Director:
David M Linton, MBChB, FCA, MPhil (Critical Care)
Head of Unit and Senior Lecturer
Department of Medicine

Physicians:
Sigal Sviri, MD

Physician and Lecturer
Olga Shatz, MD

Attending Physicians (participating in regular consultant duties and teaching):
A. Ben Yehuda, M.D. Professor of Medicine
Y. Caraco, M.D., Professor of Medicine, Pharmacologist
R. Melmed, M.D., Professor of Medicine
R. Nir-Paz, M.D., Lecturer, Physician, Resident in Infectious Diseases

Additional Nursing Staff:
26 positions for Intensive Care Nurses, Nurses, and Secretary.
Average nursing cover of one nurse for three patients with half of the nursing staff currently ICU trained

Regular (Daily) Consultant Specialists from:
Infectious Diseases
Pulmonology
Neurology
Cardiology
Nephrology
Otorhinolarynglogy
Cardio-thoracic Surgery
Hematology

Regular (Daily) Paramedical Specialists attending on rounds:
Respiratory therapists
Physiotherapists
Nutritionalists
Equipment Technicians
Pharmacists
Social Workers
Additional specialists of every Medical, Surgical, Nursing and paramedical discipline available daily in the university Hospital and consulted as required.

Fellow in Intensive Care on Rotational training program
One fellow with Board Certificate in Internal Medicine or Anesthesiology on rotational training program in agreement and cooperation with Professor C. Sprung, Director of the General ICU at Hadassah.

Resident Physicians on 6 monthly rotation:
24 hourly attendance by residents in Medicine (2 physicians every day and one at night).
Since commencing this rotation after establishing the Unit in 1996, almost all residents completing their training in Internal Medicine at Hadassah Ein Kerem were made proficient in modern Medical Intensive Care practice. (See facilities, processes and audit of the Unit below).

House Physician
One house physician under daily supervision.

Facilities
9 medical intensive care beds (arranged with 6 beds in main area plus 3 isolation beds in two separate rooms)

Central station with communications, controlled access to ICU area, computer links to laboratories and specialized unit reports and central patient monitoring station.

Monitoring equipment
latest model Mennen Envoy modular system including all available modules for invasive and non-invasive monitoring. Modules in constant, continuous use with PC based central station and remote monitoring station in resident physician's office.

Mechanical Ventilators
3 Hamilton Galileo electronic ALV controlled ventilators
3 Newport E100m electronic ventilators
(Back up: 3 - 5 as required PB 7200 electronic ventilators)

Electrical Defibrillator with monitoring and external pacing capability on mobile resuscitation trolley with all necessary resuscitation equipment and drugs.

Additional stand alone capital equipment, disposable equipment and medications in labeled and immediately accessible storage.

Dedicated basins for hand washing in each area; There are bathrooms, toilets, kitchenette and residents office/sleep-in room, with communication to the central station, all within the Unit.

Computer connections (3) for use of medical and nursing staff for on-line data collection, patient record processing and internet access for medical information 24 hours a day.

Note: New equipment and advanced monitoring techniques are constantly reviewed by the Director and Co-director of the Unit and where appropriate are being evaluated in the Unit during official trials after Helsinki Committee approvals and informed patient consent.

CLINICAL ACTIVITIES

A: Processes
Daily program for all staff designed by director and head nurse.
Medical interventions are based on a Manual of Intensive Care written by the Director based on 15 years of Intensive Care expertise as previously practiced by him in the Medical Intensive Care Unit of the University of Cape Town.

Protocols and procedures are modified as required by new knowledge and techniques as they become available internationally and nationally.
The Doctors in training in the Unit are individually taught the techniques of oral and nasal intubation, optimal mechanical ventilation, weaning from mechanical ventilation, noninvasive techniques of mechanical ventilatory support and central venous and arterial line placements. They are also taught the philosophy of modern intensive care practice, the attitude of "DO NO HARM" in intensive care management, the importance of refined diagnosis in critically ill patients to achieve successful outcomes and the advantage of using noninvasive monitoring and measurements wherever possible.

