The intensive care unit is not
merely a room or series of room
filled with patients attached to
interventional technology; it is
the home of an organization:
the intensive care team.
3. THE INTENSIVE CARE TEAM.
This team –
• Chaplains and other support
staff, builds an environment
for healing or dying.
4. CRITICAL CARE NURSING
Critical care nursing is that specialty
within nursing that deals specifically
with human responses to life-
5. SEVEN Cs OF CRITICAL CARE
• Communication (with patient and family).
• Consideration (to patients, relatives and
colleagues) and avoidance of Conflict.
• Comfort: prevention of suffering
• Carefulness (avoidance of injury)
• Closure (ethics and withdrawal of care).
6. CRITICAL CARE NURSE
A critical care nurse is a
licensed professional nurse
who is responsible for
ensuring that acutely and
critically ill patients and
their families receive
optimal care .
7. CRITICAL CARE UNIT
• Critical care unit is a specially designed
and equipped facility staffed by skilled
personnel to provide effective and safe
care for dependent patients with a life
8. THE AIM OF THE CRITICAL
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
9. THE EVOLUTION OF CRITICAL
•Forty years of development in
critical care and critical care
nursing has given rise to a
recognized speciality in nursing
•Critical care units have evolved
over the last four decades in
response to medical advances .
10. HISTORICAL PRESPECTIVES
• Florence nightingale recognized the need
to consider the severity of illness in bed
allocation of patients and placed the
seriously ill patients near the nurses’
• 1923, John Hopkins University Hospital
developed a special care unit for
neurosurgical patients .
• Modern medicines boomed to its higher
ladder after world war 2
15. HISTORICAL PRESPECTIVES
• As surgical techniques advanced
it became necessary that post
operative patient required careful
monitoring and this came about
the recovery room.
• In 1950, the epidemic of
thousands of patients requiring
respiratory assist devices and
intensive nursing care.
• At the same time came about
16. HISTORICAL PRESPECTIVES
• In 1953, Manchester Memorial
Hospital opened a four bedded
unit at Philadelphia was
• By 1957, there were 20 units
in USA and
• In 1958,the number increased
17. CONTEXTUAL FORCES
• The expansion of American
hospital system and hospital
• Architectural, hospital changes
towards private and semi private
• Reallocations for direct patient
care responsibility and creations
of new forms of care.
• During 1970’s,the term critical
care unit came into existence
18. TYPES OF ICUs
There are two types of ICUs,
• An open :-. In this type,
physicians admit, treat and
• A closed: in this type, the
admission, discharge and referral
policies are under the control of
19. 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,
• Level III: Located in a major tertiary
hospital, which is a referral hospital. It
should provide all aspects of intensive
21. 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.
22. NURSING STAFF
• The major teaching tertiary care ICU will
require trained nurses in critical care.
• It may be ideal to have an in house
training programme for critical Care
• The number of nurses ideally required for
such units is 1:1 ratio.
• In complex situations they may require
two nurses per patient.
• The number of trained nurses should be
also worked out by the type of ICU, the
workload and work statistics and type of
23. 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.
24. • 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.
25. • Participation in continuing education
programs in the field of critical care
• Hospital privileges to perform relevant
• Active involvement as an advisor and
participant in organizing care of the
critically ill patient in the community as a
• Active participation in the education of unit
26. NURSE MANAGER
• An RN (registered nurse) with a BSN (bachelor of
science in nursing) or preferably an MSN (master
of science in nursing) degree
• Certification in critical care or equivalent
• At least 2 yrs experience working in a critical
• Experience with health information systems,
quality improvement/risk management activities,
and healthcare economics
• Ability to ensure that critical care nursing
practice meets appropriate standards .
