ABOUT CRITICAL CARE NURSING

Definition of Critical Care Nursing Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems. 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. Definition of a Critically Ill Patient Critically ill patients are defined as those patients who are at high risk for actual or potential lifethreatening health problems. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care. Number of Critical Care Nurses in the United States According to "The Registered Nurse Population" study conducted in March 2004 by the Department of Health and Human Services, there are 503,124 nurses in the U.S. who care for critically ill patients in a hospital setting. Of these, 229,914 spend at least half their time in an intensive care unit (ICU); 92,826 spend at least half their time in step-down or transitional care units; 117,637 spend at least half their time in emergency departments; and 62,747 spend at least half their time in post-operative recovery. Critical care nurses account for an estimated 37% of the total number of nurses who work in a hospital setting. Where Critical Care Nurses Work According to "The Registered Nurse Population" study, 56.2% of all nurses work in a hospital setting, and critical care nurses work wherever critically ill patients are found intensive care units, pediatric ICUs, neonatal ICUs, cardiac care units, cardiac catheter labs, telemetry units, progressive care units, emergency departments and recovery rooms. Increasingly, critical care nurses work in home healthcare, managed care organizations, nursing schools, outpatient surgery centers and clinics. What Critical Care Nurses Do Critical care nurses practice in settings where patients require complex assessment, highintensity therapies and interventions, and continuous nursing vigilance. Critical care nurses rely upon a specialized body of knowledge, skills and experience to provide care to patients and families and create environments that are healing, humane and caring. Foremost, the critical care nurse is a patient advocate. AACN defines advocacy as respecting and supporting the basic values, rights and beliefs of the critically ill patient. In this role, critical care nurses:

Respect and support the right of the patient or the patient's designated surrogate to autonomous informed decision making. Intervene when the best interest of the patient is in question. Help the patient obtain necessary care. Respect the values, beliefs and rights of the patient. Provide education and support to help the patient or the patient's designated surrogate make decisions. Represent the patient in accordance with the patient's choices. Support the decisions of the patient or designated surrogate, or transfer care to an equally qualified critical care nurse. Intercede for patients who cannot speak for themselves in situations that require immediate action. Monitor and safeguard the quality of care the patient receives.

Act as a liaison between the patient, the patient's family and other healthcare professionals. The Roles of Critical Care Nurses Critical care nurses work in a wide variety of settings, filling many roles including bedside clinicians, nurse educators, nurse researchers, nurse managers, clinical nurse specialists and nurse practitioners. With the onset of managed care and the resulting migration of patients to alternative settings, critical care nurses are caring for patients who are more ill than ever before. Managed care has also fueled a growing demand for advanced practice nurses in the acute care setting. Advanced practice nurses are those who have received advanced education at the master's or doctoral level. In the critical care setting, they are most frequently clinical nurse specialists (CNS) or acute care nurse practitioners (ACNP). A CNS is an expert clinician in a particular specialty critical care in this case. The CNS is responsible for the identification, intervention and management of clinical problems to improve care for patients and families. They provide direct patient care, including assessing, diagnosing, planning and prescribing pharmacological and nonpharmacological treatment of health problems. ACNPs in the critical care setting focus on making clinical decisions related to complex patient care. Their activities include risk appraisal, interpretation of diagnostic tests and providing treatment, which may include prescribing medication. Level of Education for Critical Care Nurses To become a registered nurse (RN), an individual must earn a diploma in nursing, an associate's degree in nursing (ADN) or a bachelor's degree in nursing (BSN) and pass a national licensing exam. Requirements vary as dictated by each state's Board of Nursing. Many nursing schools offer students exposure to critical care, but most of a critical care nurse's specialty education and orientation is provided by the employer. Advanced practice nurses must earn a degree at the master's or doctoral level. Critical Care Nurse Certification Although certification is not mandatory for practice in a specialty like critical care, many nurses choose to become certified. Some employers prefer to hire certified nurses because they have demonstrated acquisition of a specific high level of knowledge in their specialty through successful completion of a rigorous, psychometrically valid, job-related examination. For example, a critical care nurse must care for critically ill patients for a minimum of two years to be eligible for the CCRN certification exam offered by AACN, one of many credentials the association offers. Because of the availability of Medicare and managed care reimbursement to clinical nurse specialists, a growing number of employers are requiring advanced practice certification. Additionally, as state boards of nursing attain statutory authority to issue advanced practice nursing licenses, nurses are often being required to pass a nationally recognized certification examination. Certified nurses validate their continuing knowledge of current practices in acute/critical care nursing through a renewal process that includes meeting continuing education and clinical experience requirements. Nursing Shortage More Pronounced for Critical Care Nurses The nursing shortage is especially acute in the specialty areas of nursing, as noted in the skyrocketing number of requests for temporary and traveling critical care nurses to fill staffing gaps in every part of the U.S. These requests are most pronounced for adult critical care units, pediatric and neonatal ICUs and emergency departments. Recruitment advertising for critical care nurses in AACN's publications continues to grow, especially in the annual Career Guide. Hospitals are offering critical care nurses ever more attractive incentives, including sign-on bonuses, relocation bonuses, and reimbursement for continuing education and certification. In addition, many hospitals are launching critical care orientation and internship programs, such as the Web-based Essentials of Critical Care Orientation (ECCO) program, to attract and prepare

