The intensive care unit (ICU) is a distinct organisational and geographic entity for clinical activity and care, operating in cooperation with other departments integrated in a hospital. The ICU is used to monitor and support threatened or failing vital functions in critically ill patients, who have illnesses with the potential to endanger life, so that adequate diagnostic measures and medical or surgical therapies can be performed to improve outcome.1 Hence intensive care patients may be:
1. Patients requiring monitoring and treatment because one or more vital functions are threatened by an acute (or an acute-on-chronic) disease (e.g. sepsis, myocardial infarction, gastrointestinal haemorrhage), or by the sequelae of surgical or other intensive treatment (e.g. percutaneous interventions) with the potential for developing life-threatening conditions
2. Patients already having failure of one or more vital functions such as cardiovascular, respiratory, renal, metabolic, or cerebral function but with a reasonable chance of a meaningful functional recovery. In principle, patients in known end-stages of untreatable terminal diseases are not admitted.
ICUs developed from the postoperative recovery rooms and respiratory units of the mid twentieth century when it became clear that concentrating the sickest patients in one area was beneficial. Intermittent positive-pressure ventilation (IPPV) was pioneered in the treatment of respiratory failure in the 1948–9 poliomyelitis epidemics, and particularly in the 1952 Copenhagen poliomyelitis epidemic when IPPV was delivered using an endotracheal tube and a manual bag, before the development of manual ventilators.
As outlined below, the ICU is a department with dedicated medical, nursing and allied health staff that operates with defined policies and procedures and has its own quality improvement, continuing education and research programmes. Through its care of critically ill patients in the ICU and its outreach activities (see Ch. 2), the intensive care department provides an integrated service to the hospital, without which many programmes (e.g. cardiac surgery, trauma and transplantation) could not function.
The delineation of roles of hospitals in a region or area is necessary to rationalise services and optimise resources. Each ICU should similarly have its role in the region defined, and should support the defined duties of its hospital. In general, small hospitals require ICUs that provide basic intensive care services. Critically ill patients who need complex management and sophisticated investigative back-up should be managed in an ICU located in a large tertiary referral hospital. Three levels of adult ICUs are classified as follows by the College of Intensive Care Medicine (Australia and New Zealand).2 The European Society of Intensive Care Medicine has a similar classification. The American College of Critical Care Medicine also has a similar classification but uses a reversed-numbering system.3 It should be noted that full-time directors and directors with qualifications in intensive care medicine are less common in the USA,4 as are the requirements for a dedicated doctor for the ICU around the clock, and referral to the attending ICU specialist for management.5 Nurse staffing should be in line with accepted standards that are outlined in Chapter 6, Critical Care Nursing.
1. Level I ICU: a Level I ICU has a role in small district hospitals. It should be able to provide resuscitation and short-term cardiorespiratory support of critically ill patients. It will have a major role in monitoring and preventing complications in ‘at-risk’ medical and surgical patients. It must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring for a period of several hours. A Level I ICU should have an established relationship with a Level II or a Level III unit that should include mutual transfer and back transfer policies and an established joint review process. The medical director should be a certified intensive care specialist.
2. Level II ICU: a Level II ICU is located in larger general hospitals. It should be capable of providing a high standard of general intensive care, including multisystem life support, in accordance with the role of its hospital (e.g. regional centre for acute medicine, general surgery, trauma). It should have a medical officer on site and access to pharmacy, pathology and radiology facilities at all times, but it may not have all forms of complex therapy and investigations (e.g. interventional radiology, cardiac surgical service). The medical director and at least one other specialist should be certified intensive care specialists. Patients admitted must be referred to the attending intensive care specialists for management. Referral and transport policies should be in place with a Level III unit to enable escalation of care.
