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Archive for the ‘ICU’ Category

ED ICU Cooperation/Transfer Policy

Policy regarding MICU/ED cooperation & transfers from ED to MICU, and to clarify aspects of process improvement and practice parameters for the triage and management of critically ill patients.

1. Goal: MICU patients should be transferred from the ED to an available MICU bed in under one hour.

2. Inter-department communication: ED and MICU leadership will designate liaisons who will work to resolve ED/ICU issues both in real time as they arise (by prompt email reporting) and with regular meetings to address patient care issues that affect both departments. The points below stem from such inter-departmental communication:

2. Transfer of moribund patients from the ED to the ICU: The ED will seek to identify the subset of critically ill patients not expected to survive more than 1-2 hours, and the management focus for these patients will be on optimizing all aspects of care in the ED rather than transfer to the ICU. A set of criteria Criteria to identify these patients was discussed and includes are:
– serum ph<7 in an intubated patient - HR <40 or SBP<60 on high dose vasopressors - two or more cardiac arrests in the ED. The ICU will be available to provide consultative intensivist support in the ED for these patients and their families, but will not assume primary management of the patient. If patient is sustained >2hours after initial notification of the ICU, despite moribund physiology, then transfer to MICU will be discussed on a case-by-case basis, as the MICU recognizes the need to admit patients with sustained care needs.

3. Management of patients who are difficult to ventilate or oxygenate after intubation. Routine post-intubation blood gas analysis will be obtained promptly after intubation. The ED will focus on identifying the subset of intubated patients who are difficult to ventilate; this includes but is not be restricted to the following specific criteria: high peak airway pressures [>35 sustained despite sedation attempt], refractory hypoxemia, and severe patient ventilator dyssynchrony. Repeat blood gas analysis will be performed as soon as difficult to ventilate status is detected. The ICU will strive to arrange for early transfer of these patients and, when this is not possible, will focus on providing timely substantive intensivist consultation in the ED.

4. Recognition and early intervention for severe sepsis: The ED and MICU have initiated efforts to join the GNYHA sepsis identification and treatment collaborative STOP Sepsis (Strengthening Treatment and Outcomes for Patients) project. This participation includes adoption of an automated EPIC-based ED triage instrument that helps to identify patients with severe sepsis or sepsis with shock, and to utilize protocol driven resuscitation measures. Time stamped data collection will document the completeness, timeliness, and effectiveness of protocol components including time to antibiotics, time to fluid resuscitation, lactate clearance measurement, ivc collapsibility index measurement, cvp measurement, according to protocol triage instrument/resuscitation protocol/ data collection instrument.

5. No Beds policy. This is to reaffirm existing medical board policy [circa 2003] regarding the situation when no bed is readily available for a patient accepted by the MICU. If the patient is deemed by the MICU fellow as an appropriate candidate for MICU admission, then several situations may occur:
a. If no bed is available, all attempts should be made as rapidly as possible to create an open bed for the patient. Ongoing efforts to increase the available stepdown beds and to establish a safe/acceptable cohorting program are two examples of efforts to enhance throughput and improve bed availability. If no patient can be transferred out of the MICU safely, then the MICU fellow is responsible to call the fellow on call in another ICU [in the following order: SICU, NSICU, and then CCU]; he/she will arrange transfer. The fellow will notify the MICU attending of the transfer process.
b. If the patient is accepted to another ICU, daily attempts will be made by the MICU attending and fellow to transfer the patient to the MICU according to bed availability, with fellow to fellow communication on a daily basis.
c. A top down evaluation will be undertaken by ED/MICU/hospital administration to develop an improved process to address the care needs of the critically ill patient who remains in the ED for an extended interval because of bed unavailability. At present, MICU will not be responsible for managing the patient in the ED, but the MICU attending and fellow are available to provide Critical Care Consultation for patient management questions. Critical Care consultation is not an avenue to “make” a bed for a patient or to adjudicate triage decisions. The MICU not having available beds does not preclude formal consultation when intensivist decision support is requested by the ED.
d. Patients who are intubated in the ED but deemed not to benefit from ICU admission (e.g., severe co-morbidity that precludes meaningful functional recovery) may be admitted to available step down or medical ward floor bed as appropriate. Each medical floor has capacity to accept at least 2 patients with mechanical ventilatory needs, and the palliative care service may be an appropriate destination for some patients in this category.

