The ICU is highly
specified and sophisticated area of a hospital which is specifically designed,
staffed, located, furnished and equipped, dedicated to management of critically
ill patients, injuries or complications. 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. No compromise can be made on quality and health care delivery
to the critically sick, yet acceptable guidelines can be adopted for ICU design
that may be good for both rural and urban areas as also for smaller and
tertiary centres which may include teaching and non teaching institutes.
Following
areas are covered.
1
Initial Planning
• Team Formation and
Leader/Coordinator
• Data Collection and
analysis
• Beginning of the
Process and decide about Budget allocation , aims and objectives
2
Decision About ICU Level, Number of beds, Design and Future Thoughts
• Planning level of
ICU like I, Level II or Level III (Tertiary Unit)
• Number of beds and
number of ICUs needed for the institution
• Designing each bed
lay out and providing optimum space for the same
• Modulation
according to various types of space availability
• Free hanging power
columns vs. head end panel facilities
3
Central Nursing Station designing and planning
- Location, space,
Facilities
4
Equipment
• Will depend on
number of beds, Level of the ICU
• Most important
decisions will be No of Ventilated beds and Invasive monitoring
• ICU Vs HDU
• Collecting
information about available equipment with specifications
5
Support System Recommendations
• Storage
• Communication
• Computerisation
• Meeting needs of
Nursing and Doctors
• Meeting needs of
relatives and Attendants
• Relationship and
Coordination with other areas like ER and other support areas
6
Environmental Planning
• Effective steps and
planning to control nosocomial infections
• Flooring, walls,
pillars and ceilings
• Lighting
• Surroundings
• Noise
• Heating/
AC/Ventilation
• Waste disposal and
pollution control
• Protocol about
allowing visitors, shoes etc inside ICU
7
Human Resource development
Doctors, Nurses,
Respiratory Therapist, Physiotherapist, Nutritionist, Pharmacist, Computer
Programmer, etc and support staff like Clerks, social worker, X-ray technician,
Lab technicians, Cleaning staff, etc who are trained to the needs of ICUs.
This is a very
Critical area and turnover is very high because of the big gap between demand
and supply. This can put a lot of stress on the team and patient outcome.
8
Other areas like
• Education
• Research
• Data Collection
• Documentation
• Record keeping
Designing
ICU/Level/No of ICUs/No of Beds and Individual Bed
Following ICU Levels
are proposed
Level
I
• 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
• Able to Ventilate a patient for at least
24 to 48 hrs, including non invasive ventilation
• Non-invasive Monitoring like - SPO2, HR
and rhythm (cardioscope), NIBP, ECG Temperature
• ABG Desirable.
• Able to have arrangements for safe
transport of the patients to secondary or tertiary centres
• The staff should be encouraged to do
short training courses like Fundamentals of Critical Care Support (FCCS) or
Basic Assessment and Support in Intensive Care (BASIC) courses.
• In charge should be preferably a trained
doctor in ICU technology and knowledge
• Blood Bank support
• Should have basic clinical Lab (CBC, BS,
Electrolyte, LFT and RFT) and Imaging back up (X-ray and USG), ECG
• Microbiology support is desirable
• At least one book on Critical Care
Medicine as ready reckoner
Level
II
• Recommended for above 75 bedded or
larger General Hospitals
• Bed strength 8 to 12
• Director be a trained/qualified
Intensivist
• Multisystem life support
• Invasive and Non invasive Ventilation
• Invasive Monitoring
• Long term ventilation ability
• Trascutaneous Pacing
• Access to ABG, Electrolytes and other
routine diagnostic support 24 hrs
• Strong Microbiology support with facility
for Fungal Identification desirable
• Nurses and duty doctors trained in
Critical Care
• CT must & MRI is desirable
• Protocols and policies for ICUs are
observed
• Research will be highly recommended
• Should be supported ideally by
Cardiology and other super specialities of Medicine and Surgery
• HDU facility will be desirable
• Should fulfil all requirements for IDCC
Course
• Resident doctors must be exposed to FCCS
course/BASIC course/Ventilation workshops and other updates
• Blood banking either own or outsourced
Level
III
• Recommended for tertiary level hospitals
• Bed strength 12 to 16 with one or
multiple ICUS as per requirement of the institution
• Multidisciplinary unit headed by
Intensivist
• Preferably Closed ICU
• Protocols and policies are observed
• Have all recent methods of monitoring,
invasive and non invasive including continuous cardiac output, SCvO2 monitoring
etc
• Long term acute care of highest
standards
• Intra and inter-hospital transport
facilities available
• Multisystem care and referral available
round 24 hrs
• Should become lead centres for IDCC and
Fellowship courses
• Bedside x-ray, USG, 2D-Echo available
• Own or outsourced CT Scan and MRI
facilities should be there
• Bedside Broncoscopy
• Bedside dialysis and other forms of RRT
available
• Adequately supported by Blood banks and
Blood component therapy
• Optimum patient/Nurse ratio is
maintained with 1/1 pt/Nurse ratio in ventilated patients.
