Critical Care Medicine

Overview

The Intensive Care Unit is providing critical care to patients and family who have sustained a life-threatening injury, illness or condition. Rapid medical and nursing care is provided to patients with changing mental or physical status or life-threatening conditions that require continuous assessment, technology, immediate intervention and prompt treatment.

Direct patient service is provided in the ICU by a multidisciplinary team that includes medical primary care physicians, designated physician intensivists, specialty physician consults, critical care trained registered nurses, advanced practice nurses (APNs and CNSs), RN case managers, respiratory therapists, physiotherapists, nutritionists, social workers, financial and spiritual care providers. This department serves as a transitional unit to the emergency room and to the general nursing units for patients and families based on admission and discharge criteria for proper utilization and cost control associated with this high level of care.

Multidisciplinary services are actualized through the direction of a Medical Director, Director of Nursing, Patient Care Supervisors and a cohort mix of staff to address patients physical, social, emotional, environmental, cognitive, informational and spiritual needs. The use of daily interdisciplinary Grand Rounds supports the communication and goal development for achievement of best practice and outcomes management. The consultation and use of medical intensivists, based on recommended monitoring of high risk patients, is scheduled at maximum 24 hours post admission to maintain ICU standards of care and consistent use of protocols and standardized order sets to insure best practice and core measure attainment.

Intensive Care Admission Criteria:

The provision of intensive care services will be offered in the following circumstances:

Life Support:

Complex interventions requiring frequent and sophisticated adjustments [titration of vasopressor dose and volume infusions, advanced mechanical ventilation using high level of PEEP or alterations in I:E ratio, frequent vital sign checks (one hour or less) during times of instability or post-procedure or high risk interventions.

Transitioning to:

Basic, more stable (Fixed dose vasopressor infusions, stable patients requiring prolonged mechanical ventilation as patient is assessed to be stable for transfer to subspecialty units)

Monitoring:

High level (use of specialty equipment including intracranial, intra-cardiac monitoring systems)

Transitioning to:

Basic or more stable (frequent vital sign checks and neurological exams, hourly intake and output measurements, central venous pressure monitoring for fluid management, continuous pulse oximetry, cardiac and continuous rhythm monitoring)

Concentrated Nursing Care:

When the ratio of nursing service to patient care require 1:1 or 1:2 to assure safety, security, and monitoring to assure stability of physiological and psychological measures. This could include drug and alcohol use patients or metabolically unstable patients like diabetic ketoacidotic admissions.

ICU Discharge Criteria: Based on Milliman Guidelines

ICU discharge is indicated when physiologic status has stabilized such that ICU care is no longer needed and ALL the following are present:

  • No ICU specific intervention or monitoring currently needed or anticipated
  • Discontinuation of parenteral vasopressor and inotropic medication
  • Stabilized on anti-hypertensive, anti-anginal, and anti-arrhythmic agents for more than 4 hours with stable hemodynamics
  • Discontinuation of ICU assisted ventilation needs as indicated by ANY ONE of the following:
    • Stable chronic ventilator or long term weaning needs
    • Extubation and discontinuation of assisted ventilation with stable respiratory status for at least 4 hours
  • Requirements for care with a staffing ratio of 1 nurse to 3 patients or more.

 

Provision of Care and Standards

The provision of care in ICU provides specialized monitoring and surveillance of patients using advanced technology that is available in the ICU 24 hours a day.

Treatments available are:

  • Invasive hemodynamic monitoring
  • Central Line access and monitoring for fluid status and medication management
  • Continuous Renal Replacement (CRRT) Therapy for ultrafiltration and dialysis
  • Cardiac pacing
  • Mechanical and non-invasive ventilation methods
  • Intracranial monitoring for pressure and oxygenation
  • Hypothermia interventions and monitoring for cardiac arrest protocols
  • Titration and monitoring of vasoactive, sedative, paralytic and analgesia medication

 

Pathways and nursing care plans are instituted based on patient ICD-9 medical diagnosis and expected nursing interventions through care planning that is individualized to patient and family needs.

Discharge planning in activated from admission to discharge through medication reconciliation processes, assessment and interventions of patient and family needs, and referral systems for interdisciplinary intervention that include physical/occupational/speech therapy, nutrition services, and care management services through use of an RN case manager and social worker.