• Preparation to participate in the on-site education
of critical care unit nursing staff
27. NURSE MANAGER
• Ability to foster a cooperative atmosphere
with regard to the training of nurses,
physicians, pharmacists, respiratory
therapists, and other personnel involved in
the care of critical care unit patients
• Regular participation in ongoing continuing
• Knowledge about current advances in the
field of critical care nursing
• Participation in strategic planning and
28. Critical Care Unit nursing
• 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/didactic critical care
course before assuming full
responsibility for patient care.
• Unit orientation is required before
assuming responsibility for
29. Critical Care Unit nursing
• All critical care nurses must participate in
• 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
30. RESPIRATORY CARE PERSONNEL
• Respiratory care services should be
available 24 hrs a day, 7 days a week.
• An appropriate number of respiratory
therapists with specialized training must
be available to the unit at all times. Ideal
levels of staffing should be based on
acuity, using objective measures
• Therapists must undergo orientation to the
unit before providing care to ICU patients.
31. RESPIRATORY CARE PERSONNEL
• The therapist must have expertise in the
use of mechanical ventilators, including
the various ventilatory modes.
• Proficiency in the transport of critically ill
patients is required.
• Respiratory therapists should participate in
continuing education and quality
improvement related to their unit activities.
32. • Ideally, 24-hr in-house coverage should be
provided by intensivists who are dedicated
to the care of ICU patients and do not
have conflicting responsibilities.
• Ideal intensivist-to-patient ratios vary from
ICU to ICU depending on the hospital’s
unique patient population. Hospitals
should have guidelines for these ratios
based on acuity, complexity, and safety
• The following physician subspecialists
prevents and treat chest
mobilization, and prevent
2. Pharmacists A advise on potential drug
interactions and side
effects, and drug dosing in
patients with liver or renal
3. Dietitians Advise on nutritional
requirements and feeds
36. OTHER PERSONNEL:
A variety of other personnel may contribute
significantly to the efficient operation of the
ICU. These include:-
• Unit clerks
• physical therapists
• occupational therapists
• Advanced practice nurses
• Physician assistants
• Dietary specialists, and
• Biomedical engineers.
37. 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.
38. 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.
39. ORGANIZATION OF ICU
• It requires intelligent planning.
• One must keep the need of the hospital and
• 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,
40. 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
• ICU should be sited in close
proximity to relevant areas viz.
operating rooms, image logy,
acute wards, emergency
41. ORGANIZATIONAL MODELS FOR
• the open model allows many different
members of the medical staff to manage
patients in the ICU.
• the closed model is limited to ICU-certified
physicians managing the care of all patients;
• 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.
42. DEFINITION OF INTENSIVE CARE UNIT
• 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.
• An ICU may be designed and equipped
to provide care to patients with a range
of conditions, or it may be designed
and equipped to provide specialized
care to patients with specific
• Intensive care unit equipment
• patient monitoring
• life support and emergency
• diagnostic devices
54. THERAPEUTIC ELEMENTS IN ICU
•Window and art that provides natural
views; views of nature can reduce stress,
hasten recovery, lower blood pressure and
lower pain medication needs.
•Family participation ,including facilities
for overnight stay and comfortable waiting
55. THERAPEUTIC ELEMENTS IN ICU
• Providng a measure of privacy and personal
control through adjustable curtains and blinds
,accessible bed controls ,and TV ,VCR and CD
• Noise reduction through computerized pagers and
• Medical team continuity that allows one team to
follow the patient through his or her entire stay.
57. ICU TEAM
ICU deign should be approached by
multidisciplinary team consisting of :-
• ICU MEDICAL DIRECTORS
• ICU NURSE MANAGER
• THE CHIEF ARCHITECT
• THE OPERATING ENGINEERING STAFF
59. • THE CHIEF ARCHITECT -He must be
experienced in hospital space
programming and hospital functional
• ENGINEER – He should be experienced
in the design of mechanical and
electrical systems For hopitals,especially
critical care unit.
