Introduction to the Medical ICU

Introduction to the Medical ICU
Bharat Awsare MD FCCP
Director, MICU
Assistant Professor of Medicine
Thomas Jefferson University Hospital
July 5, 2013
 History of ICU medicine
 Types of ICU
 Triage criteria
 Role of fellow in the ICU
 Protocols of note
 Initiatives of note
Florence Nightingale
 Born 1820 in Florence Italy
 Crimean War in Turkey 1854
 Only 1/6 of soldiers who
died did so of wounds
 Rest died of typhus,
cholera, dysentery
 Recognized improved
outcomes when patients with
similar diseases and severity
could be grouped in specific
areas of hospital
Phillip Drinker
 Harvard (1927): Iron lung
developed and presented in
article titled “The use of a
new apparatus for the
prolonged administration
of artificial respiration: A
fatal case of poliomyelitis”
 Donation to Bellevue
Hospital where it saved a
woman dying from
overdose of an unknown
W.E. Dandy
 1928: established a 3 bed post-
neurosurgical ICU in Baltimore
at Johns Hopkins
World War II
 Shock wards established for
 Transfusion practices in
early stages
 After WWII, nursing
shortage forced grouping of
postoperative patients in
recovery areas
History of ACLS
 1947—Claude Becker
invents first
 1947—1st life saved
with debrillator
Polio epidemic
 1950’s: use of mechanical
ventilation (“iron lung”) for
treatment of polio
 Development of respiratory
intensive care units
 At the same time, general ICU’s
developed for sick and
postoperative patients
Peter Safar
 First intensivist doctor
 Received anesthesia training at
Started “Urgency and Emergency
Room”—now known as ICU in
1958 (Baltimore)
Artificial ventilation, cardiac
massage became popular
Father of cardiac resuscitation
1962—Pittsburgh establishes first
critical care fellowship
Increase in ICU beds
 1958: ¼ of community hospitals with 300 beds had an ICU
 Late 1960’s: most US hospitals had ICU’s
 1970: SCCM established by 29 physicians in Los Angeles
 1986: critical care certification through anesthesiology,
surgery, internal medicine, pediatrics
Types of ICU’s
 Open ICU model—patient admitted under care of an
internist, family practitioner, surgeon, or specialist with an
elective critical care consultation
 Intensivist co-management—open ICU with mandatory
critical care consultation
 Closed ICU—patients transferred to care of intensivist after
 Mixed ICU model—overlap of above
Jefferson MICU
 5th floor Gibbon
 17 full ICU beds
 5 interns, 3 residents provide 24/7 coverage
 24/7 fellow coverage
 Attending intensivist available 10-12 hrs/day in house and the
rest on call for backup
 3rd floor Gibbon
 8 full ICU beds
 Nurse practitioners provide 24/7 coverage
 24/7 fellow coverage
 Attending intensivist available 10-12 hrs/day in house and the
rest on call for backup
 MICU no longer has an intermediate ICU such as ISICU,
Intensivist job description
 Patient care
 Multidisciplinary rounds
 Bed allocation/triage
 Quality control (infection control, safety, evidence based practive)
 Protocol development
 Education
 Residents, fellows, med students, nurses, respiratory therapists, nurse
 Research
 Quality assurance projects
 Clinical trials
 Database-driven projects
Admission/discharge criteria
 Meant to be used as a guideline to triage patients
 Remember: ICU beds are a finite resource—it is the job of
the intensivist to best utilize this finite resource
 Diagnosis model for triage
 Objective parameters model
Diagnosis model for triage
Objective parameters model
Admissions to MICU
 ER (Average approx. 30/month)
 Wards (Average approx. 35/month)
 Transfers (Average approx. 25 month)
 Less common
 Jefferson ICUs
 Direct admissions
 Right heart catherization
 Desensitization
General guidelines
 All patient movement requires notification of the patient
flow management center (PFMC): transfer center plus
central scheduling (5-1515)
 Intensivist or designee (fellow) should be notified for all
 Jefferson has mandated a “Don’t say no” policy for outside
General guidelines for bed
 Role of the ICU attending/fellow should be facilitator
 Get the patient to the ICU as soon as reasonably feasible
 Patient care improved in ICU setting as compared to ER or general
 Physician at the bedside should have the advantage in deciding
 All conflicts should go up chain of command quickly
 ie FellowICU attendingICU directorCritical Care Co-
directorChief Medical Officer
 Conflicts should be handled attending to attending ultimately
