Regular (Daily) Paramedical Specialists attending on rounds:
- Respiratory therapists
- Equipment Technicians
- 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 2 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).
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.
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.
- 5 Hamilton Galileo ventilators
- 3 Hamilton Raphael ventilators
- 3 Newport E100m electronic ventilators
- 3 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.
- Disinfectant fluid apparatus on every bed and 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.
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 - 33%
Cardiac - 11%
Renal - 13%
Infectious - 19%
Hepatic - 5%
Neurological - 3%
Metabolic - 3%
Hematological - 5%
GIT - 3%
Poisoning - 2%
Annual patient admissions: 300/year
Mean age: 61 years
Mean ICU stay: 9 days
Mean Apache II score: 22
Predicted Deaths (Apache II): 44%
Average Annual ICU Mortality: 20-24%
NOTE: These statistics compare favorably with data published from Intensive Care Units in other University Hospital based Intensive Care Units in First World Countries.
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
FOUR YEAR EXPERIENCE WITH ADAPTIVE SUPPORT VENTILATION
A descriptive study on the largest group of patients published to date using Adaptive Support Ventilation as the primary mode if ventilation. Analysis of patient characteristics, diagnoses, length of ventilation and complications of ventilation in comparison with other modes will be performed.
TRANSPORT AND HOME MECHANICAL VENTILATION
Development and clinical evaluation of the Flight Medical transport ventilator designed in Israel and used extensively by the Israeli Air Force in transporting critically ill patients. Dr Linton established the contacts between the Flight Medical Company and the Newportcompany 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 (NIMV)
Clinical evaluation and use of noninvasive respiratory with Pressure Support ventilation by face mask using the Newport E100m ventilator and with Biphasic Cuirass ventilators using the Medivent RTX and Cuirass 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 Medivent company donated one Hayek Oscillator and two RTX Biphasic Cuirass ventilators to the Medical ICU at Hadassah.
A prospective study is planned by Dr Sviri and Prof Linton to compare non-invasive positive pressure mask ventilation with biphasic cuirass ventilation in patients with acute respiratory failure in the Medical ICU. The study will compare the usefulness in avoiding intubation and mechanical ventilation, complication rate and side-effects between the two modes.
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.
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 Prof Linton in 1997 after agreement between Prof Linton and Professor Y Elidan, Head of the Department of Ear, Nose and Throat Surgery.
Prof Linton and Professor Elidan did the first few procedures together in the Surgical Intensive Care Unit and Prof Linton then trained all the attending specialists working in the Ear Nose and Throat Department in 1997. To date Prof 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 $1000 per patient. Therefore the introduction of this procedure at Hadassah as part of the Medical ICU service by Prof Linton has conservatively saved the institution some $250,000 in the last 7 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 Prof Linton.
QUALITY CONTROL OF PROCESSES IN MICU
A study of patients' recollection of their stay in the Medical ICU was initiated by Prof 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 using questionnaires given by the nursing staff to consecutive patients at the time they were ready for discharge from the Unit. This study is ongoing in the Unit.
OUTCOME PREDICTION IN THE MEDICAL ICU
Outcome prediction in the Medical Intensive Care Unit using a database of 900 consecutive patients admitted to the unit between 2003-2006. An outcome prediction model will be developed using this extensive database in order to better predict parameters that most influence outcome in our patient group. Subset analysis will be performed on elderly patients (>75) and Hematological patients admitted to the Unit.
ETHICAL CONSIDERATIONS IN CHRONICALLY VENTILATED PATIENTS
This is a prospective study (Dr Sigal Sviri, Dr Esther-Lee Marcus) using questionnaires aimed to evaluate the attitudes of first degree relatives of chronically ventilated patients (in the Herzog chronic care facility), regarding end-of-life decisions for their relatives compared to their wishes for themselves. This is an innovative study as it evaluates attitudes of relatives not at the time of crisis but several months down the line. It also examines the relatives' view on end-of-life ethical dilemmas in the population in general.
PROGNOSTICATION OF OUTCOME IN SEPSIS, USING NON-INVASIVE IMPEDANCE CARDIOGRAPHY
This prospective study will examine the hemodynamic factors influencing outcome and complications of early septic shock, using continuous non-invasive monitoring of hemodynamic variables (such as cardiac output, filling index, systemic vascular resistance etc) by impedance cardiography (Physioflow). Preliminary data have shown that certain early hemodynamic changes are predictive of worse outcome and the development of respiratory and renal complications in patients with septic shock.
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.
Another study examines the rate of cross-infection of resistant organisms (ESBL, CDT, VRE etc) before and after the institution of infection control protocols in the unit.
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.