The ICU without walls concept

In-hospital cardiac arrest

Patient deterioration
Scoring concept
The ICU without walls concept

In-hospital cardiac arrest

Hendri pangestu
 Pasien ruangan Operasi
Kembali ke ruangan
Resiko operasi kecil dan klinis pasien tidak bermasalah

Kembali keruangan dan bermasalah di ruangan

Karena tindakan op dan pasien resiko tinggi

Dibentuk ICU untuk pasien2

yang akan dioperasi dengan
Berkembang pasien BEDAH dan NON BEDAH
resiko yang menjadi turun
keadaan umumnya post operasi
 (Critical Care Medicine)
pengawasan ketat

Pasien post operasi epidemi polio di Denmark ICU di lambangkan dgn

tersedianya ventilator

(Ahli bedah) prosedur2

yang beresiko tinggi
(Bedah vaskuler,
jantung, transplant, dll)

Lebih spesifik dan

Pasien2 non bedah
komplex, pemantauan
juga menjadi fokus,
ketat, ICU berkembang
seperti infeksi berat,
“equipment and tools”
syok, luka bakar berat
juga ”man power ”nya
dll.
 (Critical Care Medicine)

thn 2008 di deklarasikan di

the ICU patients for the most part have come Eropa apa yg disebut “ICU
through the ED, without walls”. Dengan
…. and ward konsep yaitu “actually, many
ICU patients outside the ICU”

guideline CPR (Cardiopulmonary

Resuscitation) tahun 2005
pertama the chain of
survival disebutkan
prevention cardiac arrest (CA).

CA bisa terjadi di luar RS (out-of-

hospital cardiac arrest =
OHCA) atau di dalam RS (in-
hospital cardiac arrest = IHCA).
 Data
IHI (Institute of Health care
Pada umumnya
Improvement) implementasi
pasien pasien yg
EWS yaitu system:
masuk ICU
1) EMT (emergency medical
70% pasien dari
team =physician lead),
ruangan
2) RRT (Rapid Response
20% dari IGD dan
Team) = nurse lead),
10% dll dari kamar
operasi dan unit2 lain
dalam RS
Analisa, beberapa pasien ICU kasus yang “preventable”. pasien mengalami
delayed recognition delayed treatment

Dari data AHA update 2012-2013 menunjukkan survival

rate pada IHCA lebih rendah daripada out-of-hospital
cardiac arrest (OHCA).

IHCA  sekunder dari proses non-jantung seperti

septic shock, pneumonia berat, trauma perdarahan,
intoksikasi dll.
Etiology  perbedaan dalam penatalaksanaanya,
contoh CA karena hipoksia adalah memberikan terapi
oksigen atau menguasai jalan nafas darurat. Atau pada
hipotensi krn septic shock atau perdarahan butuh
vasopressor atau transfusi darah,
para ahli (ahli jantung dan Anestesi dan Intensivist) di Amerika dan Eropa
menyimpulkan tidak proporsional mengenai pencegahan cardiac arrest.
Trilyunan dolar amerika  upaya2 pencegahan akan OHCA ( primary PCI
dengan sophisticate tools and Stent, menemukan obat2 baru antikolesterol,
antihipertensi dll)

Namun pencegahan IHCA juga penting.

Dibuatlah kesepakatan untuk mengimplementasi lingkar 1 pada
chain of survival CPR 2005 tersebut dalam bentuk suatu konsep
dasar.
 Milestones on the Way to International Guidelines 2000—The First International
Conference on Guidelines for CPR and ECC
1966—First Conference on CPR: National Academy of
Sciences, National Research Council
1973—Second National Conference on CPR:
American Heart Association, National Academy of
Sciences, National Research Council
1979—Third National Conference on CPR:
American Heart Association
1983—First National Conference on Pediatric
Resuscitation:
American Academy of Pediatrics, American Heart
Association
1985—Fourth National Conference on CPR and ECC:
American Heart Association, American Academy of
Pediatrics
1992—Fifth National Conference on CPR and ECC:
American Heart Association plus collaborating
Councils. First meeting of ILCOR
2000—The First International Guidelines Conference on
CPR and ECC: International Collaboration of AHA, ERC,
HSFC, RCSA, ARC, CLAR, and others
Recommended training medical, allied health, and
other professional personnel in external chest
compressions according to American Heart Association
standards
Recommended that CPR training programs be
extended to the general public.
Developed ACLS; recommendations for training,
testing, and supervising medical and allied health
personnel.
Developed guidelines for pediatric BLS and ALS, with
separate guidelines for neonatal ALS.
Reviewed experimental and clinical research published
since the 1979 conference.
Reviewed developments over the previous 7 years.
These required review and resolution of disputes and
disagreements. ILCOR founded; began 2 meetings a
year until 2000.
First conference that was international in planning,
topics, experts, writing, review, and publication. First
to be evidence-based; used new class of
recommendations.
 1950
PETER SAFAR
- KOUWENHOVEN
Pengendalian jalan napas
1960 Kompresi jantung tertutup
& Pernapasan buatan

