Bharat Awsare MD FCCP Director, MICU Assistant Professor of Medicine Thomas Jefferson University Hospital July 5, 2013 Introduction to the Medical ICU.
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Slide 1
Bharat Awsare MD FCCP Director, MICU Assistant Professor of
Medicine Thomas Jefferson University Hospital July 5, 2013
Introduction to the Medical ICU
Slide 2
Overview History of ICU medicine Types of ICU Triage criteria
Role of fellow in the ICU Protocols of note Initiatives of
note
Slide 3
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
Slide 4
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 compound
Slide 5
W.E. Dandy 1928: established a 3 bed post- neurosurgical ICU in
Baltimore at Johns Hopkins
Slide 6
World War II Shock wards established for resuscitation
Transfusion practices in early stages After WWII, nursing shortage
forced grouping of postoperative patients in recovery areas
Slide 7
History of ACLS 1947Claude Becker invents first defibrillator
19471 st life saved with debrillator
Slide 8
Polio epidemic 1950s: use of mechanical ventilation (iron lung)
for treatment of polio Development of respiratory intensive care
units At the same time, general ICUs developed for sick and
postoperative patients
Slide 9
Peter Safar First intensivist doctor Received anesthesia
training at Penn Started Urgency and Emergency Roomnow known as ICU
in 1958 (Baltimore) Artificial ventilation, cardiac massage became
popular Father of cardiac resuscitation 1962Pittsburgh establishes
first critical care fellowship
Slide 10
1957
Slide 11
Increase in ICU beds 1958: of community hospitals with 300 beds
had an ICU Late 1960s: most US hospitals had ICUs 1970: SCCM
established by 29 physicians in Los Angeles 1986: critical care
certification through anesthesiology, surgery, internal medicine,
pediatrics
Slide 12
Types of ICUs Open ICU modelpatient admitted under care of an
internist, family practitioner, surgeon, or specialist with an
elective critical care consultation Intensivist co-managementopen
ICU with mandatory critical care consultation Closed ICUpatients
transferred to care of intensivist after evaluation/approval Mixed
ICU modeloverlap of above OUR MEDICAL ICU IS A CLOSED ICU
MODEL
Slide 13
Jefferson MICU 5 th 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 3 rd 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, INICU
Slide 14
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 practitioners Research Quality assurance projects Clinical
trials Database-driven projects
Slide 15
Admission/discharge criteria Meant to be used as a guideline to
triage patients Remember: ICU beds are a finite resourceit is the
job of the intensivist to best utilize this finite resource
Diagnosis model for triage Objective parameters model
Slide 16
Diagnosis model for triage
Slide 17
Objective parameters model
Slide 18
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
Slide 19
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 admissions Jefferson has mandated a Dont say no
policy for outside transfers
Slide 20
General guidelines for bed management 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 wards Physician at the bedside should
have the advantage in deciding triage 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 attending
Slide 21
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
Slide 22
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
Slide 23
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
Slide 24
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 institutions responsibility
to ensure safe transfer (ie stable airway, relatively stable
hemodynamics, etc)
Slide 25
Post-code 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
Slide 26
Post-RRT About half of RRTs 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 doesnt 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
Slide 27
Non-RRT/code transfers No more heads 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 ICU 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 supervision 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
Slide 28
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)
Slide 29
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 issues) 4pm-5 pm Afternoon rounds 7 pm
Signout to overnight fellow 7 pm-? Nocturnal rounds with
housestaff, nursing
Slide 30
ICU expectations (from fellow handbook) 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/NPs Ventilatory management Team liaison for case
management Help populate ICU database (Dr. Oxman to speak further)
Professionalism Over three years, work toward independent decision
making
Slide 31
Additional fellow responsibilities 4 th Tuesday each month MICU
working group Discussion of infection rates, QA issues, ICU
projects 1 st Wednesday each month Special Care Unit Subcommittee
Hospital wide patient care and safety issues Tuesday, Thursday at 1
pmCase management rounds
Slide 32
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
Slide 33
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 ETTs
ABCDE
Slide 34
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 TRANSFER SHOULD NOT COMPROMISE PATIENT CARE
Antibiotics IV access, fluids, pressors Central line if pressors
needed
Slide 35
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, 10% Organ dysfunction - one of the following must
be new and thought to be due to infection: Hypotension (SBP 4mmol/L
UOP 0.5 mg/dL above baseline PaO2/FiO2 ratio 4L NC O2 to maintain
O2 sat>90% Platelets 1.5 or PTT>60 sec
Slide 36
Slide 37
Processes of care being monitored Blood Culture before
antibiotics Antibiotics within 3 hours Adequate initial fluid bolus
(now 30 cc/kg) Pressors if MAP