PHYSICAL FACILITIES OF ICU:
Physical facilities can be classified as: * Patient Area. * Auxilary Area. * Entrance to the ICU. * Ancillary Area.

1.ENTRANCE TO THE ICU:

2.PATIENT CARE AREA:

3.AUXILLARY AREA:

4.ANCILLARY AREA:

LEVELS OF ICU:

There are five different types and levels of ICU defined according to three main criteria: the nature of the facility, the care process and the clinical standards and staffing requirements. All levels and types of ICU must be separate and self-contained facilities in hospitals and.The five types of ICU are briefly described below: * Adult intensive care unit, level 3: must be capable of providing complex, multisystem life support for an indefinite period; be a tertiary referral centre for patients in need of intensive care services and have extensive backup laboratory and clinical service facilities to support the tertiary referral role. It must be capable of providing mechanical ventilation, extracorporeal renal support services and invasive cardiovascular monitoring for an indefinite period; or care of a similar nature. * Adult intensive care unit, level 2: must be capable of providing complex, multisystem life support and be capable of providing mechanical ventilation, extracorporeal renal support services and invasive cardiovascular monitoring for a period of at least several days, or for longer periods in remote areas or care of a similar nature (see ACHS guidelines). * Adult intensive care unit, level 1: must be capable of providing basic multisystem life support usually for less than a 24-hour period. It must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring for a period of at least several hours; or care of a similar nature. * Paediatric intensive care unit: must be capable of providing complex, multisystem life support for an indefinite period; be a tertiary referral centre for children needing intensive care; and have extensive backup laboratory and clinical service facilities to support this tertiary role. It must be capable of providing mechanical ventilation, extracorporeal renal support services and invasive cardiovascular monitoring for an indefinite period to infants and children less than 16 years of age; or care of a similar nature. * Neonatal intensive care unit, level 3: must be capable of providing complex, multisystem life support for an indefinite period. It must be capable of providing mechanical ventilation and invasive cardiovascular monitoring; or care of a similar nature. Definitions for high-dependency unit and coronary care unit are under development.

STAFFING OF ICU:

Consultants Consultants are the most senior member of the team who will be assisted by other doctors called registrars and senior house officers.The consultant intensive care doctor is in overall charge of the unit on a day to day basis and responsible for the care of the patients.There is always a careful handover from one consultant to the next, discussing each of the current patients in turn and the other patients in the hospital whose doctors have asked the intensive care team to advise on. . Many intensive care units are run by consultant anaesthetists. Other specialist doctors will visit the ICU to advise on particular aspects of patient care.
Junior Doctors
The junior doctors will provide much of the specialist procedures and patient assessments under the direction and advice of the consultant.There will be one or two "tiers" of junior doctors working in intensive care.There is always a junior doctor available on the intensive care unit who can perform an emergency intubation (inserting a breathing tube and assisting a patient's breathing). The junior doctors will be working a shift system of 8-13 hours at a time.
Staff who visit the intensive care unit
A physiotherapist visits the ICU every day. They may treat a patient's chest, depending on a patient's condition, to clear their lungs. Many patients are at risk from chest infections because their lungs are not functioning well enough to prevent a build-up of secretions. A physiotherapist removes the secretions using a small suction tube passed down a patient's throat.
Physiotherapists are also involved in rehabilitating conscious, recovering patients by helping them gently exercise their limbs.
A radiographer takes x-rays of patients, either in the unit using a portable x-ray machine or in the radiography department. A radiographer also performs ultrasound scans.
A pharmacist is involved in monitoring the effects of medicines on patients. Pharmacists also ensure that an ICU has sufficient supplies of necessary drugs.
A dietician ensures that each patient is receiving the appropriate type of food and is receiving enough calories and nutrients.

Nursing staff
The senior nurse who co-ordinates the care in an ICU is called a sister, if female, or a charge nurse, if male. The nurses who look after individual patients' needs are called staff nurses. In some ICUs a nurse is assigned to each patient as their primary nurse and spends the majority of their time looking after that patient. Sometimes there may be student nurses on,the unit who work under close supervision.
Expert nursing is the most important element in the intensive care of the patient. It is therefore essential that the intensive care unit nursing staff should be highly trained and of above average competence. The nursing staff should be knowledgeable about the emotional and rehabilitative aspect of the ICU patient and capable of applying appropriate therapeutic intervention. The recommended nurse patient ratio is 1:1.

