Intensive Care Unit ICUNationalHEU Health Service Division MOHFWww - PDF document

Intensive Care Unit (ICU)NationalHEU, Health Service Division, MOHFWwww.qis.gov.bd Intensive Care Unit (ICU)NationalHEU, Health Service Division, MOHFWwww.qis.gov.bd Bangladesh stands out as a country that has taken giant steps in healthcare and has made a significant improvement in the health sector, which makes it an example for other developing countries even though being a resource-poor country. Over the last decades, key health indicators such as life expectancy and coverage of i

mmunization have improved notably, whilst infant mortality, The Government of Bangladesh is politically committed to meet the UN-sponsored SDGs. But challenges are there. Quality of care is one to mention. MOHFW has instituted Quality Improvement Secretariat (QIS) with its main mandate to improve quality in all spheres of health services. QIS has rightly underpinned the ICU, a very important and sensitive unit of a hospital where Historically, in 1950, anesthesiologist Peter Safar est

ablished the concept of "Advanced Support of Life", keeping patients sedated and ventilated in an intensive care environment, where many patients required constant ventilation and surveillance. In 1980, the first ICU in Bangladesh was established in NICVD. Thereafter, ICUs have been opened in many Govt. and private hospitals which are being unregulated, established without following standardized requirements I would like to thank QIS and all the specialists & experts who had been invo

lved in developing this very important document. The document has clearly all the ambiguities making the ICU concept and structure understandable and useful for assessment & monitoring. This sort of document on ICU was a long required instrument which will have a great impact on improving the care of I hope this work will remain as a great landmark in quality improvement of critical Zahid MalequeZahid Maleque, MPMinisterMinistry of Health of Family WelfareGovt. of the People’s Republ

ic of Bangladesh Maintaining an intensive care unit (ICU) and ensuring the proper care to the patients who need the service is a task of paramount difficulty specially in a resource poor setting as it requires huge personnel, technology, and material resources. The complexity of the care processes involved, and the fluctuation in the number of patients needing intensive care at a specific time, makes managing intensive care resources more challenging. Having too many facilities can be

unaffordable and can also lead to an inappropriate use of ICU beds, while having too few ICU resources prevents timely admission of patients, increases the risk of poor outcomes, and may paradoxically increase costs by unnecessarily prolonging patients' stay in the ICU. Optimizing the whole patient care process—including the pre-ICU, ICU, and post-ICU phases—has the greatest potential for efficient resource use and improved outcomes. In fact, the challenges of ICU management are noth

ing new and the main management areas of discussion are architecture and design of ICUs, organization, staffing, Quality Improvement Secretariat of Ministry of Health & Family Welfare has developed a ICU QI framework for improvement of the ICU services and ensuring the Quality of care. I hope that it will be of great help for improvement of ICU Md Ashadul IslamMd Ashadul IslamSecretaryHealth Service DivisionMinistry of Health of Family WelfareGovt. of the People’s Republic of Banglad

esh Intensive Care Units (ICUs) look after patients whose conditions are life-threatening and need close monitoring and constant support from equipment and medication in order to maintain normal bodily functions. As a result ICU are usually provided with higher levels of monitoring and treatment equipments, specially trained doctors, specialists, critical care nurses, etc in caring for the Intensive Care Medicine presents an interesting paradox. Broad inspection of the research lit

erature suggests that most gains are to be made from interventions which facilitate earlier diagnosis and treatment to minimize the harmful effects of organ support, enhance communication and promote a proactive system-wide approach to the care of patients at risk of critical illness. The art of intensive care therefore lies more in integrating multi-professional care and complex interventions over time, across locations and between teams, than in the delivery of any single treatment.

Consequently, intensivists must be ICUs should be fully equipped with bio-medical equipment’s such as mechanical ventilators to assist breathing through an end tracheal tube or a tracheotomy tube, cardiac monitors including those with external pacemakers, 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 and a wide array of

drugs to treat the Critical care medicine is the direct delivery of medicalcare by a physician to a critically ill or criticallyinjured patient. Critical illness or injury acutelyimpairs one or more vital organ systems and this creates furious probability of imminent or Care of these patients can take place anywhere in theinpatient hospital setting, although it typically occursin the ICUs. Critical care involves highly complexdecision making to assess, manipulate, and supportvital sy

stem functions, to treat single or multiple vitalorgan system failure, and/or to prevent further life-threatening deterioration of the patients’ condition.Intensive care has emerged as a distinct The QI framework developed by QIS will help the ICU services to improve Quality of Care which is at present very challenging for health service delivery in Bangla- List of Abbreviations and Acronyms BP Blood PressureCCU Coronary Care UnitCCM Critical Care MedicineCNS Computer Network SystemCP

