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Health Information 2 (HI- 2)

Analysis of Hospital organization

The intensive care unit
Intensive Care Unit
Intensive care Unit
• Critical care has been defined as the provision of sophisticated
life support system, with appropriate medications for
• a wide variety of patients, in a setting of close monitoring.
• Intensive care unit is a nursing unit specially designed,
• equipped and staffed to manage critically-ill patients with
• potentially reversible lesions, requiring constant observation,
• irrespective of age, sex and diagnosis, and requiring
• extraordinary nursing care.
Intensive care Unit
• It is a nursing unit where intensive
monitoring, active life support, specific
therapy and specialized nursing care is
provided, where technical expertise and
sophisticated equipment are concentrated for
critically-ill patients.
Intensive care Unit(week 7)
• The aim is to support life in a crisis, prevent life-
threatening conditions, and then try to remove
the cause of dysfunction by specialized treatment
and skilled nursing. Contrary to popular belief, ICU
is a place and not a form of treatment, as many
lay persons tend to believe.
Intensive care Unit(week 7)
• At present intensive care facilities are not
available in all hospitals. Very few of even the
Government district level hospitals have a proper
ICU. However, the need for a ICU in all hospitals
has been realized by clinicians and administrators
Intensive care Unit
Where it is not possible to provide a modicum of
reasonable care for critical illness in medium sized
intermediate level hospitals, say up to a district hospital level,
then it can be achieved by providing a better staffed and
better equipped high-dependency ward in every district
hospital. These wards would not qualify as critical care units
but could offer better care, with improved results at smaller
Intensive care Unit
• Reason demands that well-equipped critical care
units should be confined to medium and large
hospitals which have the infrastructure to support
such units. It would also be wiser and profitable to
organize general all-purpose intensive care units
in different specialties and sub-specialties
Intensive care Unit
• A multidisciplinary ICU permits concentration of meagre
• resources with regard to staffing, equipment and technical
• expertise. Above all, it encourages a more holistic approach,
• so that problems in the critically-ill are considered in an
• overall perspective rather than in terms of disease affecting
• isolated organ systems.
Intensive care Unit
• An intensive care unit has its own advantages and
• disadvantages. The chief advantage is that it provides better
• and more organized care. The main disadvantage is of a
• holistic environment contributing to anxiety, emotional
stress, loneliness, fear, and a greater risk of developing
• infections.
Intensive care Unit
• Crises in ICU arise mainly because many people
presume that every medical problem has a
solution, and the expectation from the hospital to
do everything possible, which unnecessarily raises
the cost of ICU care
Intensive care Unit
The number of beds in a ICU is variable from hospital-to hospital.
In the early eighties, it was observed that 3 to 6
per cent of all cases being admitted in any hospital needed
intensive care. The 1968 report of the Study Group on
Hospitals had recommended that 10 per cent of beds in
teaching hospitals in cities with population over 10 lakh and
5 per cent of beds in district hospitals should be kept apart
for emergency cases.
Intensive care Unit
• In 1978 the Hospital Review Committee for Delhi
• Hospitals suggested 2 per cent as ICU beds.3 Due to increase
• in the number of accident cases, advancements in surgery,
• and increased awareness among people as well as medical
• professionals the percentage of intensive care beds has
• gradually risen. In UK one ICU bed for every 100 acute
• beds is recommended. In USA up to four times this
• proportion is followed and in Germany 5 per cent of total
• hospital beds are for ICU.
Intensive care Unit
• Although there are varying opinions regarding number
• of beds an ICU should have, an ICU of less than 4 beds,
• with less than 200 admissions annually, is uneconomical.
• On average, a 8-bedded ICU should admit about 600 cases
• in a year. Very small units have not been found to be viable
• in terms of economy of facilities and manpower. Large units
• have the danger of turning unwieldy and chaotic. For larger
• units the beds can be grouped as pods or clusters of about.
Intensive care Unit
7-8, grouped together to form a larger department under a
single roof.
In Pediatrics, 8 per cent of pediatric beds should be
earmarked for pediatric ICU. In Thoracic and Neurosurgery
units the ICU beds to clinical beds ratio is about 15 per
cent. An important factor in utilization of beds is the
unpredictability of demand and occupancy. Under-utilization
cannot always be avoided entirely but it can be minimized
by careful planning.
