Intensive Care Unit
Assignment

By,
Barkha Bijlani
MBA-HHM (2012-14)
12040141007

Intensive Care Unit
Introduction:
Timely and efficient management by doctors combined with concerted nursing efforts have revolutionized the management of critically ill patients. With the persistent demographic trend towards an aging population nearing the age of 65 and above, the number of patients requiring critical care will rise but many patients who might have had no chance of survival can now be treated successfully. And during last two decades critical care medicine has undergone rapid changes and emerged as a discipline by itself.
Intensive care units (ICU), also called critical care or intensive therapy departments, is highly specified and sophisticated area of a hospital which is specifically designed, staffed, located, furnished and equipped, dedicated to management of critically ill patients whose conditions are life-threatening and need constant, close monitoring and support from equipment and medication to keep normal body functions going. It is a department with dedicated medical, nursing and allied staff. It operates with defined policies; protocols and procedures, having its own quality control, education, training and research programmes. It is emerging as a separate specialty and can no longer be regarded purely as part of anaesthesia, Medicine, surgery or any other speciality. It has to have its own separate team in terms of doctors, nursing personnel and other staff who are tuned to the requirement of the speciality.
Definition:
“ICU is the specialty nursing unit designed, equipped, and staffed with specially skilled personnel for treating very critical patients with potentially reversible lesions or those requiring specialized care and equipment”.

Functions:
A multidisciplinary ICU permits concentration of meager resources with regard to staffing, equipment and technical expertise. Thereby it encourages a more holistic approach.
The basic functions of ICU are: * To concentrate in one centralized area the critically ill patients. * To enhance the physician’s ability to treat acutely ill patients * To provide close personal and monitor-assisted surveillance of critically ill patients * To utilize equipment and highly trained personnel
Physical Facilities: * Individual rooms with full height glass walls between the rooms and the corridor are recommended this will allow visibility of patients face and minimize cross infection. * Mechanical / Electrically operated beds that can be adjusted to various positions are recommended. * Rooms should be sound proofed and air conditioned with individual room controls and adequate air exchange for prevention of cross contamination. * The ICU allows control of temperature, humidity and air change. If this not be possible then one should have windows which can be opened (‘Tilt and turn' windows are a useful design.). * The main light at the bed head is with fitted with a dimmer switch and the bed head also has an emergency buzzer switch connected to central buzzer at central nursing station. * A stand-by generator is a reliable alternate source of power for ICU. * All toilets in private rooms and cubicles and on the non-cubicle side are allowed with wheel chairs and grab bars and panic buttons with pull cords. * Considerable storage space is essential for stocking of large number of items like tracheostomy strays, pacemakers, dressing trays, linen, housekeeping supplies. * Provision should be made for a nourishment center for ICU patients who are largely on liquid. * A family waiting room is essential with toilet and pay phone facility.
Flow pattern of Patients in ICU:

