this presentation is based on indian society of critical care medicine 2010 guidelines

1. PRESENTER : DR RAJESH MUNIGIAL
MODERATOR : DR MAMATHA H K
HOD : DR ARUN KUMAR A
SSIMS & RC , davanagere ,

2. • In India, First Coronary ICU was started at King Edward
memorial hospital, Mumbai.
• ICU care was then followed by other big hospitals of
Mumbai like Breach candy and in other large cities of
India.
• All India Institute of Medical Sciences, Delhi and some
corporate/chain hospitals in metropolitan cities like
Apollo, Max hospitals have started different types of
ICU’s

4. • Initial planning
• Design about ICU levels , number of beds , design an future
thoughts .
• Central nursing station designing and planning
• Equipmentation
• Support system recommendations
• Environmental planning
• Human resource development

5. • ICU is highly
specified and
sophisticated
area of a
hospital which is
specifically
designed,
staffed, located,
furnished and
equipped,
dedicated to
management of
critically sick
patient, injuries
or
complications.
• It is a
department with
dedicated
medical, nursing
and allied staff.

6. It is emerging as a separate specialty and can no longer be
regarded purely as part of anaesthesia, Medicine, surgery
or any other speciality.
• It has to have its own separate team in terms of doctors,
nursing personnel and other staff who are tuned to the
requirement of the speciality

8. • It is recommended for small district hospital, small private
Nursing homes, Rural centres
• Ideally 6 to 8 Beds
• Provides resuscitation and short-term Cardio respiratory
support including Defibrillation.
• ABG Desirable.
• It should be able to Ventilate a patient for at least 24 to 48
hrs and Non invasive Monitoring facilities like - SPO2, H R
and rhythm (ECG), NIBP, Temperature should be available.

9. • should have arrangements for safe transport of the patients to
secondary or tertiary centres
• The staff should be encouraged to do short training courses like
FCCS or BASIC ICU Course.
• Should have basic clinical Lab (CBC, BS, Electrolyte, LFT and
RFT) and Imaging back up (X-ray and USG), ECG
Blood bank support

10. Recommended for larger General Hospitals
• Bed strength 6 to 12
• Director to be a trained/qualified Intensivist
• Multisystem life support
• Invasive and Non invasive Ventilation
• Invasive Monitoring
• Long term ventilation ability
• TC pacing

11. • Access to ABG, Electrolytes and other routine diagnostic support
24 hrs
• Strong Microbiology support with facility for Fungal Identification
desirable
• Protocols and policies for ICUs to be followed
• Nurses and duty doctors trained in Critical Care
• CT must & MRI is desirable
• Should be supported ideally by Cardiology and other super
specialties of Medicine and Surgery
• HDU facility will be desirable

12. Recommended for tertiary level hospitals
• Bed strength 10 to 16
• Headed by Intensivist
• Preferably closed ICU
• Have all recent methods of monitoring, invasive and non
invasive including continuous cardiac output, SCvO2 monitoring
etc
• Long term acute care of highest standards and Multisystem
care
• Bed side x-ray, USG, 2D-Echo should be available

13. • Own or outsourced CT Scan and MRI facilities should be there
• Bedside Bronchoscopy
• Bedside dialysis and other forms of RRT available
• Optimum patient/Nurse ratio should be 1/1 in ventilated
patient.
• Patient area should not be less than 100 sq ft per patient
(>125 sq ft will be ideal). In addition there should be optimum
additional space for storage, nursing station and relatives
• Doctors, Nurses and other support staff should be continuously
updated in newer technologies and knowledge in critical Care
• Protocols observed about prevention of infection

19. • Triage of admissions and discharges
• Development of treatment protocol and guidelines
• Involvement in unit budget approval
• Updating of equipment and unit practices
• Promotions of efficient use of material and personnel
resources
• Responsibility for coordination and dissemination of
continuing education of hospital and ICU based
personnel.

20. Post graduates from Anaesthesia, Medicine or Respiratory
Medicine or other allied branches even surgical specialties.
• it is suggested that one PG resident with one graduate
resident may be good for an ICU of 10 to 14 beds

21. Nursing – 1/1 nursing for Ventilated patients is desirable
but in no circumstance the ratio should be < 2 /3 (Two
nurses for 3 such patients).

