INTENSIVE CARE UNIT(ICU)

by Vidya
 INTENSIVE CARE UNIT
ICU is highly specified & sophisticated area of a hospital which is specifically designed,
staff, located furnished and equipped, dedicated to management of critically sick patient,
injuries or complications.

It is a department with dedicated medical, nursing and allied staff.

It has its own team of doctors, nurses and other staff who are trained to requirement.

The design of ICU, or the modification of existing units, requires not only a knowledge of
regulatory agency standards but also the expertise of critical care practitioners who are
families with special needs of this patient population

In 1988 the society of critical care medicine developed guideline for the design of ICUs.
 Functions of ICU

• Close observation and treatment of critically ill patient

• To provide specialized treatment with specialized manpower and equipment

• To utilize staff more effectively and efficiently

• Care for post surgical operations

• Provide care for medical emergency

• Provide care for cardiac emergency

• To provide support to critically ill patient

 Indicator for Admission
• Pre and Post operative patient and who underwent major surgeries.

• Craniotomy patient: A craniotomy is the surgical removal of part of the bone from the
skull to expose the brain. then replaced after the brain surgery has been done.

• Thoracotomy patient: it is a surgery of chest usually performed to remove cyst, tumor, or

part of lung.

• Ultra major surgeries.

• Unstable multiple trauma patient.

• Patient with head or spine trauma requiring mechanical ventilation.

• Any surgical patient who requires continuous monitoring or continuous life support.
 Monitoring System

• Blood pressure
• Central venous pressure CVP
• Heart rate
• Pulmonary artery pressure PAP
• Oxygen saturation
• Patient temperature
• Intra cerebral pressure
• ECG (Electro Cardio Gram)
 Planning and Organisation of ICU

HODs Surgeon,
Medical
Anaethesia Neuron
Superintendent
surgeon

Central Public ICU planning

Work Dept. committee

Nursing Physician,
Architect
Superintendent Paediatrician
 TYPES of ICU

TRADITIONAL ORGAN SYSTEM

Types of
ICUs

CLINICAL
CLIENTELE
SYNDROME
 Types of ICU
➢ Traditional
▪ Surgical
▪ Medical
▪ Paediatric
➢ Organ System
▪ Cardiac
▪ Neuro
▪ Renal
▪ Respiratory
➢ Clinical Syndrome
▪ Burn
▪ Trauma
▪ Stroke
➢ Clientele
▪ Neonatal
▪ Paediatric
▪ gynaecology
 Types of ICU
• NICU: Neonatal I C U
• PICU: Paediatric I C U
• SICU: Surgical I C U
• CCU: Coronary Care Unit
• HDU: High Dependency Unit
• MICU: Medical I C U
• TICU: Trauma/ Transplant I C U
• CVICU: Cardio Vascular ICU
• BICU: Burn I C U
• RCU: Renal Care Unit
• SCBU: Special Care Baby Unit
 Decision Making
➢ The planning committee will take the following decision
• Critical care need of hospital

• Type and size of the ICU

• Appointment of ICU In- charge

• Appointment of ICU Matron

• Planning, designing and physical facilities

• Guideline, policies and procedure in ICU functioning

 Physical Facilities
• Location- close to OT/ Recovery room
• Easy access to emergency, respiratory therapy, surgery, pathology, radiology
• Bed strength 6-20
• Patient space minimum 5sq.ft of clear area
• Nursing call- two way communication system
• Hand washing patient bed area
• Patient’s services pipeline oxygen compressed air, electrical socket 5/15 ampere
• Lighting- nonreflecting 25-30 Lux active, treatment, 150-200Lux doctor’s/ nurse’s room
• Temperature- 60-70 degree F, Noise- 50decible, Humidity- 50-60%
• Electricity: round the clock with UPS, Inverter, Stand by
• Medication- essential drugs, IV- fluids, refrigerator, SOP for inventory control
• Isolation room
• Storage area- house keeping & other supplies
 Physical facilities