1974 American Heart Association

Cardiopulmonary Resuscitation (CPR)

1993 International Liaison Committee

on Resuscitation (ILCOR)

1999 Konferensi I  Guidelines 2000 for 2010 ABC  CAB

Cardiopulmonary Resuscitation and Emergency Resuscitation
Cardiovascular Care for babies at
birth
2005 Konferensi II  International Consensus
Conference on Cardiopulmonary Resuscitation
2015 ?
and Emergency Cardiovascular Care Science
With Treatment Recommendations
 1992 : ILCOR = International Liaison Comittee on Resuscitation

The worldwide distribution of these guidelines will be enhanced by publication in

an official journal of the AHA, Circulation, and the official journal of the European
Resuscitation Council, resuscitation. Circulation and Resuscitation will publish
the International Guidelines 2000 as a statement that strongly merits the
description “international.” Publication of the guidelines is the product of these
councils:

 American Heart Association

 Australian Resuscitation Council
 European Resuscitation Council
 Heart and Stroke Foundation of Canada
 New Zealand Resuscitation Council
 Resuscitation Councils of Latin America
 Resuscitation Councils of Southern Africa
Konsepnya adalah "early recognition and early treatment". Early recognition
adalah first response oleh bystander atau petugas medis di dalam RS sewaktu
menemukan gejala dan tanda akan sakit kritis pada pasien2 yg di rawat di RS

memenuhi kriteria yg sdh

dibuat oleh masing2 RS
maka petugas medis tsb
melakukan “calling ICU”
(EMT or EWS)

"bring the ICU"ke luar

ICU, dan merupakan cikal
bakal berkembangnya
konsep "ICU without
walls"
 Pembaruan pedoman AHA 2015 untuk CPR dan ECC

EWS

Pengawasan dan
pencegahan
 2005

The first link indicates the importance of recognising those at risk of

cardiac arrest and calling for help in the hope that early treatment can
prevent arrest.
The central links in this new chain depict the integration of CPR and
defibrillation as the fundamental components of early resuscitation in an
attempt to restore life.
The final link, effective post resuscitation care, is targeted at preserving
function, particularly of the brain and heart
The first link of this chain indicates the importance of recognising those at risk of
cardiac arrest and calling for help in the hope that early treatment can prevent arrest.
The central links depict the integration of CPR and defibrillation as the fundamental
components of early resuscitation in an attempt to restore life. Immediate CPR can
double or triple survival from VF OHCA. Performing chest-compressiononly CPR is
better than giving no CPR at all. Following VF OHCA, CPR plus defibrillation within 3–5
min of collapse can produce survival rates as high as 49–75%. Each minute of delay
before defibrillation reduces the probability of survival to discharge by 10–12%.
The final link in the Chain of Survival, effective post-resuscitation care, is targeted at
preserving function, particularly of the brain and heart. In hospital, the importance
of early recognition of the critically ill patient and activation of a medical emergency
or rapid response team, with treatment aimed at preventing cardiac arrest, is now
well accepted.

