MICU admission criteria: resource utilization

[VentdependenT]

any thoughts? It would be great if there were standard admission criteria to cut down on abuse of the system.

For example known lung mets in end stage cancer pt with dyspnea.

DNR pneumonia in demented nursing home pt

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[glorfindel]

any thoughts? It would be great if there were standard admission criteria to cut down on abuse of the system.

For example known lung mets in end stage cancer pt with dyspnea.

DNR pneumonia in demented nursing home pt

I haven't seen much abuse of the system where I'm at. I'm assuming you're referring to DNR patients in the ICU? In that case, sure, that's inappropriate unless the pt cannot be made comfortable in a non-icu environment (an absurd notion, usually).

I'm inclined to think that the solution isn't standard admission criteria. To the extent that you can agree on what they should be, they're of trivial importance, because everyone can easily agree, and then who needs the criteria?. To the extent that you can't, they don't help, because even if you could get them adopted, you'd still have too much arguing at the point when a doc wants a marginal patient in the unit and it's so-so whether they meet the criteria.

Better, perhaps, to have a system whereby, when the unit's full, there's a medical director who can negotiate with docs about which pts need the unit the most.

 

[Bostonredsox]

This topic is part of my residency QI project. 'ED-ICU admission process" part of it is absurd admissions. "Gi bleeds" that are stable pts with one episode of Melena and a Hb of 14. We adopted the recommended ICU admission criteria from SCCM's standard guidelines. Has a set of diagnostic criteria and a set of vital-sign with unknown diagnosis based criteria. Seems to have cut down the crappy admit calls though I am still in the trial phase for another 6 months. Data is trending well though. We also developed a set of automatic admit criteria that bypasses the slow general admission process. Example, ED doc calls bed control MICU senior, we just incubated pt X his CO2 was 140 and he was unresponsive. We automatically give them a bed, if available and they send the pt within 45 min generally. What I am running into trouble with is "hey I have a RVR responding to dilt drip and is now down to 130 on 10 mg, but there are no SDU beds. Ends up coming to MICU. Other major problem are the "overdose patients" who took 9 Ativan in a suicide attempt. Psych says no f'n way not for 24 hours and the MICU is our only other locked unit, so I end up admitting them for 24 hours regardless of wether they took 6 Ativan or 106. That is a crap admit to me.

And as for the DNR pneumonia pt from NH, if they are not going on the vent, are not eligible for CpR when they code, and there families say no invasive procedures (no Aline no pressures no triple lumen) they go to stepdown, I refuse them. In fact, they are starting to refuse them in SDU, and rightly so. If you are a DNR but ok with intubation, pressors and invasive monitoring, just no shocks if you code, I'll take you to MICU.

 

[VentdependenT]

dude thanks again for coming through. ill try to find it on the website unless you wanna post the link . Friggen awsome project btw. we get "hey i just tubed a drunk guy so he has to come to the unit" all the time. I go down, flip off propofol, do SBT, extubate, tell them to call medicine. Same for opiate overdose: turn off sedation, hand titrate narcan until responsive, sbt, extubate on narcan drip, off to stepdown to medicine with psych consult.

I have done this on several occasions. ER attendings not too stoked initially but Ive earned their respect concerning my judgement

 

[Bostonredsox]

dude thanks again for coming through. ill try to find it on the website unless you wanna post the link . Friggen awsome project btw. we get "hey i just tubed a drunk guy so he has to come to the unit" all the time. I go down, flip off propofol, do SBT, extubate, tell them to call medicine. Same for opiate overdose: turn off sedation, hand titrate narcan until responsive, sbt, extubate on narcan drip, off to stepdown to medicine with psych consult.

I have done this on several occasions. ER attendings not too stoked initially but Ive earned their respect concerning my judgement

Haha no problem.

as requested, http://www.sccm.org/professional_resources/guidelines/table_of_contents/Documents/ICU_ADT.pdf

I have also gone down, looked at the 75 year old who lost the ability to count 5 years ago and whose husband says, I dont know how many of her oxycontin she took. Turned to the ED doc, again, a crappy FP doc from the 80s who knows nothing about EBM...have you given any narcan?.....no theyll seize if they withdrawl....narc withdral doesnt cause seizures, etoh and benzos do.....oh well where i trained we didnt reverese narc OD because they can aspirate and code....so you dont give narcan during code blues that arrive by ems with 9 fentanyl patches stuck to them??....no answer.....ok watch this.....I push 0.04, then another 0.04, then another 0.04 (still only 1/3 the code dose)....Oh my god shes awake its a MIRACLE!!!...call the general med team shes not coming to micu.....

once they have intubated I am stuck. My attendings are often hospitalist who dont want to deal with it in the ED so they just say take them and we extubate them after rounds and they can go to the floor.

