SETTING UP AN INTENSIVE CARE UNIT

Leah MacadenLeah Macaden

COLLEGE OF NURSINGCOLLEGE OF NURSING

CMC, VELLORECMC, VELLORE

OBJECTIVE

• TO PROVIDE A FUNCTIONAL AND USER-

FRIENDLY ENVIRONMENT.

CORE COMPONENTS OF AN ICU

• CONSTANT MONITORINGCONSTANT MONITORING

• RAPID SKILLED INTERVENTIONRAPID SKILLED INTERVENTION

• MULTI DISCIPLINARY TEAM MULTI DISCIPLINARY TEAM WORKWORK

FACTORS TO CONSIDER

• SOURCES OF PATIENTS• ADMISSION AND DISCHARGE

CRITERIA• EXPECTED RATE OF OCCUPANCY• ECONOMIC INVESTMENT• FINANCIAL VIABILITY• PERSONNEL REQUIRED• TECHNOLOGICAL RESOURCES

LEVELS OF ICU CARE

• LEVEL I –LEVEL I – PROVIDES MONITORING, PROVIDES MONITORING, OBSERVATION AND SHORT TERM OBSERVATION AND SHORT TERM VENTILATION.VENTILATION.

• LEVEL II –LEVEL II – PROVIDES PROVIDES OBSERVATION, MONITORING & OBSERVATION, MONITORING & LONG TERM VENTILATION WITH LONG TERM VENTILATION WITH RESIDENT DOCTORS.RESIDENT DOCTORS.

• LEVEL III – LEVEL III – PROVIDES ALL PROVIDES ALL ASPECTS OF INTENSIVE CARE ASPECTS OF INTENSIVE CARE INCLUDING INVASIVE HAEMO INCLUDING INVASIVE HAEMO DYNAMIC MONITORING & DIALYSIS.DYNAMIC MONITORING & DIALYSIS.

DESIGNING AN ICU

THE TEAM SHOULD CONSIST OFTHE TEAM SHOULD CONSIST OF

AN INTENSIVE CARE DIRECTORAN INTENSIVE CARE DIRECTOR

NURSING ADMINISTRATORS &NURSING ADMINISTRATORS &

SUPERVISORS SUPERVISORS

HOSPITAL ADMINISTRATORSHOSPITAL ADMINISTRATORS

AN ARCHITECTAN ARCHITECT

ENGINEERS (Electrical, Civil, ENGINEERS (Electrical, Civil, Bioengineering, Electronics etc)Bioengineering, Electronics etc)

ALL POTENTIAL USERSALL POTENTIAL USERS

• ENVIRONMENTAL ENGINEERS, INTERIOR DESIGNERS, STAFF NURSES, PHYSICIANS, PATIENTS AND FAMILIES MAY BE ASKED FOR COMMENTS.

DESIGNPNEUMATICS - V

• P – PATIENT CARE P – PATIENT CARE • N- NURSINGN- NURSING• E- EATING (Clean area for E- EATING (Clean area for food preparation & delivery)food preparation & delivery)• U- UNCLEAN (Dirty linen & U- UNCLEAN (Dirty linen & equipment)equipment)• M- MEDICATION STORAGE M- MEDICATION STORAGE

• A – ADMINISTRATION (CLERKING & A – ADMINISTRATION (CLERKING & STATIONARY)STATIONARY)

• T – TEACHINGT – TEACHING

• I – INFECTION CONTROL & ELIMINATION I – INFECTION CONTROL & ELIMINATION (STERILIZATION & DISINFECTION)(STERILIZATION & DISINFECTION)

• C – CLEAN AREAC – CLEAN AREA

• STORAGESTORAGE

• VISITORSVISITORS

(OTHERS- BEREAVEMENT / QUIET(OTHERS- BEREAVEMENT / QUIET

ROOM, OFFICE ROOMS, DUTY ROOM, OFFICE ROOMS, DUTY DOCTOR’SDOCTOR’S

ROOM, STAFF LOUNGE, LIBRARY etc).ROOM, STAFF LOUNGE, LIBRARY etc).

