You have been asked by your director to assist in the planning and development of a new level Ⅱ intensive care unit.

a) Define what is meant by level Ⅰ, level Ⅱ and level Ⅲ ICUs

b) Briefly outline the principal considerations you should cover during the planning phase with specific attention to physical design of the unit and staffing

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College Answer

This information is covered in the college document IC-1 and candidates should be familiar with at least the broad areas that are covered when a new unit is planned.

a) Definitions

A Level I ICU should be capable of providing immediate resuscitation and short-term cardio-respiratory support for critically ill patients. It will also have a major role in monitoring and prevention of complications in “at risk” medical and surgical patients. It must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring for a period of at least several hours.

A Level II ICU should be capable of providing a high standard of general intensive care, including complex multi-system life support, which supports the hospital’s delineated responsibilities.

A Level III ICU is a tertiary referral unit for intensive care patients and should be capable of providing comprehensive critical care including complex multi-system life support for an indefinite period. Level III units should have a demonstrated commitment to academic education and research. All patients admitted to the unit must be referred for management to the attending intensive care specialist.

b) Design and staffing

Design

A Level II ICU should have at least 6 beds. The unit needs to provide a suitable environment with adequate space for patient care delivery, storage, staff accommodation (including office space), education and research. (CICM IC-1 2011)

Bed space

There should be adequate space around each bed to allow easy access to the patient from all sides

– with at least one hand basin for every 2 beds. Adequate lighting and service outlets need to be provided for each bed space and there should be provision for adequate privacy.

At least one isolation room should be available.

Environment

The unit should have appropriate air conditioning which allows control of temperature, humidity and air change.

Storage

Pharmacy/drug preparation

Equipment storage area.

Dirty utility – area for cleaning appliances, urine testing, emptying and cleaning bed pans and urine bottles.

Staff accommodation

Including offices, tea room and education areas.

Relatives Area

Including a waiting room with basic facilities and separate room for interviewing or seeing distressed relatives.

Staffing

Medical Staff

A dedicated director (should be a Fellow of the College) and team of specialists with junior medical cover. One specialist exclusively rostered to the unit at all times, structured bedside ward round.

Nursing Staff

A minimum of 1:1 for ventilated and other critically ill patients, and 1:2 nursing staff for lower acuity

Consideration should also be given to ancillary staff: Clerical, Wardsmen, Physiotherapists, social workers and cleaning staff

Discussion

This question distinguishes which candidates have been ferreting around in the morass of college policy documents.

What is this document IC-1, from 2011? Why, its Appendix 15: "Minimum Standards for Intensive Care Units" , of course. It outlines the minimum standards for ICUs in Australia. American guidelines are also available, and they are equally verbose, laying out rules about each minute detail of the ICU.

Staffing recommendations

  • A medical director
  • At least one specialist rostered
  • At least one other doctor rostered
  • Patient reviews at least daily, and ideally twice daily
  • 1:1 nursing for ventilated patients and 1:2 for HDU-level patients (any fewer nurses, andmortality seems to increase)
  • There should be a nursing team leader, and nurse in charge of the unit
  • There should be at least one nurse educator per 50 nurses
  • There should be a documented educational program

Structure

  • All patients should be easily visible.
  • At least 20m2 per patient, or 25m2 per single room
  • At least one isolation room per every 6 patient beds
  • At least one wash basin for every 2 patient cubicles
  • At least 16 powerpoints per bed space
  • Windows are "desirable".
  • There should be several dedicated areas:
    • A staff working area and adequate storage space
    • A pharmacy preparation room
    • An equipment storage room
    • A dirty utility
    • A staff room
    • A seminar room
    • Senior nurse offices
    • Senior medical offices
    • Secretary offices
    • A family room for relatives
    • A cleaner's room
    • A blood gas machine
    • Library facilities

Equipment

The following basic equipment should be available:

  • ventilators for invasive and/or non-invasive ventilation
  • hand ventilating assemblies
  • suction apparatus
  • airway access equipment, including a bronchoscope and equipment to assist with the management of the difficult airway
  • vascular access equipment
  • monitoring equipment, both non-invasive and invasive
  • defibrillation and pacing facilities
  • equipment to control patient temperature
  • chest drainage equipment
  • infusion and specialised pumps
  • portable transport equipment
  • specialised beds
  • lifting/weighing equipment
  • access to ultrasound for placement of intravascular catheters 

Monitoring

Patient monitoring equipment should be

  • modular
  • with trending capability
  • visible and audible alarms
  • unobstructed, comfortable viewing
  • capacity for alarm recording
  • capacity to print hard copy

Levels of intensive care units

Level 1

  • Mechanical ventilation
  • Simple invasive cardiovascular monitoring
  • 24-hour timeframe is the limit unless staffed by a FCICM

Level 2

  • Complex multi-system life support for an indefinite period
  • Minimum of 6 beds
  • At least 4 full time specialists on the roster

Level 3

  • Complex multi-system life support for an indefinite period
  • Commitment to academic education and research
  • At least 4 full time specialists per 12-bed "pod"

PICU

  • as for a Level 3 unit, but dedicated to the under-16s

References

References

CICM Policy Document IC-01: Minimum Standards for Intensive Care Units.

Leaf, David E., Peter Homel, and Phillip H. Factor. "Relationship between ICU design and mortality." CHEST Journal 137.5 (2010): 1022-1027.

Frankel, Stephen K., and Marc Moss. "The Effect of Organizational Structure and Processes of Care on ICU Mortality as Revealed by the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study*." Critical care medicine 42.2 (2014): 463-464.

Stoddart, J. C. "Design, staffing, and equipment requirements for an intensive care unit." International anesthesiology clinics 19.2 (1981): 77-96.