The ICU is a specialised area where the sickest patients and the expertise to manage them are both concentrated. The patients are high-maintenance, as they have the need of special beds, numerous large machines which keep them alive, as well as towering stacks of drug pumps and complex monitoring equipment. All this stuff needs lots of electrical outlets and an uninterrupted power supply. Moreover, the expert staff who look after these patients are also high maintenance and require offices, break rooms, family conference lounges, overnight on-call beds, education facilities, and an uninterrupted coffee supply. Clearly, to meet the demands for both of these groups of organisms an artificial environment (functionally equivalent to a terrarium) must be constructed, which is complicated and expensive.
Question 7 from the first paper of 2012 asked the candidates to "assist in the planning and development of a new level 2 intensive care unit". The college answer was long and reached to great depths, referring to some bureaucratic policy document with which the candidates were expected to be at least "broadly familiar". That document was IC-1, or "Minimum Standards for Intensive Care Units". It can be found along with numerous other such publications in the CICM "Professional Documents" page, where the college hide their various policies and standards. There, one can find guidance on such diverse topics as bullying, harassment, health of asylum-seekers (one paragraph), and how to gracefully transition into frail old age while still clinging on to one's FTE 1.0 staff specialist position. On a related topic, Question 6 from the second paper of 2021 asked the trainees to outline their approach to implementing a savage on-site weekend and evening intensivist roster.
To answer Question 7 from the first paper of 2012, one might make notes based on the detailed college answer. Or, one might read the "Minimum Standards for Intensive Care Units" policy document mentioned above. Or, one might read the very first chapter of Oh's Manual ("Design and organisation of intensive care units" by Vineet V Sarode and Felicity H Hawker). These options would be equal in their usefulness. For example, all three resources use exactly the same wording throughout their descriptions of Level 1 2 and 3 ICUs. With so much duplication, the time-poor candidate only needs to read one (ideally, the Oh's Manual chapter - because surely in the design of an ICU one would want to apply more than just the "minimum standard").
For the vast majority of people to go beyond this minimum level of preparation would be a waste of such resources as could be put to better use in feeding pigeons or observing the behaviour of ducks in a pond. However, if one is in need of greater detail, one may wish to explore the following:
An ICU is "a specially staffed and equipped, separate and self-contained area of a hospital dedicated to the management of patients with life-threatening illnesses, injuries and complications, and monitoring of potentially life-threatening conditions". This line from the college document is also reproduced in Oh's Manual.
As separate from their statement on what an ICU is, CICM have Guideline Document IC-13 to explain to us what they mean by "high dependency". A High Dependency Unit 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." The following recommendations are made regarding their design:
These places are dangerous to the CICM trainee. Allow your roster to dip too deep into a HDU, and one might find the college extending the duration of your core training. Conceivably, one might have to do several extra years purely because the hospital where you work has a high volume of elective surgical turnover, requiring large numbers of ICU staff to be diverted to looking after high dependency patients.
Judging by the college document, this is supposed to be essentially a HDU. The Level 1 ICU is usually found in a small rural or regional centre, which (in Australia) may be about 350km from the next highest level of care. The population serviced by such a unit may consist of 25,000 people, and may be dispersed over a vast terrain which shares many features with the surface of Venus. Alternatively, Level 1 ICU may be found attached to a small metropolitan private hospital, where it is used as an extension of the theatres and recovery room. Actual "intensive care" (such as non-invasive or invasive mechanical ventilation or invasive haemodynamic monitoring by arterial and central lines) can only be provided for several hours - presumably, after that you need to get the patient retrieved to a real ICU.
"Immediate resuscitation and short term cardio-respiratory support" is what this sort of unit can offer, with the expectation that the person managing it has some experience with such techniques. Locally (and according to rumors) such places are usually run by anaesthetists respiratory physicians or cardiologists, i.e. medical specialities who have at least some idea about the haemodynamic effects of vasoactive drugs and NIV. The after-hours cover typically consists of disinterested locums or SRMOs trying to get in to other specialities. Little education or research activities take place,
The college document calls for the following minimum standards:
Realistically, these place have:
What sort of patient can you have here? HDU patients. The college policy document describes them as:
So, it's a HDU. The college allows for the possibility that a FCICM-qualified intensivist might be managing the patient, and - if that were the case - "provision of mechanical ventilation and simple invasive cardiovascular monitoring for more than 24 hours is acceptable". However, it must be pointed out at this stage that such units are classically managed by people who are not fellows of the college. And yet, these people go around calling themselves intensivists. So little protection is afforded by CICM to its workforce that essentially anybody can walk in off the street and start fiddling with the ventilators. One wonders as to how much of the current Australian ICU specialist job shortage is caused by people who can't intubate, nesting in peripheral centres and claiming a salary as an "intensive care specialist".