TECHNICAL SPACE FOR A LAB, TECHNICAL SPACE FOR A LAB,

BLOOD GAS ANALYSER etc.BLOOD GAS ANALYSER etc.

RELATIVES’ WAITING ROOM RELATIVES’ WAITING ROOM WITHWITH

A TELEPHONE, TV, BEVERAGE A TELEPHONE, TV, BEVERAGE

FACILITIES etc. FACILITIES etc.

LOCATION

• Should be a geographically distinct area within the hospital, with controlled access.

• No through traffic to other departments should occur. Supply and professional traffic should be separated from public/visitor traffic.

• Location should be chosen so that the unit is adjacent to, or within direct elevator travel to and from, the Emergency Department, Operating Room, Intermediate care units, and the Radiology Department.

BED STRENGTH

• IDEALLY 8 TO 12 BEDSIDEALLY 8 TO 12 BEDS

• LARGER AREAS – DIFFICULT TO ADMINISTER AND LARGER AREAS – DIFFICULT TO ADMINISTER AND SMALLER AREAS NOT BEING COST EFFECTIVESMALLER AREAS NOT BEING COST EFFECTIVE

• 3 TO 5 BEDS PER 100 HOSPITAL BEDS FOR A 3 TO 5 BEDS PER 100 HOSPITAL BEDS FOR A LEVEL III ICU / 2 TO 20% OF THE TOTAL NUMBER LEVEL III ICU / 2 TO 20% OF THE TOTAL NUMBER OF HOSPITAL BEDSOF HOSPITAL BEDS

(In CMC – 68 ICU Beds, 60 Nursery beds, 43 HDU (In CMC – 68 ICU Beds, 60 Nursery beds, 43 HDU beds)beds)

• 1 ISOLATION BED FOR EVERY 10 ICU BEDS 1 ISOLATION BED FOR EVERY 10 ICU BEDS

BED SPACE & BEDS

• 150 – 200 SQUARE FEET PER OPEN BED 150 – 200 SQUARE FEET PER OPEN BED WITH 8 FEET IN BETWEEN BEDS.WITH 8 FEET IN BETWEEN BEDS.

• 225 – 250 SQUARE FEET PER BED IF IN A 225 – 250 SQUARE FEET PER BED IF IN A SINGLE ROOM.SINGLE ROOM.

• SINGLE ROOM – WITH AN ANTEROOM (20 SINGLE ROOM – WITH AN ANTEROOM (20 FEET) FOR HAND WASHING, GOWNING etc FEET) FOR HAND WASHING, GOWNING etc

• BEDS - ADJUSTABLE, NO HEAD BOARD, BEDS - ADJUSTABLE, NO HEAD BOARD, SIDE RAILS AND WITH WHEELS.SIDE RAILS AND WITH WHEELS.

ACCESSORIES

• 3 OXYGEN OUTLETS, 3 3 OXYGEN OUTLETS, 3 SUCTION OUTLETS (GASTRIC, SUCTION OUTLETS (GASTRIC, TRACHEAL & UNDERWATER TRACHEAL & UNDERWATER SEAL), TWO COMPRESSED AIR SEAL), TWO COMPRESSED AIR OUTLETS AND 16 POWER OUTLETS AND 16 POWER OUTLETS PER BED.OUTLETS PER BED.

• STORAGE BY EACH BEDSIDE STORAGE BY EACH BEDSIDE (BUILT IN / ALCOVE).(BUILT IN / ALCOVE).

• HAND RINSE SOLUTION BY HAND RINSE SOLUTION BY EACH BEDSIDE.EACH BEDSIDE.

• EQUIPMENT SHELF AT THE EQUIPMENT SHELF AT THE HEAD END (MIND THE HEIGHT HEAD END (MIND THE HEIGHT OF THE CARE GIVER).OF THE CARE GIVER).

