1. بسم الله الرحمن الرحیم

2. By: Dr.Roushanfekr Anesthesiologist 2015

3.  The relative risk for hospital mortality was reduced by 29% and for ICU mortality was reduced by 39% with high-intensity staffing.  By the year 2030,only 30% of the intesivists needed will be available to staff ICUs.  0.5% to 1% of the U.S. gross domestic product is spent on critical care, and patients 65 years of age and older make up over 50% of all ICU admissions.

4.  Considering the magnitude of this expense, extensive research has focused on how the most cost-effective care can be delivered.  With an aging population and increasing availability of medical technology, ICUs have become a critical component of modern hospital care.

5.  The practice of critical care medicine, which originated in the 1940s with anesthesiologists providing life support to patients with poliomyelitis, has undergone revolutionary changes.  The development of new equipment, procedures, and medications has enabled intensivists to treat critically ill patients and support them through increasingly invasive procedures.

6.  In the past decade, another revolution has taken place, the introduction of evidence- based medicine into (ICU) practice.  intensivist staffing might lead to improved outcomes, specifically through the implementation of evidence-based practices.  Particular attention is paid to the implementation and cost-effectiveness of new clinical practices.

7.  Considering the magnitude of expense, extensive research has focused on how the most cost-effective care can be delivered.  ICUs as open wards : where any physician could admit patients.  ICUs as closed wards : Most ICUs now have a designated medical director who is responsible for the overall management of patient care and policies.

8. 1. Open ICU versus closed ICU 2. Medical ICU & Surgical ICU 3. Full-time intensivist 4. The consultant intensivist 5. Multiple consultants 6. The single-physician without intensivist 7. Larger hospitals versus smaller hospitals 8. Economic inasmuch & quality & mortality

9.  Care of critically ill patients has been revolutionized by technology and drug development and the application of evidence- based medicine to critical care practice.  ARDS are mechanically ventilated with larger- smaller TV (12 ↔ 6 mL/kg IBW)→ improve oxygenation ratio↔significantly higher mortality rates  → randomized, prospective trials

10.  Each ICU should have a physician who is board certified or board eligible in critical care medicine.  to ensure the quality and safety of patient care in the ICU: 1- patient triage decisions 2- education of house staff members 3- development of clinical protocols 4- and improvement of performance  Anesthesiologists for surgical&Internist for medical ICUs  Salary support by hospital

11. 1. Triage of admissions and discharges 2. Development of treatment protocols or guidelines 3. Collection of data 4. Involvement in unit budget approval 5. Updating of equipment and unit practices 6. Promotion of efficient use of material and personnel resources 7. Responsibility for coordination and dissemination of continuing education of hospital- and ICU-based personnel

12.  intensivists will continue to direct the care of only one third of critically ill patients.  the proportion of patients in the ICU whose care is directed by an intensivist were to increase to two thirds, then the large potential growth in utilization of intensivist services represents a shortage of 1500 critical care providers.

13.  Anesthesiologists accounted for only 6.1% of all intensivists in the workforce  In America, Reimbursement for critical care services is generally less than that for surgical anesthesia services.  In Europe, where such a payment discrepancy between the surgical unit and the ICU does not exist.  In Australia and New Zealand, critical care training has become a separate specialty with its own residency.

14.  For general and subspecialty patient populations, most studies suggest that an intensivist should provide care to critically ill patients.  In addition to increased mortality (threefold),the patients not seen by an intensivist also had an increased risk for cardiac arrest, renal failure, septicemia, platelet transfusion, and reintubation.  intensivists should be continually present in ICUs even overnight.

15.  a safe and effective alternative : nurse practitioners (NPs) and physician assistants (PAs), under the supervision of attending physicians.

16.  One approach to lowering ICU mortality and improving quality is to optimize the organization of ICU services.  The multidisciplinary model approach is to complement intensivist staffing with nurses, respiratory therapists, clinical pharmacists, and other staff members who can provide critical care as a team.

17.  The exact number of nurses needed to produce the best patient outcomes is not known.  Many factors may affect patient outcomes, and nurse staffing is only one potential contributor.  Some hospitals prefer flexible scheduling, meaning ICU nurses are scheduled on the basis of anticipated workload in the unit at the start of the shift.

18.  as a result of contributions to medication safety, improved patient outcomes, reduced drug costs, and house staff education.  Their most important benefit is the potential to decrease adverse drug events: from 10.4 per 1000 patient days to 3.5 per 1000 patient days.

19.  improves compliance with weaning protocols and decreases the duration of mechanical ventilation.  reduced the rate of ventilator-associated pneumonia (VAP) from 4.3 per 1000 ventilator days to 1.2 per 1000 ventilator days.

20.  it is an attractive alternative  less than 15% of ICUs continue to have dedicated intensivist coverage.  Overall, the available data suggest that eICUs can have the most impact and improve outcomes in ICUs that initially begin with a deficit in intensivist coverage or have a need to supplement current coverage levels, have high severity-adjusted mortality and LOS rates.

21.  Hospitals must customize the protocols to fit their practices, but protocols should not be used in place of good clinical judgment.  They should be used as a complementary tool, and physicians should be able to justify departures from the protocol.  Despite the limitations, when applied to large populations of patients, practice protocols usually decrease mortality and reduce costs.

24.  Protocols should be devised with the intention: 1. improving the quality of patient care 2. improving patient outcome 3. the efficiency of care 4. While at the same time, decreasing practice variation and costs.

25. 1. percentage of patients with ventilator- associated Complications 2. percentage of patients with resistant infections 3. percentage of patients with CVC infections 4. number of complications per patient 5. average days of mechanical ventilation 6. rate of GE bleeding 7. average intensive care unit length of stay 8. patient satisfaction

26. 1. enhancing quality of care 2. improving efficiency 3. decreasing cost 4. decreasing errors 5. enabling rigorous clinical research

27.  “‘Evidence based medicine’ is a phrase that is currently familiar to only a few doctors, but all will know it by the millennium.”  “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. ”

29.  Some investigators have advocated systematic development of checklists to remind team members of the multitude of goals for every patient, rather than increased protocol generation.  An example is the FASTHUG : F: Feeding A: Analgesia S: Sedation T: Thromboprophylaxis H: Head of bed elevation U: Ulcer prophylaxis G: Glycemic control