Leitlinien und Empfehlungen

MedKlin IntensivmedNotfmed2018 ·113:33–44https://doi.org/10.1007/s00063-017-0369-7Published online: 7 November 2017© Springer Medizin Verlag GmbH 2017

C. Waydhas1,2 · E. Herting3 · S. Kluge4 · A. Markewitz5 · G. Marx6 · E. Muhl7 ·T. Nicolai8 · K. Notz9 · V. Parvu10 · M. Quintel11 · E. Rickels12 · D. Schneider13 ·K. R. Steinmeyer-Bauer14 · G. Sybrecht15 · T. Welte16

1 Chirurgische Universitätsklinik und Poliklinik, Berufsgenossenschaftliches UniversitätsklinikumBergmannsheil, Bochum, Germany; 2Medizinische Fakultät, Universität Duisburg-Essen, Essen, Germany;3 Department of Paediatrics and Adolescent Medicine, Lübeck, Germany; 4 Intensive Care Medicine,Hamburg-Eppendorf University Hospital, Hamburg, Germany; 5 Unit XVII—Department of CardiovascularSurgery, BwZK, Koblenz, Germany; 6 Surgical Intensive Care Medicine and Intermediate Care, UniklinikRWTH Aachen, Aachen, Germany; 7 Interdisciplinary Surgical Intensive Care Unit, UKSH Campus Lübeck,Lübeck, Germany; 8 v. Haunersches Kinderspital, Campus Innenstadt, Munich, Germany; 9 TeachingFacilities, Akademie, Kreiskliniken Reutlingen GmbH, Reutlingen, Germany; 10 Deutsche InterdisziplinäreVereinigung für Intensiv- und Notfallmedizin e.V., Berlin, Germany; 11 Centre for Anaesthesiology,Emergency and Intensive Care Medicine, Universitätsmedizin Göttingen, Göttingen, Germany;12 Neurotraumatology, Allgemeines Krankenhaus Celle, Celle, Germany; 13 Internal Medicine, Neurologyand Psychiatry, Department of Anaesthesiology and Intensive Care Therapy, Universitätsklinikum LeipzigAöR, Leipzig, Germany; 14 Brühl, Germany; 15 Deutsche Interdisziplinäre Vereinigung für Intensiv- undNotfallmedizin e.V., SIN mbH, Berlin, Germany; 16 Department of Pneumology, MHH Hanover, Hannover,Germany

Intermediate care unitsRecommendations on facilities and structure

Electronic supplementary mate-rial

The online version of this article (https://doi.org/10.1007/s00063-017-0369-7) includesthe following appendices: GNPI statementon structure of paediatric IMCs, Inclusioncriteria, and Research strategies. The article isavailable at http://www.springermedizin.de/mk-im. The videos can be found at the end ofthe article under “Supplementarymaterial”.

Introduction

A growing number of patients with in-creasingly complex or specialised dis-eases are being treated in German hos-pitals. The treatment requirements ofsome of these patients are exceeding thecapacity of standard nursing units. How-ever, the severity of these diseases or thetreatment requirements for these specificclinical pictures do not always justify ad-mission to an intensive care unit (ICU).For this reason, an increasing numberof special units (intermediate care units,IMC) are being set up to offer highlyspecialised treatment and close moni-toring, in order to fulfil an intermedi-ate role between the standard care unit(SCU) and the intensive care unit (ICU).

The recommendations of theGerman In-terdisciplinary Association for IntensiveCare andEmergencyMedicine (DIVI)onthe capacity, equipment and structure ofthese units are intended to provide theframework for the setting up and op-eration of IMCs in collaboration withexperts on both an evidence-based andan expert-based basis (where scientificevidence is not available). Where onlyminimal or indirect evidence is avail-able, patient safety is paramount in theformulation of the recommendation. Intheunanimous viewof allDIVI represen-tatives, this has the highest priority forthose entrusted with intermediate careof critically ill and at-risk patients.

Target group

The recommendations on the structureand equipment on IMC apply to adultpatients. The opinion of the GermanSociety for Neonatology and PaediatricIntensive Care Medicine (GNPI) can befound in Appendix 1 (Electronic supple-mentary material).

Definitions

There has not yet been a generally orinternationally binding definition of in-termediate care or of an IMC. An IMCis intended to be a unit where those pa-tients are treated that do not require theresourcesof intensive careunit (ICU),butare too ill or on too highmaintenance fortreatment on an SCU. The English defi-nition of intermediate care, which refersto high-maintenance, usually elderly pa-tients in transition from the inpatient tooutpatient sector and corresponds best toshort-term care (Kurzzeitpflege) in Ger-many, is explicitly not intended here.

It is important, therefore, to distin-guish the IMC from both the ICU andthe SCU:

Definition of intermediate careunit

The IMC is suited to the monitoring andtreatment of patients with moderate orpotentiallysevere instabilityofphysiolog-ical parameters that require equipment-basedmonitoring and organ support, butdo not require organ replacement. Thisincludes patients that require less thannormal intensive care, but more than is

Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018 33

Leitlinien und Empfehlungen

possible on the SCU [1, 2]. The IMCis not intended to replace an ICU. Ofcourse, there may be overlaps betweenthese two forms of unit; whether cer-tain forms of organ support are providedon an IMC rather than on an ICU maydepend on considerations such as thosedetailed below.

The task of the IMC is to care forpatients whose treatment is so intensiveand/or complex that they require con-stant or close monitoring. These are pa-tients whose conditions suggest possiblefailure of one or more organs, or whoseconditions are too serious or unstableafter failure of one or more organs fora return to a SCU and who, therefore,require continuous monitoring. This in-cludes prevention, diagnosis and treat-ment of all medical and surgical diseasesthat could lead to the failure of vitalfunctions. The IMC also offers highlyspecialised treatment, such as neurolog-ical or cardiology treatment (stroke unit,coronary care unit, etc.), to ensure thebest possible standard of treatment [3].

Definition of intensive care unit

The ICU is a specially equipped unitstaffed by specialist personnel to ensurethe medical care of critically ill patients[4]. The critically ill patient is charac-terised by life-threatening disorders of oneormorebodysystemsasaresultofdiseaseor injury:4 Cardiovascular function4 Respiratory function4 Central nervous system4 Neuromuscular function4 Kidneys4 Liver4 Gastrointestinal tract4 Metabolism4 Disorders of temperature regulation4 Haemorrhagic diathesis

Definition of standard care unit

An SCU is an area where the patients be-ing cared for require the special resourcesof a hospital for a procedure or due to theseverity of a disorder, but do not requireconstant monitoring (or support) of vi-tal functions; in addition, patients do notrequire highly elaborate care and there is

no concrete risk of a life-threatening ororgan-threatening disorder.

Distinction between intensive careunit, intermediate care unit andstandard care unit

It is evident from the above-mentioneddefinitions that there is a continuousspectrum of disease severity and treat-ment requirements in the crossoverbetween the three units and a clear dis-tinction is generally not possible. Amongother factors, the allocation of patientsto units also depends on the relevantstructures and facilities and, thus, onthe resources available to the hospital orunit.

