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ICU LayoutICU Layout

The intensive care unit should be easily accessible by The intensive care unit should be easily accessible by departments from which patients are admitted and departments from which patients are admitted and close to departments which share engineering close to departments which share engineering services.services.

It is desirable that critically ill patients are separated It is desirable that critically ill patients are separated from those requiring coronary care or high from those requiring coronary care or high dependency care where a quieter environment is often dependency care where a quieter environment is often needed.needed.

It is possible to provide intensive care and high It is possible to provide intensive care and high dependency care in the same unit so long as patients dependency care in the same unit so long as patients can be separated within the unit.can be separated within the unit.

However, the differing requirements of these patients However, the differing requirements of these patients may limit such flexibility.may limit such flexibility.

The floor sizes given below represent a minimum The floor sizes given below represent a minimum guide.guide.

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SizeSize Intensive care bed requirements depend on the Intensive care bed requirements depend on the

activity of the hospital with additional beds activity of the hospital with additional beds required for regional specialties such as required for regional specialties such as cardiothoracic surgery or neurosurgery.cardiothoracic surgery or neurosurgery.

Small (<6 beds) or very large (>14 beds) units Small (<6 beds) or very large (>14 beds) units may be difficult to manage although larger units may be difficult to manage although larger units may be divided operationally and allow better may be divided operationally and allow better concentration or resources.concentration or resources.

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Patient areasPatient areas Patient areas must provide unobstructed passage Patient areas must provide unobstructed passage

around the bed with a floor space of 20maround the bed with a floor space of 20m22 per bed. per bed. Curtains or screens are required for privacy.Curtains or screens are required for privacy.

Floors and ceilings must be constructed to support Floors and ceilings must be constructed to support heavy equipment (some may weigh 1000 kg.)heavy equipment (some may weigh 1000 kg.)

Doors must allow for passage of bulky equipment as Doors must allow for passage of bulky equipment as well as wide beds.well as wide beds.

Every bed should have access to a was hand basin.Every bed should have access to a was hand basin. The specification should include at least 1 cubicle The specification should include at least 1 cubicle

per 6 beds with 30mper 6 beds with 30m22 floor area for isolation. Air floor area for isolation. Air conditioning should allow for positive and negative conditioning should allow for positive and negative pressure control in cubicles, temperature and pressure control in cubicles, temperature and humidity control.humidity control.

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Services must include adequate electricity supply Services must include adequate electricity supply (at least 20 scokets per bed) with emergency (at least 20 scokets per bed) with emergency back-up supply. Oxygen (3) medical air (2) and back-up supply. Oxygen (3) medical air (2) and suction (2) outlets must be available for every suction (2) outlets must be available for every bed. bed.

The bed areas should have natural daylight and The bed areas should have natural daylight and patients and staff should ideally have an outside patients and staff should ideally have an outside view.view.

Communications systems include an adequate Communications systems include an adequate number of telephones to avoid all telephones number of telephones to avoid all telephones being in use at once, intercom systems to allow being in use at once, intercom systems to allow bed to bed communication and a system to bed to bed communication and a system to control entry to the department. control entry to the department.

Computer networks should enable communication Computer networks should enable communication with central hospital administration and with central hospital administration and laboratory system. laboratory system.

Other areasOther areas Other areas include storage space (12mOther areas include storage space (12m22 per bed), per bed),

dirty utility (20mdirty utility (20m22), clean utility (10m), clean utility (10m22), Offices ), Offices (45m(45m22), doctor’s bedroom (15m), doctor’s bedroom (15m22), laboratory ), laboratory (15m(15m22), seminar room (30m), seminar room (30m22), cleaner’s room ), cleaner’s room (10m(10m22), staff rest room, locker room, toilets, ), staff rest room, locker room, toilets, relatives’ area, bedroom and interview room.relatives’ area, bedroom and interview room.