experienced and newly licensed nurses to work in critical care and the Essentials of Nurse Manager Orientation program. History of Critical Care Nursing Although there have always been very ill and severely injured patients, the concept of critical care is relatively modern. As advances have been made in medicine and technology, patient care has become more complex. To provide appropriate care, nurses needed specialized knowledge and skills, and the care delivery mechanisms needed to evolve to support the patients' needs for continuous monitoring and treatment. The first intensive care units emerged in the 1950s to provide care to very ill patients who needed one-to-one care from a nurse. From this environment the specialty of critical care nursing emerged. Future of Critical Care Nursing Rapid advances in healthcare and technology have contributed to keeping more people out of the hospital. However, patients in critical care units are more ill than ever. Many patients who would have been cared for in a critical care unit five years ago are now being cared for on medical floors or at home. Many patients in today's critical care units would not have survived in the past. It has been proposed that hospitals of the future will be large critical care units, and other types of care will be provided in alternative locations or at home. Critical care nurses will need to keep pace with the latest information and develop skills to manage new treatment methods and technologies. As issues relating to patient care become increasingly complex and new technologies and treatments are introduced, critical care nurses will need to become ever more knowledgeable.

critical care unit a unit in a hospital in which special patient care staff and units, including ECG, blood gas analysis apparatus, resuscitation and life support equipment are available and used.

critical care care of a patient in a life-threatening situation of an illness. Includes artificial life support system.

critical care unit (CCU),

a specially equipped hospital area designed for the treatment of patients with sudden life-threatening conditions. CCUs contain resuscitation and monitoring equipment and are staffed by personnel specially trained and skilled in recognizing and immediately responding to cardiac and other emergencies. See also intensive care unit.

intensive care unit a hospital unit in which are concentrated special equipment and skilled personnel for the care of seriously ill patients requiring immediate and continuous attention; abbreviated ICU.

unit (unit)
1. a single thing. 2. a quantity assumed as a standard of measurement. Symbol U.

Angstrm unit angstrom. atomic mass unit (u) (amu) the unit mass equal to 112 the mass of the nuclide of carbon-12. Called also dalton.

