ICU scoring systems and ICU
administration
Panel discussion
A 14 year old child is brought to the ER by ambulance
complaining of abdominal pain after traumatic injury [MVC]
pt was a belted back seat passenger. The pt on initial review
is noted to have pancreatic injury without duct disruption.
What is the disposition of this patient?
1.
2.
3.
4.
Admit to the ICU
Keep the patient indefinitely in the ER
Admit to the wards
I don’t know
What ICU scoring system would you use in
this setting?
1.
2.
3.
4.
APACHE 2
Ranson’s criteria
Injury Severity Score
I would just use my clinical judgement [no
ICU scoring system]
ICU admission, Discharge and
Triage Criteria
How do you make a determination
for ICU admission?
1. We have formal criteria for ICU admission
and discharge.
2. We make use of scoring systems as indicators
of severity of illness in a prospective manner
3. We only make clinical judgments on whether
the patient needs to be admitted to the ICU
Levels of Recommendations
for the Intensive Care Unit
• Rating system
– Level 1: Convincingly justifiable on scientific
evidence alone
– Level 2: Reasonably justifiable by available
scientific evidence and strongly supported by
expert critical care opinion
– Level 3: Adequate scientific evidence is
lacking but widely supported by available data
and critical care expert opinion
A 15 year old male s/p motor vehicle crash is
noted to be hypotensive after admission to the
ER. He was intubated by the emergency medical
technicians prior to arrival in the ER.
In the ER, resuscitation is initiated and the
patient is noted to have
1. a small hemopneumothorax [managed with
Chest tube]
2. A small splenic laceration [managed nonoperatively]
3. Respiratory failure [managed with intubation
and mechanical ventilation]
Hospital course
• The patient develops VAP
• Despite being treated with appropriate antibiotics the patient continues with respiratory
failure
• The patient subsequently develops renal
dysfunction followed by failure requiring
dialysis
• Despite full resuscitative efforts the patient
dies 2 weeks after admission with MOFS
You are now reviewing this case as
part of the QI process at your
hospital. Was this mortality:
1. Preventable
2. Potentially preventable
3. Non-preventable
Critical care delivery in the intensive care
unit: Defining clinical
roles and the best practice model
• Multidisciplinary care models– presence of a team of health professionals from
various disciplines, working in concert, may
improve efficiency, outcome, and the cost of care
for patients hospitalized in the ICU
Intensivist
• The intensivist is responsible for coordinating
and providing integrated care to the patient
with acute and chronic complex illnesses.
– Proximity to the patient is required
– When multiple consultants are involved, the
intensivist, acting as the multispecialty team
leader, coordinates the care provided by the
consultants, thus providing an integrated approach
to the patient and family.
Do you find that you are able to work with
consultants even when you override their
recommendations?
1. Yes, but I pay a price in political capital within
my institution
2. I feel that I am unable to override their
recommendations
3. Consultants feel inhibited in my ICU and
often simply agree with my management.
Intensivist
• Administrative responsibilities:
– Patient triage based on admission and discharge criteria,
bed allocation, and discharge planning
– Development and enforcement of, in collaboration with
other ICU team disciplines, clinical and administrative
protocols that are intended to improve the safe and efficient
delivery of clinical care and to meet regulatory
requirements;
– Coordination and assistance in the implementation of
quality improvement activities within the ICU.
What are the greatest pitfalls
which you face with regard to
administrative responsibilities?