22. • Respiratory therapist
• Physiotherapist
• Technicians
• Computer person
• Biomedical person
• Nutritionist
• Cleaning class IV
• Guards
• Having professionals from Clinical Lab, Microbiology,
Imaging, Pharmacy for support whenever needed will be
desirable.
• One person should be responsible for observing protocols
of Pollution and Infection control.

27. • ICUs having <6 beds are not cost effective and also they
may not provide enough clinical experience and exposure
to skilled HR of the ICU
• At the same ICU with bed strength of >24 are difficult to
manage and major problems may be encountered in
management and outcome.
• Recommendations suggest that efficiency may be
compromised once total number of beds crosses 12 in
ICU.
• Therefore, it is recommended that total bed strength in ICU

29. • Safe, easy, fast transport of a critically sick patient should be priority in
planning its location,
• therefore, ICU should be located in close proximity of ER, Operating
rooms, trauma ward.
• Corridors, lifts & ramps should be spacious enough to provide easy
movement of bed/ trolley of a critically sick patient.
• Close/easy proximity is also desirable to diagnostic facilities, blood
bank, pharmacy etc.
• No thoroughfare can be provided through ICU.
• There should be single entry/exit point to ICU, which should be manned.
• However, it is required to have emergency exit points in case of
emergencies and disasters.

31. • Space per bed has been recommended from 125 to 150
sq ft area per bed in the patient care area or the room of
the patient. Some recommendation has placed it even
higher up to 250 sq ft per bed.
• In our country it is suggested that 100-125sq ft is
appropriate wherein you are comfortable with monitors ,
ventilator , other equipment and procedures

32. • One or two bigger rooms for procedures like ECMO ,
RRT .
• 10% rooms for isolation icu and with 20% extra large
space.

34. • It is recommended that there should be a partition/separation
between rooms
• Standard curtains soften the look and can be placed
between two patients which is very common in most Indian
ICU
• two rooms may be separated by unbreakable fixed or
removable partisans, which may be aluminium, wood or fibre
• There are also electronic windows which are transparent
when the switch is off and are opaque when the switch is on

35. 1 Head wall Panel
2 Free standing systems (power columns) usually from the
ceiling
• Flexibility is usually desirable,
• Panels on head wall systems allow for free movements
• Adaptable power columns can move side to side or rotate,
• Mounts on power columns are also usually adjustable,
• Flexible systems are expensive and counterproductive if
the staff never move or adjust them
• Ceiling mounted moveable rotary systems may reduce
clutter on the floor and make a lot of working space

39. • Each room should be designed to accommodate portable
bedside x-ray, Ultrasound and other equipment such as
ventilators and IA Balloon pumps;
• In addition, the patient's window view (If available) to the
outside should be preserved.

40. Doctors and nurses may have chronic head tilting leading
to cervical neck discomfort and disorders,
Therefore, the levels of monitors should be at comfortable
height for doctors and nurses
Keep Bed 2 ft away from Head Wall

41. Provision for RRT
Two beds should be specially designated for RRT
(HD/CRRT) where outlets should be available for RO/de-
iodinated water supply for HD machines
Isolation Rooms
10% of beds ( 1 or 2 ) rooms may be used exclusively as
isolation cases like for burns , serious contagious infected
patients .

42. • Each group should decide if they want to provide the
patient access to music (audio), telephone etc.
• However an alarm bell which has both indicators by
sound and light must be provided to each patient and he
be taught about it, how to use it when needed

43. Standards AIA/AAH IEEE SCCM (2)
O2 OUTLETS 2-3 2 2-3
Vaccum outlets 2-4 3 2-3
Compressed air
outlets
1-3 1 1-2
Electric outlets 7 8 11-12
Room size 132 - 150-250
Isolation room 150 - 250
Anteroom 20 - 20
Unit size - - 12 beds

44. • Bed space- minimum 100 sq ft (Desirable) >125.
• Additional space for the ICU (Storage/Nursing
stn/doctors/circulation etc) 100 % extra of the bed space (Keep
the future requirement in mind)
• Oxygen outlets 2
• Vacuum outlets 2
• Compressed air outlets 1
• Electric outlets 12 of which 4 may be near the floor 2 on each
side of the patient.
• Electric outlets/Inlets should be common5/15 amp pins. Should
have pins to accommodate all standard International Electric
Pins/Sockets.
• Adapters should be discouraged since they tend to become

46. • 3 oxygen outlets, 2 compressed air, 2 vacuum
(adjustable), 12 to 14 electric outlets, a bedside light one-
telephone outlets and one data outlet .

