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CONCEPT OF CRITICAL CARE
INTRODUCTION
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.
THE INTENSIVE CARE TEAM.
This team –
• Doctor
• Nurses
• Therapists
• Nutritionists
• Chaplains and other support
staff, builds an environment
for healing or dying.
CRITICAL CARE NURSING
Critical care nursing is that specialty
within nursing that deals specifically
with human responses to life-
threatening problems.
SEVEN Cs OF CRITICAL CARE
• Compassion
• Communication (with patient and family).
• Consideration (to patients, relatives and
colleagues) and avoidance of Conflict.
• Comfort: prevention of suffering
• Carefulness (avoidance of injury)
• Consistency
• Closure (ethics and withdrawal of care).
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 .
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
threatening problem.
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.
THE EVOLUTION OF CRITICAL
CARE
•Forty years of development in
critical care and critical care
nursing has given rise to a
recognized speciality in nursing
practice .
•Critical care units have evolved
over the last four decades in
response to medical advances .
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’
station.
• 1923, John Hopkins University Hospital
developed a special care unit for
neurosurgical patients .
• Modern medicines boomed to its higher
ladder after world war 2
Bennett, D. et al. BMJ 1999;318:1468-1470
Bennett, D. et al. BMJ 1999;318:1468-1470
Bennett, D. et al. BMJ 1999;318:1468-1470
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
poliomyelitis necessitated
thousands of patients requiring
respiratory assist devices and
intensive nursing care.
• At the same time came about
HISTORICAL PRESPECTIVES
• In 1953, Manchester Memorial
Hospital opened a four bedded
unit at Philadelphia was
started.
• By 1957, there were 20 units
in USA and
• In 1958,the number increased
to 150.
CONTEXTUAL FORCES
• The expansion of American
hospital system and hospital
insurance.
• Architectural, hospital changes
towards private and semi private
accommodations.
• Reallocations for direct patient
care responsibility and creations
of new forms of care.
• During 1970’s,the term critical
care unit came into existence
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.
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
STAFFING
• Large hospital requires bigger team.
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.
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
nursing.
• 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
patient load.
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.
• 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.
• 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.
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
graduate education
• At least 2 yrs experience working in a critical
care unit
• 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
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
nursing education
• Knowledge about current advances in the
field of critical care nursing
• Participation in strategic planning and
redesign efforts
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/didactic critical care
course before assuming full
responsibility for patient care.
• Unit orientation is required before
assuming responsibility for
patient care.
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.
RESPIRATORY CARE PERSONNEL
REQUIREMENTS
• 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
whenever possible.
• Therapists must undergo orientation to the
unit before providing care to ICU patients.
RESPIRATORY CARE PERSONNEL
REQUIREMENTS
• 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.
• 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
considerations.
• The following physician subspecialists
PHYSICIAN SUBSPECIALISTS
• General surgeon or trauma surgeon
• Neurosurgeon
• Cardiovascular surgeon
• Obstetric-gynecologic surgeon
• Urologist
• Thoracic surgeon
• Vascular surgeon
• Anesthesiologist
• Cardiologist with interventional capabilities
PHYSICIAN SUBSPECIALISTS
• Gastroenterologist
• Hematologist
• Infectious disease specialist
• Nephrologist
• Neuroradiologist (with interventional
capability)
• Pathologist
• Radiologist (with interventional capability)
• Neurologist
S.NO
.
THERAPIST FUNCTION
1. Physiotherap
ists
prevents and treat chest
problems, assist
mobilization, and prevent
contractures in
immobilized patients
2. Pharmacists A advise on potential drug
interactions and side
effects, and drug dosing in
patients with liver or renal
dysfunction
3. Dietitians Advise on nutritional
requirements and feeds
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.
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.
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.
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.
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
ORGANIZATIONAL MODELS FOR
ICUs:
• 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;
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.
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.
PURPOSE
• 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
conditions
DESCRIPTION
• Intensive care unit equipment
includes:-
• patient monitoring
• life support and emergency
resuscitation devices
• diagnostic devices
PATIENT MONITORING
EQUIPMENTS
• Acute care physiologic monitoring
system
• Pulse oximeter
• Intracranial pressure monitor
• Apnea monitor
Bennett, D. et al. BMJ 1999;318:1468-1470
LIFE SUPPORT & RESUSCITATIVE
EQUIPMENTS
• VENTILATOR
• INFUSION PUMP
• CRASH CART
• INTRAAORTIC BALOON PUMP
Bennett, D. et al. BMJ 1999;318:1468-1470
DIAGNOSTIC EQUIPMENTS
• MOBILE X-RAYS
• PORTABLE CLINICAL LAB. DEVICES
• BLOOD ANALYZER
THERAPEUTIC ELEMENTS IN ICU
ENVIORNMENT
•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
rooms.
