DESIGN%20AND%20ORGANIZATION%20OF%20INTENSIVE%20CARE%20UNITS

1
DESIGN AND ORGANIZATION OF INTENSIVE CARE UNITS

• Prof. Amir B. Channa
• Professor
• Department of Anaesthesia
• King Khalid University Hospital

2
Critical Care of MORIBUND Patient

• Definition of Critical Care
• Care of the problem with which the patient has
  been admitted.

3
(No Transcript)
4
1.Holistic Approach2.Challenges

• General care
• CNS
• Respiration
• CVS
• Renal
• Hemopoetic system care
• Renal replacement therapy

5
Holistic Approach

• GIT
• Nutritional care fluid electrolyte status
  maintenance
• Psychological
• Locomotor system
• Skin care
• Prevention of nosocomial infection
• Patients are/may become immunocompromised
• In case of death or demise sympathy with kin or
  kith

6
Design of ICU

• Services required

7
Basic requirement of ICU
8

• Policies and procedures and protocols
• Consultations of other subspecialties
• Back of LABORATORIES, pharma depth
• x-rays
• MRI
• CT
• Facilities for emergency surgery
• End stages diseases policies
• Brain stem dead patients
• Policies for harvesting organs transplant
  surgery

9
ROLE OF THE ICU

• Level I Adult ICU Small District Hospital.
• Level II Adult ICU General Hospital
• Level III Adult ICU Tertiary Hospital
• Provide all aspects of intensive care required by
  its referral role for indefinite periods.
• Staffed by specialist intensivists with trainees,
  critical care nurses, allied health
  professionals, clerical and scientific staff.
• Support of complex investigations, imaging and
  specialists of all disciplines.

10
HIGH DEPENDENCY UNIT

• An HDU is a specially staffed and equipped
  section of an intensive care complex that
  provides a level of care intermediate between
  intensive care and general ward care.

11
TYPE, SIZE AND SITE OF AN ICU

• Medical ICU CCU
• Surgical ICU
• Burns ICU
• Pediatric ICU
• Neonatal ICUs
• Multidisciplinary ICU

12
TYPE, SIZE AND SITE OF AN ICU

• Number of ICU beds
• 1 to 4 per 100 total hospital beds
• ICUs with less than 4 beds are considered not to
  be cost effective
• Over 20 non-high dependency beds maybe difficult
  to manage

13
TYPE, SIZE AND SITE OF AN ICU

• ICU should be sited in close proximity to
  relevant acute areas
• Operating rooms
• Emergency department
• CCU
• Labour ward
• Acute wards
• Investigational departments (e.g. radiology,
  organ imaging, and pathology laboratories)

14
TYPE, SIZE AND SITE OF AN ICU

• Critically ill patients are at risk when they are
  moved
• Sufficient numbers of lifts
• With door and corridors
• Spacious enough to allow easy passage of beds and
  equipment
• Often ignored by planning experts

15
Patient Care in the ICU

• Assess current status, interval history, and
  examination
• Review vital signs for interval period (since
  last review)
• Review medication record, including continuous
  infusions Duration and dose. Change in dose or
  frequency based on changes in renal, hepatic or
  other pharmacokinetic function. Changes in
  route of administration. Potential drug
  interactions

16
Patient Care in the ICU

• Correlate changes in vital signs with medication
  administration and other changes by use of
  chronologic charting
• Review, if indicated
• Respiratory therapy flow chart
• Hemodynamics records
• Laboratory flow sheets
• Other continuous monitoring

17
Patient Care in the ICU

• Integrate nursing, respiratory therapists,
  patient, family, and other observations.
• Review all problems, including adding, updating,
  consolidating or removing problems as indicated
• Periodically, review supportive care
• Intravenous fluids
• Nutritional status and support
• Prophylactic treatment and support
• Duration of catheters and other invasive devices
• Review and contrast risk and benefits of
  intensive care.

18
General ICU Care

• Nosocomial infections, especially line-and
  catheter related.
• Stress gastritis
• Deep venous thrombosis and pulmonary embolism
• Decubitus ulcers
• Psychosocial needs and adjustments.
• Toxicity of drugs (renal, pulmonary, hepatic,
  CNS)
• Development of antibiotic-resistant organisms.

19
General ICU Care

• Complications of diagnostic tests
• Correct placement of catheters and tubes
• Need for vitamins (thiamine, C, K)
• Tuberculosis, pericardial disease, adrenal
  insufficiency, fungal sepsis, rule out myocardial
  infarction, pneumothorax, volume overload or
  volume depletion, decreased renal function with
  normal serum ceratinine, errors in drug
  administration or charting, pulmonary vascular
  disease, HIV-related disease.