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ICU Staffing (Medical)ICU Staffing (Medical) Intensive care has evolved from the early success Intensive care has evolved from the early success

in simple mechanical ventilation of the lungs of in simple mechanical ventilation of the lungs of polio victims to the present day where patients polio victims to the present day where patients admitted to intensive care will usually have failure admitted to intensive care will usually have failure or dysfunction of one or more organs systems or dysfunction of one or more organs systems requiring mechanical support and monitoring. requiring mechanical support and monitoring.

The intensive care unit should have dedicated The intensive care unit should have dedicated consultant sessions allocated with additional consultant sessions allocated with additional allocation for management and audit activities.allocation for management and audit activities.

These sessions should be divided between several These sessions should be divided between several intensive care specialists. intensive care specialists.

In addition, the intensive care specialist should be In addition, the intensive care specialist should be supported by junior doctors in training who can supported by junior doctors in training who can provide 24h per day cover on a rota which provide 24h per day cover on a rota which provides for adequate rest.provides for adequate rest.

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Required skills of intensive care medical staff.Required skills of intensive care medical staff.ManagementManagement Senior intensive care medical staff, together with Senior intensive care medical staff, together with

their senior nursing colleagues, command the their senior nursing colleagues, command the primary responsibility for the financial primary responsibility for the financial management of the intensive care unit.management of the intensive care unit.

It is through their actions that treatment of the It is through their actions that treatment of the critically ill is initated and perpetuated; they are critically ill is initated and perpetuated; they are ultimately responsible for the activity of the unit ultimately responsible for the activity of the unit and patient out come.and patient out come.

Decision makingDecision making In the ICU most decisions are ultimately made by In the ICU most decisions are ultimately made by

team consensus. team consensus. Clinical decisions in the intensive care unit can be Clinical decisions in the intensive care unit can be

thought of under three categories : thought of under three categories : i)i) Decisions relating to common or routine problems Decisions relating to common or routine problems

for which a unit policy exists;for which a unit policy exists;ii)ii) Decisions relating to uncommon problems Decisions relating to uncommon problems

requiring discussion with all ICU and non-ICU staff requiring discussion with all ICU and non-ICU staff currently involved and.currently involved and.

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Decisions of an urgent nature taken by intensive Decisions of an urgent nature taken by intensive care staff without delay.care staff without delay.

Practical skillsPractical skills Expertise in the management of complex Expertise in the management of complex

equipment, monitoring procedures and equipment, monitoring procedures and performance of invasive procedures are required.performance of invasive procedures are required.

Clinical experienceClinical experience Medical staff require experience in the recognition, Medical staff require experience in the recognition,

prevention and management of critical illness, prevention and management of critical illness, infection control, anesthesia and organ support.infection control, anesthesia and organ support.

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Technical knowledgeTechnical knowledge The intensive care specialist has an important role The intensive care specialist has an important role

in the choice of equipment used in the intensive in the choice of equipment used in the intensive care unit.care unit.

Pharmacological knowledge Pharmacological knowledge drug therapy regimens are clearly open to the drug therapy regimens are clearly open to the

problems of drug interactions and, in addition, problems of drug interactions and, in addition, pharmacokinetics are often severely altered by pharmacokinetics are often severely altered by the effects of major organs system dysfunction, the effects of major organs system dysfunction, particularly involving the liver and kidneys. particularly involving the liver and kidneys.

Teaching and trainingTeaching and training The modern intensive care specialist has acquired The modern intensive care specialist has acquired

a number of skills that cannot be gained outside a number of skills that cannot be gained outside the intensive care unit. It is therefore necessary to the intensive care unit. It is therefore necessary to be able to provide this education to junior doctors be able to provide this education to junior doctors in tainting for intensive care.in tainting for intensive care.

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ICU staffing (nursing)ICU staffing (nursing) Critically ill patients require close nursing supervision. Critically ill patients require close nursing supervision.

Many will require 1:1 nursing throughout a 24h period Many will require 1:1 nursing throughout a 24h period while other are of a lower dependency and can share while other are of a lower dependency and can share nurses. nurses.