For example, the personnel on theSCU and their qualifications (includingnight-time personnel), its technical re-sources (basic ECG monitoring, non-invasive blood pressure measurement,pulse oximetry with central monitoringand alarm function), structural layout(walking distances, audibility of alarmssounds, physician availability) and theexperience of personnel (e. g. in han-dling special, intravenouslyadministereddrugs, recognising developing problems)have a significant influence on treatmentoptions.

The crossover between intermediateand intensive care may be no less fluid.To which unit should non-invasive ven-tilation be assigned? Is invasive bloodpressure measurement or the adminis-tration of catecholamines possible on anIMC?This distinction is extremely vaguein the integrated organisation model (see“Organisational forms”).

Therefore, it is necessary todefine spe-cific admission and discharge criteria.

In this context, the following criteriarepresent an assessment framework [1,2]:a. Impaired or threatened organ func-

tionb. Specialised surgical procedures, con-

ditions or disorders that carry the riskof developing a (potentially) threat-ening dysfunction and thereforerequire close monitoring

c. Specialised pathological findings orlaboratory values

d. Conditions requiring a high level ofcare

“Intermediate Care Unit” can be under-stood as an umbrella term for variouslabels or names that correspond to theabove assessment framework. Such la-bels include:4 Coronary Care Unit/Chest Pain Unit4 High Dependency Care Unit4 Intermediate Care Unit4 Post-Anaesthesia Care Unit4 Step-Down Unit4 Stroke Unit4 Vascular Assist Device (VAD) Unit

The recommendations discussed belowrelate to a general IMC according to theabove-mentioned inclusion and exclu-sion criteria for treatment on an IMC.These need be adapted to local require-ments and conditions and the focus ofeach unit. If more extensive services areofferedonan IMC, staffingand structuralarrangements need to be increased ac-cording to requirements and, conversely,reduced for a less extensive range of ser-vices.

The procedure for developing the rec-ommendations is detailed in the “Meth-ods” section at the end of themanuscript.In general, there is scant scientific evi-dence relating to the structure and facili-tiesof IMCs. Manyrecommendationsaretherefore based on interdisciplinary andinterprofessional expert consensus (as setout below). A “1C” recommendation, forexample, corresponds to a strong recom-mendationbasedonanexpert consensus.

General recommendations

IMC inclusion and exclusion criteria

Key statement

Specific admission and discharge/transfercriteria need to be defined to regulate thetransfer between the various levels of care(intensive care, intermediate care, standardcare). These criteria (for admission to andtransfer from an IMC) should be bindinglyagreed in consultationwith the adjoiningunits (1C).

34 Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018

ThereisaconsensusthateachIMCshoulddevelop specific admission and transfercriteria [1, 5, 6].

In addition to the general criteria forthe admissionor transfer of patients, spe-cific criteria can be applied for certainunits, which take into consideration thetreatmentof specific diseases (e. g. StrokeUnit, Coronary Care Unit) or treatmentsituations (e. g. Weaning Unit). Thesespecific criteria (see Special Section) candirectly affect the structure and facilitiesoftherespectiveunit,whichmaylieabove(or possibly below) the requirements ofa general IMC.

Organisation

Organisational forms

Key statement

The organisational form recommended iseither an integrationmodel within an ICU ora parallel model adjacent to an ICU (withcommonmanagement) or a stand-alone IMC.The choice of organisational form should bechosen according to local factors (1C).

Due to the particular factors in heartsurgery, other organisational forms mayalso be considered and implemented [7].A prerequisite of this is compliance withthe personnel, equipment, layout and or-ganisational requirements cited in thisrecommendation.

Integration model in an intensive careunit [7, 8].Ona combined unit, intensivecare and intermediate care patients aretreated together. The formal allocation toone or other category is made using a listof criteria. The advantages here lie inextremely high flexibility in terms of theassignment of personnel (service plan-ning) and the option of flexible (short-term) personnel management and flex-ible care: nurse:patient ratio. Adjustingtreatment to patient needs is straight-forward and patients do not need to betransferred if their status changes. Thiscan reduce the loss of information andensure optimum continuity of treatment.A physician is permanently present. It isnot necessary to make two sets of equip-ment available (ultrasound, ECG, defib-rillator, transport ventilator, blood gas

analysis [BGA] equipment, etc.). Disad-vantages include the cost of basic equip-ment for each patient bed; the loud andturbulent environment of an ICU for in-termediate care patients that are awake;the difficulty of categorising patients asintensive care or intermediate care due tothe various influences and interests; andthe potential for conflictwhen it comes tobed allocation on interdisciplinary units.The possible advantage of flexible per-sonnel management can be highly de-manding and may also be subject to theinfluence of various conflicts of interest.

Parallelmodel onan intensive careunit[7, 8]. ICU and IMC are separated intodefined areas with differing facilities, butare adjacent to each other and can accessthe same resources. Advantages include:the common use of (technical) intensivecare resources (ultrasound, ECG, defib-rillator, transport ventilator, BGA, etc.);a common administration; the constantpresence of readily available physicians;highflexibility in the exchange of nursingpersonnel between IMC and ICU; uni-fied medical and nursing managementwith uniform standards and treatmentpaths; simplified qualification measuresfor IMC personnel; excellent treatmentcontinuity in the transfer between ICUand IMC with little loss of information;a short transfer distance between IMCand ICU; the possibility of joint moni-toring (a single, central office); immedi-ate support from ICU personnel for IMCpersonnel in medical emergencies; andsimplified patient allocation, with uni-fied medical and nursing managementand improved admission capacity for in-tensive care. Possible disadvantages in-clude: the need tomove patients betweenICUand IMC(transfer to another room);the risk of misallocation of patients onan IMC that should have been treatedin an ICU (insidious development of anintensive care situation with a poor per-sonnel:patient ratio); a possible lack ofaccess to certain hospital departmentsand a possible conflict in bed allocationif intermediate care is interdisciplinary.

Independent intermediate care unit(stand-alone) [7, 8]. This IMC is de-fined as an independent unit in terms of

Abstract · Zusammenfassung

Med Klin IntensivmedNotfmed 2018 ·113:33–44https://doi.org/10.1007/s00063-017-0369-7© Springer Medizin Verlag GmbH 2017

C. Waydhas · E. Herting · S. Kluge ·A. Markewitz · G. Marx · E. Muhl · T. Nicolai ·K. Notz · V. Parvu · M. Quintel · E. Rickels ·D. Schneider · K. R. Steinmeyer-Bauer ·G. Sybrecht · T. Welte

Intermediate care units.Recommendations onfacilities and structure

AbstractA growing number of patients withincreasingly complex or specialized diseasesare being treated in hospitals worldwide.The treatment requirements of some ofthese patients are exceeding the capacityof standard nursing units. However, theseverity of these diseases or the treatmentrequirements for these specific clinicalpictures do not always justify admissionto an intensive care unit. For this reason,an increasing number of special units(intermediate care units) are being set up tooffer highly specialized treatment and closemonitoring, in order to fulfil an intermediaterole between the standard care unit and theintensive care unit. The recommendationsof the German Interdisciplinary Associationfor Intensive Care and Emergency Medicine(DIVI) on the personnel, capacity, equipmentand structure of these units are intended toprovide the framework for the setting upand operation of intermediate care unitsin collaboration with experts on both anevidence-based and an expert-based basis(where scientific evidence is not available).Where only minimal or indirect evidence isavailable, patient safety is paramount in theformulation of the recommendation.