20
Nutrition

• Set goals for appropriate nutrition support
• Avoid or minimize catabolic state
• Acquired vitamin K deficiency while in ICU
• Avoidance of excessive fluid intake
• Diarrhea (lactose intolerance, low
  protein,hyperosmolarity drug-induced, infection)

21
Nutrition

• Minimize and anticipate hyperglycemia during
  parenteral nutritional support
• Adjustment of support rate or formula in patients
  with renal failure or liver failure
• Early complications of refeeding
• Acute vitamin insufficiency

22
Acute Renal Failure

• Volume depletion, hypoperfusion, low cardiac
  output, shock
• Nephrotoxic drugs
• Obstruction of urine outflow
• Interstitial nephritis
• Manifestation of systemic disease, multiorgan
  system failure
• Degree of preexisting chronic renal failure

23
Diabetic Ketoacidosis

• Evaluate degree of volume depletion and
  relationship of water to solute balance
  (hyperosmolar component)
• Avoid excessive volume replacement
• Look for a trigger for diabetic ketoacidosis
  (infection, poor compliance, mucormycosis, other)
• Avoid hypoglycemia during correction phase
• Calculate water and volume deficits
• Evaluate presence of coexisting acid-base
  disturbances (lactic acidosis, metabolic
  alkalosis)
• Avoid hypokalemia during correction phase

24
Hyponatermia

• Consider volume depletion (nonosmolar stimulus
  for ADH secretion)
• Consider edematous state with hyponatremia
  (cirrhosis, nephrotic syndrome, congestive heart
  failure)
• SIADH with nonsuppressed ADH
• Drugs (thiazide diuretics)
• Adrenal insufficiency, hypothyroidism

25
Hypernatermia

• Diabetes insipidus
• Diabetes mellitus
• Has patient been water-depleted for a long-time?
• Concomitant volume depletion?
• Is the urine continuing to be poorly concentrated?

26
Hypotension

• Volume depletion
• Sepsis (Consider potential sources may need to
  treat empirically)
• Cardiogenic (Any reason to suspect?)
• Drugs or medications (prescribe or not)
• Adrenal insufficiency
• Pneumothorax, pericardial effusion or tamponade,
  fungal sepsis, tricyclic overdose, amyloidosis

27
Swan-Ganz Catheters

• Site of placement (safety, risk, experience of
  operator)
• Coagulation times, platelet count, bleeding time,
  other bleeding risk
• Document in medical record
• Estimate need for monitoring therapy
• Predict whether interpretation of data may be
  difficult (mechanical ventilation, valvular
  insufficiency, pulmonary hypertension)

28
Upper Gastrointestinal Bleeding

• Rapid stabilization of patient (hemoglobin and
  hemodynamics)
• Identification of bleeding site
• Does patient have a non-upper GI bleeding site?
• Consider need for early operation
• Review for bleeding, coagulation problems

29
Upper Gastrointestinal Bleeding

• Determine when excessive amounts of blood
  products given
• Do antacids, H2 blockers, PPIs play a role?
• Reversible causes or contributing causes.

30
Fever, Recurrent Or Persistent

• New, unidentified source of infection
• Lack of response of identified or presumed source
  of infection
• Opportunistic organism (drug-resistant, fungus,
  virus, parasite, acid-fast bacillus)
• Drug fever
• Systemic noninfectious disease.

31
Fever, Recurrent Or Persistent

• Incorrect empiric antibiotics
• Slow resolution of fever (deep-seated infection
  endocarditis, osteomyelitis)
• Infected catheter site or foreign body (medical
  appliance)
• Consider infections of sinuses, CNS, decubitus
  ulcers septic arthritis

32
Pancytopenia (After Chemotherapy)

• Fever, presumed infection, response to
  antimicrobials
• Thrombocytopenia and spontaneous bleeding
• Drug fever
• Transfusion reactions
• Staphylococcus, candida, other opportunistic
  infections

33
Pancytopenia (After Chemotherapy)

• Infection sites in patient without granulocytes
  may have in duration, erythema, without
  fluctuance
• Pulmonary infiltrates and opportunistic infection

34
DESIGN OF AN ICU

• Single entry and exit point
• Attended by the unit receptionist
• NO Through traffic of goods
• People to other hospital areas must NEVER be
  allowed
• Rooms for public reception
• Patient management and support services.