It is estimated that a 10 bed multidisciplinary ICU should
meet the requirement of up to 300 bed district hospital. It
may not be practicable to maintain a separate ICU for a
small hospital, of say 50 beds or so. However, every hospital
above 100 beds should have a fully equipped and staffed
Efficiently functioning critical care units in the
foreseeable future will largely be confined to the big cities
in our country. Promoting a modicum of better care for
critical illnesses in the huge population of our country that
reside outside the big cities can, for the present, only be
achieved by providing a better staffed and better equipped
high-dependency ward in every District Hospital.
• These wards would not qualify by western
standards as critical care units, but could offer
better care, with improved results, at a smaller
cost. Because ICU beds are expensive to maintain
no hospital can afford to create or maintain excess
of beds. Some decision will have to be made to
distribute resources so that no patient is deprived
of necessary care.
• It is inappropriate to devote limited ICU resources
to a patient whose prognosis has resolved to one
of a vegetative state. A separate facility,
• adjoining the ICU, with better focus on care of
dying patients resulting in reduction of
unnecessary activities, can be a possible way out.
Intensive care Unit
A question common in the minds of those working in the
hospital as well as those outside is, which type of patient
should be treated in the ICU. The selection of patients
appropriate for intensive care not only depends upon purely
medical and organizational factors but also on financial, legal,
ethical and moral issues.
• The following are the main considerations for admission of a
patient in ICU:
• 1. Physiologically unstable patients who require constant reaction
to change in their condition and rapidly redefining therapy.
• Patients may also be considered only for monitoring and
observation for early detection and rapid response to impending
• 3. It is questionable to devote ICU resources to a patient whose
prognosis has resolved to one of a “point of no return”.
In view of expectations of what medicine can achieve,
intensive care must be provided for the first two categories
However, these distinctions are not always possible, and
not necessarily desirable. It cannot be said with certainly
that if a particular patient was not admitted to ICU he would
have died, or if a particular patient was admitted he would
have survived or recovered.
Infective conditions will not be treated in the ICU, neither
it is intended as a halting place for terminal care of moribund
patients. Random occurrence of catastrophic events or
unpredictable clinical crises are a characteristic of most
patients in ICU. Death may occur unexpectedly. Initial
therapeutic success may not be sustained
Sometimes it is sad to see intensive care units cluttered
with patients who could unquestionably be better looked
after in the ward or at home. However, some patients
requiring only monitoring and observation, even if they are
physiologically stable may be considered as appropriate
cases, for the purpose of early detection of changing
symptoms and rapid response to serious complications.
• While specialties in medicine or surgery are sharply focused on a single
organ system within the body, a general medicine or surgery critical
care unit is devoted to the patient as a whole, recognizing the
overwhelming fact that there is a tremendous interdependence and
interrelationship between various organ system, so that a serious
involvement of one strongly jeopardizes the function of others.
• The approach to critical care medicine is thus simultaneously holistic,
viewing the patient in an overall perspective, and yet focused on one or
more problems that constituted an immediate threat to life.
A good intensive care unit necessarily uses the
infrastructure of a well-equipped general hospital, and has
therefore the back-up and support of sophisticated
investigations, imaging techniques, physiotherapists, specialists
and super-specialists in different fields of medicine and surgery.
In the western world, particularly in the United States, most
large institutions have special ICUs for different specialties and
of trauma, burns, cardiac surgery, respiratory care,
coronary care, and neurosurgery. In our country, generally
all-purpose units are to be preferred. This allows for
concentration of rather meagre resources with regard to
staffing, equipment and technical expertise. Physicians and
surgeons in all-purpose critical care units are more
appropriately trained to fulfill the holistic approach to the
ravages of life-threatening diseases, as compared to their
colleagues working in specialty care units.
A general exception to this could be a separate neonatal care unit.
Thus depending upon types of patients admitted,
Intensive Care Units can be classified:
• MICU - Medical Intensive Care Unit
• SICU - Surgical Intensive Care Unit
• ICCU - Intensive Coronary Care Unit
• BICU - Burns Intensive Care Unit
• NICU - Neonatal Intensive Care Unit
• PICU - Pediatric Intensive Care Unit
• PICU - Pulmonary Intensive Care Unit
• OICU - Obstetrics Intensive Care Unit
Intensive care requirements of very young children and
neonates need special equipment, facilities and expertise.