KeywordsOrganization · Personnel · Medical staff ·Equipment

space, organisation and staff. In additionto its clear structure, consistent treat-ment paths are seen predominantly asstrengths. This model represents a goodsolution if there are structural restric-tions in the ICU. It can also be useful asa specialised treatment unit in buildingswithout their own ICU. However, it mustnot be used as a replacement ICU, butrather there should be an agreementwith ICUs at other institutions to ensurethat patients meeting the criteria forintensive care can be transferred at any

Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018 35

Leitlinien und Empfehlungen

time. It can be a disadvantage that: thereis less flexibility for small units in termsof planning nursing rotas; very smallunits need to fulfil minimum nursingcover per shift with two nurses present;there may be a lack of continuity in thetransition from and to the ICU with lossof information; and personnel may havemore difficulty qualifying in intensivecare needs. Units of this kind requirea full technical infrastructure of theirown (ultrasound, ECG, defibrillator,transport ventilation, BGA, etc.). It maybe further to transport patients betweenICU and IMC, with reduced flexibilityin terms of transfers and higher require-ments for documentation (e. g. transferreports, handover protocols).

Integration model in, or parallel modelto, anormalunit [7].Onajointunit, SCUand IMC patients are treated together orin immediately adjacent areas. The for-mal allocation to one or other category ismade using a list of criteria. Advantagesinclude: easier transfer between IMCandSCU; greater incentive for nursing per-sonnel on the SCU to gain higher quali-fications; and better and easier control ofpatient flow in a department with manyhigh-risk patients. Set against this is therisk of lower staff qualifications, espe-cially poor or lacking skills in intensivecare nursing; longer transfer distancesbetween IMC and ICU; lack of conti-nuity during transfer between IMC andICU with loss of information; possiblypoorer physician availability and the lackof a designated, continuous unit director;promptmanagementofemergenciesmaybe hampered and acute patient deterio-ration may ensue; and finally, difficult-to-implement personnel exchanges be-tween IMC and ICU with the possibilityof loss of competence over time.

Bed numbers

Key statement

Units with 10–12 beds are recommended forstand-alone IMC wards. An integration orparallel model is preferable for lower bednumbers. Bed requirements should beindividually determined for each institution.Structural, organisational and facilityrequirementsmust be fulfilled irrespective ofbed numbers (1C).

Scientific evidence on medically recom-mended bed numbers or unit size is notavailable (thismay also depend on the in-dividual organisational form). Predomi-nantly organisational and economic con-siderations can therefore be used here, aswell as the requirements of special pa-tient groups and clinical pictures. Thesize of the “unit” is not the same as thesize of a ward. The latter may be largerand consist of several “units” (see be-low). However, the required structural,personnel and facility criteria must befulfilled irrespective of bed numbers.

For patients undergoing cardiac pro-cedures, 0.75 beds per 100 proceduresinvolving a heart–lung machine are rec-ommended [7]. Various different cal-culation models have been described ina DGAI position paper, although thesehave not been validated (in [9]). It isnot possible to make a generally validrecommendation on the required num-ber of beds. Local requirements must bedetermined for each institution. For ex-ample, the following parameters can beused to calculate requirements.4 Number of patients treated as inpa-

tients in the hospital as a whole4 Disease severity of patients treated as

inpatients (e. g. case mix index)4 De-registration or refusal rates due

to a lack of ICU beds for surgicalprocedures, emergency patients,transfers from other hospitals, etc.

4 Rates of “mis-allocation” of patientsnot requiring intensive therapy toICUs

4 Rates of (unplanned) transfer fromSCUs back to ICUs due to complica-tions

4 Excessive demands (on staff) andundertreatment (of patients) onSCUs

4 Where available: deployment ofa rapid response team or numberof modified early warning score(MEWS)-triggered alarms

4 Mortality in the case of selecteddiagnoses (e. g. sepsis, pneumonia,pancreatitis, coronary infarction,stroke, femoral neck fracture)

At least 10–12 beds are recommended forstand-alone wards [3, 5, 6, 10]. It makeslittle economic sense to equip smallerunits with the required structure. If theIMC is linked to another acute medicinedepartment (e. g. parallel model ICU),then bed numbers can be lower [3, 6].There is no reliable information on anupper limit for bed numbers in an IMC.Sizes of 22–28 beds have been estab-lished. There is a tendency to considervery large units more difficult tomanage.Dividing larger units into smaller unitsof 10–12 beds is recommended.

36 Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018

Range of services offered byhospitals with an IMC and their(24 h) availability

Key statement

The following services should be available inhospitals with an IMC (1A):24-Hour availability (presence)4 Conventional X-ray4 Computer tomography4 Bronchoscopy4 Ultrasound

24-Hour availability on site or asa cooperationmodel within 30min4 Interventional cardiology diagnosis and

therapy4 Surgical capacity for emergency proce-

dures4 Gastroscopy4 Bloodbank and competence in transfusion

medicine4 Clinical chemistry laboratory4 ICUa

Availabilitywithin 24 h (on call or asa cooperationmodel)4 MRI4 Angiography/digital subtraction angiog-

raphy (DSA)4 Neurology4 Microbiology4 Pharmacy4 Hygiene

Additional servicesmay be necessarydepending on special requirements of thepatient collective.aIn institutionswithout an ICU, provisionmustbe made for transfer to an ICU elsewhere.

Key statement

In hospitals with an IMC, the followingspecialistmedical expertisemust be available(1A):24-Hour availability (presence)4 Internal medicine4 Surgery4 Anaesthesiology

24-Hour availability (on call within 30min)4 Additional specialist presence may

be necessary depending on specialrequirements of the patient collectivea

aFor more details, the reader is referred to therecommendations of specialist societies orcertification institutions, e. g. Stroke Units [6,10–12] or Chest Pain Units [13, 14].

The services maintained by a hospital toensure safe treatment of adequate qual-

ity for severely ill or at-risk patients isbased on a medical assessment regardedas equally necessary by numerous na-tional and international specialist soci-eties and committees [3, 6, 7, 15]. Fallingshort of this standard would lead to se-rious complications—which can be ex-pected in IMC patients and are indeedtherationalebehindtheirmonitoringandtreatment on an IMC unit—that cannotbe treated with the due (specialist) andprompt standard care.

Procedures on the unit

Key statement

Regulations for medical rounds, instructionson organisational and uniform medical care(between ICU and IMC) and visiting hoursetc., need to be specified in writing (1C).

