icu management system - sepsiseasy · 2020. 3. 10. · admission discharge outcome decision making...
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ICU Management System
Department of Internal Medicine Buddhachinaraj Hospital, Thailand
Ratapum Champunot
Nataya KamsawangPanya Tuandoung
Department of Internal Medicine Buddhachinaraj Hospital, Thailand
Present by…
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We are here !
Buddhachinaraj Phitsanulok Hospital
• Tertiary care Hospital• University affliliate Hospital • 900 Beds
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If I have seen a little furtherIt is by standing on the shoulders of Giants
Isaac Newton
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Ms.Panya Tuandoung
Ms. Nataya KamsawangMe Too!
Intensive care units (ICU)
Places in the hospital where the most seriouslyill patients are cared for by specially trained staff
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Nursing support
Special type of Equipment
specially trained staff
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ICU Resource and Performance
• ICU MED1 = 9 beds (can add 1 bed fast-track)
• ICU MED2 = 10 beds (can add 2 beds fast-track)
• ICU MED3 = 10 beds (can add 2 beds fast-track)
• CCU = 12 beds (can add 2 beds fast-track)
• SubICUMED=11 beds (can add 2 beds fast-track)
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ICU Resource and Performance
• ICU surgery = 10 beds
• ICU CVT = 10 beds
• ICU neurosurgery = 14 beds
Performance Review
AdmissionDischargeOutcomeDecision making process
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The Criteria Admit to ICU
• Prioritization model• Diagnosis model• Objective parameters model
Admission and discharge of critically ill patients.Current Opinion in Critical Care 2010,16:499–504
Prioritization model
Priority 1Priority 2Priority 3Priority 4
Task Force of the American College of Critical Care Medicine.Society of Critical Care Medicine. Guidelines for intensive care unit admission, discharge and triage. Crit Care Med 1999; 27:633–638.
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Diagnosis model
ICU
General Ward
Crit Care Med 1999; 27:633–638
Objective parameters model
• Vital signs• Laboratory values• Radiography/ultrasound/Tomography• EKG• Physical findings
Crit Care Med 1999; 27:633–638
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Patients who do not take benefitfrom the ICU
‘Too sick to benefit’
‘Too well to benefit’
ICU Admission centerICU Admission center
Take responsibility for screening patients from waiting lists and Fast-track patients from ER department
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ICU Admission centerICU Admission center
IPD patients Computer-based waiting listFast-track pathway by direct calling
Emergency Department patientsFast-track pathway by direct calling
Dr.Witsanu Sirichote
Leader of Center of computer managementBuddhachinaraj Hospital, Thailand
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Part 1 General data and check-list criteria
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Criteria for ICU admissionCriteria for ICU admission
Acute respiratory failure
Shock that need vasopressor
ARDS
Status Epilepticus
Hypertensive crisis
Massive Hemoptysis
Severe intoxication
Thyroid storm
Others
Criteria for admission SUB ICUMed
• Chronic Respiratory failure
• AKI that need Peritoneal dialysis
• DKA,HHNK
• Severe UGIH
• Pt. close obseve ect. Weaning off tube
• Others
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Part 2 severity score
