ICU SETTING.ppt

ICU Setting

1. CONCEPTOF CRITICAL CARE

2. INTRODUCTION
Theintensivecareunitisnot
merelyaroomorseriesofroom
filledwithpatientsattachedto
interventionaltechnology;itis
thehomeofanorganization:
theintensivecareteam.

3. THE INTENSIVE CARE TEAM.
Thisteam–
•Doctor
•Nurses
•Therapists
•Nutritionists
•Chaplainsandothersupport
staff,buildsanenvironment
forhealingordying.

4. CRITICAL CARE NURSING
Critical care nursing is that
specialty within nursing that deals
specifically with human responses
to life-threatening problems.

5. CRITICAL CARE NURSING
Critical care nursing is that
specialty within nursing that deals
specifically with human responses
to life-threatening problems.

6. SEVEN Cs OF CRITICAL CARE
•Compassion
•Communication (withpatientandfamily).
•Consideration(topatients,relativesand
colleagues)andavoidanceofConflict.
•Comfort:preventionofsuffering
•Carefulness(avoidanceofinjury)
•Consistency
•Closure(ethicsandwithdrawalofcare).

7. CRITICAL CARE NURSE
Acriticalcarenurseisa
licensedprofessionalnurse
who isresponsible for
ensuringthatacutelyand
criticallyillpatientsand
their families receive
optimalcare.

8. CRITICAL CARE UNIT
•Criticalcareunitisaspeciallydesigned
andequippedfacilitystaffedbyskilled
personneltoprovideeffectiveandsafe
carefordependentpatientswithalife
threateningproblem.

9. THE AIM OF THE CRITICAL
CARE:-
is to see that one provides a care
such that patient improves and
survives the acute illness or tides
over the acute exacerbation of the
chronic illness.

10. TYPES OF ICUs
There are two types of ICUs,
•An open :-. In this type, physicians admit,
treat and discharge and
•A closed: in this type, the admission,
discharge and referral policies are under the
control of intensivists.

11. ICUS CAN BE CLASSIFIED AS:
•Level I: This can be referred as high dependency is
where close monitoring, resuscitation, and short term
ventilation <24hrs has to be performed.
•Level II: Can be located in general hospital, undertake
more prolonged ventilation. Must have resident doctors,
nurses, access to pathology, radiology, etc.
•Level III: Located in a major tertiary hospital, which is a
referral hospital. It should provide all aspects of intensive
care required.

12. Medical staff
•Carrier intensivists are the best senior medical
Staff to be appointed to the ICU.
•He/she will be the director.
•Less preferred are other specialists viz. From
Anaesthesia, medicine and chest who have
clinical Commitment elsewhere.
•Junior staff are intensive care trainees and
trainees on deputation from other disciplines.

13. NURSING STAFF
•ThemajorteachingtertiarycareICUwillrequiretrained
nursesincriticalcare.
•Itmaybeidealtohaveaninhousetrainingprogramme
forcriticalCarenursing.
•Thenumberofnursesideallyrequiredforsuchunitsis
1:1ratio.
•Incomplexsituationstheymayrequiretwonursesper
patient.
•Thenumberoftrainednursesshouldbealsoworked
outbythetypeofICU,theworkloadandworkstatistics
andtypeofpatientload.

14. UNIT DIRECTOR:-
Specific requirements for the unit director include the
following:
•Training, interest, and time availability to give clinical,
administrative, and educational direction to the ICU.
•Board certification in critical care medicine.
•Time and commitment to maintain active and regular
involvement in the care of patients in the unit.

15. •Availability (either the director or a similarly qualified
surrogate) to the unit 24 hrs a day, 7 days a week for
both clinical and administrative matters.
•Active involvement in local and/or national critical care
societies.

