DESIGN AND ORGANIZATION OF INTENSIVE CARE UNITSProf. Amir B. ChannaProfessorDepartment of AnaesthesiaKing Khalid University Hospital

Patient Care in the ICU

Critical Care of MORIBUND Patient

Definition of Critical Care:

Care of the problem with which the patient has been admitted.

Patient Care in the ICU

Patient Care in the ICU

1.Holistic Approach2.Challenges General care CNS Respiration CVS Renal Hemopoetic system care Renal replacement therapy

Patient Care in the ICU

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

Patient Care in the ICU

Design of ICUServices required

Patient Care in the ICU

Basic requirement of ICU

Patient Care in the ICU

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

Patient Care in the ICU

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

Patient Care in the ICU

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

Patient Care in the ICU

TYPE, SIZE AND SITE OF AN ICUMedical ICU CCUSurgical ICUBurns ICUPediatric ICUNeonatal ICUsMultidisciplinary ICU

Patient Care in the ICU

TYPE, SIZE AND SITE OF AN ICUNumber of ICU beds1 to 4 per 100 total hospital bedsICUs with less than 4 beds are considered not to be cost effectiveOver 20 non-high dependency beds maybe difficult to manage

Patient Care in the ICU

TYPE, SIZE AND SITE OF AN ICUICU should be sited in close proximity to relevant acute areasOperating roomsEmergency departmentCCULabour wardAcute wardsInvestigational departments (e.g. radiology, organ imaging, and pathology laboratories)

Patient Care in the ICU

TYPE, SIZE AND SITE OF AN ICUCritically ill patients are at risk when they are movedSufficient numbers of liftsWith door and corridorsSpacious enough to allow easy passage of beds and equipmentOften ignored by planning experts

Patient Care in the ICU

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

Patient Care in the ICU

Patient Care in the ICU Correlate changes in vital signs with medication administration and other changes by use of chronologic chartingReview, if indicated: Respiratory therapy flow chart Hemodynamics records Laboratory flow sheets Other continuous monitoring

Patient Care in the ICU

Patient Care in the ICUIntegrate nursing, respiratory therapists, patient, family, and other observations. Review all problems, including adding, updating, consolidating or removing problems as indicatedPeriodically, review supportive care: Intravenous fluidsNutritional status and supportProphylactic treatment and support Duration of catheters and other invasive devices Review and contrast risk and benefits of intensive care.

Patient Care in the ICU

General ICU CareNosocomial infections, especially line-and catheter related.Stress gastritisDeep venous thrombosis and pulmonary embolism Decubitus ulcers Psychosocial needs and adjustments. Toxicity of drugs (renal, pulmonary, hepatic, CNS)Development of antibiotic-resistant organisms.

Patient Care in the ICU

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

Patient Care in the ICU

Nutrition Set goals for appropriate nutrition supportAvoid or minimize catabolic stateAcquired vitamin K deficiency while in ICU Avoidance of excessive fluid intakeDiarrhea (lactose intolerance, low protein,hyperosmolarity drug-induced, infection)

Patient Care in the ICU

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

Patient Care in the ICU

Acute Renal FailureVolume depletion, hypoperfusion, low cardiac output, shockNephrotoxic drugsObstruction of urine outflowInterstitial nephritisManifestation of systemic disease, multiorgan system failure Degree of preexisting chronic renal failure

Patient Care in the ICU

Diabetic KetoacidosisEvaluate degree of volume depletion and relationship of water to solute balance (hyperosmolar component)Avoid excessive volume replacementLook for a trigger for diabetic ketoacidosis (infection, poor compliance, mucormycosis, other)Avoid hypoglycemia during correction phaseCalculate water and volume deficitsEvaluate presence of coexisting acid-base disturbances (lactic acidosis, metabolic alkalosis)Avoid hypokalemia during correction phase

Patient Care in the ICU

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

Patient Care in the ICU

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

Patient Care in the ICU

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

Patient Care in the ICU

Swan-Ganz CathetersSite of placement (safety, risk, experience of operator)Coagulation times, platelet count, bleeding time, other bleeding riskDocument in medical recordEstimate need for monitoring therapy Predict whether interpretation of data may be difficult (mechanical ventilation, valvular insufficiency, pulmonary hypertension)

Patient Care in the ICU

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

Patient Care in the ICU

Upper Gastrointestinal Bleeding Determine when excessive amounts of blood products givenDo antacids, H2 blockers, PPIs play a role?Reversible causes or contributing causes.

