ICU Management System - SEPSISEASY · 2020. 3. 10. · Admission Discharge Outcome Decision making...

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ICU Management System

Department of Internal Medicine Buddhachinaraj Hospital, Thailand

Ratapum Champunot

Nataya KamsawangPanya Tuandoung

Department of Internal Medicine Buddhachinaraj Hospital, Thailand

Present by…

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We are here !

Buddhachinaraj Phitsanulok Hospital

• Tertiary care Hospital• University affliliate Hospital • 900 Beds

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If I have seen a little furtherIt is by standing on the shoulders of Giants

Isaac Newton

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Ms.Panya Tuandoung

Ms. Nataya KamsawangMe Too!

Intensive care units (ICU)

Places in the hospital where the most seriouslyill patients are cared for by specially trained staff

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Nursing support

Special type of Equipment

specially trained staff

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ICU Resource and Performance

• ICU MED1 = 9 beds (can add 1 bed fast-track)

• ICU MED2 = 10 beds (can add 2 beds fast-track)

• ICU MED3 = 10 beds (can add 2 beds fast-track)

• CCU = 12 beds (can add 2 beds fast-track)

• SubICUMED=11 beds (can add 2 beds fast-track)

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ICU Resource and Performance

• ICU surgery = 10 beds

• ICU CVT = 10 beds

• ICU neurosurgery = 14 beds

Performance Review

AdmissionDischargeOutcomeDecision making process

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The Criteria Admit to ICU

• Prioritization model• Diagnosis model• Objective parameters model

Admission and discharge of critically ill patients.Current Opinion in Critical Care 2010,16:499–504

Prioritization model

Priority 1Priority 2Priority 3Priority 4

Task Force of the American College of Critical Care Medicine.Society of Critical Care Medicine. Guidelines for intensive care unit admission, discharge and triage. Crit Care Med 1999; 27:633–638.

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Diagnosis model

ICU

General Ward

Crit Care Med 1999; 27:633–638

Objective parameters model

• Vital signs• Laboratory values• Radiography/ultrasound/Tomography• EKG• Physical findings

Crit Care Med 1999; 27:633–638

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Patients who do not take benefitfrom the ICU

‘Too sick to benefit’

‘Too well to benefit’

ICU Admission centerICU Admission center

Take responsibility for screening patients from waiting lists and Fast-track patients from ER department

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IPD patients Computer-based waiting listFast-track pathway by direct calling

Emergency Department patientsFast-track pathway by direct calling

Dr.Witsanu Sirichote

Leader of Center of computer managementBuddhachinaraj Hospital, Thailand

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Part 1 General data and check-list criteria

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Criteria for ICU admissionCriteria for ICU admission

Acute respiratory failure

Shock that need vasopressor

ARDS

Status Epilepticus

Hypertensive crisis

Massive Hemoptysis

Severe intoxication

Thyroid storm

Others

Criteria for admission SUB ICUMed

• Chronic Respiratory failure

• AKI that need Peritoneal dialysis

• DKA,HHNK

• Severe UGIH

• Pt. close obseve ect. Weaning off tube

• Others

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Part 2 severity score

MEWS score

Part 2 severity score

MPM II score

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WARD

ICU

ICU and general ward can see situation of each other

Available bed Ongoing process

Summary of data in waiting list ICU/Sub ICU

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Fast-track ER• Set criteria for Fast-track ER department• Pass to the ICU directly in condition that ICU bed is

available

ER ICU

1.1 Acute Respiratory Failure เชน ARDS ,

COPD with AE, asthmatic attack , pneumonia

1.2 Septic shock and severe sepsis

1.3 Shock that need vasopresser

1.4 Stroke Fast Track

Fast track ER

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หอผปวยหนกอายกรรม

( Fast track ICU Med )