ICU EQUIPMENTS:
Arterial Line
A very thin tube (catheter) is inserted into one of the patient's arteries (usually in the arm) to allow direct measurement of the blood pressure and to measure the concentration of oxygen and carbon dioxide in the blood. Arteries carry oxygen and nutrient-rich blood from the heart to tissues and organs throughout the body. Veins carry blood that is higher in waste products and carbon dioxide back to the heart and lungs. The arterial line allows nurses and doctors to monitor these levels at regular intervals. The arterial line is attached to a monitor.
Brain Stem Evoked Response Equipment
Auditory brain stem responses evoked by stimulating the brain stem with painless sound waves using headphones. These sound waves are received by the brain, and a machine is used to test whether the brain stem has received the signals.
The quality of the brain stem's functioning in a comatose patient is thought to be an important indicator of the degree and location of brain injury. This highly specialized equipment is not available in all hospitals.
Electrocardiogram (ECG/EKG)
The recording made by small, round electrode pads located on the patient's chest to monitor heart rate and rhythm. These are connected to a monitor and uses routinely in the intensive care unit.
Intracranial Pressure (ICP) Monitor
A monitoring device to determine the pressure within the brain. It consists of a small tube (catheter) attached to the patient's skull by either a ventriculostomy, subarachnoid bolt or screw and is then connected to a transducer, which registers the pressure.
Ventriculostomy is a procedure for measuring intracranial pressure by placing an ICP monitor within one of the fluid-filled, hollow chambers of the brain, called ventricles. These four natural cavities are filled with cerebrospinal fluid (CSF), which also surrounds the brain and spinal chord.
Respirator/Ventilator
A machine that does the breathing work for the unresponsive patient. It serves to deliver air in the appropriate percentage of oxygen and at the appropriate rate. The air is also humidified by the respirator.
Shunt
A procedure to draw off excessive fluid in the brain. A surgically-placed tube running from the ventricles which deposits fluids into either the abdominal cavity, heart or large veins of the neck

"Space Boots" (Spenco Boots)
Padded support devices made of lamb's wool used to position the feet and ankles of the patient. Without this support and alignment, patients who are unconscious for long periods may develop deformities limiting future movement
Support Hose/TEDS
Anti-embolic stockings. Tight knee or thigh-high stockings that support the leg muscles and thus help prevent pooling of blood in veins of legs. Swan-Ganz Monitor
A catheter (tube) similar to the Central Venous Pressure (CVP) Line. It is used to measure blood pressure and blood gas concentrations in the right side of the heart, in vessels of the lungs and in the left side of the heart
Tracheostomy Tube
A tube inserted into a temporary surgical opening at the front of the throat providing access to the trachea and windpipe to assist in breathing. Traction
A weighted traction setup composed of pulleys and lines used in the care of the patient with broken leg or spine. After repair of the fractures and application of the appropriate casts, weights are used to keep the bones in alignment. Transducer
A sensitive electronic device which detects bodily functions, such as heart rate and blood pressure, and transmits signals representing those functions to a monitor so that the can be observed.
Some of the other equipment are:
Portable x-ray machine, Infusion Pump, Crash-Cart, IABP Machine etc. * Infusion pump device that delivers fluids intravenously or epidurally through a catheter. Infusion pumps employ automatic, programmable pumping mechanisms to deliver continuous anesthesia, drugs, and blood infusions to the patient. The pump is hung on an intravenous pole placed next to the patient's bed. * Crash cart also called a resuscitation or code cart. This is a portable cart containing emergency resuscitation equipment for patients who are "coding." That is, their vital signs are in a dangerous range. The emergency equipment includes a defibrillator, airway intubation devices, a resuscitation bag/mask, and medication box. Crash carts are strategically located in the ICU for immediate availability for when a patient experiences cardiorespiratory failure.

FLOW PATTERN IN ICU :
Patient who leaves the ICU (Recovery/Mortality)
Patient who leaves the ICU (Recovery/Mortality)

Transferred to another hospital due to unavailability of bed
Transferred to another hospital due to unavailability of bed

1. Regional emergency arrivals

2. Elective arrivals

3. Internal emergency arrivals

4. Patients that can be pre- discharged if necessary

5. Patients leaving the ICU due to recovery or mortality

1. Regional emergency arrivals

2. Elective arrivals

3. Internal emergency arrivals

4. Patients that can be pre- discharged if necessary

5. Patients leaving the ICU due to recovery or mortality

Internal emergency patients not transferred to ICU, placed in an over-bed.
Internal emergency patients not transferred to ICU, placed in an over-bed.
Discharge is at hand, can be pre-discharged in case of an incoming emergency.
Discharge is at hand, can be pre-discharged in case of an incoming emergency. Sent home to return later due to unavailability of bed
Sent home to return later due to unavailability of bed

