Significance and outcome of critical care system management
© BioMed Central Ltd 2005
Published: 7 March 2005
To set up a holistic critical care system.
Ramathibodi Hospital is a 1000-bed medical school, tertiary care and referral center. The ICU of the Department of Medicine was founded in 1980 and comprised six beds that served the total 132 medical inpatient beds. The ratio of ICU:total beds was thus 0.4:10. In 1990, the number of ICU beds was extended to eight, which raised the new ICU:total bed ratio to 1:10. Such a proportion of ICU beds was apparently too small. This resulted in a number of critical patients being treated in the general medical wards with difficulties in raising and maintaining the standards of critical and respiratory care. The unclear job description also deteriorated working morale and led to a rapid turnover rate among the nursing personnel.
Steps of development
(1) In 1989–1990, attempts was made to validate the precision of the APACHE II scoring system when applied to our group of ICU patients. Among the 334 patients tested, the APACHE II scoring system was proved to be valid and the ICU performance as assessed by the Actual Death/Predicted death ratio was 1.17. (2) To estimate the actual critical care beds needed, the number of patients who were mechanically ventilated in the general wards were recorded over years (1995–1996). The data showed at least 12–20 patients were mechanically ventilated outside the ICU each day – a number that indicated the minimum additional critical care beds required. (3) In 1998, one of the 30-bed general wards was renovated to be a 20-bed intermediate care unit (IMU). The total inpatient beds was thus reduced by 10 and the new critical:total beds ratio was 2.5:10. Criteria of critical patients' admission pathways to the ICU or IMU were set. A critical care team was formed to raise and maintain standards of patient and equipment care, and to provide continued medical education in critical care medicine. A number of indices of quality control were also monitored and evaluated continuously.
Since October 1998, none of the patients who were hemodynamically unstable and/or needed ventilatory support was treated in the general ward. Despite the reduction of total inpatient beds by 10, the total number of inpatient admission has increased from 3742 in 1997 to 4657 in 2003 (24% increment). The average hospital length of stay (LOS) of the Department of Medicine has declined from 10.84 days in 1997 to 8.81 days in 2003 (18.7% reduction). The overall inpatient hospital mortality has reduced from 17.37% in 1997 to 9.90% in 2003 (43% reduction). The critical care unit performance as measured by the Actual Death/Predicted Death ratio has reduced from 1.17 in 1990 to 0.76 and 0.72 in 2002 and 2003, respectively.
Our holistic critical care system management not only resulted in a better care of critical patients, but also led to an overall improvement in department performance.