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Estructura y Org de Uci

Estructura y Org de Uci

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Published by: Auditoria Salud Total EPS on Jan 30, 2013
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Andreas ValentinPatrick FerdinandeESICM Working Groupon Quality Improvement
Recommendations on basic requirements for intensive care units: structuraland organizational aspects
Received: 7 February 2011Accepted: 9 June 2011
Copyright jointly held by Springer andESICM 2011This article is discussed in the editorialavailable at doi:10.1007/s00134-011-2332-z.
Electronic supplementary material
The online version of this article(doi:10.1007/s00134-011-2300-7) containssupplementary material, which is availableto authorized users.A. Valentin (
)General and Medical ICU,Rudolfstiftung Hospital, Juchgasse 25,1030 Vienna, Austriae-mail: andreas.valentin@meduniwien.ac.atTel.:
43-1-711652229P. FerdinandeSurgical and Transplantation ICU,University Hospital Gasthuisberg,Leuven, Belgium
To provideguidance and recommendations forthe planning or renovation of inten-sive care units (ICUs) with respect tothe specific characteristics relevant toorganizational and structural aspectsof intensive care medicine.
The Working Groupon Quality Improvement (WGQI) of the European Society of IntensiveCare Medicine (ESICM) identifiedthe basic requirements for ICUs by acomprehensive literature search andan iterative process with severalrounds of consensus finding with theparticipation of 47 intensive carephysicians from 23 countries. Thestarting point of this process was anESICM recommendation published in1997 with the need for an updatedversion.
The documentconsists of operational guidelines anddesign recommendations for ICUs. Inthe first part it covers the definitionand objectives of an ICU, functionalcriteria, activity criteria, and themanagement of equipment. The sec-ond part deals with recommendationswith respect to the planning process,floorplan and connections, accom-modation, fire safety, central services,and the necessary communicationsystems.
This docu-ment provides a detailed framework for the planning or renovation of ICUs based on a multinational con-sensus within the ESICM.
Intensive care medicine
Quality of care
Consensus paper
AHCP Allied health careprofessionaldB DecibelESICM European Society of Intensive Care MedicineESM Electronic supplementarymaterialFTE Full time equivalentHDU High dependency unitICU Intensive care unitiv IntravenousLOC(s) Level(s) of careM and F Male and femaleWQI Working Group of QualityImprovement (ESICM)
In 1997 a task force of the European Society of IntensiveCare Medicine (ESICM) published a paper aimed todescribe minimum requirements for intensive caredepartments [1]. These recommendations had an impactin guidelines of national intensive care societies as well aslegislative documents (e.g., in Greece). Since thenintensive care medicine and even more the conditions of its practice have changed considerably causing the need
Intensive Care MedDOI 10.1007/s00134-011-2300-7
for an update of these recommendations. In 2008 theESICM Working Group of Quality Improvement (WGQI)addressed this task and was endorsed by the ESICMcouncil and the ESICM executive committee.
The formal work on this project was started during ameeting of the WGQI in March 2009 (Brussels) andcontinued with meetings in October 2009 (Vienna),March 2010 (Brussels), and October 2010 (Barcelona).An advisory group with 47 participants from 23 countrieswas constituted (see Acknowledgements). A comprehen-sive literature search in Medline (starting with the year1990) was performed and then complemented by refer-ences proposed by the members of the advisory group. Animportant limitation that was obvious from the beginningof the process was that evidence from the literature forthis subject is scarce, and the document is therefore basedon expert opinion in many places. In a first step of theprocess detailed and structured comments on the paperfrom 1997 were collected from the members of theadvisory group and this built the basis for a first draft of the new document. The document in progress wascirculated by e-mail three times in total and edited by allmembers of the advisory group at each stage. Remainingdisagreements were discussed and resolved during theWGQI meetings stated above, where an agreement of atleast 75% of the WGQI members present had to bereached. After a final round by e-mail, to check that theadvisory group agreed on the final version, the documentwas ultimately approved by the WGQI on 12 October2010 in Barcelona.The document consists of operational guidelines anddesign recommendations for intensive care units. All partswith listings or detailed technical descriptions have beenmoved to the electronic supplementary material (ESM)and are available there.
Recommendations—part I: operational guidelines
Definition and objectives of an intensive care unitThe intensive care unit (ICU) is a distinct organizationaland geographic entity for clinical activity and care, oper-ating in cooperation with other departments integrated in ahospital. The ICU is preferably an independent unit ordepartment that functions as a closed unit under the fullmedicalresponsibilityoftheICUstaffincloseconcertwiththe referring medical specialists [2,3]. It has a defined geographical location concentrating the human and tech-nical resources, such as manpower, professional skills andcompetencies, technical equipment, and the necessaryspace. The characteristics of medical, nursing, and alliedhealth personnel staffing; technical equipment; architec-ture; and functioning should be clearly defined [46]. Interdisciplinary written arrangements about workflow,competencies, medical standards, regulations of coopera-tion, and mechanisms for decision-making are helpful toembed competencies and to standardize clinical workflow.The objectives of an ICU are the monitoring andsupport of threatened or failing vital functions in criticallyill patients who have illnesses with the potential toendanger life, in order to perform adequate diagnosticmeasures and medical or surgical therapies to improveoutcome. The patient population may present with a largevariety of pathologies but shares the potential reversibilityof one or more threatened vital functions. Every ICUshould provide the know-how and equipment based on themission statement of the individual ICU to assure ‘‘state-of-the-art intensive care medicine.’’Timely mobilization of the ICU team and its supportservices plays an important role in the efficient use of acute care facilities, for the coverage, triage, and outreachmanagement of critically ill patients outside the ICU.Shared protocols between the ICU and other departmentsof the hospital (e.g., the emergency department) enhancethroughput and decrease overall hospital mortality of critically ill patients [7].These proposed guidelines are valid for ICUs caringfor adult patients. Neonatal/pediatric ICUs may have to beadapted accordingly. Specific pediatric units are desirableif the turnover rate justifies such a unit and warrantsexpertise. Whenever possible pediatric patients should betreated in specialized pediatric ICUs [8].Functional criteria
