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TATA MOTORS HOSPITAL Chapter Name: COP

Quality Assurance Programme for Intensive Care Document No.: TMH/COP/QSP/07

Units& HDU

Quality Assurance Programme for

Intensive Care Units& HDU

Approved By: Medical Director

Quality System Issue No. : 01
Procedure
Issued By: Quality Manager Rev. No. : 00
Issue Date: Rev. Date: 00
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TATA MOTORS HOSPITAL Chapter Name: COP

Quality Assurance Programme for Intensive Care Document No.: TMH/COP/QSP/07

Units& HDU

AUTHORIZED SIGNATORY

1. Approved By Managing Director

2. Issued By Quality Manager

Approved By: Medical Director

Quality System Issue No. : 01
Procedure
Issued By: Quality Manager Rev. No. : 00
Issue Date: Rev. Date: 00
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TATA MOTORS HOSPITAL Chapter Name: COP

Quality Assurance Programme for Intensive Care Document No.: TMH/COP/QSP/07

Units& HDU

AMENDMENT SHEET

Sl. Page No. Clause No. Date of Amendment Made Reasons Signature of Quality
Amendment Manager
No.

Approved By: Medical Director

Quality System Issue No. : 01
Procedure
Issued By: Quality Manager Rev. No. : 00
Issue Date: Rev. Date: 00
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TATA MOTORS HOSPITAL Chapter Name: COP

Quality Assurance Programme for Intensive Care Document No.: TMH/COP/QSP/07

Units& HDU

INDEX

Sl. No. Policy & Procedure Page No.

1. Quality assurance programme for intensive care 5-7

units

Approved By: Medical Director

Quality System Issue No. : 01
Procedure
Issued By: Quality Manager Rev. No. : 00
Issue Date: Rev. Date: 00
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TATA MOTORS HOSPITAL Chapter Name: COP

Quality Assurance Programme for Intensive Care Document No.: TMH/COP/QSP/07

Units& HDU

QUALITY ASSURANCE PROGRAMME FOR INTENSIVE CARE UNITS:

1. Introduction:
A quality assurance (QA) program focuses on the procedures that are being followed to provide
quality patient care to all patients requiring Intensive care.
Our goal is to provide advanced patient care to reduce unnecessary variability; and improve
patient care and condition and achieve expected outcomes.
The QA program helps to analyze and identify safety issues; steps to improve patient safety and
reduce the risk of medical errors and improve the quality of care.
2. Type of Facilities we have:

ICU (with lifesaving equipment).

3. Man power:

Well trained qualified and experienced nurses, doctors & ROMs are available round the clock.
The patient in intensive care receives individualized care where nurse: bed ratio is 1:2
(depending on the patient condition) and for patients on ventilator the ratio is 1:1.

4. Equipments available:

 Ventilator
 Defibrillator
Approved By: Medical Director
Quality System Issue No. : 01
Procedure
Issued By: Quality Manager Rev. No. : 00
Issue Date: Rev. Date: 00
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TATA MOTORS HOSPITAL Chapter Name: COP

Quality Assurance Programme for Intensive Care Document No.: TMH/COP/QSP/07

Units& HDU

 Pulse Oxymeter.
 Nebulization Machine
 Syringe Pump
 Infusion Pump.
 Cardiac Output monitoring device.

5. Isolation facility:

There is one isolation bed in ICU respectively for infected patients or patients requiring isolation.

6. Calibration and Maintenance of those equipments:

Periodic calibration and maintenance check are regularly carried out by the Maintenance and
Biomedical department as per Calibration Plan for smooth functioning of the equipments in the
Critical and High Dependency units.

