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Definition
An intensive care unit, or ICU, is a specialized section of a hospital that provides comprehensive and continuous care for persons who are critically ill and who can benefit from treatment.
Purpose
The purpose of the intensive care unit (ICU) is simple even though the practice is complex. Healthcare professionals who work in the ICU or rotate through it during their training provide around-the-clock intensive monitoring and treatment of patients seven days a week. Patients are generally admitted to an ICU if they are likely to benefit from the level of care provided. Intensive care has been shown to benefit patients who are severely ill and medically unstable—that is, they have a potentially life-threatening disease or disorder.
Although the criteria for admission to an ICU are somewhat controversial—excluding patients who are either too well or too sick to benefit from intensive care—there are four recommended priorities that intensivists (specialists in critical care medicine) use to decide this question. These priorities include:
ICU care requires a multidisciplinary team that consists of but is not limited to intensivists (clinicians who specialize in critical illness care); pharmacists and nurses; respiratory care therapists; and other medical consultants from a broad range of specialties including surgery, pediatrics, and anesthesiology. The ideal ICU will have a team representing as many as 31 different health care professionals and practitioners who assist in patient evaluation and treatment. The intensivist will provide treatment management, diagnosis, interventions, and individualized care for each patient recovering from severe illness.
Demographics
A large and comprehensive study conducted in 1992 by the Society of Critical Care Medicine in collaboration with the American Hospital Association found that approximately 8% of all licensed hospital beds in the United States were designated for intensive care. The average size of an adult or pediatric ICU averaged 10–12 beds per unit. Small hospitals with fewer than 100 beds usually had one ICU, whereas larger hospitals with more than 300 beds usually had several ICUs designated for medical, surgical, and coronary patients. Smaller hospitals do not usually have a full-time board-certified specialist in critical care medicine, whereas larger medical centers generally employ certified intensivists—60% of hospitals with more than 500 beds had full-time specialist directors at the time the survey was conducted.
With regard to the nursing staff in ICUs, the proportion of nurses with specialized and advanced training in critical care medicine is higher in larger medical centers—about 16% in hospitals with 100 beds or fewer, but 21% in hospitals with more than 500 beds.
Most pediatric ICUs have four to six beds per unit. The mortality rate in pediatric ICUs tends to increase in proportion to size, with larger units reporting more deaths (approximately 8% in the larger units). Eighty percent of pediatric ICUs have full-time medical directors.
Description
ICUs are highly regulated departments, typically limiting the number of visitors to the patient's immediate family even during visiting hours. The patient usually has several monitors attached to various parts of his or her body for real-time evaluation of medical stability. The intensivist will make periodic assessments of the patient's cardiac status, breathing rate, urinary output, and blood levels for nutritional and hormonal problems that may arise and require urgent attention or treatment. Patients who are admitted to the ICU for observation after surgery may have special requirements for monitoring. These patients may have catheters placed to detect hemodynamic (blood pressure) changes, or require endotracheal intubation to help their breathing, with the breathing tube connected to a mechanical ventilator.
In addition to the intensivist's role in direct patient care, he or she is usually the lead physician when multiple consultants are involved in an intensive care program. The intensivist coordinates the care provided by the consultants, which allows for an integrated treatment approach to the patient.
Nursing care has an important role in an intensive care unit. The nurse's role usually includes clinical assessment, diagnosis, and an individualized plan of expected treatment outcomes for each patient (implementation of treatment and patient evaluation of results). The ICU pharmacist evaluates all drug therapy, including dosage, route of administration, and monitoring for signs of allergic reactions. In addition to checking and supervising all levels of medication administration, the ICU pharmacist is also responsible for enteral and parenteral nutrition (tube feeding) for patients who cannot eat on their own. ICUs also have respiratory care therapists with specialized training in cardiorespiratory (heart and lung) care for critically ill patients. Respiratory therapists generally provide medications to help patients breathe as well as the care and support of mechanical ventilators. Respiratory therapists also evaluate all respiratory therapy procedures to maximize efficiency and cost-effectiveness.
Large medical centers may have more than one ICU. These specialized intensive care units typically include a CCU (coronary care unit); a pediatric ICU (PICU, dedicated to the treatment of critically ill children); a newborn ICU or NICU, for the care of premature and critically ill infants; and a surgical ICU (SICU, dedicated to the treatment of postoperative patients).
