Friday, April 10, 2009
Thursday, April 9, 2009
Monday, April 6, 2009
GENERAL INTENSIVE CARE UNIT
The General Intensive Care Unit of the Hospital is a level 1 ICU* that manages critically ill patients with complicated needs requiring the continuous availability of sophisticated equipment, specialized nurses and doctors trained in the care of the critically ill. The management of the unit is the responsibility of the Department of Anaesthesia & Intensive Care.
This document is prepared in view of the need for guidelines’ that would serve those who require the services of the Intensive Care Unit.
It is hoped that these guidelines would avoid the misuse or inappropriate use of facilities and staff and improve the utilization of scarce and costly resources.
These policies and guidelines would be reviewed and revised, as necessary, on a regular basis. Compliance with these guidelines will be monitored by the Department of Anaesthesia & Intensive Care.
* A Level 1 ICU is one capable of providing all forms of intensive care monitoring and therapy, have 24-hour access to diagnostic facilities, have dedicated medical staff roistered for 24 –hour duty and have a preponderance of nursing staff with intensive care certification.
ADMISSION AND DISCHARGE POLICY
An ICU provides services that include both intensive monitoring and intensive treatment. During times of high utilization and scarce beds, patients requiring intensive treatment ( Priority 1) have priority over patients requiring intensive monitoring ( Priority 2 ) and terminally or critically ill patients with a poor prognosis for recovery ( Priority 3 ). Eligibility for ICU admission and discharge is also based on reversibility of the clinical problems as well as the likely benefits of ICU treatment and expectation of recovery.
It is the responsibility of the patient’s attending doctor (or designee) to request ICU admission and to promptly transfer patients who meet discharge criteria.
It is to responsibility of the ICU specialist (or designee) to decide if the patient meets eligibility requirements for ICU.
In case of conflict regarding admission or discharge criteria, the ICU specialist (or designee) of the admitting unit will decide which patient should be given priority.
Admission Criteria
Priority 1
Critically ill, unstable patients with single system disorder and/or good reversibility of conditions and who require ventilatory support and/or continuous vasoactive drug infusion:
· Post-operative patients for stabilization and ventilation.
· Acute respiratory failure from a reversible cause e.g. Guillain-Barre Syndrome, Myasthenia Gravis, Bronchial Asthma, Drug Overdose.
· Patients with multiple trauma.
· Patients with acute obstetric complications e.g. post- partum haemorrhage, eclampsia.
Priority 2
Patients, who at the time of admission are not critically ill but whose condition requires intensive monitoring. These patients who are at risk for needing immediate intensive treatment would benefit from monitoring available in the ICU e.g. peripheral or pulmonary arterial monitoring, pulse oximetry.
· Patients with underlying hearts, lung or renal disease with acute exacerbation of the illness or the illness or who have undergone major surgery.
· Patients with progressive paralysis of neuromuscular origin
Some of these patients may be more suitable for High Dependency Ward admission. The underlying disease/s must be reversible or at least have a favourable outcome.
Priority 3
Critically ill, unstable patients whose previous state of health, underlying disease, or acute illness, either alone or in combination severely reduce the likelihood of recovery and benefits from ICU treatment,:
· Patients with metastatic malignancy complicated by infection.
· Patients with end-stage heart or lung disease complicated by a severe acute illness.
Patients who do not meet routine admission criteria are:
· Patients who have clinical evidence of brain death.
· *organ donors but only for the purpose of life support before organ donation.
· Patients with non-traumatic coma causing a permanent vegetative state.
Discharge Criteria
Priority 1 patients are discharged when their need for intensive treatment is no longer present.
Priority 2 patients are discharged when intensive monitoring has not resulted in aneed for intensive treatment and the need for intensive monitoring is no longer present.
Priority 3 patients are discharged when the need for intensive treatment is no longer present, but may be discharged earlier if continued is no longer present, but may be discharged earlier if continued treatment is futile or request for ICU bed for a Priority 1 or 2 patient is made.
Patients who are unlikely to benefit from continued ICU treatment include:
· Patients of advanced age with three or more organ system failures who have not responded to 72 hours or more of intensive therapy.
· Patients who are brain dead (*exception).
· Patients who have non-traumatic coma leading to a permanently vegetative state and a very low probability of meaningful recovery.
· Patients with protracted respiratory failure who have not responded to initial aggressive efforts and who are also suffering from haematologic malignancy.
