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MANAGEMENT OF INTENSIVE CARE
DEVELOPMENTS IN CRITICAL CARE MEDICINE AND ANESTHESIOLOGY
Management of Intensive Care
Guidelines for Better Use of Resources
D. REIS MIRANDA, A. WILLIAMS and PH. LOIRAT
Kluwer Academic Publishers DORDRECHT/BOSTON/LONDON
Library of Congress Cataloging-in-Publication Data
Management of 1ntens1ve care gUlde11nes for better use of resources I edited by D. Re1s M1randa, A. Wi l11ams, Ph. Loirat.
p. cm. -- (Developments in critical care medicine and anesthes1ology ; 16)
Includes bibliograph1cal references.
1. Intensive care units--Managellent. 1. Miranda, D. Reis
Preface by Luciano Gattinoni, President of the European Society of Intensive Care Medicine
Foreword XIII by lean-Fram;ois Girard, Directeur General de la Sante (France)
The working group xv
List of abbreviations used in the text XXI
CHAPTER I: INTRODUCTION
Peter F. Hulstaert and Wolfgang Kox
1. Intensive Care Medicine 1 1.1 Fundamentals of Intensive Care Medicine 1 1.2 The facilities 2 1.3 The different interpretations of Intensive Care Medicine 2 1.4 ICM to whom? 3 1.5 Ethics 4
2. Guidelines for Intensive Care Medicine 4 2.1 Why guidelines? 4 2.2 The target-groups 5 2.3 The guidelines 6
CHAPTER II: THE PATIENTS
Jean-Roger Le Gall, Philippe Loirat, Daniel Mathieu and Alan Williams
1. Introduction 11 2. Measuring the type of patients 12
2.1 Referral source 12 2.2 The problem of diagnosis 13
3. Measuring the previous health status and the severity of illness 16 3.1 Previous Health Status 17 3.2 Severity Indexes 19
4. Measuring the workload 21 4.1 The TISS system 21 4.2 The Omega system 22 4.3 The PRN system 23
5. Measuring the evolution of severity of illness 24 5.1 The OSF system 24 5.2 The Sickness Scoring (SS) 24
6. Stratification of patient related data 25 6.1 Essential data 25 6.2 Important data 25 6.3 Desirable data 26 6.4 Optional data 26
References 26 Tables 29
CHAPTER III: THE FACILITIES
1. Introduction 2. ICUs in Europe: The great diversity
55 56 56
2.2 Utilization pattern 2.3 Education and training 2.4 Classification of ICUs
3. The type and size of Intensive Care facilities 3.1 The type of ICUs 3.2 The size of ICUs 3.3 The location of ICUs
4. General standard for ICUs
4.1 Space and technical conditions 4.2 Attendance protocols and procedure manuals 4.3 Ancillary services 4.4 Quality assurance