3. Level III ICU: a Level III ICU is located in a major tertiary referral hospital. It should provide all aspects of intensive care management required by its referral role for indefinite periods. These units should have a demonstrated commitment to education and research. Large ICUs should be divided into smaller ‘pods’ of 8–15 patients for the purpose of clinical management. The unit should be staffed by intensive care specialists with trainees, critical care nurses, allied health professionals and clerical and scientific staff. Complex investigations and imaging and support by specialists of all disciplines required by the referral role of the hospital must be available at all times. All patients admitted to the unit must be referred to the attending intensive care specialist for management.
The classification of types of ICU must not be confused with the description of intensive care beds within a hospital, as with the UK classification of intensive care beds.
An institution may organise its intensive care beds into multiple units under separate management by single-discipline specialists (e.g. medical ICU, surgical ICU, burns ICU). Although this may be functional in some hospitals, the experience in Australia and New Zealand has favoured the development of general multidisciplinary ICUs. Thus, with the exception of dialysis units, coronary care units and neonatal ICUs, critically ill patients are admitted to the hospital's multidisciplinary ICU and are managed by intensive care specialists (or paediatric intensive care specialists in paediatric hospitals).
There are good economic and operational arguments for a multidisciplinary ICU as against separate, single-discipline ICUs. Duplication of equipment and services is avoided. Critically ill patients develop the same pathophysiological processes no matter whether they are classified as medical or surgical and they require the same approaches to support of vital organs.
The ICU may constitute up to 10% of total hospital beds. The number of beds required depends on the role and type of ICU. Multidisciplinary ICUs require more beds than single-specialty ICUs, especially if high-dependency beds are integrated into the unit. ICUs with fewer than four beds are considered not to be cost-effective and are too small to provide adequate clinical experience for skills maintenance for medical and nursing staff. On the other hand, the emerging trend of very large ICUs6 can create major management problems. There is a suggestion that efficiency deteriorates once the number of critically ill patients per medical team exceeds 12.7 Consequently as detailed above these unit should be divided into ‘pods’. Cohorting of patients in these subunits may be based on specific processes of care or the underlying clinical problem.
An HDU is a specially staffed and equipped area of a hospital that provides a level of care intermediate between intensive care and the general ward care. Although HDUs may be located in or near specialty wards, increasingly they are located within or immediately adjacent to an ICU complex and are often staffed by the ICU.
The HDU provides invasive monitoring and support for patients with or at risk of developing acute (or acute-on-chronic) single-organ failure, particularly where the predicted risk of clinical deterioration is high or unknown. It may act as a ‘step-up’ or ‘step-down’ unit between the level of care delivered on a general ward and that in an ICU. Equipment should be available to manage short-term emergencies (e.g. need for mechanical ventilation). Earlier studies have shown conflicting results about benefits to outcome associated with the introduction of HDUs,8 whereas a more recent survey where HDU care was based on a ‘single-organ failure and support model’ has shown that HDUs play a crucial role in management.10
The goal of design is to create a healing environment – a design that produces a measurable improvement in the physical or psychological states of patients, staff and visitors. Optimal ICU design helps to reduce medical errors, improve patient outcomes, reduce length of stay, increase social support for patients and can play a role in reducing costs.11
The layout of the ICU should allow rapid access to relevant acute areas including operating theatres and postoperative areas, the emergency department, functional testing departments (e.g. cardiac catheterisation laboratory, endoscopy) and the medical imaging department. Lines of communication must be available around the clock. Safe transport of critically ill patients to and from the ICU should be facilitated by centrally located, keyed, oversized lifts and doors, and corridors should allow easy passage of beds and equipment. There should be a single entry and exit point, attended by the unit receptionist. Through traffic of goods or people to other hospital areas must never be allowed. An ICU should have areas and rooms for public reception, patient management and support services. The total area of the unit should be 2.5–3 times the area devoted to patient care.