OE Computerized Physician Order EntryCPR Cardiopulmonary ResuscitationCRBSI Catheter Related Blood Stream InfectionCRRT Continuous Renal Replacement TherapyDMCH Dhaka Medical College HospitalDVT Deep Vein ThrombosisER Emergency RoomET CO2 End-Tidal Carbon Dioxidefc Foot CandlesHD High Definition HDU High Dependency UnitHEPA High-Efficiency Particulate AirHVAC Heating, Ventilation and Air-conditioningICD Implantable Cardioverter DefibrillatorICU Intensive Care UnitLED Light Emitting Di

odeLOS Length of StayMV Mechanical VentilationNIBP Non-Invasive Blood PressureNICVD National Institute of Cardiovascular DiseaseQI Quality ImprovementRR Respiratory RateRRT Renal Replacement TherapySBT Spontaneous Breathing TrailSCCM Society of Critical Care MedicineSPO2 Saturation of Peripheral OxygenUHC Upazilla Health ComplexUPS Uninterrupted Power Supply VAP Ventilated Associated ICU is highly specified and sophisticated area of a hospital which is specifically management of criti

cally ill patient, injuries or complications. It is a unit with dedicated medical, nursing and allied staff. ICU provide for patient is that patient need to have chance for potentially recover. ICU treatment is highly expensive and not for terminal care patient. It operates with defined policies; protocols and procedures should have its own quality control, education, training and research programmes. It should have its own separate team in terms of doctors, nursing personnel and o

ther staff who are tuned to the The ICU's roots can be traced back to the Monitoring Unit of critical patients The Crimean War began in 1853 when Britain, France, and the Ottoman Empire (Turkey) declared war on Russia. Because of the lack of critical care and the high rate of infection, there was a high mortality rate of hospitalized soldiers, Dandy created the first ICU in the world, 03 beds in Boston in 1926. Bjørn Aage Ibsen (1915–2007) graduated in 1940 from medical school at the

University of Copenhagen and trained in anesthesiology from 1949 to 1950 at the Massachusetts General Hospital, Boston. He became involved in the 1952 poliomyelitis outbreak in Denmark, where 2722 patients developed the illness in Treatment had involved the use of the few negative pressure respirators available, but these devices, while helpful, were limited and did not protect against aspiration of secretions. Ibsen changed management directly, instituting protracted positive pressur

e ventilation by means of intubation into the trachea, and enlisting 200 medical students to manually pump oxygen and air into the patients' lungs. At this time Carl-Gunnar Engström had developed one of the first positive pressure volume controlled ventilators, which eventually replaced the In this fashion, mortality declined from 90% to around 25%. Patients were managed in three special 35-bed areas, which aided charting and other management. In 1953, Ibsen set up what became the wor

ld's first Medical/Surgical ICU in a converted student nurse classroom in Kommunehospitalet (The Municipal Hospital) in Copenhagen, and provided Intensive Care Unit (ICU)Quality Improvement (QI) FrameworkPart-1 1.b. Objectives management. Regarding development of ICU Quality tools it has considered To Standardized the ICU development, service and its management. To Provide management protocols of ICU. To Develop QI indicators/ tools for ensuring the Quality of Care in ICU. To prov

ide constant and regular monitoring of equipments and maintaining To inspect, test and calibrate various ICU equipment so as to ensure they are To clean and carry out disinfection/ sterilization procedure. Safe, easy, fast transport of a critically sick patient should be priority in Corridors, lifts & ramps should be spacious enough to provide easy Close/easy proximity is also desirable to diagnostic facilities, blood bank, There should be single entry/exit point to ICU, which s

hould be manned. Location/entry/exit points of ICU in Hospital (Structure demarcation of RED) Space per bed has been recommended from 125 to 150 sq ft area per bed After reviewing and feedback from various ICUs in our country it may be It may be prudent to make one or two bigger rooms or area which may be It is recommended that there should be a partition/separation between Standard curtains soften the look and can be placed between two patients Keep Bed 2 ft away from Head Wa

ll: A usual problem observed in ICU is Heating, Ventilation and Air-conditioning (HVAC) system of ICU The ICU should be fully air-conditioned which allows control of temperature, Suitable and safe air quality must be maintained at all times. Air cutter The dirty utility, sluice and laboratory need five changes per hour, but two Central air-conditioning systems and re-circulated air must pass through It is recommended that all air should be filtered to 99% efficiency down to Smo