• Protocols observed about prevention of
infection
• Provision for research and participation
in National and International research programmes
• Patient area should not be less than 100
sq ft per patient (>125 sq ft will be ideal). In addition there is optimum
additional space for storage, nursing station and relatives
• The hospital should an Infection Control
Committee, Ethics Committee, etc
• Doctors, Nurses and other support staff
be continuously updated in newer technologies and knowledge in critical Care
There is regular
sharing of knowledge, mishaps, incidents, symposia and seminars etc related
closely to the department and in association with other specialties
ICU
Staffing
ICU staffing is one
of the most important tasks and components of the whole programme. Dedicated,
highly motivated, ready to work in stress situations for long periods of time
are the type of personal needed. They include
• Intensivist/s
• Resident doctors
• Nurses,
• Respiratory Therapists,
• Nutritionist
• Physiotherapist
• Technicians, Computer programmer,
• Biomedical Engineer, and
• Clinical Pharmacist
• Social worker or counsellor
• Other support staff. Like cleaning
staff, guards and Class IV.
Not only do they have
to be qualified but have to be trained and have to be a team person scarce availability of these qualities has made their availability extremely difficult and
the turn over is high. It may be almost
impossible to implement ideal ICU staffing.
Nursing
staff
• Nursing – 1/1 nursing for Ventilated or
MOFS patients is desirable but in no circumstance the ratio should be < 2
nurses for three patients.
• This will affect the outcome immensely.
• 1/2 to 1/3 nurse patient ratio is
acceptable for less seriously sick patients who do not require above
modalities.
Location/entry/exit
points of ICU in Hospital
• Safe, easy, fast transport of a
critically sick patient should be priority in planning its location. Therefore,
the ICU should be located in close proximity of ER, Operating rooms, trauma
ward, etc
• 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.
ICU
Bed Designing and Space Issues
• 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 addition there
should be 100 to 150% extra space to accommodate nursing station, storage,
patient movement area, equipment
area, doctors and nurses rooms and toilet.
• However in Indian circumstances after
reviewing and feedback from various ICUs india, it may be satisfactory to
suggest an area of 100 to 125 sq ft be provided in patient care area for comfortable working
with a critically sick patient.
• It may be prudent to make one or two
bigger rooms or area which may be utilised for patients who may undergo big
bedside procedures like ECMO, RRT etc and have
large number Gadgets attached to them.
• 10 % (one to two) rooms may be
designated isolation rooms where immuno- compromised patients may be kept.
These rooms may have 20% extra space than other rooms.
• The planners may provide for application
of advanced technology like ECMO, Nitric Oxide, Xenon clearance, lamellar flow
etc. In the future.
Partition
between two room sand maintaining privacy of patients
• It is recommended that there should be a
partition/separation between rooms when patient privacy is desired
• Standard curtains soften the look and
can be placed between two patients which is very common in most Indian ICUs.
However they are displaced and become unclean easily and patient privacy is
disturbed
• Therefore, two rooms may be separated by
unbreakable fixed or removable partitions, which may be of aluminium, wood or
fibre. However permanent partitions take away the flexibility of increasing
floor space temporarily (In Special circumstances) for a particular patient
even when the adjoining bed/room may not be in use.
• There are also electronic windows, which
are transparent when switched is off and are opaque when the switch is on. This
option allows a view of the external surroundings, but presently is expensive.
Pendant
vs. Head End Panel
One of the most
important decisions is to how to plan bedside design Two approaches are usually
practised
1 Head wall Panel
2 Free standing systems (power columns)
usually from the ceiling Each can be fixed or moveable and flexible. It can be
on one or both sides of the patient.
• 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,
• Head wall systems can be oriented to one
side of the patient or to both sides,
• Some units use two power columns, one on
each side of the patient,
• Other units use a power column on one
side in combination with some fixed side wall options on the opposite side,
• Ceiling mounted moveable rotary systems
may reduce clutter on the floor and make a lot of working space available,
However, this may not be possible if the
weight cannot be structurally supported
• Power columns may not be possible in
smaller rooms or units.