Bothintermsoforganisationandmedicaltreatment, an IMC requires clear, con-sistent and thorough regulations for thesmooth running of the unit. This appliesto all patients, irrespective of the medicalspeciality responsible for the treatmentoftheunderlyingdisease. These regulationscover the entire spectrum of basic care,monitoring of vital functions and gen-eral therapies and prophylaxis. Special-ist departments treating patients on anIMCneed todevelopabindingconsensusfor this. Independently of this, specificmedical decisions, particularly those forthe treatment of underlying diseases bythe treating discipline, must be made inagreementwith themedicalmanagementof the IMC.

Thefollowingregulations inparticularneed to be set:4 Regular rounds/consultations of all

disciplines and professional groupsinvolved in treatment [1]

4 Instructions, standard operatingprocedures (SOPs), algorithms,guidelines or instructions, etc. fororganisational and general areas(hygiene plans, provisions, responsi-bilities, etc.).

4 Instructions, SOPs, algorithms,guidelines or instructions, etc. formedical areas (difficult airway man-agement, sedation/delirium, nutri-tion, non-invasive ventilation (NIV)/

bronchial toilet, the clinical picturesto be treated, frequently performedprocedures) [5]

4 Regulation of visiting hours

Quality assurance

Key statement

Documented and transparent internal qualityassurance should be carried out on the IMC,as well as an at least annual report onperformance figures and results and, wherepossible, an external quality assurance (1C).

General criteria or parameters and in-struments for an external quality com-parison of IMCs have not yet been estab-lished. Nevertheless, quality assurancemeasures as established in medicine ingeneral, and in intensive care medicinein particular, can be carried out. Theseinclude (without any claim to exhaus-tiveness) interdisciplinary and interpro-fessional case conferences,morbidityandmortality (M&M) conferences, infectionstatistics, complication statistics and thecollectionofprocess parameters. Peer re-view can also be carried out on the IMC.With the exception of quality indicatorsfor ventilation, the quality indicators ofthe Peer Review process in intensive caremedicine can also be applied on the IMC.

The basis for this is regular report-ing, which should include data onpatientnumbers, patient flow, treatment mea-sures, cost description (e. g. therapeuticintervention scoring system [TISS]-28,or similar) and other items, in additionto the above information.

External quality and benchmarkinginstruments have already been estab-lished for specific areas [6, 15, 16].

Special recommendations

Admission, exclusion anddischarge criteria

Key statement

The criteria for the admission of patients to anIMC, for transfer from an IMC and for patientswho should not be placed on an IMC shouldbe based on the list below (1C).

Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018 37

Leitlinien und Empfehlungen

The use of criteria for the admission ofa patient to an IMC is strongly recom-mended, as well as criteria on the basisof which they should not be admittedto an IMC, but instead require intensivecare treatment. It should also be speci-fied when a patient can be transferred toa SCU and when transfer to an ICU isrequired. Additional or modified criteriacan be defined for specialised IMCs. Forunits that do not meet the recommendedstandards, the admission criteriamust bemodified such that only patients that canbe safely cared for with the available re-sources are admitted. The following cri-teria are recommended largely as a basisfor the development of the relevant listof criteria. This list also represents a ba-sis for setting requirements in terms ofstructure and equipment for the IMC.

Admission criteriaGeneral.4 Need for monitoring more than

6×/day or every 4 h4 Absence of criteria requiring admis-

sion to ITS4 Increased need for care

The increased need for care could, e. g.be defined according to the Swiss clas-sification in categories 2 and 3 (in spe-cial cases also 1A and 1B, if any of theother criteria below are present) on thebasis of the nine equivalents of nursingmanpower (NEMS) and the Richmondagitation–sedation scale (RASS) [3]. Thenursing activities score (NAS) offers an-other possibility, although this is not cur-rently widespread in Germany [17–19].

A. Cardiac System.4 Exclusion of acute myocardial infarc-

tion [1]4 Non-ST elevation myocardial infarc-

tion, haemodynamically stable [1,14]

4 Arrhythmia, haemodynamicallystable [1]

4 Haemodynamically stable patientwithout myocardial infarction, butrequiring a temporary cardiac pace-maker [1]

4 Acute heart failure without shock(Killip Class I, II) [1]

4 Hypertensive emergency withoutevidence of acute organ damagerequiring treatment [1]

B. Respiratory System.4 Patients with mild respiratory fail-

ure or the risk of deteriorationof respiratory failure requiring closemonitoring and/or intermittent respi-ratory support (e. g. NIV/continuouspositive airway pressure [CPAP]/highflow oxygen) [1]

4 Patients who require close checkson vital parameters or intensiverespiratory physiotherapy (e. g.tracheal aspiration more often than3×/day) [1]

C. Neurological System.4 Acute neurological–neurosurgical

picture with the need for frequentneurological examination or frequentsuctioning of the oral cavity orpositioning [1]

4 Disoriented patients requiring closemonitoring and examination forsigns of neurological deterioration[1]

4 Stable neurological patients requiringcerebrospinal fluid (CSF) drainage[1]

4 Patients with chronic neurologicaldisorders, e. g. neuromuscular dis-ease requiring frequent care measures[1]

D. Poisonings and Overdoses.4 Any patient requiring frequent

neurological, respiratory or car-diovascular monitoring followingpoisoning or overdose and that ishaemodynamically stable [1]

E. Gastro-intestinal Disorders.4 Gastro-intestinal bleeding with mild

orthostatic hypotension that reacts tovolume administration [1]

F. Endocrine System.4 Diabetic ketoacidosis requiring

continuous and constant intravenousinsulin administration or morefrequent insulin injections in theearly phase once ketoacidosis hasbeen controlled [1]

4 Hyperosmolar syndrome with in-creased risk of coma [1]

4 Thyrotoxicosis, hypothyroidismrequiring close monitoring [1]

G. Surgical Conditions.4 Postoperative patients following

major procedures that are haemody-namically stable but with an increasedneed for volume and transfusion,caused by large fluid shifts [1]

4 Stable postoperative patients but witha high postoperative risk of bleeding(e. g. following mass transfusion, tak-ing anticoagulant therapy, bleeding atthe end of the procedure)

4 Postoperative patients requiring closenursing care and monitoring, e. g.following carotid endarterectomy,peripheral vessel reconstruction,V-P shunt revision, kidney transplant[1]

H. Other.4 Treated and regressing sepsis without

shock or secondary organ failure [1]4 Patients requiring close monitoring

of fluid management [1, 20]4 Obstetric patients during pregnancy

or post-partum with (pre)eclampsiaor other medical problems [1]

4 Any patient requiring frequentmonitoring or very complex woundmanagement that does not fall intoany of the above categories (e. g.Addisonian crisis, acute renal failure,delirium tremens, hypercalcaemia)[1]

Exclusion criteriaThe following conditions are usually notsuitable for admission to an IMC. Theseshould also be locally defined and mayvary depending on the equipment onthe unit, the experience of the treatmentteam, the type of patient or the diseasecondition.4 Acute ST-elevation myocardial in-

farction, acute coronary syndromewith haemodynamic instability, tem-porary pacemaker, haemodynamicinstability of other cause, pulmonaryoedema with the risk of an indicationfor intubation or the risk of heartrhythm disorders [1, 21]