47. • This is the nerve centre of ICU
• All/near-all monitors and patients must be observable from
there, either directly or through the central monitoring
system.
• A monitor technician is required
• The unit Nursing clerk and the supervising nurse will
usually work together to oversee the efficient interaction
among the staff and with support services
• The space should accommodate computer terminals and
printers.

50. • It is also important that a storage space is provided for
equipment, linen, instruments, drugs, medicines,
disposables, stationary and other articles to be stored at
the Nursing station must be provided. All these
cupboards should be labeled
• The latest generation of monitoring systems allows
access to patient data from any bedside;
• Ideally in Indian ICUs, there are over bed tables with
each bed.
• These tables may be so deigned of stainless steel to
have a broad top to accommodate charts and cupboards
enough in number and size to store medicines,
disposables investigations and records of the patient.

53. Sr
no
Equipment Number specification
1 Bedside Monitors
(For ICU)
One per Bed Modular -2 Invasive BP,
SPO2,NIBP, ECG, RR, Temp
Probes with trays
2 Monitors for HDU Same Same but without Invasive BP but
upgradeable
3 Ventilator 6 With paediatric and adult
provisions, graphics and Non-
Invasive Modes (Two Ventilators
should be with inbuilt Compressor.
each should have a Fisher and
Paykel Humidifier (These can be
bought directly from F &P
4 Non invasie
ventilators
3 With provision of CPAP and IPAP
5 Infusion pumps 2 Per bed in
ICU 1 Per Bed
in HDU
Volumetric with all Recent
upgraded drug calculations

54. 7 Head end
panel
1 per bed With 2 O2 Outlets, two vacuum,
one compressed air and 12
electric outlets , provision for
Music, Alarm, trays for two
monitors, Two Drip stands, One
Procedure light
8 defibrillator Two with TCP
facility (one standby
Adult and paediatric pads with
Trascutaneous pacing facility
9 ICU Beds
(Shock Proof)
(Fibre)
One for each bed Manoeuvred with all positions
possible with mattress. Now beds
are available which give lateral
positions also
10 Over bed tables One for each bed ALL SS with 6 to 8 cupboards in
each to store Drugs Medicines, side
tray for x-rays, BHT, on wheels
11 ABG machine One + one Facility for ABG and electrolytes
12 Crash trolley Two for ICU + One
for HDU
To hold all resuscitation equipment
and Medicines
13 Pulse oximeter 2 1 for standby

55. 15 Intermittent Leg Compressing
Machine
2 To prevent DVT
16 Airbeds 6 To prevent bed sores
17 Intubating video scope 1 To make difficult intubation easy
18 ICU Dedicated Ultrasound and
Echo machine
1 With recent advances to look
instantly even at odd hours.
Vascular filling, central lines, etc
19 Bedside X ray 1
20 Ambu Mask different sizes 10 Silicon , ETO steriliable

56. It is important to decide what is to be stored
• By the bedside
• At the Nursing station
• Nursing stores
• Remote central store
• Most ICUs lack storage space. They should have a total
of 25-30% of all patient and central station areas for
storage.
• Clean and dirty utility rooms should be separate each
with its own access.
• Disposal of soiled linen and waste must be catered for

57. • The ICU should be fully air-conditioned which allows
control of temperature, humidity and air change.
• Suitable and safe air quality must be maintained at all
times. Air movement should always be from clean to dirty
areas.
• It is recommended to have a minimum of six total air
changes per room per hour, with two air changes per
hour composed of outside air.
• The dirty utility, sluice and laboratory need five changes
per hour, but two per hour are sufficient for other staff
areas.