Patient Care in the ICU

Fever, Recurrent Or Persistent New, unidentified source of infectionLack of response of identified or presumed source of infectionOpportunistic organism (drug-resistant, fungus, virus, parasite, acid-fast bacillus)Drug feverSystemic noninfectious disease.

Patient Care in the ICU

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

Patient Care in the ICU

Pancytopenia (After Chemotherapy)Fever, presumed infection, response to antimicrobials Thrombocytopenia and spontaneous bleedingDrug feverTransfusion reactionsStaphylococcus, candida, other opportunistic infections

Patient Care in the ICU

Pancytopenia (After Chemotherapy)Infection sites in patient without granulocytes may have in duration, erythema, without fluctuance Pulmonary infiltrates and opportunistic infection

Patient Care in the ICU

DESIGN OF AN ICUSingle entry and exit pointAttended by the unit receptionistNO Through traffic of goodsPeople to other hospital areas must NEVER be allowedRooms for public receptionPatient management and support services.

Patient Care in the ICU

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

Patient Care in the ICU

TABLE I.I Physical Design of a Major ICUReception AreaWaiting room for visitorsDistressed (crying) / interview roomOvernight relatives room

Patient Care in the ICU

TABLE I.I Physical Design of a Major ICUPatient AreasOpen multi-bed wardsCentral nurse station (including drug storage)Specialized rooms/beds if necessary, for procedures/minor surgery (e.g. tracheostomy), haemodialysis, burns, and use of bypass or intra-aortic balloon pump machines.

Patient Care in the ICU

TABLE I.I Physical Design of a Major ICUStorage and Utility AreasMonitoring and electrical equipmentRespiratory therapy equipmentDisposables and central sterilizing suppliesLinenStationeryFluids, vascular catheters and infusion setsNon-sterile hardware (e.g. drip stands and bed rails)Clean utilityDirty utilityEquipment sterilization.

Patient Care in the ICU

Patient Care in the ICU

Patient Care in the ICU

Patient Care in the ICU

Patient Care in the ICU

Patient Care in the ICU

Patient Care in the ICU

TABLE I.I Physical Design of a Major ICUTechnical AreasLaboratoryWorkshop for repairs, maintenance, and development.

Patient Care in the ICU

TABLE I.I Physical Design of a Major ICUStaff AreasLounge/rest room (with facilities for meals)Changing roomsToilets and showersOfficesDoctors on-call roomsSeminar/conference room.

Patient Care in the ICU

TABLE I.I Physical Design of a Major ICUOther Support AreasCleaners roomPlant room/alcove

Patient Care in the ICU

TABLE I.I Physical Design of a Major ICUThe ratio of single room beds to open-ward beds would depend on the role and type of the ICU, built 1:6 is recommendedSingle rooms are essential for isolation cases and (less importantly) privacy for conscious long stay patients.VENTILATION !!!!!!!!!!!!Sufficient numbers of non-splash hand wash basins, one for every two ward beds, should be built close to the beds.

Patient Care in the ICU

TABLE I.I Physical Design of a Major ICUUtilities per bed space as recommended for a level III ICU are:3 oxygen2 air3 suction16 power outletsA bedside lightAdequate and appropriate lighting for clinical observation Services are supplied from floor columnWall mountedBed pendent

Patient Care in the ICU

Patient Care in the ICU

Patient Care in the ICU

Patient Care in the ICU

STORAGE AND SUPPORTING SERVICES AREASMost ICUs lack of storage space. Storage areas should total a floor space of about 25-30% of all.EquipmentStaffingMedical Staff- ICU director- Sufficient specialist staff- Administration- Teaching- Research- Reasonable working hours.

Patient Care in the ICU

Patient Care in the ICU

TABLE I.2 Equipment in a Major ICUMonitoringRadiologyRespiratory TherapyCardiovascular TherapySupport Therapy Dialytic TherapyLaboratory

Patient Care in the ICU

Patient Care in the ICU

Intensive care Unit Bed

Patient Care in the ICU

Use of computers for patient monitoring.

