P Marik, J Varon
icu, micu, more icu's
P Marik, J Varon. Do We Need More ICUs?. The Internet Journal of Emergency and Intensive Care Medicine. 1996 Volume 1 Number 3.
The health care reform in the United States has become an issue of major national concern. In 1992, Americans spent $838 billion on healthcare. This figure is more that double that spent on education. Despite of this enormous expenditure, well over 30 million Americans have no health care coverage and many more are underinsured. The excessive and inappropriate use of high technology medicine has played a major role in the escalation of healthcare costs in the United States. probably one of the major culprits of this escalation in costs has been the so-called “ICU epidemic”.
What is “The ICU Epidemic”?
Since the initial development of the intensive care units (ICUs), there has been a rapid and remarkable growth of ICUs in the United States. It is estimated that there are presently over 50,000 ICU beds in the United States. What seems to be scary is that these units and what we call “The ICU Epidemic” consume about 2 % of the gross national product. This is by no means new information........
We well know that many patients admitted to ICU die there. The exact figures vary from hospital to hospital but it has been estimated that 15 to 25 % of all patients admitted die in the ICU. In our minds, the admission of a patient to an ICU means either a life saving measure, prevention of potential complications or the beginning of a potentially long-term,slow and painful death.
Is There an Ideal ICU?
The answer is quite simple: Not at this time! The basic concepts mentioned above are important for critical care practitioners. The so-called “Ideal ICU” should be that critical care unit with very low mortality and good allocation of human resources. Unfortunately, this combination is quite difficult to achieve.
We believe that we need more “ideal ICUs” with good ICU teams. A “good” ICU team should decide which are the goals of the admission, such as saving the salvageable and helping those who have no chance of meaningful survival to have a peaceful and dignified death. Not every patient deserves an ICU admission!
How Can We Help?
In an effort to prevent or improve points such as the mentioned above there have been many investigations leading to predictors of who will survive and who will die. The initial concept of an ICU being a place of monitoring and life-support for the critically ill and injured with the use of high technology is still valid. With all this new techniques and knowledge, physicians must make good prognostic predictions for the critically ill patient. The severity of illness must be codified so that patient populations can be compared.
Predictors of Outcome
Multiple systems are available for assessment of severity of illness. Although the ability to survive or not does not depend on a score, these systems can help to determine the chances of survival. For example, the use of therapeutic interventions prevents known and severe complications which are likely to develop if certain clinical conditions are allowed to continue unchecked. Examples of these systems include: The Therapeutic Intervention Scoring System (TISS), and The Acute Physiology and Chronic Health Evaluation System (APACHE) among others. TISS was designed as an index of severity score for intensive care patients. The single basic assumption is that the more interventions required to care for a patient, the sicker the patient must be. Items in this system are divided into those which require active monitoring and those which involve routine tasks. A score of 1 to 4 points is applied to various interventions based on their risk, invasiveness and implications. There are 73 potential services that can be given to a patient with this system. Four points are given to emergency surgery or institution of mechanical ventilation while one point is given for a routine dressing change or the presence of a Foley catheter. Three and two points are given to intermediate actions. Points are tailored for each 24 hour period resulting in the TISS for that day. High points are associated with prolonged morbidity, mortality and high cost. It is also valuable for prognosis, comparison and cost analysis. Although TISS may not be valid for prognosis because it is based on therapy which is discretionary, in some centers it is considered that if the patient does not have at least 20 points the he/she does not belong in the ICU.
The APACHE classification’s purpose is to classify groups of patients on the basis of the severity of illness which in turn defines the probability of mortality. It is composed of two parts: 1) The first is the physiology score which represents the degree of acute illness, this during the first 32 hours of admission, utilizing 34 measures of the sickness of 1 or more of the 7 important systems (neurological, cardiovascular, gastro-intestinal, renal, metabolic, hematological, etc.), except for those patients with acute myocardial infarction or burns, which have their own classification system. All the measures are evaluated by a 0-4 scale. Those patients with 31 or more points have 70 % chances of dying in the hospital. 2) The second is the patient’s previous health. One of its limitations is the enormous variation between individuals, but with this system it has been possible to describe patients’ characteristics. There have been several revisions and validations of the APACHE system in clinical practice. For example, the APACHE II is much more simplified that the original APACHE. It has only 12 physiological variables. Some of the previous points such as serum osmolality, lactic acid and anergy were deleted. Others were replaced such as creatinine for BUN and pH for bicarbonate. They found that the smallest number of variables to maintain statistical precision was 12 and all should be measured. It was established that age and chronic medical problems reduce the physiological reserve. This study was validated in 13 institutions with a maximum possible score of 71. Although there is a difference in the timing of the events and the first day APACHE II scores do not perfectly predict death rates for individual patients, the system is available to stratify a wide variety of patients prognostically. The statistical precision of the APACHE II predictions is comparable to that found with the burn index. It also estimates the risk of in-hospital death. It has been postulated that using the worst physiologic APACHE II values during the first 24 hours of care is an accurate predictor of mortality. Nevertheless, APACHE II was never shown to be better than APACHE by sensitivity/specificity or correct classification. Other systems are in use in other countries around the globe. LeGall et al in 1984 (prior to the publication of the APACHE II), published the Simplified Acute Physiology Score (SAPS) which is very similar to the APACHE II, but it uses 14 variables. This study was more complex and required more data collection. Most of that data was easy to collect. It is not currently in use in the United States, but is widely used in Europe. Rhee et al developed the Rapid Acute Physiology Score (RAPS), which was evaluated using a group of helicopter-transported patients. This system takes those elements from the APACHE II that can be obtained reliably on all patients on the field or in an Emergency Room. This is commonly used for the evaluation of critically ill patients who are to be transported. Measures such as pulse, blood pressure, respiratory rate and Glasgow Coma Scale have different points than the original APACHE II or Glasgow Coma Scale. The RAPS range is between 0 and 16 points. The less the number of points assigned to the patient the better the prognosis of the patient. If APACHE II and RAPS are used together they do not increase the predictive accuracy. The only advantage of RAPS is that it is easy to score.
Of all of the above systems probably the most widely used are APACHE II and the TISS. More recently, new systems such as the APACHE III and the Mortality Predictor Model are undergoing clinical trials and have been validated.
Do We Need More ICUs?
Despite the modern advances in medical pharmacology and technology, many patients admitted to an ICU, die there. The answer to this problems is not to have more ICUs, but to understand the philosophy of these units and to distribute human and economical resources in an appropriate manner.
Given the finite resources available for health care, common sense and good medical practice should serve as the primary justification to admit patients to an ICU. It is the responsibility of the physician to adequately screen admissions to these units based on accurate predictors of outcome. This can be done in the following manner:
Discuss with the patient and his family whether or not he or she belongs to the ICU, presenting them facts about outcome.
Discuss with the patient or immediate relative the “Code Status”.
Do an intensive effort during the first few days to save the patient’s life and return the patient to the expected reasonable quality of life, unless otherwise requested by the patient or his/her family.
If after 72 hours the patient has not recovered any meaningful function in spite of aggressive treatment, he/she becomes chronically critically ill, and at that time will be suitable to die from any of the common ICU complications such as sepsis, bleeding, arrhythmias, airway problems and others. At that time reassessment of the situation should be done as well as a management plan.
If all of the above points are followed probably the ICU will become a part of the medical system which will integrate the patient’s best wishes, specially his or her interpretation of quality of life as well as the latest medical management and monitoring in the patient’s best interest.