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Edit Comment Close Premium member Presentation Transcript Critical Care Delivery in ICU : Critical Care Delivery in ICU Defining the clinical roles and the best practice model From: Crit Care Med 2001:29:2007 -2019 Economic Impact of ICU (1994) : 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 : ICU So expensive per patient per time interval We need data about the type and quality provided in ICU Two Questions : Two Questions 1. Role and practice of an intensivist 2. The best practice model in ICU USA vs Taiwan : USA vs Taiwan ???????10????? 10-15???????????? 1991 Survey in USA : 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 : 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 : 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 Survey (1997) ICU administrator Anesthesia : 0.6% Medicine : 36.7% Surgery : 16% Free : 29.1% Others : 17.6% ICU Model Care : 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) : 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 intensivists : Full time intensivists More common in Larger hospital Managed care penetration higher MICU ICU physicians (1997)During office hours : ICU physicians (1997)During office hours Full time in ICU : 27% Elsewhere in hospital : 44% Presence off site : 24% Unknown : 5% ICU Resident (1997) : ICU Resident (1997) Full time in ICU : 53% Cover (ICU & ward) : 42% Other : 5% Slide 16: NP (nurse practitioner ) PA (physician assistant ) <10% 1991?1997 consistent patterns : 1991?1997 consistent patterns 1/3 ICU administered by medicine department 60% ICU patients are in general ICU Full time intensives treated 23% of all ICU patients, esp. in larger hospital, MICU resident: 44% , fellow: 21% of all ICU ICU coverage by non-physician: very uncommon ?????? 5–10 ?? ICU : ?????? 5–10 ?? 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 : An Ideal ICU Multidisciplinary& Collaborative approach to ICU care : 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 : Team Dynamics A multidisciplinary team to effectively attain specified objective Physician team leader & critical care nurse manager Intensivists : 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 : 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 : 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 : Critical Care Practice Pattern Open Closed transitional Open Units : 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 : 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 : 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 : Advantages of Intensivists Morbidity (ICU, 30-day, hospital) ? Cost ? Length of stay (ICU, hospital) ? Complication ? A Good ICU : 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 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 : 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 : Discussion For NTUH SICU: Technician team ? complex treatment SICU CNS ? uncommon in USA Communication Team dynamics You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.