Preparation
Persons who are critically ill may be admitted to the ICU from the emergency room, a surgical ward, or from any other hospital department. ICUs are arranged around a central station so that patients can be seen either through the room windows or from a nursing station a few steps away. Patients are given 24-hour assessments by the intensivist. Preparatory orders for the ICU generally vary from patient to patient since treatment is individualized. The initial workup should be coordinated by the attending ICU staff (intensivist and ICU nurse specialist), pharmacists (for medications and IV fluid therapy), and respiratory therapists for stabilization, improvement, or continuation of cardiopulmonary care. Well-coordinated care includes prompt consultation with other specialists soon after the patient is admitted to the ICU. The patient is connected to monitors that record his or her vital signs (pulse, blood pressure, and breathing rate). Orders for medications, laboratory tests, or other procedures are instituted upon arrival.
In general there are eight categories of diseases and disorders that are regarded as medical justification for admission to an ICU. These categories include disorders of the cardiac, nervous, pulmonary, and endocrine (hormonal) systems, together with postsurgical crises and medication monitoring for drug ingestion or overdose. Cardiac problems can include heart attacks (myocardial infarction), shock, cardiac arrhythmias (abnormal heart rhythm), heart failure (congestive heart failure or CHF), high blood pressure, and unstable angina (chest pain). Lung disorders can include acute respiratory failure, pulmonary emboli (blood clots in the lungs), hemoptysis (coughing up blood), and respiratory failure. Neurological disorders may include acute stroke (blood clot in the brain), coma, bleeding in the brain (intracranial hemorrhage), such infections as meningitis, and traumatic brain injury (TBI). Medication monitoring is essential, including careful attention to the possibility of seizures and other drug side effects.
When patients are transferred to the ICU from another hospital department, treatment orders and planning must be reviewed and new treatment plans written for the patient's current status. For example, a chronically ill inpatient may grow markedly worse within a few hours and may be transferred to the ICU, where the staff must reevaluate orders for his or her care.
Resources
Periodicals
Brilli, R. J., A. Spevetz, R. D. Branson, et al. "Critical Care Delivery in the Intensive Care Unit: Defining Clinical Roles and the Best Practice Model." Critical Care Medicine 29 (October 2001): 2007-2019.
Ethics Committee, Society of Critical Care Medicine. "Consensus Statement of the SCCM Ethics Committee Regarding Futile and Other Possibly Inadvisable Treatments." Critical Care Medicine 25 (May 1997): 887-891.
Truog, R. D., A. F. Cist, S. E. Brackett, et al. "Recommendations for End-of-Life Care in the Intensive Care Unit: The Ethics Committee of the Society of Critical Care Medicine." Critical Care Medicine 29 (December 2001): 2332-2348.
Organizations
American Hospital Association. One North Franklin, Chicago, IL 60606-3421. (312) 422-3000. www.hospitalconnect.com.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). One Renaissance Blvd., Oakbrook Terrace, IL 60181. (630) 792-5000 or (630) 792-5085. www.jcaho.org/.
Society of Critical Care Medicine (SCCM). 701 Lee Street, Suite 200, Des Plaines, IL 60016. (847) 827-6869; Fax: (847) 827-6869. www.sccm.org.
— Laith Farid Gulli, M.D.,M.S.
Bilal Nasser, M.D.,M.S.
Uchechukwu Sampson, M.D., M.P.H.,M.B.A.
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Intensive care medicine or critical care medicine is a branch of medicine concerned with the provision of life support or organ support systems in patients who are critically ill and who usually require intensive monitoring.
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Patients requiring intensive care may require support for hemodynamic instability (hypertension/hypotension), airway or respiratory compromise (such as ventilator support), acute renal failure, potentially lethal cardiac arrhythmias, or the cumulative effects of multiple organ system failure. They may also be admitted for intensive/invasive monitoring, such as the crucial hours after major surgery when deemed too unstable to transfer to a less intensively monitored unit.
Intensive care is usually only offered to those whose condition is potentially reversible and who have a good chance of surviving with intensive care support. Since the critically ill are so close to dying, the outcome of this intervention is difficult to predict. Many patients, therefore, die in the intensive care unit.[citation needed] A prime requisite for admission to an Intensive Care Unit is that the underlying condition can be overcome.
