1. Determining the Appropriate Level of Care
Zorawar Noor
Fundamentals In Medicine Series
7/22/2015

2. Goal:
After this talk, you should be more comfortable determining the appropriate level of care for your patients and advocating for them.

3. Objectives Understand the guidelines for ICU triaging and admission.
List the indications for admission to telemetry.
Learn a few simple rules to prevent making errors in triage.

4. “The ICU is for patients who are intubated or on pressors.”
LIES !

5. Which types of patients are triaged to the ICU?
Those with:
Shock
Respiratory failure
GI bleeding
Acute Coronary Syndrome
DKA
Drug Overdose
… and many others

6. Who belongs in the ICU?
“ICUs should, in general, be reserved for those with reversible medical conditions who have a ‘reasonable prospect of substantial recovery.’ ”
1 “Guidelines for ICU Admission, Triage, and Discharge.” Society of Critical Care Medicine, 1999

7. How do we triage patients into the ICU?
Appropriate triage allows:
Available beds for those that need them most
The best patient care
Prioritization Model
Diagnosis Model
Objective Parameters Model *** Least useful.
***The authors write “these criteria have been requested ... and while arrived at by consensus are arbitrary.”
1 “Guidelines for ICU Admission, Triage, and Discharge.” Society of Critical Care Medicine, 1999

8. A Quick Word on the Objective Model
This model is the least useful. Don’t wait to see a SBP < 80 to transfer.
HR< 40 or >150
SBP < 80 or 20 below patient’s usual
MAP < 60
RR > 35
Na < 110 or > 170
PaO2 < 50 (really? Approx. a Hgb Sat of 85%)
Glucose > 800
Anuria

9. Prioritization Model Severely ill without limitations on care
Intensive monitoring and potentially need immediate intervention
High risk of death but limited chance of recovery
Require a discussion with the ICU team, but less likely to need ICU:
Frequent monitoring but unlikely to need immediate intervention
Terminal and irreversible diseases, “Too sick for the ICU”
Examples:
Intubated and on vasopressors
2) Multiple comorbidities with a severe debilitating event
3) Metastatic laryngeal cancer patient with airway obstruction
4) a) conscious drug overdose
b) hospice patients
1 “Guidelines for ICU Admission, Triage, and Discharge.” Society of Critical Care Medicine, 1999

10. Diagnosis Model
Let’s go over some scenarios

11. Scenario 1 – Shortness of Breath
You are called to evaluate a 23 year-old man with severe asthma exacerbation. In the ED, he received two Duoneb treatments. He is satting 95% on room air with RR 22, HR 115, and BP 155/85. Appears very distressed and using accessory muscles to breathe and is paradoxically breathing. Labs demonstrate an unremarkable CBC and BMP. ABG shows hypocapnea and mild hypoxemia. CXR with hyper- expansion without consolidations.
What would you like to do?

12. Scenario 1 – Shortness of Breath
Either you intubate this patient, or you send him to the ICU.
In the words of Dr. Leven:
“Intubation is not an addiction. When people say, ‘He’ll never get off the vent.’ That isn’t a thing, if that’s the case, then consider hospice.”
“If you anticipate that your patient will require intubation anytime in the next 24 hours, don’t wait, intubate now.”
Pearl #1: Intubate Early! Otherwise, make sure you have a contingency plan in place. I.e. Don’t fall into what I call the “BiPAP trap.” This is when the pulm fellow says, “oh, it’s okay we’ll just BiPAP him, he doesn’t need to go to the unit.”
I recommend you 1) Notify the Pulm fellow of your crashing patient and have them come assess the patient, at bedside, together, make a plan. So, A) You intubate and send to the unit. Or B) Okay, “we will try BiPAP for 30 minutes. At that point, we will reassess. If a repeat ABG is not improved and the patient is not appearing clinically improved, he goes to the ICU.” This assures that the patient doesn’t stay on the floor all night, “blocked” out of the unit and end-up crashing.
Pearl: Don’t wait, intubate or escalate!