An ideal patient room should incorporate three zones: a patient zone, a family zone and a caregiver zone.11 Each patient bed area in an adult ICU requires a minimum floor space of 20 m2 with single rooms being larger (at least 25 m2), to accommodate patient, staff and equipment. There should be at least 2.5 m traffic area beyond the bed area. Single rooms should have an optimal clearance of not less than 1.2 m at the head and the foot of the bed, and not less than 1.8 m on each side. The ratio of single-room beds to open-ward beds will depend on the role and type of the ICU. Single rooms are essential for isolation; with the emergence of resistant bacterial strains in ICUs around the world, single rooms are recommended. They have been shown to decrease acquisition of resistant bacteria and antibiotic use.12 Isolation rooms should be equipped with an anteroom of at least 3 m2 for hand washing, gowning and storage of isolation material. Some isolation rooms should be negative-pressure ventilated for contagious respiratory infections. A non-splash hand wash basin with elbow- or foot-operated taps and a hand disinfection facility should be available for each bed.
Bedside service outlets should conform to local standards and requirements (including electrical safety and emergency supply, such as to the Australian Standard, Cardiac Protected Status AS3003).
Utilities per bed space as recommended for a Level III ICU are:
Adequate and appropriate lighting for clinical observation must be available. Patients should be able to be seen at all the times to allow detection of changes in status. All patient rooms should have access to natural light. Patients exposed to sunlight have been shown to experience less stress, require fewer analgesics and have improved sleep quality and quantity.13 Lack of natural light or outside view increases the incidence of disorientation in patients and stress levels in staff.14,15
Efforts should be made to reduce sound transmission and therefore noise levels (e.g. walls and ceilings should be constructed of materials with high sound-absorbing capability). Suitable and safe air quality should be maintained at all times. Air conditioning and heating should be provided with an emphasis on patient comfort. A clock and a calendar at each bed space are useful for patient orientation. It is widely held that transporting long-stay ICU patients outdoors is good for their morale, and access to an outside area should be considered in the design process.
The medical utility distribution systems configuration (e.g. floor column, wall mounted, or ceiling pendant) depends on individual preference. There should be room to place or attach additional portable monitoring equipment and, as far as possible, equipment should be kept off the floor. Space for charts, syringes, sampling tubes, pillows, suction catheters and patient personal belongings should be available, often in one or more moveable bedside trolleys.
Since critical care nursing is primarily at the bedside, staffing of a central nurse station is less important and emphasis should be on ‘decentralised’ stations just inside the room or outside the room – often paired to permit observation of two adjacent rooms. Nevertheless, the central station and other work areas should have adequate space for staff to allow centralised clinical management, staff interaction, mentoring and socialisation. This central station usually houses a central monitor, satellite pharmacy and drug preparation area, satellite storage of sterile and non-sterile items, telephones, computers with internet connections, patient records, reference books and policy and procedure manuals. A dedicated computer for the picture archive and communication system (PACS) or a multidisplay X-ray viewer should be located within the patient care area.
Storage areas should take up a total floor space of at least 10 m2 per bed.11 They should have separate access remote from the patient area for deliveries, and be no farther than 30 m from the patient area. Frequently used items (e.g. intravenous fluids and giving sets, sheets and dressing trays) should be located closer to patients than infrequently used or non-patient items. There should be an area for storing emergency and transport equipment within the patient area with easy access to all beds.
Two separate spaces for clean (15 m2) and dirty (25 m2) utility rooms with separate access are necessary. Facilities for estimating blood gases, glucose, electrolytes, haemoglobin, lactate and sometimes clotting status are usually sufficient for the unit's laboratory. There should be a pneumatic tube or equivalent system to transfer specimens to pathology. Adequate arrangements for offices (receptionist, medical and nursing), doctor-on-call rooms (15 m2), staff lounge (with food/drinks facilities) (40 m2 per eight beds), wash rooms and seminar room (40 m2) should be available and an interview room should be taken into consideration.