king should not be allowed in the ICU complex. Heating should be provided with an emphasis on the comfort of the patients For critical care units having enclosed patient modules, the temperature A few cubicles may have a choice of positive or negative operating Power back up in ICU is a serious issue. The ICU should have its own power It should be bright enough to ensure adequate vision without eyestrain. Higher frequency fluorescent lights and coated phosphorus lamps may be Pa

tients may need rest and quiet surroundings during the day, Blackout the staff requires a high level of lighting at the bedside while the patient Lights that come on automatically when cupboard doors or drawers are Floor lighting may be important for safety at the bedside and in the hallways Light switches should be strategically located to allow some patient control A second remote control can be turned on/off by the nurses/doctors to Hall lights controls should subdivided into

smaller independent areas and A watch ticks at about 20 dBA, A normal conversation is at about 55 dBA. A vacuum cleaner produces Noise level monitors are commercially available. lf the unit noise exceeds that level, a light comes on or flashes to remind the Vinyl sheeting is another viable option, It can be non-porous, strong and easy to clean, However, the life of Vinyl flooring is not long and a small damage in one corner may trigger damage of entire flooring and make it Dura

bility, ability to clean and maintain, flame retardance, mildew It has been very useful to have a height up to 4 to 5 ft finished with similar tiles For rest of the wall soothing paint with glass panels on the head end at the Wooden paneling has also found favor with some architects but costs may It is the ceiling surface patients see most often, sometimes for hours on end, Ceiling should be Soiling and break proof due to leaks and condensation. Tiles may not the most appealing o

r soothing surface, but for all practical Two beds should be specially designated for RRT (HD/CRRT-may be This is the nerve centre of ICU, despite lots of development, the old standard All/near-all monitors and patients must be observable from there, either Patients in rooms may be difficult to observe and therefore may be placed Some ICUs have unit pods of about four or five beds, each served by a A monitor technician is required, The unit Nursing clerk and the supervising nur

se will usually work together to Careful consideration of what level or type of activity will occur in the central station will insure adequate space planning, new equipment At times of high use the number of people in the central station can increase The space should accommodate computer terminals and printers. A large Adequate space for charting on the platform is absolutely important. Patients must be easily visible from the charting area whether the nurse is In case of space

constraint, Collapsible desktops or shelves that can flip up Space allotted for storage of the previous charts of patients currently in the An operation room style sink with Elbow or foot operated water supply This sink should have an immaculate drainage system, which usually may All entrants (Irrespective of Doctors or nurses should don mask and cap in No dirty/soiled linen/material should be allowed to stay in ICU for long times All surroundings of ICU should be kept absolut

ely clean and green if possible All ICUs should be designed to handle disasters both within ICU and outside Within ICU may be fire, accidents and Infection or unforeseen incidents. Similarly outside the ICU there may be major or minor disasters like fire, There must be an emergency exit in ICU to rescue pts in times of internal HDU may be the best place if beds are vacant. There should be adequate fire fighting equipment in side ICU and ICU is location for Infection epidemics, th

erefore, it is imperative that all Patients recovered from Critical Sickness. Patient who are less sick like single organ failure not requiring invasive Patients requiring close observation that are strong suspects of getting Doctor/Pt ratio and Nurse/Pt ratio may be much more relaxed There are conflicting reports suggesting usefulness of such units. But in Indian Cutting costs of patients and health service provider requiring close Allows close observation of potentially critic

ally sick patients both who are Psychological relief to the family and patients that he is being observed It may be handy to public hospitals where there is always shortage of ICU Many guidelines suggest that l-l/2 to 2 seats per patient bed be provided in In rural and semi-urban India, there are large and extended families; this 29Intensive Care Unit (ICU)Quality Improvement (QI) Framework2.a. List of Equipment (12 Bedded ICU and 8 Bedded HDU):No.Name of equipmentNumber Specific

ation 1 Bedside Monitors (For ICU) In cases of 5 bedded ICU need 1 extra machine Must have multi parameter monitor (Tertiary level ICU) which have Modular - Invasive BP(alternative bed or 1 machine per 3 bed) , SPO2,NIBP, ECG, RR, Temp Probes with trays and ET CO 2, - If ET CO 2 not possible than 1 2 Ventilators monitor for visualization with alarm 1portable ventilator In cases of 5 beded ICU need 1 extra machine With pediatric and adult provisions, invasiveand Non- Invasive Mode

s 3 Syringe Pumps 6 per bed in ICU With recent up gradation 4 Defibrillator 1 for 5 patients Adult and pediatric pads (with Transcutaneous pacing facility 5 ICU Beds (Shock Proof) (Fibre) Bed facility Electronically Maneuvered with all positions possible with mattress. Now beds are available which give lateral positions also All position X-ray facilities CPR facilities In case of power failure have the facilities for manual CPR 6 Over Bed Tables ALL SS with 6 to 8 cupboards in eac

