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S. E. Amory
Results Review andContinuous
Improvement
Age-based screening guidelines are well established in many HICs but not so in all LMICs
communities. In resource-limited settings where
volunteer activity is focused, one may need to
adjust these guidelines to prioritize groups at
highest risk. Reviewing a robust database can
help to focus and practice. For example, one may
choose a lower age cutoff in LMICs if life expectancy is signicantly lower than the norm.
Symptomatic patients will inevitably present to
screening programs, skewing outcomes if these
patients are not properly identied and recorded
in the database.
Develop Local Resources
Colon cancer screening is usually not a single
event in a patient’s life. To achieve maximal benet, follow-up procedures at prescribed intervals
are necessary. From the outset, one should envision a sustainable program. Involving and training local providers is the ideal solution for
sustainability. The initial success of a program
can be valuable in attracting necessary investments from the local authorities or private
sources. A sustainable program can proceed
indenitely with progressively less input from
those who initiated it, while attention and effort
shift to the next community in need.
Conclusion
This is a brief summary of a complex organization of a new medical effort in an underserved
country, challenged by a foreign environment,
culture, and health care system. Whether the
effort is highly focused, as the one described
above or one that encompasses a broader program, as described in previous Chaps. (9 and
10) undertaking, the most important factors
contributing to success include collaboration
with local health care providers, institutions,
and regulatory bodies and major emphasis on
education by involving local professionals in
the development of the new effort so as to make
it a permanent independent service operated by
local providers. The effort must be based on
mutual respect, planning, discussions, and decisions guided throughout by the interests and
dedication of the community and the local
health care providers and hospitals. The
involvement and support of the health care
authorities and independent funding agencies
can be both supportive and sometimes, necessary to make colon cancer screening by creating a colonoscopy service both successful and
effective.
How toEstablish andExpand
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anIntensive Care Unit inaLowandMiddle-Income Country
EmnetTesfayeShimber
Experience is not what happens to you, it’s what you do with what happens to you.
– Aldous Huxley
11
Abbreviations
BP Blood pressure
CCU Critical care unit
CVP Central venous pressure
ETT Endotracheal tube
GCS Glasgow Coma Scale
ICU Intensive care unit
IPC Infection Prevention and Control
ITU Intensive treatment unit
IV Intravenous
LMICs Low- and middle-income countries
NGT Nasogastric tube
NICU Neonatal intensive care unit
E. T. Shimber (*)
Hawassa University College of Health Sciences
and Medicine, Hawassa, Ethiopia
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_11
109
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Introduction
An intensive care unit (ICU), also known as an
intensive therapy unit or intensive treatment unit
(ITU) or critical care unit (CCU), is a special
department of a hospital or health care facility
that provides intensive medical care. ICUs provide continuous care and monitoring for patients
with severe or life-threatening illnesses and injuries with the help of life support equipment and
medications until the failed organ or system
improve. Critical care is a holistic care delivered
to severely ill persons; otherwise, the situation
may proceed to life-threatening conditions [1]. It
is the delivery of a more advanced care with frequent follow-up and precise monitoring. It can be
delivered at any site if the expertise and necessary resources are available.
ICUs are staffed by physicians, nurses, and
respiratory and physio-therapists who received
training in caring for critically ill patients. The
units need and have a higher staff-to-patient ratio
than regular units, despite general shortage of
professional staffs. Advanced organ support
medications and equipment is required which
may not be available in routine wards. In low- to
middle-income countries (LMICs) the commonest causes of admission to an ICU are Acute
Respiratory Distress Syndrome, Sepsis and
Septic shock, Heart failure, and Severe trauma.
Sources of admission include emergency department, operation theatre, ward, and high dependency units. There are also specialized types of
ICUs for disease-specic treatments including
surgical, medical, neuro, cardiac, pediatric, neonatal and obstetrics. Most of the ICUs in Africa
are general ICUs which provide services for all
types of critical illnesses [2].
Africa is facing a triple burden of disease.
Though epidemiologic transition studies have
shifted disease burden from highly infectious and
fatal to non-communicable ones, primarily surgical, both remain a large and inadequately served
burden. Trauma remains a major cause of mortality which outweighs age-matched chronic illness
mortality. Injury is the current epidemic in most
of the LMICs in relation to urbanization,
increased utilization of vehicles, poor legal
enforcement, and inadequate infrastructure
which results in ineffective transport from the site
of injury to an appropriate health facility [3].
Most of the health care systems in LMICs are
immature, especially in the delivery of intensive
care. Since priority has been given to maternal
and child health, neonatal care, and STDs, the
advancement of critical care has been hindered.