A few patients are so ill with the need for multiple A few patients are so ill with the need for multiple interventions that their real nursing requirement is interventions that their real nursing requirement is >1:1.>1:1.

In addition to the bedside nurses, the department In addition to the bedside nurses, the department needs additional staff to manage the day to day needs additional staff to manage the day to day operation of the unit, to assist in lifting and handling operation of the unit, to assist in lifting and handling of patients, to relieve bedside nurses for rest period of patients, to relieve bedside nurses for rest period and to collect drugs and equipment. and to collect drugs and equipment.

These additional nurses can be termed the fixed These additional nurses can be termed the fixed nursing establishment and the nature of their duties nursing establishment and the nature of their duties is such that they will usually be higher grade nurses.is such that they will usually be higher grade nurses.

The bedside nurses are a ‘variable establishment’ and The bedside nurses are a ‘variable establishment’ and their numbers are dependent on activity such that their numbers are dependent on activity such that more patients require higher numbers. more patients require higher numbers.

Most departments fix their variable establishment by Most departments fix their variable establishment by assuming an average activity. assuming an average activity.

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Fixed establishmentFixed establishment In the UK providing 1 nurse per shift for 24h per day 7 In the UK providing 1 nurse per shift for 24h per day 7

days per week requires 4.5 nurses. days per week requires 4.5 nurses. In addition, staff , leave, study leave and sickness are In addition, staff , leave, study leave and sickness are

usually calculated at 22% such that 1 additional nurse usually calculated at 22% such that 1 additional nurse is required.is required.

Thus the provision of 1 nurse in charge of each shift Thus the provision of 1 nurse in charge of each shift and 1 nurse to support the bedside nurses requires 11 and 1 nurse to support the bedside nurses requires 11 additional nurses. In larger units there may be a need additional nurses. In larger units there may be a need for additional support nurses and less in smaller units.for additional support nurses and less in smaller units.

Variable establishmentVariable establishment The same principles apply for the provision of bedside The same principles apply for the provision of bedside

nurses. nurses. Thus, to provide 1:1 nursing for a bed requires 5.5 Thus, to provide 1:1 nursing for a bed requires 5.5

nurses and to provide 1:2 nursing requires 2.75 nurses and to provide 1:2 nursing requires 2.75 nurses.nurses.

The total number required depends on the occupancy The total number required depends on the occupancy and the nurse to patient ratio for each occupied bed.and the nurse to patient ratio for each occupied bed.

One of the difficulties in staffing an intensive care unit One of the difficulties in staffing an intensive care unit relates to the variable dependency and occupancy.relates to the variable dependency and occupancy.

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An average dependency weighted occupancy An average dependency weighted occupancy (average occupancy x average nurse to patient ratio) (average occupancy x average nurse to patient ratio) should be used to set the establishment of bedside should be used to set the establishment of bedside nurses with additional nurses being drafted in from a nurses with additional nurses being drafted in from a bank or agency to cover peak demands.bank or agency to cover peak demands.

Skill Mix Skill Mix Nursing skill mix is the subject of much controversy Nursing skill mix is the subject of much controversy

as the need for economy is balanced against the as the need for economy is balanced against the need for quality. need for quality.

As stated above the fixed nursing will usually be of As stated above the fixed nursing will usually be of higher grade since the role incorporates the higher grade since the role incorporates the administration of the unit and supervisory nursing. administration of the unit and supervisory nursing.

The bedside nurses will be made up of those who The bedside nurses will be made up of those who have received post qualification training in intensive have received post qualification training in intensive care and those who have not.care and those who have not.

The ratio of trained to untrained intensive care The ratio of trained to untrained intensive care nurses should be of the order of 3:1 of facilitate in nurses should be of the order of 3:1 of facilitate in service teaching. service teaching.

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Medicolegal aspectsMedicolegal aspects The intensive care unit is a source of many The intensive care unit is a source of many

medicolegal problems. Patients are often not medicolegal problems. Patients are often not competent to consent to treatment.competent to consent to treatment.