In practice, one can roughly distinguish three patient types: elective patients, internal emergency patients and external/regional emergency patients. Elective patients arrive from the operating theatre after undergoing a planned operation. If no operational IC bed is available, the operation is cancelled. An exception is made for operations that involve many people (staff and patients), for example a liver transplantation with a living donor. For such patients, beds are reserved that will not be taken by another patient. Emergency patients arrive unexpectedly and require immediate care. Internal emergency patients arrive from a nursing ward. Regional emergency patients arrive through the emergency room, mostly brought by ambulance. The ambulance nurse does not have information on the availability of IC beds. If there is no bed available for an emergency patient, an attempt is made to create place. For instance, another patient may be predischarged from the ICU but only if the discharge of the patient was already at hand. Also, a patient who came from a different hospital for some special procedure may be sent back if the special procedure is finished. If none of these options is available, the solution depends on the type of patient. An internal emergency patient should be kept in the hospital mostly because it is not desirable to transport a critically ill patient, but also because juridically a patient can only be transferred if it is beneficial for the patient. Therefore, for an internal emergency patient an over-bed is created, which is an IC bed that was not staffed. The drawback of the over-bed is that physicians and nurses have to work harder as they have an extra patient to take care of, which requires flexible staff and negatively affects the quality of care. As soon as a patient is discharged, the over-bed is cancelled. For regional patients an over-bed is generally not an option because the hospitals tend to give priority to already admitted patients, and juridically, a patient not yet admitted to the hospital can be sent to another hospital. Thus, for a regional emergency patient, generally an operational bed in another hospital is sought, and sometimes an available bed can be found only outside the region. Figure above schematically depicts the patient flows for two ICU’s. Flow 1 reflects the regional emergency patients, that are transferred to another hospital/region in case all beds are occupied. Flow 2 is the flow of elective patients. If no operational bed is available at their arrival, they are sent home to return later. Flow 3 corresponds to the flow of internal emergency patients who are not transferred in case of a full ICU, but are placed in an over-bed. Flow 4 depicts the patients whose discharge is at hand and who can be predischarged in case of an incoming emergency. We do not take this flow into account. Flow 5 is the flow of patients who leave the ICU (because of recovery or mortality)

CHALLENGES FACED BY THE MANAGEMENT:

Maintenance of patient data:
The Intensive care unit is the area in patient care where the amount of patient data from a variety of sources is particularly large.Use of software for performing basic clinical functions data entry, data review, medications and data analysis can be done for maintaining the accurate data.
Ex- meta-vision software
ICU Sepsis Management:
It is one of the challenge faced in the ICU.It can be solved by: * Assessment of sepsis and potential organ failure * Early goal directed therapy (EGDT) * Antibiotic selection and Ensure rapid initiation of appropriate antibiotics.

Shortage of ICU beds:

The number of ICU beds available is disproportionately low, both in private as well as public hospitals. Obtaining a bed in ICU is quite often difficult for critically ill patients. Owing to shortage of ICU beds, only the most critical of the deserving patients are provided ICU care, that could contribute to high mortality inside the ICU as well as outside the ICU (in the wards). There appears a strong need to increase the ICU beds to at least 10% of total beds in all hospitals; and even upto 15-20% in some leading public as well as private tertiary care centres.

Problems of staff and shortage of professionals:
There should be better understanding of the problems faced by the working staff on a day to day basis.Also the nursing shortage is seriously challenging hospitals to provide safe, quality care to acute and critically ill patients. Most frequently reported are the registered nurse (RN) shortages in intensive care units (ICUs) and step-down units. Issues surrounding the nursing shortage are multifaceted and require comprehensive solutions. Also there is a shortage of other paramedical staff which is also an area of concern for hospitals.
Making all the professional work as a team is one of the challenges faced by the hospital.One must always go with the Team building approach and good communication will always prevent or minimize the effect of human error. Development of interpersonal skills and make contingency plans will help in better management.It minimizes errors that occur during administration of medication and when communicating clinical information.

Maintenance of Equipment :
Since ICU equipment is used continuously on critically ill patients, it is essential that equipment be properly maintained, particularly those devices used for life support and resuscitation. ICU staff should perform daily checks on equipment and inform biomedical engineering staff when equipment needs maintenance, repair, or replacement. For mechanically complex devices, service and preventive maintenance contracts are available from the manufacturer or third-party servicing companies.

Relatives management
To calm down the anxiety of patient’s relatives some provisions should be made.For eg. Relatives waiting room with telephone, television, beverages facilities, toilets should be provided.Always fully disclose the patients current status and prognosis to the relatives.Clearly explain all reasonable management options. Always Consider the importance of patient and family communication and involvement in ICU care.