The clinical care of the hospitalized seriously ill patient must be ensured by the healthcare institution throughout the clinical evolution of the individual, from hospital admission to discharge home. When the presenting clinical condition is sufficiently serious, such care starts in the Emergency Area, and immediately thereafter continues in the Intensive Care Unit (ICU). Following clinical improvement, the patient is moved to a conventional hospital ward, where he or she remains until hospital discharge, provided the clinical course is favorable. However, if the clinical condition worsens while in the ward, the patient may have to be readmitted to the ICU. However, in other cases the presenting clinical condition of the patient is not serious enough to warrant direct admission to the ICU, and after a more or less brief period of initial clinical stabilization, the patient is moved to a conventional hospital ward. Here again, if the clinical condition subsequently worsens, admission to the ICU (in this case for the first time) may prove necessary.

However, what would happen if we could identify patients at risk, before critical worsening occurs, when the subject is still in the Emergency Area or in the conventional hospital ward? Undoubtedly, anticipative clinical care in these patients at risk could have a positive impact upon the clinical course and prognosis of the illness. In effect, if the identified clinical condition was serious enough, necessary admission to the ICU could be decided earlier – thereby avoiding unnecessary delays in treatment. Furthermore, and perhaps even more importantly, if the clinical condition of the patient were to warrant a diagnostic reorientation or intensification of the therapeutic measures, it might be possible to achieve clinical improvement allowing us to avoid admission to the ICU–with the added advantage of better management of the available healthcare resources. Thus, the care of the seriously ill patient, while centered on the ICU, can be extended beyond the latter, representing a continuous process throughout the hospital stay of the patient.

Stated in other words, if we were to define patient flow in the ICU, we would see that admission to the latter is either programmed or emergency based. Programmed admissions to the ICU normally correspond to high-risk postoperative patients, while the emergency cases can come from the Emergency and Observation Area, from a conventional hospitalization ward, or from some other hospital center. In turn, practically all patients admitted to the ICU are subsequently moved to a hospitalization ward (Fig. 1). The patient flow can vary in magnitude from one center to another, though globalizing the care process of the seriously ill patient could allow us to attempt to modify the flow in itself. Specifically, if we emphasize activity aimed at ensuring the early detection of seriously ill cases, we could transform emergency and possibly late patient inflow, attended by medical personnel on duty, into programmed and early management, with better distribution among the personnel members of the Unit. All this in turn would be valid in the settings of both the Emergency and Observation Area and the different conventional hospitalization wards.

Figure 1.

Patient flow of the Intensive Care Unit.

(0.15MB).

The above idea gains importance with our awareness that delays in treatment, or the provision of inadequate care in the hospitalization ward, independently of the cause, often result in non-anticipated emergency admissions to the ICU, and imply longer hospital stay and even greater mortality,1–particularly in diseases regarded as being “time-dependent”, where delays in starting treatment can lead to a marked increase in patient morbidity–mortality. This circumstance has been documented in the literature for quite some time.2 Indeed, it has been estimated that up to 50% of all hospitalized patients do not receive adequate treatment before their admission to the ICU, and that on the other hand a full 40% of admissions to the ICU could be avoided.3 Furthermore, patients admitted to the ICU from a conventional hospital ward may suffer greater mortality than those directly admitted to the ICU from the Emergency Area.4,5 However, the early identification of these patients at risk is not always easy in a conventional hospital ward. This is due to a number of reasons, including a possible lack of sufficient human or material resources, inadequate organization of the functional area, insufficient personnel training, a lack of supervision of the activities carried out, underestimation of the clinical condition of the patient, late identification of the alarms signs and symptoms, a delay in the diagnostic or treatment decision-taking process, or delays in requesting necessary clinical counseling. In any case, and as an example, almost 80% of all patients suffering cardiorespiratory arrest in hospital manifest physiopathological alterations in the previous 6–24h, in the form of undetected or unnoticed changes in blood pressure, heart or breathing rate, oxygenation, diuresis or level of consciousness.6–9

Intensivists, thanks to their professional capacitation and daily clinical activities, are undoubtedly the hospital professionals with the best training not only for the early identification of serious illness with an integral vision of the patient, but also for establishing therapeutic priorities and taking quick clinical decisions. In recent years, this has led to the development of medical care teams with different integrating members and different particularities in different centers and countries–though almost always dependent upon an intensivist, and with the same purpose in mind: the early identification of risk patients outside the ICU.10–12 In fact, in the United States these teams form part of the “five million lives” program of the Institute for Healthcare Improvement, as one of the evidence-based interventions designed to improve patient prognosis and reduce the number of unnecessary deaths.13 Although the individual results vary,14–16 the benefits afforded by such teams appear clear–particularly as regards reduction in the risk of cardiorespiratory arrest (RR: 0.66; 95%CI: 0.54–0.80)17–and they have already been incorporated to the clinical guides on cardiopulmonary resuscitation.18 However, and explained in part by differences in the composition of these medical teams, their different intervention methods or different evaluated objectives, the benefits derived in terms of lessened mortality remain to be adequately defined (RR: 0.96; 95%CI: 0.84–1.09).17,19,20

