ORGANIZATION AND MANAGEMENT OF THE ICUs

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ORGANIZATION AND MANAGEMENT OF THE ICUs

• Arzu TOPELI-ISKIT,MD
• Hacettepe University Faculty of Medicine
• Medical Intensive Care Unit
• 22 April 2006

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ICUs are specialized units where intensive
monitorization and organ supportive therapies can
be applied to patients with physiologic
instability, continuously and with same
standarts, i.e., 24 hours a day, 7 days a week
and 365 days a year.
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• Physical Design

1. Guidelines for intensive care unit design, 1992
   www.sccm.org Crit Care Med 199523582-8.
2. Recommendations on minimal requirements for
   intensive care departments TASK FORCE of the
   ESICM. Intensive Care Med 199723226-32.
3. Intensive care unit design and environmental
   factors in the acquisition of infection J Hosp
   Infect 200045255-62.
4. Guidelines on critical care services and
   personnel Recommendations based on a system of
   categorization of three levels of care Crit
   Care Med 2003312677-83.
5. Guidelines for environmental infection control
   in health-care facilities, 2003.
   Recommendations of CDC and HICPAC. www.cdc.gov

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Physical Design

• Members to be present in ICU planning
• Medical director of the ICU
• Director of the hospital
• ICU chief nurse
• Hospital architect and engineer
• Other departments wrelated with the ICU
• Points that have to be taken into consideration
• Patient population
• Admission and discharge criteria
• ICU occupancy
• Tha status of the other hospitals
• Categorization according to level of care
• Staff and visitor number
• Necessity of the other support units

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Level of CareGuidelines on critical care
services and personnel Recommendations based on
a system of categorization of three levels of
care Crit Care Med 2003312677-83.

• LEVEL I Units having staff and technologic
  equipment so that every critically ill patient
  can be managed
• LEVEL II Units managing the critically ill
  patients but not in all fields (e.g.,
  neurosurgery, transplantation, etc) and having
  protocols to transfer these patients to
  appropriate units
• LEVEL III Units where critically ill patients
  can be stabilized but can not be fully treated
  and having protocols to transfer these patients
  to appropriate units

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Level of Care Recommendations on minimal
requirements for intensive care departments
TASK FORCE of the ESICM. Intensive Care Med
199723226-32.
Level of Care Nurse/patient Total nurse no/bed
III 1/1 6
II 1/1.6 4
I 1/3 2
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Level of CareRecommendations on minimal
requirements for intensive care departments
TASK FORCE of the ESICM. Intensive Care Med
199723226-32.
III II I
Total doctor no/6-8 bed 5 4 3
Min 6 bed N N R
Presence of antre in isolation rooms (2.5 m2) N R O
...
N Necessary R Required O Optional
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Physical Design

• SPESIFIC or GENERAL (Multi-diciplinary)
• In intracranial bleeding, head trauma, follow up
  in the neurointensive care increases survival.
• ICUs should be close to each other far away from
  the main hospital traffic, close to ER, OR, lab,
  radiology department and elevators
• 5-10 of hospital beds
• Ideal bed no 8-12

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Physical Design

• Beds OPEN, SEPERATE (ISOLATED ROOMS), MODULAR
  (UNITS OF A COUPLE OF BEDS)
• Bed no Total area / 40
• Support units (clean room, dirty room, etc) Bed
  area
• Open system 20 m2/bed isolated rooms 25 m2/bed
• In the open system beds should be seperated by
  2.5 m from each other
• Central monitorization (direct veya indirect)

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Physical Design

• Other areas
• Rooms for staff (director, physicians, nurses,
  secretary, others showers, meals, alarms,
  communication, etc)
• Rooms for equipment, drugs, sinks, security...
• Clean room (10-15 m2)
• Dirty room (20 m2, seperate enterance and air
  conditionng, etc.)
• Seminar room for education
• Room for relatives (1-1.5 chair/bed room for
  talk)

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Physical Design

• For each bed 2 O2 (5 bar), air (5 bar) and vacum
  (500 mmHg) source lightning 16 electrical
  socket alarms
• Water supply for dialysis
• Clock, tv, radio
• Beds, monitors
• Natural lightning (window)
• Chairs for relatives
• Seperate enterance for staff, equipment, relative
  (seperate corridors for patient transport
• lt 8 persons / rounds
• Material used for walls, floor should be cleaned
  easily, absorb noise (day 45 dB(A), night 20
  dB(A))

