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ICU Protocol

Table of Contents


ICU Admission & Discharge Policy

1. ICU Admission Policy

The components of ICU admission policies should include

1.1. Clinical Criteria: These criteria assess the patient's clinical condition and determine whether admission to the ICU is necessary. Clinical criteria may include factors such as severity of illness, acuity of illness, and stability.

1.2. Physician Referral: This criterion assesses the patient's need for specialized care and may involve a referral from a general practitioner or a specialist.

1.3. Capacity: This criterion assesses the availability of beds in the ICU and whether the patient can be safely accommodated in the ICU.

1.4. Patient Choice: This criterion assesses the patient's preferences for admission to the ICU and provides the patient with an opportunity to make an informed decision about their care. Family members may act as substitute decision makers.

1.5. Cost Considerations: This criterion assesses the potential costs associated with ICU admission and ensures that resources are used efficiently.

1.6. Admission Protocols: This criterion outlines the steps involved in the admission process and ensures efficient and safe care for the patient.

1.7. Utilization Review: This criterion assesses the appropriateness of ICU admission and helps to ensure that resources are used effectively and efficiently.

1.8. Quality Measures: This criterion assesses the quality of care provided in the ICU and helps to ensure that the highest standards of care are maintained.

1.9. Outcome Measures: This criterion assesses the effectiveness of care provided in the ICU and helps to ensure that the best possible outcomes are achieved.

2. ICU Admission Best Practices

Establish a clear plan of care for the patient, including goals, assessments, interventions, and expected outcomes.

Ensure that the patient is assessed and stabilized upon admission to the ICU.

Monitor the patient’s vital signs and other parameters, such as fluid balance and nutrition, to ensure that the patient’s condition does not deteriorate.

Consult with other healthcare providers, such as physicians and nurses, to ensure that the patient is receiving appropriate care.

Provide adequate pain management and other comfort measures to ensure the patient’s comfort.

Ensure that the patient’s family is informed of the patient’s condition, prognosis, and care plan.

Ensure that the patient is transitioned to a lower level of care as soon as possible.


3. ICU Admission Criteria

3.1. General criteria

Patients presenting with acute illness or injury that require close monitoring and/or specialized treatments.

Patients requiring intensive management of multiple systemic organ failure.

Patients at risk of organ failure with a high probability of death without intensive monitoring and treatment.

Patients with complex medical issues that require a multi-disciplinary approach.

Patients with complex surgical procedures that require intensive monitoring.

3.2. Specific criteria (Diagnosis model)

Respiratory

Acute respiratory failure requiring ventilatory support.

Pulmonary embolism with hemodynamic instability.

Respiratory deterioration in intermediate care unit.

Need for nursing/respiratory care not available in lesser care areas such as floor or intermediate care unit.

Massive hemoptysis.

Respiratory failure with imminent intubation.

Cardiovascular

Acute myocardial infarction with complications.

Cardiogenic shock.

Complex arrhythmias requiring close monitoring and intervention.

Acute congestive heart failure with respiratory failure and/or requiring hemodynamic support.

Hypertensive emergencies.

Unstable angina, particularly with dysrhythmias, hemodynamic instability, or persistent chest pain.

S/P cardiac arrest.

Cardiac tamponade or constriction with hemodynamic instability.

Dissecting aortic aneurysms.

Complete heart block.

Neurologic

Acute stroke with altered mental status.

Coma: metabolic, toxic, or anoxic.

Intracranial hemorrhage with potential for herniation.

Acute subarachnoid hemorrhage.

Meningitis with altered mental status or respiratory compromise.

Central nervous system or neuromuscular disorders with deteriorating neurologic or pulmonary function.

Status epilepticus.

Brain dead or potentially brain-dead patients who are being aggressively managed while determining organ donation status.

Severe head injured patients.

Renal

Acute renal failure with need for acute renal replacement therapy.

Severe hypercalcemia with altered mental status, requiring hemodynamic monitoring.

Hypo or hypernatremia with seizures, altered mental status.

Hypo or hypermagnesemia with hemodynamic compromise or dysrhythmias.

Hypo or hyperkalemia with dysrhythmias or muscular weakness.

Hypophosphatemia with muscular weakness.

Endocrine

Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status, respiratory insufficiency, or severe acidosis.

Thyroid storm or myxedema coma with hemodynamic instability.

Hyperosmolar state with coma and/or hemodynamic instability.

Other endocrine problems such as adrenal crises with hemodynamic instability.

Hematologic

Severe anemia (Hb < 8 gm/dL) requiring organ support.

Severe coagulopathy.

Gastrointestinal

Life threatening gastrointestinal bleeding including hypotension, angina, continued bleeding, or with comorbid conditions.

Fulminant hepatic failure.

Severe pancreatitis.

Esophageal perforation with or without mediastinitis.

Drug Ingestion and Drug Overdose

Hemodynamic instability following drug ingestion.

Altered mental status with inadequate airway protection following drug ingestion.

Seizures following drug ingestion.

Surgical

Post operative patient requiring hemodynamic monitoring.

Post operative patient requiring ventilatory or extensive nursing care.