THERAPEUTIC ELEMENTS IN ICU
ENVIORNMENT
• Providng a measure of privacy and personal
control through adjustable curtains and blinds
,accessible bed controls ,and TV ,VCR and CD
players.
• Noise reduction through computerized pagers and
silent alarms.
• Medical team continuity that allows one team to
follow the patient through his or her entire stay.
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
OTHER ADDITIONAL
MEMBERS
• ENVIORNMENTAL ENGINEER
• INTERIOR DESIGNERS
• STAFF NURSES
• PHYSICIANS
• PATIENTS
• FAMILIES
• THE CHIEF ARCHITECT -He must be
experienced in hospital space
programming and hospital functional
planning.
• ENGINEER – He should be experienced
in the design of mechanical and
electrical systems For hopitals,especially
critical care unit.
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
institution.
FLOOR PLAN AND DESIGN
• Eight to twelve beds per unit is
considered best from a functional
perspective .
• 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.
FLOOR PLAN AND DESIGN
• Each intensive care unit should be a
geographically distinct area within the
hospital, when possible, with controlled
access.
• 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
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.
RECOMMENDED NOISE
RANGES
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
daytime,
• 40 dB(A) in the evening,
• 20 dB(A) at night.
CENTRAL STATION
• A central nursing station should
provide a comfortable area of sufficient
size to accommodate all necessary
staff functions.
• 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.
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
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
radiographs.
An illuminated viewing box or carousel of
appropriate size should be present to allow
for the simultaneous viewing of serial
radiographs.
 A "bright light" should also be available.
WORK AREAS AND
STORAGE
 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
RECEPTION AREA
RECEPTIONIST AREA
• Each ICU or ICU cluster should have a
receptionist area to control visitor
access.
• Ideally, it should be located so that all
visitors must pass by this area before
entering.
• The receptionist should be linked with
the ICU(s) by telephone and/or other
intercommunication system.
• It is desirable to have a visitors'
entrance separate from that used by
healthcare professionals.
Special Procedures Room.
• If a special procedures room is desired, it should
be located within, or immediately adjacent to,
the ICU.
• 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
ICU.
• Room size should be sufficient to accommodate
necessary equipment and personnel.
Special Procedures Room.
• Monitoring capabilities, equipment, support
services, and safety considerations must be
consistent with those provided in the ICU
proper.
• 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
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.
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
materials.
• There should be designated
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.
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.
Staff Lounge.
• A staff lounge must be available on or
near each ICU or ICU cluster to
provide a private, comfortable, and
relaxing environment.
• 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
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.
Visitors' Lounge/Waiting Room.
• A visitors' lounge or waiting area
should be provided near each ICU or
ICU cluster.
• 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
provided.
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
desirable.
• Educational materials and lists of hospital
and community-based support and resource
services should be displayed.
• A separate family consultation room is
strongly recommended.
Patient Transportation Routes
• Patients transported to and from an ICU
should be transported through corridors
separate from those used by the visiting
public.
• Patient privacy should be preserved and
patient transportation should be rapid and
unobstructed.
• When elevator transport is required, an
oversized keyed elevator, separate from
public access, should be provided.
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 corridor.
• This helps to minimize any disruption
of patient care activities and minimizes
unnecessary noise.
Supply and Service Corridors
• The corridor should be at least 8 feet in
width.
• 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
difficulty .
Patient Modules
• Ward-type icus should allow at least
225 square feet of clear floor area per
bed.
• Icus with individual patient modules
should allow at least 250 square feet
per room (assuming one patient per
room),
• Provide a minimum width of 15 feet,
excluding ancillary spaces (anteroom,
toilet, storage).
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
private.
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
discernable.
• Space and surfaces for computer terminals
and patient charting should be incorporated
into the design of each patient module as
indicated.
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
discharge.
• Every effort should be made to
provide an environment that minimizes
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
IMPROVING SENSORY ORIENTATION
Additional approaches to improving sensory
orientation for patients may include :-
• the provision of a clock, calendar, bulletin
board,
• pillow speaker connected to radio and
television.
• Televisions must be out of reach of patients
and operated by remote control.
• If possible, telephone service should be
provided in each room.
• Comfort considerations should
include methods for establishing
privacy for the patient. Shades,
blinds, curtains, and doors should
control the patient's contact with
his/her surroundings.
• 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
• To provide for visual interest, one
or more walls within patient view
may be selected for an accent
color, texture, graphic design or
picture .
• Advice from environmental
engineers and designers should be
sought to deinstitutionalize patient
care areas as much as possible.
Utilities
• 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
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
plug.