Bethesda unit a measure of the level of inhibitor to coagulation factor VIII; equal to the amount of inhibitor in patient plasma that will inactivate 50 per cent of factor VIII in an equal volume of normal plasma following a 2-hour incubation period. Bodansky unit the quantity of alkaline phosphatase that liberates 1 mg of phosphate ion from glycerol 2phosphate in 1 hour under standard conditions. British thermal unit (BTU) the amount of heat necessary to raise the temperature of one pound of water one degree Fahrenheit, usually from 39F to 40F. CGS unit any unit in the centimeter-gram-second system. CH50 unit the amount of complement that will lyse 50 per cent of a standard preparation of sheep red blood cells coated with antisheep erythrocyte antibody. coronary care unit a specially designed and equipped hospital area containing a small number of private rooms, with all facilities necessary for constant observation and possible emergency treatment of patients with severe heart disease. intensive care unit a hospital unit in which are concentrated special equipment and skilled personnel for the care of seriously ill patients requiring immediate and continuous attention; abbreviated ICU. International unit (IU) a unit of biological material, as of enzymes, hormones, vitamins, etc., established by the International Conference for the Unification of Formulas. motor unit the unit of motor activity formed by a motor nerve cell and its many innervated muscle fibers. SI unit any of the units of the Systme International d'Units (International System of Units) adopted in 1960 at the Eleventh General Conference of Weights and Measures. Somogyi unit that amount of amylase which will liberate reducing equivalents equal to 1 mg of glucose per 30 minutes under defined conditions. Svedberg unit (S) a unit equal to 1013 second used for expressing sedimentation coefficients of macromolecules. terminal respiratory unit the anatomical and functional unit of the lung, including a respiratory bronchiole, alveolar ducts and sacs, and alveoli. toxic unit , toxin unit the smallest dose of a toxin which will kill a guinea pig weighing about 250 gm in three to four days. USP unit one used in the United States Pharmacopeia in expressing potency of drugs and other preparations.

Dorland's Medical Dictionary for Health Consumers. 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.

intensive care unit

n. Abbr. ICU A specialized section of a hospital containing the equipment, medical and nursing staff, and monitoring devices necessary to provide intensive care. Also called critical care unit.
The American Heritage Medical Dictionary Copyright 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company. All rights reserved.

intensive care unit (ICU),

a hospital unit in which patients requiring close monitoring and intensive care are kept. An ICU contains highly technical and sophisticated monitoring devices and equipment and is staffed by personnel trained to deliver critical care. A large tertiary care facility usually has separate units specifically designed for the intensive care of adults, infants, children, or newborns or for other groups of patients requiring a certain kind of treatment. See also coronary care unit.

Mosby's Medical Dictionary, 8th edition. 2009, Elsevier.

intensive care unit (ICU)

a hospital unit in which is concentrated special equipment and specially trained personnel for the care of seriously ill patients requiring immediate and continuous attention (intensive CARE). Called also critical care unit.

Setting up an Intensive Care unit Presentation Transcript

1. SETTING UP AN INTENSIVE CARE UNIT Leah Macaden COLLEGE OF NURSING CMC, VELLORE 2. OBJECTIVE TO PROVIDE A FUNCTIONAL AND USER- FRIENDLY ENVIRONMENT . 3. CORE COMPONENTS OF AN ICU CONSTANT MONITORING RAPID SKILLED INTERVENTION MULTI DISCIPLINARY TEAM WORK 4. FACTORS TO CONSIDER SOURCES OF PATIENTS ADMISSION AND DISCHARGE CRITERIA EXPECTED RATE OF OCCUPANCY ECONOMIC INVESTMENT FINANCIAL VIABILITY PERSONNEL REQUIRED TECHNOLOGICAL RESOURCES

5. LEVELS OF ICU CARE LEVEL I PROVIDES MONITORING, OBSERVATION AND SHORT TERM VENTILATION. LEVEL II PROVIDES OBSERVATION, MONITORING & LONG TERM VENTILATION WITH RESIDENT DOCTORS. 6. LEVEL III PROVIDES ALL ASPECTS OF INTENSIVE CARE INCLUDING INVASIVE HAEMO DYNAMIC MONITORING & DIALYSIS. 7. DESIGNING AN ICU THE TEAM SHOULD CONSIST OF AN INTENSIVE CARE DIRECTOR NURSING ADMINISTRATORS & SUPERVISORS HOSPITAL ADMINISTRATORS 8. AN ARCHITECT ENGINEERS (Electrical, Civil, Bioengineering, Electronics etc) ALL POTENTIAL USERS 9. ENVIRONMENTAL ENGINEERS, INTERIOR DESIGNERS, STAFF NURSES, PHYSICIANS, PATIENTS AND FAMILIES MAY BE ASKED FOR COMMENTS. 10. DESIGN PNEUMATICS - V P PATIENT CARE N- NURSING E- EATING (Clean area for food preparation & delivery) U- UNCLEAN (Dirty linen & equipment) M- MEDICATION STORAGE 11. A ADMINISTRATION (CLERKING & STATIONARY) T TEACHING I INFECTION CONTROL & ELIMINATION (STERILIZATION & DISINFECTION) C CLEAN AREA