Miscellaneous

Septic shock with hemodynamic instability.

Hemodynamic monitoring.

Clinical conditions requiring ICU level nursing care.

Environmental injuries (lightning, near drowning, hypo/hyperthermia).

New/experimental therapies with potential for complications.

3.3. Specific criteria (Objective Parameters Model)

Vital Signs

Pulse < 40 or > 150 beats/minute.

Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the patient’s usual pressure.

Mean arterial pressure < 60 mm Hg.

Diastolic arterial pressure > 120 mm Hg.

Respiratory rate > 35 breaths/minute.

Laboratory Values (newly discovered)

Serum sodium < 120 mEq/L or > 160 mEq/L.

Serum potassium < 3.0 mEq/L or > 6.0 mEq/L.

PaO 2 < 50 mm Hg.

pH < 7.2 or > 7.6

Serum glucose > 500 mg/dL.

Serum calcium > 15 mg/dL.

Toxic level of drug or other chemical substance in a hemodynamically or neurologically compromised patient.

Radiography/Ultrasonography/Tomography (newly discovered)

Cerebrovascular hemorrhage, contusion or subarachnoid hemorrhage with altered mental status or focal neurological signs.

Ruptured viscera, bladder, liver, esophageal varices or uterus with hemodynamic instability.

Dissecting aortic aneurysm.

Electrocardiogram

Myocardial infarction with complex arrhythmias, hemodynamic instability or congestive heart failure.

Sustained ventricular tachycardia or ventricular fibrillation.

Complete heart block with hemodynamic instability.

Physical Findings (acute onset)

Unequal pupils in an unconscious patient.

Coma.

Burns covering > 10% BSA.

Continuous seizures.

Anuria.

Cardiac tamponade.

Airway obstruction.

Cyanosis.

4. Clinical Decision-Making Process

4.1. Patient Assessment

A comprehensive clinical assessment of the patient is performed to determine if ICU admission criteria is met.

The patient is assessed for severity of illness and the likelihood of a positive outcome with ICU care.

The patient and family are informed of the risks, benefits and alternatives associated with ICU admission.

4.2. Clinical Decision-Making Tool

A clinical decision-making tool, such as the Simplified Acute Physiology Score (SAPS) or Sequential Organ Failure Assessment (SOFA) score or the Acute Physiology and Chronic Health Evaluation (APACHE) score should be used to evaluate the patient’s current physiological status and to predict the severity of illness and the probability of death.

The score is used to determine the best course of action for the patient and to identify those patients who are likely to benefit from ICU admission.

5. ICU Admission Process

Perform comprehensive clinical assessment of patient to determine if ICU admission criteria is met.

Assess severity of illness and likelihood of positive outcome with ICU care.

Inform patient and family of risks, benefits and alternatives associated with ICU admission.

Calculate Simplified Acute Physiology Score (SAPS) or Sequential Organ Failure Assessment (SOFA) score or Acute Physiology and Chronic Health Evaluation (APACHE) score.

Determine best course of action for patient.

Identify those patients likely to benefit from ICU admission.

Admit patient to ICU if criteria is met and score is high enough.

Monitor the patient closely and adjust treatment accordingly.

6. ICU Discharge Policy

ICU discharge policy is a set of standardized protocols and procedures for discharging critically ill patients from the intensive care unit (ICU). The goal of the policy is to ensure that patients are discharged in a safe, timely, and cost-effective manner.

6.1. Components for ICU discharge plan

Consultation between physician and patient/family about the plan for discharge.

Assessment of the patient's condition and ability to perform activities of daily living.

Development of an appropriate discharge plan.

Organization of needed services and follow-up care.

Education of the patient and family about the discharge plan.

Evaluation of the patient's response to the plan.

Continuation of follow-up care and monitoring after discharge.


6.2. General Criteria for ICU discharge

When a patient's physiologic status has stabilized and the need for ICU monitoring and care is no longer necessary for at least 12 hours.

If the patient (or relatives, next of kin) is requesting the transfer for care elsewhere or withdraws the consent for further care (self-discharge).

Patients will be transferred to another hospital if they require specialized care.

Further Readings:

1. Nates, J. L., Nunnally, M., Kleinpell, R., Blosser, S., Goldner, J., Birriel, B., ... & Sprung, C. L. (2016). ICU admission, discharge, and triage guidelines: a framework to enhance clinical operations, development of institutional policies, and further research. Critical Care Medicine, 44(8), 1553-1602.

2. Smith, G., & Nielsen, M. (1999). Criteria for admission. Bmj, 318(7197), 1544-1547.

3. Stretch, B., & Shepherd, S. J. (2021). Criteria for intensive care unit admission and severity of illness. Surgery (Oxford), 39(1), 22-28.

4. Lesieur, O., Quenot, J. P., Cohen-Solal, Z., David, R., De Saint Blanquat, L., Elbaz, M., ... & Rigaud, J. P. (2021). Admission criteria and management of critical care patients in a pandemic context: position of the Ethics Commission of the French Intensive Care Society, update of April 2021. Annals of Intensive Care, 11(1), 1-3.

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