• HOOKS & DEVICES TO HANG HOOKS & DEVICES TO HANG INFUSIONS / BLOOD BAGS – INFUSIONS / BLOOD BAGS – SUSPENDED FROM THE SUSPENDED FROM THE CEILING WITH A SLIDING RAIL CEILING WITH A SLIDING RAIL TO POSITION.TO POSITION.

• INFUSION PUMPS TO BE INFUSION PUMPS TO BE MOUNTED ON STANDS / POLES.MOUNTED ON STANDS / POLES.

INFRASTRUCTURE

• PATIENTS MUST BE SITUATED SO THAT DIRECT OR INDIRECT (E.G. BY VIDEO MONITOR) VISUALIZATION BY HEALTHCARE PROVIDERS IS POSSIBLE AT ALL TIMES.

• THE PREFERRED DESIGN IS TO ALLOW A DIRECT LINE OF VISION BETWEEN THE PATIENT AND THE CENTRAL NURSING STATION.

• MODULAR DESIGN – SLIDING GLASS DOORS & PARTITIONS TO FACILITATE VISIBILITY.

ENVIRONMENT

• SIGNALS & ALARMS – ADD TO THE SENSORY OVERLOAD; NEED TO BE MODULATED.

• FLOOR COVERINGS AND CEILING WITH SOUND ABSORPTION PROPERTIES.

• DOORWAYS – OFFSET TO MINIMISE SOUND TRANSMISSION.

• LIGHT & SOFT MUSIC (EXCEPT 10 PM TO 6 LIGHT & SOFT MUSIC (EXCEPT 10 PM TO 6 AM).AM).

• LIGHTING – FOCUSSED & CENTRAL LIGHTING.LIGHTING – FOCUSSED & CENTRAL LIGHTING.

• AIRCONDITIONING (SPLIT / CENTRAL) – 25 + AIRCONDITIONING (SPLIT / CENTRAL) – 25 + OR – 2 DEGREES CENTIGRADE.OR – 2 DEGREES CENTIGRADE.

• CLEANING – VACUUM CLEANING & WET CLEANING – VACUUM CLEANING & WET MOPPING OF THE FLOOR. FUMIGATION IS NO MOPPING OF THE FLOOR. FUMIGATION IS NO LONGER RECOMMENDED. LONGER RECOMMENDED.

• NATURAL ILLUMINATION AND VIEW - WINDOWS ARE AN IMPORTANT ASPECT OF SENSORY ORIENTATION; HELPS TO REINFORCE DAY/NIGHT ORIENTATION.

• WINDOW TREATMENTS SHOULD BE DURABLE AND EASY TO CLEAN, AND A SCHEDULE FOR THEIR CLEANING MUST BE ESTABLISHED.

• ADDITIONAL APPROACHES TO IMPROVING SENSORY ORIENTATION FOR PATIENTS MAY INCLUDE THE PROVISION OF A CLOCK, CALENDAR,

BULLETIN BOARD, AND/OR PILLOW SPEAKER CONNECTED TO RADIO AND TELEVISION.

UTILITIES

• ELECTRICAL – ADEQUATE SOCKETS (5AMPS ELECTRICAL – ADEQUATE SOCKETS (5AMPS & 15 AMPS), GENERATOR SUPPLY & & 15 AMPS), GENERATOR SUPPLY & BATTERY BACK UP.BATTERY BACK UP.

• MEDICAL GAS & VACUUM PIPELINE – MEDICAL GAS & VACUUM PIPELINE – COLOUR CODED AND NOT COLOUR CODED AND NOT INTERCHANGEABLE.INTERCHANGEABLE.

• WATER FROM A CERTIFIED SOURCE WATER FROM A CERTIFIED SOURCE ESPECIALLY IF USED FOR HAEMODIALYSIS. ESPECIALLY IF USED FOR HAEMODIALYSIS.

• HANDWASHING AREAS – HANDWASHING AREAS – UNINTERRUPTED WATER SUPPLY, UNINTERRUPTED WATER SUPPLY, DISPOSABLE PAPER TOWELS / DISPOSABLE PAPER TOWELS / HAND DRIER. (NO CLOTH TOWELS HAND DRIER. (NO CLOTH TOWELS PLEASE)PLEASE)

• TELEPHONES & COMPUTERS FOR TELEPHONES & COMPUTERS FOR COMMUNICATION.COMMUNICATION.