Criteria การรบผปวยจาก ER1.1 Acute Respiratory Failure เชน ARDS ,

COPD c AE, asthmatic attack , pneumonia

1.2 Septic shock และ severe sepsis

1.3 Shock ทไมดขนหลง resuscitate volume

และตองใช vasopresser

1.4 Stroke Fast Track

STEMI

คาจากดความ กลมงานอายรกรรม ไดกาหนดเกณฑการรบผ ปวยจาก ER เขาICU Med ในระบบ fast track

ไมตองผานเขา IPD โดยกรณท ICU เตยงวางใหรบผ ปวยไดเลย

แตกรณท ICU เตยงเตมใหเปดเตยงท 9 ตาม criteria ทกาหนดไว

ICU admission centerมกราคม - เมษายน ICU 2 โทร 1877/1413

พฤษภาคม - สงหาคม ICU 3 โทร 1878/1427

กนยายน - ธนวาคม ICU 1 โทร 1879/1875

ccuโทร 1876/1400

พบผปวยตาม Criteria

Admit ตามระบบ

Fast track ไดเลย

Poster at ER department

Admission


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Performance Review


Clinical appropriateness ofDischarge from ICU

• Reversal of acute pathological condition• Lack of expectations of reversal• Expected benefits of transfer

Admission and discharge of critically ill patients.Current Opinion in Critical Care 2010,16:499–504

Early discharge VS Late discharge

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Performance Review


SCOREII

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General data

Chronic health score

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Acute Physiologic score

Result and Analysis

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Outcome Assessment

• Severity adjusted outcomes should be utilized whenever possible in order to minimize the effect of severity of illness on raw mortality data, independent of policy or care standards

• Database able to track these and other variables would be extremely useful

Guidelines for ICU Admission, Discharge, and Triage. American College of Critical Care Medicine of the Society of Critical Care MedicineCrit Care Med 1999 Mar; 27(3):633-638

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0

10

20

30

40

50

60

70

80

90

0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 > 40

Apache score: Actual death & Predicted death ICUMED

2006

Actual death Predicted death

Actual death more than Predicted death

Performance improvement process

1.ลงขอมลใหครบทกราย

2.ทบทวน

1.ลงขอมลโดย RN

2.สงรายชอ Peer review กบแผนก

1.ขอมลไมถกตอง

2.Peer review ไดไมครบ

3.อตราตายลดลงแตยง>predicted death

1. ปรบปรงการลงขอมล

2.peer review เอง

3.พฒนาความรเรอง ventilator

และการดแลผปวย septic shock

วงลอท1วงลอท1P

D

S

A

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Develop Care Map

การประเมนผปวย

การใหขอมลและเสรมพลงการเขาถงและเขารบบรการ การวางแผน

การดแลตอเนอง การดแลผปวย

3.1วางแผนการดแลผปวย

3.2วางแผนจาหนาย

4.1 การดแลทวไป

4.2 การดแลทมความเสยงสง

4.3 การดแลเฉพาะ

Performance

parameter

Performance

parameter

Parameter Tool Aim

Performance

improvement target

Mortality rate of pt.

APACHE<20

predicted dead<30%

<5%

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0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 > 40

Apache II score

0 0 1.16 2.48 3.03

13.85

54.84

72.84

85.56

3.68 6.1712.91

26.62

43.58

58.36

75.2184.63

93.95

Apache score ICUMED 2007

Actual death Predicted death

Actual death less than Predicted death

2008

Actual death less than Predicted death

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Parameter Aim

Mortality rate of pt. APACHE <20

predicted dead <30% <5%

Unexpected death rate 0

Event rate of risk level G,H,I 0

Performance

Other performance parameter in ICU

อตราผปวยหนกทมคะแนน Apache II score > 20 , Risk of death > 31 68.33 %อตราตายผปวยหนกทมคะแนน Apache II score< 20 , Risk of death < 30 2.25 %อตราการ readmit ในICU ภายใน 3 วน 0.92 %ET tube day (วน/คน)