12. STORAGE VISITORS (OTHERS- BEREAVEMENT / QUIET ROOM, OFFICE ROOMS, DUTY DOCTORS ROOM, STAFF LOUNGE, LIBRARY etc). 13. TECHNICAL SPACE FOR A LAB, BLOOD GAS ANALYSER etc. RELATIVES WAITING ROOM WITH A TELEPHONE, TV, BEVERAGE FACILITIES etc. 14. LOCATION Should be a geographically distinct area within the hospital, with controlled access. No through traffic to other departments should occur. Supply and professional traffic should be separated from public/visitor traffic. 15. Location should be chosen so that the unit is adjacent to, or within direct elevator travel to and from, the Emergency Department, Operating Room, Intermediate care units, and the Radiology Department. 16. BED STRENGTH IDEALLY 8 TO 12 BEDS LARGER AREAS DIFFICULT TO ADMINISTER AND SMALLER AREAS NOT BEING COST EFFECTIVE 3 TO 5 BEDS PER 100 HOSPITAL BEDS FOR A LEVEL III ICU / 2 TO 20% OF THE TOTAL NUMBER OF HOSPITAL BEDS (In CMC 68 ICU Beds, 60 Nursery beds, 43 HDU beds) 1 ISOLATION BED FOR EVERY 10 ICU BEDS

17. BED SPACE & BEDS 150 200 SQUARE FEET PER OPEN BED WITH 8 FEET IN BETWEEN BEDS. 225 250 SQUARE FEET PER BED IF IN A SINGLE ROOM. SINGLE ROOM WITH AN ANTEROOM (20 FEET) FOR HAND WASHING, GOWNING etc BEDS - ADJUSTABLE, NO HEAD BOARD, SIDE RAILS AND WITH WHEELS.

18. ACCESSORIES 3 OXYGEN OUTLETS, 3 SUCTION OUTLETS (GASTRIC, TRACHEAL & UNDERWATER SEAL), TWO COMPRESSED AIR OUTLETS AND 16 POWER OUTLETS PER BED. STORAGE BY EACH BEDSIDE (BUILT IN / ALCOVE).

19. HAND RINSE SOLUTION BY EACH BEDSIDE. EQUIPMENT SHELF AT THE HEAD END (MIND THE HEIGHT OF THE CARE GIVER). 20. HOOKS & DEVICES TO HANG INFUSIONS / BLOOD BAGS SUSPENDED FROM THE CEILING WITH A SLIDING RAIL TO POSITION. INFUSION PUMPS TO BE MOUNTED ON STANDS / POLES. 21. INFRASTRUCTURE PATIENTS MUST BE SITUATED SO THAT DIRECT OR INDIRECT (E.G. BY VIDEO MONITOR) VISUALIZATION BY HEALTHCARE PROVIDERS IS POSSIBLE AT ALL TIMES. THE PREFERRED DESIGN IS TO ALLOW A DIRECT LINE OF VISION BETWEEN THE PATIENT AND THE CENTRAL NURSING STATION. MODULAR DESIGN SLIDING GLASS DOORS & PARTITIONS TO FACILITATE VISIBILITY.