 

[ResidentMD]

Haha no problem.

as requested, http://www.sccm.org/professional_resources/guidelines/table_of_contents/Documents/ICU_ADT.pdf

I have also gone down, looked at the 75 year old who lost the ability to count 5 years ago and whose husband says, I dont know how many of her oxycontin she took. Turned to the ED doc, again, a crappy FP doc from the 80s who knows nothing about EBM...have you given any narcan?.....no theyll seize if they withdrawl....narc withdral doesnt cause seizures, etoh and benzos do.....oh well where i trained we didnt reverese narc OD because they can aspirate and code....so you dont give narcan during code blues that arrive by ems with 9 fentanyl patches stuck to them??....no answer.....ok watch this.....I push 0.04, then another 0.04, then another 0.04 (still only 1/3 the code dose)....Oh my god shes awake its a MIRACLE!!!...call the general med team shes not coming to micu.....

once they have intubated I am stuck. My attendings are often hospitalist who dont want to deal with it in the ED so they just say take them and we extubate them after rounds and they can go to the floor.

I have heard the excuse regarding giving narcan and causing vomiting --> aspiration multiple times before. I have seen that as an excuse not to give it, and intubate instead.
I am curious.....what is people's general experience on this forum regarding this? How many patients (in whom narcan have been given) actually vomit and aspirate, versus just waking up and avoiding an intubation for themselves?

 

[Bostonredsox]

I have heard the excuse regarding giving narcan and causing vomiting --> aspiration multiple times before. I have seen that as an excuse not to give it, and intubate instead.
I am curious.....what is people's general experience on this forum regarding this? How many patients (in whom narcan have been given) actually vomit and aspirate, versus just waking up and avoiding an intubation for themselves?

I havent seen it. And even if it were a legit concern, put them in the lateral decubitis position with a 1:1 sitter in case they vomit. This is in contrast to the actual withdrawl from benzos which when the OD is reversed with flumaz, can be lethal. There is no excuse to not give narcan. Even if your so crazy worried about their airway, after you tube them, still give the narcan, then well extubate them 20 minutes later when they are fully awake and agitated from that 8-0 jammed in their mouth. And if they are completely out, GCS of 5 or something, well then you should intubate them. But again, you have to reverse the underlying pathophys for why you are tubing them in the first place...or theyll never wake up or worse, have a arrythmia/cardiac arrest from all the narcotic load. To me, under any circumstances, intubated or not, not giving narcan to an OD's is the same as employing EGDT in the severe septics but skipping the antibiotics...if you dont correct the problem, the rest of the **** dont work.

 

[meister]

Our MICU admission criteria: be tubed, or be on pressors.

 

[B-Bone]

Anybody know the half life of narcan in comparison to any of the various narcotics? On the rare occasion that I need to give narcan to somebody post-op (rather than wait out narcotic side effects in PACU), I will usually have them admitted to a monitored bed (not necessarily ICU, but frequently). A short-sighted thing to do is give narcan, say "look everybody, he's awake!", and then send home or to a non-monitored floor. Narcan tends to wear off quickly, and then you're back to square one with respect to respiratory depresion. Food for thought.

 

[Bostonredsox]

Anybody know the half life of narcan in comparison to any of the various narcotics? On the rare occasion that I need to give narcan to somebody post-op (rather than wait out narcotic side effects in PACU), I will usually have them admitted to a monitored bed (not necessarily ICU, but frequently). A short-sighted thing to do is give narcan, say "look everybody, he's awake!", and then send home or to a non-monitored floor. Narcan tends to wear off quickly, and then you're back to square one with respect to respiratory depresion. Food for thought.

I would never do this. The general admit team handles the telemetry and stepdown admissions and that is what I meant when I said not coming to MICU. Of course they would be in a monitored bed.

and it lasts around 60 minutes to my knowledge.

 

[mrpankration]

Another important factor to consider is the nursing ratio of the particular unit. Our step down unit has a 1:3 nursing ratio. Oftentimes these are very sick patients so the nurses usually have their hands full. Even if a patient is on a monitor, no one may be actually laying eyes on them for quite some time. Once the Narcan wears off, a patient who was previously alert may become altered and stop protecting their airway without anyone seeing them, next thing you know, they code. I think there are definitely times when ICU admission for close monitoring is warranted and the right thing to do, even if the patient is not intubated or on pressors. I think this is especially so in young, otherwise healthy patients whose only problem is that they overdosed. It'd be a shame to have a young person suffer an anoxic brain injury that could have potentially been avoided.