Need for total isolation of burns patients also necessitates
separate and independent units. Open heart surgery cases
need specialized monitoring and care. Barring these, available
evidence suggests that for all other cases, intensive care
can be organized efficiently in a multidisciplinary ICU. The
discussion which follows relates to such a general and
multidisciplinary ICU.
In the past, ad-holism has been the rule in trying to create
a special unit in preexisting ward areas, or where existing
ones were upgraded. Planning of ICUs has suffered from
overemphasis on gadgets and spatial designs. It is best to form
a committee to determine the need and scope of services,
planning norms and functional requirements
The committee should be headed by the senior physician, with members
from the clinical disciplines of surgery and anesthesia and representatives
of nursing services and hospital administration.
The task of the committee would include:
1. Identify the type of clinical units likely to utilize the facility
2. Determine types of cases likely to be catered for
3. Study existing physical layout of the hospital
4. Determine the facilities and equipment needed
5. Determine the size (Number of beds) of the ICU
6. Determine staffing pattern.
• Location and Spatial Requirements
The ICU should preferably be located on the ground floor
with convenient access from the operation theatre suit and
emergency department and easy accessibility for wards.
However, there is no bar on its location on upper floors, if
other factors are suitable. Here, the hospital should ensure
rapid vertical transport through fast-moving, promptly
available elevators. The location should be away from the
main hospital traffic corridors.
ICU location
• The ICU has a relationship with the casualty and emergency
ward, with the laboratory, with radiology department, and
with physiotherapy department. If the hospital has a step-
down or a high dependency ward, the ICU must have a close
relationship with such a ward. The importance of a fairly large
high-dependency ward does not seem to be realized by many
hospital planners. Such a combination enables the ICU to be
reserved exclusively for patients who truly deserve critical
ICU location
• It also enables a quicker turnover of patients and therefore
results in a more economic, efficient and correct use of
critical care. A higher level of privacy should be made
available, where appropriate, with walls, doors blinds or
curtains in an environment which features enough glass to
ensure that clinical observation requirements can easily be
met as necessary.
A good design should be able to deliver the
extremes of high observation and protected privacy as well
as various intermediate levels of visual and acoustic privacy.
Corridors around the ICU should only serve the traffic meant
for the unit staff, and should not become a major
thoroughfare for other hospital personnel and public.
Design and Layout
The design of the ICU should take into consideration the
integration and smooth functioning of three areas, these
A. The patient area
B. The staff area
C. The support area.
• Private ICU Room Vs Open Ward
There is a trend towards a higher proportion of critical care
beds to be found in individual private rooms or isolation
rooms. In the open-bay or ward type accommodation the
premise is that the high level of observation and clinical
intervention required offsets the risk and loss of privacy.
ICU design
The design should meet four basic requirements. They
1. Direct observation of the patient by nursing and medical
2. Surveillance of physiological monitoring
3. Provision and efficient use of routine and emergency
diagnostic procedures and therapeutic interventions
4. Recording and maintenance of patient information.
An ICU has to be spacious and uncluttered so that the
ICU design
An ICU has to be spacious and uncluttered so that the
movement of staff and equipment is easy, and free. While designing a
new ICU this can be easily
achieved. However, in a renovated unit, the configuration
of the existing structure often determines or restricts the
design of the unit. Since most ICUs in the past were created
by modifying some existing nursing unit, the design in a
majority of them is rectangular. Later, other types of designs
were developed.
ICU design
• The following standards are for the common type of multi-
disciplinary critical care facility appropriate to the needs of a
general hospital.
• It is reiterated that the two fundamentals that have a bearing o-n
the design and layout of a ICU are observability, and efficiency of
operation. `
• ICU design still reflects the observation requirements for the
practical reason that there is a limit to the number of high acuity
patients for which a staff member may carry responsibility. Staff
need access to all the various supplies, equipment and medications
used in the delivery of medical
ICU design
A total area ranges from 350 to 500 sq. feet per bed
which includes circulation area, nursing station, sanitary
and ancillary accommodation. The shapes for these units
include semicircles, boxes, horseshoes and linear or
staggered configurations. A square shaped unit design is
preferable to a rectangular one
ICU design
Patient Bed Area
The essential planning feature is a fully observable bed area
with adequate space for positioning of equipment.
