hospital administration BY drauaz555 ICU Planning and Designing in India – Guidelines 2010 Guidelines Committee ISCCM Dr Narendra Rungta (Convenor) Members – Dr Deepak Govil, Dr Sheila Nainan, Dr Manish MunJal Dr J,Divatia (President) , Dr C K Jani (Secretary) Background ICU is highly specified and sophisticated area of a hospital which is specifically designed, staffed, located, furnished and equipped, dedicated to management of critically sick patient, injuries or complications.
It is a department with dedicated medical, nursing and allied staff. It operates with defined policies; protocols and rocedures should have 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 (1 ,2,57,58,75) .
In India the scenario of ICU development is fast catching up and after initiatives, promotion, education and training programmes of ISCCM during last 1 5 yrs, there has been stupendous growth n this area but much needs to be done in area of infrastructure, human resource development, protocol, guidelines formation and research which are relevant to Indian circumstances.
An acceptable and logistically feasible no compromise can be made on quality and health care delivery to critically sick, yet an acceptable guidelines can be adopted for making ICU designing guidelines which may be good for both rural and urban areas as also for smaller and tertiary centres which may include teaching and non teaching institutes . There are pre-existing guidelines on the website of ISCCM, made in 2003. There has been a sea change since then and therefore need for new guidelines. The existing guidelines have been taken as base line for the present recommendations. Following areas are covered.
Initial Planning Team Formation and Leader/Coordinator Data Collection and analysis Beginning of the Process and decide about Budget allocation , aims and objectives 2 Decision About ICU Level, Number of beds, Design and Future Thoughts Planning level of ICU like l, Level II or Level Ill or Tertiary Unit Number of beds and number of ICUs as needed for the institution Designing each bed lay out and providing optimum pace for the same Modulation according to various types of space availability 3 Central Nursing Station designing and planning Location, space, Facilities 4 Equipmentation Will depend on number of beds, target level of the ICU Most important decisions will be No of Ventilated beds and Invasive monitoring ICU vs HDU Collecting information about various equipments available with specifications 5 Support System Recommendations Storage Communication Computerisation Meeting needs of Nursing and Doctors Meeting needs of relatives and Attendants Relationship and Coordination with other areas like ER and other super speciality
ICUS 6 Environmental Planning Effective steps and planning to control nosocomial infections Flooring, walls, pillars and ceilings Lighting Surroundings Noise Heating/ ACNentilation Waste disposal and pollution control Protocol about allowing visitors, shoes etc inside ICU 7 Human Resource development Doctors , Nurses , Respiratory Therapist , Computer Programmer , and support staff like Clerks ,X-ray technician, Lab technicians , Cleaning staff who are trained to the gap between demand and supply and can put a lot of stress on the team and patient outcome. 8 Other areas like Research Data Collection Documentation Record keeping Team Formation Team may consist of following Intensivist Administrator Finance officer Architect and Engineers Nurse Any other person if is relevant Who should Co-ordinate/lead the team ?
Coordinator is the most important person who coordinates with every one involved. Intensivist/ln-charge is best suited to be the Co-ordinator because – He has technical skill and knowledge to plan and guide He will prevent mistakes to bare minimum He can suggest changes during the development phase itself if finds problems However, in some countries or some set ups particularly public sector hospitals dministrators are usually the coordinators of such project implementation process since they can coordinate with all the major individuals and groups whose inputs/ help are needed in achieving the target in time and quality, It may be difficult for Intensivist to spare so much of time needed and coordinate with others.
Aims and Objectives, Budget allocation and other target settings It is important to decide about priorities based on inputs from Team members and should answer following questions – Budget available Level of ICU needed Location Number of Beds needed Designs Human Resource Development Engineering and designing constraints What type of Case mix the ICU team is likely to deal with and therefore help in prioritise equipment type mistakes Patient safety and prevention of infection programme Transition in case of relocation during reconstruction of the existing ICU Following thoughts may help in making decisions and implementation easier (88s) Features that must be adopted Features that should be adopted Features that can be adopted Features that should not be adopted Features that must not be adopted.