• 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.
Height
of Monitoring System
Excessive height may
be a drawback to the way monitoring screens are typically well above eye level
and display more parameters. 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
• A usual problem observed in ICU is getting
access to the head of the bed in times of emergency and weaving through various
tangled lines. And at the same time patient also should not feel enclosed and
surrounded by equipment and induced uncalled for fear
• About 6 inches high and 2 ft deep
step(Made of wood) usually temporary/removable (which would otherwise would
stay there only) is placed between the headwall and the bed lt will keep the bed away from the
wall and automatically gives caregivers a place to stand in emergencies without
too much of problems.
• Lines may be routed through a fixed band
of lines tied together.
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. Self-contained HD machines are
also available (Cost may be high)
Isolation
Rooms
10% of beds (1 or 2)
rooms may be used exclusively as isolation cases like for burns, serious
contagious infected patients or immune suppressed patients.
Alarms.
Music. Phone etc
• However an alarm bell which has both
sound and light indicators must be provided to each patient. Patients should be
instructed in its use.
Oxygen/Vacuum/
Compressed air outlets and No of Electric female Plugs for tertiary centre
Summary of key Recommendation
for Minimal standards in ICU
Standards
|
AIA/AAH (1)
|
IEEE
|
SCCM (2)
|
O2 outlets
|
2 to 3
|
2
|
2 to 3
|
Vacuum
outlets
|
2 to 4
|
3
|
2 to 3
|
Compressed
air outlets
|
1 to 3
|
1
|
1 to 2
|
Electric
outlets
|
7
|
8
|
11 to 12
|
Room size
(sq ft)
|
132
|
-
|
150 to 250
|
Isolation
room
|
150
|
-
|
250
|
Anteroom
|
20
|
-
|
20
|
Unit size
|
-
|
-
|
12 beds
|
Adopted from Don Axon DCA FAIA Losangeles
Recommendations
for Indian ICUs
The following
recommend for Level I and Level II Indian ICUs Unit size 8 to 12 beds
• 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
loose.
Utilities
per bed as recommended for Level III Indian ICUs
3oxygen outlets, 2
compressed air, 2 vacuum (adjustable), 12 to 14 electric outlets, a bedside
light one-telephone outlets and one data outlet. Each group should decide if
they want to provide the patient access to music (audio), telephone etc.
Central
Nursing station
• This is the nerve centre of ICU. Despite
lots of development, the old standard of a central station still holds good and
is endorsed by most guidelines and regulations even today.
• All/nearly-all monitors and patients
must be observable from there, either directly or through the central
monitoring system. Most ICUs use the central station, serving six to twelve
beds arranged in an L, U or circular fashion,
• Patients in rooms may be difficult to
observe and therefore may be placed on remote television monitoring, These
monitors may satisfy regulatory requirements but do not really provide adequate
patient safety if the clarity of the picture is poor.
• Some ICUs have unit pods of about four
or five beds, each served by a separate workstation. Nurses assigned to
patients in the pod form a team,
• 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,
• Careful consideration of what level or
type of activity will occur in the central station will insure adequate space
planning. New equipment purchased over the next decade will probably increase
the amount of desk and shelf space required.
• At times of high use the number of
people in the central station can increase several fold. Having enough space
and chairs to meet needs during such times should be provided for.
• The space should accommodate computer
terminals and printers. A large number of communication cables may be required
per bedside to connect computers and faxes to other departments, as well as to
other institutions and offices,
• Adequate space for charting on the
platform is absolutely important.
• Patients must be easily visible from the
charting area whether the nurse is sitting or standing, taller chairs are often
necessary.
• In case of space constraint, Collapsible
desktops or shelves that can flip up off the wall can be planned
• Space allotted for storage of the
previous charts of patients currently in the unit should also be provided
• 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 labelled
• The latest generation of monitoring
systems allows access to patient data from any bedside; This means that the
doctor who is busy caring for one patient can monitor others without leaving
that bedside.
• Consoles can be programmed to
automatically display critical events from one bedside at several sites without
personnel calling for it. There is need for more effective alarming system with
less noise, which can send signals to CNS as well as remote pager carried by
the caregiver.
• 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.
• The CNS has in charge nursing, duty
doctors/s, clerk/computer guy, machines, store attached and monitors and spare
machines/spares, linen and other ancillaries
Environmental
Requirements
Heating,
Ventilation and Air-conditioning (HVAC) system of ICU
• The ICU should be fully air-conditioned
which allows control of temperature, humidity and air change. If this not be
possible then one should have windows which can be opened (‘Tilt and turn'
windows are a useful design.).