Intensive Care Unit
Each patient can be accommodated in a series of
partitioned rooms or in cubicles separated by curtains.
ICU design
An ICU bedroom or cubical requires space to accommodate
ventilator, cardiac monitor, pulse oximeter, suction machine,
oxygen cylinder on trolley, procedure trolley, and mobile
X-ray machine. Each patient bed area should have a minimum
floor space of 150 to 200sq. feet in an open-bay design in
which curtains on overhead railings suspended from the
ceiling partition each bed area.
ICU design
• There should be a minimum distance of 8 feet
between beds. The advantages of the open bay
design is the ability to utilize floor space of an
adjoining bed just by opening the curtain when
space for addition equipment becomes necessary.
The major advantages of partitioned cubicles is it
allows privacy.
ICU design
• An acute crisis (for example dying or death) can
remain more isolated, and not effect the
emotional and physical well being of other
critically-ill patients. Each room design should
incorporate large windows that allow natural light.
Windowless ICUs are important contributors to
patient disorientation and stress.
ICU design
Each bed must have an oxygen outlet, a central suction
outlet and a number of power outlets. As far as possible,
oxygen outlets, suction outlets and monitoring equipment
should be wall mounted. This saves space and allows more
easy movement.
ICU design
Some installations include wall mounted
equipment such as blood pressure cuff and shelves
for supplies. The monitor is normally wall-mounted, above
the working zone, but with reachable controls for staff.
Headwalls can be custom-built, with the architect
specifying the locations and mounting brackets of outlets
ICU design
The problem with headwall design is the requirement to
move the bed away from the wall. At the moment of crisis,
when the team is actively administering intensive care, the
bed must be physically relocated to allow access to the
patient’s airway. The staff must carefully step over the
various lines and umbilical connections to life support
systems and monitoring interfaces, in order to stand over
the head of the bed to reach the patient.
ICU hand washing
The practice of hand washing is followed very frequently
by the doctors and nurses before or after examining or
handling each patient. Therefore, there should be adequate
number of washbasins appropriately placed in the unit. One
washbasin to two beds is suggested.
The overall proportion of circulation area should not be
less than 20 per cent of the total floor area of the unit.
ICU design
• Central Nursing Station
The central nursing station should be located so as to allow
an unobstructed view of each patient. This is problematic if
the patient beds are in straight line, and easier if the beds are
placed along an arch opposite the nursing station. For this
reason the nursing station can be located on an elevated
platform at such a vantage location that all patients come
under the gaze of the nurse sitting at this station.
ICU & nursing station
• The distance between the nursing station and each patient
bed should be short yet not be so short as to obstruct
movement of equipment and personnel. It should provide
seating arrangement for at least one nurse and one doctor.
The station should have adequate room for storage of
records, forms, charts and supplies. A telephone at the
nursing station is a must.
ICU design & nursing station
Also, an alarm button should be provided here
which can be activated whenever there is any dire
emergency in the ICU. The alarm button activates a bell in
the Residents quarters or elsewhere for additional help. A
mobile emergency trolley carrying all emergency drugs
required for cardiopulmonary resuscitation and also a
defibrillator should be at hand at the nursing station.
ICU design & nursing station
Bed should be so oriented that the patients can see the
nurse but not other patients. This area will have adequate
space for storage of essential items, and counters for writing
notes and for reception and interaction with other ICU staff.
Its location is determined to maximize efficiency, with least
mobility of personnel.
ICU design
• Although the medication preparation area is separate, it
should be close to the nursing station and patient area,
located at a site where there is no visual observation by
patients and no interruption by phone calls. Equipment in this
area includes a counter top, a refrigerator, locked cabinet for
narcotics and expensive drugs, and a washbasin.
ICU design & nursing station
The other accommodation in the ICU will include the
usual ward facilities viz. nurses room with toilet, doctor’s
room with toilet, store room, clean and dirty utility rooms.
