Speaker: Dr. Saurav MittalModerator: Dr. Anju R. Bhalotra

Introduction

Intensive care unit (ICU) is a specially staffed and equipped hospital ward dedicated to management of patients with life threatening illnesses, injuries or complications.

Levels of Adult ICUs

Level I-Small district hospital and small private nursing homes for resuscitation and short term support

Level II- General hospital provides high standard of general intensive care

Level III-Tertiary hospital provides all aspects of intensive care for indefinite periods

Other ICUs

Pediatric ICU-for infants and children; with pediatric intensive care specialists

Neonatal ICU-for neonates; managed by neonatologists

High dependency unit (HDU)-intermediate between intensive care and general ward care

Coronary care unit (CCU)

The old concept of identifying ICU as just a separate area with high-tech gadgets no longer holds true. One should take cognizance of the recent developments and the various recommendations by bodies like the Society of Critical Care Medicine (SCCM), Indian Society of Critical Care Medicine (ISCCM) and the published literature on the subject. An important dimension is the concerns of the patients and their families, who often complain about overwhelming feelings of insecurity, disorientation, anxiety, fear and anger. The sheer volume of technology, the unfamiliar, sterile surroundings, lack of privacy, constantly revolving medical teams, incessant noise and glaring light, and the lack of natural forms, materials, and sensory experiences all add to this traumatic experience. As a result, the patients feel trapped in an environment they dislike and cannot control, and their families feel helpless.

Planning of ICU

Design team should consist of:Critical care specialistsCritical care nursesAdministratorsEngineers and Architects Inputs from other departments eg.

medicine, surgery, anaesthesia, biochem, radiology etc.

Staffing of icu

· Intensivist/s· Resident doctors· Nurses,· Respiratory Therapists,· Nutritionist· Physiotherapist· Technicians, Computer programmer,· Biomedical Engineer, and· Clinical Pharmacist· Social worker or counsellor· Other support staff. Like cleaning staff, guards and Class IV.

Determining ICU function Level of care to be provided Multidisciplinary vs single discipline unitMultidisciplinary have economic and operational

advantagesDuplication of equipment and services is avoidedApproach to treatment of all critically ill patients is similar

Single discipline units eg. neurosurg, cardiac surg, burns, trauma managed by single discipline doctors are economically and operationally demanding

Site of ICU

ICU should be geographically distinct area in hospital

Function as autonomous department with controlled access and no through traffic

In close proximity (horizontally or vertically) to operating rooms, emergency dept, investigational dept so that minimal transport of critically ill patients.

Lifts, doors and corridors to be spacious for easy passage of beds and equipments

There should not be any thorough traffic to other departments from the ICU. It is a good idea to separate the supply and professional traffic from public/ visitor traffic. A direct elevator is an excellent idea to transfer sick patients to and fro from the ICU, reducing transport time and avoiding the visitors. The patient transport corridors should be separate than those used by the visiting public. Patient privacy should be preserved and transportation should be rapid and unobstructed. The elevators should be oversized keyed elevators, separate from public access. The support facilities should include nursing stations, storage, clerical space, administrative and educational requirements, and other services unique to the institution.

Size of ICU

Number of ICU beds usually 1-4 per 100 hospital beds depending upon type and role of ICU

Multidisciplinary require more beds than single discipline

Requirement also depends on availability of separate high dependency beds

ICU to have no less than 4 and not more than 20 beds, 8-12 beds best functionally

Design of ICU-Floor Plan

Open ward design vs multiple single rooms Single rooms offer isolation and privacy but

requires more nursing staff Open ward ICU requires some single rooms Ratio of isolation room beds to open ward

beds to be 1:10 for multidisciplinary ICU Traffic flow patterns-for patient transport,

restocking bed side supplies, rapid staff access

Physical Design of ICU

Reception area Patient Areas Support and storage areas Staff areas Technical areas

Reception Area

Receptionist at the entrance of ICU who controls access

Waiting room for visitors (1-2 seats for every ICU bed)

Interview room for grieving relatives Overnight relatives’ room

Patient Areas

125-150 sq. ft. floor area for each open area bed space and 150-180 sq. ft. for single rooms*

Hand washing and gowning areas for each isolation room

Positive/negative pressure air conditioning for isolation rooms

*Intensive care society Guidelines

Utilities per bed space

3 oxygen(centrally supplied oxygen must be at50- 55 psi) 2 air 3 suction(must maintain vacum of 290 mmhg at farthest outlet) 16 power outlets A bed side light(should illuminate patient with minimum 150 fc)

Usually mounted at wall as beds are traditionally placed with the head towards the wall