35
PATIENT AREAS

• Each patient bed area in an adult ICU requires a
  minimum floor space of 20 m2 (215 ft2)

36
TABLE I.I Physical Design of a Major ICU

• Reception Area
• Waiting room for visitors
• Distressed (crying) / interview room
• Overnight relatives room

37
TABLE I.I Physical Design of a Major ICU

• Patient Areas
• Open multi-bed wards
• Central nurse station (including drug storage)
• Specialized rooms/beds if necessary, for
  procedures/minor surgery (e.g. tracheostomy),
  haemodialysis, burns, and use of bypass or
  intra-aortic balloon pump machines.

38
TABLE I.I Physical Design of a Major ICU

• Storage and Utility Areas
• Monitoring and electrical equipment
• Respiratory therapy equipment
• Disposables and central sterilizing supplies
• Linen
• Stationery
• Fluids, vascular catheters and infusion sets
• Non-sterile hardware (e.g. drip stands and bed
  rails)
• Clean utility
• Dirty utility
• Equipment sterilization.

39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
TABLE I.I Physical Design of a Major ICU

• Technical Areas
• Laboratory
• Workshop for repairs, maintenance, and
  development.

46
TABLE I.I Physical Design of a Major ICU

• Staff Areas
• Lounge/rest room (with facilities for meals)
• Changing rooms
• Toilets and showers
• Offices
• Doctors on-call rooms
• Seminar/conference room.

47
TABLE I.I Physical Design of a Major ICU

• Other Support Areas
• Cleaners room
• Plant room/alcove

48
TABLE I.I Physical Design of a Major ICU

• The ratio of single room beds to open-ward beds
  would depend on the role and type of the ICU,
  built 16 is recommended
• Single rooms are essential for isolation cases
  and (less importantly) privacy for conscious long
  stay patients.VENTILATION !!!!!!!!!!!!
• Sufficient numbers of non-splash hand wash
  basins, one for every two ward beds, should be
  built close to the beds.

49
TABLE I.I Physical Design of a Major ICU

• Utilities per bed space as recommended for a
  level III ICU are
• 3 oxygen
• 2 air
• 3 suction
• 16 power outlets
• A bedside light
• Adequate and appropriate lighting for clinical
  observation
• Services are supplied from floor column
• Wall mounted
• Bed pendent

50
(No Transcript)
51
(No Transcript)
52
(No Transcript)
53
STORAGE AND SUPPORTING SERVICES AREAS

• Most ICUs lack of storage space. Storage areas
  should total a floor space of about 25-30 of
  all.
• Equipment
• Staffing
• Medical Staff
• - ICU director
• - Sufficient specialist staff
• - Administration
• - Teaching
• - Research
• - Reasonable working hours.

54
(No Transcript)
55
TABLE I.2 Equipment in a Major ICU

• Monitoring
• Radiology
• Respiratory Therapy
• Cardiovascular Therapy
• Support Therapy
• Dialytic Therapy
• Laboratory

56
(No Transcript)
57
Intensive care Unit Bed
58
Use of computers for patient monitoring.
59
ICU
Bed
Bed
Bed
Bed
Nurse station
Telemetry
WEB connection
60
Some instruments in mind
61
And more...
62
Types of Data Used in Patient monitoring in
different ICUs
63
TABLE I.3 Staff of a Major ICU

• Medical
• Director
• Staff Specialist intensivists
• Junior Doctors

64
TABLE I.3 Staff of a Major ICU

• Nurses
• Nurse Managers
• Nurse Specialists
• Nurse Educators
• Critical Care Nurse Trainees

65
TABLE I.3 Staff of a Major ICU

• Allied Health
• Physiotherapists
• Pharmacist
• Dietician
• Social Worker
• Respiratory Therapists

66
TABLE I.3 Staff of a Major ICU

• Technicians
• Secretarial
• Secretary
• Ward Clerk

67
TABLE I.3 Staff of a Major ICU

• Radiographers
• Supporting Staff
• Orderlies
• Cleaners

68
TABLE I.3 Staff of a Major ICU

• Nursing Staff
• 11 Nursing
• Single bed requires 6 nurses

69
OPERATIONAL POLICIES

• Clear cut administrative policies
• An open ICU has unlimited access to multiple
  doctors
• A closed ICU has admission
• Quality assurance, continuing education and
  research
• Consideration of relatives
• Effective communication
• Physical environment

70
OPERATIONAL POLICIES

• Other supportive measures
• Social worker
• Counselor
• Priest or religious
• Follow-up counseling
• Emotional support for staff
• Death occurs
• Family should be allowed privacy to mourn, to
  view, touch, and hold the deceased.