 All patients not accepted to ICU should be discussed with the ICU
Methods to admit
 Through ER
 ER may directly admit to ICU without another evaluation by
the MAR or ICU resident (Hospital by-law)
 ER physician will call fellow or attending
 Unit charge nurse notified for bed allocation
 Goals:
 Initiate therapy in ED
 Therapy may be modified after consultation of ICU team
 Transfer patient to ICU ASAP without having ICU housestaff including
fellow leave ICU
ER “4 hour rule”
 JHACO requirement
 Patients triaged to admission must be transported out of the
ER within 4 hours
 TJUH has allocated 90 minutes for “acceptance”
 THUH has allocated 150 minutes for signout and transport
Methods to admit
 From floors
 Primary team resident evaluates patient on floors, discuss with
ICU team for admission
 Not necessary to have housestaff leave ICU
 Handoff should include chart documentation of plan of care and
physician to physician communication
Methods to admit
 From outside institutions
 Attending:attending exchange of information
 Fellow may be asked to assist
 Notify patient flow management center (5-1515)
 Notify charge nurse
 Obtain more detailed patient related information
 For transfers from outside institutions, it is the outside
institution’s responsibility to ensure safe transfer (ie stable
airway, relatively stable hemodynamics, etc)
 Patient triaged at bedside by Code Blue team leader
 ICU fellow and/or attending notified of transfer
 Primary team attending notified of change of status
 Family notified of change of status
 About half of RRT’s come to ICU
 About 1/3 are intubated (automatic transfer)
 Senior physician at bedside currently triages patient (fellow
or resident)
 If resident feels patient should come to ICU
 Notify primary attending (if patient doesn’t emergently need to
come to ICU)
 If attending agrees, patient comes to ICU  notify fellow
 If resident feels patient does not need ICU
 Notify primary attending  if that attending disagrees, resident
is overruled and patient is transferred to ICU  fellow notified
Non-RRT/code transfers
 No more “head’s up” calls to fellows
 Fellows/unit residents do not do ICU evaluations (done by
primary team)
 Floor residents should go up chain of command prior to calling
 i.e. intern  resident  GI fellow  GI attending
 After going up chain of command, options are:
 1. Manage patient on wards with primary attending/fellow
 2. Call fellow after evaluating patient and discuss why patient should
come to ICU and patient is triaged by fellow/ICU attending
 If primary attending disagrees, should call ICU attending
 3. Pulmonary/critical care consultation when there is uncertainty
General principles
 Keep primary attending informed
 Keep families informed
 Keep Patient Flow Management Center (PFMC) informed
 If there is disagreement between where a patient should go,
go up the chain of command (ultimately attending-attending
discussion is always encouraged)
Typical ICU day for fellow
7:00-7:30 Overnight signout
7:30-8:30 Conferences
8:30-9 am ABCDE rounds with charge nurse, RT, PT, nurse
9am-12pm Multidisciplinary rounds
12-1pm Lunch/conference (ICU lecture series)
1pm-4pm Patient care (lines, interact with consultants, follow-up
 4pm-5 pm Afternoon rounds
 7 pm Signout to overnight fellow
 7 pm-? Nocturnal rounds with housestaff, nursing
ICU expectations (from fellow
Knowledge of all patients on service
Implementation of daily care plan
Coordination of care
Admission/triage of new patients
 All new patients need note from fellow or attending
Knowledge of protocols/initiatives/research studies
Supervision of housestaff/NP’s
Ventilatory management
Team liaison for case management
Help populate ICU database (Dr. Oxman to speak further)
Over three years, work toward independent decision making
Additional fellow responsibilities
 4th Tuesday each month
 MICU working group
 Discussion of infection rates, QA issues, ICU projects
 1st Wednesday each month
 Special Care Unit Subcommittee
 Hospital wide patient care and safety issues
 Tuesday, Thursday at 1 pm—Case management rounds
Triage points
 Triage decisions will never be 100% accurate
 Better to be wrong about a soft admission who leaves ICU
within 24 hours rather than the borderline patient who is
transferred from wards to ICU within 48 hours
 Propensity scores can sometimes help, but they will never
replace clinical judgment of physician at the bedside