A "high standard of general intensive care" is supposed to be on offer in a Level 2 ICU. These places can be found in large regional centres of Australia ("base" hospitals) as well as medium-sized urban hospitals with bed numbers in in the 250-400 range.
According to the college document, the ICU in such a hospital should consist of at least six beds. It is unclear how the college arrived at this number, or how six beds is superior to five or seven as a threshold for being able to "adequately discharge clinical and teaching functions".
The presence of several basic medical and surgical specialties makes for a more diverse practice, and therefore for a greater diversity of complications. In order to deal with these, the ICU must have facilities permitting more extensive and sophisticated organ support, and for a longer term. The college document recommends that such an ICU be exposed to a least 200 mechanically ventilated patients per annum in order to maintain some sort of minimum standard of expertise, of which (presumably) some are intubated. Mechanical ventilation, renal replacement therapy or cardiovascular monitoring should be available for an "indefinite period".
What's the bare minimum for medical staffing?
Other staffing requirements:
Unlike the Level 1 ICU description, to maintain the elevated position of Level 2 the ICU needs to demonstrate some interest in data collection, so that an SMR may be calculated and benchmarking may be carried out.
What's not available? Neurosurgery, ENT, cardiothoracics, plastics, ophthalmic surgery, interventional radiology, rheumatology, immunology, haematology, medical and/or radiation oncology, basically any specialised area of medicine where a successful first-time job applicant needs to be waving around a PhD to even get an interview. The Level 2 ICU does not have access to such refined services and must make external referrals for transfer.
A Level 3 ICU is a "centre of excellence", swarming with professors and full of expensive equipment. "Comprehensive critical care" is provided here, for an indefinite period.
The description of the medical director in the Level 3 ICU is no different to the description of a Level 2 director, nor are any additional qualities listed. "Superintelligent sociopath" is not mentioned anywhere. As far as medical staffing goes, each 12-14 bed pod of the ICU requires at least 4.0 FTE staff specialists. All of them should be FCICMs. Beyond these directives, the description of a Level 3 ICU is no different to the description of a Level 2 ICU.
In the document, further mention is made that a single "pod" of such a large unit should ideally be no larger than 15 beds, as this is a sensible number of patients to look after.
Broadly speaking, ICUs arose out of the need to keep post-operative cardiothoracic patients intubated for some time following their sternotomy. An excellent article by Robinson (1966) details some of the early progress in ICU design. Robinson described the establishment of a small 8-bed ICU at the entrance to the general medical ward at the 516-bed Whiston Hospital of Prescot in the UK. The following issues were discovered during this early experience:
Rashid (2006) presents a study of 19 units each of which had become the recipient of an ICU design award from SCCM and AACCN. Analysis of these units was carried out, and characteristics (positive and negative) were identified.
Positive characteristics included the following:
Negative characteristics included the following:
After reviewing the available literature, Thompson et al (2012) published the "Guidelines for intensive care unit design" featuring recommendations which have been absorbed into the CICM guidelines.
That depends on how loose your admission policy is and how incompetent your ward staff are. The models vary from place to place. In the American civilization, up to 20% of all beds in a hospital might be classified as "ICU", but be staffed by 1:3 or 1:4 nursing ratio and contain reasonably healthy patients. Contrast that with the British model where only 2% of the beds in a hospital are ICU beds and where only the sickest of the sick end up admitted. O's Manual (p. 4) seems to support the elitist British model. Some points are made in the Oh's chapter:
There does not seem any evidence behind the decision as to how large an ICU should be. The larger the ICU, the more permissive the admission practice. In ICU which is too large for its hospital, the concentration of truly sick (ventilated, dialysed) patients will be smaller and the staff will not have exposure to them frequently enough to maintain the skill level required for high quality care provision.
A barn full of expensive machinery has several advantages:
However, single rooms are favoured in modern ICUs;
For whataver reason, the Australian environment has favoured the development of "multidisciplinary" ICUs in most hospitals. Some places with specialised interests may separate the cardiothoracic ICU from the "general" area, and in some other places a "neuro and trauma" pod may develop - but the Oh's Manual chapter speaks against such single-discipline organisation. Arguments against having superspecialised ICUs are offered:
However, specialised ICUs have the advantage of being cheaper, because general ICUs have to be able to solve a greater range of problems and would therefore require a larger support infrastructure and a greater diversity of equipment. The concentration of specialised skilled staff also gives the impression of expertise. Are outcomes are improved? This is uncertain.
Contrary to the gruff dismissal of the importance of positioning seen in the paper by Robinson et al (1966), the position of an ICU is an important conasideration for logistics of patient movement. Recent developments locally had yielded an initial hospital redesign where the acute care services building (Emergency, operating theatres etc) were well over 1000 metres away from the main ICU area, and another 500m away from the blood bank. This is an extreme example of how logistics could be important.
