HomeHealth A-ZCritical CareWhat is an Intensive Care Unit ?

What is an Intensive Care Unit ?

Overview

Intensive Care Unit (ICU) refers to a place where specialized treatment is given to patients who are acutely unwell and need special attention and support. It provides critical care and life support for acutely ill and injured patients.

History of ICU

The concept of ICU was first developed in 1854, during the Crimean war where seriously injured patients were separated from less injured persons by Florence Nightingale[1]. This simple step reduced mortality from 40 percent to 2 percent on the battle field. The first Intensive Care Unit in the world was formed in Copenhagen in 1953[2]. The pioneer was the Danish anesthetist, Bjorn Ibsen. This was developed when an epidemic of polio out-break happened in Denmark. The first ICU in India was established by Professor N. P. Singh at Irwin Hospital, Delhi [3].

Admission criteria for ICU

The ICU is a special area of the hospital where the focus is on intense observation and treatment with increased staff and resources. This helps healthcare providers to respond immediately during emergency conditions. The trained doctors and nurses with the help of a multi-disciplinary team makes sure that the critical patient recovers rapidly and goes home. Patient who needs close monitoring and treatment are admitted to an Intensive Care Unit (ICU). Some examples of patients needing ICU care include:

  • Patients with difficulty in breathing needing special machines called, ventilators
  • Patients with low blood pressure needing monitoring and medicines to treat it
  • Patients with infections causing septic shock
  • Patients who need close observation after certain surgeries, such as brain surgery, heart bypass and trauma surgery.

ICU is a place where patients are monitored acutely. ICU patients are monitored and treated by critical care team which include critical care specialists (intensivists), resident doctors, nurses, respiratory therapists, etc. Other staff at ICU include dieticians, physiotherapists, clinical pharmacists and other supportive staff like cleaning staff, security guards, etc. Fortunately, modern technology has progressed a lot and we can get intricate details of a patient’s vital parameters like heart rate, breathing rate, oxygen level and blood pressure. This is done by making use of multiple devices with numerous wires that are seen, which are constantly monitoring the patient.

 Who is an Intensivist?

An intensivist is a trained super specialist in critical care medicine after completion of his/her advanced degrees in Anesthesiology/Internal Medicine/Pulmonology. Also called the critical care specialists, they are responsible for the patients in the Intensive Care Unit. Major decisions are taken by Intensivist after discussion with the primary and referral consultants. Daily family meetings are done to brief the patient’s attendants about their health condition and work collaboratively on the plan of care. The Intensivist holds senior responsibility of the Unit and the other healthcare professionals work in coordination with her or him.

Cost of Critical Care

Critical care is often described as expensive care. It remains a challenge to accurately assess the cost of intensive care [4] due to lack of standardized methodology. There is also considerable heterogeneity between countries and even within the country in allocation of resources and distribution of critical care services and cost of personnel and price of drugs. Every Intensivist shall actively be involved in understanding the cost in their individual unit and how it relates to the therapeutic activity, case mix and clinical outcome. This would help to allocate resources efficiently, thereby improving the volume and quality of care. There are only very few studies looking into cost of intensive care unit in India. This is not surprising as critical care medicine is relatively a new field, though it has evolved significantly over the past decade. In order to understand the cost, it is important to understand the current organization of critical care services in India and its inherent diversity. It is estimated that there are about 70,000 ICU beds available including all types and across all hospitals and small time nursing homes in India that cater to 50 lakhs patients requiring ICU admission every year  (that means there are 72 patients for one bed).

 According to some prior estimates, India was projected to spend 283,000 crore rupees on healthcare by 2012. About 80 percent of investment will have to come from the for-profit private and charitable sector where critical care accounts for 20-30 percent of hospital budget. In the absence of comprehensive insurance cover, more than 80 percent have to pay out of their pocket for health care services. Despite growth in economy and development of a middle class population with purchasing power, it is well accepted that one episode of hospitalization is  enough to account for 58 percent of per capita expenditure pushing 2.2 percent below the poverty line. Understanding these issues create ethical dilemma for the clinician, particularly when the clinical status of the patient suggest a poor outcome. Unfortunately, the common man perceives that miracles regularly happen in ICU and lacks a realistic expectation of critical care outcomes.