Intensive care is delivered mostly by professionals untrained in ICU techniques and at sites with
low resources. The cumulative effect of low standards and inadequate personnel contributes to the
observed high mortality and morbidity of critically ill patients [4].
Critical care is a relatively new concept in
LMICs. Short- and long-term trainings are now
available in this specialty. Majority of trainees
prefer short-term skill-based training and since
the demand is very high, professionals with any
kind of training, or even without any specic
training, can be employed in ICUs in LMICs.
Most of the knowledge transfers are through
informal interaction with trained colleagues.
Nurses often take one- or two-week training
courses in basic ICU care prior to employment
and continue training on the job. Only very
recently, higher level Master of Science in critical care programs are being recognized in a few
institutes in LMICs. There are only few physicians with advanced critical care specialty training and most of them are concentrated in capital
cities. Other ICUs are led by non-specialty
trained physicians or by remote consultation
with experts in large centers. Consultation process is initiated by the primary physician before
transfer of the patient from their initial location
which might be an ER, an OR, or a ward. After
the ICU team evaluates the patient and decides
on admission, critical care begins on site and
continues through transfer and admission to the
ICU [5].
Continent-wide critical care capacity assessment survey was done in Africa in 2020 and
showed that the rate of ICU beds and mechanical
ventilators were 3.1 and 0.97 respectively, per
100,000 people. This range may vary from 0.53
to 8.59 beds and 0.14 to 2.49 ventilators. There
was an average of 2.42 total anesthesia providers
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(physician and non-physician) per 100,000 people ranging from 1.24 to 0.66in LMICs and in
the Middle African region [6, 7].
Access to critical care is a crucial component
of healthcare systems in LMICs, but the capacity
to provide such care in ICUs is limited. Patients
with physiologic disasters (shock, sepsis, arrhythmias) are forced to stay and be managed for days
in emergency departments resulting in high mortality rates. Neither the emergency departments
nor wards are adequately staffed or equipped
with the necessary equipment, supplies, and personnel. Most of the ICUs in resource-limited
areas have too few beds and ventilator machines
to accommodate the overow of critically ill
patients. Establishment of new ICU centers and
expanding the existing ones is of paramount
importance to improving health care quality in
LMICs [7–9].
Most healthcare providers in LMICs have little experience in designing, organizing, and operating an intensive care unit. This chapter aims to
guide the reader in how to either establish a new
ICU or how to renovate or expand an already
existing one.
The ICU Design
The developed world follows “Evidence-based
design” procedure which focuses on collective
knowledge from researches and benchmarking of
best practices. Optimal design facilitates better
patient outcome with appropriate cost and guaranteed staff satisfaction. It should create natural
environment incorporating both outside views
and painting over the wall as well as ceiling.
Since ICU design is completely different from
other hospital areas, a multi-disciplinary team of
health professionals and non-clinicians should be
recruited for both planning and execution of such
a task. Because of complexity of the design, different needs of the clients, and signicant cost of
the infrastructure, composition of a team of such
a diverse group is critical. All efforts must ensure
the satisfaction and well-being of patients, the
staff, and of all involved in the creation of a new
ICU [10–12].
Project team members and their primary roles
likely include:
1. Hospital management: this team is responsi-
ble for the overall generation of ideas and
allocating the necessary budget. Also, the
team supervises the progress of the project
until it is completed.
2. The clinical team: a multidisciplinary group,
including physicians, nurses, infection control
specialists, pharmacists, therapists, and ancillary staff; decides on the capacity of the ICU
with respect to size, sterility, non-clinical
areas, and other clinically focused areas.
3. The design team: this team includes archi-
tects, engineers, and technology planners.
They design the plan with focus on general
structure, electricity and water supply, and on
installation of information technology. All
this is based on the input acquired from other
teams. The overall design should incorporate
the creation of a healing natural environment
which facilitates rapid physiologic, social,
behavioral, and psychologic response.
4. Other hospital service representatives: (facil-
ity management, environmental services, food
service, and others), this team is mainly
involved in supporting the overall service by
facilitating safe and secured environment.
Common Design Elements
ICUs are often placed in an area adjacent to
emergency rooms, operation theaters, and delivery units. The outside environment should have a
waiting area for visitors with cafeteria service.
Access to entrance should be limited to only
allowed visitors and authorized staff. This can be
controlled by security personnel with the help of
camera monitoring. Assigning a porter may help
in connecting staff with families especially in
need of outsourced laboratory investigations and
medications. A guard assigned at the entrance of
an ICU needs to control the entry and exit of family, visitors, and guests. Telephone communication with the waiting room can be established for
specialized ICUs between family and staff.
