

STAFFING

Anesthesiologists accounted for only 6.1% of all intensivists in the workforce

In America, Reimbursement for critical care services is generally less than that for surgical anesthesia services.

In Europe, where such a payment discrepancy between the surgical unit and the ICU does not exist.

In Australia and New Zealand, critical care training has become a separate specialty with its own residency.

Anesthesiologists in Critical Care Medicine

For general and subspecialty patient populations, most studies suggest that an intensivist should provide care to critically ill patients.

In addition to increased mortality (threefold) ,the patients not seen by an intensivist also had an increased risk for cardiac arrest, renal failure, septicemia, platelet transfusion, and reintubation.

intensivists should be continually present in ICUs even overnight.

Physicians

a safe and effective alternative :

nurse practitioners (NPs) and physician assistants (PAs), under the supervision of attending physicians.

Advanced Health Care Practitioners

One approach to lowering ICU mortality and improving quality is to optimize the organization of ICU services.

The multidisciplinary model approach is to complement intensivist staffing with nurses, respiratory therapists, clinical pharmacists, and other staff members who can provide critical care as a team.

Multidisciplinary Care Teams

The exact number of nurses needed to produce the best patient outcomes is not known.

Many factors may affect patient outcomes, and nurse staffing is only one potential contributor.

Some hospitals prefer flexible scheduling, meaning ICU nurses are scheduled on the basis of anticipated workload in the unit at the start of the shift.

Nursing

as a result of contributions to medication safety, improved patient outcomes, reduced drug costs, and house staff education.

Their most important benefit is the potential to decrease adverse drug events:

from 10.4 per 1000 patient days to 3.5 per 1000 patient days.

Pharmacists

improves compliance with weaning protocols and decreases the duration of mechanical ventilation.

reduced the rate of ventilator-associated pneumonia (VAP) from 4.3 per 1000 ventilator days to 1.2 per 1000 ventilator days.

Respiratory Therapists

it is an attractive alternative

less than 15% of ICUs continue to have dedicated intensivist coverage.

Overall, the available data suggest that eICUs can have the most impact and improve outcomes in ICUs that initially begin with a deficit in intensivist coverage or have a need to supplement current coverage levels, have high severity-adjusted mortality and LOS rates.

Telemedicine

Hospitals must customize the protocols to fit their practices, but protocols should not be used in place of good clinical judgment.

They should be used as a complementary tool, and physicians should be able to justify departures from the protocol.

Despite the limitations, when applied to large populations of patients, practice protocols usually decrease mortality and reduce costs.

IMPLEMENTATION OF EVIDENCE-BASED PRACTICE

Protocols should be devised with the intention:

1. improving the quality of patient care2. improving patient outcome3. the efficiency of care4. While at the same time, decreasing practice

variation and costs.

Critical Care Protocols

1. percentage of patients with ventilator-associated Complications

2. percentage of patients with resistant infections3. percentage of patients with CVC infections4. number of complications per patient5. average days of mechanical ventilation6. rate of GE bleeding7. average intensive care unit length of stay8. patient satisfaction

Quality measures that were found to be valuable (based on effect, feasibility , strength of evidence) included:

1. enhancing quality of care2. improving efficiency3. decreasing cost4. decreasing errors5. enabling rigorous clinical research

the rationale for care protocolsin the context of achieving five goals:

“‘Evidence based medicine’ is a phrase that is currently familiar to only a few doctors, but all will know it by the millennium.”

“the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. ”

What is the definition of quality?

Some investigators have advocated systematic development of checklists to remind team members of the multitude of goals for every patient, rather than increased protocol generation.

An example is the FASTHUG :F: FeedingA: AnalgesiaS: SedationT: ThromboprophylaxisH: Head of bed elevationU: Ulcer prophylaxisG: Glycemic control

checklists