Nursing interventions are based on a Manual of Intensive Care Nursing published by the Medical Intensive Care Unit of the University of Cape Town and based on years of experienced Intensive Care Nursing under the supervision of the director.
Nursing procedures and processes have been modified as required by local regulations, needs and experience as advised by the previous and current Head nurses of the Unit and are constantly updated as new knowledge and techniques become available.

B: Peer review and Audit of the Medical ICU
Facilities, processes, protocols and patient outcome in this Medical Intensive Care Unit are under constant peer review by colleagues within the Hadassah University Hospital Departments. There is an exceptional amount of interdepartmental consultation which is encouraged at all levels for optimal patient evaluation, diagnosis and management. In addition, because of the severity of illness of patients there is a high incidence of external consultations by family members for reassurance. This is encouraged and supported by the staff of the Unit in the best interests of patient care and family satisfaction.
There are regular (weekly) Departmental meetings to present and discuss difficult medical cases; morbidity and mortality discussions and interdisciplinary discussions are held whenever necessary for difficult decision making.
A statistical audit of annual admissions, severity of illness scoring (Apache II) and predicted and actual outcome analysis is done to confirm cost-effective, cost-beneficial and optimal use of the Unit resources.

C: Currently available statistics:

PATIENT ADMISSION DISEASE PROFILE:

Respiratory        46%
Cardiac               22%
Renal                  17%
Infectious            13%
Hepatic                12%
Neurological        8%
Metabolic              5%
Hematological     4%
GIT                         4%
Poisoning            2%

OUTCOME DATA:

Annual patient admissions:            300/year

Mean age:                                            58 years

Mean ICU stay:                                     9 days

Mean Apache II score:                        19

Predicted Deaths (Apache II):           32%

Average Annual ICU Mortality:     15-17%

In hospital Mortality:                            22%

NOTE: These statistics compare favorably with data published from Intensive Care Units in other University Hospital based Intensive Care Units in First World Countries.

RESEARCH ACTIVITIES

MECHANICAL VENTILATION

CLOSED LOOP AUTOMATIC MECHANICAL VENTILATION (Adaptive Lung Ventilation)

Clinical evaluation of new software and computerized user interface developed for the Hamilton Galileo closed loop mechanical ventilators. In return the company for which the research was done donated one new mechanical ventilator and free new software packages for the three Galileo ventilators (The value of these donations negotiated by Dr Linton to the Medical ICU at Hadassah exceeded $50,000.)

Development and clinical evaluation of the Flight Medical transport ventilator designed in Israel and used extensively by the Israeli Airforce in transporting critically ill patients. Dr Linton established the contacts between the Flight Medical Company and the Newport company in the USA which led to the development and production of the highly successful Newport HT50 ventilator. The clinical study for FDA approval of this machine was done in the Medical ICU at Hadassah (with a financial grant from the Flight Medical Company, Israel).
Further studies on the use of this ventilator for home and ground and air transport of ventilated patients are pending.

NONINVASIVE MECHANICAL VENTILATION

Clinical evaluation and use of noninvasive respiratory with Pressure Support ventilation by face mask using the Newport E100m ventilator and with negative pressure ventilators using the Hayek Oscillator and Curaiss to avoid mechanical ventilation. These new techniques are taught and practiced in many clinical situations including cardiac failure and early ARDS.
In return for this clinical work, the Newport Medical Company donated one E100m ventilator and the Hayek company donated one Hayek Oscillator and two curaisses to the Medical ICU at Hadassah. The combined value of this equipment negotiated by Dr Linton as a donation to the Medical ICU at Hadassah was approximately $ 35,000.
Further studies are planned with new advances in ventilator technology which make the application of NIMV more comfortable and safer for the patient and more easy to apply for the physician.

NONINVASIVE MONITORING OF VENTILATORY USING END-TIDAL CO2.