13. What about BiPAP for my CHF patients?
BiPAP is only allowed for a short amount of time on the floors
Fabled to be 1 hour maximum on floor …. vs 1.5 hours… vs 3 hours??
BiPAP can be done for several hours if:
Stable on home settings
In the DOU or ICU at the VA
In the step-down or ICU at UCI

14. Patients with neuromuscular disorders and SOB
Likely need close ICU monitoring or early intubation
Check vital capacity / NIF, but do not be reassured if they appear clinically well.

15. Scenario 2 – Palpitations
45 year-old man with palpitations with associated shortness of breath, found to be in 2nd degree type II AV block. His heart rate is 52 bpm, BP 110/85, RR 20.
What’s his appropriate level of care?

16. Scenario 2 - Palpitations
Send this patient to the CCU for a possible pacemaker for a high- degree AV block and also for monitoring of his symptomatic bradycardia.

17. Who Needs to be on Telemetry?
Have you been asked, “Does this patient need to be on telemetry?”
Here are the criteria:
A) Cardiac (Cardiac Monitoring)
“rule-out” ACS
s/p cardiac procedure like cath or AICD
Decompensated heart failure
Suspected hemodynamically significant bradyarrhythmia or tachyarrhythmia
B) Pulmonary (Continuous Pulse Ox)
Hypoxia/ hypoxemia, or with acute illness requiring supplemental oxygen
OSA, COPD exacerbation

18. Do my CHF patients go to Cardiology?
A new diagnosis of CHF goes to the Cardiology service
All decompensated CHF patients go to telemetry
Decompensated CHF patients requiring with significant respiratory failure (i.e. on face mask or BiPAP) should be considered for management by Cardiology service.

19. What about A fib with RVR?
New onset atrial fibrillation should be evaluated by the Cardiology service.
If atrial fibrillation is easily controlled with IV push and PO medication then the patient is safe for telemetry.
Patients with hypotension or difficult to control RVR should be admitted to the CCU.

20. Where do you want to admit this patient?
Scenario 3 – Chest Pain
55 year-old man with MI in 2013 on Beta-blocker, statin, ASA, CCB, and Imdur who for 3 weeks has his usual chest pain but it now occurs after walking four feet as opposed to his baseline of 15 feet.
Where do you want to admit this patient?
What’s the most likely diagnosis?

21. Scenario 3 – Chest Pain
“ACS rule-out” can go to the telemetry, but actual ACS goes to Cards
Don’t miss unstable angina in a patient admitted to you from the ED
Patients are at significant risk for fatal arrhythmia in first 48 hours

22. Scenario 4 – Uncontrolled Diabetes
35 yo man with type I DM in DKA from medication non-compliance who is hemodynamically stable, with Glu 600, ketones 1.0, pH 7.3 and anion gap of 14.
35 yo man with type I DM in DKA with glucose 800 and pH 7.1 and gap 20.
Where do you want to admit this patient?
Where do you want to admit this patient?

23. Scenario 4 – Uncontrolled Diabetes
Mild DKA can be managed on the floor with q4 BMP checks
UpToDate includes a protocol to treat DKA without drip
Reasons to admit DKA/HONK to ICU:
Hemodynamic instability
Altered mental status
Respiratory insufficiency
Severe acidosis
1 “Guidelines for ICU Admission, Triage, and Discharge.” Society of Critical Care Medicine, 1999

24. Scenario 5 – Uncontrolled HTN
88 yo man with HTN did not take his medications, in ED for diabetic foot ulcer. BP 190/120, HR 88. Troponin = 0.1. EKG without T-wave or ST changes. CXR unremarkable.
Where do you want to send this patient?

25. Scenario 5 – Uncontrolled HTN
Hypertensive urgency can be managed as an outpatient with oral medications.
Lower the BP by 20% in 24 hours
Hypertensive emergency (end-organ damage) goes to the ICU.
Lower the BP by 15-20% with drip for tight control
In this case, a mild troponin bump might be “demand” in a patient that is 88 years old, and while they may or may not deserve an ACS rule-out on telemtry, they do not necessarily need the ICU.