Populations Served:

The Adult Intensive Care Unit provides critical care to patients and family who have sustained a life-threatening injury, illness or condition. Occasionally, adolescent patients (15-18) will be admitted to the unit for stabilization and treatment. Rapid medical and nursing care is provided to patients with changing mental or physical changes or life-threatening condition that requires continuous assessment, use of technology, immediate intervention and prompt treatment. This intervention is spread to the nursing units of the hospital via a Rapid Response Team which includes intensive care nurse and respiratory care personnel on patients who pose a “risk for emergency”.

Hours of Operation and Design:

Twenty Four Hour service is provided to patients and families in alarm enhanced private suites providing a safe and secure area for high level care.

A security enhanced family waiting area and conference rooms are available close to the Intensive Care unit to accommodate family waiting and privacy needs.

Staffing:

The nursing staff consists of registered nurses, patient care assistants, and health unit coordinators.

Registered nurses (RN) are assigned to patients based on patient needs and skill competency of the registered nurse. The ratio of registered nurse to patient is 1:1 to 1:2 depending on acuity of patient needs.

Patient care assistants (PCA) are available to assist in patient care, management of physical environment of the unit and transport of patients/family to other levels of care or services.

The Health Unit Coordinators (HUC) provide comprehensive physician order management and greeting services to control access to the ICU environment to provide safety, security and privacy management. Service excellence communication approaches are used in the provision of access to the ICU unit.

An ICU designated RN case manager, Chaplain and Social worker are available Monday through Friday and on-call for the needs of specialty planning for the ICU.

Respiratory Therapists are available in the ICU on a 24 hour basis to manage oxygenation and ventilation support for all the patients.

Attending physicians are responsible to seeing their patients within 4 hours of admission or transfer to the ICU. House staff (Medical, Surgical and Family) is available to assist in the management of these patients under the direction of the teaching physician.

A Nephrology Medicine consult is required for all ICU patients on hemodialysis and CRRT.

Required licenses/certifications, competencies, and skills

Physician Staff are board certified and credentialed and privileged to provide intensive care to patients. A consultant intensivist is consulted for all intubated and high risk patients.

Registered nurses are licensed in Abu Dhabi to practice under the Registration and Licensing Laws for Professional Nursing practice. All physicians and nurses are required to be BLS and ACLS certified.

Critical Care Orientation and Guided Preceptor Orientation is facilitated by interdisciplinary methods that include training with experienced preceptors, instructional modules and self-study modules.

Annual education and competency to assure standards of care are performed in compliance with regulatory requirements.

Leadership:

The Nursing Director is a master prepared licensed RN with managerial experience and authority. The Director is in charge of the unit 24 hours a day and provides managerial and administrative direction to the standards and scope of nursing services.

The Head of department is in charge of the medical services provided in the ICU to comply with privileging and specialty services provided by the medical staff. Intensivists, are DoH certified physicians who specialize in the care of critically ill patients and are available for consultation and assignment within 24 hours of patient admission to the ICU and those that are high risk.

Goals:

The Intensive Care functions within the guidelines set forth by the Quality and Regulatory agencies, such as The Joint Commission and professional affiliations, such as the Institute for Health Care Improvement (IHI), the Society for Critical Care Medicine (SCCM). Our goals are standardized to provide patient and family care based on an assessment of disease management and chronic illness trajectory. The goals are to match the patient/family needs with the proper level of care of service while attending to the resources that are available and appropriate for the presenting and co-morbid conditions.

The Goals of Patient/Family Centered Care in the ICU are:

  • Continuous assessment and prompt intervention by professional registered nurses
  • Immediate medical, nursing and other professional interventions to address life threatening events
  • Collaboration between professional and ancillary staff to meet individual patient care needs and plan for future care needs (continuity of care, palliative care, and chronic illness management)
  • Communication with patient, family and significant others in patient-centered dialogue to determine values and expectations of care
  • Provide palliative and end-of-life services when life sustaining measures are no longer indicated
  • Utilize and control hospital resources to provide care/support to patients and family in accordance with insurance and other financial support services

Performance Improvement:

A ICU/Quality Improvement and Management Shared Governance committee of unit leadership with physician and interdisciplinary attendees meet twice a month to address the protocol needs and standards of care of the unit.

Evidence Based Practice Improvement projects and research is undertaken to determine outcomes of care as determined by the department.

Team that Cares

Dr. Nicholas Wyon

Consultant - Anesthesia / Critical Care Medicine

Dr. Ahmed Shaban

Specialist - Critical Care Medicine

Dr. Khaled Mahmoud Abdelhamid Aboeldahab

Specialist - Critical Care Medicine