• 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. Where
air-conditioning is not universal, cubicles should have fifteen air changes per
hour and other patient areas at least three per hour.
• The dirty utility, sluice and laboratory
need five changes per hour, but two per hour are sufficient for other staff
areas.
• Central air-conditioning systems and
re-circulated air must pass through appropriate filters.
• It is recommended that all air should be
filtered to 99% efficiency down to 5 microns. Smoking should not be allowed in
the ICU complex.
• Heating should be provided with an emphasis
on the comfort of the patients and the ICU personnel.
• 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.
• A few cubicles may have a choice of
positive or negative operating pressures (relative to the open area). Cubicles
usually act as isolation facilities, and their lobby areas must be appropriately ventilated in line
with the function of an isolation area (i.e. pressure must lie between that in
the multi-bed area and the side ward).
• 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.
• This power should be sufficient to maintain temperature and run the ICU
equipment (even though most of the
essential ICU equipment has a battery backup). Voltage stabilisation is also
mandatory. An Uninterrupted Power Supply (UPS) system is preferred for the ICU
Negative pressure
isolation rooms
(Isolation of
patients infected/suspected to be Infected with organisms spread via airborne
droplet nuclei <5 µm in diameter) In these rooms the windows do not open.
They have greater exhaust than supply air volume. Pressure differential of 2.5
Pa. Clean to dirty airflow i.e. direction of the airflow is from the out side
adjacent space (i.e.. corridor, anteroom) into the room. Air from room
preferably exhausted to the outside, but may be re-circulated provided is
through HEPA filter NB: re-circulating air taken from areas intended to isolate
a patient with TB is a risk not worth taking and is not recommended
Positive
pressure isolation rooms
(To provide protective environment for
patients at Highest risk of infection e.g. Neutopenia, post transplant)These
rooms should have greater supply than exhaust air. Pressure differential of 2.5
– 8 Pa, preferably 8 Pa. Positive airflow relative to the corridor (i.e. air
flows from the room to the outside adjacent space). HEPA filtration is required
if air is returned.
LIGHTING
Light
in room
• Natural Light – Access to outside
natural light is recommended by regulatory authorities in USA,
• This may improve the Staff Morale and
Patient outcome,
• Data suggests that synthetic artificial
daylight use in work environment may deliver better results for night time
workers
• 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.
• Access to natural light also means one
may have access to viewing external environment which may be developed into
green and soothing.
Light
for Procedures
• 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.
Light
required for general patient care-
• It should be bright enough to ensure
adequate vision without eyestrain.
• Overhead lighting should be at least
20-foot candles (fc).
• Higher frequency fluorescent lights and
coated phosphorus lamps may be good for assessing skin colour and tone
• Patients may need rest and quiet
surroundings during the day, Blackout curtains or blinds or Individual eye may
be used, These may be helpful when the staff requires a high level of lighting
at the bedside while the patient is resting.
• Lights that come on automatically when
cupboard doors or drawers are opened are useful.
• Floor lighting may be important for
safety at the bedside and in the hallways at night and should be about l0fc.
• Glare created by reflected light should
be diffused
• Light switches should be strategically
located to allow some patient control and adequate staff convenience.
• A second remote control can be turned
on/off by the nurses/doctors to observe patients intermittently at night
without entering the room and disturbing the patient.
• Hall lights controls should subdivided
into smaller independent areas and dimmer switches may be desirable
The Illuminating
Engineering Society of North America published useful guidelines on this
subject.
Noise
Control in ICU
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 (dBA is a scale that filters out low frequency sounds and is more
like the human hearing range than plain dB)
Standard
examples are
• A watch ticks at about 20 dBA,
• A normal conversation is at about 55
dBA.
• A vacuum cleaner produces -about 70 dBA
• A garbage disposal-- about 80 dBA.
• Noise level monitors are commercially
available.
• lf the unit noise exceeds that level, a
light comes on or flashes to remind the staff to decrease the noise level.
FLOOR,
WALL AND CEILING COVERINGS
Floor
–
• The ideal floor should be easy to clean,
non slippery, able to withstand abuse and absorb sound while enhancing the
overall look and feel of the environment,
• Carts and beds equipped with large
wheels should roll easily over it.