They may be admitted following trauma, They may be admitted following trauma, violence or poisoning, all of which may involve violence or poisoning, all of which may involve a legal process. Admission may also follow a legal process. Admission may also follow complications of treatment of medical mishaps complications of treatment of medical mishaps occurring elsewhere n the hospital. occurring elsewhere n the hospital.

The nature of critical illness is such that The nature of critical illness is such that complication are common and litigation may complication are common and litigation may follow.follow.

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ConsentConsent Many procedures in intensive care are invasive or Many procedures in intensive care are invasive or

involve significant risk. involve significant risk. The patient is often not competent to consent for The patient is often not competent to consent for

such treatment such that the next of kin must be such treatment such that the next of kin must be involved. involved.

It is essential that the risks and benefits are It is essential that the risks and benefits are explained to the person giving assent and a chance explained to the person giving assent and a chance is given for the patients wishes to be taken into is given for the patients wishes to be taken into account.account.

It is all too easy to achieve assent from a relative It is all too easy to achieve assent from a relative without giving adequate explanation of the option. without giving adequate explanation of the option.

Research present consent problems in the critically Research present consent problems in the critically ill and requires close ethical committee supervision.ill and requires close ethical committee supervision.

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Note keepingNote keeping It is impossible to record everything that happens in It is impossible to record everything that happens in

intensive care in the patients’ notes. intensive care in the patients’ notes. The 24h observation chart provides that most detailed The 24h observation chart provides that most detailed

record of what has happened but summary notes are record of what has happened but summary notes are essential. essential.

Such notes must be factual without unsubstantiated Such notes must be factual without unsubstantiated opinions about the patient or about previous treatment opinions about the patient or about previous treatment ..

All entries must be timed and signed. All entries must be timed and signed. Records of ward rounds must record the name of the Records of ward rounds must record the name of the

consultant leading the round. consultant leading the round. It must be remembered that the notes may be used It must be remembered that the notes may be used

later in legal proceedings.later in legal proceedings. They may be used against you but if well kept will They may be used against you but if well kept will

usually form the best defence. usually form the best defence. In the event of a medical mishap the episode should In the event of a medical mishap the episode should

be clearly documented after witnessed explanation to be clearly documented after witnessed explanation to relatives. relatives.

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Dealing with the policeDealing with the police

Most police enquiries relate to patients who are Most police enquiries relate to patients who are admitted after suspicious circumstances. admitted after suspicious circumstances.

While there is a duty to patient confidentiality it While there is a duty to patient confidentiality it may be in the patient’s interests to impart may be in the patient’s interests to impart information about them.information about them.

This may be with the consent of the patient or This may be with the consent of the patient or the next of kin.the next of kin.

Written statements or verbal information may be Written statements or verbal information may be requested. requested.

Any information given should avoid opinion and Any information given should avoid opinion and stick to facts.stick to facts.

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Dealing with the jurist Dealing with the jurist

The Corner must be informed of any death where The Corner must be informed of any death where as death certificate cannot be issued.as death certificate cannot be issued.

Death certificate can be issued where the death is Death certificate can be issued where the death is due to a natural cause and the patient has been due to a natural cause and the patient has been seen professionally by the doctor within 14 days seen professionally by the doctor within 14 days prior to death.prior to death.

The table documents the conditions requiring the The table documents the conditions requiring the coroner to be informed. Where there is any doubt coroner to be informed. Where there is any doubt the corner should be informed.the corner should be informed.

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Deaths which must be informed to Deaths which must be informed to the jurist the jurist Unidentified bodyUnidentified body No doctor attending within prior 14 No doctor attending within prior 14 daysdays Death without recovery from Death without recovery from anesthesia anesthesia Sudden or unexplained deathSudden or unexplained death Medical mishapMedical mishap Industrial accident or diseaseIndustrial accident or disease Violence, accident or Violence, accident or misadventuremisadventure Suspicious circumstances.Suspicious circumstances. AlcoholismAlcoholism PoisoningPoisoning Death in custodyDeath in custody