Organizational Issues

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CHAPTER 1 ORGANIZATIONAL ISSUES

INTRODUCTION

Modern intensive care originated during the poliomyelitis epidemics of the 1950s, when tracheal intubation and positive pressure ventilation were applied to polio victims, resulting in a substantial improvement in survival. Patients were managed in a specific part of the hospital and received one-to-one nursing care, features that still largely define intensive care units (ICUs) to this day. From these beginnings, there was a gradual development until the ICU was a recognizable component of most general hospitals.

In the early days of intensive care, patients were often young and previously fit, with only single organ failure. If they survived, a full functional recovery could be anticipated. Today, in keeping with the changing structure of society, patients are often elderly and many have complex pre-existing medical problems, which predispose them to develop multiple organ failure during critical illness. As a consequence, the prospects for survival from critical illness are sometimes limited. This, together with the realization of the large costs involved in providing intensive care, typically approaching £2000 per day, has led to debate about how intensive care should be provided in the future. In particular, there is increasing focus on the complex ethical issues that surround admission, provision and discontinuation of intensive care therapy.

Nevertheless, intensive care medicine has become an established and fundamental part of modern health care. Critical illness may arise from a variety of disease processes, but the pathophysiological changes that result lead to common patterns of organ dysfunction. By recognizing these patterns and understanding the interactions between different organ systems, intensive care teams can improve the outcome of critically ill patients. The role of intensive care includes:

Resuscitation and stabilization

Physiological optimization of patients to prevent organ failure

Facilitation of complex surgery

Support of failing organ systems

Recognition of futility.

DEFINITIONS

Traditional definitions of ICUs and high dependency units (HDUs) attempt to separate the functions of each.

Intensive care unit (ICU)

An area for patients admitted for the treatment of actual or impending organ failure, especially those requiring assisted ventilation. There is usually at least one nurse per patient and a doctor assigned solely to the intensive care unit throughout the 24-h period.

High dependency unit (HDU)

An area for patients who require more intensive observation or intervention than can be provided on a general ward, but who do not require assisted ventilation. Nurse-to-patient ratios are generally between those of an ICU and a general ward. There is not usually dedicated medical cover.

There are, however, difficulties with such definitions. In many smaller hospitals for example, the ICU, HDU and coronary care unit (CCU) are often combined in one area, with nursing and medical staff working flexibly as required. Post-anaesthesia care units (PACUs) or recovery rooms may be used to ventilate patients when the ICU is full. Many patients with chronic respiratory disease are now ventilated on respiratory wards, either via face / nasal masks or by long-term tracheostomy.

It is increasingly recognized, therefore, that the level of medical and nursing care received by individual patients should not be a function of their physical location, in an ICU or on the ward, but a function of their clinical condition. This has led to the classification of levels of care for critically ill patients based solely on need.

LEVELS OF CARE

Critically ill patients can be classified according to the level of medical and nursing care required (see Intensive Care Society 2002 Levels of Critical Care for Adult Patients www.ics.ac.uk/icmprof/downloads/icsstandards-levelsofca.pdf) (Table 1.1).

TABLE 1.1 Levels of critical care

Level 0	Patients whose needs can be met by ward-based care in an acute hospital.
Level 1	Patients at risk of their condition deteriorating (including those recently moved from higher levels of care) whose needs can be met on a normal ward with additional advice or support from the critical care team.
Level 2	Patients requiring more advanced levels of observation or intervention than can be provided on a normal ward, including support for a single failing organ system.
Level 3	Patients requiring advanced respiratory support alone or basic respiratory support together with support for at least two organ systems.

Specialist care is recorded by attaching one of the following letters as a suffix.

N – neurosurgical, C – cardiac, T – thoracic, B – burns, S – spinal injury, R – renal, L – liver, A – other specialist care.

Patients should be nursed in an area capable of providing the appropriate level of care. While level 2 care may be provided in an HDU or ICU, true level 3 care can only be provided in a suitably equipped ICU. In reality, these levels of care are not discrete entities, but represent points on a continuum or spectrum. As their condition changes, patients may need a greater or lesser level of care, and frequently move between the defined levels.