The type and quantity of equipment will vary with the type, size and function of the ICU and must be appropriate to the workload of the unit. There must be a regular programme in place for checking its safety. Protocols and in-service training for medical and nursing staff must be available for the use of all equipment, including steps to be taken in the event of malfunction. There should also be a system in place for regular maintenance and service. The intensive care budget should include provision to replace old or obsolete equipment at appropriate times. A system of stock control should be in place to ensure consumables are always in adequate supply. The ICU director should have a major role in the purchase of new equipment to ensure it is appropriate for the activities of the unit. Level II and III ICUs should have an equipment officer to coordinate these activities.
For relatives, there should be a separate area of at least 10 m2 per eight beds (two chairs per bed), and an additional facility with bed and shower as sleep or rest cubicles can be considered. There should be facilities for tea/coffee making and a water dispenser, and toilets should be located close by. Television and/or music should be provided. It is desirable to have separate entrances to the ICU for visitors and health care professionals. One or more separate areas for distressed relatives should be available.
The level of staffing depends on the type of hospital, and tertiary hospital ICUs require large teams. Whatever the size of the team, it is crucial that there is clear and proper communication and collaboration among team members and a true multidisciplinary approach. Knaus et al in a classic study16 first showed the importance of the relationship between the degree of coordination in an ICU and the effectiveness of its care. Other studies have shown relationships between collaboration and teamwork and better outcomes for patients and staff.17,18 Inadequate communication is the most frequent root cause of sentinel events.19
An intensive care department should have a medical director who is qualified in intensive care medicine and who coordinates the clinical, administrative and educational activities of the department. The duties of the director should involve patient care, supervision of trainees/other junior doctors, the drafting of diagnostic and therapeutic protocols, responsibility for the quality, safety and appropriateness of care provided and education, training and research. It is recommended that the director be full time in the department.
The director should be supported by a group of other specialists trained in intensive care medicine who provide patient care and contribute to non-clinical activities. In an ICU of Level II or III there must be at least one specialist exclusively rostered to the unit at all times. Specialists should have a significant or full-time commitment to the ICU ahead of clinical commitments elsewhere. There should be sufficient numbers to allow reasonable working hours, protected non-clinical time and leave of all types. Participation in ICU outreach activities (rapid response calls, outpatient review; see Ch. 2) has increased the workload of intensive care specialists as well as junior staff in many hospitals, resulting in the need to increase the size of the medical team.
There should also be at least one junior doctor with an appropriate level of experience rostered exclusively to Level II and III units at all times. Junior medical staff in the ICU may be intensive care trainees, but should ideally also include trainees of other acute disciplines (e.g. anaesthesia, medicine, surgery and emergency medicine). It is imperative that junior doctors are adequately supervised, with specialists being readily available at all times.
Medical work patterns are important for quality of treatment and should be supervised by the director. These patterns include rosters, structure of handover and daily rounds. Appropriate rostering influences satisfaction and avoids burnout syndrome in staff. It reduces tiredness after night shifts or long shifts and consequently improves attention and reduces errors. It also improves the quality of information transfer during handovers and daily rounds.21
This physician-staffing model has been used in Australia and New Zealand for many years, but has not been common in the USA. A systematic review22 has shown that when there has been mandatory intensive care specialist consultation (or closed ICU), compared with no or elective intensive care specialist consultation or open ICU, both ICU and hospital survival were improved and there was a reduced length of stay in ICU and in hospital.
Critical care nursing is covered in Chapter 6. The bedside nurse conducts the majority of patient assessment, evaluation and care in an ICU. When leave of all kinds is factored in, long-term 24-hour cover of a single bed requires a staff complement of six nurses. Nurse shortages have been shown to be associated with increased patient mortality and nurse burnout, and adversely affect outcome and job satisfaction in the ICU.23,24
There should be a nurse manager who is appointed with authority and responsibility for the appropriateness of nursing care and who has extensive experience in intensive care nursing as well as managerial experience. In tertiary units the nurse manager should participate in teaching, continuing education and research. Ideally, all nurses working in an ICU should have training and certification in critical care nursing.