MEWS score
Part 2 severity score
MPM II score
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WARD
ICU
ICU and general ward can see situation of each other
Available bed Ongoing process
Summary of data in waiting list ICU/Sub ICU
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Fast-track ER• Set criteria for Fast-track ER department• Pass to the ICU directly in condition that ICU bed is
available
ER ICU
1.1 Acute Respiratory Failure เชน ARDS ,
COPD with AE, asthmatic attack , pneumonia
1.2 Septic shock and severe sepsis
1.3 Shock that need vasopresser
1.4 Stroke Fast Track
Fast track ER
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หอผปวยหนกอายกรรม
( Fast track ICU Med )
Criteria การรบผปวยจาก ER1.1 Acute Respiratory Failure เชน ARDS ,
COPD c AE, asthmatic attack , pneumonia
1.2 Septic shock และ severe sepsis
1.3 Shock ทไมดขนหลง resuscitate volume
และตองใช vasopresser
1.4 Stroke Fast Track
STEMI
คาจากดความ กลมงานอายรกรรม ไดกาหนดเกณฑการรบผ ปวยจาก ER เขาICU Med ในระบบ fast track
ไมตองผานเขา IPD โดยกรณท ICU เตยงวางใหรบผ ปวยไดเลย
แตกรณท ICU เตยงเตมใหเปดเตยงท 9 ตาม criteria ทกาหนดไว
ICU admission centerมกราคม - เมษายน ICU 2 โทร 1877/1413
พฤษภาคม - สงหาคม ICU 3 โทร 1878/1427
กนยายน - ธนวาคม ICU 1 โทร 1879/1875
ccuโทร 1876/1400
พบผปวยตาม Criteria
Admit ตามระบบ
Fast track ไดเลย
Poster at ER department
Admission
ICU Admission centerICU Admission center
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Performance Review
AdmissionDischargeOutcomeDecision making process
Clinical appropriateness ofDischarge from ICU
• Reversal of acute pathological condition• Lack of expectations of reversal• Expected benefits of transfer
Admission and discharge of critically ill patients.Current Opinion in Critical Care 2010,16:499–504
Early discharge VS Late discharge
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Performance Review
AdmissionDischargeOutcomeDecision making process
SCOREII
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General data
Chronic health score
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Acute Physiologic score
Result and Analysis
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Outcome Assessment
• Severity adjusted outcomes should be utilized whenever possible in order to minimize the effect of severity of illness on raw mortality data, independent of policy or care standards
• Database able to track these and other variables would be extremely useful
Guidelines for ICU Admission, Discharge, and Triage. American College of Critical Care Medicine of the Society of Critical Care MedicineCrit Care Med 1999 Mar; 27(3):633-638
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0
10
20
30
40
50
60
70
80
90
0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 > 40
Apache score: Actual death & Predicted death ICUMED
2006
Actual death Predicted death
Actual death more than Predicted death
Performance improvement process
1.ลงขอมลใหครบทกราย
2.ทบทวน
1.ลงขอมลโดย RN
2.สงรายชอ Peer review กบแผนก
1.ขอมลไมถกตอง
2.Peer review ไดไมครบ
3.อตราตายลดลงแตยง>predicted death
1. ปรบปรงการลงขอมล
2.peer review เอง
3.พฒนาความรเรอง ventilator
และการดแลผปวย septic shock
วงลอท1วงลอท1P
D
S
A
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Develop Care Map
การประเมนผปวย
การใหขอมลและเสรมพลงการเขาถงและเขารบบรการ การวางแผน
การดแลตอเนอง การดแลผปวย
3.1วางแผนการดแลผปวย
3.2วางแผนจาหนาย
4.1 การดแลทวไป
4.2 การดแลทมความเสยงสง
4.3 การดแลเฉพาะ
Performance
parameter
Performance
parameter
Parameter Tool Aim
Performance
improvement target
Mortality rate of pt.