5. Staffing 6. Comparing facilities
Addendum I Addendum II
Addendum III Addendum IV References
CHAPTER IV: NATIONAL AND REGIONAL ORGANISATION
Dinis Reis Miranda and Dieter Langrehr
1. Introduction 2. Estimating the total number of ICU beds required
2.1 Rates of occupancy and availability 3. Factors influencing regional planning
3.1 Hierarchy of IC facilities 4. Levels of care
4.1 Determinants of levels of care 5. Calculating manpower needs 6. Conclusions References
60 60 63
67 67 68
69 69 69 69 70
74 76 81
CHAPTER V: MANAGEMENT CONTROL IN THE ICU
John F.A. Spangenberg, Jan H.R. van de Poel and Gaetano /apichino
1. Planning and control
2. The ICU: Expense or responsibility centre?
3. Performance criteria 4. Incentives and constraints of ICU performance
4.1 Patient characteristics 4.2 Admissions and discharge decisions 4.3 ICU inputs 4.4 ICU throughputs 4.5 Final ICU outputs
5. Conclusions References
CHAPTER VI: EDUCA nON AND TRAINING
Hilmar Burchardi and Belinda Atkinson
106 108 109 110
118 120 121
1. Introduction 125 2. The actual education and training of Intensive Care Medicine 126
2.1 Physicians 127
2.2 Nurses 128
2.3 Other personnel
3. General recommendations 3.1 Physicians 3.2 Nurses 3.3 Other personnel
4. Conclusions Addendum I. Present situation in European countries Addendum II. Basic education Addendum III. Special education Addendum IV. Catalogue of skills for special Intensive Care
140 142 143 153 154
Addendum V. General Intensive Care nursing for registered general nurses 160
Addendum VI. Special Intensive Care training for nurses in West-Germany 162
CHAPTER VII: EVALUATION IN INTENSIVE CARE
Philippe Loirat, John Spangenberg and Lis Dragsted
1. What should or could be evaluated 1.1 Technologies and interventions 1.2 Organisational studies
2. Who should evaluate? 2.1 Internal audit 2.2 External audit 2.3 Concensus conference 2.4 Recommendations
3 Intensivists should try to adopt common definitions and classifications 3.1 Classification of patients in large series 3.2 Classification of patients by specific diagnoses 3.3 DRGs and evaluation
4. Evaluation studies must have a proper scientific design 4.1 Study design 4.2 Proper control group 4.3 Stratification
5. The proper judgement criteria must be employed 6. Long term evaluation of Intensive Care: Health status and
quality of life 6.1 Definitions 6.2 Proper scale 6.3 General characteristics of the scales 6.4 Functional status scales 6.5 Generic measures of health status
165 165 166 168 168 168 169 169
170 170 170 171 171 171 172 172 173
174 174 175 175 176 176
6.6 Measurements of perceived quality of life 177 6.7 Recommendations 178
7. Economic evaluation of intensive care utilisation 180 7.1 Cost-Benefit Analysis (CBA) 181 7.2 Cost-Effectiveness Analysis (CEA) 186 7.3 Conclusions and general recommendations 187
Table 1. Data for Evaluation of ICM 191 Table 2. Components of the Activity of Daily Living 192 Table 3. Elements of the Sickness Impact Profile 193 Table 4. Components of the Quality of Well Being 194 Table 5. Components of the Perceived Quality of Life Index 195 Table 6. Costs and Benefits of Intensive Care 196 Table 7. Cost Accounting in the I CU 197
CHAPTER VIII: EPILOGUE
1. Introduction 2. Quantification 3. Regionalisation 4. Professionalisation 5. Levels of responsibility 6. Intensive Care Medicine societies 7. Concluding comments
Directory of Intensive Care Organisations
Subject Index and Abbreviations Nigel Turner
199 200 201 202 203 205 206
Intensive Care Medicine has been continuously growing and expanding, culturally, technically and geographically.
Monitoring and instrumentation are continuously improving and more and more hospitals are getting Intensive Care facilities. The costs have proportionally increased over the years, so that ICUs represent today a major cost for health structures. Since the available resources are limited, a real need is emerging to set the limits and indications of Intensive Care. It is understood that the problem not only involves medical considerations, but also ethical and economical aspects of the utmost importance. For the first time in Europe, this book edited by Reis Miranda and his colleagues tackles systematically the many structural aspects of the European Intensive Care. The organisation and financing of health care in the Old Continent is deeply different from the American one, and the results and consequent proposals obtained in the USA cannot simply be transferred to this side of the Atlantic Ocean.
Weare extremely pleased to welcome this first European attempt to discuss the Intensive Care problem. It lays no claims to giving definite replies in a continuously developing field, but it will surely become the basis for future discussions and proposals.
I am particularly happy that this work has mainly developed within the European Society of Intensive Care, whose final target is to ensure a common standard of therapy in our old Europe, beyond national differences.
We warmly congratulate the authors, and I am sure that their work will find wide diffusion and consent.
Luciano Gattinoni, President European Society oj Intensive Care Medicine
The rates at which the various branches of medicine progress are by no means uniform. To even the most casual observer of the medical scene, it is evident that intensive care medicine is now moving ahead at an unprecedented speed. The demand for intensive care is spreading rapidly in all the hospital units, either medical, surgical or pediatric.