Access to physiotherapists, dietitians, social workers and other therapists should also be available. A dedicated ward clinical pharmacist is invaluable and participation of a pharmacist on ward rounds has been associated with a reduction in adverse drug events.25 Respiratory therapists are allied health personnel trained in and responsible for the equipment and clinical aspects of respiratory therapy, a concept well established in North America, but not the UK, continental Europe and Australasia. Technical support staff, either members of the ICU staff or seconded from biomedical departments, is necessary to service, repair and develop equipment.
Provision should be made for adequate secretarial support.15 Transport and ‘lifting’ orderly teams will reduce physical stress and possible injuries to nurses and doctors. If no mechanical system is available to transport specimens to the laboratories (e.g. air-pressurised chutes), sufficient and reliable couriers must be provided to do this day and night. The cleaning personnel should be familiar with the ICU environment and infection control protocols. There should also be a point of contact for local interpreters, chaplains, priests or officials of all religions when there is need for their services.
Clear-cut administrative policies are vital to the functioning of an ICU. An open ICU has unrestricted access to multiple doctors who are allowed to admit and manage their patients. A closed ICU has admission, discharge and referral policies under the control of intensive care specialists. Improved cost benefits are likely with a closed ICU and patient outcomes are better, especially if the intensive care specialists have full clinical responsibilities.22,26 Consequently ICUs should be closed under the charge of a medical specialist director. All patients admitted to the ICU are referred to the director and his/her specialist staff for management, although it is important for the ICU team to communicate regularly with the parent unit and to make referrals to other specialty units when appropriate.
There must be clearly defined policies for admission, discharge, management and referral of patients. Lines of responsibilities must be delineated for all staff members and their job descriptions defined. The director must have final overall authority for all staff and their actions, although in other respects each group may be responsible to respective hospital heads (e.g. the Director of Nursing).
Policies for the care of patients should be formulated and standardised. They should be unambiguous, periodically reviewed and familiarised by all staff. Examples include infection control and isolation policies, policies for intra- and inter-facility transport, end-of-life policies (e.g. do not resuscitate (DNR) procedure) and sedation and restraint protocols. A rigorous fire safety and evacuation plan should be in place. It should be noted, however, that when protocols involve complex issues (such as weaning from mechanical ventilation) they might be less efficient than the judgement of experienced clinicians.27 Clinical management protocols (e.g. for feeding and bowel care) can be laminated and placed in a folder at each bed or loaded on to the intranet.
ICU patient management should be multidisciplinary, with medical, nursing and other staff working together to provide the best care for each patient. The critical care nurse is the primary carer at the bedside and monitors, manages and supports the critically ill patient (see Ch. 6). The medical team consists of one or more registrars, residents or fellows who direct medical care with an intensive care specialist. The patient should be assessed by a formal ward round of the multidisciplinary team twice daily, usually at a time when the junior medical staff members are handing over. The nurse coordinating the floor, pharmacists and dietitians should also take part in daily rounds. Each patient should be assessed clinically (examination, observations and pathology, radiological and other investigation results), the medication chart reviewed, progress determined and a management plan developed for the immediate and longer term. The ward round is also an opportunity to assess compliance with checklists such as Fast Hug (Feeding Analgesia Sedation Thromboembolic prophylaxis Head of bed elevation stress Ulcer prophylaxis Glyceamic control).28 Clearly, unstable patients will require much more frequent assessment and intervention.
It is crucial that all observations, examination findings, investigations, medical orders, management plans (including treatment limitations) and important communications with other medical teams and patients' families are clearly documented in the appropriate chart or part of the medical record either electronically or in writing.
