PROTOCOLS OF INTENSIVE CARE UNIT

INTRODUCTION
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment
unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility
that provides intensive care medicine.
Intensive care units cater to patients with severe and life-threatening illnesses and injuries, which
require constant, close monitoring and support from specialist equipment and medications in
order to ensure normal bodily functions. They are staffed by highly trained doctors
and nurses who specialize in caring for seriously ill patients. ICU's are also distinguished from
normal hospital wards by a higher staff-to-patient ratio and access to advanced medical
resources. Common conditions that are treated within ICUs include ARDS, trauma, multiple
organ failure and sepsis
DEFINITION

An Intensive Care Unit (ICU) is a specially staffed and equipped, separate and selfcontained area of a hospital dedicated to the management of patients with lifethreatening illnesses, injuries and complications, and monitoring of potentially lifethreatening conditions.

It provides special expertise and facilities for support of vital functions and uses the skills
of medical, nursing and other personnel experienced in the management of these
problems.

In many units, ICU staff are required to provide services outside of the ICU such as
emergency response (eg rapid response teams) and outreach services. Where applicable
the hospital must provide adequate resources for these activities.

CATEGORIES OF ORGAN SYSTEM MONITORING AND SUPPORT

Advanced respiratory system monitoring / support is indicated by one of

more of the following:

Mechanical ventilatory support, excluding mask (CPAP) or non-invasive methods, e.g.

mask ventilation
Extracorporeal respiratory support

Basic respiratory system monitoring / support is indicated by one or more of

the following:

More than 50% oxygen by fixed performance mask

Patients recently extubated after a prolonged period of intubation and mechanical

ventilation Mask CPAP or non-invasive ventilation

Patients who are intubated to protect the airway but needing no ventilatory support and
who are otherwise stable.

The potential for deterioration to the point of needing advanced respiratory support
Physiotherapy to clear secretions at least two hourly, whether via a trachesotomy,
minitracheostomy, or in the absence of an artificial airway

Circulatory system monitoring / support is indicated by one of more of the

following:

Vasoactive drugs to support arterial pressure or cardiac output

Intra aortic balloon pumping.

Circulatory instability due to hypovolaemia from any cause

Patients resuscitated after cardiac arrest where intensive care is considered clinically
appropriate

Neurological system monitoring / support is indicated by one or more of the

following:

Central nervous system depression, from whatever cause, sufficient to prejudice the
airway and protective reflexes

Invasive neurological monitoring, e.g. ICP, jugular bulb sampling.

Renal system monitoring / support is indicated by:

Acute renal replacement therapy ( haemodialysis, haemofiltration etc.).

GENERAL REQUIREMENTS FOR INTENSIVE CARE UNITS

Depending upon the designated level, function, size, and case mix of the hospital and/ or region
that it serves, an ICU may range from four to over 50 beds.
Lager ICU should be divided into pods of 8-15 patients
Staffing

Medical staffing, including a director, with sufficient experience to provide for patient
care, administration, teaching, research, audit, outreach.

Nursing staff: Australian College of Critical Care Nurses requires 1:1 for ventilated
patients and 1:2 for lower acuity patients. Nurse in charge with post registration ICU
qualification

allied health and ancillary staff

Medical staffing
Director of the intensive care unit. The responsibility for the administrative and medical
management of the unit is held by a physician, whose professional activities are devoted fulltime or at least 75% of the time to intensive care, who holds the position of director of the
ICU. The head of the ICU has the sole administrative and medical responsibility for this unit

and cannot hold top-level responsibilities in other departments or facilities of the hospital.
The head of the ICU should be a senior accredited specialist in intensive care medicine as
defined at country level, usually with a prior degree in anesthesiology, internal medicine, or
surgery and have had a formal education, training, and experience in intensive care medicine
as described by the ESICM guidelines

Medical staff members.

The head of the ICU is assisted by physicians qualified in intensive care medicine. The
number of staff required will be calculated according to the number of beds in the unit,
number of shifts per day, desired occupancy rate, extra manpower for holidays and
illness, number of days each professional is working per week, and the level of care and
as a function of clinical, research, and teaching workload. Extended work shifts have
been shown to negatively impact the safety of patients as well as medical staff. The
number of full time equivalent (FTE) physicians qualified in intensive care medicine per
six to eight intensive care beds (at level of care II, see section Activity Criteria) can be
calculated (according to the European working hours directives) with the formula
provided in paragraph 9 of the ESM . An experienced physician certified in intensive care
medicine is on duty and available upon request at short notice in the hospital during off
duty hours. The regular medical staff members of the ICU treat patients using state-ofthe-art techniques and may consult specialists in different medical, surgical, or diagnostic
disciplines whenever necessary