• STERILISING AREA – LARGE WATER STERILISING AREA – LARGE WATER BOILER / GEYSER & EXHAUST FANS.BOILER / GEYSER & EXHAUST FANS.

• CLEAN AND A DIRTY UTILITY WITH CLEAN AND A DIRTY UTILITY WITH NO INTERCONNECTION.NO INTERCONNECTION.

• SHELVING & CABINETS OFF THE SHELVING & CABINETS OFF THE GROUND FOR STORAGE.GROUND FOR STORAGE.

• WASTE & SHARPS DISPOSAL.WASTE & SHARPS DISPOSAL.

• WORK AREAS AND STORAGE FOR CRITICAL SUPPLIES SHOULD BE LOCATED IMMEDIATELY ADJACENT TO EACH ICU.

• ALCOVES SHOULD PROVIDE FOR THE STORAGE AND RAPID RETRIEVAL OF CRASH CARTS AND PORTABLE MONITOR/DEFIBRILLATORS.

• THERE SHOULD BE A SEPARATE MEDICATION AREA OF AT LEAST 50 SQUARE FEET CONTAINING A REFRIGERATOR FOR PHARMACEUTICALS, A DOUBLE LOCKING SAFE FOR CONTROLLED SUBSTANCES, AND A TABLE TOP FOR PREPARATION OF DRUGS AND INFUSIONS.

EQUIPMENT

MONITORING EQUIPMENTMONITORING EQUIPMENT

THERAPEUTIC EQUIPMENTTHERAPEUTIC EQUIPMENT

DIGITAL & ANALOGUE DISPLAYDIGITAL & ANALOGUE DISPLAY

AUDIO & VISUAL ALARMSAUDIO & VISUAL ALARMS

BATTERY BACK UP & CHARGINGBATTERY BACK UP & CHARGING

PERSONNEL

• NURSE PATIENT RATIO – 1: 1.NURSE PATIENT RATIO – 1: 1.

• ICU NURSE MANAGERICU NURSE MANAGER

AN RN (REGISTERED NURSE) WITH AAN RN (REGISTERED NURSE) WITH ABSN OR PREFERABLY AN MSN DEGREE. BSN OR PREFERABLY AN MSN DEGREE. CERTIFICATION IN CRITICAL CARE OR CERTIFICATION IN CRITICAL CARE OR EQUIVALENT GRADUATE EDUCATION EQUIVALENT GRADUATE EDUCATION WITH AT LEAST 2 YRS EXPERIENCE WITH AT LEAST 2 YRS EXPERIENCE

WORKING IN A CRITICAL CARE UNIT.WORKING IN A CRITICAL CARE UNIT.

• EXPERIENCE WITH HEALTH EXPERIENCE WITH HEALTH INFORMATION SYSTEMS, QUALITY INFORMATION SYSTEMS, QUALITY IMPROVEMENT/RISK MANAGEMENT IMPROVEMENT/RISK MANAGEMENT ACTIVITIES, AND HEALTHCARE ACTIVITIES, AND HEALTHCARE ECONOMICS. ECONOMICS.

• ABILITY TO ENSURE THAT CRITICAL ABILITY TO ENSURE THAT CRITICAL CARE NURSING PRACTICE MEETS CARE NURSING PRACTICE MEETS APPROPRIATE STANDARDS.APPROPRIATE STANDARDS.

• PREPARATION TO PARTICIPATE IN PREPARATION TO PARTICIPATE IN THE ON-SITE EDUCATION OF THE ON-SITE EDUCATION OF CRITICAL CARE UNIT NURSING CRITICAL CARE UNIT NURSING STAFF. STAFF.

