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Making a referral to ICU can be daunting.
But you shouldn’t feel intimidated, especially as there’s a good chance you’ll often be referring to an anaesthetist with a somewhat limited medical knowledge.
There’s a few key points which will make your life, and that of the person receiving the referral, a lot easier.
Here I’ve put together a few top tips to help you settle the nerves, get the key points of your referral across and most importantly - sound like a boss.
I should add a disclaimer: I am not an expert in intensive care, I simply have been on the receiving end of referrals for ICU at a registrar level on call. I therefore have received my fair share of good but also rather terrible referrals.
Know the role of ICU and it’s limitations.
ICU buys time to patients to allow them to overcome their current disease process.
It can provide organ support alongside medical treatments, and help bridge people through major surgery. It can provide monitoring for high-risk patients or those at risk of deterioration.
Finally, ICU can provide outreach to the wards, to help advise on management, to try and avoid the patient needing admission to intensive care.
Intensive care unfortunately can’t save everyone
- It can’t cure incurable diseases or make chronic pathology disappear
- It can’t replace organs indefinitely
- It isn’t a place to diagnose complex pathology
Intensive therapies are invasive and can, and often does, leave patients with significant post traumatic stress as well as months and sometimes years of rehabilitation.
A patients pre-admission state is key to understanding how they will do during and post-ICU. A patient who is normally running marathons has far greater musculoskeletal and cardiorespiratory reserve to deal with these invasive, stressful therapies, than a patient who can’t walk up stairs without fatigue or breathlessness.
Therefore, the marathon runner will fair far better in ICU, irrespective of pathology.
Will the patient gain meaningful benefit from the admission?
- A palliative metastatic cancer patient with 6 months prognosis is not going to receive an acceptable quality of life from an ICU stay and subsequent rehabilitation that spans 6 months
- A frail bed bound patient is very unlikely to benefit from ventilation as they are unlikely to have the musculoskeletal reserve to wean off the ventilator, even if their acute disease process such as a pneumonia improves
- A chronic liver cirrhosis patient, who is still drinking and deemed not suitable for transplant, in hepatorenal failure will not benefit from haemodialysis as their kidneys are extremely unlikely to recover without transplant
- A relatively well patient with pneumonia and sepsis will benefit from a period of cardiovascular and respiratory support while time allows their antibiotics to work
- A post-operative laparotomy may benefit from enhanced monitoring and one-to-one nursing, or a degree of organ support just while they recover from their operation
There are many examples to be had but understanding ICU is not appropriate for everyone is important to triaging your own referrals and really considering whether there is likely to be any benefit to invasive management.
A quick breakdown of organ support
- Inotropes to improve the contractility of a poorly functioning heart, e.g. after an acute myocardial infarction
- Vasopressors to improve blood pressure in septic shock
- Advanced cardiac output monitoring to guide fluid management
The aim of the game is to perfuse the organs effectively without overloading the patient with fluid or exhausting their heart
- Airway protection e.g. for low GCS or airway obstruction
- Non-invasive and invasive ventilation e.g. for an exhausted asthma patient
The aim of the game is to reduce the work of breathing, and therefore oxygen demand, for the patient, to allow them to overcome their respiratory pathology
- Hemofiltration e.g. in a patient with severe refractory hyperkalaemia or fluid overload despite medical management
- Dialysis e.g. in a long-term dialysis patient who becomes acutely unwell and cannot travel to their usual dialysis session
The aim of the game is maintaining acid-base, electrolyte and fluid balance, while the kidneys recover from an acute pathology, or until they're well enough to have their usual dialysis
- Management of seizures e.g. status epilepticus requiring deep sedation
- Reducing cerebral metabolic rate e.g. in a head injury patient
- Monitoring intracranial pressure e.g. in an intracranial bleed
The aim of the game is maintaining perfusion to the brain, and reducing the cerebral metabolic demand, until the patient is well enough to wake up and wean off the ventilator
Context is key
I remember being very frustrated with one particular referral at 7am, after a busy night shift, which ultimately led to a very protracted Q&A session rather than a quick solution.
- Me: Good morning, It’s Jonny ICU Reg
- ED Reg: the blood pressure is 60 systolic
- Me: Ok… [insert stream of questions to determine the relevance and urgency]
I often use the example; Who is more in need of ICU:
- A patient with a BP 60/40 or
- A patient with a BP of 110/50
If you said patient 1, you’re wrong. Sorry.