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Physical Design - Infection

• More infection risk in ICU patients
• Multi-drug resistant microorganisms
• Min 1-2/10 isolation rooms (25 m2)
• Antre for dressing, hand wash, etc
• Sink and bathroom
• Open sytem 1 sink/2 beds isolated rooms 1
  sink/bed 2 sinks/each module
• Operated by elbow, foot deep and wide enough
  easy to reach
• Alcohol based disinfectants for each bed
• Standarts for cleaning and disinfection

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Physical Design - Infection

• Appropriate air flow and conditioning
• Positive and negative pressure rooms
• Filtration 5 µm particulate, 99 efficient
• Temp and humidity could be adjusted 16-27C,
  30-60, 6-15 cycles of air flow/hour
• Dirty rooms (20 m2)
• Seperate air flow
• Seperate corridor for garbage

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Continuity
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• 3.5 years 18 ICU 23,000 admissions
• Adjusted mortality
• Weekend vs. weekday admission 1.20 (1.01 1.43)
• Night vs. dayadmision 6.89 (5.96 7.96)

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Chest 20041261292-8

• 7 years single center (USA) 29,000 admissions
• Adjusted mortality
• SICU Weekend vs. weekday 1.23 (1.03 1.48)
• No difference in MICU and general ICU

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Hacettepe MICU, AnkaraArzu Topeli, N. Defne
Altintas, Melda Aybar. Toraks Dergisi 20045 (Ek
1)83

• 20 month period, single center, prospective 331
  pts hospitalized for gt24 hours
• Adjusted mortality
• Holiday admissions (including weekend and
  holidays) 2.0 (1.0 4.1)

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Team Work
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ICU team
Intensivist Director
Physicians
Nurses
Resp therapists
Clinical Pharmacist
Others
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Lancet 2000356185-9

• Workload ? occupancy nursing care (1.3 nurses /
  pt)
• Adjusted mortality
• Increased workload 3.1 (1.9 5.0)

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TISS-28 (Therapeutic Intervention Scoring
System-28 )
1 TISS score 10.6 min/shift
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Hacettpe MICU

• 30.3 5.4.2006 (1 week) 9 beds
• 100 occupancy
• Mean TISS 28 (11-39)
• 40 hours/shift
• 5 nurses (4-6) /shift are required

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Aust J Physioth 20045067-73

• Randomized prospective study
• Acute hypercapnic resp failure NIMV
• 17 pts no physiotherapy Length of NIMV 6.7 days
• 17 pts physiotherpy Length of NIMV 5.0 days

p0.03
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JAMA 1999282267-70

• MICU CCU
• Clin Pharmacist rounding with ICU staff everyday,
  consultation is asked at other times
• 66 ? in medication errors (10.4/1000 ? 3.5/1000
  pt day, plt0.001)

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Hacettepe, MICUDeniz Yilmaz, Arzu Topeli Iskit,
Kutay Demirkan. Yogun Bakim Derg 20055 (Ek 1)

• Seminar to the physicians was given by the
  pharmacist about blood level monitorization and
  drug application accordingly
• Prior to education 110 (30 pts), after education
  90 (21 pts) blood level monitorization
• Prior to education 39 (35.5) levels, After
  education 15 (16.7) levels were monitored in a
  wrong way (plt0.05).

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Definition of an Intensivist

• Education in the main specialty and then
  education in Critical Care Medicine
• Spending 50 75 of his/her professional time in
  the ICU

SCCM 1992 ICM 1997
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USA
Pulmonary
Medicine
Anestesiology
CCM (1-3 yrs)
Surgery
Pediatrics
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Europe
Medicine
Anestesiology
CCM (1-2 yrs)
Surgery
Pediatrics
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Duties of the Director

• Communication, coodination, Primary
  responsibility in pt care
• Responsibility in admission, discharge, triage
• Role in physical design, supplying equipments
  etc.
• Continuous education

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ICU Admission and Discharge CriteriaCrit Care
Med 199927633

• Critically ill pts with reversible underlying
  condition or having a reasonable life expectancy
  should be admitted.
• Terminally ill pts or pts too good to be followed
  in a ward should not be admitted.
• If pt becomes terminally ill after admission to
  an ICU limited/no support should be given or the
  pt should be transferred outside.