16. •Participation in continuing education programs in the
field of critical care medicine.
•Hospital privileges to perform relevant invasive
procedures.
•Active involvement as an advisor and participant in
organizing care of the critically ill patient in the
community as a whole.
•Active participation in the education of unit staff.
•Active participation in the review of the appropriate use
of ICU resources in the hospital.

17. Critical Care Unit nursing
requirements:-
•All patient care is carried out directly by or
under supervision of a trained critical care
nurse.
•All nurses working in critical care should
complete a clinical/critical care course
before assuming full responsibility for patient
care.
•Unit orientation is required before assuming
responsibility for patient care.
•Nurse-to-patient ratios should be based on
patient acuity according to written hospital
policies.

18. Critical Care Unit nursing
requirements :-
•All critical care nurses must participate in continuing
education.
•An appropriate number of nurses should be trained in
highly specialized techniques such as renal replacement
therapy, intra-aortic balloon pump monitoring, and
intracranial pressure monitoring.
•All nurses should be familiar with the indications for and
complications of renal replacement therapy.

19. PHYSICIAN SUBSPECIALISTS
•General surgeon or trauma surgeon
•Neurosurgeon
•Cardiovascular surgeon
•Obstetric-gynecologic surgeon
•Urologist
•Thoracic surgeon
•Vascular surgeon
•Anesthesiologist
•Cardiologist with interventional capabilities
•Pulmonologist

20. PHYSICIAN SUBSPECIALISTS
•Gastroenterologist
•Hematologist
•Infectious disease specialist
•Nephrologist
•Neuroradiologist (with interventional capability)
•Pathologist
•Radiologist (with interventional capability)
•Neurologist
•Orthopedic surgeon

21. OTHER PERSONNEL :
Avarietyofotherpersonnelmaycontributesignificantlyto
theefficientoperationoftheICU.Theseinclude:-
•Unitclerks
•physicaltherapists
•occupationaltherapists
•Advancedpracticenurses
•Physicianassistants
•Dietaryspecialists,and
•Biomedicalengineers.

22. LABORATORY SERVICES
•A clinical laboratory should be
available on a 24-hr basis to provide
basic hematologic, chemistry, blood
gas, and toxicology analysis.
•Laboratory tests must be obtained in a
timely manner, immediately in some
instances. "STAT" or "bedside"
laboratories adjacent to the ICU or
rapid transport systems.

23. Radiology and imaging services:
•The diagnostic and therapeutic radiologic
procedures should be immediately
available to ICU patients, 24 hrs per day.
•Portable chest radiographs affect decision
making in critically ill patients.

24. ORGANIZATION OF ICU
•It requires intelligent planning.
•One must keep the need of the hospital and
its location.
•One ICU may not cater to all needs.
•An institute may plan beds into multiple
units under separate management by single
discipline specialist viz. medical ICU,
surgical ICU, CCU, burns ICU, trauma ICU,
etc.

25. ORGANIZATION OF ICU
•The number of ICU beds in a hospital ranges
from 1 to 10 per 100 total hospital beds.
•Multidisciplinary requires more beds than
single speciality. ICUs with fewer than 4 beds
are not cost effective and over 20 beds are
unmanageable.
•ICU should be sited in close proximity to
relevant areas viz. operating rooms, image
logy, acute wards, emergency department.
•There should be sufficient number of lifts
available to carry these critically ill patients
to different areas.

26. ORGANIZATIONAL MODELS FOR ICUs:
•the open modelallows many different
members of the medical staff to manage
patients in the ICU.
•the closed modelis limited to ICU-certified
physicians managing the care of all patients;
and
•the hybrid model,which combines aspects
of open and closed models by staffing the
ICU with an attending physician and/or team
to work in tandem with primary physicians.

27. DEFINITION OF INTENSIVE CARE UNIT
EQUIPMENTS:-
•Intensive care unit (ICU) equipment includes
patient monitoring, respiratory and cardiac
support, pain management, emergency
resuscitation devices, and other life support
equipment designed to care for patients who
are seriously injured, have a critical or life-
threatening illness, or have undergone a
major surgical procedure, thereby requiring
24-hour care and monitoring.