• In Indian context Vitrified non-slippery
tiles seem to be the best option which can be fitted into reasonable budgets,
easy to clean and move on and may be stain proof
• Vinyl sheeting is another viable option,
It can be non-porous, strong and easy to clean, However, the life of Vinyl
flooring is not long and a small damage in one corner may trigger damage of
entire flooring and make it accident prone. It may require frequent replacement
making it an inconvenient choice.
Walls
– Should meet following criteria:
• Durability, ability to clean and
maintain, flame retardance, mildew resistance, sound absorption and visual
appeal.
• It has been very useful to have a height
up to 4to5 ft finished with similar tiles as of floor for similar reasons.
• For rest of the wall soothing paint with
glass panels on the head end at the top may be good choice.
• Wooden panelling has also found favour
with some architects but costs may go high.
• Doorstoppers and handrails should be
placed well to reduce abuse and noise to minimum; it helps patient movement and
ambulation.
Ceiling
• lt is the ceiling surface patients see
most often, sometimes for hours on end, over several days or weeks. In
addition, bright spotlights or fluorescent lights can cause eye strain,
• Ceiling should be Soiling and break
proof due to leaks and condensation.
• Tiles may not the most appealing or
soothing surface, but for all practical purposes it is
easier to remove individual or few tiles for repairs over ceiling in times of
need. Ceiling design may be enhanced by varying the ceiling height, softening
the contours, griddled lighting surfaces, painting it with a medley of soft
colours rather than a plain back ground colour, or decorating it with mobiles,
patterns or murals, to make it more patient and staff friendly.
• It is recommended that no lines or wires
be kept or run over ceiling or underground because damages do occur once in a
while and therefore, it should be easy to do repairs if the lines and pipes are
easily explorable without hindering patient care
Waste
Disposal and Pollution Control
• This is mandatory and a huge safety
issue both for the patient and staff/doctors of the hospital and society at
large
• It is important that all government
regulations (State Pollution control Board in this particular case) should
strictly be complied with.
• 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. This is needed to dispose off different grades of wastes.
Hand
Hygiene and Prevention of Infection
• Every bed should have attached alcohol
based anti-microbial instant hand wash solution source, which is used before
caregiver (doctor/Nurse/relative/Paramedical) handles the patient.
• Water basin at all bedside has not
proven popular and successful because of poor compliance by one and all and
also for reasons of space constraints and maintenance issues.
• An operation room style sink with Elbow
or foot operated water supply system with running hot and cold water supply
with antiseptic soap solution source should be there at a point easily
accessible and unavoidable point, where two people can wash hands at a time.
• This sink should have an immaculate
drainage system, which usually may become a point of great irritation and
nuisance in later yrs or months.
• All entrants should don mask and cap in
ICU.
• 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. Dirty linen should be
replace regularly at fixed intervals.
• All surroundings of ICU should be kept
absolutely clean and green if possible for obvious reasons
Disaster
Preparedness
• All ICUs should be designed to handle
disasters both within ICU and outside the ICU. Outside the ICU may include
inside the hospital and in the city or state.
• Within ICU may be fire, accidents and
Infection or unforeseen incidents.
• Similarly outside the ICU there may be
major or minor disasters like fire, accidents, Terrorist acts etc.
• There must be an emergency exit in ICU
to rescue pts in times of internal disaster. There should be provision for some
contingency room within hospital where critically sick patients may be shifted
temporarily.
• HDU may be the best place if beds are
vacant.
• There should be adequate fire fighting
equipment in side ICU and protection from Electrical defaults and accidents.
• ICU is location for Infection epidemics,
therefore, it is imperative that all protocols and recommendation practises
about infection control and prevention are observed and if there is a break out
then adequate steps taken to control this and disinfect the ICU if indicated.
Meeting
the needs of Care givers, other departments and relatives of Pts
Needs
of doctors and Nurses
• The space and facilities planned for
them are often inadequate. Space is usually scarce and it is tempting to limit
the support areas in favour of larger patient rooms.
• Multi-purpose rooms may be a solution
which may be used for meetings, leisure, lectures, library, lounge and break
areas with food services (microwave, coffeemaker, refrigerator),
• This is especially useful for night
shift staff when the cafeteria is closed, Multipurpose seating, stackable or
folding chairs and a wide variety of lighting options can increase flexibility.
• This should be in close proximity to the
unit (within the same broader complex) and can even have windows with curtains,
blinds, or one-way glass to allow those inside to continue to observe unit
activity,
• Additional space is needed for staff
lockers with areas to change clothes and, ideally, shower.
• Separate areas are required for men and
women,.
• 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.