38 Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018

4 High catecholamine requirementsor sharply varying/increasing dose,drugs requiring extensive haemody-namic monitoring

4 Acutemechanical circulatory support[20]

4 Patients with shock (septic, haem-orrhagic, cardiogenic, anaphylactic)[20]

4 Acute dialysis, continuous renalreplacement therapy (CRRT)

4 Patients with acute respiratory failurethat have recently been intubated orin whom intubation may be required[1]

4 Patients with an endotracheal tube4 Patients requiring extensive invasive

haemodynamic monitoring (PiCCO,pulmonary artery or right atrialcatheter or similar) or cranial pressuremeasurement [1, 20]

4 Patients in status epilepticus [1]4 Patients with elevated cranial pressure

[20], subarachnoid haemorrhage(SAH) with vasospasm [20]

Transfer/discharge criteria4 If the patient’s condition does not

require intensive monitoring andtreatment is possible on an SCU [1]

4 If the patient’s condition has deterio-rated to the extent that active organreplacement is required or probablyrequired, transfer should be madeto the ICU based on a unit-specificprotocol [1]

Staffing

Medical personnel (number,qualification, availability)

Key statement

A unit director and a deputy should beappointed. The director should be boardcertified in intensive care and the deputyshould be a specialistwith at least 1 year’sexperience in intensive care (1C).The director or deputy should do daily roundsand visit all patients on the unit at least twicea day on all normal working days (1C).The continuous presence of a physician isrequired and may be organised at night andweekends in the form of an on-call service inthe hospital. The on-call servicemust reachthe patient within 5min. The unit physicians(including the on-call service)must know thepatients. (1C).It is essential to ensure that a specialist withknowledge of intensive care can be presenton the unit at any time (within 5min) (1C).

The 1998 recommendation that respon-sibility for the management of an IMCshould be taken by an appointed directorwho isboardcertified in intensive care [1]has since been unreservedly confirmedby numerous specialist societies and isconsidered to be medically indispens-able. As well as organisational respon-sibility, the management function alsocomprises, in particular, specialist mon-itoring, further education and trainingof doctors and nurses on the unit. Mak-ing bedside visits twice daily representsa minimum requirement for assumingmedical responsibility. Continuous spe-cialist monitoring must also be ensured(see below) and should be largely cov-ered by the director and deputy. In theintegration model and the parallel mod-els, joint management of intensive careand intermediate care simultaneously isdesirable and beneficial. There can beseparate managements for stand-aloneIMCs, but simultaneous management isalso possible, assuming the prerequisitesare fulfilled (full-timemanagement of in-tensive care, twice daily patient roundson normal working days).

A clearly regulated and appointeddeputy with comparable competence isrequired to compensate for absences dueto official trips, holiday and illness, etc.without loss of quality. In all current

Swiss guidelines on the recognition ofIMC [3] for appointed deputies, a spe-cialist with 12 months of intensive caretraining or 6 months of intensive caretraining plus 6 months of training inemergency admissions or anaesthesia oron an IMC are required. Extrapolatedto the German training regulations, thiswould mean, in addition to specialistphysician status, formally verifiable qual-ification in the form of evidence of boardcertification in intensive care or boardcertification in emergency medicine orthe anticipated future board certificationin clinical emergency medicine.

In thepast, a continuousmedicalpres-ence was not regarded as essential onan IMC [7–9]. However, it is indis-putable that there are numerous situa-tions when the presence of a physicianis essential [7, 9]. Examples include sit-uations such as the status of a patientless than 2 h following extubation, dur-ing admission and discharge procedures,patients with unstable vital functions andlarge case numbers. Typical serious com-plicationscanoccurinparticularlyat-riskand ill patients on an IMC as a result ofacutely deteriorating vital functions oremergencies. The immediate availabil-ity of a physician who knows the patientwithin a maximum of 5min is now con-sideredessential [7, 9]. Toensure this, theIMC physician on duty should not per-form any activities that keep him/her outof or away from the IMC even for a shorttime. S/hemust stay on theward or in theimmediate vicinity. The Swiss guidelinesrequire that it must be possible to carryout emergency measures at any time [3].Certainly, a response time of 5min ap-pears relatively long for patients knownto be sick and under medical care. It istherefore essential that the IMC physi-cian is also actually continuously presenton the ward, is immediately close by orhis/her on-call room is in direct proxim-ity to the IMC.

Specialistmonitoringmustbe ensuredby a physician with at least 1 year’s expe-rience in intensive care in cases where itcannot be performed by the director ordeputy (e. g. during on-call times). Con-tinuous specialist monitoring by a physi-cian board certified in intensive care isconsidered essential [3, 7].

Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018 39

Leitlinien und Empfehlungen

Table 1 Listing of technical equipment required formonitoring anddiagnostic procedures

Recommen-dationa

Comment

Electrocardiographic/heart rhythm 1 Ca –

Non-invasive blood pressure measurement 1 Ca –

Intra-arterial blood pressure measurement 1 Ca –

Central venous pressure measurement 1 Ca –

Temperature 1 Ca –

Pulse oximetry 1 Ca –

Breathing ratemeasurement 2 Ca –

Monitoring with connection to a central point 1 Ca –

Blood gas analysis 1 Cs Including lactate, glu-cose, electrolytes

Arrhythmia monitoring 2 CaFS3 and FS2(cardiac surgery)1 Ca

–

ST analysis 2 CaFS3 and FS2(cardiac surgery)1 Ca

–

Bed scales 2 Cs –

Mobile 12-lead ECG 1 Cs –

Transport monitor 1 Cs –

Bronchoscopy 1 Cs –

Ultrasound (including Doppler) 1 Cs –

Transthoracic echocardiography 1 Cs –

Transoesophageal echocardiography FS2 (cardiacsurgery) andFS3

Available in the hospital

Transcranial Doppler, colour duplex ultrasound Only FS4: 1 Cs –

X-ray equipment, mobile 1 Cs –

Capnometry 1 Cv –

Electroencephalography and EVOPS FS4: Available inthe hospital

–

aStrength and type of recommendations defined in. Table 4

Special requirementsmust also be ful-filled for specialised IMCs such as StrokeUnits. The German [6] and Swiss [10]regulations cited as an example here havecomparable validity in other countriesand throughout Europe [11, 12]. Usingthe regional Stroke Units in Germany asan example, management by a neurolog-ical or medical specialist, the presence ofat least two neurological specialists in thehospital and the assignment of a physi-cian to the StrokeUnit at all times (whosetime for other tasksmust not exceed 20%of his total work time) is required. Fortransregional Stroke Units, managementmust be by a neurology specialist andthere must be a 24 h medical presence

(neurology specialist or in further neuro-logical training), on weekdays through-out the day a minimum 12 h presenceof a physician dealing exclusively withpatients on the stroke unit (without ad-ditional tasks). In Switzerland, similarrequirements are specified for the man-agement of a stroke unit and the presenceof a neurologist and other specialist dis-ciplines.