 

[Hernandez]

I agree, our step down is a mess right now due to poor management and lasy or inexperienced nurses, my usual philosophy is I'm the Intensive Care Unit not theIntensive Babysitting unit (except for neck abscess PTs) if it isn't highly likely I will be doing an intervention that can't timely be done else where. They don't come to the unit., but it's a shame that ineptness in a unit that should be able to handle it can't, and it's partially the IM docs and they're residents who are lazy and don't look after those PTs like they should, they treat them like overnight observation PTs and only see them once, they're of the mind set that if they have to see them more than once for rounds the they should be in an ICU. Needless to say I don't have many friends in the medicine department

 

[Bostonredsox]

Our SDU nurses are being cross trained in the MICU so they can provide both types of care if needed. Our MICU is usually 2:1 with some 1:1 and occasionally a 3:1 if its an OD pt 24 hours out waiting to be transferred or a post perm pacer or post carotid just hanging out till the morning. the SDU nurses are 3:1 or 4:1. At night we assign a particular intern to those pts, which cap at 8, our major drawback, and the MICU senior is also 'aware of the sick ones', having been given a pre-empttive heads up from one of the gernal floor seniors. The nursing care is not quite as good their but its pretty good. And we cannot just admit patients to MICU for the level of nursing care all of the time. The surgeons try and do this constantly because they are 'worried about their patient on the floor tonight so will you watch them in the unit overnight?' this results in me not having beds for true ICU patients all to frequently and transfers from the ED that should not need to be transferred. In general, if you are taking up a $7,000 a day MICU bed, you should be requiring INTENSIVE care therapy.

where are you at Hernandez? I will come whip your CCU naive medicine residents into shape in a few years

 

[nlax30]

Our place is also in the middle of revamping out SDU (previously CV surg step down) and has been cross training those nurses with unit RNs because they've been taking some stable vent pts on the floor (stable trach still needing CPAP or something).

Right now it's a little of a mess as the hospital wants to use it as an "intermediate critical care" unit but in reality it's more of a cardiac floor. Some of the post-cath pts I'm fine with, but lately they've been sending BS chest pain r/o obs pts there as well.

 

[deuist]

narc withdral doesnt cause seizures

Sure can if narcan is given: http://www.ncbi.nlm.nih.gov/pubmed/15167188 . You don't get seizures if the withdrawal is nature, occurring over several days.

There is a push from our toxicologists to give low doses of narcan such as 0.04 mg (The usual recommended dose is 0.4 mg, 10x higher). The goal of this low-dose approach is to get the patient breathing again, even if he is still asleep. Sometimes we use bag-valve mask ventilation as an adjunct. If you give a huge dose such a 2mg in an addict, you can cause ARDS. I've seen it twice when EMS pours narcan into opioid addicts and it's not pretty.

 

[Bostonredsox]

Sure can if narcan is given: http://www.ncbi.nlm.nih.gov/pubmed/15167188 . You don't get seizures if the withdrawal is nature, occurring over several days.

There is a push from our toxicologists to give low doses of narcan such as 0.04 mg (The usual recommended dose is 0.4 mg, 10x higher). The goal of this low-dose approach is to get the patient breathing again, even if he is still asleep. Sometimes we use bag-valve mask ventilation as an adjunct. If you give a huge dose such a 2mg in an addict, you can cause ARDS. I've seen it twice when EMS pours narcan into opioid addicts and it's not pretty.

If you read my above posts, I used 0.04mg, as you have just mentioned. I never under any circumstances push 0.4 unless they are a cardiac arrest suspected to be from narc overdose. I am unaware if their is seizure data from narc withdrawl whilst pushing successive doses of 0.04mg until arousal. As far as I am concerned, the 1/10 dose is the standard of care in repeated doses unless the patients has arrested.

 

[glorfindel]

I never under any circumstances push 0.4 unless they are a cardiac arrest suspected to be from narc overdose. I am unaware if their is seizure data from narc withdrawl whilst pushing successive doses of 0.04mg until arousal. As far as I am concerned, the 1/10 dose is the standard of care in repeated doses unless the patients has arrested.

That's my practice too.

I'm unconvinced by the linked study that deuist gave supporting the assertion that narc withdrawal causes seizures. That study doesn't seem to suggest that it does (hypoxia maybe, reversing the narcs, no). I suspect that the occasional ARDS is probably also from hypoxia and not from opiate reversal.

I don't drown these patients in narcan because I don't want an aggressive patient with profuse diarrhea interrupting my ER flow...

 

[deuist]

I suspect that the occasional ARDS is probably also from hypoxia and not from opiate reversal.

The thought is that a catecholamine surge is the cause of the ARDS.

 

[VentdependenT]

any overdose can cause ARDS either directly (aspiration) or indirectly.

I do NOT push flumazenil on out of hospital benzo overdose for the aforementioned complications.

 

[glorfindel]

any overdose can cause ARDS either directly (aspiration) or indirectly.

Ok -- Hypoxia, aspiration, the original overdose (some undefined mechanism). Reversal of opioids? Still very skeptical. For me it's all about the diarrhea.