The development of intensive care has been based on permanent multidisciplinary contacts. As soon as precise indications have been defined, intensive care medicine proved its efficiency among these hospital units.
At the same time, this important development raised serious problems for two main reasons. First, intensive care is based on small teams, a few persons whose competence, vigilance and motivation are constantly on alert. Second, surveillance and treatment procedures are more and more sophisticated and therefore very costly.
Due to these problems and economic constraints, the reorganisation of intensive care medicine in a more rational way is seen as a necessity.
The task force of the European Society for Intensive Care Medicine recommend in the present document a new method of organisation. As far as organisation is concerned, measures of the type of patients, of the severity of illness and of the quality of medical care are defined. Personnel and equipment for each type of hospital are precisely analysed. Strategic options at regional or national levels are exposed.
Task force members, all international experts, either health professionals or economists, have had the capacity to make propositions which could apply to each European country.
I do believe in the success of this handbook, a reference for intensive care specialists and hospital managers as well as for policy makers.
This document highlights the cooperation between European countries of health care systems, for the best care of everyone.
The Working Group
In the summer of 1986, during the III European Congress of Intensive Care Medicine, at the General Assembly of the European Society of Intensive Care Medicine (ESICM), it was decided that efforts should be made to standardize intensive care in Europe, and that the ESICM should take such initiative.
In this meeting one of the editors was asked to form a working group with the task of describing standards for intensive care medicine in Europe. The members of the working group are indicated below. This working group is composed of private persons, without official representation, and it had its first meeting in Groningen in February 1987. After discussing the prospective work plan, two subgroups were formed to prepare in more detail material which was presented and discussed subsequently in 4 plenary meetings. Therefore, although the subjects addressed are presented in this book by individual members (those charged to prepare them) the whole guidelines carry the personal expertise and agreement of all members.
Given the diversity found among European countries, instead of writing standards which would be prescriptive, rigid, authoritarian and insensitive to local circumstance, the working group preferred to recommend guidelines for improving intensive care medicine in Europe, which should be advisory, guiding, helpful and flexible, indicating the direction in which progress might be sought, from whatever situation happens to be your own particular starting point. The fruits of our labours are presented in this handbook, with the purpose of meeting those objectives.
We thank Miss Wienie Buurma for her patience and excellent secretarial assistance during the preparation of these guidelines.
Ricardo Abizanda I Campos, M.D., Ph.D. ICU Department Hospital Son Dureta
07014 Palma de Mallorca Spain
Belinda L. Atkinson, R.N.
Clinical Services Manager
Intensive Care Services
Southampton General Hospital Tremona Road Southampton S09 4XY
Hilmar Burchardi, M.D., Ph.D.
Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin
3400 Gottingen West-Germany
Lis Dragsted, M.D.