When every thing has been put in writing and approved by the whole team, the rocess must be began in the earnest and a time frame work should be fixed and all efforts must be made to accomplish the implementation within the stipulated time unless there are unforeseen circumstances. Budget and Human Resource (Residents and Nurses) are the most important limiting factors. Engineering related problems like drainage systems, leaks, slopes etc are easily overlooked. It is advised that engineering work be done in a manner so that repairing when ever needed should be easily possible without Jeopardising patient care. Therefore, least concealed or over-the-false roof pipelines, wires should be voided.
Designing ICU/Level/No of ICUs/No of Beds and Individual Bed Following ICU Levels are proposed Level I It is recommended for small district hospital, small private Nursing homes, Rural centres Ideally 6 to 8 Beds Provides resuscitation and short-term Cardio respiratory support including Defibrillation. ABG Desirable. It should be able to Ventilate a patient for at least 24 to 48 hrs and Non invasive Monitoring like – SP02, H R and rhythm (ECG), NIBP, Temperature etc Able to have arrangements for safe transport of the patients to secondary or tertiary centres The staff should be encouraged to do short training courses like FCCS or BASIC ICU Course.
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 RET) and Imaging back up (X-ray and USG), ECG Some Microbiology may be desirable At least one book on Critical Care Medicine as ready reckoner Level II (Recommendations of Level I Plus) Recommended for larger General Hospitals Bed strength 6 to 12 Multisystem life support Invasive and Non invasive Ventilation Invasive Monitoring Long term ventilation ability -rc pacing Access to ABG, Electrolytes and other routine diagnostic support 24 hrs Strong Microbiology support with facility for Fungal Identification desirable Nurses and duty doctors trained in Critical Care CT must & MRI is desirable Protocols and policies for ICUs are observed Research will be highly recommended Should be supported ideally by Cardiology and other super specialities of Medicine and Surgery HDLJ facility will be desirable Should fulfil all requirements for IDCC Course Resident doctors must be exposed to FCCS course/BASlC courseNentilation workshops and other updates Blood banking either own or outsourced
Level Ill (All recommendations of Level II Plus) Recommended for tertiary level hospitals Bed strength 10 to 16 with one or multiple ICUS as per requirement of the institution Headed by Intensivist Preferably Closed ICU Protocols and policies are observed Have all recent methods of monitoring, invasive and non invasive including continuous cardiac output, SCv02 monitoring etc Long term acute care of highest standards Intra and inter-hospital transport facilities available Multisystem care and referral available round 24 hrs Should become lead centres for IDCC and Fellowship courses Bedside x-ray, USG, 2D-Echo available Own or outsourced CT Scan and MRI facilities should be there Bedside Broncoscopy Bedside dialysis and other forms of RRT available Adequately supported by Blood banks and Blood component therapy Optimum patient/Nurse ratio is maintained with 1/1 pt/Nurse ratio in ventilated patients. Protocols observed about prevention of infection Provision for research and participation in National and International research programmes Patient area should not be less than 100 sq ft per patient (>125 sq ft will be ideal).
In addition there is optimum additional space for storage, nursing station and relatives The unit is assisted by an Ethical Committee which formulates policies about DNAR, Organ donation, EOLS etc technologies and knowledge in critical Care There is regular sharing of knowledge, mishaps, incidents, symposia and seminars etc related closely to the department and in association with other specialties Human Resource for ICU (1 5,5588) Human resource development is one of the most important task and component 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/s
Resident doctors Nurses, Respiratory Therapists, Nutritionist Physiotherapist Technicians, Computer programmer, Biomedical Engineer, and Clinical Pharmacist Other support staff. Like cleaning staff, guards and Class IV. Not only they have to be qualified but have to be trained and have to be a team person Scarce availability of these qualities all in one has made their availability extremely difficult and the turn over is high. Team Leader It is important to have a good team led by an Intensivist (who spends >50% of his time in ‘CU). He should be a full timer particularly for tertiary centres. He should be qualified and trained and able to lead the team. Experience is absolutely essential to lead the ICU team .
