Determining the
Appropriate Level of Care
Zorawar Noor
Fundamentals In Medicine Series
7/22/2015
Goal:
• After this talk, you should be more comfortable determining the
appropriate level of care for your patients and advocating for them.
Objectives
1. Understand the guidelines for ICU triaging and admission.
2. List the indications for admission to telemetry.
3. Learn a few simple rules to prevent making errors in triage.
“The ICU is for patients who are intubated or
on pressors.”
Which types of patients are triaged to the ICU?
Those with:
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Shock
Respiratory failure
GI bleeding
Acute Coronary Syndrome
DKA
Drug Overdose
… and many others
Who belongs in the ICU?
“ICUs should, in general, be reserved for those with reversible medical
conditions who have a ‘reasonable prospect of substantial recovery.’ ”
1 “Guidelines for ICU Admission, Triage, and Discharge.” Society of Critical Care Medicine, 1999
How do we triage patients into the ICU?
• Appropriate triage allows:
- Available beds for those that need them most
- The best patient care
1. Prioritization Model
2. Diagnosis Model
3. Objective Parameters Model *** Least useful.
***The authors write “these criteria have been requested
... and while arrived at by consensus are arbitrary.”
1 “Guidelines for ICU Admission, Triage, and Discharge.” Society of Critical Care Medicine, 1999
A Quick Word on the Objective Model
This model is the least useful. Don’t wait to see a SBP < 80 to transfer.
• HR< 40 or >150
• SBP < 80 or 20 below patient’s usual
• MAP < 60
• RR > 35
• Na < 110 or > 170
• PaO2 < 50 (really? Approx. a Hgb Sat of 85%)
• Glucose > 800
• Anuria
Prioritization Model
1. Severely ill without limitations on care
2. Intensive monitoring and potentially need immediate intervention
3. High risk of death but limited chance of recovery
4. Require a discussion with the ICU team, but less likely to need ICU:
a) Frequent monitoring but unlikely to need immediate intervention
b) Terminal and irreversible diseases, “Too sick for the ICU”
1 “Guidelines for ICU Admission, Triage, and Discharge.” Society of Critical Care Medicine, 1999
Diagnosis Model
• Let’s go over some scenarios
Scenario 1 – Shortness of Breath
• You are called to evaluate a 23 year-old man with severe asthma
exacerbation. In the ED, he received two Duoneb treatments. He is
satting 95% on room air with RR 22, HR 115, and BP 155/85. Appears
very distressed and using accessory muscles to breathe and is
paradoxically breathing. Labs demonstrate an unremarkable CBC and
BMP. ABG shows hypocapnea and mild hypoxemia. CXR with hyperexpansion without consolidations.
What would you like to do?
Scenario 1 – Shortness of Breath
• Either you intubate this patient, or you send him to the ICU.
• In the words of Dr. Leven:
“Intubation is not an addiction. When people say, ‘He’ll never get off the vent.’
That isn’t a thing, if that’s the case, then consider hospice.”
“If you anticipate that your patient will require intubation anytime in the next
24 hours, don’t wait, intubate now.”
Pearl: Don’t wait, intubate or escalate!
What about BiPAP for my CHF patients?
• BiPAP is only allowed for a short amount of time on the floors
• Fabled to be 1 hour maximum on floor …. vs 1.5 hours… vs 3 hours??
• BiPAP can be done for several hours if:
• Stable on home settings
• In the DOU or ICU at the VA
• In the step-down or ICU at UCI
Patients with neuromuscular disorders and
SOB
• Likely need close ICU monitoring or early intubation
• Check vital capacity / NIF, but do not be reassured if they appear
clinically well.
Scenario 2 – Palpitations
• 45 year-old man with palpitations with associated shortness of breath, found
to be in 2nd degree type II AV block. His heart rate is 52 bpm, BP 110/85, RR 20.
What’s his appropriate level of care?
Scenario 2 - Palpitations
• Send this patient to the CCU for a possible pacemaker for a highdegree AV block and also for monitoring of his symptomatic
bradycardia.
Who Needs to be on Telemetry?
• Have you been asked, “Does this patient need to be on telemetry?”
• Here are the criteria:
• A) Cardiac (Cardiac Monitoring)
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“rule-out” ACS
s/p cardiac procedure like cath or AICD
Decompensated heart failure
Suspected hemodynamically significant bradyarrhythmia or tachyarrhythmia
• B) Pulmonary (Continuous Pulse Ox)
• Hypoxia/ hypoxemia, or with acute illness requiring supplemental oxygen
• OSA, COPD exacerbation
Do my CHF patients go to Cardiology?
• A new diagnosis of CHF goes to the Cardiology service
• All decompensated CHF patients go to telemetry
• Decompensated CHF patients requiring with significant respiratory
failure (i.e. on face mask or BiPAP) should be considered for
management by Cardiology service.
What about A fib with RVR?
• New onset atrial fibrillation should be evaluated by the Cardiology
service.
• If atrial fibrillation is easily controlled with IV push and PO medication
then the patient is safe for telemetry.
• Patients with hypotension or difficult to control RVR should be
admitted to the CCU.