An ICU will be situated in a hospital with appropriatedepartments to ensure that the multidisciplinary needs of intensive care medicine are met [911]. Surgical and medical diagnostic and therapeutic facilities must berepresented, and medical, anesthesiological, surgical, andradiological consultants must be available for ICU pur-poses on a 24 h/day basis. Not all hospitals will developtheir ICU facilities in the same way, with the samecompetencies and identical structures and equipment.ICUs must be adapted to the region and the hospital theyserve in terms of size, staffing, and technology.
An ICU should accommodate as a minimumat least 6 beds[12,13], with 8–12 beds considered as the optimum.
Hospitals with several smaller units should be encouragedto rearrange these units into a single larger department toimprove efficiency. On the other hand, a larger ICUmay take the opportunity to create separate, specializedfunctional subunits with 6–8 beds, sharing the same geo-graphical, administrative,and other facilities.Cohortingof patients in such subunits may be based on specific pro-cesses of care or pathology. The size of the unit is alsoinfluenced by the geographical and economic situation.Avolume-effect interms ofsufficientnumbers ofadmittedpatients and numbers of therapeutic interventions is alsorecognized to maintain the quality of activities such as theprovision of mechanical ventilation and renal replacementtherapy [1416].
 Medical staffing Director of the intensive care unit.
The responsibilityfor the administrative and medical management of theunit is held by a physician, whose professional activitiesare devoted full-time or at least 75% of the time tointensive care, who holds the position of director of theICU. The head of the ICU has the sole administrativeand medical responsibility for this unit and cannot holdtop-level responsibilities in other departments or facili-ties of the hospital. The head of the ICU should be asenior accredited specialist in intensive care medicine asdefined at country level, usually with a prior degree inanesthesiology, internal medicine, or surgery and havehad a formal education, training, and experience inintensive care medicine as described by the ESICMguidelines [17].
 Medical staff members.
The head of the ICU is assistedby physicians qualified in intensive care medicine. Thenumber of staff required will be calculated according tothe number of beds in the unit, number of shifts per day,desired occupancy rate, extra manpower for holidays andillness, number of days each professional is working perweek, and the level of care and as a function of clinical,research, and teaching workload. Extended work shiftshave been shown to negatively impact the safety of patients as well as medical staff [1820]. The number of  full time equivalent (FTE) physicians qualified in inten-sive care medicine per six to eight intensive care beds(at level of care II, see section ‘‘Activity Criteria’’) can becalculated (according to the European working hoursdirectives) with the formula provided in paragraph 9 of the ESM [21]. An experienced physician certified inintensive care medicine is on duty and available uponrequest at short notice in the hospital during ‘off dutyhours.’The regular medical staff members of the ICUtreat patients using state-of-the-art techniques and mayconsult specialists in different medical, surgical, ordiagnostic disciplines whenever necessary.The regular medical staff members have the task of coordinating the referring physician and consultingmedical specialties. The staff members of the ICU takeover the medical and administrative responsibilities of thecare of the patients admitted to the unit. They defineadmission and discharge criteria and carry the responsi-bility for diagnostic and therapeutic protocols tostandardize care in the ICU. An important task of themedical staff in training centers is to supervise and teachthe doctors in training. For this purpose formal dailyrounds are organized to give information and plantherapy. All ICU health professionals involved in directpatient care should participate in these rounds.
 Medical trainees.
Trainees in medical and surgicalspecialties (e.g., anesthesiology, internal medicine,pulmonology, surgery) may, after 2 years of training intheir primary specialty and within the frame of theirspecialty, work in an ICU under clearly defined supervi-sion. Depending on the legal framework operating in theindividual country, these training periods should have aminimum duration of 6 months (optimally 1 year) forthose planning to qualify in intensive care medicine and3 months (optimally 6 months) for others. During thesetraining periods, the trainees are involved full-time in theactivities of the ICU.Trainees assure supervised continuity and participatein the duties of the ICU under the supervision of a qual-ified intensive care physician. The regular staff carriesfinal medical responsibility. Under ideal conditions, thereshould be an overlapping in the training periods to rein-force the expertise in the group of trainees.
Continuity of medical activity.
The continuity of medi-cal care in the ICU during nights, weekends, and holidaysis assured by the regular medical staff of the ICU on a24 h/day basis [2224]. They can be assisted by skilled and experienced residents from other departments withbasic training in intensive care medicine, provided there isa back-up of the regular staff around the clock [2528]. This activity needs to be considered in the calculation of requested regular staff.
 Nursing staff Organization and responsibilities.
Intensive care medi-cine is the result of close cooperation among doctors,nurses, and allied health care professionals (AHCP). Anefficient process of communication has to be organizedbetween the medical and nursing staff of the ICU. Tasksand responsibilities have to be clearly defined.
 Head nurse.
The nursing staff is managed by a dedi-cated, full-time head nurse, who is responsible for thefunctioning and quality of the nursing care. The head

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