Intensivists:providing primary care for critically ill patients Pr Georges Offenstadt Medical ICU...

Intensivists:providing primary care for critically ill patients

Pr Georges OffenstadtMedical ICU

Saint Antoine Hospital Paris

What is an ICU ?What is an ICU ?

• An Official text has defined ICU in FranceOfficial text has defined ICU in France

« Décret » April 5th 2002« Décret » April 5th 2002• Minimum requirements :Minimum requirements :

- Number of beds : at least 8 - Number of beds : at least 8 - ICU director certified in intensive care medicine- ICU director certified in intensive care medicine- Physician dedicated solely to the ICU during the - Physician dedicated solely to the ICU during the nightnight- Non medical personnel :- Non medical personnel :

* Patients to nurses ratio : 2.5 / 1* Patients to nurses ratio : 2.5 / 1* Patients to nurses’aides ratio : 4 / 1* Patients to nurses’aides ratio : 4 / 1

Other criteria• Ability to provide :

– Continuous monitoring– Organ support : mechanical ventilation, dialysis

techniques, cardiovascular support,….

• Proximity to other hospital units– Emergency room– Operating room– Radiology department

• Description of the activity– Severity scores– Workload indexes– Case mix

What is the ICU’s contribution to the hospital activity ?

• Besides diagnosis and treatment of patients admitted to the ICU

• To perform procedures for patients not admitted in ICU– Insertion of central venous line– Dialysis– Broncho alveolar lavage or transbronchial biopsy for

hypoxic patients….

• To evaluate patients for ICU admission– Ethical issue

Clinical activity is not restricted to the patients admitted in the ICU

Teaching of critical care in EuropeTeaching of critical care in Europe

– Formal training in ICM : 18/21 countries (85%)Formal training in ICM : 18/21 countries (85%)– No standardisation of curriculum contentNo standardisation of curriculum content– Length of training : 18 to 30 months (median Length of training : 18 to 30 months (median

24 months)24 months)– Access to ICMAccess to ICM specialty specialty

• Multidisciplinary : 57%Multidisciplinary : 57%• Anaesthesia (28%)Anaesthesia (28%)

– Accreditation in ICM : 18 countries Accreditation in ICM : 18 countries • including 12including 12/18/18 with dual registration in a base with dual registration in a base

specialty and in ICM specialty and in ICM

Garcia-Barbero. Crit Care Med 1996, 24 : 696 ,BionGarcia-Barbero. Crit Care Med 1996, 24 : 696 ,Bion. . Intensive care Med 1998, 24 : 372Intensive care Med 1998, 24 : 372..

Partial list of trained physician Partial list of trained physician activitiesactivities

• Coordination of patient careCoordination of patient care• Liaison with: hospital adminLiaison with: hospital adminisistration,physician staff,nursing staff,respiratory tration,physician staff,nursing staff,respiratory

therapist,laboratory ,radiology,department of medicine, surgery, therapist,laboratory ,radiology,department of medicine, surgery, anaesthesia,Clergy:pastoral care….anaesthesia,Clergy:pastoral care….

• Medical consultant both formal and informalMedical consultant both formal and informal• Continuous quality improvementContinuous quality improvement

– CommitteesCommittees– Morbidity and mortality reviewMorbidity and mortality review

• Risk managementRisk management• TeachingTeaching, , Self educationSelf education

• Medical-legal issuesMedical-legal issues• Policy makerPolicy maker• Epidemiology and infection controlEpidemiology and infection control• Resource allocation (includes triage)Resource allocation (includes triage)• ResearchResearch• Technology assessmentTechnology assessment• Computers/Medical information system……Computers/Medical information system……

ScheduleSchedule of of French French ICU physiciansICU physiciansone week survey in 2002, 32 units including 13 teaching one week survey in 2002, 32 units including 13 teaching

hospitalhospital

Type of activity Total Percentage Fellows Full time Dr Professor

Patient care 49 72 67 52 29ICU organisation 5 7 4 5 8Hospital organisation 4 6 1 4 7Self education 6 9 5 5 7Teaching 2 3 1 2 6Research 2 3 2 2 4Total (hours per week) 68 100 80 70 61

No speciaIty has had to try to prove its worth like critical care medicine. When the subspecialties of internaI medicine branched from the generaI medicine services, they were not forced to prove through scientific research that they offered statistical and financiaI benetits to patients, to their colleagues, and to heaIth care in generaI !!!!