Patient care Area Auxiliary Area

Physical
Facilities

Entrance Ancillary Area

 Physical Planning

Location Designing Size

Physical
Planning

Physical Environmental
Facilities Planning
 Physical Planning
➢ Location:
▪ Should be centrally located with easy access to emergency and other wards, OT, OPD
▪ Easily approachable
▪ Away from general hospital traffic
▪ Restricted entry
➢ Size:
▪ Size of ICU depends on the type of service provided
▪ In Super specialty hospital 10% of the total beds
▪ In general hospital 2% of hospital
▪ Optimum size is 14 beds and minimum 4beds
▪ If No. of beds required is 14 then it’s better to have two ICUs be opened, an ideal ICU has
10 bedded
 Designing of ICU
Ample space around
All patients can be
bed for free
closely observed
movement

Principle of
designing

Adequate Light,
Piped Gas supply
Electrical fixture
 Patient Care Area

Nursing
Bed Space Monitoring Call Bell System
station

Patient Care

Equipment Hand Washing Wall Fixtures

 PATIENT AREA
NURSING STATION ISOLATION ROOM

I
C
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Y
P
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R
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 Patient Care Area
➢ Bed Space: Sufficient space is required for each bed for free movement and keeping
ventilator, monitoring system and other equipment.
• They are required for each bed 100-120 sq. ft. in open ICU 140- 180sq. ft. of clear area
• Minimum 15sq ft. of clear area
• Head wall space 1-2ft.
• Space between two bed 5-8ft.
• The cubicle must have glass partition or transparent curtains for clear observation from monitoring station.
➢ Bed Head Fixture and Call Bell:
• High intensity spot light connected to generator
• Wall panel and call button near the bed
• Sufficient electric socket for plugging
• Wall suction tube and piped oxygen supply
• Equipment with CV stabilizer/ UPS
• No extension were to be used
• Small wash basin
 EQUIPMENT
Monitoring Equipment Therapeutic Equipment

Cardiac monitor Ventilator

Pulse- Oxymeter Nebulizer

ECG Laryngoscope, Bronchoscope,

Endoscope
USG, 2D Echo Defibrillator

Diagnostic Instruments
Endoscope Tracheostomy set
ECG Machine Cut- open set for IV line
X-ray machine Pace maker attached
USG Machine
 EQUIPMENT

CARDIAC MONITOR PULSE- OXYMETER ECG ULTRA SOUND

NEBULIZER LARYNGOSCOPE
VENTILATOR DEFIBRILATOR
BRONCHOSCOPE PORTABLE X-RAY BLOOD PRESSURE MACHINE

I V- LINES SUCTION PUMP

PACEMAKER
Nursing Station
 Nursing Station
• A central nursing station should provide a comfortable area of sufficient size to
accommodate all necessary staff functions.

• When an ICU is of a modular design each nursing substation should be capable of

providing most if not all functions of a central station.

• There must be adequate overhead and task lighting and a wall mounted clock should be
present.

• Adequate space for computer terminals and printers is essential when automated system
are in use.

• Patient records should be readily accessible.

 AUXILARY AREA
MEDICATION & NURSING CHANGING
DOCTOR’S DUTY ROOM
NURSING AREA ROOM

ISOLATION ROOM/
DRESSING ROOM
AREA

AUXILARY AREA

PANTRY STORE

CLEAN & DIRTY EQUIPMENT

UTILITY ROOM MAINTENANCE
 AUXILIARY AREA

CLEAN & DIRTY UTILITY ROOM DOCTOR’S DUTY ROOM

DRESSING ROOM STORE ROOM PANTRY EQUIPMENT MAINTENANCE

 ISOLATION ROOM
➢ The working area is equal to total bed area. This area has the 14sq. Yards area comprises
of:

• Washing, utility area

• Securable cabinet for staff room

• Clean supply room

• Work room with separate sink

• Toilet and dirty utility

• X-ray viewing, special examination/ procedure

• 24hrs lab, radiology and pharmacy

 Clean & Dirty Utility Room
• Clean and dirty utility room must be separate room that lacks inter connection.