Dept. of Intensive Care Herlev Hospital
University of Copenhagen
Peter F. Hulstaert, M.D. (secretary) Director I CU Department of Surgery University Hospital of Utrecht Heidelberglaan 100 3584 CX Utrecht The Netherlands
Gaetano Iapichino, M.D. Director ICU Department of Anaesthesia ICU 'E. Vecla" University of Milan IRCCS Ospedale Maggiore Via F. Sforza 35 20122 Milano Italy
Wolfgang Kox, M.D., Ph.D. Director ICU Intensive Care Unit Charing Cross Hospital Fulham Palace Road London W6 8RF United Kingdom
Dieter Langrehr, M.D. Emeritus Professor Anaesthesia (Groningen, The Netherlands) Am Lohhof 14 2822 Swaneweck 1 West-Germany
Jean-Roger Le Gall, M.D. Professor Intensive Care Medicine, Director ICU Reanimation Medicale Hospital St. Louis 1, Av. Claude-Velie faux 75010 Paris France
Philippe Loirat, M.D. Director Intensive Care Department Reanimation Polyvalente Centre Medico-Chirurgical Foch 40, Rue Worth 92151 Suresnes France
Jean Micheels, M.D. Anaesthesist Service d' Anesthesiologie et Reanimation Coordinateur du Service des Urgences C.H.U. - Sart Tilman (B 35) 4000 Liege Belgium
Dinis Reis Miranda, M.D. (convenor) Lecturer, Director ICU Division of Intensive Care Department of Surgery University Hospital of Groningen Oostersingel 59 9700 RB Groningen The Netherlands
Gertjan N. Nooij, Psychologist (chairman) Assistant-Professor School for Management and Organisation Director Human Factors Consulting Stationslaan 2 9919 AB Loppersum The Netherlands
Jan H.R. van de Poel, Economist Professor of Accounting University of Limburg PO Box 616 6200 MD Maastricht The Netherlands
John F.A. Spangenberg, Economist, Ph.D. Senior Consultant Hay Management Consultants Catharijnesingel 42 3511 GC Utrecht The Netherlands
Alan Williams, Economist
Professor of Economics, Institute for Research in the Social Sciences University of York Heslington York YOI 5DD United Kingdom
Proofreading and preparation of the Index by:
Nigel McB Turner, F.F.A.R.C.S.I., F.C. Anaes. Fellow in Intensive Care Department of Surgery University Hospital of Groningen Oostersingel 59 9700 RB Groningen The Netherlands
List of abbreviations used in the text
ADC ADL AE AIDS ALOS ANIARTI
APACHE APS ARDS ASB BACCN CBA CCU CEA COPD CPAP CPPV DE DIVI
DRG EEC ENB ESICM FCAnaes FISC
Average Daily Census Activities of Daily Living Admission Error Acquired Immunodefficiency Syndrome Average Length of Stay Associone Nationale Imfirmica Anestesia, Reanimazione e Therapia Intensiva Acute Physiology and Chronic Health Evaluation Acute Physiology Scale Adult Respiratory Distress Syndrome Assisted Spontaneous Breathing British Association of Critical Care Nurses Cost-Benefit Analysis Coronary Care Unit Cost-Effectiveness Analysis Chronic Obstructive Pulmonary Disease Continuous Positive Airway Pressure Continuous Positive Pressure Ventilation Discharge Error Deutsche Interdisziplinare Vereinigung fur Intensivmedizin Diagnostic Related Groups European Economic Community English National Board European Society of Intensive Care Medicine Fellow of the college of Anaesthetists Diagnostic Fichier of the French Society of Intensive Care
FRCS GI IC ICD rCM
ICU IMV HO HI HICMO
HPT HS LOC LOS MMV MPM MRCP NHP OSF OMEGA PEEP PQOL PRN QUALY QWB RA RO SAPS SEIUC
Fellow of the Royal College of Surgeons Gastrointestinal Intensive Care International Classification of Diseases Intensive Care Medicine Intensive Care Unit Intermittent Mandatory Ventilation Zero hypothesis Alternative hypothesis Adaptation Hospitaliere de la Classification Inter-nationale des Maladies et des Operations Higher Professional Training Health Status Level of Care Length of Stay Mandatory Minute Ventilation Mortality Prediction Model Member of the Royal College of Physicians Nottingham Health Profile Organ System Failure Catalogue of medical intervention in IC patients Positive End-Expiratory Pressure Perceived Quality of Life Project of Research of Nursing Quality Adjusted Life Years Quality of Well-being Rate of Availability Rate of Occupancy Simplified Acute Physiology Score Spanish Society of Intensive and Coronary Care Nursing
SEMIUC Spanish Society for Intensive and Coronary Care SIAAR TI Societe Italiena di Anestesia, Analgesia, Rianimazione
e Therapia Intensiva SICU Surgical Intensive Care Unit SIP Sickness Impact Profile
SIZ SS TISS TOSS UEMS WHO
Societeit voor Intensieve Zorg Sickness Scoring Therapeutic Intervention Scoring System Time-orientated Severity Score European Union of Medical Specialists World Health Organisation