I do NOT push flumazenil on out of hospital benzo overdose for the aforementioned complications.

+1

Benzo reversal is a dangerous thing. Flumazenil is a dangerous drug. Pushing it on an out-of-hospital OD is ridiculous. Agreed.

 

[Bostonredsox]

any overdose can cause ARDS either directly (aspiration) or indirectly.

I do NOT push flumazenil on out of hospital benzo overdose for the aforementioned complications.

agreed as mentioned above. Romazicon kills patients. benzo and EtOH withdrawl are killers. The argument is whether narc withdrawl can be as dangerous. My understanding of the data and experince is No. If you reverse them slowly in the aforementioned aliquots of 0.04mg pushed until they are atleast breathing above 12 and can follow simple commands, i would be hard pressed to believe that can induce a seizure with subseqent aspiration and death. The pathophysiology is just not there lile it is for benzos. I would want to see real data for that.

 

[logos]

If you read my above posts, I used 0.04mg, as you have just mentioned. I never under any circumstances push 0.4 unless they are a cardiac arrest suspected to be from narc overdose. I am unaware if their is seizure data from narc withdrawl whilst pushing successive doses of 0.04mg until arousal. As far as I am concerned, the 1/10 dose is the standard of care in repeated doses unless the patients has arrested.

I generally don't see the point in giving narcan in codes. The etiology of the arrest is suspected to be respiratory depression due to opiates. Instead of reversing the opiates you need to reverse the respiratory depression and get their heart started again. So instead intubate and then focus on your chest compressions.

 

[VentdependenT]

I generally don't see the point in giving narcan in codes. The etiology of the arrest is suspected to be respiratory depression due to opiates. Instead of reversing the opiates you need to reverse the respiratory depression and get their heart started again. So instead intubate and then focus on your chest compressions.

What?

 

[glorfindel]

I generally don't see the point in giving narcan in codes. The etiology of the arrest is suspected to be respiratory depression due to opiates. Instead of reversing the opiates you need to reverse the respiratory depression and get their heart started again. So instead intubate and then focus on your chest compressions.

Neurology resident?

 

[Bostonredsox]

I generally don't see the point in giving narcan in codes. The etiology of the arrest is suspected to be respiratory depression due to opiates. Instead of reversing the opiates you need to reverse the respiratory depression and get their heart started again. So instead intubate and then focus on your chest compressions.

Lol. Too funny. Yet scary at the same time...

 

[VentdependenT]

I dont even know where to begin with that.

 

[VentdependenT]

Anyway what about end stage cirrhotic with HCC s/p palliative sir spheres implantation presents with altered mental status, temp 34C, dustbunnies in foley, Hb of 5 with neg rectal, lactate of 16, ph 6.8, family want full f'n code despite prognosis.

Thats misuse of resources.

 

[redy]

Anyway what about end stage cirrhotic with HCC s/p palliative sir spheres implantation presents with altered mental status, temp 34C, dustbunnies in foley, Hb of 5 with neg rectal, lactate of 16, ph 6.8, family want full f'n code despite prognosis.

Thats misuse of resources.

Can the ICU attending say prognosis is extremely poor for the acute situation on top of the dismal outlook of the original disease and not take the patient to the ICU? Can he say the patient will not benefit from ICU and instead should be made comfortable or looked at alternatives such as inpatient hospice? Is that realistic?

 

[Bostonredsox]

Can the ICU attending say prognosis is extremely poor for the acute situation on top of the dismal outlook of the original disease and not take the patient to the ICU? Can he say the patient will not benefit from ICU and instead should be made comfortable or looked at alternatives such as inpatient hospice? Is that realistic?

Yes. Medically Futile care can be deemed by an attending. It is a sticky medical-legal situation but I have seen it done. You can't refuse to treat the pt, but you can refuse any and all procedures citing to family 'risk outweights benefit and I am not willing to perform it'. when they have horrible comorbids and that initial lactate is above 10 I generally tell them they will die tonight. regardless of whatever I do. do you want him to die with me shoving very large and painful needles into him or do you want us to make him comfortable. Have yet to have one insist on care. Now, once they are tubed and lined, because somone else wouldnt give it to the family straight, getting them to withdraw care is a nightmare.

In the end though, as the resident I dont argue. The way I see it, it is an extra airway, line, aline, etc. and the more I do, the better my skills will be.

 

[glorfindel]

Can the ICU attending say prognosis is extremely poor for the acute situation on top of the dismal outlook of the original disease and not take the patient to the ICU? Can he say the patient will not benefit from ICU and instead should be made comfortable or looked at alternatives such as inpatient hospice? Is that realistic?

Yep. Physicians decline to perform medically futile care all the time. Most common example is the surgeon saying, "this pt is not a surgical candidate, I'm not operating on him."