Levels of ICU:
Following ICU Levels are proposed
Level I: * It is recommended for small district hospital, small private Nursing homes and rural centers. * Ideally 6 to 8 Beds are recommended. * Provides resuscitation and short-term Cardio respiratory support including Defibrillation * Able to ventilate a patient for at least 24 to 48 hours, including non-invasive ventilation * Non-invasive Monitoring like - SPO2, HR and rhythm, NIBP and invasive monitoring like ABG is desirable. * In charge should be preferably a trained doctor in ICU technology and knowledge * Blood Bank support * Should have basic clinical Lab (CBC, BS, Electrolyte, LFT and RFT) and Imaging back up (X ray and USG), ECG * Microbiology support is desirable * At least one book on Critical Care Medicine as ready reckoner
Level II (Recommendations of Level I Plus): * Recommended for larger General Hospitals with bed strength of 6 to 12. * Director be a trained/qualified Intensivist * Multisystem life support * Invasive and Noninvasive Ventilation * Invasive Monitoring * Transcutaneous Pacing * Nurses and duty doctors trained in Critical Care * CT & MRI is desirable * Protocols and policies for ICUs are observed * Should be supported ideally by Cardiology and other super specialties of Medicine and Surgery * Should fulfill all requirements for IDCC Course * Resident doctors must be exposed to FCCS course/BASIC course/Ventilation workshops and other updates
Level III (All recommendations of Level II Plus): * Recommended for tertiary level hospitals with bed strength 10 to 16 and one or multiple ICUs as per requirement of the institution * Multidisciplinary unit headed by Intensivist * Preferably Closed ICU * Have all recent methods of monitoring, invasive and noninvasive including continuous cardiac output, SCvO2 monitoring etc. * Long term acute care of highest standards * Intra and inter-hospital transport facilities available * Should become lead centers for IDCC and Fellowship courses * Bedside x-ray, USG, 2D-Echo available * Bedside bronchoscopy, dialysis are available * Optimum patient/Nurse ratio is maintained with 1/1 patient/Nurse ratio in ventilated patients. * Provision for research and participation in National and International research programmes * The hospital should an Infection Control Committee, Ethics Committee, etc. * There is regular sharing of knowledge, mishaps, incidents, symposia and seminars etc. related closely to the department and in association with other specialties ICU Staffing:
ICU staffing is one of the most important tasks and components of the whole programme. Dedicated, highly motivated, ready to work in stress situations for long periods of time are the type of personal needed. They include * Intensivist: "Intensivists are specifically trained to handle critical care patients," says Barbara Rudolph, director, leaps and measures, for the Leapfrog Group. "Most ICU patients have suffered traumatic events or experienced system failure. Intensivists are trained to quickly identify and treat these patients to prevent further complications." Intensivists direct a team of practitioners that includes nurses, pharmacists, respiratory therapists and nutritionists—all with experience in dealing with critically ill patients.

* Resident doctors: He provides 24 hour medical service within the hospital on call basis. He document clinical findings and attends ward rounds with consulting staff and discusses patient treatment plans. * Senior Residents: This resident must be a physician with a post graduate degree in general medicine .he will initiate and carry out when necessary even with permission of the admitting consultant. Generally the senior residents shift is of 12hours and at least two such senior residents will be required. * Junior Residents: A junior resident is generally a fresh medical graduate in training for experience and higher knowledge. At least two such junior residents will be on duty round the clock in a ten bed unit. They can be turned over on an 8 hour shift. However in many ICU’s the duty shift lasts 12 hours to coincide with that of the senior resident.

* Nurses: The nurse is the key to success of the entire system of ICU. The ideal ratio of nurses to ICU bed is 1:1, in each shift. However it may be impossible in real cases, so lower ratio of one nurse for two patients in a shift is acceptable as a compromise. And one hardly finds 1:1 ratio in all shifts. On the basis of Time Utilization Study of nurses in ICU the number of patients that could be conveniently looked after by 1 nurse was * Morning shift: 2.4 patients * Evening shift: 3.2 patients * Night shift: 5.5 patients (plus one in charge sister in each shift)

* Respiratory Therapists: He looks after ventilator management and respiratory physiotherapy. And their offices should be readily accessible so that he/she can be promptly summoned to attend to patients in any respiratory crisis.

* Nutritionist: They have to be trained in desired practices and should be more inclined towards enteral feeding than Total Parentral Nutrition (TPN).

* Physiotherapist help in positioning and mobilization of patients. * Technicians can perform simple procedures like taking samples and sending them to proper place. * Computer Operator can prepare reports, enter data and bring out print outs as and when needed. * Biomedical Engineer within the campus makes the job of ICU less frustrating when snags creep in within sensitive ICU equipment. * Other support staff like Clinical Pharmacist, clinical Lab staff, Microbiology and Imaging staff, Social worker or counselor, cleaning staff, guards etc.