71
Factors influencing outcome from a critical
illness

• Patient factors
• - Pervious health status
• - Physiological reserves
• - Biological age
• - Co morbidity
• Disease factors
• - Type of disease
• - Severity of disease
• Treatment factors
• - Treatment available?
• - Timing if therapy
• - Suitability of therapy
• - Response to treatment

72
Scoring systems for ICU surgical patients
General scores SAPS II and predicted mortality APACHE II and predicted mortality APACHE III SOFA (Sequential Organ Failure Assessment) MODS (Multiple Organ Dysfunction Score) ODIN (Organ Dysfunctions and / or INfection) MPM (Mortality Probability Model) on admission 24 hours 48 hours MPM Over Time (admission-24 h-48 h) MPM II (Mortality Probability Model) on admission 24 h, 48 h, 72 h LODS (Logistic Organ Dysfunction System) TRIOS (Three days Recalibrated ICU Outcome Score) RIYADH scoring system MEES (Mainz Emergency Evaluation System) PGH MPM Philippines General scores PRISM (Pediatric RISk of Mortality) DORA (Dynamic Objective Risk Assessment) PELOD (Pediatric Logistic Organ Dysfunction) PIM II (Paediatric Index of Mortality II) PIM (Paediatric Index of Mortality)
73
Scoring systems for ICU surgical patients
Specialized and Surgical Intensive Care - Preoperative evaluation EUROSCORE (cardiac surgery) ONTARIO (cardiac surgery) Parsonnet score (cardiac surgery) System 97 score (cardiac surgery) QMMI score (coronary surgery) Early mortality risk in redocoronary artery surgery MPM for cancer patients POSSUM (Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity) (surgery, any) Portsmouth POSSUM (surgery, any) IRISS score graft failure after lung transplantation Glasgow Coma Score Specialized Neonatal, Surgical, Meningococcal septic shock CRIB II (Clinical Risk Index for Babies) CRIB (Clinical Risk Index for Babies) SNAP (Score for Neonatal Acute Physiology) SNAP-PE (SNAP Perinatal Extension) SNAP II and SNAPPE II MSSS (Meningococcal Septic Shock Score) GMSPS (Glasgow Meningococcal Septicaemia Prognostic Score) Rotterdam Score (meningococcal septic shock) Children's Coma Score (Raimondi) Paediatric Coma Scale (Simpson Reilly)
74
Scoring systems for ICU surgical patients
Trauma scores ISS (Injury Severity Score), RTS (Revised Trauma Score), TRISS (Trauma Injury Severity Score) ASCOT (A Severity Characterization Of Trauma) 24 h - ICU Trauma Score Pediatric Trauma Scores Pediatric Trauma Score
75
TABLE 1 Scoring systems for ICU surgical
patients
Therapeutic intervention, nursing ICU scores TISS (Therapeutic Intervention Scoring System) TISS-28 simplified TISS Pediatrics therapeutic intervention, nursing ICU scores NTISS Neonatal Therapeutic Intervention Scoring System
76
The APACHE II scoring system
Variable
Maximum points
Temperature 4 Mean arterial pressure 4 Heart rate 4 Respiratory rate 4 Oxygenation 4 Arterial pH 4 Sodium 4 Potassium 4 Creatinine 8 Haematocrit 4 White cell count 4 Glasgow coma scale 12 Acute physiology score 16 Age 6 Chronic health evaluation 5 APACHE II score 71
77
Scoring of Various Acute physiological Variables

• A APACHE II
• 4 3
  2 1
  1 2 3 4
• Temperature 41 39-40.9 38.5-38.9
  36-38.4 34-35.9 32-33.9 30-31.9
  29.9
• MAP 160 130-159 110-129 70-109
  50-69 49
• HR 180 140-179 110-139 70-109
  55-69 40-54 39
• RR 50 35-49 25-34
  12-24 10-11 6-9 5
• Oxygenation1 500 350-499 200-349 lt
  200
• 
  
  PaO2gt 70 61-70 55-60 lt 55
• pH 7.7 7.6-7.69 7.5-7.59
  7.33-7.49 7.25-7.32 7.15-7.24 lt 7.15
• Na 180 160-179 155-159 150-154
  130-149 120-129 111-119
  110
• K 7 6.6-6.9 5.5-5.9
  3.5-5.4 3-3.4 2.5-2.9 lt2.5

78
(No Transcript)