The document discusses the concept of critical care including the intensive care team, critical care nursing, the seven Cs of critical care nursing, the roles of critical care nurses and units. It describes the organization, staffing, equipment and facilities required for an intensive care unit. It discusses ICU admission and discharge criteria including prioritization models based on patient stability and likelihood of benefit, as well as diagnosis-based models. The goal is to provide intensive treatment and monitoring to critically ill patients who can benefit from care that can't be delivered elsewhere.

1. CONCEPT OF CRITICAL CARE

2. INTRODUCTION
The intensive care unit is not
merely a room or series of room
filled with patients attached to
interventional technology; it is
the home of an organization:
the intensive care team.

3. THE INTENSIVE CARE TEAM.
This team –
• Doctor
• Nurses
• Therapists
• Nutritionists
• Chaplains and other support
staff, builds an environment
for healing or dying.

4. CRITICAL CARE NURSING
Critical care nursing is that
specialty within nursing that deals
specifically with human responses
to life-threatening problems.

5. CRITICAL CARE NURSING
Critical care nursing is that
specialty within nursing that deals
specifically with human responses
to life-threatening problems.

6. SEVEN Cs OF CRITICAL CARE
• Compassion
• Communication (with patient and family).
• Consideration (to patients, relatives and
colleagues) and avoidance of Conflict.
• Comfort: prevention of suffering
• Carefulness (avoidance of injury)
• Consistency
• Closure (ethics and withdrawal of care).

7. CRITICAL CARE NURSE
A critical care nurse is a
licensed professional nurse
who is responsible for
ensuring that acutely and
critically ill patients and
their families receive
optimal care .

8. CRITICAL CARE UNIT
• Critical care unit is a specially designed
and equipped facility staffed by skilled
personnel to provide effective and safe
care for dependent patients with a life
threatening problem.

9. THE AIM OF THE CRITICAL
CARE:-
is to see that one provides a care
such that patient improves and
survives the acute illness or tides
over the acute exacerbation of the
chronic illness.

10. TYPES OF ICUs
There are two types of ICUs,
• An open :-. In this type, physicians admit,
treat and discharge and
• A closed: in this type, the admission,
discharge and referral policies are under the
control of intensivists.

11. ICUS CAN BE CLASSIFIED AS:
• Level I: This can be referred as high dependency is
where close monitoring, resuscitation, and short term
ventilation <24hrs has to be performed.
• Level II: Can be located in general hospital, undertake
more prolonged ventilation. Must have resident doctors,
nurses, access to pathology, radiology, etc.
• Level III: Located in a major tertiary hospital, which is a
referral hospital. It should provide all aspects of intensive
care required.

12. Medical staff
• Carrier intensivists are the best senior medical
Staff to be appointed to the ICU.
• He/she will be the director.
• Less preferred are other specialists viz. From
Anaesthesia, medicine and chest who have
clinical Commitment elsewhere.
• Junior staff are intensive care trainees and
trainees on deputation from other disciplines.

13. NURSING STAFF
• The major teaching tertiary care ICU will require trained
nurses in critical care.
• It may be ideal to have an in house training programme
for critical Care nursing.
• The number of nurses ideally required for such units is
1:1 ratio.
• In complex situations they may require two nurses per
patient.
• The number of trained nurses should be also worked
out by the type of ICU, the workload and work statistics
and type of patient load.

14. UNIT DIRECTOR:-
Specific requirements for the unit director include the
following:
• Training, interest, and time availability to give clinical,
administrative, and educational direction to the ICU.
• Board certification in critical care medicine.
• Time and commitment to maintain active and regular
involvement in the care of patients in the unit.

15. • Availability (either the director or a similarly qualified
surrogate) to the unit 24 hrs a day, 7 days a week for
both clinical and administrative matters.
• Active involvement in local and/or national critical care
societies.

16. • Participation in continuing education programs in the
field of critical care medicine.
• Hospital privileges to perform relevant invasive
procedures.
• Active involvement as an advisor and participant in
organizing care of the critically ill patient in the
community as a whole.
• Active participation in the education of unit staff.
• Active participation in the review of the appropriate use
of ICU resources in the hospital.

17. Critical Care Unit nursing
requirements:-
• All patient care is carried out directly by or
under supervision of a trained critical care
nurse.
• All nurses working in critical care should
complete a clinical/critical care course
before assuming full responsibility for patient
care.
• Unit orientation is required before assuming
responsibility for patient care.
• Nurse-to-patient ratios should be based on
patient acuity according to written hospital
policies.