Resident Doctors (only MCI endorsed) Post graduates from Anaesthesia, Medicine or Respiratory Medicine or other allied branches even surgical specialties. Other residents may be graduates depending upon total Bed strength of ‘CU. Though need of resident doctors per number of patient has not been prescribed in literature, however, it is understood and recommended that one doctor cannot take care of more than five patients who are critically sick on ventilator and/or undergoing nvasive monitoring with MOFS. Therefore, it is suggested that one PG resident with one graduate resident may be good for an ICU of 10 to 14 beds with 1/3 of the pts may be falling into above category. Total no of residents should include who will relieve those going on leave or have to take sudden offs.
Nursing staff ( only NCI Endorsed) (34??5??6??7??8??9) Nursing – 1/1 nursing for Ventilated or MOFS patients is desirable but in no circumstance the ratio should be < 2 13 (Two nurses for 3 such patients). This will affect the outcome immensely. require above modalities. Other staff Respiratory Therapist looks after the patients being ventilated respiratory physiotherapy, this takes away lot of load off the duty doctor and the nurses Physiotherapist help in mobilisation, and Technicians who can perform simple procedures like taking samples and sending them to proper place in proper manner makes the task easy and less stressful. Computer person can prepare reports, enter data and bring out print outs as and when needed. He can also maintain library, Internet and protocols practiced in 'CU.
Biomedical engineer within the campus makes the Job of ICU less frustrating when nags creep in within sensitive ICU equipment. He can be correct them fast. Nutritionist is also a very important professional who can contribute to outcome of patient. They have to be trained in desired practices and should be more inclined towards enteral feeding than TPN. Cleaning, class IV and Guards are also important to ICU particularly when they understand needs of ICU and its patients. They have a huge role to play in prevention of Nosocomial infection, keeping ICU clean and protect from overcrowding. One person should be responsible for observing protocols of Pollution and Infection ontrol.
Such person should act in close collaboration of Microbiology personnel In addition the ICU should be ably supported by clinical Lab staff, Microbiology and Imaging staff who can understand the protocols of ICU and act within discipline of ICU protocols. Having professionals from Clinical Lab, Microbiology, Imaging, Pharmacy for support whenever needed will be desirable. How many ICUS and Beds are needed (81 ,82,83) Brain storming sessions should be held as to decide how many ICU beds are needed and how many ICUs should be made which may include Advanced ‘CU, HDLJ, PICU nd Speciality related ICU like Neurointensive care, Cardiac Intensive Care and Trauma.
The number of Intensive Care beds will depend on the data available from the hospital and current/future requirements of the hospital. Some ICUs particularly in Private set ups in our country may be main speciality in the hospital and they should be very careful in deciding about the number of beds and budgetary provisions and viability issues are very important in such cases. Numbers of ICU Beds recommended in a hospital are usually 1 to 4 per 100 hospital beds ICUs having 24 are difficult to manage and major problems may be encountered in anagement and outcome. Recommendations suggest that efficiency may be compromised once total number of beds crosses 12 in ICU.
The Canadian Department of National Health and Welfare has developed a formula for calculating the number of ICU beds required based on the average census in the existing unit and the desired probability of having an ICU bed immediately available Therefore, it is recommended that total bed strength in ICU should be between 8 to 12 and not 14 in any case Location/entry/exit points of ICU in Hospital Safe, easy, fast transport of a critically sick patient should be priority in planning its ocation, therefore, ICU should be located in close proximity of ER, Operating rooms, trauma ward. Corridors, lifts & ramps should be spacious enough to provide easy movement of bed/ trolley of a critically sick patient.
Close/easy proximity is also desirable to diagnostic facilities, blood bank, pharmacy No thoroughfare can be provided through ICU. There should be single entry/exit point to ICU, which should be manned. However, it is required to have emergency exit points in case of emergencies and disasters. ICU Bed Destgntng and space Issues (1 20,21 Space per bed has been recommended from 125 to 150 sq ft area per bed in the atient care area or the room of the patient. Some recommendation has placed it even higher up to 250 sq ft per bed. In addition there should be 100 to 150% extra space to accommodate nursing station, storage, patient movement area, equipment area, doctors and nurses rooms and toilet.
