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

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

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

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

USA vs Taiwan
10
10-15

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

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

ICU director authorized admission to ICU

Pediatric: 31%
Neonatal: 30%
Surgical: 20%
Medical: 2%

<100 beds: 9%
>500 beds: 56%

In general, not in charge of ICU admission

ICU Survey (1997)

ICU administrator
Anesthesia : 0.6%
Medicine : 36.7%
Surgery
: 16%
Free
: 29.1%
Others
: 17.6%

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

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%

Full-time
intensivist

Consultant
intensivist

Consultant
sprcialist

Single
physician

12
9
40
36

7
14
14
19

50
55
37
34

30
20
4
10

19
47
21
21

13
17
18
13

46
33
45
52

17
3
14
14

Hospital size
small
medium
large
very large
Type of ICU
general
MICU
SICU
specialty

Full time intensivists

More common in
Larger hospital
Managed care penetration higher
MICU

ICU physicians (1997)

During office hours

Full time in ICU :

27%
Elsewhere in hospital : 44%
Presence off site :
24%
Unknown
:
5%

ICU Resident (1997)

Full time in ICU :
53%
Cover (ICU & ward) : 42%
Other
: 5%

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

19911997 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

 510 ICU
medical center sub special ICU not common
MICU, Vs SICU
General ICU

Full-time intensivist, closed unit

?
Resident ICU care
Vs + NSP, not NSP alone

An Ideal ICU

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

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

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

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

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

Critical Care Practice Pattern

Open
Closed
transitional

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

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

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

Advantages of Intensivists

Morbidity (ICU, 30-day, hospital)

Cost
Length of stay (ICU, hospital)
Complication

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

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

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

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