With these premises, our Unit has developed a management system in Intensive Care Medicine, based on the safety of the seriously ill patient during the entire hospitalization process, and which we refer to as an Extended Intensive Care Service (EICS) (Fig. 2). Specifically, we have established two well differentiated strategic lines, according to the place of hospitalization of the patient: “Early detection of the seriously ill patient outside the ICU” and “Patient safety in the ICU”. The first of these strategic lines refers to the identification of patients at risk outside the ICU, based on the identification, diagnostic orientation and early treatment of the seriously ill patient, in collaboration with other clinical specialties and independently of the actual place or hospitalization involved. Thus, either when the patient meets a series of well defined severity criteria and the supervising physician or nurse alerts the EICS team, or when the EICS team in the course of its daily programmed activities directly identifies a patient at risk, the required level of medical care is assessed, and decisions are taken regarding the best location for such care–always in coordination with the supervising physician. Such activity focuses on patients still in the Emergency and Observation Area, patients admitted to a conventional hospitalization ward, and patients admitted to such wards after discharge from the ICU but who are considered to be at high risk (postsurgical cases with concomitant medical disorders, patients with evolving organ failure, patients still strongly dependent upon nursing care, early discharges forced by healthcare necessities, etc.). A tool of help in the required follow-up of a concrete patient, and which moreover serves as quality control, is the so-called Sabadell index.21 This instrument, recently validated in a Spanish national multicenter study,22 is a subjective scale that grades the patient prognosis at discharge from the ICU in terms of survival of the hospital episode (Table 1).

Figure 2.

Healthcare process of the seriously ill patient in the Hospital Universitario del Henares (Coslada, Madrid–Spain).

(0.44MB).

The second strategic line logically refers to clinical care in the actual ICU, and is based on two aspects: (a) the promotion of safety and the adoption of a dynamic related incidents communicating system allowing the rapid adoption of corrective actions; and (b) the vigilance of nosocomial infections specifically and directly related to known risk factors and/or associated to increased morbidity–mortality among critical patients: mechanical ventilation-associated pneumonia, urethral catheter-related urinary infections, primary bacteremias and bacteremias related to catheters and secondary bacteremia. This distinction is necessary, since Departments of Intensive Care Medicine are hospital units with an added potential risk for the patient, due to the inherent seriousness of the clinical condition of such cases, the sometimes simultaneous undertaking of multiple activities, invasive diagnostic and treatment procedures, and the ever increasing sophistication and complexity of the care provided. Indeed, it has been estimated that the risk of suffering an incident without damage as a mere consequence of having been admitted to the ICU is 73%, and that the risk of suffering an adverse event is 40%.23 In turn, the estimated probability of suffering at least one safety-related incident (including nosocomial infection) is almost 62%,23 while the risk of experiencing an adverse event in the ICU increases between 8 and 26% for each added day of stay in the Unit.24,25 The national and international literature regularly points to medication-related problems as the most common incidents, representing almost a quarter of all cases. Other frequent incidents in turn are related to medical apparatuses or equipment, the care received, the use of vascular accesses and catheters, and problems related to the artificial airway and mechanical ventilation. Although more serious, incidents related to nosocomial infections are less frequent (8%).23

The approach adopted by this organizational model of the activities of the Intensive Care Unit has several connotations. A first and simple concern is to actively ensure the care of those patients admitted to the ICU properly in an efficient, effective and safe manner. This is easily generalizable, requiring the modifications logically related to the individual characteristics of each center and Unit. It is also necessary, and to one degree or other, and in a more or less systematized manner, has always been present in our professional activity.

A second and not always easily generalizable concern is the change in the traditional functional model of the ICU at both organizational and conceptual levels. In effect, the patient is no longer seen as only the individual admitted to the Unit, but now moreover also includes those individuals whose clinical condition can worsen, regardless of where they are hospitalized, because early clinical care in such cases can benefit the ulterior patient course. Benefit in this case is not limited to the patient, since modifying patient flow from the emergency circuit to the preferential care circuit makes it possible to lessen the burden upon the former–supervised only by professionals on duty. More precise knowledge of the clinical situation of these evaluated patients therefore allows for improved management of the existing resources. Lastly in our experience, working closer to the rest of the clinical specialties has served to improve knowledge of our daily work as intensivists, affording greater professional recognition and, undoubtedly, a greater institutional influence on the part of our Unit within the hospital.

The authors have no conflict of interest to declare.