 Pneumonia Severity Index
 Rockall Score (GI bleed)
 APACHE score
 Severe sepsis criteria
Important initiatives
 Sepsis pathway
 GI bleed pathway
 Ventilator management
 ARDS protocol
 Ventilator bundle (“VAP bundle”)
 DVT prophylaxis
 GI prophylaxis
 HOB elevation
 Oral care
 Sedation management
 NOTE: most MICU patients have subglottic suctioning ETT’s
Severe sepsis initiative
 Severe sepsis identified using electronic chart alerts
 Protocol driven initial management in ER, continued in ICU
 Goal is to quickly transfer patients to ICU
 “Automatic” acceptance of patients diagnosed as severe sepsis
 ER to notify fellow who notifies PGY 2 (**Physician information order**)
 ER will notify patient flow management center who will notify charge nurse
 Antibiotics
 IV access, fluids, pressors
 Central line if pressors needed
Inclusion Criteria
Suspected Infection AND at least 2 of SIRS Criteria
 SIRS Criterion: Fever (core temperature > 38.3 C or 101.0 F) or hypothermia (core
temperature < 36 C or 96.8 F)
 SIRS Criterion: Heart rate > 90 beats/min
 SIRS Criterion: Respiratory rate > 20 breaths min or PaCO2 < 32 or need for mechanical
ventilation for an acute respiratory process
 SIRS Criterion: WBC > 12,000/mm3, < 4,000/mm3, or bands > 10%
Organ dysfunction - one of the following must be new and thought to be due to infection:
 Hypotension (SBP<90mmHg or MAP < 65mmHg despite initial fluid bolus)
 Lactate > 4mmol/L
 UOP < 0.5 mL/kg/hr despite initial fluid bolus or creatinine increase > 0.5 mg/dL above
 PaO2/FiO2 ratio < 300 or requiring > 4L NC O2 to maintain O2 sat>90%
 Platelets < 100,000mm3 or INR>1.5 or PTT>60 sec
Processes of care being monitored
 Blood Culture before antibiotics
 Antibiotics within 3 hours
 Adequate initial fluid bolus (now 30 cc/kg)
 Pressors if MAP<65 or systolic BP<90
Our Progress to Date
TJUH, Inc. Sepsis Mortality Ratio
Sepsis TJUH: Premier vs UHC MSDRG 870872
Our Progress to Date
Sepsis Mortality: UHC 2012 Risk model TJUH, Inc.
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
20102010201020122011 2011 2011 2011 2012201220122012
GI bleed pathway
 Same paradigm
 Early risk stratification and triage (using Rockall score)
 Early protocol driven management
 Evidence based guideline to therapeutic management
 Coordination of care between multiple specialties
 Education
 Implementation
 Monitoring
 Tweaking
Changing Paradigm of ICU Care
What are the components of
the ABCDE Bundle?
Awakening and Breathing Coordination
Choice of Analgesics and Sedatives
Delirium Identification and Management
Early Exercise and Mobility
Choice of
Analgesics and Sedatives
The Points
 Goals•forBolus
and then
 Clinical pharmacology
consider continuous
 Costs
• Assess and target.
• Daily interruption
Patient Factors
Increased age
Alcohol use
Male gender
Living alone
Renal disease
Delirium: What Can We Do?
Less Modifiable
Admission via ED or
through transfer
No clock
No daylight
No visitors
Use of physical restraints
More Modifiable
Predisposing Disease
Cardiac disease
Cognitive impairment
(eg, dementia)
Pulmonary disease
Acute Illness
Length of stay
Medicine service
Lack of nutrition
Metabolic disorders
- Anticholinergics
- Corticosteroids
- Benzodiazepines
Diagnosis is Key !!
Confusion Assessment Method for the ICU (CAM-ICU)
Feature 1: Acute change or
fluctuating course of mental status
Feature 2: Inattention
Feature 3: Altered
level of consciousness
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Ely, et. al. CCM 2001; 29:1370-1379.4
Ely, et. al. JAMA 2001; 286:2703-2710.5
Feature 4:
Disorganized thinking
Treatment of delirium in the ICU
Treatment of inciting condition
Familiar objects from home
Cognitive stimulation
 Television news
 Non-verbal news
Minimize unwanted noise
Sleep hygiene
Early mobilization
Range of motion
Remove restraints, catheters, lines
Eye glasses, hearing aids
 Review analgesics,
 Haloperidol
 Risperidol, quetiapine, etc.
Immobility not beneficial
and associated with
 Myopathy and/or
 Delayed weaning
from ventilator
 Delirium
 Infections
 Pressure ulcers
Early Progressive
Exercise and Mobility
Early progressive mobility
programs result in:
 Better patient outcomes
 Shorter hospital stays
 Decreased development of
hospital acquired complications
The level of exercise and
mobility is individualized and
incrementally progressed
Early Progressive Exercise and Mobility
It Takes a Team!

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