· Patients with a variety of other diagnosis ( advanced chronic obstructive airway disease, end-stage cardiac disease or widespread carcinoma) who have failed to respond to ICU therapy, whose short term prognosis is also extremely poor and for whom no potential therapy exits to either the prognosis.
· Physiologically stable patients who are at low risk of requiring ICU treatment.
The least justifiable ICU activity on cost-benefit analysis lies in the management of diseases causing multi-system failure and a low survival rate in patients with short remaining lifespans.
The decision to discharge the patient will be made by the ICU specialist and the primary unit will be informed of this. The primary unit should then make arrangements for appropriate ward or intermediate care and promptly transfer the patient out of ICU.
The ICU SHOULD NOT be used as a High Dependency Ward. Nursing care in acute surgical wards should be upgraded to manage patients who require close monitoring.
TRIAGE IN THE ICU
Role Of ICU Specialist As Triage Officer
In times when patient load exceeds optimal operational capacity ( in terms of bed or ICU nurse availability ), there should be a clear policy as to who is responsible for triage within the unit.
The regulation of admission and discharge of patients into and out of ICU is a standard function assigned to the ICU specialist. However, another unenviable task of the latter is that of being a triage officer.
The triage officer should be a senior person who is knowledgeable about the prognosis of the various diseases related to the patients in the unit ( or able to obtain the information rapidly ), unbiased and a good negotiator. He / she must communicate directly with various primary attending doctors in order to identify any additional factors not readily apparent that might charge priority listing. He must not be overruled by other doctors during periods of high census.
The person best suited to make complex and dynamic triage decisions is the ICU specialist who has been regularly involved in the care of the patients.
Patients factors considered during high census :-
Functional outcome.
Chronic underlying condition (s)
Age .
Marginal benefit present.
Hospital mortality probability estimate.
Conditions defining limited medical suitability :-
DNR orders issued.
Patient considered unsalvageable clinically ( no marginal benefit)
Rapidly fatal underlying condition.
Persistent vegetative state.
High probability estimate of hospital mortality.
Triage Approach
To reduce inflow of patients to ICU
· Keep patient in Recovery bay, Casualty or other ICUs while queering to come to ICU.
· Hold transfer of patients from ICUs of other hospitals.
· Postpone high-risk elective surgery.
Increase performance of high census ICU
· Identify triage patient on daily basis such that patient can be promptly transferred when the need when arises. ICU Specialists should perform this together at a fixed time e.g.1500 hrs.
· Rapidly wean and extubate post-operative elective patient such that they are transferred out if stable for 4-6 hours after extubation.
Decrease workload per patient
Reducing nursing hours per patient by performing fewer invasive procedures e.g. deferring insertion of PAC.
Transfer to alternative sites
· Transfer the following patients to general wards.
· Patients who have failed aggressive ICU therapy.
· Patients who are considered unsalvageable.
· “Stable” ventilator-dependent patients.
· Transfer short-term recoverable patients to intermediate units e.g. other ICUs
· It is preferable such transfers be done during the daytime or on a scheduled or planned basis rather than late at night or as an emergency triage. Scale back orders before transferring.
*if all ICU beds in hospital are full, then the primary unit should seek permission from Director of Hospital to transfer patient to another hospital. (This is applicable to only Priority 1 patients who are citizens of Malaysia ).
BED REQUESTS FOR ELECTIVE SURGICAL CASES
The details of the patient and date of surgery will be documented on the ICU board.
The patient’s attending Surgeon/ Anaesthetist must inform and discuss with the ICU specialist in advance of the need for ICU Care for his post-operative patient.
In the event that there are more requests for ICU beds than beds available, than priority should be given to the following :
1. patient whose surgical condition is likely to deteriorate within days if surgery is postponed.
2. maternity patients.
3. patient whose surgery has been repeatedly postponed due to lack of ICU bed.
If a bed is not available for elective admission, the surgeon has the option of
1. Postponing surgery.
2. Arranging alternative ICU care within the hospital.
It must be emphassised that priority of admission will always be given to unscheduled, emergency admissions over scheduled elective requests.
WITHDRAWAL OF INTENSIVE THERAPY
The decision to withdraw therapy should be joint decision between the
1. Primary physician.
2. ICU specialist in-charge of the patient.
3. Designated senior specialist of the Department of Anaesthesia & Intensive Care.
The decision and rationale should be recorded in the medical record.