61. FLOOR PLAN AND DESIGN
IT SHOULD BE BASED ON:-
• Patient admission pattern
• Staff & visitor traffic patterns
• Need for support facilities such a nursing
station ,Storage, clerical space,
• Administrative & educational requirements.
• Services that are unique to the individual
62. FLOOR PLAN AND DESIGN
• Eight to twelve beds per unit is
considered best from a functional
• Each healthcare facility should consider
the need for positive- and negative
pressure isolation rooms within the ICU.
• This need will depend mainly upon
patient population and State Department
of Public Health requirements.
63. FLOOR PLAN AND DESIGN
• Each intensive care unit should be a
geographically distinct area within the
hospital, when possible, with controlled
• No through traffic to other
departments should occur. Supply and
professional traffic should be separated
from public/visitor traffic.
• Location should be chosen so that the
unit is adjacent to, or within direct
elevator travel to and from, the
64. 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
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
65. RECOMMENDED NOISE
Signals from patient call systems,
alarms from monitoring equipment,
and telephones add to the sensory
overload in critical care units.
The International Noise Council has
recommended that noise levels in
hospital acute care areas
• not exceed 45 dB(A) in the
• 40 dB(A) in the evening,
• 20 dB(A) at night.
67. CENTRAL STATION
• A central nursing station should
provide a comfortable area of sufficient
size to accommodate all necessary
• When an ICU is of a modular design,
each nursing substation should be
capable of providing most if not all
functions of a central station.
• There must be adequate overhead and
task lighting, and a wall mounted clock
should be present.
68. CENTRAL STATION
• Adequate surface space and seating for
medical record charting by both physicians
and nurses should be provided.
• Shelving, file cabinets and other storage for
medical record forms must be located so that
they are readily accessible by all personnel
requiring their use.
• Although a secretarial area may be located
separately from the central station, it should
be easily accessible as well
70. X-RAY VIEWING AREA.
A separate room or distinct area near each
ICU or ICU cluster should be designated for
the viewing and storage of patient
An illuminated viewing box or carousel of
appropriate size should be present to allow
for the simultaneous viewing of serial
A "bright light" should also be available.
71. WORK AREAS AND
Work areas and storage for critical
supplies should be located within or
immediately adjacent to each ICU.
There should be a separate medication
area of at least 50 square feet
containing a refrigerator for
pharmaceuticals, a double locking safe
for controlled substances, and a sink
with hot and cold running water.
Countertops must be provided for
medication preparation, and cabinets
74. RECEPTIONIST AREA
• Each ICU or ICU cluster should have a
receptionist area to control visitor
• Ideally, it should be located so that all
visitors must pass by this area before
• The receptionist should be linked with
the ICU(s) by telephone and/or other
• It is desirable to have a visitors'
entrance separate from that used by
75. Special Procedures Room.
• If a special procedures room is desired, it should
be located within, or immediately adjacent to,
• One special procedures room may serve several
ICUs in close proximity.
• Consideration should be given to ease of access
for patients transported from areas outside the
• Room size should be sufficient to accommodate
necessary equipment and personnel.
76. Special Procedures Room.
• Monitoring capabilities, equipment, support
services, and safety considerations must be
consistent with those provided in the ICU
• Work surfaces and storage areas must be
adequate enough to maintain all necessary
supplies and permit the performance of all
desired procedures without the need for
healthcare personnel to leave the room
77. Clean and Dirty Utility Rooms.
• Clean and dirty utility rooms must be
separate rooms that lack interconnection.
• They must be adequately temperature
controlled, and the air supply from the
dirty utility room must be exhausted.
• Floors should be covered with materials
without seams to facilitate cleaning.
• The clean utility room should be used for
the storage of all clean and sterile
supplies, and may also be used for the
storage of clean linen.
78. Clean and Dirty Utility Rooms.
• Shelving and cabinets for storage
must be located high enough off the
floor to allow easy access to the floor
underneath for cleaning.
• The dirty utility room must contain a
clinical sink and a hopper both with
hot and cold mixing faucets.