IDENTIFICATION OF PATIENTS AT RISK

As the level of care required by an individual patient can change rapidly, it is important that those at risk of deterioration and needing increased levels of care are identified early, so that the appropriate interventions can be instituted.

A number of scoring systems have been developed to help staff detect those patients who are at risk. These are based on the principle that patients develop abnormal physiological parameters as their condition starts to deteriorate. The scoring system can be used by any member of the ward medical or nursing staff and if appropriate, the intensive care outreach team can be called (see below). An example of a typical early warning scoring system is shown in Table 1.2. The response triggered by the scoring system is shown in Table 1.3.

TABLE 1.2 Typical early warning scoring system

TABLE 1.3 Typical response to early warning scoring system

Ward area	Score > 3	Call outreach team
High dependency area	Score > 3 Score > 5	Call responsible medical staff Call outreach team / ICU
Any area	Score > 10	Call outreach Team / ICU

CRITICAL CARE OUTREACH

Outreach is a relatively new concept in critical care. Traditionally, intensive care staff have tended to stay in the ICU and await the referral of patients from other areas by the attending medical staff. It is increasingly recognized, however, that the ICU staff have much to offer critically ill and potentially critically ill patients outside the ICU. This has led to the development of critical care outreach teams.

These teams commonly consist of senior members of medical, nursing and physiotherapy staff from the ICU who provide a liaison service and an immediate point of contact between the ICU and other areas of the hospital. Their roles include:

Identification of patients at risk

Prevention of further deterioration and the need for subsequent ICU admission

Support for level 1 care on the wards

Education and the promotion of critical care skills

Identification of patients unlikely to benefit from ICU admission

Facilitation of discharges from higher levels of care back to the ward.

Once contacted, the outreach team will usually assess a patient and may offer advice and support to ward staff. Early advice on matters such as fluid management and provision of intermediate respiratory support (e.g. physiotherapy / high flow oxygen / CPAP) may prevent further deterioration and enable the care of the patient to continue at ward level (level 1 care). Alternatively, the team may institute more advanced therapy and expedite transfer to an area capable of providing a higher level of care (level 2 or 3).

Occasionally the outreach team may, in consultation with the patient, relatives, and the parent medical team, decide that a patient is unlikely to benefit from intensive care and that admission would not be appropriate (see Limitation of treatment, p. 430).

ADMISSION POLICIES

The aim of intensive care is to support patients while they recover. It is not to prolong life when there is no hope of recovery. Sometimes difficult decisions have to be made about whether or not to admit a patient to intensive care, as there is often a shortage of intensive care beds and a requirement to use the available resources responsibly and equitably. To aid decision making, some units have written admission policies. A typical admission policy is shown in Box 1.1.

Box 1.1 Admission policy

Requests for admission

• Patients will be admitted to ICU who in the opinion of the ICU consultant are likely to benefit from a period of intensive care. Patients in whom further treatment is considered futile will not normally be admitted.

• Requests for admission should be made by contacting the ICU consultant on call. Requests should normally come from a consultant who has seen the patient immediately prior to making a referral.

• In the case of elective surgery where the admission of the patient can be foreseen a request should be made at least 24 hours prior to surgery. The bed should be confirmed immediately prior to commencement of anaesthesia.

Bed management issues

• All problems related to availability of beds will be dealt with initially by the ICU consultant on call, who is in a position to make decisions about the potential admission and the needs of the patients already in the ICU.

• If there are no beds immediately available, the continued provision of care at an appropriate level to the patient remains the responsibility of the staff in attendance, supported where possible by the ICU outreach team.

• Where no ICU bed is available, the ICU consultant may be able to give advice as to the location of other available ICU beds; however, their prime responsibility is to patients already in the ICU.

Joint responsibility

• All patients will be admitted under the care of a named ICU consultant and the ICU team will assume responsibility for the patients care. (Responsibility may be shared jointly with the admitting team.)

Discharges

• Will be arranged by the ICU staff in conjunction with the responsible consultant. In cases of emergency, however, patients may be discharged by the consultant on-call for the ICU.