Intensive care therapies that are no longer indicated in such circumstances include:
CPR
Dialysis
Inotropes
Antibiotics
Parenteral nutrition
Therapy should be limited only to hygienic care and comfort.
The option to continue treatment for pain and suffering is available. Analgesics and anxiolytics may be used for this purpose.
The removal of life support from a patient should not be regarded as an abandonment of the patient by the healthcare team. Rather, the attention of the healthcare team must at this point be redirected to alleviating the suffering of the patient and his family and ensuring death comes with dignity.
PHYSICAL FACILITIES IN ICU
Bed requirements
Number of ICU beds per hospital should depend on type of services available in the hospital as well as the needs of the community.
Ranges from 2-6% of total number of hospital beds
working area about 200sq. ft/bed.
Open concept is highly preferred.
placing of bed in semi-circular position.
All patients can be viewed from the nursing station.
Windows located near the bed.
Day light in ICU.
Nursing station with central monitor ( optional ).
Sister’s office.
Male and female changing room with toilet and shower facilities.
Common rest rooms.
Treatment / preparation room.
Mini laboratory for essential test e.g. ABG, BUSE.
Sluice room.
Pantry.
Reception / conference room and library.
Waiting room for immediate family members.
Store room
Isolation room.
Doctor’s room.
Family waiting room.
BASIC EQUIPMENT FOR ICU
Basic monitoring equipment / bed
2 Electrocardiograph / Respiratory display
Pressure display – 2 to 3 channels
Temperature display
Pulse oximetry
Non-invasive blood pressure – adults, paediatrics and infants
Cardiac Output
12 Lead ECG monitor / recorder } to be available
Defibrillator – adult / paediatrics paddles }
Ventilators
High end to medium range ventilators for both adults and paediatrics patients.
Neonatal ventilators if ( admitting neonatal patients )
Sufficient number for all beds with spares.
Other Equipment
a) Manual resuscitation sets for adults, paediatrics and infants ( every bed – 1 set each )
b) Oxygen flowmeters (wall mounted humidification )
- Hot ( large volume nebulizers / cigar blower )
- Cold
c) suction regulators / wall mounted with high and low suction
d) syringe driver pump – 6 units / bed
e) transport monitors / ventilators
f) flexible fiberoptic scopes
g) essential airway equipment
Beds
Adult with facilities for:
- Positioning
- Resuscitation
- X-ray cassette placement
- Weighing
Paediatrics with facilities for:
- Central heating
- Phototherapy
- Oxygen / suction
- X-ray cassette placement
- Weighing facilities
- Apnoea alarms
Bedside facilities
i.Intravenous support system
ii.Railing for curtains
iii.Adjustable shelves for syringe pumps
iv.Railing systems for oxygen therapy and suction
v.Pendants or suitable mounting for monitors / IV lines.
vi.Adequate facilities for washing hands ( elbow control, hot and cold water )
Other requirements
a) Pipelines / outlet :-
3 Oxygen
2 Compressed Air
2 Vacuum ( 1 low and 1 high pressure )
b) Power
· 12 per bed with 6 UPS
· Emergency lighting – 2 power supply to all points
· Separate output for X-ray.
c) Cooling and heating devices
· Radiant heater
· Portable cooling mattress
d) Emergency trolley – 1 per cubicle
· Adults
· Paediatrics
e) Flooring
· Non-slippery surface
f) Furniture
· Table and chair ( for nursing staff ) for each bed.
g) X-ray
· Multiple viewing boxes for comparison of films
ICU BED SET UP
Monitor cables, arterial line, NIBP cuff and pulse oximeter.
Oxygen apparatus and resuscitation bag.
suction catheters of various sizes.
Writing table and chair.
Ventilator.
Resuscitation trolley.
Defibrillator.
ICU bed.
ORIENTATION OF NEW STAFF
ICU layout
staffing ; Roster :-
Checking of roster daily
Request
Annual leave
Emergency leave
Sick leave
Changing of duty
Attitudes ; Initiative :-
Acceptance of Correction
Work with rationale
Team work
Caring towards fellow staff, clients and relatives / visitors
Superiors
Keep up with current knowledge – reading, attending seminars or attending hospital’s CME.
Dress Code :- Scrub suit or apron , Cap and Mask during procedures
Documentation :- Admission Book, Census, Computers
Address Book – Home and contactable address and phone . numbers.
