Department of Intensive Care Services

2008 Annual Report

By Lt. Col. Dr. Yasser Mandourah, FRCP(C), FCCP

Introduction:

This is the 4^th year since the new intensive care 5-year plan was implemented. It was set in 5 stages:

Stage IV- 2008 ICS

1.      GICU - 21 fully operational beds

2.      SICU - 5 fully operational beds

3.      Fast Track - 9 beds - 50% operational

4.      RICU established from LTVU - 5 beds fully operational

5.      Royal ICU - 5 beds

6.      Mobile ICU - 5-10 beds

Total Operational ICS beds - 50 beds   -   2^nd Line ICU Beds - 40 beds as HDU

Total of all RMH-ICS Beds:

1^st line - 60 beds

2^nd line - 40 beds

Total ICU - 100 beds

CIS & RC

1.      FCCS  training of 1000 candidate

2.      FDM 200 candidates

3.      Starting Rapid response course

4.      Starting Mechanical ventilation course

5.      Saudi Board critical fellowship 4 candidates

6.      Critical care nursing diploma 2nd patch

7.      Respiratory therapy 2^nd and 3ed patch

8.      7 studies running.

ALL 2008 GOAL WERE ACHIVED

Total of all ICS Beds:

1^st line - 60 beds

2^nd line - 40 beds

Total ICU - 100 beds

RMH-ICS is the largest ICU in the Kingdom

The Results:

I - Admission RMH-ICS

- Total number of admissions to Intensive Care Services was 1850 patients for 2008.

Standards Satisfaction:  RMH - ICS Had The Highest Admission Rate in Saudi Arabia.

There was an increase almost four times increase in total patients admitted to ICS between 2004 and 2008.

The most noticeable increase is in admission cases.

Mobile ICU and Surgical count for the majority of the increase in admissions.  There was a plateau curve with Medivac ICU.

II - Outcome

1) Mortality Rate (MR) - Overall 2008 mortality rate was 15.8%

Standards Satisfaction:  The lowest mortality rate in the country.  Meets International Standard.

There was a remarkable drop in the mortality rate from 2004 of 32% to 2008 of 15.8% (including DNR).  This is better than National Guard's mortality rate of 19% and KFSH&RC mortality rate of 18% in 2007.

VI. Top 7 Services with Highest Survival Rate

1)      ENT

2)      Plastic surgery

3)      Obstetrics

4)      Opthamology

5)      Orthopedics

6)      Thoracic surgery

7)      Vascular surgery

VII. Special Services in Mortality Rate

Despite the high mortality in these specialized services without a major increase in the number of cases admitted, there was an impressive drop in the mortality rate from 2004 and even in 2005 and 2006.  This may reflect the effect of new equipment and protocolized care.  We noticed this improvement was in specialized cases such as hematology, oncology and cardiology cases.

III- GICU

IV- SICU

Surgical cases have increased 10 times since 2004.  The reasons are most likely due to

1)      Surgical ICU

2)      Fast Track and

3)      Increased need for Surgical ICU beds

We had a target in 2008 to do 1000 surgical critical care cases to increase it to a 10-fold increase for 2004.

We achieved 850 surgical case admissions in 2008.

Services who had top 4 increases in their admission to ICU were mostly surgical.

The above tremendous increase between 1 and 18 fold increase is due to RMH becoming a specialized Tertiary Surgical Center.

The overall SICU MR was 7% which follows the International best standards and lowest in the country.

V - Mobile ICU

Mobile ICU has increased its admissions by 2 times since 2005 due to increased demand.  This has been associated with the decrease in cardiac arrests from 11% in 2004 to 3.3% in 2008.  This is accompanied by a drop in post cardiac arrest MR from 70% to 33%.

A&E Patients

There was increase in admissions from A&E by one-quarter fold. This reflect expansion in A&E beds

Cardiac Arrest

Mobile ICU decreases MR and frequency of cardiac arrest. It also increases the admission to ICU and decreases MR in-patient admitted to the ICU. It decreases MR due to cardiac arrest.