Effect of a medical intensivist on patient care

Mathous Mayo Clin Proc 1997, 72 : 391

Full time medical intensivist no yes p

MICU mortality 20.9 14.9 0.02in-hospital mortality 34 24.6 0.002

Mean ICU LOS 5 3.9 <0.05Mean hospital LOS 22.6 17.7 <0.05

Resident test score 53.8% 67.5% <0.01

ExExaample of intensive mple of intensive communication intervention communication intervention

Lilly, Am J Med 2000; 109 : 469Lilly, Am J Med 2000; 109 : 469

• Method : multidisciplinary meetings held within 72 hours of Method : multidisciplinary meetings held within 72 hours of critical care admission : patients, families, critical care critical care admission : patients, families, critical care team. + follow-up meetings to discuss palliative care team. + follow-up meetings to discuss palliative care options when continued advanced supportive technology options when continued advanced supportive technology couldcould not achiev not achievee the patient’s goal. the patient’s goal.

• The implementation of this active communication haThe implementation of this active communication hass – reduced the median LOS (4 vs 3 days; p = 0.01) reduced the median LOS (4 vs 3 days; p = 0.01)

– while the mortality remained the same or even decreasewhile the mortality remained the same or even decreasedd

(31% vs 23%; p = 0.06).(31% vs 23%; p = 0.06).

Impact of organisational Impact of organisational characteristics of ICU to outcomecharacteristics of ICU to outcome

Pronovost , JAMA 1999, 281 : 1310Pronovost , JAMA 1999, 281 : 1310

• Example of abdominal aortic surgery. Example of abdominal aortic surgery.

– Maryland hospitals; 1994-1996Maryland hospitals; 1994-1996– Measure of the impact of not having daily Measure of the impact of not having daily

roundsroundsOR 95% CI

in-hospital mortality 3 [1.9-4.9]Risk of cardiac arrest 2.9 [1.2-7.0]acute renal failure 2.2 [1.3-3.9]septicemia 1.8 [1.2-2.6]platelet transfusion 6.4 [3.2-12.4]reintubation 2 [1-4.1]

Medical staff of French ICUMedical staff of French ICUa 1999 survey of 174 unitsa 1999 survey of 174 units

Type of hospital Non teaching Teaching

ICU (n) 130 44Beds (n) 10.3 19.9LOS (days) 6.6 8.3Mechanical ventilation (%) 53 55

Full time physician (n) 2.7 3.3Part time (n) 0.1 0.7Fellows (n) 0.8 1.8Full time equivalent (n) 3.6 5.8FTE / bed 0.35 0.29

Residents (n) 0.9 3.1

Night dutiesNight dutiesType of hospital Non teaching Teaching

Type of night duties (%) On site (%) 91.5 100 For ICU solely (%) 71 84

Together with resident always (%) 14 47 sometimes (%) 16 32 never (%) 70 21

On calls (%) 27 34

Physicians on the list (%) n 7.6 10.5

% of Dr belonging to the ICU 59 66

Qualification of physicians (%) Medical doctors 95 88

CCM specialists 77 44

The French model,Now!!!

• Maximum working time per week : 48 h, including on nights duties.