Min 1.00 วน

Max 20.03 วน

LOSผปวยทม Apache II score>20,Risk>30 4.31 วน

ผปวยทม Apache II score<20,Risk<30 3.52 วน

ประสทธภาพการดแลผปวย Sepsis & Septic shock อตราผปวยหนกทได Resucitate time < 6hr 48.25 %

อตราตายผปวย sepsis and septic shock ทม Apache<20,Risk<30 3.06 %จานวนผปวยทนอนนาน > 7 วน 75.67อตราการเกดทอชวยหายใจหลด 13.57จานวนการเกด Risk ระดบ GHI 0.00อตราการเกด VAP 13.11จานวนการเกด Unexpected death 0.37

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วงลอท3ดแลผปวยตามแนวทางท

กาหนดไว

รวมกนของสหวชาชพ

1.ใชCPG ดแลผปวย sepsis/WHAP/DUE

2.ใชWI-ARCAในการบรหารความเสยง

3.พฒนาcompetencyและจรยธรรมใหเจาหนาท

4.เขารวมกจกรรมพฒนาคณภาพของ PCTและโรงพยาบาล

1. actual death<predicted death

ในทกชวงคะแนน

2. ไมพบ unexpected death & risk GHI

Maintenance การปฎบตใหคงอย

และmonitor อยางตอเนอง

P

D

S

A

Development of performance review in ICUDevelopment of performance review in ICU

• ICU committee develop and review objectives of all

parameters in each ICU

• Develop care map of top 5 diseases in ICU

• Review performance of each ICU by using Apache II score

• Develop CPG in ICU eg. Sepsis, Weaning, WHAP

(prevent VAP)

54

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Critical Care Triage

Triage ( /ˈtriːɑːʒ/ (UK English) or /triːˈɑːʒ/ (US English))

• Process of determining the priority of patients' treatments based on the severity of their condition

• Treatment efficiently when resources are insufficient for all to be treated immediately

Number of potential ICU patients exceeds the available beds

Critical Care Triage

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MEWS scoreSOS score

• Early warning score(EWS) was developed as a track and trigger tool

• Not all unwell patients can be monitored on intensive care or high dependency units

• Deteriorating patients can be identified(Before too profound)

BACKGROUND AND RATIONALE

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PUP (Physiologically unstable patient) score

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SOS score (search out sepsis score)

score 3 2 1 0 1 2 3temp ≤35 35.1-36 36.1-38 38.1-38.4 ≥38.5

Sys BP ≤80 81-90 91-100 101-180 181-199 ≥200 On vasopressor

HR ≤40 41-50 51-100 100-120 121-139 ≥140

RR ≤8 On ventilator

9-20 21-25 26-35 ≥35

Neuro New ConfusionAgitation

AAlert

VRespond to voice

PRespond to pain

Uunresponsiveness

Urine/dayหรอ

Urine/8 hrหรอ

Urine/4 hrหรอ

Urine/1 hr

≤500≤160≤80≤20

501-999161-31981-15921-39

≥ 1,000≥ 320≥160≥40

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Nurse assistance

Nurse Physician

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Performance Review


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Reasons and Rates of Perceived Inappropriateness of Care Reported by Clinicians

“Too much care”290 situations [65%; 95%CI, 58%-73%]

JAMA. 2011;306(24):2694-2703

APPROPRICUS study

“Other patients would benefit more” 168 situations[38%; 95%CI, 32%-43%]

≠

APPROPRICUS studyJAMA. 2011;306(24):2694-2703

• Lack of participation in decision making

• Persistent nonadherence of the patient

• Lack of accurate information giving

• Perceptions of poor-quality patient care

• Disregarding a patient’s wishes

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Put the right patient to the right place ,right time and

right therapy

ICU Management System - SEPSISEASY · 2020. 3. 10. · Admission Discharge Outcome Decision making...

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