The difficulty with all admission policies, however, is that it is impossible to predict with complete accuracy which individual patients stand to benefit from admission to intensive care.

In practice, therefore, the decision whether or not to admit a patient to intensive care is usually based on the outcome of multidisciplinary discussion and clinical expertise.

Instantaneous judgements regarding the continuation or withdrawal of treatment from patients in the operating theatre, resuscitation room or on the wards are often difficult and increasingly, lawyers, patient advocates, independent mental capacity advocates (IMCAs) and clinical ethicists are being involved in the most difficult decisions. Senior staff should be involved early on. In many cases, unless the outlook is truly hopeless, patients will be admitted for a trial of treatment to see whether they will stabilize and improve over time.

Additionally, patients with little or no prospect of survival may occasionally be admitted to intensive care. For example, patients from the resuscitation room, or those who have suffered catastrophic complications during surgery, may be admitted even though they are likely to die. This is to facilitate more appropriate terminal care, or to allow the relatives time to visit and the bereavement process to be better managed. This is a justifiable and appropriate use of a critical care facility. Admission policies need, therefore, to be sufficiently flexible to allow the admission of what may seem, on occasion, like inappropriate cases (see Treatment limitation decisions, p. 430).

PREDICTION OF OUTCOME

The difficulties outlined above have led to a wealth of work, using scoring systems, to predict the outcome of patients treated in intensive care. This generally involves the collection of a large amount of data from many patients, stratification of the data to produce a risk score, prospective validation of the score, and its subsequent application to clinical decision making in specific cases. There are, however, major difficulties with this approach:

There is, as yet, no satisfactory diagnostic categorization for intensive care patients. Often the problems relating to intensive care admission bear little relation to the original presenting complaint or diagnostic category.

Although patients may survive to leave the ICU, there is a significant mortality on the wards, and later at home, after leaving intensive care. Many studies use 28-day mortality as an end point. It has been suggested that 6-month or 1-year outcomes of mortality and measures of morbidity (quality of life measures) are better end points.

Scoring systems may accurately predict population outcomes, but are unreliable for prediction in individual cases.

The APACHE II score, for example (see below), which is arguably the best known outcome score, takes into account both acute physiological disturbance and individual pre-existing co-morbidity, and correlates well with the risk of death for the intensive care population as a whole, but does not accurately predict individual mortality.

Attempts have been made using computer modelling to improve the accuracy of outcome prediction models in individual patients. The Riyadh Intensive Care Program, for example, uses daily scores as a basis on which to predict those patients in which further treatment is futile. This approach has, however, failed to gain widespread support.

Severity of illness scoring systems therefore cannot be used to predict individual patient outcomes. Their value lies in the ability to predict accurately the overall mortality expected in a particular intensive care unit based on the local ‘case mix’. The ratio of the actual mortality to the predicted case mix adjusted mortality provides a measure (standardized mortality ratio) by which individual units can be compared for audit purposes. A standardized mortality ratio (SMR) less than 1 implies better than predicted outcomes, whilst a SMR greater than 1 implies a worse than predicted outcome.

In the UK, a scoring system that predicts critical illness outcomes more accurately in a British patient population has been developed by the Intensive Care National Audit and Research Centre (ICNARC). Continuous ongoing data collection will enable the score to be further refined and improved. See National audit databases, p. 15.

APACHE II SEVERITY OF ILLNESS SCORE

The APACHE II (acute physiological and chronic health evaluation) tool is the most widely used severity of illness scoring system in intensive care. While now somewhat dated and originally related to an index population in the United States, it remains widely used because it is well known, reasonably well validated and internationally accepted as a ‘case mix adjustment tool’.

A score is assigned to each patient on the basis of:

worst physiological derangement, occurring in the first 24 h of admission (Table 1.4)

age (Table 1.5)

chronic health status (Box 1.2).