A ward pantry will be an advantage. A sanitary area housing
at least two western type WCs with basins should be
The patient care area should be separated from the service
area by a central service corridor.
Two layouts of ICU are shown in Figures 5.1 and 5.2.
ICU layout design
Toilets for the ICU

A satisfactory solution for disposal of human waste in the

critical care unit is a tricky problem in the design of ICU.
There can be rooms with or without toilets. When toilets
are present, they may be individual, or shared between
Toilets for the ICU

A common alternative to a toilet is the mobile (or portable)

commode chair. The ability to move the chair directly
adjacent to the bed allowing the toileting to occur without
disconnecting leads contributes to patient confidence. Sitting
is always preferred by patients over using a pan while prone
in the bed.
Toilets for the ICU

The best disposal method for bedpan, whether used in

bed or a chair, would be a deep clinical sink with
size and a bedpan washer to properly clean a bedpan.
Selecting a toileting option remains one of the difficult
decisions in critical care design because the options are
ICU design & nursing station
Portable X-ray machine, portable image intensifier,
portable ultrasound machine and equipment for respiratory
therapy should not clutter the patient area in front of the
nursing station but should be kept in the nearby equipment
store room. The incidence of medication errors is obviated if
the medication preparation area is undisturbed.
ICU design
• Storage Room
An ICU has a large number of items of various equipment.
It is necessary to have a large storage area to house
equipment, stretchers, ECG machines and numerous other
items of storage. The storage room should have an area of
about 15-20 per cent of the patient area.
ICU design
• Equipment
• The level of equipment will depend on the type of ICU. In a
• general, all-purpose intensive care unit, besides the
equipment usually found in every acute care ward, a list of
equipment desirable for a tertiary unit or a hospital reputed
for critical care is given in the next table
ICU design
• Clean and Dirty Utility Rooms
The clean utility room contains procedure trays, bandages,
pads, linen, intravenous solutions, catheters, and other
similar items.
The dirty utility room should be separate from the other
work areas. Waste material, disposable, soiled material
awaiting transfer to central supply, and soiled linen are all
housed in this room. The room should have one or two
large sinks.
ICU Staff
• Medical Staff
• ICU In charge
• There should always be one individual in charge who
• controls and directs the activities of ICU.
• His responsibilities should cover:
• 1. Continuity of care
• 2. Administrative matters
ICU staff
• 3. Supervision, including training of junior staff like nurses,
technicians and ward boys in patient care and handling of
• 4. Care and maintenance of equipment.
He should be a person respected by all for his tact as well as his
clinical and administrative abilities.
ICU staff
• Senior Residents
• This resident must be a physician with a postgraduate degree
• in general medicine. He will initiate and carry out emergency
• Junior Residents / House Officers
• A Junior resident is generally a fresh medical graduate, in
• training for experience and higher knowledge and skill. At
• least two such junior resident will be on duty round the
• clock in a 10 bed unit. Junior residents can be turned over
ICU staff
• on an eight-hour shift. However, in many ICUs the duty
• shift lasts twelve hours, to coincide with that of the senior
• resident.
• The duties of the junior resident cover monitoring,
• maintaining patients’ records, initiate immediate
interventions, administer urgent life saving treatment before
• arrival of senior resident, and preparing case summaries.
ICU staff
The ideal ratio of nurses to ICU bed is 1:1, in each shift.
However, this may be impossible to meet in many cases. A
lower ratio of one nurse for two patients in a shift has been
accepted by some authorities as a compromise, and one
seldom finds a 1:1 ratio in all shifts. On the basis of a time
utilization study of nurses in ICU carried out by National
Institute of Health and Family Welfare (NIHFW)
ICU staff
• the number of patients that could be conveniently looked
after by one nurse was as under:-
• Morning shift : 2. 4 patients
• Evening shift : 3. 2 patients
• Night shift : 5. 5 patients, plus one In charge sister
• in each shift.
ICU staffing
• Nevertheless, it should be realized that many critically ill
• patients may not be very dependent on a nurse. Conversely,
• a few patients who may be highly dependent on a nurse
• (e.g. stroke) are not critically ill. There is a need for constant
alertness because most patients are highly dependent for physical
functions such as bladder and bowel functions and vital functions
such as maintenance of blood pressure and respiration, gastric
• aspiration, electrolyte and fluid balance.