Various in-hospital clinical evaluations have been done by the staff of the Medical ICU of new O2/CO2 Nasal Filter-line disposable tubes designed by the Oridion Medical company based in Jerusalem, as part of routine monitoring of end-tidal CO2.
In return for this work the Oridion Medical company donated a stand alone Gemini capnograph unit to MICU for use before our new Mennen Envoy Capnograph modules became available. In addition Oridion Medical donated a portable hand held Capnography Unit for use during the transport of patients to and from the Unit.
The company also provided all the required disposable tubing, connectors and in-line filters free of charge. The combined value of these donations to the Medical ICU negotiated with the company over the last 5 years by Dr Linton exceeds $20,000.

PERCUTANEOUS BEDSIDE TRACHEOSTOMY

The technique of percutaneous tracheostomy (PcT) performed at the bedside using a guide wire dilating forceps (GGWDF) was introduced to Hadassah by Dr Linton in 1997 after agreement between Dr Linton and Professor Y Elidan, Head of the Department of Ear, Nose and Throat Surgery.
Dr Linton and Professor Elidan did the first few procedures together in the Surgical Intensive Care Unit and Dr Linton then trained all the attending specialists working in the Ear Nose and Throat Department in 1997. To date Dr Linton has personally done more than 250 percutaneous tracheostomies without serious complications in any patient, half of these were done in the various Intensive Care Units in Hadassah and many more have been done by the ENT department. The cost saving of each procedure in terms of equipment, operating room time and costs of anesthesia and personnel is between $500 and $750 per patient. Therefore the introduction of this procedure at Hadassah as part of the Medical ICU service by Dr Linton has conservatively saved the institution some $150,000 in the last 4 years. A further major benefit to patients and the staff of the various intensive care units has been the significant reduction in waiting time and problems with airway management before each procedure.
A multi-center study with the objective of determining the post ICU discharge and long term outcome associated with percutaneous tracheostomy (PcT) performed at the bedside using the "Griggs"guidewire dilating forceps (GGWDF) has been initiated by Dr Linton and will include data from Australia, South Africa, Israel and Ireland. The database should include over 1000 patients if all the centers obtain their Helsinki committee approvals.

QUALITY CONTROL OF PROCESSES IN MICU

A study of patients' recollection of their stay in the Medical ICU was initiated by Dr Linton during the elective period of a medical student from Australia, Mr Jason Kaplan. The objective of the study was a quality control project to evaluate patient recollection of their time in the Medical ICU and their impressions of the Unit in terms of satisfaction with the comfort and care they received.. A prospective, consecutive open case study was commenced with of questionnaires by the nursing staff to consecutive patients at the time they were ready for discharge from the Unit. Analysis of this data on 50 patients is being done by Dr Sigal Sviri in Australia.

QUALITY CONTROL OF OUTCOME OF MICU ADMISSION STUDY

A quality control study of the outcome of mechanical ventilation in patients over the age of 80 years admitted to MICU was commenced in 1999 by Drs Linton, Sviri and an elective medical student form England, Mr Dean Noimark.
The objective is to determine whether advanced age influences outcome of mechanical ventilation in the MICU in order to assess the appropriateness of admission to an ICU for mechanical ventilation at this extreme age.
50 patients, 80 years of age or older, admitted to MICU (27 patients ventilated and 23 not ventilated) during a one year period have been included in this retrospective cohort study. We will compare the in-unit and in-hospital mortality rate and length of stay and duration of mechanical ventilation. The data is currently being processed by Dr Sigal Sviri in Australia.

F: Infection control and antibiotics use in the critically ill.

Our current interest is in infection control in the overcrowded intensive care environments at Hadassah and the restricted use of antibiotics to prevent and control outbreaks of highly resistant strains of hydrophilic organisms like acinetobacter and pseudomonas species and the incidence of fungal sepsis after prolonged antibiotic use. Also the early conversion of I.V. administered antibiotics to oral antibiotics is encouraged where possible to avoid infection from I.V. lines. A multi center study is being considered for the use of a new orally administered anti-fungal agent for fungal sepsis in the ICU

G: Analgesia, Sedation and Muscle relaxants in the ICU.

All our current research protocols include the application of life support as non-invasively as possible with optimal patient ventilator interaction to be able to completely exclude the use of muscle relaxants and minimize the use of sedation in the ICU for patient safety and more rapid recovery from their illnesses.