TABLE 1.4 APACHE II

A: Acute physiological derangement score sheet

TABLE 1.5 APACHE II

B: Age points

Box 1.2 APACHE II

C: Chronic Health Score

For patients with severe organ system insuffi ciency or immune compromise, assign scores as shown.
Condition must have been evident prior to this hospital admission and conform to the defi nitions below.
Category	Score
For non-operative or emergency postoperative patients	+5
For elective postoperative patients	+2

Definitions

CVS New York Heart Association Class IV.

Respiratory Chronic restrictive, obstructive or vascular disease resulting in severe exercise restriction, i.e. unable to climb stairs or perform household duties, or documented chronic hypoxia, hypercapnia, secondary polycythaemia, severe pulmonary hypertension or respiratory dependency.

Renal Receiving chronic dialysis.

Liver Biopsy proven cirrhosis and documented portal hypertension, episodes of past upper GI bleeding attributed to portal hypertension or prior episodes of hepatic failure / encephalopathy / coma.

Immunity Decreased resistance to infection, resulting from immunosuppressive therapy, chemotherapy, radiation, long-term or recent high-dose steroids, or has a disease that is suffi ciently advanced to suppress resistance to infection, e.g. leukaemia, lymphoma, AIDS.

ALTERNATIVE SEVERITY OF ILLNESS SCORING SYSTEMS

APACHE III score

The APACHE II score has now been superseded by an updated APACHE III score. Five new variables have been added (urine output, serum albumin, urea, bilirubin and glucose), while two variables (potassium and bicarbonate) have been removed. In addition, the Glasgow Coma Scale and acid–base balance components have been altered. A complex matrix grid scoring system is used with a maximum score of 299.

SAPS

The Simplified Acute Physiology Score is similar to APACHE, and is used more commonly in mainland Europe. It utilizes 12 physiological variables assigned a score according to the degree of derangement.

TISS

The Therapeutic Intervention Score System assigns a value to each procedure performed in the ICU. The implication is that the more procedures that are performed on a patient, the sicker they are. It is dependent on the doctor and unit, however, since different hospitals will have varying thresholds for carrying out many procedures. The score is therefore not good for comparing outcome between patients or between different units, but is useful as a general guide to the type of care and resources likely to be needed by patients on an individual unit.

SOFA score

The Sequential Organ Failure Assessment score tracks changes in the patient’s condition over time. It comprises scores assigned to each of six components: respiratory, cardiovascular, hepatic, neurological, coagulation and renal. These are summed to produce an overall score. A score higher than 11, or between 8 and 11 and not improving, is generally associated with an adverse outcome.

DISCHARGE POLICIES

Discharge policies are just as hard to define as admission policies (above). Patients may be discharged in the following circumstances:

Either: the patient’s condition has improved to the extent that intensive care is no longer required.

Or: the patient’s condition is not improving and the underlying problems are such that continued intensive care is considered futile by staff on the ICU.

In the second of these situations, the patient may either die on the ICU or be transferred back to the ward in anticipation that they will not be resuscitated or readmitted to the ICU if their condition deteriorates further. It is imperative that the referring staff, the patient’s family and, where possible, the patient, agree that such decisions are appropriate and that decisions are clearly documented.

For patients whose condition is improving and for whom discharge is considered, two questions should be asked, as follows.

1. When are patients fit to be discharged?

In simple terms, patients are fit for discharge from intensive care when they no longer require the specialist skills and monitoring available on the ICU. This generally means that they have no life-threatening organ failure and that their underlying disease process is stable or improving. Table 1.6 gives some guidance.

TABLE 1.6 Criteria for discharge from ICU

Airway	Adequate airway and cough to clear secretions (if inadequate, tracheostomy and suction, see below)
Breathing	Adequate respiratory effort and blood gases May be on oxygen (e.g. from face mask) Not requiring CPAP or non-invasive ventilation (unless discharged to HDU or respiratory unit), see below
Circulation	Stable, no inotropes
Neurological function	Adequate conscious level Adequate cough and gag refl exes (if inadequate, e.g. bulbar palsy or brain injury may need tracheostomy to make airway safe and allow suction)
Renal function	Renal function stable or improving Not requiring renal support unless discharged to a unit which performs dialysis
Analgesia	Adequate pain control