Nursing personnel (number,qualification)

Key statement

A head nurse and a deputy should beappointed for the unit. The head nurse shouldhave specialist training in intensive care andat least 3 years’ working experience on anICU. The deputy should have at least specialisttraining in intensive care or intermediate care(1C).The head nurse should have a clearly defineddaily period specifically identified in theroster for administrative and organisationalmanagement tasks, during which s/he shouldnot be involved in any patient care tasks (1C).The nurse:patient ratio should be at least 1:4.A higher ratio is required for higher treatmentrequirements. A minimumof two nursesshould be present in the unit at all times. Atleast one nurse with specialist intensive caretraining should be present during each shift(1A)a.At least 20% of nurses in the whole teamshould have training in intensive care. Theremaining nursing staff should have trainingin intermediate care or have passed thenursing examination (1C)a.aCompliancewith this key statement shouldbe achieved on at least 95% of shifts.

There is no doubt among nursing andmedical associations that a unit of thishigh level of specialisation with severelyill patients requiring far more than thepossibilities of a normal unit requiresa dedicated and competent head nurse.Severely ill patients on an IMC are usu-ally in transition to an ICU, so headnurses require a qualification resultingfrom further training in intensive care.A minimum of 3 years of working on anICU is strongly recommended [1]. Thehead nurse also requires structured timeavailable in order to fulfil administrative,organisational, nursing, medical and in-structing tasks. Themedical director andthe head nurse must be in constant con-tact. Therefore, sufficient time must beallowed in the job planning and dutyroster without duties in patient care [1].As a guide, units with 12 beds or moreare assumed to be a full-time position(without working in patient care).

A deputy head nurse is needed fortimes of absence. Their qualificationsshould be sufficiently high to allow noreduction in quality.

40 Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018

A ratio of one nurse to four patients(1:4) is required to cover patients thatmeet the admission and transfer criteriafor an IMC. There is evidence of a clearassociation between nurse:patient ratiosand morbidity and mortality for ICUs,where a ratio of less than 1:2 was asso-ciated with a poorer result. It is highlyprobable that a similar association alsoexists for IMCs and corresponds withthe experiences of most IMC operators.Generally, the ratio of 1:4 is regardedas the minimum requirement for IMCby a wide variety of medical societies ina large number of countries [5, 8, 15,23]. Numerous medical societies con-sider a nurse:patient ratio of 1:3 to benecessary [7, 8, 15, 22, 23], dependingin part on the severity of the disease orthe time of day 1:2 [7, 8, 15].

In some models, e. g. Switzerland,a flexible nurse:patient ratio is promoted,depending on the severity of the dis-ease and nursing costs [3]. As a sup-plement to the Swiss calculation model,other calculation systems for patient-de-pendent nursing staff requirements ac-cording to patient numbers have beensuggested [24, 25]. Such highly flexiblepersonnel requirements (changing fromday to day, sometimes hour to hour) aredifficult to implement, so it may be as-sumed that, with bed allocation consis-tent with the above admission criteria,there is an averagely even distribution ofnursing staff, chiefly depending on bedallocation. However, prior commitmentsmust always be taken into account.

It has been shown inGreat Britain thatthe nurse:patient ratio was on average 1:3across the country and worse than 1:4 inonly 16%of IMCs [26]. It was also shownthat using a TISS-28 of on average 23 andanursingdependency score ofonaverage1.0, cover of at least 1:2 would have beenrequired [27].

By nurses, one means a fully qual-ified nurse [3], as a minimum require-ment for care of such severely ill patients.Personnel with lower qualifications arenot regarded as sufficiently competentto ensure the safety of patients to therequired extent. We recommend usingonly nurses with at least 1 year of pro-fessional experience [9]. A specific re-quirement profile has been defined for

IMC nurses [2]. A rotation of nursesbetween intensive care and intermediatecare is recommended as highly desirableand as an approach to staff qualificationand personal development.

At least one nurse with specialist in-tensive care training should be presentduring each shift. Compliance with thiscover should be achieved on at least 95%of shifts. For specialised patient groups,e. g. on the stroke unit, additional qual-ifications may be required [3, 6].

Furthermore, at least 20% of nursingpositions in the team should be coveredby nurses with specialist training in in-tensive care.

Specialist traininginintermediatecareis now being recommended by the Ger-man Hospital Association, which maycontribute to an increase in specialistcompetence in nursing. However, thisdoes not replace a basic component (seeabove) of nursing competence with spe-cialist training in intensive care.

It is recommended that staff positionsfor mentors for specialist training shouldbe budgeted for [9, 22]. The greatestchallenge for IMCs in the coming yearswill be the funding of the next generationnurses and commitment to one’s ownestablishment.

Physiotherapy

Key statement

Physiotherapy should be available every day(including weekends and public holidays)(1C).

Physiotherapy is a key component of thetreatment of critically ill patients [1]. Ata minimum, physiotherapy should beprovided on at least 5 out of 7 days [5].Whether this is actually sufficient is re-garded critically, and daily physiotherapyis considered essential by the majorityof authors [6, 7, 10, 15]. There is evi-dentlynobasis inmedical argumentationfor two or sometimes more days withoutphysiotherapy. Integrating physiothera-pists into the care teammay be beneficial[3].

Other personnel

Key statement

Additional posts should be made available fornon-patient-related activities (logistics,ordering systems, patient transport,telephone service/officework) (1A)

Key statement

The following personnel functions should beavailable 24 h a day (1A):4 Cleaning staff4 Specialist personnel (e. g. cardio techni-

cians, respiratory therapists) dependingon specific diseases, insofar as the relevanttasks cannot be taken on by nursing staff

Key statement

The following personnel functions should beavailable on weekdays at least (1A):4 Social services4 Hygiene officer4 Clinical pharmacy4 Psychologist4 Logotherapy/swallowing therapya

4 Ergotherapya

4 Unit secretary4 Support staff (logistics, ordering systems,

etc.)

The following staff functions are desirable(2C):4 Nutritional advice4 Care assistant

aRequired for specific diseases/IMC criteria.

Medical and nursing personnel mustbe supplemented by other professionalgroups and staff in terms ofwork sharing,competence and responsibility, as well assmooth and safe functioning of the unit.Comprehensive recommendations weremade on this by the American Collegeof Critical Care Medicine [1] and areequally valid for Germany [9, 22].