2010
 2015

1: Early recognition and call for help

Recognising the cardiac origin of chest pain, and calling the emergency services before a
victim collapses, enables the emergency medical service to arrive sooner, hopefully
before cardiac arrest has occurred, thus leading to better survival. Once cardiac arrest
has occurred, early recognition is critical to enable rapid activation of the EMS and
prompt initiation of bystander CPR. The key observations are unresponsiveness and not
breathing normally.
2: Early bystander CPR The immediate initiation of CPR can double or quadruple survival
after cardiac arrest. If able, bystanders with CPR training should give chest compressions
together with ventilations. When a bystander has not been trained in CPR, the
emergency medical dispatcher should instruct him or her to give chest-compression-only
CPR while a waiting the arrival of professional help.
3: Early defibrillation
Defibrillation within 3–5 min of collapse can produce survival rates as high as 50–70%.
This can be achieved by public access and onsite AEDs.
4: Early advanced life support and standardised post-resuscitation care Advanced life
support with airway management, drugs and correcting causal factors may be needed if
initial attempts at resuscitation are unsuccessful.
Representatives from Europe at the
International Consensus Conference
held in Dallas, USA, in January 2005
(Germany), (UK), (Israel), (Austria), (Belgium), (France), (Sweden), (Italy),
(Spain), (Netherlands), (Norway), (Finland), (Denmark), (Czech Republic),
(Norway).
• Section 1. Introduction
• Section 2. Adult basic life support and use of
automated external defibrillators
• Section 3. Electrical therapies: Automated external
defibrillators, defibrillation, cardioversion and pacing
• Section 4. Adult advanced life support
• Section 5. Initial management of acute
• coronary syndromes
• Section 6. Paediatric life support
• Section 7. Cardiac arrest in special circumstances
• Section 8. The ethics of resuscitation and end-of-life
decisions
• Section 9. Principles of training in resuscitation
 Prevention of in-hospital cardiac
arrest
• The problem
• Nature of the deficiencies in acute care
• Recognising the critically ill patient
• Response to critical illness
• Appropriate placement of patients
• Staffing levels
• Resuscitation decisions
• Guidelines for prevention of in-hospital cardiac
arrest
Basic airway management
• 1. Executive summary;
• 2. Adult basic life support and use of automated
external defibrillators;
• 3. Electrical therapies: automated external
defibrillators, defibrillation, cardioversion and pacing;
• 4. Adult advanced life support;
• 5. Initial management of acute coronary syndromes;
• 6. Paediatric life support;
• 7. Resuscitation of babies at birth;
• 8. Cardiac arrest in special circumstances: electrolyte
abnormalities, poisoning, drowning, accidental
hypothermia, hyperthermia, asthma, anaphylaxis,
cardiac surgery, trauma, pregnancy, electrocution;
• 9. Principles of education in resuscitation;
• 10. The ethics of resuscitation and end-of-life
decisions.
 Prevention of in-hospital cardiac
arrest
• The problem
• Nature of the deficiencies in the recognition and
response to patient deterioration
• Education in acute care
• Monitoring and recognition of the critically ill patient
• Calling for help
• The response to critical illness
• Appropriate placement of patients
• Staffing levels
• Resuscitation decisions
• Guidelines for prevention of in-hospital cardiac arrest
1. Executive summary
2. Adult basic life support and automated external
defibrillation.
3. Adult advanced life support.
4. Cardiac arrest in special circumstances.
5. Post-resuscitation care.
6. Paediatric life support.
7. Resuscitation and support of transition of babies at
birth.
8. Initial management of acute coronary syndromes.
9. First aid.
10. Principles of education in resuscitation.
11. The ethics of resuscitation and end-of-life decisions
Prevention of in-hospital cardiac arrest
• The problem
• Nature of the deficiencies in the recognition and
response to patient deterioration
• Education in acute care
• Monitoring and recognition of the critically ill patient
• Calling for help and the response to critical illness
• Appropriate placement of patients
• Staffing levels
• Resuscitation decisions
• Guidelines for prevention of in-hospital cardiac arrest
 Kamar OperasI
Rujukan
Bangsal
Fokus “Patien safety”
IGD/
Poliklinik ICU IGD

Kamar
Pulang Operasi
Bangsal

Pindah RS ICU
Jika di umumkan atau alaram di
aktifkan (“code blue at…” ) maka
sekelompok dokter, perawat, spesialis
(code blue team) serentak
meninggalkan yang sedang dia Code Blue
kerjakan dan beranjak ketempat Saving Lives at a
dimana terjadi code blue Moment's Notice

Kode biru (code blue) adalah Late?

jika petugas medis menemukan
keadan pasien dalam keadaan
tidak merespon (tidak bernafas
dan atau jantung berhenti
berdenyut)
 Profil:
LT 4000 m2
LB 52000 m2
35 lantai

Padat penduduk dan banyak nya RS membuat bengunan RS bervariasi

Berbentuk vertikal
 The Process of Dying*
Primary ventricular
fibrillation
0 min
Primary Asystole

Alveolar anoxia 2-3 min Code blue

Asphyxia:
(Airway Obstruction) 5-12 min
(Apnea)
Circulatory Arrest
Exsanguination

Pulmonary Failure

Shock

Brain Failure
*Safar P. Cerebral resuscitation after cardiac arrest: research initiatives and
future directions. Ann Emerg Med 22:324,1993
 Mengapa MET/RRT
• Masalah medik yg makin komplex
• Respon (kebiasaan ruangan)
• Tim asuhan kritis  multi disiplin
• Membiasakan ruangan utk terlatih
(emergency thinking)
• “early intervention”
• Menurunkan angka kejadian “unexpected CA
& unplanned Icu admissions”
 1/3 IHCA
• Penilaian pasien (assessment) yg kurang baik
• Peringatan menurunnya keadaan umum
pasien yg kurang baik
• Pengenalan kondisi yg kritis di ruangan kurang
baik.
• Tidak bereaksi
• Tidak adanya komunikasi dengan dokter
senior
National confidential enquiry into patient outcome and death (NCEPOD) 2012
Royal college of anaesthetists
 Pasien yang masuk ICU dengan tidak terencana
memiliki hubungan dengan mortality
4

3.5

2.5

2
no mortality
1.5 yes mortality

0.5

0
terencana tdk
terencana
Changi General Hospital
 Bagaimana implementasi EWS ?