• Rest of at least 11 hours after on night duty• Minimum requirements for a 10 beds unit :

– 3 physicians for morning– 2 physicians for afternoon– 1 physician for night

This requires 6.5 FTE per unit

Direct medical costsStudy on 21 french ICUs

(kilo PKR)

Yearly totalCost per ICU

Cost/patient/day

Cost/stay C/bed/day

Mean 285 004 77 466 55

Std deviation

86 217 20 213 14

Lowest 148 743 52 282 37

Highest 499 522 119 979 87

R2 = 0,86

0

1 000 000

2 000 000

3 000 000

4 000 000

5 000 000

6 000 000

7 000 000

0 1 000 2 000 3 000 4 000 5 000 6 000 7 000 8 000

Number of patient days

Tot

al c

ost

(€)

Total cost vs.Number of patient daysUniversity hospitals

Structure of ICU costsStudy on 21 French ICUs

73,2%

32,8%

62,3%

18,0%

5,7%

28,4%

5,6%

17,3%

2,5%11,1%

51,1%

0,3%0%

10%

20%

30%

40%

50%

60%

70%

80%

Staff costs Clinical supportservices

Equipments Consumables

Highest Mean Lowest

Organisational models of ICUsOrganisational models of ICUs• Organisational model :Organisational model :

– Open units : patients remains under the responsibility of the Open units : patients remains under the responsibility of the admitting physicianadmitting physician

– Closed units : medical director and designee screen all Closed units : medical director and designee screen all admissions and discharges and assume direct patient care admissions and discharges and assume direct patient care responsresponsaabilbiliitiesties

• Closed units :Closed units :– Reduction of LOS, morbidity and mortality…….Reduction of LOS, morbidity and mortality…….

– Requires more doctorsRequires more doctors

Analysis of the effect of conversion from open to closed surgical intensive care unit

S Ghorra Ann Surg 1999;229:163

•Data were prospectively collected in all consecutive patients who required ICU admission for >24 hrs in three different periods.

•The first period (open) lasted 5 mos (June to October 1996), during which time one of the investigators prospectively collected data

•The investigator then left to pursue ICU training for 2 yrs.

• The second period (early cIosed) lasted 6 months (November 1998, to April , 1999).

•The third period (late cIosed) lasted 12 months (March 2000 to February 2001).

•Medical lCU of a l,OOO-bed university hospita!, Ankara, Turkey.

Effect of closed unit policy and appointing an intensivist in a developping country

Topeli A Crit Care Med 2005;33;299Topeli A Crit Care Med 2005;33;299

•The unit operated under an open policy forma without an intensivist.

•Attending physicians with a wide variation in medical training admitted and managed patients in the lCU.

• These attending physicians were assisted in the care of the patient admitted to the lCU by one senior resident and three junior from the Department of Medicine.

•An intensivist was not available for consultation or management of patients admitted to the lCU

•No structured teaching was provided to the residents during this period.


Open Policy Period

Closed Policy Period • Newly trained intensivist was appointed, as the director of the lCU and a closed unit policy was simultaneously adopted. The director of the lCU screened aIl admissions and, directIy managed aIl patients with the assistance of one senior medicine resident and three junior medicinresidents. The nurse-to-patient ratio was not affected by the change in policy and remained at one nurse for three to four patients

• Changes in the organization during the closed policy periods included:

•direct supervision by the intensivist of physicians-in-training assigned to the ICU,

• a single team of physicians being responsible for writing orders

•an intensivist ,responsible for integrating input from various consultants;

•continuous training of house staff consisting of bedside teaching during formaI daily rounds; nursing training by the intensivist; active participation of the nursing staff in formaI daily rounds;

• aIl medical care, including setting of mechanicaI ventilation and daily assessmenf of readiness for weaning was provided by the trained intensivist;

• invasive procedures performed by, or under the supervision of, the intensivist;

• avoidance of oversedation; implementation of fIowcharts; and, for the most complex patients, bedside meetings held by the ICU team


SMR = standardized mortality rate (ratio of observed-to-predicted mortality rate)

Period

open early closed late closed

ICU observedmortality

21 % 30 % 40 %

Hospital observed

mortality26 30 % 42 %

Predicted hospital

mortality19 32 38

SMR 1,34 0,95 1,09


How to appreciate the performance of ICUs?