• Separate covered containers must be
provided for soiled linen and waste
• There should be designated
79. Equipment Storage
• An area must be provided for the storage
and securing of large patient care
equipment items not in active use.
• Space should be adequate enough to
provide easy access, easy location of
desired equipment, and easy retrieval.
• Grounded electrical outlets should be
provided within the storage area in
sufficient numbers to permit recharging of
battery operated items.
80. Nourishment Preparation Area
• A patient nourishment preparation area
should be identified and equipped with food
preparation surfaces, an ice-making
machine, a sink with hot and cold running
water, a countertop stove and/or microwave
oven, and a refrigerator.
• The refrigerator should not be used for
the storage of laboratory specimens.
• A hand washing facility should be located in
or near the area.
81. Staff Lounge.
• A staff lounge must be available on or
near each ICU or ICU cluster to
provide a private, comfortable, and
• Secured locker facilities, showers and
toilets should be present.
• The area should include comfortable
seating and adequate nourishment
storage and preparation facilities,
including a refrigerator, a countertop
stove and/or microwave oven.
• The lounge must be linked to the ICU
82. Conference Room.
• A conference room should be conveniently located for ICU
physician and staff use.
• This room must be linked to each relevant ICU by telephone or
other intercommunication system, and emergency cardiac
arrest alarms should be audible in the room.
• The conference room may have multiple purposes including
continuing education, house staff education, or
multidisciplinary patient care conferences.
• A conference room is ideal for the storage of medical and
nursing reference materials and resources, VCRs, and
computerized interactive and self-paced learning equipment.
• If the conference room is not large enough for educational
activities, a classroom should also be provided nearby.
83. Visitors' Lounge/Waiting Room.
• A visitors' lounge or waiting area
should be provided near each ICU or
• Visitor access should be controlled
from the receptionist area. One and
one-half to two seats per critical care
bed are recommended.
• Public telephones (preferably with
privacy enclosures) and dining
facilities must be available to visitors.
• Television and/or music should be
84. Visitors' Lounge/Waiting Room.
• Warm colours, carpeting, indirect soft
lighting, and windows are desirable .
• A variety of seating, including upright,
lounge, and reclining chairs, is also
• Educational materials and lists of hospital
and community-based support and resource
services should be displayed.
• A separate family consultation room is
85. Patient Transportation Routes
• Patients transported to and from an ICU
should be transported through corridors
separate from those used by the visiting
• Patient privacy should be preserved and
patient transportation should be rapid and
• When elevator transport is required, an
oversized keyed elevator, separate from
public access, should be provided.
86. Supply and Service Corridors
• A perimeter corridor with easy
entrance and exit should be provided
for supplying and servicing each ICU.
• Removal of soiled items and waste
should also be accomplished through
• This helps to minimize any disruption
of patient care activities and minimizes
87. Supply and Service Corridors
• The corridor should be at least 8 feet in
• Doorways, openings, and passages into each
ICU must be a minimum of 36 inches in width
to allow easy and unobstructed movement of
equipment and supplies.
• Floor coverings should be chosen to
withstand heavy use and allow heavy
wheeled equipment to be moved without
88. Patient Modules
• Ward-type icus should allow at least
225 square feet of clear floor area per
• Icus with individual patient modules
should allow at least 250 square feet
per room (assuming one patient per
• Provide a minimum width of 15 feet,
excluding ancillary spaces (anteroom,
89. Patient Modules
• Isolation rooms should each contain at
least 250 square feet of floor space
plus an anteroom.
• Each anteroom should contain at
least 20 square feet to accommodate
hand-washing, gowning, and storage.
• If a toilet is provided, it must be
90. Patient Modules
• A cardiac arrest/emergency alarm button
must be present at every bedside within the
ICU. The alarm should automatically sound in
the hospital telecommunications center,
central nursing station, ICU conference
room, staff lounge, and any on-call rooms.