• Ketika perawat melakukan pemeriksaan tanda tanda

vital dan melakukan pencatatan, maka ada nilai (score)
yang di jadikan tolak ukur pengaktifan EWS (determine
a MEWS score for the patient):
– Laju pernafasan
– Laju nadi
– Tekanan darah sistolik
– Level kesadaran Score/Nilai
– suhu
– Produksi urin perjam
(dinilai per 2 jam)
• A. Initial Resuscitation
• B. Screening for Sepsis and Performance Improvement
• C. Diagnosis
• D. Antimicrobial Therapy
• E. Source Control
• F. Infection Prevention
• G. Fluid Therapy of Severe Sepsis Early warning
• H. Vasopressors
• I. Inotropic Therapy
• J. Corticosteroids
• K. Recombinant Human Activated Protein C (rhAPC)
• L. Blood Product Administration
RRT/MET concept?
EWS concept?
Pengenalan pasien
sakit kritis
Patient deterioration
 Objectives

• Memahami pentingnya identifikasi dini

pada pasien-pasien yang beresiko menjadi
sakit kritis
• Mengenali tanda-tanda awal sakit kritis
• Mendiskusikan penilaian awal pasien sakit
kritis
Kenapa pasien mati ?
(atau mengapa terjadi mati otak?)

• Kekurangan oksigen
• Kehilangan energi (ATP)
• Toksin
• Kerusakan fisik
 6 Key steps in oxygen cascade
O2
Uptake in the Lung Oxygenation PaO 2

Carrying capacity Haemoglobin SaO2 - Ht

Delivery Cardiac Output Flow rate - ø

Organ distribution Autoregulation

Nervous Syst
Humoral
Diffusion Distance Diffusion distance
Local Control

Cellular use Mitochondria

Sensitivity of measured parameters in vulnerable patients
Sensitivity of measured parameters in vulnerable patients
 Timeline Critical ILL

Redistribution blood flow to vital Post

op(tindakan),
organ (saving Heart & Brain)
☠
khemo,
Fail/ Early Sign Partus, PEB,
decomp Compensation; & Symptom Infection,
perdarahan,
Preserve brain and heart Trauma dll

Onset of
Compensatory phase illness
Depends on; Tachypnea
Henti Bradycardia • Age Tachycardia
Hypotension Hypertension
Jantung/ • Severity of illness  pH
Alkalosis
Death Severe • Preexisting disease Lactate
CRP
Acidosis
 Normal Leucocyte

Where were should we?

Oxygen requirements of organs
 Kesadaran merupakan variabel
lemah dalam menilai keadaan
umum pasien.
 Dalam keaadaan CO yang rendah
kesadaran masih bisa baik
 Dibutuhkan data2 lain dalam
menilai keadaan umum pasein
secara utuh
 Dibutuhkan “Score”
• Tim Reaksi Cepat / RRT akan bereaksi dengan
adanya perubahan dari satu parameter tanda
vitas yang kontras/ekstrim, contoh adanya
perubahan TD atau warna kulit.
• Satu parameter dapat menyelamatkan pasien,
EWS menggabungkan beberapa parameter
dengan sistem yang baik akan lebih membantu
tim medis dalam mengenali pasien yang dalam
penurunan keadaan umum secara dini.
CEO / direktur
Komdik
Intensivis / dr.ICU
Spesialis
Dokter Jaga
Perawat
 Apa peran METs/RRT ?
• Nilai
• Stabilkan
• Bantu dan komunikasikan
• Pendidikan dan bantuan terhadap perawat
ruangan dan keluarga
• Nilai dan transfer ke unit lebih tinggi bila
diperlukan
 MET aktivasi
6

3
MET aktivasi
2

0
2009 2010 2011 2012 2013 2014

Changi General Hospital

 kesimpulan
• EWS lebih awal melakukan intervensi dari “code
blue”
• Membawa sistem ICU ke luar area ICU
• Menjalankan EWS dengan baik membutuhkan
waktu.
• Membutuhkan dukungan penuh dari para
pemimpin RS.
• EWS Merubah budaya / kebiasaan yang sudah
ada (secara positif)
• EWS dapat menurunkan angka kematian dan
kecacatan
 kesimpulan
• Edukasi staff, hindari konflik dan evaluasi secara
konstan
• Dibutuhkan dukungan Team yang solid untuk
menjalankan EWS (Termasuk Direksi)
• “Assess acceptance and get feedback”
• Dapat dijadikan proses “learning by doing” untuk
para tetaga medis
• Pemantauan skor EWS tidak berlaku untuk pasien
dengan “Do Not Resuscitate”
Terima kasih semoga bermanfaat