• Outlets at the sides and foot of the bed
Water Supply.
• The water supply must be from a certified
source, especially if hemodialysis is to be
performed.
• 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-
type units.
Lightning
• Total luminance should not exceed 30
foot-candles .
• 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
periods.
• Separate lighting for emergencies and
procedures should be located in the
ceiling directly above the patient and
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
air.
• For rooms having toilets, the required
toilet exhaust of 75 cubic feet per
minute should be composed of outside
air.
• Central air-conditioning systems and
recirculated air must pass through
appropriate filters.
• Air-conditioning and heating should be
provided with an emphasis on patient
comfort.
• For critical care units having enclosed
patient modules, the temperature
should be adjustable within each
module.
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
activities.
• Bedside terminals facilitate patient
management by permitting nurses and
physicians to remain at the bedside
during the charting process.
OTHER FACILITIES
• Voice Intercommunication Systems
• Satellite Laboratory
• Physician On-Call Rooms
• Administrative Offices
233663644-Concept-of-Critical-Care.ppt
233663644-Concept-of-Critical-Care.ppt

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233663644-Concept-of-Critical-Care.ppt

  • 2. INTRODUCTION 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 – • Doctor • Nurses • Therapists • Nutritionists • 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- threatening problems.
  • 5. SEVEN Cs OF CRITICAL CARE • Compassion • Communication (with patient and family). • Consideration (to patients, relatives and colleagues) and avoidance of Conflict. • Comfort: prevention of suffering • Carefulness (avoidance of injury) • Consistency • 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 threatening problem.
  • 8. 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.
  • 9. THE EVOLUTION OF CRITICAL CARE •Forty years of development in critical care and critical care nursing has given rise to a recognized speciality in nursing practice . •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’ station. • 1923, John Hopkins University Hospital developed a special care unit for neurosurgical patients . • Modern medicines boomed to its higher ladder after world war 2
  • 11.
  • 12. Bennett, D. et al. BMJ 1999;318:1468-1470
  • 13. Bennett, D. et al. BMJ 1999;318:1468-1470
  • 14. Bennett, D. et al. BMJ 1999;318:1468-1470
  • 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 poliomyelitis necessitated 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 started. • By 1957, there were 20 units in USA and • In 1958,the number increased to 150.
  • 17. CONTEXTUAL FORCES • The expansion of American hospital system and hospital insurance. • Architectural, hospital changes towards private and semi private accommodations. • 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 discharge and • A closed: in this type, the admission, discharge and referral policies are under the control of intensivists.
  • 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, etc. • Level III: Located in a major tertiary hospital, which is a referral hospital. It should provide all aspects of intensive
  • 20. STAFFING • Large hospital requires bigger team.
  • 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 nursing. • 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 patient load.
  • 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 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.
  • 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 graduate education • At least 2 yrs experience working in a critical care unit • 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 nursing education • Knowledge about current advances in the field of critical care nursing • Participation in strategic planning and redesign efforts
  • 28. 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/didactic critical care course before assuming full responsibility for patient care. • Unit orientation is required before assuming responsibility for patient care.
  • 29. 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.
  • 30. RESPIRATORY CARE PERSONNEL REQUIREMENTS • 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 whenever possible. • Therapists must undergo orientation to the unit before providing care to ICU patients.
  • 31. RESPIRATORY CARE PERSONNEL REQUIREMENTS • 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 considerations. • The following physician subspecialists
  • 33. PHYSICIAN SUBSPECIALISTS • General surgeon or trauma surgeon • Neurosurgeon • Cardiovascular surgeon • Obstetric-gynecologic surgeon • Urologist • Thoracic surgeon • Vascular surgeon • Anesthesiologist • Cardiologist with interventional capabilities
  • 34. PHYSICIAN SUBSPECIALISTS • Gastroenterologist • Hematologist • Infectious disease specialist • Nephrologist • Neuroradiologist (with interventional capability) • Pathologist • Radiologist (with interventional capability) • Neurologist
  • 35. S.NO . THERAPIST FUNCTION 1. Physiotherap ists prevents and treat chest problems, assist mobilization, and prevent contractures in immobilized patients 2. Pharmacists A advise on potential drug interactions and side effects, and drug dosing in patients with liver or renal dysfunction 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 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.
  • 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 are unmanageable. • ICU should be sited in close proximity to relevant areas viz. operating rooms, image logy, acute wards, emergency
  • 41. ORGANIZATIONAL MODELS FOR ICUs: • 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; 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.
  • 42. 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.