APACHE<20
predicted dead<30%
<5%
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0-5 6-10 11-15 16-20 21-25 26-30 31-35 36-40 > 40
Apache II score
0 0 1.16 2.48 3.03
13.85
54.84
72.84
85.56
3.68 6.1712.91
26.62
43.58
58.36
75.2184.63
93.95
Apache score ICUMED 2007
Actual death Predicted death
Actual death less than Predicted death
2008
Actual death less than Predicted death
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Parameter Aim
Mortality rate of pt. APACHE <20
predicted dead <30% <5%
Unexpected death rate 0
Event rate of risk level G,H,I 0
Performance
Other performance parameter in ICU
อตราผปวยหนกทมคะแนน Apache II score > 20 , Risk of death > 31 68.33 %อตราตายผปวยหนกทมคะแนน Apache II score< 20 , Risk of death < 30 2.25 %อตราการ readmit ในICU ภายใน 3 วน 0.92 %ET tube day (วน/คน)
Min 1.00 วน
Max 20.03 วน
LOSผปวยทม Apache II score>20,Risk>30 4.31 วน
ผปวยทม Apache II score<20,Risk<30 3.52 วน
ประสทธภาพการดแลผปวย Sepsis & Septic shock อตราผปวยหนกทได Resucitate time < 6hr 48.25 %
อตราตายผปวย sepsis and septic shock ทม Apache<20,Risk<30 3.06 %จานวนผปวยทนอนนาน > 7 วน 75.67อตราการเกดทอชวยหายใจหลด 13.57จานวนการเกด Risk ระดบ GHI 0.00อตราการเกด VAP 13.11จานวนการเกด Unexpected death 0.37
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วงลอท3ดแลผปวยตามแนวทางท
กาหนดไว
รวมกนของสหวชาชพ
1.ใชCPG ดแลผปวย sepsis/WHAP/DUE
2.ใชWI-ARCAในการบรหารความเสยง
3.พฒนาcompetencyและจรยธรรมใหเจาหนาท
4.เขารวมกจกรรมพฒนาคณภาพของ PCTและโรงพยาบาล
1. actual death<predicted death
ในทกชวงคะแนน
2. ไมพบ unexpected death & risk GHI
Maintenance การปฎบตใหคงอย
และmonitor อยางตอเนอง
P
D
S
A
Development of performance review in ICUDevelopment of performance review in ICU
• ICU committee develop and review objectives of all
parameters in each ICU
• Develop care map of top 5 diseases in ICU
• Review performance of each ICU by using Apache II score
• Develop CPG in ICU eg. Sepsis, Weaning, WHAP
(prevent VAP)
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Critical Care Triage
Triage ( /ˈtriːɑːʒ/ (UK English) or /triːˈɑːʒ/ (US English))
• Process of determining the priority of patients' treatments based on the severity of their condition
• Treatment efficiently when resources are insufficient for all to be treated immediately
Number of potential ICU patients exceeds the available beds
Critical Care Triage
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MEWS scoreSOS score
• Early warning score(EWS) was developed as a track and trigger tool
• Not all unwell patients can be monitored on intensive care or high dependency units
• Deteriorating patients can be identified(Before too profound)
BACKGROUND AND RATIONALE
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PUP (Physiologically unstable patient) score
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SOS score (search out sepsis score)
score 3 2 1 0 1 2 3temp ≤35 35.1-36 36.1-38 38.1-38.4 ≥38.5
Sys BP ≤80 81-90 91-100 101-180 181-199 ≥200 On vasopressor
HR ≤40 41-50 51-100 100-120 121-139 ≥140
RR ≤8 On ventilator
9-20 21-25 26-35 ≥35
Neuro New ConfusionAgitation
AAlert
VRespond to voice
PRespond to pain
Uunresponsiveness
Urine/dayหรอ
Urine/8 hrหรอ
Urine/4 hrหรอ
Urine/1 hr
≤500≤160≤80≤20
501-999161-31981-15921-39
≥ 1,000≥ 320≥160≥40
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Nurse assistance
Nurse Physician
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Performance Review
AdmissionDischargeOutcomeDecision making process
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Reasons and Rates of Perceived Inappropriateness of Care Reported by Clinicians
“Too much care”290 situations [65%; 95%CI, 58%-73%]
JAMA. 2011;306(24):2694-2703
APPROPRICUS study
“Other patients would benefit more” 168 situations[38%; 95%CI, 32%-43%]
≠
APPROPRICUS studyJAMA. 2011;306(24):2694-2703
• Lack of participation in decision making
• Persistent nonadherence of the patient
• Lack of accurate information giving
• Perceptions of poor-quality patient care
• Disregarding a patient’s wishes
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Put the right patient to the right place ,right time and
right therapy