Nursing staff
Organization and responsibilities. Intensive care medicine is the result of close cooperation
among doctors, nurses, and allied health care professionals (AHCP). An efficient process of
communication has to be organized between the medical and nursing staff of the ICU. Tasks and
responsibilities have to be clearly defined. Head nurse. The nursing staff is managed by a
dedicated, full-time head nurse, who is responsible for the functioning and quality of the nursing
care. The head nurse should have extensive experience in intensive care nursing and should be

supported by at least one deputy head nurse able to replace him (her). The head nurse should
ensure the continuing education of the nursing staff. Head nurses and deputy head nurses should
not normally be expected to participate in routine nursing activities. The head nurse works in
collaboration with the medical director, and together they provide policies and protocols, and
directives and support to the team.
Allied health care personnel
Physiotherapists. One physiotherapist with dedicated training and expertise in critically ill
patients should be available per five beds for level III care on a 7 day/week basis.
Technicians. Maintenance, calibration, and repair of technical equipment in the ICU must to be
organized. This facility can be shared with other departments of the hospital but a 24-h
availability has to be organized with priority for the ICU.
Radiology technician. Should be on call around the clock. Interpretation of the medical imaging
by the radiologist must be available at all times.
Dietician. Should be on call during normal working hours.
Speech and language therapist. Should be available to consult during normal working hours.
Psychologist. Should be available to consult during normal working hours.
Occupational therapist. Should be available to consult during normal working hours.
Clinical pharmacist. Should be available to consult during normal working hours. A sufficient
collaboration with pharmacy is of particular importance with respect to patient safety.
Administrative personnel One medical secretary is required per 12 intensive care beds. Basic
tasks are patient administration, external and internal communication exchange, and typing of
reports and documents. One secretary per six beds may be desirable if she/he is also involved in
arranging laboratory journals and medical files. Another approach is to calculate the number of

medical secretarial assistants as one FTE per 500700 admissions. Support for formal teaching
activities may increase the need.
Cleaning personnel A specialized group of cleaning personnel familiar with the ICU
environment should be available for the ICU. They should be familiar with infection control,
prevention protocols, and hazards of medical equipment. Cleaning and disinfection of the patient
areas are performed under the nurses supervision. A checklist of the cleaning status must be
kept. Regular updates should be provided to ensure cleaning protocols reflect best practice.
Operational

Documented educational programme

agreed policies

team approach

surge capacity for emergencies

documented procedures for audit

peer review

quality assurance

Site

separate unit

appropriate access to ED, theatre, radiology

Design

Patient cubicles (> 20 m2), wash basin, service outlets, appropriate electrical standards,
privacy

Work areas, equipment and storage areas, staff facilities, seminar room, offices, relatives
area

Equipment: appropriate equipment and regular system for checking safety

Monitoring equipment: for each patient, for unit (.eg. gas supply alarms), and for patient
transport

Criteria for a level I, II and III ICU and a PICU

LEVELS OF INTENSIVE CARE UNITS

LEVEL 1

should be capable of providing immediate resuscitation and short-term cardiorespiratory

support for critically ill patients

will also have a major role in monitoring and prevention of complications in at risk
medical and surgical patients

must be capable of providing mechanical ventilation and simple invasive cardiovascular

monitoring for a period of at least several hours

LEVEL II

should be capable of providing a high standard of general intensive care, including

complex multi-system life support, which supports the hospitals delineated
responsibilities

minimum of 6 beds

LEVEL III

a tertiary referral unit for intensive care patients

should be capable of providing comprehensive critical care including complex multisystem life support for an indefinite period

should have a demonstrated commitment to academic education and research

All patients admitted to the unit must be referred for management to the attending
intensive care specialist

all consultants are FCICMs

may have over 50 beds, should include pods of 8-15 beds

ORGANIZATION OF INTENSIVE CARE UNIT

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.

Design of ICU

There should be a single entry and exit.

ICU must have areas and rooms for public reception, patient management and support
services.

Full commitment must be given from administration and a designated team to work on
various tasks.

There should be sufficient number of lifts available to carry these critically ill patients to
different areas.

The total design of the ICU must take into account the following areas;

P= Patient care

N= Nursing

E= Eating (clean area for food preparation and delivery)

U= Unclean (dirty linen, equipment)

M= Medication storage (drugs, I V fluids)

A= Administration (clerking, stationary)

T= Teaching

I= Infection elimination (sterilizing area)

C= Clean area (fresh linen, equipment)

S= Storage (back up equipment)

V= Visitors

BED STRENGTH

The number of ICU beds in a hospital ranges from 1 to 10 per 100 total hospital beds.

Multidisciplinary requires more beds than single speciality.

ICUs with fewer than 4 beds are not cost effective and over 20 beds are unmanageable.

IDEALLY 8 TO 12 BEDS

1 ISOLATION BED FOR EVERY 10 ICU BEDS

BED SPACE & BEDS

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

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

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

Patient areas

Single rooms are essential for isolation and privacy.

