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

Intensivists:providing primary care for critically ill patients Pr Georges Offenstadt Medical ICU Saint Antoine Hospital Paris. What is an ICU ?. An Official text has defined ICU in France « Décret » April 5th 2002 Minimum requirements : - Number of beds : at least 8

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

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  1. Intensivists:providing primary care for critically ill patients Pr Georges Offenstadt Medical ICU Saint Antoine Hospital Paris

  2. What is an ICU ? • AnOfficial text has defined ICU in France « Décret » April 5th 2002 • Minimum requirements : - Number of beds : at least 8 - ICU director certified in intensive care medicine - Physician dedicated solely to the ICU during the night - Non medical personnel : * Patients to nurses ratio : 2.5 / 1 * Patients to nurses’aides ratio : 4 / 1

  3. 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

  4. 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

  5. Teaching of critical care in Europe • Formal training in ICM : 18/21 countries (85%) • No standardisation of curriculum content • Length of training : 18 to 30 months (median 24 months) • Access to ICM specialty • Multidisciplinary : 57% • Anaesthesia (28%) • Accreditation in ICM : 18 countries • including 12/18 with dual registration in a base specialty and in ICM Garcia-Barbero. Crit Care Med 1996, 24 : 696 ,Bion. Intensive care Med 1998, 24 : 372.

  6. Partial list of trained physician activities • Coordination of patient care • Liaison with: hospital administration,physician staff,nursing staff,respiratory therapist,laboratory ,radiology,department of medicine, surgery, anaesthesia,Clergy:pastoral care…. • Medical consultant both formal and informal • Continuous quality improvement • Committees • Morbidity and mortality review • Risk management • Teaching, Self education • Medical-legal issues • Policy maker • Epidemiology and infection control • Resource allocation (includes triage) • Research • Technology assessment • Computers/Medical information system……

  7. Schedule of French ICU physiciansone week survey in 2002, 32 units including 13 teaching hospital

  8. 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 !!!!

  9. Effect of a medical intensivist on patient careMathous Mayo Clin Proc 1997, 72 : 391

  10. Example of intensive communication intervention Lilly, Am J Med 2000; 109 : 469 • Method : multidisciplinary meetings held within 72 hours of critical care admission : patients, families, critical care team. + follow-up meetings to discuss palliative care options when continued advanced supportive technology could not achieve the patient’s goal. • The implementation of this active communication has • reduced the median LOS (4 vs 3 days; p = 0.01) • while the mortality remained the same or even decreased (31% vs 23%; p = 0.06).

  11. Impact of organisational characteristics of ICU to outcomePronovost , JAMA 1999, 281 : 1310 • Example of abdominal aortic surgery. • Maryland hospitals; 1994-1996 • Measure of the impact of not having daily rounds

  12. Medical staff of French ICUa 1999 survey of 174 units Type of hospital Non teaching Teaching ICU (n) 130 44 Beds (n) 10.3 19.9 LOS (days) 6.6 8.3 Mechanical ventilation (%) 53 55 Full time physician (n) 2.7 3.3 Part time (n) 0.1 0.7 Fellows (n) 0.8 1.8 Full time equivalent (n) 3.6 5.8 FTE / bed 0.35 0.29 Residents (n) 0.9 3.1

  13. Night duties Type 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

  14. 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

  15. Direct medical costsStudy on 21 french ICUs(kilo PKR)

  16. Total cost vs.Number of patient daysUniversity hospitals

  17. Structure of ICU costsStudy on 21 French ICUs 80% 73,2% 70% Highest Mean Lowest 62,3% 60% 51,1% 50% 40% 28,4% 32,8% 30% 20% 18,0% 17,3% 5,6% 10% 11,1% 5,7% 2,5% 0% 0,3% Staff costs Clinical support Equipments Consumables services

  18. Organisational models of ICUs • Organisational model : • Open units : patients remains under the responsibility of the admitting physician • Closed units : medical director and designee screen all admissions and discharges and assume direct patient care responsabilities • Closed units : • Reduction of LOS, morbidity and mortality……. • Requires more doctors

  19. Analysis of the effect of conversion from open to closed surgical intensive care unit S Ghorra Ann Surg 1999;229:163

  20. Effect of closed unit policy and appointing an intensivist in a developping country • Medical lCU of a l,OOO-bed university hospita!, Ankara, Turkey. • 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). Topeli A Crit Care Med 2005;33;299

  21. Open Policy Period • 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. Topeli A Crit Care Med 2005;33;299

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

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

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

  25. SMR = standardized mortality rate (ratio of observed-to-predicted mortality rate) Topeli A Crit Care Med 2005;33;299

  26. How to appreciate the performance of ICUs? • Few examples • Which markers should be used? • How to interpret the results ? • Specificities of ICU

  27. 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

  28. 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 ?

  29. 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.

  30. Only similar institutions can be compared Performance assessment has to be multidimensional

  31. 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?

  32. 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?

  33. 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 ?

  34. 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 ?

  35. Performance- Whose point-of-view ? • Health plan • Accreditation • Payment authorities (social security, insurance companies, HMO, ...) • Patients • Physicians • Members of the ICU team

  36. Patients • Mortality • LOS • Satisfaction • communication between patient and staff • pain relief • lack of complications • improvement of subjective health • Good long-term quality of life.

  37. Refering physicians • Admission delay • Quality of patient care • Respect of deontology • Hospitalisation summary • quality ? • how long after discharge ?

  38. 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

  39. Mortality and SMRaccording to the origin of the patients CUB-REA 1998 ; 34 ICUs ; Paris arean = 18 698 patients In ICU mortality In ICU SMR Hospital mortality Hospital SMR 16.6% 0.64 20.6 % 0.78 Total emergency room or SAMU 14.7 % 0.57 16.7 % 0.66 Hospital units 17.8 % 0.69 26.2 % 0.92 other hospitals 22.8 % 0.80 24.9 % 0.91 SMR = standardized mortality rate (ratio of observed-to-predicted mortality rate)

  40. Mortality and SMRaccording to diagnosis In ICU Mortality In ICU SMR Hospital mortality Hospital SMR 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 SMR = standardized mortality rate (ratio of observed-to-predicted mortality rate)

  41. 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 2005

  42. 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

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

  44. Intensivists:providing primary care for critically ill patients We need to work together!!!

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