Wherever possible clinical management should be evidence based and derived through consensus of the members of the ICU team, accepting, however, that evidence-based medicine has limitations when applied to intensive care medicine.29
Well-structured collaboration among physicians, nurses and the other professionals is essential for best possible patient care, which includes presence of inter-professional clinical rounds, standardised and structured processes of handover of inter-disciplinary and inter-professional information and use of clinical information systems.1
ICU care includes sensitive handling of relatives. It is important that there are early and repeated discussions with patients' families to reduce family stress and improve consistency in communication. Ideally one senior doctor should be identified as the ICU representative to liaise with a particular family. Discussions should be interactive and honest and an attempt made to predict the likely course, especially with respect to outcome, potential complications and the duration of intensive care management required. The time, date and discussion of each interview should be recorded. Cultural factors should be acknowledged and spiritual support available, especially before, during and after a death. Open visiting hours allow families maximum contact with their loved one and promote an atmosphere of openness and transparency.
Non-clinical activities are very important in the ICU, as they enhance the safety, quality and currency of patient care. The College of Intensive Care Medicine recommends that full-time intensive care specialists should have as protected non-clinical time three sessions per fortnight.20 Nursing and allied health staff should also seek protected time for these activities.
It is essential that staff members promote a culture of quality improvement (QI) within the ICU, whatever its size and role. Every ICU should maintain a database that is sufficiently well structured to allow easy extraction of benchmarking, quality control and research data. All ICUs should have demonstrable and documented formal audit and review of its processes and outcomes in a regular multidisciplinary forum. Staff members who collect and process the data should have dedicated QI time.
There are three types of quality indicators:
1. Structure: structural indicators assess whether the ICU functions according to its operational guidelines and conforms to the policies of training and specialist bodies (e.g. clinical work load and case mix, staffing establishment and levels of supervision).
2. Clinical processes: clinical process indicators assess the way care is delivered. Examples include whether deep-vein thrombosis prophylaxis is given, time to administration of antibiotics and glycaemic control.
3. Outcomes: examples of outcome measures include survival rate, quality of life of survivors and patient satisfaction.
The QI process involves identification of the indicator to be improved (e.g. high ventilator-associated pneumonia (VAP) rate), development of a method to improve it (e.g. checklist such as Fast Hug28), implementation of the method to improve it (e.g. requirement to tick off the checklist on the morning ward round), and re-evaluation of the indicator (e.g. VAP rate) to ensure the intervention has improved the outcome and finally to ensure sustainability (e.g. print checklist on ICU chart).
Activities that assess processes include clinical audit, compliance with protocols, guidelines and checklists and critical incident reporting. Activities that assess outcomes are calculating risk-adjusted mortality using a scoring system such as the Acute Physiology and Chronic Health Evaluation III (APACHE III) and calculation of standardised mortality ratios (see Ch. 3), measurement of rates of adverse events, and surveys.
Risk management is a closely related field. In the ICU, risks can be identified from critical incident reports, morbidity and mortality reviews and complaints from staff, patients or family members. Using similar methodology to the QI process, risks must be identified, assessed and analysed, managed and re-evaluated. A major patient safety incident should result in a root cause analysis.
All ICUs should have a documented orientation programme for new staff. There should be educational programmes for medical staff and a formal nursing education programme. Educational activities for intensive care trainees include lectures, tutorials, bedside teaching and trial examinations. Clinical reviews and meetings to review journals and new developments should be held regularly. Regular assessments for advanced life support and sometimes other assessments (e.g. medication safety) are often required. Increasingly, simulation centres are used to teach and assess skills and teamwork in crisis scenarios.33 A number of ICUs are also involved in undergraduate medical teaching. All staff should also participate in continuing education activities outside the hospital (e.g. local, national or international meetings) and specialists should be involved in College CPD.
In the USA critical care medicine is thought to account for 1–2% of the gross domestic product34 and has become increasingly used and prominent in the delivery of health care. Although the total number of hospitals, hospital beds and inpatient days has decreased, there has been shown to be a large increase in the number of intensive care beds and bed days.35 There is every reason to expect that other developed countries will follow this trend. As ICUs become larger and ICU staff numbers become larger still, it is crucial that the basic principles outlined in this chapter are followed and that standards of ICU design, staffing and clinical and non-clinical activities are maintained.
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