The origin of these alarms must be
• Space and surfaces for computer terminals
and patient charting should be incorporated
into the design of each patient module as
91. Patient Modules
• Storage must be provided for each
patient's personal belongings, patient
care supplies, linen and toiletries.
Locking drawers and cabinets must be
used if syringes and pharmaceuticals
are stored at the bedside.
• Personal valuables should not be kept
in the ICU. Rather, these should be
held by Hospital Security until patient
• Every effort should be made to
provide an environment that minimizes
92. Patient Modules
• Windows are an important aspect of
sensory orientation, and as many rooms as
possible should have windows to reinforce
day/night orientation .
• Drapes or shades of fireproof fabric can
make attractive window coverings and serve
to absorb sound.
• Window treatments should be durable and
easy to clean, and a schedule for their
cleaning must be established
93. IMPROVING SENSORY ORIENTATION
Additional approaches to improving sensory
orientation for patients may include :-
• the provision of a clock, calendar, bulletin
• pillow speaker connected to radio and
• Televisions must be out of reach of patients
and operated by remote control.
• If possible, telephone service should be
provided in each room.
94. • Comfort considerations should
include methods for establishing
privacy for the patient. Shades,
blinds, curtains, and doors should
control the patient's contact with
• A supply of portable or folding
chairs should be available to allow
for family visits at the bedside. An
additional comfort consideration is
the choice of color scheme for the
room, which should promote rest
95. • To provide for visual interest, one
or more walls within patient view
may be selected for an accent
color, texture, graphic design or
• Advice from environmental
engineers and designers should be
sought to deinstitutionalize patient
care areas as much as possible.
• Each intensive care unit must have :-
• Electrical power,
• Water, oxygen,
• Compressed air,
• Vacuum, lighting,
• And environmental control systems
that support the needs of
the patients and critical care team
under normal and emergency
situations, and these must meet or
exceed regulatory and accreditation
97. ELECTRIC SUPPLY
• Grounded 110 volt electrical outlets
with 30 amp circuit breakers should be
located within a few feet of each
patient's bed .
• Sixteen outlets per bed are desirable.
• Outlets at the head of the bed should
be placed approximately 36 inches
above the floor to facilitate connection,
• To discourage disconnection by
pulling the power cord rather than the
• Outlets at the sides and foot of the bed
98. Water Supply.
• The water supply must be from a certified
source, especially if hemodialysis is to be
• Zone stop valves must be installed on pipes
entering each ICU to allow service to be turned
off should line breaks occur.
• Hand-washing sinks deep and wide enough to
prevent splashing, preferably equipped with
elbow-, knee-, foot-, or sonar-operated faucets,
must be available near the entrances to patient
modules, or between every two patients in ward-
• Total luminance should not exceed 30
• It is preferable to place lighting
controls on variable-control dimmers
located just outside of the room.
• Night lighting should not exceed 6.5 fc
for continuous use or 19 fc for short
• Separate lighting for emergencies and
procedures should be located in the
ceiling directly above the patient and
100. Environmental Control Systems.
• A minimum of six total air changes per
room per hour are required, with two air
changes per hour composed of outside
• For rooms having toilets, the required
toilet exhaust of 75 cubic feet per
minute should be composed of outside
• Central air-conditioning systems and
recirculated air must pass through
101. • Air-conditioning and heating should be
provided with an emphasis on patient
• For critical care units having enclosed
patient modules, the temperature
should be adjustable within each
102. Computerized Charting
• These systems provide for "paperless"
data management, order entry, and
nurse and physician charting. If and
when a decision is made to utilize this
technology, it is important to integrate
such a system fully with all ICU
• Bedside terminals facilitate patient
management by permitting nurses and
physicians to remain at the bedside
during the charting process.
103. OTHER FACILITIES
• Voice Intercommunication Systems
• Satellite Laboratory
• Physician On-Call Rooms
• Administrative Offices