ICU Admission and Triage CriteriaPat Melanson, MD McGill University Health CenterRequests for ICU Beds excellent care abundant resources high nurse-patient ratios pharmacists,nutritionist, RTs, etc high tech equipment signs of deterioration quickly identified “give them a chance” discomfort with death convenience Demand frequently exceeds supplyThe “Expensive” Care Unit Canada 8% of total inpatient cost 0.2 % of GNP $1500 per day USA 20 - 28 % of total inpatient cost 0.8 to 1 % of the GNP 1 ICU day = 3 to 6 times non-ICU day Higher costs in non-survivors ICU resources are finiteICU Admission Criteria A service for patients with potentially recoverable conditions who can benefit from more detailed observation and invasive treatment than can be safely provided in general wards or high dependency areasICU Triage admission criteria remain poorly defined identification of patients who can benefit from ICU care is extremely difficult demand for ICU services exceeds supply rationing of ICU beds is commonPrioritization Model Priority 1 critically ill, unstable require intensive treatment and monitoring that cannot be provided elsewhere ventilator support continuous vasoactive infusions mechanical circulatory support no limits placed on therapy high likelihood of benefitPrioritization Model Priority 2 Require intensive monitoring May potentially need immediate intervention No therapeutic limits Chronic co-morbid conditions with acute severe illnessPrioritization Model Priority 3 Critically ill Reduced likelihood of recovery Severe underlying disease Severe acute illness Limits to therapies may be set no intubation, no CPR Metastatic malignancy complicated by infection, tamponade, or airway obstructionPrioritization Model Priority 4 Generally not appropriate for ICU May admit on individual basis if unusual circumstances Too well for ICU mild CHF, stable DKA, conscious drug overdose, peripheral vascular surgery Too sick for ICU (terminal, irreversible) irreversible brain damage, irreversible multisystem failure, metastatic cancer unresponsive to chemotherapyDiagnosis Model Uses specific conditions or diseases to determine appropriateness of ICU admission 48 diagnosis/ 8 organ systems Acute MI with complications cardiogenic shock complex arrhythmias acute respiratory failure status epilepticus, SAHObjectives Parameters Model Vital signs HR 150 SBP 120 RR 35JCAHCOObjectives Parameters Model Laboratory values Sodium 170 Potassium 7.0 PaO2 7.7 Glucose 800 mg/dL Calcium 15 mg/dL toxic drug level with compromiseObjectives Parameters Model Radiologic ICH, SAH, contusion with AMS or focal neuro signs Ruptured viscera, bladder, liver, uterus with hemodynamic instability Dissecting aortaObjectives Parameters Model EKG acute MI with complex arrhythmias, hemodynamic instability, or CHF sustained VT or VF complete heart block with instabilityObjectives Parameters Model Physical findings (acute onset) unequal pupils with LOC burns 10%BSA anuria airway obstruction coma continuous seizures cyanosis cardiac tamponadeICU Admission Criteria Potential or established organ failure Factors to be considered Diagnosis Severity of illness Age and functional status Co-existing disease Physiological reserve Prognosis Availability of suitable treatment Response to treatment to date Recent cardiopulmonary arrest Anticipated quality of life The patients wishesDischarge Criteria physiologic status has stabilized need for ICU monitoring and care no longer necessary physiologic status has deteriorated active interventions no longer plannedIntermediate Care Units monitoring and care of patients with moderate or potentially severe physiologic instability require technical support frequent monitoring of vital signs frequent nursing interventions not necessarily artificial life support do not require invasive monitoring require less care than ICU require more care than general wardIntermediate Care Units 22% of ICU bed days 6180/17440 admissions with less than a 10% risk of requiring active treatment based on this monitoring reduced costs with ICU demonstrated increased patient satisfactionIntermediate Care Units reduces costs reduces ICU LOS no negative impact on outcome improves patient/family satisfactionICU Outcome Studies no difference ICU vs. Ward for CEA femoral bypass GI bleeds drug overdose bone marrow transplants closed units AAAICU Triage Patients should be admitted if they can benefit with decreased risk of death patients with reversible medical conditions who have a “reasonable” prospect of substantial recovery NIH Concensus conferenceICU Triage good prognosis over poor likelihood of benefit life expectancy due to disease anticipated quality of life wishes of patient or surrogate obligations to curr