الفهرس 
A. Development of ICUOnly 14 pages are availabe for public view
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Abstract
Recent advances and increase in complexity of modern medicine in patients with a high level of physiological compromise led to the development of intensive care units. The intensive care unit is a hospital unit providing continuous surveillance and highly specialized care to acutely ill patients, either medical or surgical, whose conditions are life-threatening and require comprehensive care. Intensive care is one of the most expensive specialties and its cost is continuously rising. Resource allocation and the problem of inappropriate admissions in intensive care units (ICUs) has been a global concern, although guidelines for ICU admissions are available, the problem is still under investigated. No studies were found in Egypt to investigate this problem.
The present work aimed at assessment of appropriateness of admission to two intensive care units, through assessment of adherence to guidelines of ICU admission recommended by Society of Critical Care Medicine (SCCM), assessment of severity of illness of admitted patients using Acute Physiology And chronic Health Evaluation score (APACHE) II, assessment of utilization of ICU resources and identification of outcome of ICU admission.
The study was conducted in two ICUs of the department of critical care medicine in Alexandria Main University Hospital (AMUH), a general 1635-bed hospital.
Medical records of the adult patients admitted to the target ICUs, were the target population; 324 Patients were included in the study.
Data collection methods included, concurrent review in the ICUs during patient admission to capture day one clinical data for calculation of APACHE II score and reviewing day one ICU specific therapeutic interventions received if any and retrospectively in the medical record department after patient discharge from the hospital for retrieval of data related to outcome of ICU admission episode, if patient received mechanical ventilation after day one admission , disconnection from mechanical ventilation for calculation of days of mechanical ventilation, date of ICU discharge and date of hospital discharge and thus calculation of length of stay in ICU and hospital, respectively and finally for retrieval of any missed day one laboratory results due to delayed delivery from the laboratory.
The present study uncovered the following results:
I. Patient sample characteristics:
- The mean age of admitted patients` was 50.72 years and male patients exceed female patients by 10%.
- The majority of cases were admitted from emergency room and for medical causes and highest percent of them was admitted in the night shifts.
- Mean hospital length of stay was 13.21 and mean ICU length of stay was 11.22.
II. Guidelines of admission to ICU:
- Using the diagnosis model, nearly, all of the admitted cases were adherent to guidelines while, using the objective parameters model, 73.5% of admitted cases were adherent to guidelines
- Regarding the diagnosis model, in the group of cardiac system diseases, acute myocardial infarction with complications was the most common admission diagnosis, in the group of pulmonary system diseases, acute respiratory failure requiring ventilatory support was the most common admission diagnosis and in the group of neurological system diseases, coma metabolic, toxic or anoxic was the most frequent admission diagnosis, those three system diseases are the most common causes of ICU admission here and elsewhere.
- Cases admitted only for hemodynamic monitoring accounts for 16% of admission diagnoses.
- Regarding the objective parameters model, in the group of laboratory values, PaO2 < 50 mm Hg was the most common encountered parameter, in the group of newly discovered radiological findings, cerebral vascular hemorrhage, contusion or subarachnoid hemorrhage with altered mental status or focal neurological signs was the most common encountered finding, in the group of newly discovered ECG findings, myocardial infarction with complex arrhythmias, hemodynamic instability or congestive heart failure was the most common encountered finding and regarding physical findings, coma was the most common.
III. Severity of illness of admitted patients:
- Mean APACHE II score of admitted patients was 13.84 points.
- Mean APACHE II predicted mortality was approximately 22% of the sample while the actual mortality reached approximately 40% of the study sample.
IV. Use of ICU specific interventions in first 24 hours of admission
- A percent of 18% of admitted cases didn`t receive ICU specific interventions in the first 24 hours of admission, maximum number of intervention received was 5 interventions and mean TISS score was 5.6.
- Mechanical ventilation was the most frequent ICU specific intervention used followed by vasoactive drug infusion.
- About one third of patients admitted to ICU during the study period didn`t receive mechanical ventilation during their ICU stay
- Mean length of mechanical ventilation of ventilated patients was 10.35 days.
V. Outcome of ICU admission
- Approximately 40% of admitted patients were died.
- A percent of 33.3 % were transferred to hospital ward.
- A percent of 22.2 %were discharged against medical advice.
In the view of this work results the suggested recommendations were:
1- Because of high rate of cases of hemodynamic monitoring, unit medical director should allocate number of beds for observation away from intensive care beds, or to intensify the actual role of intermediate care unit to receive those cases who usually needs lesser care than care provided in the intensive care unit, to protect patients admitted for monitoring from hospital acquired infections and psychological problems.
2- Hospital manager should re-plan the toxicology unit present in AMUH to be better equipped by human resources like intensivists, toxicologists, adequate and experienced nursing staff and non-human resources like monitors and ventilators and medications so, it can deal with cases of alleged intake of unknown substance during their observation.
3- Hospital manager has to communicate with road and traffic authority about high referral of neurological cases due to accidents, to draw attention towards improving road safety as cases of accidents make a real overload on the healthcare system and they are actually preventable.
4- Unit medical director should necessitate documentation of expected length of ICU stay in the medical record during admission. It would help unit manager in expecting bed turnover, and managing adequate utilization .Also, it would help in investigation of causes of prolonged length of stay and causes of premature discharge.
5- Unit medical director should do a training session for the admitting physicians about ICD coding, for typical writing of the admission diagnosis in the medical record, then, follow up its application. This would greatly improve research precision.
6- Unit medical director should introduce a new form which document patient transfer from ICU to intermediate care unit or the reverse to be included in the patient medical record, for accurate retrieval of the patient outcome.
7- Hospital manager should draw attention towards medical record department which although having helpful staff, but need for its development is a must, it must be fully equipped with qualified human resources and up to date automated information technology, so that retrieval of patients’ records and required data can be done easily and quickly.
8-Unit medical director should ensure that the unit is compliant with national and international best practices.
9- The unit should adopt and distribute admission and discharge policies.