18. Critical Care Unit nursing
requirements :-
• All critical care nurses must participate in continuing
education.
• An appropriate number of nurses should be trained in
highly specialized techniques such as renal replacement
therapy, intra-aortic balloon pump monitoring, and
intracranial pressure monitoring.
• All nurses should be familiar with the indications for and
complications of renal replacement therapy.

19. PHYSICIAN SUBSPECIALISTS
• General surgeon or trauma surgeon
• Neurosurgeon
• Cardiovascular surgeon
• Obstetric-gynecologic surgeon
• Urologist
• Thoracic surgeon
• Vascular surgeon
• Anesthesiologist
• Cardiologist with interventional capabilities
• Pulmonologist

20. PHYSICIAN SUBSPECIALISTS
• Gastroenterologist
• Hematologist
• Infectious disease specialist
• Nephrologist
• Neuroradiologist (with interventional capability)
• Pathologist
• Radiologist (with interventional capability)
• Neurologist
• Orthopedic surgeon

21. OTHER PERSONNEL:
A variety of other personnel may contribute significantly to
the efficient operation of the ICU. These include:-
• Unit clerks
• physical therapists
• occupational therapists
• Advanced practice nurses
• Physician assistants
• Dietary specialists, and
• Biomedical engineers.

22. LABORATORY SERVICES
• A clinical laboratory should be
available on a 24-hr basis to provide
basic hematologic, chemistry, blood
gas, and toxicology analysis.
• Laboratory tests must be obtained in a
timely manner, immediately in some
instances. "STAT" or "bedside"
laboratories adjacent to the ICU or
rapid transport systems.

23. Radiology and imaging services:
• The diagnostic and therapeutic radiologic
procedures should be immediately
available to ICU patients, 24 hrs per day.
• Portable chest radiographs affect decision
making in critically ill patients.

24. ORGANIZATION OF ICU
• It requires intelligent planning.
• One must keep the need of the hospital and
its location.
• One ICU may not cater to all needs.
• An institute may plan beds into multiple
units under separate management by single
discipline specialist viz. medical ICU,
surgical ICU, CCU, burns ICU, trauma ICU,
etc.

25. ORGANIZATION OF ICU
• The number of ICU beds in a hospital ranges
from 1 to 10 per 100 total hospital beds.
• Multidisciplinary requires more beds than
single speciality. ICUs with fewer than 4 beds
are not cost effective and over 20 beds are
unmanageable.
• ICU should be sited in close proximity to
relevant areas viz. operating rooms, image
logy, acute wards, emergency department.
• There should be sufficient number of lifts
available to carry these critically ill patients
to different areas.

26. ORGANIZATIONAL MODELS FOR ICUs:
• the open model allows many different
members of the medical staff to manage
patients in the ICU.
• the closed model is limited to ICU-certified
physicians managing the care of all patients;
and
• the hybrid model, which combines aspects
of open and closed models by staffing the
ICU with an attending physician and/or team
to work in tandem with primary physicians.

27. DEFINITION OF INTENSIVE CARE UNIT
EQUIPMENTS:-
• Intensive care unit (ICU) equipment includes
patient monitoring, respiratory and cardiac
support, pain management, emergency
resuscitation devices, and other life support
equipment designed to care for patients who
are seriously injured, have a critical or life-
threatening illness, or have undergone a
major surgical procedure, thereby requiring
24-hour care and monitoring.

28. PURPOSE
• An ICU may be designed and equipped
to provide care to patients with a range
of conditions, or it may be designed
and equipped to provide specialized
care to patients with specific
conditions

29. DESCRIPTION
• Intensive care unit equipment
includes:-
• patient monitoring
• life support and emergency
resuscitation devices
• diagnostic devices

30. PATIENT MONITORING EQUIPMENTS
• Acute care physiologic monitoring
system
• Pulse oximeter
• Intracranial pressure monitor
• Apnea monitor

31. LIFE SUPPORT & RESUSCITATIVE
EQUIPMENTS
• VENTILATOR
• INFUSION PUMP
• CRASH CART
• INTRAAORTIC BALOON PUMP

32. DIAGNOSTIC EQUIPMENTS
• MOBILE X-RAYS
• PORTABLE CLINICAL LAB. DEVICES
• BLOOD ANALYZER

34. THERAPEUTIC ELEMENTS IN ICU
ENVIORNMENT
•Window and art that provides natural
views; views of nature can reduce stress,
hasten recovery, lower blood pressure and
lower pain medication needs.
•Family participation ,including facilities
for overnight stay and comfortable waiting
rooms.