There is not enough information to formulate a decision yet, because blood pressure is just a number and doesn't give any meaningful idea as to the state of the patient as a whole.
So who is more unwell or in need of ICU?
- A patient with a BP of 60/40, HR 90, sats 90%
- A patient with a BP of 110/60, HR 120, sats 92%
Again, we don’t know enough here to make a decision yet.
Let's try again
- A 70 year old patient with a bp of 60/40 HR 90 sats 90% on room air, GCS 15 with COPD and AF, has just turned up to ED and has received no treatment yet
- A 18 year old with BP 110/60, HR 120 Sats 92% on 15L non-rebreathe, respiratory rate 40, GCS 14. Has already had 4L crystalloid in ED.
Now we have a good idea of what's going on.
The first patient is undoubtedly unwell, but is perfusing their brain enough to be GCS 15 and hasn't actually had any treatment yet. They might get better very quickly in ED.
The 2nd patient, howecver, is showing serious signs of end organ dysfunction, with a low GCS and high oxygen requirement, despite having an essentially normal BP – they are clearly more unwell and would need urgent attention and probably ICU admission.
Context is essential in ICU referrals as it helps prioritise who needs to be seen first. Often there are many patients that do need to be seen but some with far more urgency than others.
A good structure
Do I need to say any more?
It really is as simple as this but knowing the salient features to grab attention is important. I often find myself structuring other peoples referrals for them to get the information I need. I’ll jump straight to an example:
- Where is the patient?
- How old are they?
- What's the working diagnosis?
- What have you done so far?
Make it snappy and attention grabbing. Give them a reason to listen:
I have an 18 year old in AMU being treated for chest sepsis in respiratory distress who is showing signs of cerebral hypoperfusion (ie is becoming increasingly confused)
- Medical background
- Any other important hospital admission details
Well controlled Asthma with no previous ICU admissions or recent steroid courses
Your assessment of the patient so far, using ABCDE
- Airway – own, patent
- Breathing – RR 40, sats 92% on 15L Non-rebreathe mask, working very hard, coarse crackles right base. ABG; Po2 7 PCO2 2. CXR: dense consolidation right base
- Circulation – HR 120, BP 110/60, Cap refill <1s, anuric. Has had 4L of crystalloid. ECG: Sinus tachy. pH 7.1, Lactate 4, BE -10
- Disability – GCS 14 E4V4M6 Glucose 11
- Exposure/everything else – temp 39.2, soft abdomen. Had IV antibiotics and paracetamol
- What you would like or need help with
I would like an ICU review as I am concerned and I believe they would benefit from organ support.
Be honest and be nice
This is probably my best advice.
Always as a bare minimum introduce yourself and your grade, because the person taking the referral can then gauge who they’re talking to and the level of expertise to expect.
I would always advocate for then asking how they are or other pleasantries – this gives you the opportunity to gain rapport but also tell them you’re stressed or at the end of your tether.
I think honesty is always key, I get a lot of referrals with limited information or no clear reason why they’re referring. In these cases I would much prefer that they were honest and said “my consultant has asked me to refer for XYZ” than for them to try blag a referral, or worse, fabricate important details to expedite a referral.
If you think someone is really unwell but you don’t know what is happening, just say so. We'll quite happily admit that we often don't really know what's happening, we just know the patient is seriously unwell. If you have a deteriorating patient and don’t know how to manage them, just say so. We'll be happy to help.
Equally, if you just want help because you can’t get help from within your own team, be honest.
- Hello, I’m Barry the Medical F2, How’re you?
- S – I’m really stressed and out of my depth. I’ve got a 30 year old man who looks really unwell with a NEWS of 14 and I don’t know what’s happening
- B – They’re normally fit and well, and have acutely deteriorated today
- A – ABCDE
- R – Please can you give me some advice on how to manage this patient as I can’t get hold of my SpR and I’m really worried
Being honest gives context and an understanding of the whole situation to the person receiving the referral and allows more constructive discussion to develop a management plan for the patient.
I hope this helps any doctor or health professional in making a referral to intensive care.
Understanding these principles makes it far easier for both parties to develop a meaningful management plan in a timely manner. Ultimately, an ICU consultant will decide whether or not a referral is appropriate but getting the basics and fundamentals right reduces workload and speeds up the process.
I look forward to your excellent referrals in the future!
Disgruntled but optimistic ICU SpR/anaesthetic trainee in Kent.