Facilities to hang IV and blood containers Space for monitoring equipments Space for charts, sampling tubes, syringes, suction catheters Outlets for telephone, radio optional Uninterrupted power supply and battery backup Patient call system

installation must follow NFPA standards

Central nursing station

The middle or end of open ward for direct visualization of patients

Patient and video monitors Patient records, stationary Drugs cupboard Specimens/Drugs refrigerator Telephone, intercom

Other things in patient area Hand wash sinks-deep and wide, non

splash, infra-red operated taps Distinct area for storing and viewing

radiographs Space for parking emergency trolleys

eg. defib, airway management trolleys

Support and Storage AreasEach ICU bed requires 25% floor space for

storage Monitoring, electrical equipment Respiratory therapy equipment Disposables and central sterilizing supplies Linen Stationery Fluids, vascular catheters, infusion sets Utility rooms-clean and dirty Equipment sterilization Enteral meal preparation area

Staff areas

Lounge/rest room Changing rooms Toilets and showers Offices Doctors’ on call rooms Seminar/conference room

Technical Areas

Stat laboratory for ABG, serum electrolytes, hemoglobin etc

Workshop for repairs, maintenance and equipment checks

Cleaner’s room

Equipment in Major ICU

Monitoring Radiology Respiratory therapy Cardiovascular therapy Support therapy-temp control,

transport Dialysis therapy Laboratory

List of Equipment Bedside monitors 1 per bed Gluometer-2

Ventilators – 6-12 Intubating videoscope-1

Non invasive ventilators - 3 Cervical collars-4

Infusion pumps atleast 2 per bed Spinal boards-2

Syringe pumps atleast 2 per bed Bedside x-ray-1

Head end panel Echo and Ultrasound-1

Defibrillator with pacing facility -2 Ambu mask-10

Beds -1 for each Trays for proedures

Over bed table-1 for each bed I A balloon pump-1

Abg machine-1+1 Fiberoptic bronchosope-1

Crash trolley-2

Pulse oximeter-2 as standby

Airbeds -6

Leg comprssion devices-2

Refrigerator-1+1

Computer-2

Environmental services and control Time and sensory orientation-natural

illumination, clocks, calendars Warm colours and soft furnishings Reducing noise levels(max 45db in

daytime and 20 db in night) Overhead, task lighting, bright

spotlights, night lights Air conditioning with HEPA filters Communications and networking RO water recirculation system at few

beds Exhaust at isolation rooms

Staffing of Major ICU

Medical-director, specialists, junior doctors

Nurses—head, intensive care nurses, in training, nursing helpers

Allied health-physiotherapist, pharmacist, dietician, social worker, respiratory therapist

Administrative staff-secretary Technicians, orderlies, cleaners

Operation of ICU

Open has unlimited access to multiple doctors with freedom to admit and manage their patients

Closed has admission, discharge and referral policies under intensivist’s control

Management in consultation policy-team of anesthetists look after emergency and day to day aspects but co-manages the patient with the referring specialists

Operational policies

Policies for admission, discharge, referral clearly defined

Responsibilities and job descriptions defined for all staff members

Hand washing, gowns, overshoes policies before entering

Cleanliness in ICU-floor, bed, windows, curtains, patient, swabs for cultures

Operational policies

Standardized policies for patient care which should be evidence based

Antibiotic policies not to favour emergence of resistant species

Change of cathetersChange of airway tubes to prevent

nosocomial infections

Quality assurance

Structure-documentation of ICU functioning, data on clinical work load and case mix

Clinical process-audits of clinical performance as review meetings, clinical-pathological conference, critical incident reporting

Outcome-mortality rates, scoring systems

Summary · ICU is a highly specialised part of a hospital or Nursing home where very sick

patients are treated.

· It should be located near ER and OT and easily accessible to clinical Lab. Imaging

and Operating rooms.

· No Thorough fare can be allowed trough it

· Ideal Bed strength should be 8 to 14. More than 14 beds may put stress on ICU staff

and may also have a negative bearing on patient outcome. <6 Bed strength will be

neither viable or provide enough training to the staff of ICU

· Each patient should have a room size of >100 sq ft , However a space of 125 to 150

sq ft per pt will be desirable .

· Additional space equivalent to 100 % of patient room area should be allocated to

accommodate nursing stn, storage etc.

· 10% beds should be reserved for patients requiring isolation.

· Two rooms may be made larger to accommodate more equipment for patients

undergoing multiple procedures like Ventilation, RRT Imaging and other procedures.

· There should be at least two barriers to the entry of ICU

· There should be only one entry and exit to ICU to allow free access to heavy duty

machines like mobile x-ray, -bed and trolleys on wheels and some time other

repairing machines. · At the same time it is essential to have an emergency exit for rescue

removal of patients in emergency and disaster situations. · Proper fire fighting /extinguishing machines should be there. · It is desirable to have access to natural light as much as possible to each

patient.

Thank You