Patient Care in the ICU

ICU BedBedBedBedNurse stationTelemetryWEB connection

Patient Care in the ICU

Some instruments in mind

Patient Care in the ICU

And more...

Patient Care in the ICU

Types of Data Used in Patient monitoring in different ICUs

Patient Care in the ICU

Continuous variables

Sampled variables

Coded Data

Free Text

Cardiac

ECG

Heart rate (HR)

HR variability

PVCs

Temperature

Central

Peripheral

Patient observation

Color

Pain

Position

Etc.,

All other observations or interventions that cannot be measured or coded

Blood pressure

Arterial/venous

Pulmonary

Left/right atrial/ventricular

Systolic/Dyastol

Per beat/average

Systolic time intervals

Blood Chemistry

Hb

PH

PO2

PCO2

Etc.,

Interventions

Infusions

Drugs

Defibrillation

Artificial ventilations

Anesthesia

Respiratory

Frequency

Depth/vol/flow

Pressure/Resist

Respiratory gases

Fluid balance

Infusions

Blood plasma

Urine loss

Neurological

EEG

Frequency components

Amplitudes

Coherence

TABLE I.3 Staff of a Major ICUMedicalDirectorStaff Specialist intensivistsJunior Doctors

Patient Care in the ICU

TABLE I.3 Staff of a Major ICUNursesNurse ManagersNurse SpecialistsNurse EducatorsCritical Care Nurse Trainees

Patient Care in the ICU

TABLE I.3 Staff of a Major ICUAllied HealthPhysiotherapistsPharmacistDieticianSocial WorkerRespiratory Therapists

Patient Care in the ICU

TABLE I.3 Staff of a Major ICUTechniciansSecretarialSecretaryWard Clerk

Patient Care in the ICU

TABLE I.3 Staff of a Major ICURadiographersSupporting StaffOrderliesCleaners

Patient Care in the ICU

TABLE I.3 Staff of a Major ICUNursing Staff1:1 NursingSingle bed requires 6 nurses

Patient Care in the ICU

OPERATIONAL POLICIESClear cut administrative policiesAn open ICU has unlimited access to multiple doctorsA closed ICU has admissionQuality assurance, continuing education and researchConsideration of relativesEffective communicationPhysical environment

Patient Care in the ICU

OPERATIONAL POLICIESOther supportive measuresSocial workerCounselorPriest or religiousFollow-up counselingEmotional support for staffDeath occursFamily should be allowed privacy to mourn, to view, touch, and hold the deceased.

Patient Care in the ICU

Factors influencing outcome from a critical illnessPatient factors - Pervious health status- Physiological reserves- Biological age- Co morbidityDisease factors- Type of disease- Severity of diseaseTreatment factors- Treatment available?- Timing if therapy- Suitability of therapy- Response to treatment

Patient Care in the ICU

Scoring systems for ICU & surgical patients

Patient Care in the ICU

Scoring systems for ICU & surgical patients

Patient Care in the ICU

Scoring systems for ICU & surgical patients

Patient Care in the ICU

TABLE 1: Scoring systems for ICU & surgical patients

Patient Care in the ICU

The APACHE II scoring system Variable Maximum points

Patient Care in the ICU

Scoring of Various Acute physiological Variables A APACHE II

+ 4 + 3 + 2 + 1 + 1 + 2 + 3 + 4

Temperature 41 39-40.9 38.5-38.9 36-38.4 34-35.9 32-33.9 30-31.9 29.9

MAP160 130-159 110-129 70-109 50-69 49

HR180 140-179 110-139 70-109 55-69 40-54 39

RR50 35-49 25-34 12-24 10-11 6-9 5

Oxygenation1500 350-499 200-349 < 200 PaO2> 70 61-70 55-60 < 55pH7.7 7.6-7.69 7.5-7.59 7.33-7.49 7.25-7.32 7.15-7.24 < 7.15

Na+180 160-179 155-159 150-154 130-149 120-129 111-119 110

K+7 6.6-6.9 5.5-5.9 3.5-5.4 3-3.4 2.5-2.9 0.5 record A-aO2FIO2< 0.5 record PAO2

Patient Care in the ICU

Patient Care in the ICU