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Admission and Discharge CriteriaCrit Care Med
199927633

• Priority system
• 1. priority Pt in need of full ICU care
  (MV,vasopressor treatment, etc)
• 2. priority Pts who who will get benefit from
  ICU care (acute problems in pts with
  comorbidities)
• 3. priority Pts with a low expectation of
  prolonged life but in need of ICU care for acut
  problems (acute problems in metastatic
  malignancy). Treatment might be limited.
• 4. priority Pts with no indication

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ICU
Intermediary Care Unit
Ward
23-33 unnecessarily prolonged hospitalizations
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ICU management policies

• Open Primary physicians are responsible from the
  pts
• Closed Intensivist is the responsible physician.
  
• Semi closed Primary physician and the
  intensivist sharing the decisions.

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Best management system?

• Presence of a responsible physician (director)
• Presence of an intensivist director
• Presence of an intensivist director closed
  system policy
• Presence of an intensivist in the ICU 24 hrs a
  day

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JAMA 20022882151-62

• 26 studies
• High density ICU care (mandatory intensivist
  consultation or closed system)
• Low density ICU care (no intensivist or elective
  intensivist consultation)
• Adjusted hospital mortality HD vs LD 0.71 (0.62
  - 0.82)
• Adjusted hospital mortality HD vs LD 0.61 (0.50
  0.75)
• Shorter ICU and hospital LOS in HD group

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Why closed system/intensivist director?

• Patient care is not like a standart round and
  ordering treatment, it is rather like titration.
• ICU physician, not the primary doctor, is near
  the patient all the time.
• Uncoordinated patient care by unnecessarily high
  amounts physicians is not good.

Safar Grenvik. Anesthesiology 1977
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Crit Care Med 2004322191-8

• 21 decrease in ICU mortality, 10 decrease in
  hospital mortality
• 17 decrease in LOS (3.5 ? 2.9 days)

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Crit Care Med 2004322311-7
OR (95 CI) p
APACHE III 1.07 (1.06 1.08) lt0.001
Transfer from another ICU 3 (1.4 6) lt0.01
Nörointensivist 0.7 (0.5 1) 0.04
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Hacettepe MICU, Ankara
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Crit Care Med 200533299-306
Open n200 Closed n210
APACHE II (median) 13 21
MV () 45 64
CVC () 23 47
Trach () 0 8
Unit policy - mortality Open vs. closed OR (CI) 5 (2 11) p lt0.0001
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APACHE II(Acute Physiology and Chronic Health
Evaluation)

• Physiological parameters
• Lab parameters
• GCS
• Age
• Chronic health status

Gerçek ölüm orani Beklenen ölüm orani
? 1
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• 1/31/2 of Americans spend their last year of
  life in an ICU, 1/5 of them lose their lives in
  the ICU.
• With the presence of an intensivist director,
  54,000 lives could be saved each year in USA
  where 3.5 million pts are admitted to ICUs.

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USA

• 1 of national gross product for ICUs
• 8 of hospital beds
• Mean bed no 10-12
• Bed occupancy 84
• In 35 medical director
• 1 out of 3 pts cared by an intensivist
  intensivist crisis in 2007
• Closed system 22 (big hospitals, MICU)
• Continuous respiratory therapist 48
• Nurse/pt ratio 1/2
• Presence of educated intensivists in ICUs is
  considered to be a marker for quality of health
  care

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Europe

• 75 medical surgical pts (general ICU)
• 25 gt10 beds 57 6-10 beds 18 lt6 beds (UK)
• 72 continuous physician coverage 67 medical
  director (intensivist)
• Bed occupancy 78

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Respiratory ICU Italy

• RICU Units between ICU and ward (intermediary
  care units) where pts with single organ failure
  (resp failure) can be followed
• Nurse/pt 1/2.5 1/4 continuous sufficient
  non-invasive monitorization sufficient
  experience in NIMV and intubation in case of NIMV
  failure presence of a physician 24 hrs a day
• Results
• 26 RICU
• Nurse/pt 1/2 - 1/3 (36 1/4)
• 756 pts age 68 APACHE 18 (expected mortality
  22 observed mortality 16) length of stay 12
  days
• 96 resp failure (COPD)
• 30 monitorization 62 MV 8 weaning
• 73 NIMV

Confalonieri. Thorax 200156373
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TURKEY ?

• 1978 Society of Intensive Care
• 1992 Turkish Thoracic Society Respiratory
  Intensive Care Working Group
• Education of CCM subspecialty after education in
  main specialties (Medicine, Anestesiology, Pulm
  Medicine and Pediatrics) is being prepared
• 8 March 2005 Society of Medical and Surgical
  Sciences Intensive Care Medicine

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www.dcyogunbakim.org.tr