PLANNING AND SET UP OF ICU

Speaker: Dr. Saurav Mittal Moderator: 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 specialists  Critical care nurses  Administrators  Engineers 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 unit

Multidisciplinary have economic and operational advantages Duplication of equipment and services is avoided Approach 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 Areas
Each 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 Ventilators 6-12 Non invasive ventilators - 3 Infusion pumps atleast 2 per bed Syringe pumps atleast 2 per bed Head end panel Defibrillator with pacing facility -2 Beds -1 for each Over bed table-1 for each bed Abg machine-1+1 Crash trolley-2 Pulse oximeter-2 as standby Airbeds -6 Leg comprssion devices-2 Refrigerator-1+1 Computer-2

Gluometer-2 Intubating videoscope-1 Cervical collars-4 Spinal boards-2 Bedside x-ray-1 Echo and Ultrasound-1 Ambu mask-10 Trays for proedures I A balloon pump-1 Fiberoptic bronchosope-1

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 catheters  Change 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

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