ICU scoring systems and ICU administration

1. ICU scoring systems and ICU administration Panel discussion

2. 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? • Admit to the ICU • Keep the patient indefinitely in the ER • Admit to the wards • I don’t know

3. What ICU scoring system would you use in this setting? • APACHE 2 • Ranson’s criteria • Injury Severity Score • I would just use my clinical judgement [no ICU scoring system]

4. ICU admission, Discharge and Triage Criteria

5. How do you make a determination for ICU admission? • We have formal criteria for ICU admission and discharge. • We make use of scoring systems as indicators of severity of illness in a prospective manner • We only make clinical judgments on whether the patient needs to be admitted to the ICU

6. 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

7. 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 non-operatively]3. Respiratory failure [managed with intubation and mechanical ventilation]

8. Hospital course • The patient develops VAP • Despite being treated with appropriate anti-biotics 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

9. You are now reviewing this case as part of the QI process at your hospital. Was this mortality: • Preventable • Potentially preventable • Non-preventable

10. Critical care delivery in the intensive care unit: Defining clinicalroles 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

11. 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.

12. Do you find that you are able to work with consultants even when you override their recommendations? • Yes, but I pay a price in political capital within my institution • I feel that I am unable to override their recommendations • Consultants feel inhibited in my ICU and often simply agree with my management.

13. 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.

14. What are the greatest pitfalls which you face with regard to administrative responsibilities?