28. PURPOSE
•AnICUmaybedesignedandequipped
toprovidecaretopatientswitharange
ofconditions,oritmaybedesigned
andequippedtoprovidespecialized
caretopatientswithspecific
conditions

29. DESCRIPTION
•Intensive care unit equipment
includes:-
•patient monitoring
•life support and emergency
resuscitation devices
•diagnostic devices

30. PATIENT MONITORING EQUIPMENTS
•Acute care physiologic monitoring
system
•Pulse oximeter
•Intracranial pressure monitor
•Apnea monitor

31. LIFE SUPPORT & RESUSCITATIVE
EQUIPMENTS
•VENTILATOR
•INFUSION PUMP
•CRASH CART
•INTRAAORTIC BALOON PUMP

32. DIAGNOSTIC EQUIPMENTS
•MOBILE X-RAYS
•PORTABLE CLINICAL LAB. DEVICES
•BLOOD ANALYZER

34. THERAPEUTIC ELEMENTS IN ICU
ENVIORNMENT
•Windowandartthatprovidesnatural
views;viewsofnaturecanreducestress,
hastenrecovery,lowerbloodpressureand
lowerpainmedicationneeds.
•Familyparticipation,includingfacilities
forovernightstayandcomfortablewaiting
rooms.

35. THERAPEUTIC ELEMENTS IN ICU
ENVIORNMENT
•Providngameasureofprivacyandpersonal
controlthroughadjustablecurtainsandblinds
,accessiblebedcontrols,andTV,VCRandCD
players.
•Noisereductionthroughcomputerizedpagersand
silentalarms.
•Medicalteamcontinuitythatallowsoneteamto
followthepatientthroughhisorherentirestay.

36. FLOOR PLAN AND DESIGN
IT SHOULD BE BASED ON:-
•Patientadmissionpattern
•Staff&visitortrafficpatterns
•Needforsupportfacilitiessuchanursing
station,Storage
•Administrative&educationalrequirements.
•Servicesthatareuniquetotheindividual
institution.

37. FLOOR PLAN AND DESIGN
•Eighttotwelvebedsperunitis
consideredbestfromafunctional
perspective.
•Eachhealthcarefacilityshouldconsider
theneedforpositive-andnegative
pressureisolationroomswithintheICU.
•Thisneedwilldependmainlyuponpatient
populationandStateDepartmentofPublic
Healthrequirements.

38. FLOOR PLAN AND DESIGN
•Eachintensivecareunitshouldbeageographically
distinctareawithinthehospital,whenpossible,
withcontrolledaccess.
•Nothroughtraffictootherdepartmentsshould
occur.Supplyandprofessionaltrafficshouldbe
separatedfrompublic/visitortraffic.
•Locationshouldbechosensothattheunitis
adjacentto,orwithindirectelevatortraveltoand
from,theEmergencyDepartment,Operating
Room,intermediatecareunits,andRadiology
Department

39. PATIENT AREAS.:-
Patients must be situated so that direct or indirect
(e.g. by video monitor) visualization by healthcare
providers is possible at all times. This permits the
monitoring of patient status under both routine .and
emergency circumstances. The preferred design is to
allow a direct line of vision between the patient and the
central nursing station.
In ICUs with a modular design, patients should be
visible from their respective nursing substations.
Sliding glass doors and partitions facilitate this
arrangement, and increase access to the room in
emergency situations.