Incident Book/ forms :- POMR /OTHER/STUDIES.
Severity Scoring forms
Others :-“Fall Meja” , Circulars
ICU Nursing Care
ICU Charts / Admission – Treatment Charts
Monitors / Arterial line / CVP line
Ventilators :- Settings , Alarms , Changing of ventilatorcircuits/Humidifier , Resuscitation bags
Oxygen Apparatus
· Suction Apparatus :- Pressure Control , Changing of suction liners/tubings and catheters
· ICU bed :- Manipulation
Care Of ICU patients :- Observation and Documentation – General and local
· Personal care
· Participation :- General rounds , Procedures , Investigations , Transfer out/ discharge/ death /sending for CT Scan
· Treatment :- feeding , medication oral or injection , dressing
· care of relatives/visitors
· communication skills
· counseling skills
All care given to be planned, organized and priorities to be implemented according to client’s general condition and needs.
Ø VISITING HOURS
Generally all ICUs follow the hospital guidelines for visiting hours but special privileges are extended to the next-of-kin.
Each patient is allowed to have two visitors at any one time. For every patient that is admitted to General ICU, one visitor’s pass will be given to the next-of-kin. This pass allows 2 nearest family member to visit or stay in the hospital compound. They are allowed to visit the patient briefly during non-visiting hours. However they are not allowed in during doctors round, or during medical or nursing procedures.
Ø ADMISSIONS/ TRANSFER IN OF PATIENTS TO ICU
Ø TRANSFER OUT/DISCHARGE FROM ICU ( The receiving ward staff to each patient)
Ø DEATH IN ICU
· Contact next of kin/immediate family or inform police if unable to contact immediate families.
· Inform primary unit doctor regarding death and to be present in ICU to certify the cause of death and to sign burial permit.
· Do last office.
· 3 tags used. ( Red tag for police cases)
· If police case, to inform police.
· Ward attendant to get burial permit book.
· Documentation
- Admission book/ward census/record office census and computer.
- Report writing
sent body to mortuary
cleaning of bed unit.
Preparation of bed unit for next admission.
- A.. * Clinical post mortem – unit doctor to get consent from next-of-kin. ( BHT to sent to mortuary with body and document in mortuary dispatch book)
- B. * Body of organ transplant donor. Last office to be done by ICU staff in ICU.
Ø TRANSPORTATION OF VENTILATED PATIENT FROM ICU THERAPEUTIC PROCEDURES/ TRANSFER OUT TO SPECIALIZED UNIT.
Ø SENDING PATIENT FROM ICU TO OPERATION ROOM
Ø FETCHING PATIENT FROM OT TO ICU ( Patient from outside ICU ) ELECTIVE CASES / EMERGENCY CASES
Ø ROUTINE NURSING PROCEDURES IN ICU
To check individual nursing assignment of the day
Attend nursing handover report of allocated patient and the whole cubicle report.
Assess patient’s general condition :-
Level of consciousness , Colour , Pupil sizes , Vital signs
Report any significant changes to the ICU doctor.
Ventilator checking :- Settings , Alarms
Drug checking :- Perfusors : ( To check correct dosage and dilution )
a) Sedations
b) Relaxants
c) Inotropes
d) Antibiotics
e) Others
6. Nursing care plan
· Frequency of observation
· Special test
· Dressings
· Physiotherapy / suctioning
· Care of personal hygiene
· To note changes of ventilator settings
Routine observation
HOURLY
· BP / Heart rate / respiration ( continuous monitoring )
· Oxygenation (SpO2), ventilator settings
· Urine output
· Head chart
4 HOURLY
CVP reading
Temperature
Random Blood Sugar ( Dextrostix )
Urine Output
Ryles tube Aspiration
Head Chart
( The frequency of observation varies according to patient’s general condition and doctor’s orders )
DAILY & PRN
- chest tube drainage
- abdominal drainage / T-Tube drainage / colostomy
- radivac drainage
Other Nursing Procedures ( Daily or PRN )
General dressing
Change of CVP / Arterial line dressings
Change of tracheostomy dressing
Weekly change of CVP / intravenous access / urinary catheter / Ryle’s tube
Weekly hair shampoo
Ø EMERGENCY TROLLEY AND EQUIPMENT
Ø INTUBATION – Preparation of Equipment. Intubation Procedure ( Done by doctor ) Elective or Emergency.