Regular support of the IMC by a clin-ical pharmacy, a clinical pharmacologistor as part of an Antibiotic Stewardship isurgently recommended [1]. An investi-gation of a before and after comparisonon a coronary care unit showed that thedrug costs per admission could be sig-nificantly lowered from US$ 374.05 toUS$ 233.0 by including a clinical phar-macist. Thegreatestportionof this savingwas on sedatives, oral use of antibiotics,

Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018 41

Leitlinien und Empfehlungen

Table 2 Listing of technical equipment required for therapeuticmeasures, procedures or inter-ventions

Recommen-dationa

Comment

Oxygen Insufflation 1 Ca –

Resuscitation bag 1 Cv –

Non-invasive Ventilation equipment 1 Cv or s Number depending onorganisation, includinga range of interfaces

High-flow oxygen administration 2 Cs –

Transport respirator 1 Cs –

Equipment for inhalation therapy 1 Cv –

Airway suction equipment 1 Cv or a –

Equipment for physical respiratory therapy 1 Ca or v –

Equipment for enteral nutrition 1 Cv –

Infusion and injection pumps 1 Ca Per bed1–2 infusion pumps3–4 injection pumps

Emergency equipment 1 Cs –

Defibrillator 1 Cs –

External cardiac pacemaker 1 Cs –

Cooling/warming procedure for patients 1 Cv Available in hospital

Suction device (for chest drainage, etc.) 1 Cv –

Special beds (e. g. for decubitus prophylaxis ortherapy, heavy duty beds)

1 Cv Do not need to be avail-able but must be deliv-ered promptly

Mobilisation aids 1 Cs –aStrength and type of recommendations defined in. Table 4

Table 3 Discription of the level of recomemendation accordung to the criteria by Guayatt et al[30]

1A Strong recom-mendation

High quality evidence, high quality RCTs,very strong data from observationalstudies, legal situation

Unlimited application tomostcircumstances

1B Strong recom-mendation

Good evidence, RCTs with limitations,strong data from observational studies

Unlimited application tomostcircumstances

1C Strong recom-mendation

Weak evidence, observational studies,case series, expert opinion

Could change if better evidencebecomes available

2AWeak recom-mendation

High quality evidence, high quality RCTs,very strong data from observationalstudies

Can depend on circumstances,patients, social values

2BWeak recom-mendation

Good evidence, RCTs with limitations,strong data from observational studies

Can depend on circumstances,patients, social values

2CWeak recom-mendation

Weak evidence, observational studies,case series, expert opinion

Very weak recommendation,other alternatives could beequally beneficial

improved antibiotic selection, a consid-eration of interactions and the avoidanceof double orders [28, 29].

Technical equipment

Key statement

The technical equipment in the following twotables for should be available for monitoring/diagnosis and treatment.

Monitoring and diagnosisThe equipment given in. Table 1 shouldbe available. Numerous existing recom-mendationshave been taken into accountin the present recommendation [3, 5–7,9, 15]. An explanation of the recom-mendation coding can be found in the“Methods” section.

TreatmentThe equipment given in. Table 2 shouldbe available. Numerous existing recom-mendationshave been taken into accountin the present recommendation [3, 5–7,9, 15]. An explanation of the recommen-dation coding can be found in the in the“Methods” section.

Spatial configuration

The recommendations for spatial setupand configuration contain some gener-ally valid recommendations, and somerules and regulations have been takeninto account that may be specific toGermany (e. g. DIN specifications).The full recommendations on spa-tial configuration can be seen on theDIVI homepage (http://www.divi.de/empfehlungen/imc-entwurf.html).

Methods

Advice on methodology was providedby Christoph Mosch, Institute of Re-search in Surgical Medicine (IFOM) atWitten/Herdecke University, Ostmer-heimer Str. 200, 51069 Cologne, eMail:christoph.mosch@uni-wh.de.

Literature search

TheSummary of Abstracts was a system-atic overview of all relevant publications(01 January 1990 up to 27 June 2014) thatprovide information on the structural/organisational/structural requirementsand staff/technical equipment for pa-tient care on IMCs, i. e. transition wardsbetween ICU and follow-up treatmenton an SCU. The literature search wasrepeated with the same criteria for theperiod from 28 June 2014 to 22 Novem-ber 2015. Recommendations were alsosought from German, European and

42 Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018

Table 4 Type, strengthandscopeofappli-cationof the recommendationson technicalequipment

1C Urgently required basic structure andbasic equipment

2C Strongly recommended structure andequipment

FS Specifically required structure andequipment (5 specialities)

FS1 Anaesthesia

FS2 Surgery (general and visceral surgery,cardiac surgery, thoracic surgery,orthopaedics and trauma surgery,burns medicine, transplant surgery)

FS3 Internal medicine

FS4 Neuromedicine (neurology, neuro-surgery)

FS5 Paediatric and adolescentmedicineincluding neonatology

a Permanently available at all beds

v Available on the unit and promptly orimmediately deployable at all beds

s At least one device/article availableon the unit ready for use

North American specialist societies thattreat patients in IMCs and ICUs.

Approach to study identificationand selectionTo obtain a global view of the ques-tion, the search was extended to weaningunits, post-operative monitoring roomsand Stroke Units. Paediatric IMCs werealso included in the Summary of Ab-stracts (without neonatology).

After establishing the inclusion crite-ria (see Appendix 2, Electronic supple-mentarymaterial) andcreatinga researchstrategy (see Appendix 3, Electronic sup-plementarymaterial) incooperationwiththe clinical contact, the systematic liter-ature research was carried out in twoelectronic databases (MEDLINE [usingPubMed] and EMBASE). The publica-tions identified were checked by two in-dependent colleagues for title/level of ab-stract for their fulfilment of all inclusioncriteria. Where there were deviations,a consensus was found by discussion ofeach abstract regarding inclusion or ex-clusion. Similarly, all publications in-cluded at the abstract level were checkedand thematically grouped in the full textby twocolleaguesworking independentlyof each other.

ResultsAfter carrying out the systematic searchon 27May 2014, a total of 911 potentiallyrelevant publications were identified (af-ter eliminating duplicates). In the title/abstract screening, a total of 73 publica-tions were included and checked in thefull text. A total of 23 full texts wereused as the basis for evidence (see flowchart). For the supplementary period ofthe second research, three publicationswere checked in the full text, of whichone was used as the basis for evidence.

Consensus finding

A first draft was compiled by one of theauthors (C.W.) based on the identifiedsources. This was discussed and con-sented in two Delphi rounds, one con-sensus conference (16 June 2016) andafi-nal Delphi round on 19 February 2017.The authors comprised DIVI representa-tives from five DIVI specialities (anaes-thesia, surgery, internal medicine, neu-romedicine, paediatrics), from nursingas well as structural advisers.

The recommendations were thensubmitted to the DIVI committee.This approved the recommendationsunanimously on 07 March 2017 andpublished the extended version on itsinternet presence (http://www.divi.de/empfehlungen/imc-entwurf.html).

Evidence evaluation and level ofrecommendation

The level of recommendation was set ac-cording to the criteria by Guayatt et al.([30]; . Table 3).

The recommendations on technicalequipment(. Table4)werediscussedun-der the following plan, since virtually nostudy data exists for this.

Corresponding address

Prof. Dr. C. WaydhasChirurgische Universitätsklinik undPoliklinik, BerufsgenossenschaftlichesUniversitätsklinikumBergmannsheilBürkle-de-la-Camp-Platz 1, 44789 Bochum,Germanychristian.waydhas@bergmannsheil.de

Acknowledgements. Wewould like to thank Dr.U. Dennler from the DivisionManager Medical Con-trols of Jena University Hospital for reviewing themanuscript and his valuable input.