40. RECOMMENDED NOISE RANGES
Signalsfrompatientcallsystems,alarmsfrom
monitoringequipment,andtelephonesaddtothe
sensoryoverloadincriticalcareunits.
TheInternationalNoiseCouncilhasrecommended
thatnoiselevelsinhospitalacutecareareas
• notexceed45dB(A)inthedaytime,
• 40dB(A)intheevening,
• 20dB(A)atnight.
☻Notably,noiselevelsinmosthospitalsarebetween
50-70dB(A)withoccasionalepisodesabovethis
range

42. CENTRAL STATION
•Acentralnursingstationshouldprovidea
comfortableareaofsufficientsizetoaccommodate
allnecessarystafffunctions.
•Theremustbeadequateoverheadandtasklighting,
andawallmountedclockshouldbepresent.
•Adequatespaceforcomputerterminalsandprinters
isessentialwhenautomatedsystemsareinuse.
•Patientrecordsshouldbereadilyaccessible.

45. RECEPTION AREA

46. RECEPTIONIST AREA
•EachICUorICUclustershouldhavea
receptionistareatocontrolvisitoraccess.
•Ideally,itshouldbelocatedsothatallvisitors
mustpassbythisareabeforeentering.
•ThereceptionistshouldbelinkedwiththeICU(s)
bytelephoneand/orotherintercommunication
system.
•Itisdesirabletohaveavisitors'entrance
separatefromthatusedbyhealthcare
professionals.
•Thevisitors'entranceshouldbesecurableifthe
needarises.

47. Special Procedures Room.
•Ifaspecialproceduresroomisdesired,itshould
belocatedwithin,orimmediatelyadjacentto,
theICU.
•Onespecialproceduresroommayserveseveral
ICUsincloseproximity.
•Considerationshouldbegiventoeaseofaccess
forpatientstransportedfromareasoutsidethe
ICU.
•Roomsizeshouldbesufficienttoaccommodate
necessaryequipmentandpersonnel.

48. Clean and Dirty Utility Rooms.
•Cleananddirtyutilityroomsmustbe
separateroomsthatlackinterconnection.
•Theymustbeadequatelytemperature
controlled,andtheairsupplyfromthe
dirtyutilityroommustbeexhausted.
•Thecleanutilityroomshouldbeusedfor
thestorageofallcleanandsterile
supplies,andmayalsobeusedforthe
storageofcleanlinen.

49. Clean and Dirty Utility Rooms.
•Shelvingandcabinetsforstoragemustbelocated
highenoughoffthefloortoalloweasyaccessto
thefloorunderneathforcleaning.
•Specialcontainersshouldbeprovidedforthe
disposalofneedlesandothersharpobjects.

50. Equipment Storage
•Anareamustbeprovidedforthestorage
andsecuringoflargepatientcare
equipmentitemsnotinactiveuse.

51. Nourishment Preparation Area
•Apatientnourishmentpreparationarea
shouldbeidentifiedandequippedwithfood
preparationsurfaces,asinkwithhotand
coldrunningwater,acountertopstove
and/ormicrowaveoven,andarefrigerator.
•Therefrigeratorshouldnotbeusedfor
thestorageoflaboratoryspecimens.
•Ahandwashingfacilityshouldbelocatedin
ornearthearea.

52. Staff Lounge.
•Astaffloungemustbeavailableonorneareach
ICUorICUclustertoprovideaprivate,
comfortable,andrelaxingenvironment.
•Securedlockerfacilities,showersandtoilets
shouldbepresent.
•Theareashouldincludecomfortableseatingand
adequatenourishmentstorageandpreparation
facilities,includingarefrigerator,acountertop
stoveand/ormicrowaveoven.
•TheloungemustbelinkedtotheICUbytelephone
orintercommunicationsystem,andemergency
cardiacarrestalarmsshouldbeaudiblewithin.

53. Conference Room.
•AconferenceroomshouldbeconvenientlylocatedforICU
physicianandstaffuse.
•ThisroommustbelinkedtoeachrelevantICUbytelephoneor
otherintercommunicationsystem,andemergencycardiac
arrestalarmsshouldbeaudibleintheroom.