Medical studies suggest a relation between intensive care unit (ICU) volume and quality of care for mechanically ventilated patients.[1] After adjustment for severity of illness, demographic variables, and characteristics of the ICUs (including staffing by intensivists), higher ICU volume was significantly associated with lower ICU and hospital mortality rates. For example, adjusted ICU mortality (for a patient at average predicted risk for ICU death) was 21.2% in hospitals with 87 to 150 mechanically ventilated patients annually, and 14.5% in hospitals with 401 to 617 mechanically ventilated patients annually. Hospitals with intermediate numbers of patients had outcomes between these extremes.
It is generally the most expensive, technologically advanced and resource-intensive area of medical care. In the United States estimates of the 2000 expenditure for critical care medicine ranged from US$15-55 billion accounting for about 0.5% of GDP and about 13% of national health care expenditure (Halpern, 2004).
Intensive care usually takes a system by system approach to treatment, rather than the SOAP (subjective, objective, analysis, plan) approach of high dependency care. The nine key systems (see below) are each considered on an observation-intervention-impression basis to produce a daily plan. As well as the key systems, intensive care treatment also raises other issues including psychological health, pressure points, mobilisation and physiotherapy, and secondary infections.
The nine key IC systems are (alphabetically): cardiovascular system, central nervous system, endocrine system, gastro-intestinal tract (and nutritional condition), hematology, microbiology (including sepsis status), peripheries (and skin), renal (and metabolic), respiratory system.
The provision of intensive care is generally administered in a specialized unit of a hospital called the intensive care unit (ICU) or critical care unit (CCU). Many hospitals also have designated intensive care areas for certain specialities of medicine, such as the coronary care unit (CCU) for heart disease, medical intensive care unit (MICU), surgical intensive care unit (SICU), pediatric intensive care unit (PICU), neuroscience critical care unit (NCCU), overnight intensive recovery (OIR), shock/trauma intensive care unit (STICU), neonatal intensive care unit (NICU), and other units as dictated by the needs and available resources of each hospital. The naming is not rigidly standardized. For a time in the early 1960s, it was not clear that specialized intensive care units were needed, so intensive care resources (see below) were brought to the room of the patient who needed the additional monitoring, care, and resources. It became rapidly evident, though, that a fixed location where intensive care resources and personnel were available provided better care than ad hoc provision of intensive care services spread throughout a hospital.
Common equipment in an intensive care unit (ICU) includes mechanical ventilation to assist breathing through an endotracheal tube or a tracheotomy; hemofiltration equipment for acute renal failure; monitoring equipment; intravenous lines for drug infusions fluids or total parenteral nutrition, nasogastric tubes, suction pumps, drains and catheters; and a wide array of drugs including inotropes, sedatives, broad spectrum antibiotics and analgesics.
Critical care medicine is a relatively new but increasingly important medical specialty. Physicians who have training in critical care medicine are referred to as intensivists.[2] The specialty requires additional fellowship training for physicians who complete their primary residency training in internal medicine, anesthesiology, or surgery. Board certification in critical care medicine is available through all three specialty boards. Nurse intensivists receive their training after basic education through ASTNA. Paramedics are certified to levels of CCEMTP or FP-C. Intensivists-physicians with a primary training in internal medicine sometimes pursue combined fellowship training in another subspecialty such as pulmonary medicine, cardiology, infectious disease, or nephrology. The Society of Critical Care Medicine is a well established multiprofessional society for practitioners who work in the ICU, including intensivists. Most medical research has demonstrated that ICU care provided by intensivists produces better outcomes and more cost effective care.[3] This has led the Leapfrog Group to make a primary recommendation that all ICU patients be managed or co-managed by a dedicated intensivist who is exclusively responsible for patients in one ICU. Unfortunately there is a critical shortage of intensivists in the United States and most hospitals lack this critical physician team member.