Conflict of interest. K.R. Steinmeyer-Bauer: At thetimeof joining the authors in 2014 toApril 2016,Dr. Steinmeyer-Bauerwas visiting researcher attheDepartment of Anaesthesiology, focussing onsurgical intensive caremedicine CCM/CVK, Char-ité—Universitätsmedizin Berlin.At the same time, hewasworking, and still works, for VAMEDManagementandServiceGmbHDeutschland. The unanimous as-sessment of the authorswas that therewas no conflictof interest resulting fromhis activity that had any in-fluence on the declared recommendations. E. Hertingstates that there are no conflicts of interest related tothis publication. He reports grants andpersonal feesfromChiesi andDräger, outside the submittedwork.G.Marx reports grants andpersonal fees fromBBraunMelsungenGmbH, grants andpersonal fees fromAdrenomed, grants andpersonal fees fromBiotest.G.Marx is DIVI andDGAI Boardmember andCoor-dinator of AWMFS3Guideline on volume therapy.C.Waydhas, S. Kluge, A.Markewitz, E.Muhl, T. Nicolai,K. Notz, V. Parvu,M. Quintel, E. Rickels, D. Schneider,G. Sybrecht andT.Welte declare that theyhave nocompeting interests.

References

1. Nasraway SA et al (1998) Guidelines on admissionand discharge for adult intermediate care units.American College of Critical Care Medicine of theSociety of Critical Care Medicine. Crit Care Med26:607–610

2. Stacy KM (2011) Progressive care units: differentbut thesame. CritCareNurse31:77–83

3. Schweizerische Gesellschaft für Intensivmedizin(2012) SchweizerischeRichtlinien fürdieAnerken-nung von Intensive-Care Units. http://www.sgi-ssmi.ch/index.php/imc.html. Accessed 22 Nov2015

4. Deutsche Interdisziplinäre Vereinigung für Inten-siv- und Notfallmedizin (2010) Empfehlungenzur Struktur und Ausstattung von Intensivstatio-nen. http://www.divi.de/images/Dokumente/Empfehlungen/Strukturempfehlungen/2011_StrukturempfehlungLangversion.pdf. Accessed22Nov2015

5. Bingold TM et al (2014) Modulares ZertifikatIntensivmedizin der DGAI. Anästh Intensivmed55:316–329

6. Deutsche Schlaganfallgesellschaft (2015) Zer-tifizierungskriterien 2015 – Regionale undüberregionale Stroke Units. http://www.dsg-info.de/images/stories/DSG/PDF/StrokeUnits/SU-Zertifizierungskriterien-2015.pdf. Accessed22Nov2015

7. Markewitz A et al (2012) Empfehlungen derDeutschen Gesellschaft für Thorax-, Herz- undGefäßchirurgie zur personellen, infrastrukturellenund apparativen Ausstattung einer herzchirurgis-chen Intermediate-Care-Station. Z Herz ThoraxGefäßchir26:48–55

8. Cheng DC, Byrick RJ, Knobel E (1999) Structuralmodels for intermediate care areas. Crit CareMed27:2266–2271

9. Bause H et al (2002) Intermediate care: En-twicklung, Definition, Ausstattung, Organisationund mögliche Lösungen. Anästh Intensivmed43:536–541

Medizinische Klinik - Intensivmedizin und Notfallmedizin 1 · 2018 43

10. Matis GK, Chrysou OI, Birbilis TA (2013) Orga-nizational issues in stroke treatment: the Swissparadigm – stroke units. J Neurosci Rural Pract4:S131–S133

11. Kaste M et al (2000) Organization of strokecare: education, stroke units and rehabilitation.European Stroke Initiative (EUSI). Cerebrovasc Dis10(Suppl3):1–11

12. Thijs Vet al (2009)Organisationof inhospital acutestroke care and minimum criteria for stroke careunits. Recommendations of the Belgian StrokeCouncil. ActaNeurolBelg109:247–251

13. Post F et al (2015) Criteria of the German Societyof Cardiology for the establishment of chest painunits: update2014. ClinResCardiol104:918–928

14. Post F et al (2015) Kriterien der DeutschenGesellschaft für Kardiologie –Herz- und Kreislauf-forschung für „Chest Pain Units“. Update 2015.Kardiologe9:171–181

15. Deutsche Gesellschaft für Pneumologie (2015)Erhebungsbogen zur Zertifizierung von Wean-ingzentren. http://www.pneumologie.de/fileadmin/pneumologie/downloads/Aktuelles/Erhebungsbogen_zur_Akkreditierung_von_Weaning-Zentren.pdf?cntmark. Accessed 22Nov2015

16. BingoldTMetal (2013) EntwöhnungvonderBeat-mung. DGAI-Zertifizierung anästhesiologischeIntensivmedizin. Anästh Intensivmed54:522–534

17. Goncalves LA, Padilha KG, Cardoso Sousa RM(2007) Nursing activities score (NAS): a proposalfor practical application in intensive care units.IntensiveCritCareNurs23:355–361

18. Lucchini A et al (2014) Nursing Activities Score(NAS): 5 years of experience in the intensive careunitsofan ItalianUniversityhospital. IntensiveCritCareNurs30:152–158

19. Padilha KG et al (2010) Nursing workload andstaff allocation in an intensive care unit: a pilotstudy according toNursing Activities Score (NAS).IntensiveCritCareNurs26:108–113

20. KoppRetal (2012) Intensivecareand intermediatecare under a single roof. Anästh Intensivmed53:698–608

21. Steg PG et al (2012) ESC Guidelines for themanagement of acute myocardial infarction inpatients presenting with ST-segment elevation.EurHeart J33:2569–2619

22. Deutsche Gesellschaft für Fachkrankenpflege(2010)StellungnahmederDeutschenGesellschaftfür Fachkrankenpflege und Funktionsdienste e. V.zur Intermediate Care (IMC). http://wordpress.p133885.webspaceconfig.de/wp-content/uploads/DGF_Stellungnahme_Intermediate_Care_2010.pdf. Accessed22Nov2015

23. Annonymus (2013) Nurse staffing ratios. AORN J97:604,538

24. Farnham JA, Maez-Rauzi V, Conway K (1992)Balancingassignments: aPCSforastep-downunit.NursManage23:49–50,52

25. Adomat R, Hewison A (2004) Assessing patientcategory/dependence systems for determiningthenurse/patient ratio in ICUandHDU: a reviewofapproaches. JNursManag12:299–308

26. Shakir T, Toosy N, Ridley S (1999) A survey ofadultgeneral highdependencyunits in theUnitedKingdom. Clin IntensiveCare10:219–226

27. GarfieldM, JeffreyR,RidleyS(2000)Anassessmentofthestaffinglevelrequiredforahigh-dependencyunit. Anaesthesia55:137–143

28. Gandhi PJ et al (2001) Impact of a pharmacist ondrugcosts in a coronary careunit. AmJHealthSystPharm58:497–503

29. Evans RS et al (2015) Use of computer decisionsupport in an antimicrobial stewardship program(ASP).ApplClin Inform6:120–135

30. Guyatt G et al (2006) Grading strength ofrecommendations and quality of evidence inclinical guidelines: report from an americancollege of chest physicians task force. Chest129:174–181

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