Equipment: In a general all-purpose ICU besides the equipment usually found in acute care ward, a list of equipment desirable for a hospital reputed for critical care is as follows: 1. Monitoring equipment: * Bedside and central monitor * ECG and EEG Recorder/ Monitor * Pulse oximeters * Temperature and blood glucose meters * Intravascular Pressure Monitoring devices 2. Cardiovascular Therapy Equipment: * CPR trolley * Defibrillators * Intravenous pacemakers * Infusion pumps and syringes 3. Respiratory Therapy Equipment: * Ventilators * Nebulizers * Oxygen therapy devices * Ambu bags * Fibroptic bronchoscope * Intubation/ Tracheostomy trolley 4. Radiological Equipment: * Portable x-ray machine * Image intensifier 5. Laboratory Equipment: * Blood gas analyzer * Electrolyte analyzer 6. Dialysis Equipment: * For hemodialysis * Peritoneal dialysis 7. Miscellaneous Equipment: * Dressing trolley * Drip stands * Sterilizing equipment

Indicative List of Equipment (12 Bedded ICU) Sr No | Name of the equipment | Number | Description | 1. | Bedside Monitors | One per bed | A T.V like screen with a continual display of waveforms representing different pressures and activities in the body such as B.P, SPO2,ECG etc | 2. | Ventilators | 6 to 12 | A machine that does the breathing work for unresponsive patients. | 3. | Infusion pumps | At least 2 per bed | Volumetric with all Recent upgraded drug calculations | 4. | Defibrillators | 2 | To deliver therapeutic dose of electric energy to the affected heart | 5. | ICU bed (shock proof) | 1 for each bed | Electronically manoeuvred with all positions possible with mattress. | 6. | Head end table | 1 for each bed | With 2 O2 Outlets, two vacuum, one compressed air and electric outlets , suction unit, provision for Alarm, trays for monitors, Two Drip stands, One Procedure light | 7. | ABG machines | 1 | For arterial blood gas analysis and record electrolyte levels. | 8. | Crash /Resuscitation trolley | 2 | To hold all resuscitation equipment and Medicines | 9. | Pulse Oximeter | 2 | As stand by unit to check spO2 | 10. | Refrigerator | 1+1 for staff and doctors | For storage of medical components and other for personal use by staff | 11. | Computers | 2 for ICU and 1 for in charge | With LAN, Internet facility and printer to be connected with all departments. | 12. | Intermittent Leg CompressingMachine | 2 | To prevent Deep Vein Thrombosis ( DVT) | 13. | Air beds | 6 | To prevent bed sores | 14. | Intubating video scope | 1 | To make difficult Intubations easy | 15. | Ultra sound and ECHO machine | 1 | With recent advances to look instantly even at odd hours. Vascular filling, central lines, etc | 16. | Bed side x-ray | 1 | For bed ridden and immobile patients | 17. | Spinal board | 2 | For spine cord injury patients | 18. | Rigid cervical collars | 4 | For stabilizing cervical spine | 19. | Ambu mask of different sizes | 10 sets includingtwo for Pediatric use | Silicon | 20. | Fibroptic Bronchoscope | 1 | For efficient Bronchoscopy |