35. THERAPEUTIC ELEMENTS IN ICU
ENVIORNMENT
• Providng a measure of privacy and personal
control through adjustable curtains and blinds
,accessible bed controls ,and TV ,VCR and CD
players.
• Noise reduction through computerized pagers and
silent alarms.
• Medical team continuity that allows one team to
follow the patient through his or her entire stay.

36. FLOOR PLAN AND DESIGN
IT SHOULDBE BASEDON:-
• Patient admission pattern
• Staff & visitor traffic patterns
• Need for support facilities such a nursing
station ,Storage
• Administrative & educational requirements.
• Services that are unique to the individual
institution.

37. FLOOR PLAN AND DESIGN
• Eight to twelve beds per unit is
considered best from a functional
perspective .
• Each healthcare facility should consider
the need for positive- and negative
pressure isolation rooms within the ICU.
• This need will depend mainly upon patient
population and State Department of Public
Health requirements.

38. FLOOR PLAN AND DESIGN
• Each intensive care unit should be a geographically
distinct area within the hospital, when possible,
with controlled access.
• No through traffic to other departments should
occur. Supply and professional traffic should be
separated from public/visitor traffic.
• Location should be chosen so that the unit is
adjacent to, or within direct elevator travel to and
from, the Emergency Department, Operating
Room, intermediate care units, and Radiology
Department

39. PATIENT AREAS.:-
 Patients must be situated so that direct or indirect
(e.g. by video monitor) visualization by healthcare
providers is possible at all times. This permits the
monitoring of patient status under both routine .and
emergency circumstances. The preferred design is to
allow a direct line of vision between the patient and the
central nursing station.
 In ICUs with a modular design, patients should be
visible from their respective nursing substations.
 Sliding glass doors and partitions facilitate this
arrangement, and increase access to the room in
emergency situations.

40. RECOMMENDED NOISE RANGES
 Signals from patient call systems, alarms from
monitoring equipment, and telephones add to the
sensory overload in critical care units.
 The International Noise Council has recommended
that noise levels in hospital acute care areas
• not exceed 45 dB(A) in the daytime,
• 40 dB(A) in the evening,
• 20 dB(A) at night.
☻Notably, noise levels in most hospitals are between
50-70 dB(A) with occasional episodes above this
range

42. CENTRAL STATION
• A central nursing station should provide a
comfortable area of sufficient size to accommodate
all necessary staff functions.
• There must be adequate overhead and task lighting,
and a wall mounted clock should be present.
• Adequate space for computer terminals and printers
is essential when automated systems are in use.
• Patient records should be readily accessible .

45. RECEPTION AREA

46. RECEPTIONIST AREA
• Each ICU or ICU cluster should have a
receptionist area to control visitor access.
• Ideally, it should be located so that all visitors
must pass by this area before entering.
• The receptionist should be linked with the ICU(s)
by telephone and/or other intercommunication
system.
• It is desirable to have a visitors' entrance
separate from that used by healthcare
professionals.
• The visitors' entrance should be securable if the
need arises.

47. Special Procedures Room.
• If a special procedures room is desired, it should
be located within, or immediately adjacent to,
the ICU.
• One special procedures room may serve several
ICUs in close proximity.
• Consideration should be given to ease of access
for patients transported from areas outside the
ICU.
• Room size should be sufficient to accommodate
necessary equipment and personnel.

48. Clean and Dirty Utility Rooms.
• Clean and dirty utility rooms must be
separate rooms that lack interconnection.
• They must be adequately temperature
controlled, and the air supply from the
dirty utility room must be exhausted.
• The clean utility room should be used for
the storage of all clean and sterile
supplies, and may also be used for the
storage of clean linen.

49. Clean and Dirty UtilityRooms.
• Shelving and cabinets for storage must be located
high enough off the floor to allow easy access to
the floor underneath for cleaning.
• Special containers should be provided for the
disposal of needles and other sharp objects.

50. Equipment Storage
• An area must be provided for the storage
and securing of large patient care
equipment items not in active use.

51. Nourishment Preparation Area
• A patient nourishment preparation area
should be identified and equipped with food
preparation surfaces, a sink with hot and
cold running water, a countertop stove
and/or microwave oven, and a refrigerator.
• The refrigerator should not be used for
the storage of laboratory specimens.
• A hand washing facility should be located in
or near the area.