• ABILITY TO FOSTER A COOPERATIVE ABILITY TO FOSTER A COOPERATIVE ATMOSPHERE WITH REGARD TO THE ATMOSPHERE WITH REGARD TO THE MULTIDISCIPLINARY TRAINING MULTIDISCIPLINARY TRAINING PERSONNEL INVOLVED IN THE CARE PERSONNEL INVOLVED IN THE CARE

OF CRITICAL CARE UNIT PATIENTS.OF CRITICAL CARE UNIT PATIENTS.

• REGULAR PARTICIPATION IN ONGOINGREGULAR PARTICIPATION IN ONGOING CONTINUING NURSING EDUCATION.CONTINUING NURSING EDUCATION.

• KNOWLEDGE ABOUT CURRENTKNOWLEDGE ABOUT CURRENT ADVANCES IN THE FIELD OF CRITICALADVANCES IN THE FIELD OF CRITICAL CARE NURSING.CARE NURSING.

• PARTICIPATION IN STRATEGIC PARTICIPATION IN STRATEGIC PLANNING AND REDESIGN EFFORTSPLANNING AND REDESIGN EFFORTS

MEDICAL STAFFING – COVER FOR MEDICAL STAFFING – COVER FOR EVERYEVERY

SHIFT WITH COMPETENCE TO HANDLE SHIFT WITH COMPETENCE TO HANDLE ANY EMERGENCY.ANY EMERGENCY.

ANCILLARY STAFF – THERAPISTS,ANCILLARY STAFF – THERAPISTS,TECHNICIANS, RADIOGRAPHERS etc.TECHNICIANS, RADIOGRAPHERS etc.

RECEPTIONIST, CHAPLAIN / RECEPTIONIST, CHAPLAIN / COUNSELLOR.COUNSELLOR.

PERSONNEL DEVELOPMENT

IN SERVICE EDUCATION PROGRAMMESIN SERVICE EDUCATION PROGRAMMES

DEBRIEF SESSIONS – TO BURN OUTDEBRIEF SESSIONS – TO BURN OUT

TEAM BUILDING EXERCISESTEAM BUILDING EXERCISES

INVOLVEMENT IN POLICY INVOLVEMENT IN POLICY

DEVELOPMENTDEVELOPMENT

POLICIES & PROTOCOLS

• ADMISSION, DISCHARGE & ADMISSION, DISCHARGE & WITHDRAWAL OF SUPPORT.WITHDRAWAL OF SUPPORT.

• LEGAL & ETHICAL GUIDELINES & MLC LEGAL & ETHICAL GUIDELINES & MLC POLICIESPOLICIES

• STANDING ORDERS.STANDING ORDERS.

• ORGAN DONATION.ORGAN DONATION.

INFECTION CONTROLINFECTION CONTROL

• SURVEILLANCE SURVEILLANCE

• STERILIZATION & DISINFECTIONSTERILIZATION & DISINFECTION

• QUALITY CONTROL & AUDITINGQUALITY CONTROL & AUDITING

DOCUMENTATION

• CONVENTIONALCONVENTIONAL

• ELECTRONIC MEDICAL RECORDS (EMR)ELECTRONIC MEDICAL RECORDS (EMR)

Bedside terminals

Interfaced with existing hospital data Systems, data retrieval (laboratory Results, x-ray reports, etc.).

Remote data transmission capabilities (to offices, on-call rooms, etc.)

OTHER FACILITIES

• BEREAVEMENT & AFTER CARE BEREAVEMENT & AFTER CARE SERVICESSERVICES

• COUNSELLINGCOUNSELLING

• LAST OFFICE LAST OFFICE

• SUPPORT SYSTEMS FOR PATIENT SUPPORT SYSTEMS FOR PATIENT

RELATIVES & STAFFRELATIVES & STAFF

REFERENCES

Guidelines for Intensive Care Unit Design –Crit Care Med 1995 Mar; 23(3):582-588.

John, G. Essentials of Critical Care, Edition IV, (2003), Shakti Prints, Vellore.

Worthley, L.I.G. Clinical Examination of the Critically Ill Patient, Edition II, (2000), The Australasian Academy of Critical Care Mediicne,South Australia.

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