Managerial challenges:
Critical care is starting to face some tough obstacles, and the ICU of the future will be shaped by these problems—namely an aging population and a shrinking field of expert critical care practitioners. Because of these impending changes, in 20 or 30 years your hospital’s ICU must look different and work differently in order to handle a steady influx of critically ill patients.
To continue to enhance the delivery of intensive care services, strategic framework identifies three priority areas to further improve access and quality of care.
The three priority areas are: * To build up a sustainable system * Access the right level of patient care when required. * To provide high quality ,safe and effective intensive care services
To achieve the above objectives healthcare managers have to deal effectively with the supply-and-demand quandary that is already becoming apparent in the ICU. Managers also have to examine future possibilities for staffing structure, introduction of critical care guidelines, and groundbreaking technical solutions. Prospects for critical care may look questionable now, but solutions are available. And the future just might be brighter than expected. But before building initiatives to enhance safety, healthcare managers must understand the extent of patient injuries and events in ICUs. 1. Supply and Demand of Critical Care: ( Staffing)
Critical care experts are, of course, the key to quality care in the ICU. But the population of both specially trained intensivists and experienced ICU nurses is declining. Critical care nursing is brutally hard work; it’s physically, emotionally, and spiritually exhausting, the challenge is keeping experienced nurses from leaving because they’re burned out. We need to keep their knowledge and experience, possibly by creating new positions where their knowledge, experience, and accumulated wisdom can be used to benefit the next generations of patients and providers. As for physicians, fewer are choosing critical care, which will likely lead to significant staffing issues. The graying population and the loss of critical care staff is a collision waiting to happen. As with all medical providers, appropriate credentialing mechanisms should be in place for clinicians who manage patients in the ICU. The granting of clinical privileges based on education and level of skill is an issue of paramount importance to patient safety in the critical care setting. Equally important, especially in teaching facilities, is ensuring that ICU nurses and staff have ready access to information on which providers can perform which procedures under what degree of supervision. 2. Trends in Technology:
Advances in technology and networking are likely to redefine the physical and organizational boundaries of the critical care unit. Electronic ICU with smart alerts and color-coded assessments of response to protocolized care help intensivists manage increasingly busy ICUs. eICU systems are evolving now. We’ve had a few components, such as bedside hemodynamic monitors. But the challenge for healthcare managers is to decide how to use this ICU technology in bridging the gap between limited staff and growing patient population as well as the gap between adequate care and excellent care.
Also Critical care devices and technology ranging from ventilators to respirators and infusion pumps are vital for the care and treatment of patients in the ICU. However, when devices do not undergo a rigorous evaluation for appropriateness during selection or when they are used improperly, they can contribute to patient harm. ICU equipment, technology, and systems should also be assessed from a patient safety perspective before acquisition and implementation. Such an assessment includes an evaluation of required user skills, engineering concerns, infection control issues, environmental considerations, and credentialing and also to have systems to anticipate new types of errors and enact measures to prevent such errors. 3. Patient safety:
Any ICU patient safety improvement process must start by engaging leadership. Once leadership support is obtained, implementing ICU safety becomes a team effort, supported at all levels. There must be a clearly articulated plan for improvement developed with input and involvement from frontline staff that is understood by all managers, clinicians, and staff members. Challenge here is to Identifying a specific group of individuals responsible for initiating, coordinating, monitoring, and communicating ICU safety improvements and involving them in education and training, communication, and baseline data gathering, for safety assessment of the critical care units in the hospital. In Absence of a culture of safety, individuals expected to implement ICU safety initiatives do not know how best to work together or how to communicate most effectively. Therefore, before other patient safety practices are introduced, the healthcare facility must cultivate a culture of safety in its critical care units. A survey of the safety culture should measure aspects of the units that affect patient safety as well as attitudes of clinicians and staff members. Therefor the real work is setting priorities for action, making changes to improve safety, and measuring the effectiveness of the interventions. 4. Working Environment:
Within the environment of the ICU, high workload and fatigue have been identified as major negative contributors to patient safety. Mangers should earnestly consider establishing for physicians, nurses, and other staff members work hours, work shifts, and on-call duties that are most conducive to a safe work environment.
Additional measures can be used by facilities striving to enhance the ICU work environment as a strategy to promote patient safety: * Develop a code of conduct that defines and allows zero tolerance for abusive behavior and outlines a process for managing disruptive behaviors. * Provide safety science education, including a focus on teamwork and effective communication for the ICU.
Conclusion:
ICU is high tension place where catastrophic events and unpredictable crisis are common. Therefore standard policies and procedures should be laid down and understood by all. Failure to cope up in ICU is seen as failure of entire hospital .when everyone is aware about the functioning of various aspects of the unit the chances of misunderstanding or mismanagement become remote. Physicians, nurses, and workers at all levels must be made aware of the policies and every aspect of day-to day working of the unit and procedures to be routinely followed.