ED MICU transfer Policy july 2011 kb rjs tk

Per this policy:

MICU Consult Policy

When a patient is accepted to the ICU but no beds are available, if a bed will not soon become available, the MICU fellow will call the other hospital ICUs to attempt to board patient in an alternate ICU pending availability of ICU beds.

Separate from ICU admission requests, the MICU is available to receive critical care consultations, upon which the ICU team will assess the patient in the ED and provide treatment recommendations.

Cooperation Document Rev Nov 11 2010

Written by reuben

July 9th, 2011 at 7:00 pm

Posted in ICU

ICU Evaluation and Consultation

Written by phil

November 4th, 2008 at 3:09 pm

Posted in ICU

MICU Admission Criteria

Written by reuben

September 16th, 2008 at 10:30 pm

Posted in ED Guidelines,ICU

ICU Bed Management Protocol

(a) Intensive Care Unit patients being transferred should have highest priority (over the Emergency Department and Holding Area patients) for the first available bed on the appropriate service. These decisions will not be at the discretion of the House Staff.

(b) A rotational call schedule will designate for each day a critical care fellow and attending physician (“ICU bed management team”) from the MICU, SICU, and NSICU who will have authority for movement of patients into and out of critical beds in those units, respectively. Each of these ICUs will maintain a daily priority list of patients who may be moved out of the ICU if necessary and appropriate.

(c) When a patient treated in the Emergency Department is critically ill and requires treatment in an ICU setting, the attending emergency physician will contact the clinically most appropriate unit for the patient.

(d) Upon receiving a request to transfer a patient to the ICU, the ICU bed management team of the designated ICU will determine if transfer to the ICU is appropriate, and if so, they will identify a physician to whom that patient will be admitted.

(e) If the patient is appropriate for transfer and a bed is available in the designated ICU, that ICU will make arrangements for transfer as rapidly as possible.

(f) If the patient is appropriate for transfer and no bed is available in the designated unit , the ICU bed management team of that unit will have the responsibility for finding an ICU bed for the patient at the earliest possible time. This may involve appropriate discharge of an ICU patient to another unit or “boarding” of the Emergency Department patient in another ICU. During the period that the patient is “boarding”, the critical care staff of the boarding unit will direct and manage the care of the patient. The ICU bed management team will endeavor to minimize the time that the patient is boarded by making appropriate transfers.

(g) If it is anticipated that there will be a delay in the transfer of a patient to either the designated ICU, a boarder ICU or another service, at the request of the ED Attending, the ICU team will write a critical care consultation for assistance in the management of the patient. Such consultations will be provided in accordance with Medical Board policy.

(h) On call lists for critical care attending physicians and fellows will be provided to the ED and contact numbers provided to the Telecommunications on a regular basis, with changes communicated in a timely manner.

(i) ICU and CCU admissions and consultations will have quality assurance review

Written by phil

August 17th, 2008 at 11:59 am

Posted in ICU

ICU

ICU Consult and Admission

ICU Consults: When consulting any ICU, initiate the consult via AMAC (43611). This allows the consult to be time stamped so that ICU consults can be monitored by the QA committee. The MARS team consultation criteria outline what they feel are appropriate parameters to summon a formal consultation by their team and after hours, a critical care consultation by the MICU. Be sure to print a consult with specific questions so that the consultant can provide management recommendations as needed.

MICU Admission Criteria: are available on the Mount Sinai Intranet. A copy is available here as well.

ICU Bed Management: See full policy here. If the patient is deemed appropriate for ICU admission and no bed is available, it is the responsibility of the consulted ICU to attempt to find an ICU bed where the patient may be boarded. It is then the responsibility of the ICU boarding the patient to manage the patient until a bed in the accepting ICU is available. The critical point is that the consultant state that the patient is indeed an ICU candidate, that the patient is accepted to the ICU, but that a bed is not available. The patient can not be denied solely due to bed availability. Patients accepted to an ICU who remain in the Emergency Department pending bed availability in the unit are the primary responsibility of the ED Attending – this is why it is key that management recommendations be provided by the icu consultant.

Written by phil

August 17th, 2008 at 11:57 am

Posted in ICU