• Few examples

• Which markers should be used?

• How to interpret the results ?

• Specificities of ICU

The percentage of success in the baccalaureate (high school graduation)

• Comparison of two different high schools – A : 100 %– B : 60 %

• Is high school A better than B ?– Different objectives / goals– Different selection criteria– Different areas

Airplanes

• Comparison of two different companies according to the number of crashes and near misses over a 3-year period :– A :

• no crashes • 5 near misses

– B :• one crash with 250 deaths• no near misses

• Would you choose company A or B ?

What is quality according to WHO?

Quality ensures that every single patient receives diagnostics and therapeutics procedures for the best state-of- the-art of medical science, at the best price for a similar result, together with a low iatrogenic risk and patient satisfaction in terms of procedures, results and human relationship.

Only similar institutions can be compared

Performance assessment has to be multidimensional

Volume of activity

• Low level of activity has a negative impact on performance– number of deliveries– coronary angioplasty….

• Is there a too high level of activity ?– higher risk of nosocomial infection?

Mortality• When should mortality been assessed ?

– Hospital discharge – Fixed delay after discharge (d30, d90, d?)

• For all patients or for specific cases ?

• Real question : could the death have been avoided?

LOS• Type of admission• Readmission ?• Early discharge to another hospital ?• Type of hospital ?• Selection criteria ?• Patients’ characteristics ?

• Homeless, drug addicts...• severity

• Assessment of the results ?

Nosocomial Infection is it a marker for quality of care ?

• Data collection ?– What are the procedures used to look for in

infections– completeness of data collection– accuracy

• Definitions used• Adjustment according to case mix• Could the infection have been avoided ?

Performance- Whose point-of-view ?

• Health plan • Accreditation• Payment authorities (social security,

insurance companies, HMO, ...)• Patients• Physicians• Members of the ICU team

Patients

• Mortality• LOS• Satisfaction

– communication between patient and staff– pain relief– lack of complications– improvement of subjective health

• Good long-term quality of life.

Refering physicians

• Admission delay• Quality of patient care• Respect of deontology• Hospitalisation summary

– quality ?– how long after discharge ?

The markers have to be adjusted according to case-mix variables

• Localisation and LOS before transfer to ICU

• Type of patients• Physiological state and co-morbidities• Diagnosis• Severity

In ICUmortality In ICU SMR Hospital

mortalityHospital

SMR

Total 16.6% 0.64 20.6 % 0.78

emergency room or SAMU 14.7 % 0.57 16.7 % 0.66

Hospital units 17.8 % 0.69 26.2 % 0.92

otherhospitals 22.8 % 0.80 24.9 % 0.91

Mortality and SMRaccording to the origin of the patients CUB-REA 1998 ; 34 ICUs ; Paris area

n = 18 698 patients


Keto acidosis 6.6 % 0.36 8.0 % 0.45

Acute asthma 4.8 % 0.48 4.8 % 0.48

Shock 52.2 % 0.96 57.5 % 1.05

ARDS 56.7 % 1.15 56.7 % 1.16

In ICU Mortality In ICU SMR Hospital

mortalityHospital

SMR

Mortality and SMRaccording to diagnosis


Focusing the multiprofessional team on implementing evidence-based care is effective in improving outcomes in critical care and sustaining the results.

Schilling L Crit Connections April 2005Schilling L Crit Connections April 2005

Conclusion performance markers are risky

• It’s impossible to create a single marker of quality that covers different dimensions that allow for a fair ranking of ICUs.

• Several markers should be used– without redundancy– exploring different fields– pertinent– changed every few years

Critical care medicine is no longer a field of anecdotal management, but rather one of peerreviewed evidence-based practice plans.

Intensivists:providing primary care for critically ill patients

We need to work together!!!We need to work together!!!

Intensivists:providing primary care for critically ill patients Pr Georges Offenstadt Medical ICU...

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