• A couch with working table and broadband
connected computer is quite handy.
• Optimum number of journals/books,
stationary, view boxes should be provided.
• Enough number of toilets must be
provided
.
Meeting
The Needs Of Families And Visitors
It is very important
to value family members and take care of their needs.
Many features that
ease the stress of facing threat of death because of critical illness may not
be necessarily expensive. Identifying
these needs by acting as a visitor of a patient in ICU may be useful. Some of these may be as
follows:
Signages--Clearly
marked and multilinguistic including English and Hindi + Local Language guiding
them to correct desired location, Once they reach the unit, it should be easy
for them to learn how to gain entry
into the unit.
Waiting
and seating space
• Many guidelines suggest that l-l/2 to 2
seats per patient bed be provided in the waiting area, Despite using this
ratio, many admit that their waiting area is still too small.
• In rural and semi-urban India, there are
large and extended families, This should be reflected in the size of waiting
rooms of institutions that commonly serve such populations,
• Designers can establish several small
areas within a larger space with a variety of seating and lighting options,
Large open rooms may be easier to achieve, but they are often noisy and lack
the capability to provide areas for privacy, intimacy and rest,
• Minimally, a separate small room for
grieving or private conferences should be provided near the unit with soothing
decor and comfortable seating, This may be used for counselling the family
members in times of need.
• One large TV should be provided for them
• Family members often go through periods
when they spend several long hours in the waiting room. In such cases,
recliners or even hideaway beds are greatly appreciated,
• Enough number of restrooms should be
provided.
• Some institutions have their own hotels,
motels, or guesthouses /Dharmshalas.
• Lockers be provided to families, that
can allow them to bring things they need without having to drag them all with
them whenever they come and go.
• Written information about dining
facilities inside and outside the hospital should be available.
• Ideally, a café or tea counter with
refrigerator, microwave, sink and/or vending machines can be provided in or
near the waiting area,
• An information shelf having booklets or
videos on diseases relevant to critical care are helpful.
• Pamphlets for the consumer on critical
care and on advanced directives may be very useful.
• Trained volunteer or social workers can
help families cope and to reduce their anxiety, keep them updated with
compassion about condition, progress, procedures, expenses about the patient.
• SCCM has also recently published a
manual in this regard
Communication
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. lt is better to
plan them because they may be added
after the fact in a less effective or appealing manner.
Summary
• ICU is a highly specialised part of a
hospital or Nursing home where very sick patients are treated.
• It should be located near ER and OT and
easily accessible to clinical Lab. Imaging and Operating rooms.
• No Thorough fare can be allowed trough
it
• Ideal Bed strength should be 8 to 14.
More than 14 beds may put stress on ICU staff and may also have a negative
bearing on patient outcome. <6 Bed strength will be neither viable or
provide enough training to the staff of ICU
• Each patient should have a room size of
>100 sq ft , However a space of 125 to 150 sq ft per pt will be desirable .
• Additional space equivalent to 100 % of
patient room area should be allocated to accommodate nursing stn, storage etc.
• 10% beds should be reserved for patients
requiring isolation.
• Two rooms may be made larger to
accommodate more equipment for patients undergoing multiple procedures like
Ventilation, RRT Imaging and other procedures.
• There should be at least two barriers to
the entry of ICU
• There should be only one entry and exit
to ICU to allow free access to heavy duty machines like mobile x-ray, -bed and
trolleys on wheels and some time other repairing machines.
• At the same time it is essential to have
an emergency exit for rescue removal of patients in emergency and disaster
situations.
• Proper fire fighting /extinguishing
machines should be there.
• It is desirable to have access to
natural light as much as possible to each patient.
• Head end Panels are recommended over
Pendants for monitoring, delivery of oxygen, compressed air and vacuum and
electrical points for equipment use for these patients
• List of equipment and no of Oxygen,
vacuum, compressed air outlets are listed in the guidelines
• Every ICU should have a qualified
/trained Intensivist as its leader
• One doctor for five patients may be
ideal ratio.
• 1/1 Nurse ideally but < 1/2 nurse
–patient ration is recommended for ventilated patients and patients receiving
invasive monitoring and on RRT
• Other personnel needed for ICU have been
listed.
• ICU should practise given protocols on
all given clinical conditions.
• Requirement of Furniture, storage,
light, Noise, flooring, walls, ceiling air- conditioning, ventilation etc have
been described in guidelines in details.
• Needs of doctors, Nurses and relatives
of patients should be carefully observed
• Required standards and equipment for
different levels of ICUs have been mentioned.