52. Staff Lounge.
• A staff lounge must be available on or near each
ICU or ICU cluster to provide a private,
comfortable, and relaxing environment.
• Secured locker facilities, showers and toilets
should be present.
• The area should include comfortable seating and
adequate nourishment storage and preparation
facilities, including a refrigerator, a countertop
stove and/or microwave oven.
• The lounge must be linked to the ICU by telephone
or intercommunication system, and emergency
cardiac arrest alarms should be audible within.

53. Conference Room.
• A conference room should be conveniently located for ICU
physician and staff use.
• This room must be linked to each relevant ICU by telephone or
other intercommunication system, and emergency cardiac
arrest alarms should be audible in the room.

54. • Electric supply
• Water supply
• lighting

55. OTHER FACILITIES
• Voice Intercommunication Systems
• Satellite Laboratory
• Physician On-Call Rooms
• Administrative Offices

56. ICU Admission and
discharge Criteria

57. Requests for ICU Beds
• excellent care
• abundant resources
• high nurse-patient ratios
• pharmacists,nutritionist, RT’s, etc
• high tech equipment
• signs of deterioration quickly identified
• “give them a chance”
• discomfort with death
• convenience
• Demand frequently exceeds supply

58. ICU Admission Criteria
• A service for patients with
potentially recoverable conditions
who can benefit from more detailed
observation and invasive treatment
than can be safely provided in
general wards or high dependency
areas

59. ICU Triage
• admission criteria remain poorly defined
• identification of patients who can benefit from ICU
care is extremely difficult
• demand for ICU services exceeds supply
• rationing of ICU beds is common

60. Prioritization Model
• Priority 1
• critically ill, unstable
• require intensive treatment and monitoring
that cannot be provided elsewhere
• ventilator support
• continuous vasoactive infusions
• mechanical circulatory support
• no limits placed on therapy
• high likelihood of benefit

61. Prioritization Model
• Priority 2
• Require intensive monitoring
• May potentially need immediate intervention
• No therapeutic limits
• Chronic co-morbid conditions with acute severe
illness

62. Prioritization Model
• Priority 3
• Critically ill
• Reduced likelihood of recovery
• Severe underlying disease
• Severe acute illness
• Limits to therapies may be set
• no intubation, no CPR
• Metastatic malignancy complicated by
infection, tamponade, or airway obstruction

63. Prioritization Model
• Priority 4
• Generally not appropriate for ICU
• May admit on individual basis if unusual
circumstances
• Too well for ICU
• mild CHF, stable DKA, conscious drug
overdose, peripheral vascular surgery
• Too sick for ICU (terminal, irreversible)
• irreversible brain damage, irreversible
multisystem failure, metastatic cancer
unresponsive to chemotherapy

64. Diagnosis Model
• Uses specific conditions or diseases to
determine appropriateness of ICU admission
• 48 diagnosis/ 8 organ systems
• Acute MI with complications
• cardiogenic shock
• complex arrhythmias
• acute respiratory failure
• status epilepticus, SAH

65. JCAHCO
Objectives Parameters
Model
• Vital signs
• HR < 40 or > 150
• SBP <80
• MAP <60
• DBP >120
• RR > 35

66. Objectives Parameters Model
• Laboratory values
• Sodium < 110 or > 170
• Potassium <2.0 or > 7.0
• PaO2 < 50
• pH < 7.1 or > 7.7
• Glucose > 800 mg/dL
• Calcium > 15 mg/dL
• toxic drug level with compromise

67. Objectives Parameters Model
• Radiologic
• ICH, SAH, contusion with AMS or
focal neuro signs
• Ruptured viscera, bladder, liver,
uterus with hemodynamic instability
• Dissecting aorta

68. Objectives Parameters Model
• EKG
• acute MI with complex arrhythmias,
hemodynamic instability, or CHF
• sustained VT or VF
• complete heart block with instability

69. Objectives Parameters Model
• Physical findings (acute
onset)
• unequal pupils with LOC
• burns > 10%BSA
• anuria
• airway obstruction
• coma
• continuous seizures
• cyanosis
• cardiac tamponade

70. ICU Admission Criteria
• Potential or established organ failure
• Factors to be considered
• Diagnosis
• Severity of illness
• Age and functional status
• Co-existing disease
• Physiological reserve
• Prognosis
• Availability of suitable treatment
• Response to treatment to date
• Recent cardiopulmonary arrest
• Anticipated quality of life
• The patient’s wishes

71. Discharge Criteria
• physiologic status has stabilized
• need for ICU monitoring and care no longer
necessary
• physiologic status has deteriorated
• active interventions no longer planned