VI- Medivac ICU

Medivac admissions have increased from 2004 which was 30 cases to 1.6 times in 2005 and 3 times in 2006 and 4 times in 2007 and in 2008, almost 4 times with what has been

referred to RMH in 2004.  Medivacs in 2007 to reached less than 100 cases which is 34 times the increase since 2004.  This did not change in 2008.

The total Medivac cases treated in RMH since the implementation of the new system was 200 cases  - one quarter of which were trauma cases, one half of the cases required surgical intervention where the overall mortality rate was 19%, overall surgical cases, mortality rate was 10%.  This has dropped dramatically from 2004 where the mortality rate was 75%.  This mortality rate is comparable to the overall mortality rate in GICU outcome.  Surgical Medivac mortality rate is half the average other Medivac mortality rates.

The length of stay was 15 days which was three times the average LOS in GICU. This is due to a prolonged recovery phase and complication due to primary hospital interventions. I feel the current system can not achieve the increase in Medivac transfer to more than 100 cases/year. This will only constitute 10% of cases referred to RMH. This will deprive a large proportion of eligible patients to access RMH tertiary care facility.

In my opinion, the only way to increase the Medivac transfers to RMH is by establishing the Medivac ICU.  The proper utilization of ICU beds is as follows:

1) Better utilization of ICU beds and the transfer of the patient back to the referring hospital for recovery

2) Increase in surgical Medivac transfers

3) Reserve 4 beds for Medivacs and call it Medivac ICU

4) Establish an administrative office to manage Medivac transfers called the Medivac Transfer Office

5) Establish a Policy and Procedure utilizing information technology to proper utilization RMH Tertiary Services in managing Medivac Cases.

VII - Neurosurgical Patients (Neuro ICU)

There was a 4 fold increase in neurosurgical patients. This reflects the major shift towards a specialized separated center that follows the International standards in quality and answers the marked national demand

VIII- ICS Procedures in the Procedure Room (Satellite Theatre)

The procedure Room was a unique idea introduced in the new GICU to do all procedures referred from other services in the hospital to ensure patient safety and to do all high risk operations and procedures for GICU patient and patients from other services. There was almost 150 high risk procedure that were done in the GICU Procedure Room in 2008.

IX- Length of Stay

There still maintains a decreased LOS in ICU but not as impressive as 2005.  This is due to increased Medivac admissions - 3 times and due to an increase in cases where the

average LOS was 12-15 down such as General Medicine, Hemotology and Oncology whereas surgical cases LOS was 5 days.  There was an interesting note that occupancy rate has increased from 110% to 160%.  This means there are 1.6 patient admissions to the ICU bed every day.

An average day in the ICU - 4 cases are referred to the Mobile ICU (2/3 from ward and 1/3 from A&E), 2 (double from 2004) get admitted from the ward or A&E and 4 (10 times increase from 2004) cases get admitted from OR,one Medivac every 4 days gets admitted and one case dies every 2.2 days and 2.2 cases get discharged every day.

Discussion

The year 2008 was a land mark of RMH-ICS.  Despite remarkable improvements in 2005, 2006 and 2007 compared to 2004 due to the implementation of the new systems of                  1) closed ICU

2) Mobile ICU

3) P&P

2008 has shown record high admission rates and recorded the lowest mortality rate and maintenance of shortest length of stay in the Intensive Care Unit. The jump in the number of cases admitted to RMH-ICS from 632 to 1850 from 2004 to 2008 is one of the highest increases in history.  This has impacted on answering a high demand for ICU beds and in the treatment of a large number of critically ill patients who required specialized medical, surgical and oncological and bone marrow transplant care.  Despite the fact that this has impacted the utilization of unchanged resources of medical supplies and disposables, this number may double in 2009.