The ratio of single room beds to open ward beds depends on the role and type of ICU.

A central station will have the central monitor, drug cupboard, telephone, refrigerator and
patient records.

Nursing in ICU is always at the bedside.

Sufficient hand wash areas should be provided.

X-ray views are needed in multi-bed wards.

Proper facilities for haemodialysis such as filtered water should be incorporated at the
time of ICU planning.

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 am).

Lighting focussed & central lighting.

Airconditioning (split / central) : 25 + or 2 degrees centigrade.

Cleaning vacuum cleaning & wet mopping of the floor. fumigation is no 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

ACCESSORIES

3 oxygen outlets, 3 suction outlets (gastric, tracheal & underwater seal), two compressed
air outlets and 16 power outlets per bed.
storage by each bedside (built in / alcove).

hand rinse solution by each bedside.

equipment shelf at the head end (mind the height of the care giver).

hooks & devices to hang infusions / blood bags suspended from the ceiling with a
sliding rail to position.

infusion pumps to be mounted on stands / poles.

UTILITIES

electrical adequate sockets (5amps & 15 amps), generator supply & battery back up.

medical gas & vacuum pipeline colour coded and not interchangeable.

water from a certified source especially if used for haemodialysis

handwashing areas uninterrupted water supply, disposable paper towels / hand drier. (no
cloth towels please)

telephones & computers for communication.

sterilising area large water boiler / geyser & exhaust fans.

clean and a dirty utility with no interconnection.

shelving & cabinets off the ground for storage.

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
1.
2.
3.
4.
5.

Monitoring Equipment
Therapeutic Equipment
Digital & Analogue Display
Audio & Visual Alarms
Battery Back Up & Charging

Common equipment in an ICU includes:

mechanical ventilator to assist breathing through an endotracheal tube or a tracheotomy

opening;

cardiac monitors including telemetry, external pacemakers, and defibrillators;

dialysis equipment for renal problems;

equipment for the constant monitoring of bodily functions;

a web of intravenous lines, feeding tubes, nasogastric tubes, suction pumps, drains and
catheters;

a wide array of drugs to treat the main condition(s).

Monitoring

Bed side and central monitors, 12 lead ECG recorders, intravascular and intracranial
pressure monitoring devices

Cardiac output computer

Pulseoxymeter

Pulmonary function monitoring devices

Expired CO2 analyzers

EEG monitors

Patient/ bed weighers

Enzymatic blood glucose meters

Radiology

X ray viewers

Portable x ray machine

Image intensifiers

Respiratory therapy

Ventilators, bedside &portable

Humidifiers, oxygen therapy devices &airway circuits

Intubation trolley

Manual self inflating resuscitators

Fibre-optic bronchoscope

Anaesthetic machine

Cardiovascular therapy

Cardiopulmonary resuscitation trolleys

Defibrillators

Temporary transvenous pacemaker

Intra-aortic balloon pump

Infusion pumps and syringes

Dialytic therapy

Haemodialysis machine

Peritoneal dialysis equipment

Continuous arterio venous hemofiltration setts

Laboratory

Blood gas analyzer

Selective ion electrode analyzers

Osmometer

Hematocrit centrifuge

microscope

Hardware

Dressing trolleys

Drip stands

Bed restraints

Heating/ cooling blankets

Pressure distribution mattresses

Sterilizing equipments

STORAGE AREAS/SERVICE AREAS

Most ICUs lack storage space.

They should have a total of 25-30% of all patient and central station areas for storage.

Clean and dirty utility rooms should be separate each with its own access.

Disposal of soiled linen and waste must be catered for.

A lab, which estimates blood gases, electrolytes, haemoglobin, is a must.

Good communication systems, staff lounge, food areas must be marked out.

There should be an area to teach and train students.

References
1. Ferdinande P (1997) Recommendations on minimal requirements for intensive care
departments. Members of the Task Force of the European Society of Intensive Care
Medicine. Intensive Care Med 23:226232

2. Brilli RJ, Spevetz A, Branson RD, Campbell GM, Cohen H, Dasta JF, Harvey MA,
Kelley MA, Kelly KM, Rudis MI, St Andre AC, Stone JR, Teres D, Weled BJ (2001)
Critical care delivery in the intensive care unit: defining clinical roles and the best
practice model. Crit Care Med 29:20072019
3. Morales IJ, Peters SG, Afessa B (2003) Hospital mortality rate and length of stay in
patients admitted at night to the intensive care unit. Crit Care Med 31:85886

MHR DAV INSTITUTE OF

NURSING,

JALANDHAR
NURSING MANAGEMENT
TOPIC: Protocols and standards of intensive care unit

SUBMITTED TO

SUBMITTED BY

Respected Mam Ms. Ravneet Kaur

Simranpreet kaur

Lecturer

M.Sc (N) II Year

Mental Health (Psychiatric) Nursing

Medical Surgical Nursing