22. ENVIRONMENT SIGNALS & ALARMS ADD TO THE SENSORY OVERLOAD; NEED TO BE MODULATED. FLOOR COVERINGS AND CEILING WITH SOUND ABSORPTION PROPERTIES. DOORWAYS OFFSET TO MINIMISE SOUND TRANSMISSION. LIGHT & SOFT MUSIC (EXCEPT 10 PM TO 6 AM).

23. LIGHTING FOCUSSED & CENTRAL LIGHTING. AIRCONDITIONING (SPLIT / CENTRAL) 25 + OR 2 DEGREES CENTIGRADE. CLEANING VACUUM CLEANING & WET MOPPING OF THE FLOOR. FUMIGATION IS NO LONGER RECOMMENDED.

24. NATURAL ILLUMINATION AND VIEW - WINDOWS ARE AN IMPORTANT ASPECT OF SENSORY ORIENTATION; HELPS TO REINFORCE DAY/NIGHT ORIENTATION. WINDOW TREATMENTS SHOULD BE DURABLE AND EASY TO CLEAN, AND A SCHEDULE FOR THEIR CLEANING MUST BE ESTABLISHED.

25. ADDITIONAL APPROACHES TO IMPROVING SENSORY ORIENTATION FOR PATIENTS MAY INCLUDE THE PROVISION OF A CLOCK, CALENDAR, BULLETIN BOARD, AND/OR PILLOW SPEAKER CONNECTED TO RADIO AND TELEVISION.

26. UTILITIES ELECTRICAL ADEQUATE SOCKETS (5AMPS & 15 AMPS), GENERATOR SUPPLY & BATTERY BACK UP. MEDICAL GAS & VACUUM PIPELINE COLOUR CODED AND NOT INTERCHANGEABLE. WATER FROM A CERTIFIED SOURCE ESPECIALLY IF USED FOR HAEMODIALYSIS.

27. HANDWASHING AREAS UNINTERRUPTED WATER SUPPLY, DISPOSABLE PAPER TOWELS / HAND DRIER. (NO CLOTH TOWELS PLEASE) TELEPHONES & COMPUTERS FOR COMMUNICATION. 28. STERILISING AREA LARGE WATER BOILER / GEYSER & EXHAUST FANS. CLEAN AND A DIRTY UTILITY WITH NO INTERCONNECTION. SHELVING & CABINETS OFF THE GROUND FOR STORAGE. WASTE & SHARPS DISPOSAL.

29. WORK AREAS AND STORAGE FOR CRITICAL SUPPLIES SHOULD BE LOCATED IMMEDIATELY ADJACENT TO EACH ICU. ALCOVES SHOULD PROVIDE FOR THE STORAGE AND RAPID RETRIEVAL OF CRASH CARTS AND PORTABLE MONITOR/DEFIBRILLATORS.

30. 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 TABLE TOP FOR PREPARATION OF DRUGS AND INFUSIONS.

31. EQUIPMENT MONITORING EQUIPMENT THERAPEUTIC EQUIPMENT DIGITAL & ANALOGUE DISPLAY AUDIO & VISUAL ALARMS BATTERY BACK UP & CHARGING 32. PERSONNEL NURSE PATIENT RATIO 1: 1. ICU NURSE MANAGER AN RN (REGISTERED NURSE) WITH A BSN OR PREFERABLY AN MSN DEGREE. CERTIFICATION IN CRITICAL CARE OR EQUIVALENT GRADUATE EDUCATION WITH AT LEAST 2 YRS EXPERIENCE WORKING IN A CRITICAL CARE UNIT.

33. EXPERIENCE WITH HEALTH INFORMATION SYSTEMS, QUALITY IMPROVEMENT/RISK MANAGEMENT ACTIVITIES, AND HEALTHCARE ECONOMICS. ABILITY TO ENSURE THAT CRITICAL CARE NURSING PRACTICE MEETS APPROPRIATE STANDARDS.

34. PREPARATION TO PARTICIPATE IN THE ON-SITE EDUCATION OF CRITICAL CARE UNIT NURSING STAFF. ABILITY TO FOSTER A COOPERATIVE ATMOSPHERE WITH REGARD TO THE MULTIDISCIPLINARY TRAINING PERSONNEL INVOLVED IN THE CARE OF CRITICAL CARE UNIT PATIENTS.