h to store Drugs Medicines, side tray for x-rays, BHT, on wheels Part-2 31Intensive Care Unit (ICU)Quality Improvement (QI) FrameworkSr.No.Name of equipmentNumber Specification 17 Video laryngoscope/ Fiber optic laryngoscope(optional) 1 For difficult intubation 18 Glucometer 2 19 ICU Dedicated Ultrasound with colour doppler One With recent advances to look instantly even at odd hours. Vascular filling, central lines, etc 20 Bedside X ray (Portable) 21 Sterilizer one 22 Stand

2 per bed Must be strong attached for syringe pump, Infusion and others. 23 Instrument tray, kidney tray As much as Traceostomy tray-(1 for 5 bed) Cental Venous line tray(alternative bed) 24 Self Resuscitator Go to resuscitation troly. 32 I A Balloon One Optional 33 Fibroptic 33Intensive Care Unit (ICU)Quality Improvement (QI) FrameworkSECONDARY LEVEL ICU/ Level-2(HDU)2.b. List of Equipment: Sr.No.Name of equipmentNumber Specification 1 Bedside Monitors In cases of 5 beded I

CU need 1 extra machine Must have multi parameter monitor which have - , SPO2, NIBP, ECG, RR, Temp Probes with trays and ET CO 2, - If ET CO 2 not possible than 1 2 Ventilators monitor for visualization with alarm 1portable ventilator 3 patients in With pediatric and adult provisions, invasive and Non- Invasive Modes 3 Syringe Pumps 2 per bed in ICU With recent up gradation 4 Defibrillator 1 for 5 patients Adult and pediatric pads (with Trascutaneous pacing facility) Optional 5

ICU Beds (Shock Proof) (Fibre) Electronically Manoeuvred with all positions possible with mattress. Now beds are available which give lateral positions also Bed facility All position X-ray facilities 3) CPR facilities 6 Over Bed Tables ALL SS with 6 to 8 cupboards in each to store Drugs Medicines, side tray for x-rays, BHT, on wheels 7 Bed side locker Each for patient 8 LAB ABG Machine Biochemistry One+One facility for ABG and Electrolytes Second one as stand-bye 35Intensive Ca

re Unit (ICU)Quality Improvement (QI) FrameworkPRIMARY LEVEL ICU/Level-12.c. List of Equipments:No.Name of equipmentNumber Specification 1 Bedside Monitors One per Bed In cases of 5 beded ICU need 1 extra machine Must have multi parameter monitor which have - , SPO2,NIBP, ECG, RR, Temp Probes Ventilators monitor for visualization with alarm 1portable ventilator 1 in number for 5 bed (Transport Ventilator) With paediatric and adult provisions, invasive and Non- Invasive Modes 2 Sy

ringe 1 per bed in ICU With recent up gradation 3 Defibrillator 1with TCP facility (one standby ) Adult and paediatric pads (with Trascutaneous pacing facility) Optional 4 ICU Beds (Shock Proof) (Fibre) Electronically Manoeuvred with all positions possible with mattress. Now beds are available which give lateral positions also Bed facility(May be compromise) All position X-ray facilities CPR facilities 5 Over Bed Tables ALL SS with 6 to 8 cupboards in each to store Drugs Medicines,

side tray for x-rays, BHT, on wheels 6 Bed side locker Resuscitation trolley(Details on last page) One To hold all resuscitation equipment and Medicines 1 Professor/ Chief Consultant-12 Associate Professor/ -1/ Senior Consultant-14 Assistant Professor/ Junior Consultant-1 1:1 or minimum Morning- 1 nurse per 1patient, Evening & 39Intensive Care Unit (ICU)Quality Improvement (QI) Framework SlDomainIndicator TypeRemarks StructureProcessOutcome 1EffectivenessPhysician StaffingDa

ily Interventionist Risk adjusted mortality 2EffectivenessNurse Patient RatioLOSVAP rate 3SafetyCPOE(Computerized Physician order entry)VAP (Ventilated Associated Pnumonia)preventionFollow protocolCRBSI rate 4SafetyCRBSI (catheter related blood stream infection)preventionSBT( Spontaneous breathing Trial) protocolRate of resistant infection 5EfficiencyGlycemic controlulcer 6EfficiencyTransfusionFamily satisfaction 7EfficiencyHand washingReadmission rate 8EfficiencyFamily Communication