Studies have proven that by reducing the imported component of equipment used, causes significant cost reduction of ICU. The establishment cost of a 28 bedded Neonatal Intensive Care Unit (NICU) reported to cost Rs. 80 lakhs in 1990. To extrapolate that to 2019, it is difficult to assess due to unprecedented growth and fluctuations in the real estate market and world inflation rates. There is increasing evidence that closed (or) transitional models have better outcomes and resource utilization than open ICU’s, which in turn may translate into better cost control. There is a tremendous impact of antibiotic use on the cost of therapy in the ICU settings in India. Staff training, close supervision and developing a web-based anonymous reporting gateway will improve the quality parameters of ICU.

Types of ICU

  • General ICU: This ICU provides care across a wide range of conditions, whereas specialized ICU’s [5] provide diagnosis-specific

Some common kinds of Intensive Care Units include:

  • Neonatal Intensive Care Units (NICU): This ICU provides care for new-born infants
  • Paediatric Intensive Care Units (PICU) that provide care for children,
  • Coronary Care and Cardiothoracic Units (CCU/CTU) for heart attack or heart surgery patients
  • Surgical Intensive Care Units (SICU) for surgical patients
  • Medical Intensive Care Units (MICU) that provide care for patients with medical conditions that does not require surgery
  • Transplant ICU where post-transplant patients were kept (like liver, kidney, pancreas, heart, lung transplant units).

 Role of Social Worker in ICU

The costs associated with ICUs are high and at times invasive ICU care may not be beneficial, particularly for those patients admitted to ICUs who have little hope for recovery. The process of clarifying medical goals for these patients is often facilitated by addressing psychological factors. Social workers [6] in the ICU are uniquely qualified to assess and address many of the complex psychological circumstances and can clarify potential misperceptions, enhancing communication among patients (if capacitated), their families and the medical team members. This can help improve quality of life for very sick and dying patients in the ICU and their families, and may also reduce the likelihood of decision making conflicts from arising. End-of- life issues occur frequently in the ICU.

The specific training and skills received by social workers provide them with the necessary tools to collaborate with the inter-disciplinary teams and offer holistic care to the patients and their families. Research has shown that there is great variation in the level of participation of the social worker, often because they do not have a formal role. Where the ICU team is generally busy and has time contraints, the social worker can take the necessary time to listen, educate and advocate for the patients and their families serving as a bridge between the patients, their families and the medical team. Social workers provide families with emotional support and inform about finances, insurance and care after leaving the hospital. They are a great resource to answer questions about how a patient will adjust to life after hospitalization.

Effective Communication is the Key

Good effective communication [7] among critically ill patients, their families and providers is often challenging and complex. The dissatisfaction and concerns about poor communication with care providers from patients facing life-threatening illness and their families, are well known. Often, patients cannot speak for themselves; thus family members become the surrogate spokesperson for the critically ill patients. Successful interventions have been identified to improve communication such as the team approach to communication, the formal family meeting and a bundled check list approach. Dealing with aggressive family members when the patient is sick is the most difficult job for the ICU team. To deal with this, understand the family dynamics before consulting with the family by reviewing the patients history (including work, children and marriage), ask family members to introduce themselves and specify their relationship to patients.

Being kind and gentle, but still direct; that is really the only way you can address the fear of attendants. The most effective way of communication with a patient’s family members is to try to listen to what the family members are telling, even though it may not be relevant at that critical time. This is effective because in doing so, you are able to validate the family member’s emotions and they can see how much you care about the patient. They feel that physician is responding to the emotions not the words. This offers a chance for the physicians to display their deep interest in providing relief to the patient and strengthen trust.

Dr Nagaraju Gorla, MD
Senior Consultant Critical Care
Faculty in acadamic team, Stroke team member
Apollo Hospital, Jubilee Hills, Hyderabad.

References

  1. What is an intensive care unit? A report of the task force of the World Federation of Societies of Intensive and Critical Care Medicine (Journal of Critical Care 37 (2017) 270–276)
  2. The first intensive care unit in the world: Copenhagen 1953 (Acta Anaesthesiol Scand 2003; 47; 1190-1195).
  3. N P Singh: History of the first intensive care unit in Delhi – reminiscences (Indian J Anaesth. 2010 Nov-Dec; 54(6): 574-575).
  4. Cost of intensive care in India. Indian J Crit Care Med. 2008; 12(2):55-61.
  5. Are specialized ICUs so special? Critical care (London, England) 13,5 (2009): 314.
  6. The role of social worker in the ICU: reducing family distress and facilitating end-of-life decision-making. J Soc Work End Life Palliat Care. 2006;2(2):3-23.
  7. Communication as a basic skill in critical care. J Anaesthesiol Clin Pharmacol. 2015 Jul-Sep; 31(3): 382–383. PMCID: PMC4541189. PMID: 26330721
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