Scenario 3 – Chest Pain
• 55 year-old man with MI in 2013 on Beta-blocker, statin, ASA, CCB,
and Imdur who for 3 weeks has his usual chest pain but it now occurs
after walking four feet as opposed to his baseline of 15 feet.
Where do you want to admit this patient?
What’s the most likely diagnosis?
Scenario 3 – Chest Pain
• “ACS rule-out” can go to the telemetry, but actual ACS goes to Cards
• Don’t miss unstable angina in a patient admitted to you from the ED
• Patients are at significant risk for fatal arrhythmia in first 48 hours
Scenario 4 – Uncontrolled Diabetes
• 35 yo man with type I DM in DKA from medication non-compliance
who is hemodynamically stable, with Glu 600, ketones 1.0, pH 7.3 and
anion gap of 14.
Where do you want to admit this patient?
• 35 yo man with type I DM in DKA with glucose 800 and pH 7.1 and
gap 20.
Where do you want to admit this patient?
Scenario 4 – Uncontrolled Diabetes
• Mild DKA can be managed on the floor with q4 BMP checks
• UpToDate includes a protocol to treat DKA without drip
• Reasons to admit DKA/HONK to ICU:
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Hemodynamic instability
Altered mental status
Respiratory insufficiency
Severe acidosis
1 “Guidelines for ICU Admission, Triage, and Discharge.” Society of Critical Care Medicine, 1999
Scenario 5 – Uncontrolled HTN
• 88 yo man with HTN did not take his medications, in ED for diabetic
foot ulcer. BP 190/120, HR 88. Troponin = 0.1. EKG without T-wave or
ST changes. CXR unremarkable.
Where do you want to send this patient?
Scenario 5 – Uncontrolled HTN
• Hypertensive urgency can be managed as an outpatient with oral
medications.
• Lower the BP by 20% in 24 hours
• Hypertensive emergency (end-organ damage) goes to the ICU.
• Lower the BP by 15-20% with drip for tight control
• In this case, a mild troponin bump might be “demand” in a patient
that is 88 years old, and while they may or may not deserve an ACS
rule-out on telemtry, they do not necessarily need the ICU.
Scenario 6 – GI Bleed
• 67 yo man with history of MI with UC flare with hematochezia x2. On
ROS he has some chest pain. Lying down: HR 85, BP 140/80, standing
95, BP 120/77. Hgb 12 and Plt 300.
Where do you want to admit this patient?
Scenario 6 – GI Bleed
Consider the ICU for GI bleeding patients with:
• Orthostatic hypotension
• Angina
• Continued bleeding
• Hypotension
• If patient stays on the floor, frequently reassess.
Scenario 8 – Drug overdose
• 25 year-old man overdosed on liraglutide and had a witnessed tonicclonic seizure. He is a lethargic but otherwise, his neuro exam is
unremarkable.
Scenario 8 – Drug overdose
• Patients with overdose with the following go to the ICU:
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seizure
hemodynamic instability
inadequate airway protection
Neurologically compromised
• Conscious overdose can go to floor, step-down, or telemetry
Scenario 7 - Headache
• 34 year-old lady with ITP with history of splenectomy is admitted for a
platelet count of 4. On hospital day #1 she develops an abrupt 10/10
headache associated with nausea and vomiting. BP 165/90, HR 95,
and RR 18, satting 95% on RA. Neurologic exam is unremarkable.
Preliminary CT head shows possible intra-parenchymal bleed, but not
sure if it artifact.
What would you like to do?
Scenario 7 - Headache
Category of Patient
Multi-system trauma or non-operateive
head bleed
Isolated operative traumatic ICH
Spontaneous operative ICH
Spontaneous non-operative ICH
Admission Service
Trauma, SICU
NSG, SICU
NSG, either NSCU or SICU
NSG, NSCU under neuro-critical care
Isolated non-operative head trauma with MICU
multiple co-morbidities or trauma
Seizure related closed head trauma
Neuro-critical care service, NSCU
Adapted from “Head Injury/ Bleed Patient Disposition” medicine.uci.edu/noc.
Other ICU Scenarios:
• Coma
• Severe hyponatremia (i.e. Na <110 in the Objective Model)
• Stroke with altered mental status
• Pulmonary emboli with hemodynamic instability / massive lifethreatening pulmonary emboli
• Severe pancreatitis
• “Need for nursing / respiratory care not available in lesser care areas”
Zo’s Rules
1: Don’t Block!
2: If you are called about an unstable patient. Go assess. Write a note. Also,
ask your consultant to leave a note.
3: At night, if a patient seems “very borderline” for the ICU, send them to the
ICU. Never be embarrassed that a patient did well.
4: Don’t assume everything is okay.
5: Seek help from higher-ups if you can’t agree.
Summary
• Intubation and pressors are not ICU requirements. Also, your patient
shouldn’t have to fit a parameter like HR>149 bpm to be in the ICU.
• If the patient requires frequent monitoring but little chance of an
immediate intervention, consider a step-down floor.
• Intubate early or make a safe plan. BiPAP is usually only temporary.
• Don’t block. Go assess. Write notes. Don’t blindly trust anyone.
• Don’t be embarrassed to send a patient to your colleague. Advocate and be
proud if your patient does well.
Thank you for listening!
Questions?