35. 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

36. MEDICAL STAFFING COVER FOR EVERY SHIFT WITH COMPETENCE TO HANDLE ANY EMERGENCY. ANCILLARY STAFF THERAPISTS, TECHNICIANS, RADIOGRAPHERS etc. RECEPTIONIST, CHAPLAIN / COUNSELLOR.

37. PERSONNEL DEVELOPMENT IN SERVICE EDUCATION PROGRAMMES DEBRIEF SESSIONS TO BURN OUT TEAM BUILDING EXERCISES INVOLVEMENT IN POLICY DEVELOPMENT 38. POLICIES & PROTOCOLS ADMISSION, DISCHARGE & WITHDRAWAL OF SUPPORT. LEGAL & ETHICAL GUIDELINES & MLC POLICIES STANDING ORDERS. ORGAN DONATION. 39. INFECTION CONTROL SURVEILLANCE STERILIZATION & DISINFECTION QUALITY CONTROL & AUDITING 40. DOCUMENTATION CONVENTIONAL ELECTRONIC MEDICAL RECORDS (EMR) Bedside terminals Interfaced with existing hospital data Systems, data retrieval (laboratory Results, x-ray reports, etc.). Remote data transmission capabilities (to offices, on-call rooms, etc.)

41. OTHER FACILITIES BEREAVEMENT & AFTER CARE SERVICES COUNSELLING LAST OFFICE SUPPORT SYSTEMS FOR PATIENT RELATIVES & STAFF 42. REFERENCES Guidelines for Intensive Care Unit Design Crit Care Med 1995 Mar; 23(3):582- 588. John, G. Essentials of Critical Care, Edition IV, (2003), Shakti Prints, Vellore. Worthley, L.I.G. Clinical Examination of the Critically Ill Patient, Edition II, (2000), The Australasian Academy of Critical Care Mediicne, South Australia.

Concept Of Critical Care Presentation Transcript

1. CONCEPT OF CRITICAL CARE PRESENTED BY:- JASPREET KAUR SODHI MSc.FINAL YEAR 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. CRITICAL CARE NURSING Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems.

6. SEVEN Cs OF CRITICAL CARE Compassion Communication (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 ).

7. 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 . 8. 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. 9. THE AIM OF THE CRITICAL CARE:- is to see that one provides a care such that patient improves and survives the acute illness or tides over the acute exacerbation of the chronic illness. 10. 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 .

11. 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

12. 13. Bennett, D. et al. BMJ 1999;318:1468-1470 14. Bennett, D. et al. BMJ 1999;318:1468-1470 15. Bennett, D. et al. BMJ 1999;318:1468-1470 16. 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 newer horizons in cardiothoracic surgery, with refinements in intraoperative membrane oxygen techniques.

17. 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. 18. 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 1970s,the term critical care unit came into existence which covered all types of special care

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

21. STAFFING Large hospital requires bigger team. 22. 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.

23. 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.

24. 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.

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

27. 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

28. 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

29. 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. Nurse-to-patient ratios should be based on patient acuity according to written hospital policies.

30. 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.

31. 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.

32. 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 activ ities.

33. 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 hospitals unique patient population. Hospitals should have guidelines for these ratios based on acuity, complexity, and safety considerations. The following physician subspecialists should be available and be able to provide bedside patient care within 30 mins:

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

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

36. Maintain equipment, including patient monitors, ventilators, haemofiltration machines, and blood gas analysers Medical physics technicians 5. Advise on treatment and infection control Microbiologists 4. Advise on nutritional requirements and feeds Dietitians 3. A advise on potential drug interactions and side effects, and drug dosing in patients with liver or renal dysfunction Pharmacists 2. prevents and treat chest problems, assist mobilization, and prevent contractures in immobilized patients Physiotherapists 1. FUNCTION THERAPIST S.NO.

37. 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.

