ICU scoring systems and ICU administration

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ICU scoring systems and ICU administration

• Panel discussion

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A 14 year old child is brought to the ER by
ambulance complaining of abdominal pain after
traumatic injury MVC pt was a belted back seat
passenger. The pt on initial review is noted to
have pancreatic injury without duct disruption.
What is the disposition of this patient?

1. Admit to the ICU
2. Keep the patient indefinitely in the ER
3. Admit to the wards
4. I dont know

3
What ICU scoring system would you use in this
setting?

• APACHE 2
• Ransons criteria
• Injury Severity Score
• I would just use my clinical judgement no ICU
  scoring system

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ICU admission, Discharge and Triage Criteria
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How do you make a determination for ICU admission?

1. We have formal criteria for ICU admission and
   discharge.
2. We make use of scoring systems as indicators of
   severity of illness in a prospective manner
3. We only make clinical judgments on whether the
   patient needs to be admitted to the ICU

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Levels of Recommendations for the Intensive Care
Unit

• Rating system
• Level 1 Convincingly justifiable on scientific
  evidence alone
• Level 2 Reasonably justifiable by available
  scientific evidence and strongly supported by
  expert critical care opinion
• Level 3 Adequate scientific evidence is lacking
  but widely supported by available data and
  critical care expert opinion

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A 15 year old male s/p motor vehicle crash is
noted to be hypotensive after admission to the
ER. He was intubated by the emergency medical
technicians prior to arrival in the ER.In the
ER, resuscitation is initiated and the patient is
noted to have 1. a small hemopneumothorax
managed with Chest tube2. A small splenic
laceration managed non-operatively3.
Respiratory failure managed with intubation and
mechanical ventilation
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Hospital course

• The patient develops VAP
• Despite being treated with appropriate
  anti-biotics the patient continues with
  respiratory failure
• The patient subsequently develops renal
  dysfunction followed by failure requiring
  dialysis
• Despite full resuscitative efforts the patient
  dies 2 weeks after admission with MOFS

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You are now reviewing this case as part of the QI
process at your hospital. Was this mortality

1. Preventable
2. Potentially preventable
3. Non-preventable

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Critical care delivery in the intensive care
unit Defining clinicalroles and the best
practice model

• Multidisciplinary care models-
• presence of a team of health professionals from
  various disciplines, working in concert, may
  improve efficiency, outcome, and the cost of care
  for patients hospitalized in the ICU

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Intensivist

• The intensivist is responsible for coordinating
  and providing integrated care to the patient with
  acute and chronic complex illnesses.
• Proximity to the patient is required
• When multiple consultants are involved, the
  intensivist, acting as the multispecialty team
  leader, coordinates the care provided by the
  consultants, thus providing an integrated
  approach to the patient and family.

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Do you find that you are able to work with
consultants even when you override their
recommendations?

1. Yes, but I pay a price in political capital
   within my institution
2. I feel that I am unable to override their
   recommendations
3. Consultants feel inhibited in my ICU and often
   simply agree with my management.

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Intensivist

• Administrative responsibilities
• Patient triage based on admission and discharge
  criteria, bed allocation, and discharge planning
• Development and enforcement of, in collaboration
  with other ICU team disciplines, clinical and
  administrative protocols that are intended to
  improve the safe and efficient delivery of
  clinical care and to meet regulatory
  requirements
• Coordination and assistance in the implementation
  of quality improvement activities within the ICU.

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What are the greatest pitfalls which you face
with regard to administrative responsibilities?