Patient management in intensive care differs significantly between countries. In Australia, where Intensive Care Medicine is a well established speciality, ICUs are described as 'closed'. In a closed unit the intensive care specialist takes on the senior role where the patient's primary doctor now acts as a consultant. Other countries have open Intensive Care Units, where the primary doctor chooses to admit and generally makes the management decisions. There is increasingly strong evidence that 'closed' Intensive Care Units staffed by Intensivists provide better outcomes for patients.[4][5]
The ICU's roots can be traced back to the Monitoring Unit of critical patients through nurse Florence Nightingale. The Crimean War began in 1854 when Britain, France and Turkey declared war on Russia. Because of the lack of critical care and the high rate of infection, there was a high mortality rate of hospitalised soldiers, reaching as high as 40% of the deaths recorded during the war. Nightingale and 38 other volunteers had to leave for the Fields of Scurati, and took their "critical care protocol" with them. Upon arriving, and practicing, the mortality rate fell to 2%. Nightingale contracted typhoid, and returned in 1856 from the war. A school of nursing dedicated to her was formed in 1859 in England. The school was recognised for its professional value and technical calibre, receiving prizes throughout the British government. The school of nursing was established in Saint Thomas Hospital, as a one year course, and was given to doctors. It used theoretical and practical lessons, as opposed to purely academic lessons. Nightingale's work, and the school, paved the way for intensive care medicine.
Walter Edward Dandy was born in Sedalia, Missouri. He received his BA in 1907 through the University of Missouri and his M.D. in 1910 through the Johns Hopkins University School of Medicine. Dandy worked one year with Dr. Harvey Cushing in the Hunterian Laboratory of Johns Hopkins before entering its boarding school and residence in the Johns Hopkins Hospital. He worked in the Johns Hopkins College in 1914 and remained there until his death in 1946. One of the most important contributions he made for neurosurgery was the air method in ventriculography, in which the cerebrospinal fluid is substituted with air to help an image form on an X-Ray of the ventricular space in the brain. This technique was extremely successful for identifying brain injuries. Dr. Dandy was also a pioneer in the advances in operations for illnesses of the brain affecting the glossopharyngeal as well as Meniere's syndrome, and he published studies that show that high activity can cause sciatic pain. Dandy created the first ICU in the world, 03 beds, Boston,1926.
Bjorn Aage Ibsen (1915-2007) graduated in 1940 from medical school at the University of Copenhagen and trained in anesthesiology from 1949 to 1950 at the Massachusetts General Hospital, Boston. He became involved in the 1952 poliomyelitis outbreak in Denmark, where 2722 patients developed the illness in a 6 month period, with 316 suffering respiratory or airway paralysis. Treatment had involved the use of the few negative pressure respirators available, but these devices, while helpful, were limited and did not protect against aspiration of secretions. Ibsen changed management directly, instituting protracted positive pressure ventilation by means of intubation into the trachea, and enlisting 200 medical students to manually pump oxygen and air into the patients lungs. At this time Carl-Gunnar Engström had developed one of the first positive pressure volume controlled ventilators, which eventually replaced the medical students. In this fashion, mortality declined from 90% to around 25%. Patients were managed in 3 special 35 bed areas which aided charting and other management. In 1953 Ibsen set up what became the world's first Medical/Surgical ICU in a converted student nurse classroom in Kommunehospitalet (The Municipal Hospital) in Copenhagen, and provided one of the first accounts of the management of tetanus with muscle relaxants and controlled ventilation. In 1954 Ibsen was elected Head of the Department of Anaesthesiology at that institution. He jointly authored the first known account of ICU management principles in Nordisk Medicin, September 18, 1958: ‘Arbejdet på en Anæsthesiologisk Observationsafdeling’ (‘The Work in an Anaesthesiologic Observation Unit’) with Tone Dahl Kvittingen from Norway. He died in 2007.
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Peter Safar, the first Intensivist doctor in the USA,[citation needed] was born in Austria as the son of two doctors. He first migrated to the United States in 1949. Safar first got certification as an anesthesiologist, and in the 1950s he started and praised the "Urgency & Emergency" room setup (now known as an ICU)[citation needed]. It was at this time the ABC (Airway, Breathing, and Circulation) protocols were formed, and artificial ventilation as well as cardiopulmonary resuscitation became popular.[citation needed] These experiments counted on volunteers of its team, and used only minimal sedation. It was through these experiments that the techniques for maintaining life in the critical patient were established.[citation needed]
The first surgical ICU was established in Baltimore, and, in 1962, in the University of Pittsburgh, the first Critical Care Residency was established in the United States. It was around this time that the induction of hypothermia in critical patients was also tested.[citation needed]
In 1970 the SCCM was formed. (Society of Critical Care Medicine). history reference: Brazilian Society of Critical Care SOBRATI Video:ICU History Historical photos
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