26. Where do you want to admit this patient?
Scenario 6 – GI Bleed
67 yo man with history of MI with UC flare with hematochezia x2. On ROS he has some chest pain. Lying down: HR 85, BP 140/80, standing 95, BP 120/77. Hgb 12 and Plt 300.
Where do you want to admit this patient?

27. Scenario 6 – GI Bleed Consider the ICU for GI bleeding patients with:
Orthostatic hypotension
Angina
Continued bleeding
Hypotension
If patient stays on the floor, frequently reassess.

28. Scenario 8 – Drug overdose
25 year-old man overdosed on liraglutide and had a witnessed tonic- clonic seizure. He is a lethargic but otherwise, his neuro exam is unremarkable.

29. Scenario 8 – Drug overdose
Patients with overdose with the following go to the ICU:
seizure
hemodynamic instability
inadequate airway protection
Neurologically compromised
Conscious overdose can go to floor, step-down, or telemetry

30. Scenario 7 - Headache What would you like to do?
34 year-old lady with ITP with history of splenectomy is admitted for a platelet count of 4. On hospital day #1 she develops an abrupt 10/10 headache associated with nausea and vomiting. BP 165/90, HR 95, and RR 18, satting 95% on RA. Neurologic exam is unremarkable. Preliminary CT head shows possible intra-parenchymal bleed, but not sure if it artifact.
What would you like to do?

31. Scenario 7 - Headache Category of Patient Admission Service
Multi-system trauma or non-operateive head bleed
Trauma, SICU
Isolated operative traumatic ICH
NSG, SICU
Spontaneous operative ICH
NSG, either NSCU or SICU
Spontaneous non-operative ICH
NSG, NSCU under neuro-critical care
Isolated non-operative head trauma with multiple co-morbidities or trauma
MICU
Seizure related closed head trauma
Neuro-critical care service, NSCU
Adapted from “Head Injury/ Bleed Patient Disposition” medicine.uci.edu/noc.

32. Other ICU Scenarios: Coma
Severe hyponatremia (i.e. Na <110 in the Objective Model)
Stroke with altered mental status
Pulmonary emboli with hemodynamic instability / massive life- threatening pulmonary emboli
Severe pancreatitis
“Need for nursing / respiratory care not available in lesser care areas”

33. Zo’s Rules
1: Don’t Block! 2: If you are called about an unstable patient. Go assess. Write a note. Also, ask your consultant to leave a note. 3: At night, if a patient seems “very borderline” for the ICU, send them to the ICU. Never be embarrassed that a patient did well. 4: Don’t assume everything is okay. 5: Seek help from higher-ups if you can’t agree.
5 Rules to Avoid messing up
When in the unit, don’t give the impression that you are trying to block. People see it, and it demoralizes your peers and intimidates them into asking for your help, which they may genuinely need. That scenario NEVER ends well when things go poorly.
This goes back to Dr. Swaroop’s lecture about PRNs, don’t act without thinking. When you hear about a hypotensive patient, go assess, then manage. Write a note. Do not simply give 250cc bolus after bolus and assume the best outcome.
It’s always easier for patients to leave the ICU the next morning or the same evening, but it’s impossible to go back in time. There’s no shame in sending a patient to the ICU and then having them do very well. You should be proud you were a good physician.
Be cautious when someone tells you the vitals are stable, or when a surgical consultant says “Don’t worry, it’s not appendicitis.” If you feel strongly that it is, pick-up the phone and tell them to re-evaluate. Sometimes it’s an intern (you would be surprised). Ask for their senior. If you are still concerned, you can always get upper level help. Similarly, when your GI consultant says “we don’t need to scope.” Ask them their thoughts and what alternative plan they have. Empy reassurance is meaningless.

34. Summary
Intubation and pressors are not ICU requirements. Also, your patient shouldn’t have to fit a parameter like HR>149 bpm to be in the ICU.
If the patient requires frequent monitoring but little chance of an immediate intervention, consider a step-down floor.
Intubate early or make a safe plan. BiPAP is usually only temporary.
Don’t block. Go assess. Write notes. Don’t blindly trust anyone.
Don’t be embarrassed to send a patient to your colleague. Advocate and be proud if your patient does well.

35. Thank you for listening!
Questions?