7. Standard precautions followed in these areas:

 Restricted entry
 Dress change
 Strict hand hygiene
 Sterilization of articles
 Following aseptic techniques

8. Training of staff:

 Unit classes
 Special training for handling critical patients
 Regular In-service training
 Regular Infection Control training given by Infection Control Nurse

Approved By: Medical Director

Quality System Issue No. : 01
Procedure
Issued By: Quality Manager Rev. No. : 00
Issue Date: Rev. Date: 00
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TATA MOTORS HOSPITAL Chapter Name: COP

Quality Assurance Programme for Intensive Care Document No.: TMH/COP/QSP/07

Units& HDU

9. Defined admission and discharge criteria:

There is a defined admission and discharge criteria for intensive care and the same is followed
and implemented.

Approved By: Medical Director

Quality System Issue No. : 01
Procedure
Issued By: Quality Manager Rev. No. : 00
Issue Date: Rev. Date: 00
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TATA MOTORS HOSPITAL Chapter Name: COP

Quality Assurance Programme for Intensive Care Document No.: TMH/COP/QSP/07

Units& HDU

10. Infection Control Practices:

The detailed infection control practices followed in such intensive care units are documented in
the HOSPITAL INFECTION CONTROL MANUAL

Surveillance activities:

 Daily Infection Control rounds

 Hand hygiene Audit

Monitoring of infection rates like –Ventilator Associated Pneumonia (VAP), VAT Catheter
Associated Urinary Tract Infection (CAUTI), Intra- vascular device Infection (IVDI) and
Surgical Site Infection (SSI). There should be regular monitoring and follow up of Culture
reports in coordination with laboratory.

11. Housekeeping:

Thorough mopping & Cleaning in every 2 hrs and also as and when required. The Schedule is
defined in the Infection Control Manual

12. Quality Indicators:

1. Readmission rate
2. Re-intubation rate
3. Mortality rate
4. Incidence of Ventilator Associated Pneumonia.
5. Incidence of Intra- vascular device Infection.
6. Incidence of Catheter Associated Urinary Tract Infection.
7. Incidence of Surgical site Infection.
8. Incidence of needle stick injury
9. Compliance of hand hygiene.

Approved By: Medical Director

Quality System Issue No. : 01
Procedure
Issued By: Quality Manager Rev. No. : 00
Issue Date: Rev. Date: 00
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TATA MOTORS HOSPITAL Chapter Name: COP

Quality Assurance Programme for Intensive Care Document No.: TMH/COP/QSP/07

Units& HDU

ADMISSION / TRANSFER-IN&TRANSFER -OUT CRITERIA FOR INTENSIVE CARE UNITS:

1. Criteria for admission to Intensive care units (ICU):

1. GCS < 8

2. AIRWAY

i) Unable to phonate clearly

ii) Stridor, labored breathing (tracheal tug, use of accessory muscles)

iii) Unable to cough effectively.

3. BREATHING

i) Irregular and fast breathing

ii) Slow and shallow breathing.

iii) Inability to maintain SpO2 above 90% with nasal cannula or simple face mask.

iv) Chest expansion abnormalities (pneumothorax, haemothorax, massive pleural effusion with
respiratory compromise)

4. CIRCULATION

i) SBP < 90mmhg

ii) Radial pulse impalpable

iii) Need for invasive monitoring

Approved By: Medical Director
Quality System Issue No. : 01
Procedure
Issued By: Quality Manager Rev. No. : 00
Issue Date: Rev. Date: 00
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TATA MOTORS HOSPITAL Chapter Name: COP

Quality Assurance Programme for Intensive Care Document No.: TMH/COP/QSP/07

Units& HDU

iv)Unstable arrhythmias.

5. DISABILITY/ SEVERITY

i) Cervical spine injury.

ii) Anticipated or ongoing seizures

iii) Agitation, confusion, Drowsiness

iv) High intractable fever, vomiting and/or pain

6. METABOLIC

i) Acidosis, elevated lactate, dyselectrolytemia.

7. HAEMATOLOGIC

Severe bleeding.

Approved By: Medical Director

Quality System Issue No. : 01
Procedure
Issued By: Quality Manager Rev. No. : 00
Issue Date: Rev. Date: 00