Ø EXTUBATION by nurses accompanied with doctor
Ø ENDOTRACHEAL SUCTIONING
Ø PREPARATION ICU BED
Ø SETTING OF ARTERIAL LINE
Ø SETTING OF CVP LINE
Ø INSERTION OF CHEST TUBE – Preparation of Equipment, Procedure ( To be done by Doctor )- nurses must be observed at wound site and do the dressing.
Ø ENTERNAL FEEDING
Ø TOTAL PARENTERAL NUTRITION ( TPN )
Ø INVESTIGATIONS
Recommended investigations for patient in ICU ,
The blood gas machine in ICU analyses the following:
1. hemoglobin concentration and hematocrit
2. full arterial blood gas analysis
3. Electrolytes i.e. sodium, potassium, chloride and calcium.
Test done in main laboratory.
Test on admission / transferred in
Total white and differential cell count and platelet count only.
Serum creatinine and blood urea.
Blood Sugar ( only in diabetics, severe sepsis, on TPN , liver dysfunction).
CXR ( only intubated patient, pneumonia and chest injury.
Patients requiring postoperative ventilation for few hours need not require CXR routinely ).
Tracheal aspirate culture and sensitivity on intubation.
LFT when indicated, e.g. TPN patients, sepsis.
Coagulation profile when indicated.
Tests ordered daily
1. CXR ( pneumonia or chest injury cases only )
2. RBS ( diabetics, patient on TPN or hypoglycaemic cases.)
3. Other tests when indicated only.
Tests ordered biweekly ( Monday and Thursday )
1. Tracheal aspirate C&S.
2. Serum Calcium / Phosphate / Magnesium.
3. Liver Function Tests.
Other tests when indicated only.
Septic Workout
Ø Blood C&S, urine C&S, tracheal aspirate C&S, swab C&S ( if any wounds ) – results must be traced the following day.
DIC Screening ( send to blood bank )
Ø To get Blood bank Medical Officer approval before sending
- Full Blood Picture
- Full Coagulation Profile
After office hours,
Ø PT/APTT and serum fibrinogen is done in Biochem lab.
Blood sample to be taken from vein or artery and NOT from arterial line ( due to presence of heparin ).
Orthers
Ø Serum lactate ( to get appointment and container )
Ø Serum ammonia ( to get appointment and container from lab.)
Ø Specimen taken to be stored in ice and dispatch immediately
Ø Serum cortisol.
Serum Drug Level
When organ toxic drugs are used e.g. aminoglycosides.
Drugs with narrow therapeutic index e.g.phenytoin, digoxin, aminophylline.
The 1st sample is taken after the 3rd.dose
Post- level : to be taken 1 hr after the dose is given.
Results must be traced by afternoon and / or prior to next dose.
This schedule is to be used as a guideline only. The indication and frequency of relevant investigation is based on severity of illness, progress of patients and changes in treatment modality. All results should be reviewed and upload by the ICU medical officer in the investigations chart as soon as they are traced.
INVESTIGATIONS DONE IN BACTERIOLOGY LAB
1. Blood C&S
2. Tracheal / BAL ( broncho-alveolar lavage) C&S /
3. Acid Fast Bacilli C&S
4. Urine C&S
5. Stool C&S
6. Swab (s) C&S e.g. wound swab C&S.
7. Body fluids C&S e.g. pleural fluid C&S / drainage fluid
8. C&S
9. Spinal fluid C&S
10. Fungal C&S
INVESTIGATIONS DONE IN BLOOD BANK
Blood grouping and cross matching – GXM form
HIV screening }
Hepatitis B.C }
LE ( lupus erythematosus ) cells } Pink haematology form
Coombs’ test }
Hb & Electrophoresis }
Rh factor }
Blood reaction studies – Blood reaction form due to blood transfusion
Serum Japanese B virus
All hormonal studies e.g. serum prolactin level etc.
Histopathological examination ( HPE )
Coxsackie studies
Serum dengue serology
Viral studies
Others as stated from time to time.
COLLECTION OF C&S SPECIMENS
Ø Tracheal Aspirate C&S
Ø Broncho-alveolar Lavage ( BAL ) – To be done by doctor during bronchoscopic suctioning assisted by MA. Specimen will be collected directly to the special C&S container.
Ø Drainage / Pleural Fluids
Ø Urine C&S
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