  • 43. PURPOSE • 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 conditions
  • 44. DESCRIPTION • Intensive care unit equipment includes:- • patient monitoring • life support and emergency resuscitation devices • diagnostic devices
  • 45. PATIENT MONITORING EQUIPMENTS • Acute care physiologic monitoring system • Pulse oximeter • Intracranial pressure monitor • Apnea monitor
  • 46. Bennett, D. et al. BMJ 1999;318:1468-1470
  • 47. LIFE SUPPORT & RESUSCITATIVE EQUIPMENTS • VENTILATOR • INFUSION PUMP • CRASH CART • INTRAAORTIC BALOON PUMP
  • 48. Bennett, D. et al. BMJ 1999;318:1468-1470
  • 49. DIAGNOSTIC EQUIPMENTS • MOBILE X-RAYS • PORTABLE CLINICAL LAB. DEVICES • BLOOD ANALYZER
  • 50.
  • 51.
  • 52.
  • 53.
  • 54. THERAPEUTIC ELEMENTS IN ICU ENVIORNMENT •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 rooms.
  • 55. THERAPEUTIC ELEMENTS IN ICU ENVIORNMENT • Providng a measure of privacy and personal control through adjustable curtains and blinds ,accessible bed controls ,and TV ,VCR and CD players. • Noise reduction through computerized pagers and silent alarms. • Medical team continuity that allows one team to follow the patient through his or her entire stay.
  • 56.
  • 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
  • 58. OTHER ADDITIONAL MEMBERS • ENVIORNMENTAL ENGINEER • INTERIOR DESIGNERS • STAFF NURSES • PHYSICIANS • PATIENTS • FAMILIES
  • 59. • THE CHIEF ARCHITECT -He must be experienced in hospital space programming and hospital functional planning. • ENGINEER – He should be experienced in the design of mechanical and electrical systems For hopitals,especially critical care unit.
  • 60.
  • 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 institution.
  • 62. FLOOR PLAN AND DESIGN • Eight to twelve beds per unit is considered best from a functional perspective . • 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 access. • 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 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.
  • 65. RECOMMENDED NOISE RANGES 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 daytime, • 40 dB(A) in the evening, • 20 dB(A) at night.
  • 66.
  • 67. CENTRAL STATION • A central nursing station should provide a comfortable area of sufficient size to accommodate all necessary staff functions. • 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
  • 69.
  • 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 radiographs. An illuminated viewing box or carousel of appropriate size should be present to allow for the simultaneous viewing of serial radiographs.  A "bright light" should also be available.
  • 71. WORK AREAS AND STORAGE  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
  • 72.
  • 74. RECEPTIONIST AREA • Each ICU or ICU cluster should have a receptionist area to control visitor access. • Ideally, it should be located so that all visitors must pass by this area before entering. • The receptionist should be linked with the ICU(s) by telephone and/or other intercommunication system. • It is desirable to have a visitors' entrance separate from that used by healthcare professionals.
  • 75. Special Procedures Room. • If a special procedures room is desired, it should be located within, or immediately adjacent to, the ICU. • 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 ICU. • 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 proper. • 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 materials. • 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 relaxing environment. • 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 ICU cluster. • 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 provided.
  • 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 desirable. • Educational materials and lists of hospital and community-based support and resource services should be displayed. • A separate family consultation room is strongly recommended.
  • 85. Patient Transportation Routes • Patients transported to and from an ICU should be transported through corridors separate from those used by the visiting public. • Patient privacy should be preserved and patient transportation should be rapid and unobstructed. • 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 corridor. • This helps to minimize any disruption of patient care activities and minimizes unnecessary noise.
  • 87. Supply and Service Corridors • The corridor should be at least 8 feet in width. • 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 difficulty .
  • 88. Patient Modules • Ward-type icus should allow at least 225 square feet of clear floor area per bed. • Icus with individual patient modules should allow at least 250 square feet per room (assuming one patient per room), • Provide a minimum width of 15 feet, excluding ancillary spaces (anteroom, toilet, storage).
  • 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 private.
  • 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 discernable. • Space and surfaces for computer terminals and patient charting should be incorporated into the design of each patient module as indicated.
  • 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 discharge. • 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 board, • pillow speaker connected to radio and television. • 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 his/her surroundings. • 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 picture . • Advice from environmental engineers and designers should be sought to deinstitutionalize patient care areas as much as possible.
  • 96. Utilities • 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 plug. • 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 performed. • 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- type units.
  • 99. Lightning • Total luminance should not exceed 30 foot-candles . • 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 periods. • 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 air. • For rooms having toilets, the required toilet exhaust of 75 cubic feet per minute should be composed of outside air. • Central air-conditioning systems and recirculated air must pass through appropriate filters.
  • 101. • Air-conditioning and heating should be provided with an emphasis on patient comfort. • For critical care units having enclosed patient modules, the temperature should be adjustable within each module.
  • 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 activities. • 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