• They must be adequately temperature controlled and the air supply from the dirty utility
area supply from the dirty utility area must be exhausted.

• The clean utility room should be for the storage of all the clean and sterile supplies, and
may also be used for the storage of clean linen.

• Separate covered container must be provided for soiled linen and waste materials

• There should be designated mechanisms for the disposal of items contaminated body
substances and fluids.

• Flooring should be made of seamless to facilitate clean.

 ANCILLARY AREA

Office space &

Staff rest room
record room

Ancillary
Staff lounge Janitor room
Area

ICU Matron’s
Telephone facility
office
 Medical Environment required in ICU
➢ Air Conditioner
• ICU must be air conditioned
• Temperature maintained at 250-27o C and 40- 50% humidity
• Plenty of sunlight, large window
➢ Ventilation
• 6/8 air changes per hour
• Filter less than 10 micron
• Positive pressure flow from patient area to outside
➢ Lighting
• Varying degree of illumination for patient area, working area
• Intensity 1 to 30 lumen as per need
• Soothing and glare free
• Provision of dimmer lights
➢ Noise
• To be noise free
• Soft and light music
• Noise absorbable material
• Wall reflection free, light colour
• Floor mosaic
➢ Electrical Power
• 110 volt electrical outlet with 30amp circuit
• Sixteen out let as per bed
➢ Water supply
• The water supply must be certified source
• Especially if haemodialysis is to be performed
➢ Oxygen – four terminal outlet are required for each bed grouped and not spread singly across the bed head,
gantry etc. terminal outlet are required for:
• Flow meter
• Gas mixing device
• Ventilator
• Bronchoscope entrained injector
• In an emergency to drive suction apparatus
➢ Compressed Air- atleast two outlets are required for each bed
• Flow meter
• Gas mixing device
• ventilator
➢ Vacuum
• Suction controller for tracheal aspiration
• Suction controller for continuous drainage suction
➢ Nitrous Oxide- nitrogen oxide and oxygen in 50:50 ratio is supplied not more than one outlet is needed for
each bed. An active scavenging point will be needed at any bed supplied with N2O
 Organisation of ICU services

Staffing Administration

Organisation

Policies & Admission

Guidelines criteria
 STAFFING

Nursing Staff Medical Staff

Staffing

Ancillary Staff Technical Staff

 ORGANOGRAM OF ICU

HOD
Anaesthesia

Director ICU
(Anaesthesia)

Bio-medical
Physician 24hrs ANS Technical staff Receptionist engineer

Respiratory
Nursing staff Safety Officer
Bio-medical
technician
Physiotherapist
Supporting staff
ICU test

Lab. test
 Staff Required
➢ Nursing Staff
❑ Nurses: patient ratio
▪ Day 1:1
▪ Evening 1 : 2
▪ Night 1:3
Broadly 4 to 5 nurses per bed including reliever one ANS for administration
➢ Medical Staff
▪ One physician per 5 beds
▪ Consultant ICU – 1 per shift
▪ Senior resident - 2 per shift
▪ Junior resident - 2 per shift
➢ Technical Staff
▪ Respiratory therapist – 1 per shift
▪ Physiotherapist – 1 per shift
▪ ICU Technician – 1 per shift
▪ Lab. Technician - 1 per shift
▪ OT. Assistant – 1
▪ Safety officer – 1
➢ Ancillary Staff
▪ Receptionist – 1
▪ Ward boy – 4
▪ Stretcher –2
▪ Janitors - 2
 ADMISSION CRITERIA