58. • It is recommended that all air should be filtered to 99%
efficiency down to 5 microns
• For critical care units having enclosed patient modules, the
temperature should be adjustable within each module to
allow a choice of temperatures from 16 to 25 degrees
Celsius.
• Power back up in ICU is a serious issue. The ICU should
have its own power back, which should start automatically in
the event of a power failure.

59. Light in room :
• Natural Light – Access to outside natural light is
recommended by regulatory authorities in USA
• It may be helpful in maintaining the circadian rhythm
• Natural lighting in the unit can decrease power
consumption and the electrical bill which is so
relevant to Indian circumstances.

61. • High illumination and spot lighting is needed for
procedures, like putting Central lines etc.
• They can descend from the ceiling, extend from the wall/
Panel, or be carried into the room.
• Recommended Spot lighting should be shadow free l50
foot candles (fc) strength.

62. • Overhead lighting should be at least 20-foot candles (fc).
• Patients may need rest and quiet surroundings during the
day
• Lights that come on automatically when cupboard doors
or drawers are opened are useful.
• Light switches should be strategically located to allow
some patient control and adequate staff convenience.

63. • The international Noise Council recommends that the
noise level in an ICU be under 45 dBA in the daytime, 40
dBA in the evening. and 20 dBA at night

64. • tough to withstand
• Easy to clean and maintain,
• Metal connections
• Bedside clocks, calendars and bulletin boards help the
conscious patient well oriented and in better moods

65. FLOOR:
• easy to clean, non slippery, able to withstand abuse
• Vitrified non-slippery tiles
CEILING :
• Soiling and break proof due to leaks and condensation.
• It is recommended that no lines or wires be kept or run over
ceiling or underground

67. • It is mandatory to have four covered pans (Yellow, blue,
Red, Black) provided for each patient or may be one set
between two patients two save space and funds.

68. • Every bed should have attached alcohol based anti-microbial
instant hand wash solution source,
• An operation room style sink with Elbow or foot operated water
supply system
• All entrants (Irrespective of Doctors or nurses should don
mask and cap in ICU and ideally an apron which should be
replaced daily)
• No dirty/soiled linen/material should be allowed to stay in ICU
for long times for fear of spread of bad odour, infection and
should be disposed off as fast as possible

71. • All ICUs should be designed to handle disasters both
within ICU and outside the ICU.
• Within ICU may be fire, accidents and Infection or
unforeseen incidents.
• There must be an emergency exit in ICU
• HDU may be the best place if beds are vacant.

72. • Multi-purpose rooms may be a solution which may be used for
meetings, leisure, lectures, library, lounge and break areas with
food services
• This should be in close proximity to the unit
• In Indian situation it is advisable to have separate change rooms
for nurses and doctors.
• Whether or not lockers are provided, female staff tends to keep
purses or bags near them at the bedside, (This should be
discouraged like helmets of male staff cannot be allowed in main
ICU). This can be addressed by providing a secure place for
keeping their belongings in the unit.
• Enough no of restrooms be provided

73. • A central communication area is also needed for
• unit, committee and
• hospital-wide announcements;
• newsletters and memos:
• and announcements of outside events and meetings.
• Bulletin boards are necessary but often unsightly.

75. • It is the area where patient care level is intermediate between
ICU and Floors.
• It is usually located near the ICU complex or within ICU
complex.
• Patients recovered from Critical Sickness.
• patient who are less sick like single organ failure
• Size of such units should be at least 50 % of the main ICU.
•

77. • 1/3 of these Beds may be used as palliative unit for
patients who are terminally sick
• Cutting costs of patients and health service provider
requiring close observation and not needing ICU
• Psychological relief to the family and patients that he is
being observed meant for lesser sick patients.
• It may be handy to public hospitals where there is always
shortage of ICU beds.

78. • Miller’s textbook of anesthesia
• Indian society of critical care medicine guidelines
• ORGANIZATION OF INTENSIVE CARE UNIT AND PREDICTING
OUTCOME OF CRITICAL ILLNESS , Indian J. Anaesth. 2003; 47
(5) : 328-337

79. Thank you !!!!!