38. 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. &quot;STAT&quot; or &quot;bedside&quot; laboratories adjacent to the ICU or rapid transport systems.

39. 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. 40. 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.

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

42. 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.

43. 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.

44. 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 45. DESCRIPTION Intensive care unit equipment includes:- patient monitoring life support and emergency resuscitation devices diagnostic devices 46. PATIENT MONITORING EQUIPMENTS Acute care physiologic monitoring system Pulse oximeter Intracranial pressure monitor Apnea monitor 47. Bennett, D. et al. BMJ 1999;318:1468-1470 48. LIFE SUPPORT & RESUSCITATIVE EQUIPMENTS VENTILATOR INFUSION PUMP CRASH CART INTRAAORTIC BALOON PUMP 49. Bennett, D. et al. BMJ 1999;318:1468-1470 50. DIAGNOSTIC EQUIPMENTS MOBILE X-RAYS PORTABLE CLINICAL LAB. DEVICES BLOOD ANALYZER 51. DESIGN OF ICU 52. 53. PHYSICAL SET UP OF 5 BEDDED ICU 54. 55. 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.

56. 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.

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58. ICU TEAM ICU deign should be approached by multidisciplinary team consisting of :- ICU MEDICAL DIRECTORS ICU NURSE MANAGER THE CHIEF ARCHITECT THE OPERATING ENGINEERING STAFF 59. OTHER ADDITIONAL MEMBERS ENVIORNMENTAL ENGINEER INTERIOR DESIGNERS STAFF NURSES PHYSICIANS PATIENTS FAMILIES 60. 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.

61. 62. 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.

63. 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.

64. 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 Emergency Department, Operating Room, intermediate care units, and Radiology Department

65. 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.

66. 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. Notably, noise levels in most hospitals are between 50-70 dB(A) with occasional episodes above this range

67. 68. 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. Adequate space for computer terminals and printers is essential when automated systems are in use. Patient records should be readily accessible .

69. CENTRAL STATION Adequate surface space and seating for medical record charting by both physicians and nurses should be provided. Shelving, file cabinets and other storage for medical record forms must be located so that they are readily accessible by all personnel requiring their use. Although a secretarial area may be located separately from the central station, it should be easily accessible as well

70. 71. 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 &quot;bright light&quot; should also be available.

72. 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 should be available for the storage of medications and supplies .

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74. RECEPTION AREA 75. 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&apos; entrance separate from that used by healthcare professionals. The visitors&apos; entrance should be securable if the need arises.

76. 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.

77. 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

78. 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.

79. 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 mechanisms for the disposal of items contaminated by body substances and fluids. Special containers should be provided for the disposal of needles and other sharp objects.

80. 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.

81. 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.

82. 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 by telephone or intercommunication system, and emergency cardiac arrest alarms should be audible within.

83. 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.

84. Visitors&apos; Lounge/Waiting Room . A visitors&apos; 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. Public toilet facilities and a drinking fountain should be located within the lounge area or immediately adjacent.

85. Visitors&apos; 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.

86. 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.

87. 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.

88. 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 .

89. 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).

90. 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.

91. 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.

92. Patient Modules Storage must be provided for each patient&apos;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 stress to patients and staff. Therefore, design should consider natural illumination and view.

93. 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

94. 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.

95. Comfort considerations should include methods for establishing privacy for the patient. Shades, blinds, curtains, and doors should control the patient&apos;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 and have a calming effect.

96. 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.

97. 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 agency codes and standards .

98. ELECTRIC SUPPLY Grounded 110 volt electrical outlets with 30 amp circuit breakers should be located within a few feet of each patient&apos;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 should be placed close to the floor to avoid tripping over electrical cords.

99. 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.

100. Lightning Total luminance should not exceed 30 foot-candles . It is preferable to place lighting controls on variablecontrol 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 should fully illuminate the patient with at least 150 fc shadow-free A patient reading light is desirable, and should be mounted

101. 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.

102. 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. 103. Computerized Charting These systems provide for &quot;paperless&quot; 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.

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