ICU Director

Total paracentesis with albumin replacement has become the mainstay of treatment for refractory ascites in patients with decompensated hepatic cirrhosis. The authors report one of the largest volume single-tap paracenteses in the literature (38.8 L), discuss issues surrounding the safety of this procedure, and review the challenges inherent to managing these complex patients.

Nurse practitioners are becoming established clinicians in the intensive care unit. This article describes the integration of nurse practitioners into the Critical Care Medicine Service at the University of California San Francisco Medical Center. The development and current form of the nurse practitioner role is detailed. The model of employing nurse practitioners in an academic critical care medicine service is provided as a blueprint for other institutions facing a shortage of intensivists. This study addresses future direction for program development.

Since its inception, physician assistants (PAs) have been and continue to be successfully integrated into many critical care (CC) departments across the nation. The combination of both a projected shortage of intensivists and the recent house staff work hour restrictions, enforced by the Accreditation Council for Graduate Medical Education (ACGME), will increase the demand for PA coverage. Prior success in integrating PAs into ICUs has proven that PAs can fill the large gap created by the aforementioned factors and do so in an efficient and cost-effective manner. Given that PA naïve institutions still exist specifically within the field of CC medicine, this article aims to introduce and describe how PAs can be incorporated into an ICU. In addition, areas of focus will highlight hiring, training, credentialing/billing, and evolving continuing education.

In this article, the authors describe their experience as acute care nurse practitioners (ACNPs) providing immediate, acute clinical care in a medical—surgical intensive care unit of a large private practice tertiary care hospital. ACNPs represent a subset of the growing group of advance practice registered nurses (ACRNs). The role of ACRNs has evolved over time and this article describes the national education and certification requirements for this important group of health professionals. This article describes the details of the efforts to integrate ACNPs into an intensivist-led medical—surgical intensive care unit.

The need for acute care nurse practitioners (ACNPs) in the intensive care unit (ICU) has steadily increased over the years. This is in part because of an increase in hospital admissions from an aging population that is living longer from advances in health care, especially in the critical care arena. Another factor involves recommendations by the Leapfrog Group that include fundamental critical care support be readily available to the patient’s bedside within 5 minutes. However, the largest driving force is the human resources shortage in critical care medicine. More and more patients are requiring critical care services, whereas physician numbers are not keeping pace with the growth. In addition, duty hour restrictions implemented by the Accreditation Council for Graduate Medical Education that limits residents’ work hours is contributing to the shortage. As a medium-to-large public tertiary academic medical center that serves all of northern California and part of the Central Valley, we have not been spared from the increase in workload in addition to the decrease in house staff support. The purpose of this article is to describe our experience with the use and integration of ACNPs into our multidisciplinary ICU teams.

ICU delirium is increasingly recognized as a major determinant of morbidity and mortality in critical care patients. It develops in around 2 out of every 3 ventilated critically ill patients. To detect ICU delirium, patients need to be actively screened using a validated tool otherwise it is likely to be missed. Good practice requires implementing routine delirium screening of all patients, a series of robust preventative measures targeted at risk factors—in particular sedation practices—treating the cause of delirium and using antipsychotics when indicated. An ABCDE bundle has been designed to improve the management of mechanically ventilated patients and improve outcomes for delirious patients.