Referrals
The ICU registrars are instructed to call the Duty Intensivist after they have assessed each and every referral. Some registrars have or develop the experience and capability to safely and appropriately admit without contacting the intensivist – this will happen via evolution as we come to appreciate their skills, ability and limitations.
Any patients assessed by the registrar who is NOT for ICU admission MUST have Duty Intensivist approval. There are two categories –
All of these refused and declined patients are entered into the “Refusals” book in ICU so that the ICU LN and Outreach Intensivist can review them the following day. This is both a service provision (“can we help”) and a quality activity (“did we make the right decision? If not, now we can rectify it”).
All refused admissions are reported to both ANZICS and ACHS as a clinical indicator. It allows us to measure unmet need and forms the primary basis for gaining extra resources (i.e. beds).
ICU remains involved in the care of the patient until they are safely disposed of, whether by external transfer, delayed ICU admission, or their risk of needing ICU admission has resolved. Offer your assistance if a patient is being held in ED or theatre awaiting transfer. This maintains inter-departmental relationships, is good for the patient, and allows you to triage the transfer (ie. it may be prudent to transfer a stable patient from ICU rather than the unstable patient in ED or theatre)
Any patients assessed by the registrar who is NOT for ICU admission MUST have Duty Intensivist approval. There are two categories –
- Refused admissions – appropriately referred patients that cannot be admitted due to a lack of beds.
- Declined admissions – patients who are unlikely to benefit from ICU as they are either too well or too sick
All of these refused and declined patients are entered into the “Refusals” book in ICU so that the ICU LN and Outreach Intensivist can review them the following day. This is both a service provision (“can we help”) and a quality activity (“did we make the right decision? If not, now we can rectify it”).
All refused admissions are reported to both ANZICS and ACHS as a clinical indicator. It allows us to measure unmet need and forms the primary basis for gaining extra resources (i.e. beds).
ICU remains involved in the care of the patient until they are safely disposed of, whether by external transfer, delayed ICU admission, or their risk of needing ICU admission has resolved. Offer your assistance if a patient is being held in ED or theatre awaiting transfer. This maintains inter-departmental relationships, is good for the patient, and allows you to triage the transfer (ie. it may be prudent to transfer a stable patient from ICU rather than the unstable patient in ED or theatre)
Elective referrals
Most are seen in the ICU pre-admission clinic held on Tuesday afternoon (1.45 – 3.30pm). There will be others than can usually be handled over the phone between you and the referring doctor. If a patient is referred by an anaesthetist outside of the Tuesday clinic, it is appropriate to accept the referral without having seen the patient.
In clinic, two decisions need to be documented –
The following procedures require ICU admission post-operatively:
Procedures previously admitted to ICU but now usually admitted to the ward (in case you receive a referral and are wondering why…)
These and other cases are therefore assessed on a case by case basis, cognisant of the relative lack of complex care beds.
All elective surgical procedures commence regardless of the ICU bed state as our cancellation rate is < 1%. It also eliminates phone calls from theatre asking us whether there is an ICU bed.
Most are seen in the ICU pre-admission clinic held on Tuesday afternoon (1.45 – 3.30pm). There will be others than can usually be handled over the phone between you and the referring doctor. If a patient is referred by an anaesthetist outside of the Tuesday clinic, it is appropriate to accept the referral without having seen the patient.
In clinic, two decisions need to be documented –
- Does the patient need ICU?
- What is the resuscitation plan (this includes an opportunity to discuss advanced care planning)?
The following procedures require ICU admission post-operatively:
- Oesophagectomy (Ivor-Lewis)
- Gastrectomy
- Pneumonectomy
- Major head and neck resections likely to lead to airway swelling
- Radical cystoprostatectomy and ileal conduit formation
- Anterior resections
- Lobectomy/wedge resections (*can potentially be managed in complex care)
- Bowel resections involving an anastomosis in age >60 years (as a large proportion become hypotensive in context of also having an epidural)
Procedures previously admitted to ICU but now usually admitted to the ward (in case you receive a referral and are wondering why…)
- Prostatectomy
- Nephrectomy
- VATS
- UPPP
- Thyroidectomy
These and other cases are therefore assessed on a case by case basis, cognisant of the relative lack of complex care beds.
All elective surgical procedures commence regardless of the ICU bed state as our cancellation rate is < 1%. It also eliminates phone calls from theatre asking us whether there is an ICU bed.
Emergency Referrals
Always talk to the ICU ANUM before definitively accepting a referral.
ED
Theatre
Ward
External
Always talk to the ICU ANUM before definitively accepting a referral.
ED
- Registrar review within 30 minutes of referral
- Try and admit to bed within 2 hours
- Don’t need to be admitted by parent unit first, but MUST HAVE parent unit assignment
- Use your judgement as to whether lines best inserted in ED (keeps their skills up, patient safety) vs. ICU (reduce patient time in ED, improves patient flow)
- If the ICU is full, do not use the ACCESS nurse to care for patients referred from ED. These patients must either be transferred to another hospital, be transferred to the ward or be admitted once a bed has been made available.
Theatre
- If anaesthetics refers a patient intra- or post-operatively, accept them unless there is limited ICU beds. If declining an admission, either, personally review the patient and discuss with the anaesthetist (if you’re in the hospital), or discuss with the anaesthetist over the phone. Refusing an anaesthetist’s referral via the ICU registrar usually ends up with an upset anaesthetist. Respect the anaesthetist’s professional judgement.
- If the ICU is full, do not use the ACCESS nurse to care for patients referred from OR. These patients must either be transferred to another hospital, be transferred to the ward or be admitted once a bed has been made available.
Ward
- A MET call is not a referral to ICU
- A “heads-up” IS a referral to ICU. …..we do not encourage “heads-ups”
- If the ICU is full, it is appropriate for the ACCESS nurse to care for patients who need emergent transfer to ICU from the ward.
External
- All external referrals should come through ARV
- Any referrals from an external hospital should be directed to ARV
- All referrals from ARV should theoretically involve a conference call with the ICU ANUM, Intensivist, the PFC, the referring unit and the ARV coordinator, but this does not usually happen. Usually, if the PFC says we can accept the patient, then it becomes a discussion between ARV and an intensivist or a senior ICU registrar.