Critical Care Delivery in ICU
Defining the clinical roles
and the best practice model
From: Crit Care Med 2001:29:2007 -2019
Dr. Abdul-Monim Batiha
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
• So expensive
per patient
per time interval
We need data about the type and quality
provided in ICU
Two Questions
1. Role and practice of an intensivist
2. The best practice model in ICU
USA vs Taiwan
• 現在的美國就是10年後的台灣
• 10-15年前的美國就是現在的台灣
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
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
•
•
•
•
Pediatric:
Neonatal:
Surgical:
Medical:
31%
30%
20%
2%
• <100 beds: 9%
• >500 beds: 56%
In general, not in charge of ICU admission
ICU Survey (1997)
ICU administrator
– Anesthesia : 0.6%
– Medicine : 36.7%
– Surgery : 16%
– Free
: 29.1%
– Others
: 17.6%
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)
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
intensivist
Consultant
intensivist
Consultant
sprcialist
Single
physician
12
9
40
36
7
14
14
19
50
55
37
34
30
20
4
10
19
47
21
21
13
17
18
13
46
33
45
52
17
3
14
14
Hospital size
small
medium
large
very large
Type of ICU
general
MICU
SICU
specialty
Full time intensivists
More common in
• Larger hospital
• Managed care penetration higher
• MICU
ICU physicians (1997)
During office hours
•
•
•
•
Full time in ICU :
27%
Elsewhere in hospital : 44%
Presence off site :
24%
Unknown
:
5%
ICU Resident (1997)
• Full time in ICU :
53%
• Cover (ICU & ward) : 42%
• Other
: 5%
NP (nurse practitioner )
PA (physician assistant )
<10%
19911997 consistent patterns
1. 1/3 ICU administered by medicine department
2. 60% ICU patients are in general ICU
3. Full time intensives treated 23% of all ICU
patients, esp. in larger hospital, MICU
4. resident: 44% , fellow: 21% of all ICU
5. ICU coverage by non-physician: very
uncommon
預測台灣未來 5–10 年的 ICU
• 除了 medical center‚ sub special ICU not common
– MICU, Vs SICU  區域醫院
– General ICU
 地區醫院
但台灣的醫院普遍床位較多
• Full-time intensivist, closed unit  比例可占多少 ?
• Resident 不會是ICU care 主力
• Vs + NSP, not NSP alone
An Ideal ICU
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
• A multidisciplinary team to effectively
attain specified objective
• Physician team leader & critical care nurse
manager
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
• 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
• 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
• Open
• Closed
• transitional
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
• 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
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
•
•
•
•
Morbidity (ICU, 30-day, hospital) 
Cost 
Length of stay (ICU, hospital) 
Complication 
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 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
Timely & personal intervention by an
intensivist
No difference from existing literature
• 24hr full time
• 8-12hr /day
• access in a timely period
Discussion
For NTUH SICU:
• Technician team  complex treatment
• SICU CNS
 uncommon in USA
• Communication
• Team dynamics