However in Indian circumstances after reviewing and feed back from various ICUs in our country it may be satisfactory to suggest an area of 100 to 125 sq ft be provided in patient care area for comfortable working with a critically sick patient where all the paraphernalia including monitoring systems, Ventilators & other machines like edside X-ray will have to be placed around the patient. Bedside procedures like Central lines, Intubation, Tracheostomy, ICD insertion and RRT are common. It may be prudent to make one or two bigger rooms or area which may be utilised for patients who may undergo big bedside procedures like ECMO, RRT etc and has large number Gadgets attached to them. 10 % (one to two) rooms may be designated isolation rooms where immunocompromised patients may be kept, these rooms may have 20% extra space than other rooms.
The planners may think about, if they are thinking of introducing newer technologies n their ICU like ECMO, Nitric Oxide and Xenon clearance etc. Do they need Lamellar flow for specific patient population in their ICUs. This will be highly specific for High end up ICUs and is not recommended in routine Provisions may be kept open for such options in future. Partition between two room and maintaining privacy of patients It is recommended that there should be a partition/separation between rooms when patient privacy is desired which is not unusual. very common in most Indian ICUs, however they are displaced and become unclean easily and patients privacy is disturbed Therefore, two rooms may be separated by unbreakable fixed or removable partisans, which may be aluminium, wood or fibre.
However permanent partitions takes away the flexibility of increasing floor space temporarily (In Special circumstances) for a particular patient even when the adjoining bed/room may not be in use. There are also electronic windows which are transparent when the switch is off and are opaque when the switch is on, Although expensive now, the cost of this option may come down over time, Pendant vs Head End Panel One of the most important decisions is to how to plan bedside design Two pproaches are usually practised Head wall Panel Free standing systems (power columns) usually from the ceiling Each can be fixed or moveable and flexible can be on one or both sides of the patient.
Flexibility is usually desirable, Panels on head wall systems allow for free movements Adaptable power columns can move side to side or rotate, Mounts on power columns are also usually adjustable, Flexible systems are expensive and counterproductive if the staff never move or adjust them, Head wall systems can be oriented to one side of the patient or to both sides, Some nits use two power columns, one on each side of the patient, Other units use a power column on one side in combination with some fixed side wall options on the opposite side, Ceiling mounted moveable rotary systems may reduce clutter on the floor and make a lot of working space available, However, this may not be possible if the weight cannot be structurally supported Power columns may not be possible in smaller rooms or units. Each room should be designed to accommodate portable bedside x-ray, Ultrasound and other equipment such as ventilators and IA Balloon pumps; in addition, the patient’s window view (If vailable) to the outside should be preserved. Height of Monitoring System Excessive height may be a drawback to the way monitoring screens are typically well above eye level and display more parameters.
Doctors and nurses may have chronic head tilting leading to cervical neck discomfort and disorders, Therefore, the levels of monitors should be at comfortable height for doctors and nurses Keep Bed 2 ft away from Head Wall A usual problem observed in ICU is getting access to the head of the bed in times of also should not feel enclosed and surrounded by equipment and induced uncalled for fear About 6 inches high and 2 ft deep step(Made of wood) usually temporary/removable (which would otherwise would stay there only) is placed between the headwall and the bed It will keep the bed away from the wall and automatically gives caregivers a place to stand in emergencies without too much of problems. Lines may be routed through a fixed band of lines tied together. 9 Provision for RRT Two beds should be specially designated for RRT (HD/CRRT) where outlets should be available for RO/de-iodinated water supply for HD machines.
Self-contained HD machines are also available (Cost may be high) Isolation Rooms 0% of beds ( 1 or 2 ) rooms may be used exclusively as isolation cases like for burns , serious contagious infected patients . Alarms . music . phone etc Each group should decide if they want to provide the patient access to music (audio), telephone etc. However an alarm bell which has both indicators by sound and light must be provided to each patient and he be taught about it, how to use it when needed OxygemVacuum/ Compressed air outlets and No of Electric female Plugs Fot tertiary center Summary of key Recommendation for Minimal standards in ICU Standards 02 outlets AIA/AAH (1) 2t03 IEEE SCCM (2) Vacuum outlets 2t04