When to refer patients to ICU & HDU

Ahmad Mursel Anam

When to refer patient to
ICU & HDU

Ahmad Mursel Anam

MRCP UK, MRCPE
RCPE Fellow in Acute & General Internal Medicine
Associate Consultant – Critical Care
Coordinator, High Dependency Unit
Consulting physician – Covid-19 unit
Square Hospitals Ltd. Dhaka, Bangladesh
Learning objectives

• Critical care levels of dependency

When to refer patients to ICU & HDU

• Difference between ICU & HDU

Ahmad Mursel Anam

• Criteria for admission in critical care
• Where to refer patients: ICU or HDU?
• How to refer: “SBAR”
Critical care levels of dependency
• Level 0
• General management – NO ORGAN SUPPORT required
• Ward level care

When to refer patients to ICU & HDU

• Fewer than 4-hourly monitoring

Ahmad Mursel Anam

• Level 1
• At risk of deterioration of condition
• Recently stepped-down from higher level of care
• Requiring more frequent (4-hourly or more) monitoring & input
• Additional requirements than Level 0
• >3000 ml/d fluid infusion
• Frequent tracheostomy tube suction
Singer, Mervyn and Andrew R Webb. Oxford Handbook of Critical Care 3rd Edn. Oxford University Press, 2009.
Critical care levels of dependency…
• Level 2: High Dependency Unit
• Require SINGLE ORGAN monitoring & support
• NOT INVASIVE VENTILATION

When to refer patients to ICU & HDU

• NIV

Ahmad Mursel Anam

• Inotropes
• RRT
• Support for gross physiological abnormality
• American Society of Anesthesiologists Class 3 & 4 patients following surgery
• Requiring more frequent (4-hourly or more) monitoring & input than Level 1

Singer, Mervyn and Andrew R Webb. Oxford Handbook of Critical Care 3rd Edn. Oxford University Press, 2009.
Critical care levels of dependency…
• Level 3: Intensive Care Unit
• Requires advanced respiratory support & monitoring (Invasive ventilation)
• Monitoring & support for 2 or more organ system

When to refer patients to ICU & HDU

• One organ system support with chronic impairment of one or more other

Ahmad Mursel Anam

organ system

Singer, Mervyn and Andrew R Webb. Oxford Handbook of Critical Care 3rd Edn. Oxford University Press, 2009.
Difference between ICU & HDU
Intensive Care Unit
• Critical care Level 3
• Provides invasive ventilation
support
• Provides support for 2 or more
organ system
• Patient : Nurse ratio 1:1
• Highest level of care
High Dependency Unit
• Critical care Level 2
• Does not provide mechanical
When to refer patients to ICU & HDU
Ahmad Mursel Anam
ventilation support
• Provides support for 1 organ
system
• Patient : Nurse ratio 2 or 3:1
• Can be used both as “step-
down” (from ICU) or “step-up”
(from ward) area.
Criteria for admission in critical care

When to refer patients to ICU & HDU

Ahmad Mursel Anam
Smith G, Nielsen M. ABC of intensive care. Criteria for admission. BMJ. 1999;318(7197):1544-7
 Criteria for

When to refer patients to ICU & HDU

Ahmad Mursel Anam
admission in
critical care…

Smith G, Nielsen M. ABC of intensive care. Criteria for admission. BMJ. 1999;318(7197):1544-7
Criteria for calling intensive care staff
• Threatened airway
• All respiratory arrests
• Respiratory rate >40 or <8
breaths/min
• Oxygen saturation < 90% on
>50% oxygen
• All cardiac arrests
• Pulse rate < 40 or > 140
beats/min
• Systolic blood pressure < 90 mm
Hg
• Sudden fall in level of
When to refer patients to ICU & HDU
consciousness (fall in Glasgow
Ahmad Mursel Anam
coma score > 2 points)
• Repeated or prolonged seizures
• Rising arterial carbon dioxide
tension with respiratory acidosis
• Any patient giving cause for
concern
 When to refer patients to ICU & HDU
Ahmad Mursel Anam
Score (EWS)
Warning
Early
 When to refer patients to ICU & HDU
Ahmad Mursel Anam
Early Warning
Score…
 When to refer patients to ICU & HDU
Ahmad Mursel Anam
to Critical Care
When to refer
Where to refer patients: ICU or HDU?

When to refer patients to ICU & HDU

Ahmad Mursel Anam
Davidson’s Principle and Practices of Medicine, 21 ed
 When to refer patients to ICU & HDU
Ahmad Mursel Anam
How to refer: “SBAR”
 When to refer patients to ICU & HDU
Ahmad Mursel Anam
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Any Question
When to refer patients to ICU & HDU
Ahmad Mursel Anam