54. •Electricsupply
•Watersupply
•lighting

55. OTHER FACILITIES
•Voice Intercommunication Systems
•Satellite Laboratory
•Physician On-Call Rooms
•Administrative Offices

56. ICU Admission and
discharge Criteria

57. Requests for ICU Beds
•excellent care
•abundant resources
•high nurse-patient ratios
•pharmacists,nutritionist, RT’s, etc
•high tech equipment
•signs of deterioration quickly identified
•“give them a chance”
•discomfort with death
•convenience
•Demand frequently exceeds supply

58. ICU Admission Criteria
•A service for patients with
potentially recoverableconditions
who can benefitfrom more detailed
observation and invasive treatment
than can be safely provided in
general wards or high dependency
areas

59. ICU Triage
•admission criteria remain poorly defined
•identification of patients who can benefit from ICU
care is extremely difficult
•demand for ICU services exceeds supply
•rationing of ICU beds is common

60. Prioritization Model
•Priority 1
•critically ill, unstable
•require intensive treatment and monitoring
that cannot be provided elsewhere
•ventilator support
•continuous vasoactive infusions
•mechanical circulatory support
•no limits placed on therapy
•high likelihood of benefit

61. Prioritization Model
•Priority 2
•Require intensive monitoring
•May potentially need immediate intervention
•No therapeutic limits
•Chronic co-morbid conditions with acute severe
illness

62. Prioritization Model
•Priority 3
•Critically ill
•Reduced likelihood of recovery
•Severe underlying disease
•Severe acute illness
•Limits to therapies may be set
•no intubation, no CPR
•Metastatic malignancy complicated by
infection, tamponade, or airway obstruction

63. Prioritization Model
•Priority 4
•Generally not appropriate for ICU
•May admit on individual basis if unusual
circumstances
•Too well for ICU
•mild CHF, stable DKA, conscious drug
overdose, peripheral vascular surgery
•Too sick for ICU (terminal, irreversible)
•irreversible brain damage, irreversible
multisystem failure, metastatic cancer
unresponsive to chemotherapy

64. Diagnosis Model
•Uses specific conditions or diseases to
determine appropriateness of ICU admission
•48 diagnosis/ 8 organ systems
•Acute MI with complications
•cardiogenic shock
•complex arrhythmias
•acute respiratory failure
•status epilepticus, SAH

65. JCAHCO
Objectives Parameters
Model
•Vital signs
•HR < 40 or > 150
•SBP <80
•MAP <60
•DBP >120
•RR > 35

66. Objectives Parameters Model
•Laboratory values
•Sodium < 110 or > 170
•Potassium <2.0 or > 7.0
•PaO2 < 50
•pH < 7.1 or > 7.7
•Glucose > 800 mg/dL
•Calcium > 15 mg/dL
•toxic drug level with compromise

67. Objectives Parameters Model
•Radiologic
•ICH, SAH, contusion with AMS or
focal neuro signs
•Ruptured viscera, bladder, liver,
uterus with hemodynamic instability
•Dissecting aorta

68. Objectives Parameters Model
•EKG
•acute MI with complex arrhythmias,
hemodynamic instability, or CHF
•sustained VT or VF
•complete heart block with instability

69. Objectives Parameters Model
•Physical findings (acute
onset)
•unequal pupils with LOC
•burns > 10%BSA
•anuria
•airway obstruction
•coma
•continuous seizures
•cyanosis
•cardiac tamponade

70. ICU Admission Criteria
•Potential or established organ failure
•Factors to be considered
•Diagnosis
•Severity of illness
•Age and functional status
•Co-existing disease
•Physiological reserve
•Prognosis
•Availability of suitable treatment
•Response to treatment to date
•Recent cardiopulmonary arrest
•Anticipated quality of life
•The patient’s wishes

71. Discharge Criteria
•physiologic status has stabilized
•need for ICU monitoring and care no longer
necessary
•physiologic status has deteriorated
•active interventions no longer planned