Design of the ICU layout follows a series of stereotypic patterns. The picture demonstrating the main patterns here is stolen shamelessly from an 1986 textbook of hospital architecture by James and Tatton-Brown, which was quoted in the abovementioned Rashid paper from 2006. Of the American ICUs, the majority were of the "racetrack" type with circumferential corridors to facilitate several directions of simultaneous staff and patient bed movement. This also places patient rooms out on the periphery, where they can be exposed to more natural light.
The college document describes (briefly) the following list of mod cons:
Evidence suggests that ICU design can improve the quality of infection control. According to a review by O'Connell et al (2000), putting about 20m2 between each bed space is one such design feature (i.e. one does not brush past patient beds and curtains as one make their way around the ICU). Ensuring that there is ample storage space also encourages people to store equipment there, and prevents the corridors of the unit from being packed full of pathogen-collecting boxes and apparatus.
The college has prescriptive rules regarding what the ICU bed spaces should look like:
Access to fresh air and natural light is "desirable", and patient privacy needs should be "taken into account", but no firm recommendation is made for either. Allowance is made for older style units, presumably dark windowless dungeons where naked patients are perpetually on display. While making sure their rude bits are discretely hidden, there is an imperative to make sure all the patients are highly visible: keeping them in low-visibility rooms is a recipe for disaster and has been associated with increased mortality (Leaf et al, 2010).
The specific size of the bed space is not exactly a highly scientific determination. Locally, the designers took one ICU bed, positioned all possible equipment around it, and then walked around that equipment. The perimeter described by their trajectories also described the size of the ICU single rooms they asked for, which ended up being about 25m2.
Question 6 from the second paper of 2021 presented the trainees with a situation where the medical director of the ICU has decided to take their 9-to-5 intensivists and make them work evening shifts. "Outline important aspects that will need to be considered in the implementation of such changes", the examiners guffawed. This was an excellent SAQ, as it represents a real and serious challenge to anybody in charge of an ICU, trying to govern a frequently ungovernable group of strongly opinionated people. At the time of writing n November 2021, the college has not yet provided anyone with their model answers, which we should all anticipate with some excitement, as it would be interesting to see what the "official" stance on this might be.
What follows, therefore, is a rambling expansion of the author's own uneducated take on this matter.
Clinical governance aspects
Patient safety aspects
Staff safety aspects
Change management aspects
Audit and monitoring
So. Evening and night rostering for ICU senior staff. Is this a a good thing? Emergency physicians and intensive care physicians are routinely rostered to night shifts in America, Europe, the Middle East, and generally throughout the world. British and Australian intensivists tend to stay on call from home. But is this really better for them? A shift roster can guarantee periods of sleep, whereas a being on call 24/7 for several days in a row guarantees nothing. On the other hand, the same person being in charge for a sustained block of hours and days results in increased continuity of care, and less information loss through handover.
What does the college say? The CICM document outlining minimum standards (IC-1) only states that the intensivist needs to be directly available during normal working hours. With respect to protecting the intensivist from the brutality of a junior-registrar-like roster, there is no policy statement per se, but CICM do have a welfare SIG document which describes the professional risks of sleep deprivation and offers suggestions as to how one might mitigate against them. The author finds some aspects of this document particularly relatable, including especially the statement that one should protect the hours of 3-6am for sleep (as 90% of Deranged Physiology is written during the hours of 3-6am).
What do other colleges say? ACEM, the college of emergency physicians, actually has a statement on night shift rostering, with some excellent points made to support the evening specialist shift (but not the night shift, which they don't support). Some of these can be extrapolated to the ICU with the addition of a little evidence.
What is the evidence? Some data suggest that the presence of an intensive care specialist is beneficial. For example, Arabi et al (2006) observed patient mortality in a hospital from Saudi Arabia where intensivists are rostered 24/7. The authors observed that there was no major difference in mortality in that ICU, no matter what time of day or night you were admitted there. This is entirely unlike other studies (eg. Bhongari et al, 2011) which demonstrate a clear increase in mortality during the out-of-hours and weekend periods. The authors concluded that it must have been the consistent intensivist input that made the outcomes stable and positive.
Other data suggests that evening or night staffing of ICUs with senior staff does not improve mortality. For example, Wallace et al (2012) and Kerlin et al (2013) did not find any mortality benefit from night-time intensivist cover. Garland et al (2011) looked at something completely different - nonintensivist staff satisfaction - and found that basically everyone hated having an intensivist around at night. Nurses reported more "role conflict"and junior staff reported less autonomy, which basically means that the intensivists compulsively micromanaged everything and stuck their nose in everybody's business. The intensivists, on the other hand, loved the shiftwork lifestyle. The same feedback comes through from reading Wise & Frost (2006). The authors, speaking from two years of experience in a large British ICU, reported marked improvement in their quality of life, arising mainly from uninterrupted sleep.
And this last point is a convenient segue into the chapter on the strategies to mitigate fatigue in the ICU medical workforce.