ICU staff
Maintenance of vital functions and timely intervention is crucial
and extremely demanding on the nursing staff. The
ratio of nurses to patients has to be invariably 1:1 and never
less than 1:2. of the total nurses on duty at any one time,
half should be very well-trained, the remaining half being
The central core of nurses and trainees must be headed
and actively supervised by a dedicated sister-in-charge.
ICU staff
• Auxiliary Personnel
Scales suggested by different planners range from very
meagre to very liberal. Sometimes, planners hope that a
liberal scale of staff to ICU will increase its efficiency.
However, large number of workers alone do not increase
efficiency. It is the level of training, technical efficiency
and motivation that is important in a department which is
constantly in a state of alert.
ICU staff
Diagnostic Support
A multidisciplinary ICU should have a round the clock
access to radiology, imaging, laboratory services and
Equipment Maintenance
In-house trained technicians to carry out preventive maintenance
of equipment on a regular basis, and to promptly
attend to breakdown of equipment, is of vital importance.
This aspect is neglected in many units.
• Stand-by Generator
A reliable alternate source of power is a must for ICU. The
entire ICU must be connected to a stand-by generator. The
hospital stand-by generator should be powerful enough to
take on the full load of the ICU, including a large number of
equipment. The generator should be capable of automatically
switching on within seconds on failure of the main
electrical supply.
• Air Conditioning
• Ideally, the ICU should be centrally air-conditioned, and
• designed to provide 7-8 air changes per hour and a positive
• pressure to prevent re-entry of outside contaminated air.
• Adequate number of window type air conditioners with
• efficient filters (Less than 10 microns) is the next best option.
• Lighting and Electrification
• The overall lighting requirement in ICU is for subdued
• illumination for the patient bed, with capacity for increasing
• it in case of need. The main light at the bed-head should
• therefore be fitted with a dimmer switch.
Note: The following is reproduced, with kind permission of the
• author and the publisher from “Principles of Critical Care”
• Dr Farokh E. Udwadia, published by Oxford University Press
• India. New Delhi.
• There are three basic ethical principles in critical care
• medicine.
• The first is beneficence, and its companion, non-maleficence.
Beneficence directs the physician to do good
by relieving suffering and restoring good health. Beneficence
does not merely involve technical expertise and medical skill,
it equally involves human qualities particularly in the care of
critical illnesses. It is these human qualities which
unfortunately tend to be forgotten or pushed into the
• Non-maleficence is the companion-in-arms of beneficence.
• It reminds the physician that above all, they should do no harm.
Beneficence and non-maleficence may at times in a critical care
setting be in apparent conflict.
• The second basic ethical principle governing decision making in
critical care medicine is patient autonomy. This is the patient’s right
to self-determination—the right, after being properly informed, to
accept or refuse medical treatment offered to him including life-
support measures like mechanical ventilation.
• It is indeed the proper interpretation of the balance between
the principle of beneficence and the principle of patient
autonomy that governs decision making and management in
critical care medicine. This balance is indeed difficult because
patients who are seriously ill may be unable to make proper
decisions about their own care.
The third and final ethical principle is justice–to
distinguish in patient care the right from the wrong. If, at
times this is difficult or impossible to determine in absolute
terms, one should determine what is more right or less
wrong. In developing countries where resources are limited,
justice dictates that treatment is administered to patients
who are more likely to benefit from them.
• This often produces an ethical quandary. Physicians should
unquestionably be involved in the ethics of resource distribution,
• providing equitable medical care to the society in which
• they live and work. Wisdom however, dictates that in all
• situations requiring protracted intensive care, the burden benefit
• relationship should be carefully considered, and care be tempered
with reason.
There are many factors which distort, prejudice or
interfere with autonomous decisions of patients in critical
care medicine. These include fear, anxiety, depression, panic,
lack of information and abhorrence of invasive modalities
of treatment which prompt them to decide (often wrongly)
to “die with dignity”. The working ethical principle is that
when confronted with a potentially reversible life-threatening
illness, beneficence prevails over patient autonomy