The increasing demand and the specialization of services in the rest of RMH departments would increase the rate of admissions to RMH-ICS.  Despite the increase in demand and the increase in services, RMH-ICS has performed remarkably well by recording the lowest record in MR in its history and the countrywide rate.  This was coupled with the reduction of absolute numbers of death, emphasizing the fact that the drop in mortality rate was not due to an increase in numbers of admission only.  Another fact, the average APACHI II score was 25, which reflects the very sick population of patients admitted to RMH-ICS.  There was an increased demand from specialized services such as oncology, hematology, hepatology and cardiology by double to triple accompanied by the reduction in mortality rate to ½ to 1/3 of 2004 mortality rate.  This reflects the high technology in the newly equipped RMH-ICS and highly trained medical staff and the successful implementation of the Policies and Procedures and Protocolized Care.

There was a steady growth in the rate of surgical cases by 10 fold between 2004 - 100 cases to 850 cases in 2008.  This is mainly due to the opening of the Surgical ICU and the Fast Track. The capacity of these 2 units is 1000 cases/year which is going to be our goal.

Medivac admissions have increased by 3 fold from 32 to 104.  This is not likely to increase due to the high average length of stay of 14 days for Medivac.  Surgical ICU will be the only way to increase this highly demanding service.  The turn down rate is 10 times our acceptance rate.

RICU Respiratory Intensive Care Unit (Weaning Program) Center will grow from 32 cases to 300 cases increased by 10 times.  This resource will decrease the rate of chronically ventilated patients and decrease the cost of ICU.

The average length of stay was 9 days.  This is below the average of 2004, which was 12 days, but more, record lowest 2005 average length of stay, which was 5 days.  This is due to an increase in Medivac admissions 4 folds, which average LOS is 15 days and the increase in the number of admissions where the average LOS was 10 days such as General Medicine, Hemotology and Oncology.  There was an impressive reduction in the average LOS in services notorious to prolonged admission such as General Medicine from 15 days in 2006 to 10 days, respiratology from 26 days to 10 days.  This is due to the utilization of the Special Intensive Pulmonary Therapy Unit in the new ICU.  This is conformed by a simultaneous reduction in MR in respiratory cases from 42% in 2006 to 16% in 2008.

The utilization of the hypothermia unit in the new ICU has resulted in a favorable outcome in mortality rate from 70% in 2004 to 33% in 2008. The utilization of the new equipment in the new ICU and protocolized care has resulted in the reduction of overall mortality rate from 32% in 2004 to 15.8% in 2008 and a reduction in the mortality rate in highly specialized services such as hemotology and bone marrow transplantation from 75% in 2004 to 36% in 2008 and in oncology patients from 70% in 2004 to 21% in 2008, nephrology from 40% in 2004 to 28% in 2008.  This is an impressive improvement that would encourage further admission of such specialized services that are usually turned down.

CONCLUSION

The opening of the new ICU with new equipment and protocolized care has impacted the outcome of cases admitted to RMH-ICS by decreasing the mortality rate by 50%.  The increase in the number of beds in addition to the protocolized care has improved the number of cases admitted to RMH-ICU by increasing the number of cases admitted by 4 times.  The training of the young generation of health care givers in the ICU Fellowship, nursing diploma and respiratory therapy diploma has resulted in new qualified healthcare workers that are in the desired standards to carry on and take charge of highly specialized and complicated critical care.  This is a cost effective and a national strategy that was

adopted by RMH-ICS and proven to be the most important step in the improvement of critical care at RMH-ICS.

X - Goals to be Achieved in 2009 (Last year in the 5 year plan)

Stage V- 2009

ICS

1.      - full operational ICS 55 beds

2.      - opening 20 bed Medivac ICU

3.      - opening 5 bed Neuro-ICU

4.      - solid organ transplant ICU 10 bed

Total ICS  first-line beds - 90 & 50 beds 2^nd line used as step down

ICS& RC

1.      5 Courses - FCCS, FDM, RRT,MV, ICP monitor and Neuro-ICU

2.      Graduation of 1^st Critical Fellowship batch

3.      Graduation 2^nd Critical Care Diploma batch

4.      Graduation of  2^nd Respiratory Care Diploma batch