MAJOR OPERATION REQUIRING AIRWAY

TRAUMA HEAD SUPPORT &
REQUIRING VITAL ARTIFICIAL
INJURY MONITORING VENTILATION

CRITERIA

HAEMORRAGEIC
TRANSPLANT TOXAEMIA &
SHOCK ELECTROLITE
PATIENT SEPTILEMIA IMBALANCE
 ADMISSION POLICY

➢ Level 1:
▪ Monitoring
▪ Observation
▪ Short term ventilation
➢ Level 2:
▪ Monitoring
▪ Observation
▪ Long term ventilation
➢ Level 3:
▪ Intensive care
▪ Invasive procedure
▪ Haemo dialysis
▪ Constant support
 Treatment Policies

➢ Responsibility lies with the in charge of unit admitting the case

➢ A vacant bed is allocated in original ward for patient return

➢ No direct admission to ICU but transferred from unit

➢ Admission only a recommendation of ICU director subjected to availability of bed

➢ 20% bed to be kept vacant for emergency admission

➢ Continuity of treatment is the per view of ICU in charge in consultation with unit incharge
 INFECTION CONTROL
• Measure practiced by healthcare personnel to prevent spread, transmission of infection
between critically sick patient from the healthcare provider and from patient to
healthcare provider.

• With consultation of consultant microbiologist infection control team uses certain

procedure to control infection
 Risk Due to Infection
• Low resistance of patient to infection

• Invasive procedure/ intervention

• In appropriate anti-microbial usage

• Drug resistance of endemic

• Contaminated environment
 Common Organism
Bacteria Virus

Staphylococcus Aureus Human Immunodeficiency Virus(HIV)

Enterococcus
Hepatitis B Virus (HBV)
Pseudomonas Aeruginosa
Hepatitis C Virus (HCV)
Klebsiella
Cytomegalic Virus
E- coli

Fungal Parasites
Candid Albicans Giardia
Aspergillus Lambia
 Standard Precaution
• Hand washing

• Antibiotic policy

• Protective Clothing of staff and visitors

• Sterilization

• Aseptic precaution for invasive

• Use of disposable

• Filtering of patient’s respired air

• Changing of catheters humidifier, ventilation tubing and other equipment

• Isolation risk

• Cleaning of unit
 Sterilization
➢ Procedure which would remove all microorganism including spore, from and object.

❑Sterilization method

▪ Dry heat sterilization

▪ Moist heat sterilization

▪ Chemical sterilization

▪ Radiation sterilization
 Protective Clothing for Staff and Visitors
GLOVE GOWN MASK

PROTECTIVE EYEWEAR FACE SHIELD APRON

 DISINFECTION
Reduce the number of microorganism on an object or surface but not completely
destruction of all microorganism or spores.:
➢ Type of disinfection
▪ High level disinfection
2% glutaradehyde
stabilized hydrogen
1%sodium hypochlorite

▪ Intermediate level disinfection

0.1% sodium hypochlorite
Iodophores and phenolic solution

▪ Low level disinfection

Quaternary ammonium compounds
 Bio-Medical Waste Management

➢ Biomedical waste is the waste generated at the time of treatment, diagnosis,

immunization and different types of procedures of human being or animals.

➢ Biomedical waste management is of utmost importance as its improper management

poses serious threat to healthcare workers, care giver, community and finally the
environment

➢ Segregation of biomedical waste was being done at the site of generation in almost all the
areas of the hospital in colour code polythene bags per hospital protocol.
 DISCHARGE POLICIES
➢ Discharge summary contains the reasons for admission, significant findings and
diagnosis and the patient‘s condition at the time of discharge.

➢ Discharge summary contains information regarding investigation results, any procedure

performed, medication administered and other treatment given.

➢ Discharge summary contains follow-up advice, medication and other instructions in an

understandable manner.

➢ Discharge summary incorporates instructions about when and how to obtain urgent care

➢ In case the cause of death is not clear and a post mortem is being performed (Eg MLC),
the same shall be documented.