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Visitor’s policy and information contact number
should be placed clearly at the entry. After the
rst door a green zone can be designated for
change of ICU dress codes, lockers, and familystaff information exchange area. Next, a yellow
zone can be designed for staff to be able to review
charts, conduct brief discussions, and to maintain
central patient monitoring. The nal red area is
the patient care zone where strict entry and management policy is applied. Each unit should have
an identication marker.
Communication Infrastructure
Broadband internet and telecom device installation must be part of the initial plan. Both internal
and external communication is vital for effective
patient care. Internal communication between
staff on duty and on call personnel is essential for
patient care. External communication includes
interaction with families, laboratory units, blood
banks, liaison units, consultants, and other
hospitals.
Patient Transportation
ICU design must consider both vertical and horizontal transport paths. Patient elevators should
be near the ICU and be deep and wide enough to
accommodate patient beds, support equipment,
and transportation staff. Some elevators should
have electrical power supplies for emergency
use. Separate elevators for service trafc are
recommended. Other considerations include
corridor widths, door-swing directions, and
timed hold-open hardware. Emergency power
sources should be available in the event of medical equipment battery depletion during patient
transport.
The Critical Care Unit Zones
The critical care unit design consists of four
major zones:
1. The Patient Care Zone: its primary function is
direct patient care equipped with appropriate
monitoring devices and sources for suction,
and gases for ventilation.
2. The Clinical Support Zone consists of an area
which subserves functions closely related to
direct patient care; not only in inpatient rooms
but also in other areas of the unit, including
areas for storage of supplies, locked area for
pharmaceutical agents (refrigerator),
Laboratory for “quick” tests (centrifuge and
microscope) and storage of cultures and uids
for future analysis.
3. The Unit Support Zone: overall administrative issues and staff support space which
includes communication and rest space.
4. The Family Support Zone is intended to give
comfort to family and visitors.
Patient Care Zone
The Patient Care Zone refers to areas for direct
patient care and is equipped with appropriate
monitoring devices and sources for suction, and
gases for ventilation along with space to accommodate visits by family members. Single rooms
or isolated cubicles are preferable for privacy.
Such rooms should resemble home arrangements
to create familiarity. Children’s units especially
should arrange sufcient room for close family to
care for the children. Multi-bed rooms should
have shields and isolation curtains between beds
when care and counseling is given. Bed arrangements should consider adequate space for multiple procedures and devices on all sides of the
bed. Windows that can open at each bedside create views of natural environment which accelerate recovery. Electronic Medical Recording
system with central monitoring is necessary for
effective follow-up. Alternatives include glass
walls for direct observation and frequent checks.
Other considerations include sound and light
control. Most of ICU equipment produce sounds
which put patients under stressful condition and
interfere with rest and sleep. Being able to adjust
light and sound to an optimal level is important
knowing that day and night illumination change
facilitates normal physiologic responses.
Each room must have the following elements:
Clear Floor Area
Clear oor space is an area occupied by neither
a patient nor equipment. The head of the bed
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should be placed at least 1 m away from the
wall and the sides of the bed should be at least
2m apart from adjacent beds. Beside privacy,
this area is needed for staff activities and for
portable imaging, echocardiography, transcranial Doppler examination equipment, electrocardiogram, dialysis equipment, and more. A
separate room which serves all these purposes
on a preset schedule is recommended and more
desirable.
Medical Utility Distribution System
This system includes electronic equipment and
supplies, medical gas supply, and a suction system. The medical utility outlets can be designed
in one of the following ways: a at headwall system, xed column, suspended column, and boom
congurations forms. Grounding is critical in any
electric system as is a generator backup that can
be promptly activated when need arises.
Medical gas, vacuum, and electrical outlets
should be available for each bed. The power supply can be directly accessible from the main
power source of the hospital. In case of absence
of the routine electric system, automatic generator should be on standby. The oxygen system is
usually accessible from a cylinder in developing
countries. The storage and protection as well as
inspection of the tanks on a scheduled basis is
mandatory and needs to be recorded. Wall oxygen, suction, and vacuum air systems should be
planned for the future, if they cannot be established immediately.
Intravenous Pumps are needed since most of
ICU drugs need infusion pumps. This may
require space and electric source.
Medications Cabinets for frequently needed
medications should be placed by the side of the
patient with the appropriate dose and clearly
written order of administration.
Bedside Cabinet for food and drinks, clothes,
sanitary materials, water and personal protective
materials depending on the patient’s need may be
placed here.
Supplies’ storage is needed for all other supplies which are necessary for routine care, infection prevention, and control hygiene accessories;
re extinguishers and electronic devices should
also be stored in a room inside ICU with the necessary inventory and combination lock protection
to prevent theft or misuse. Bedside dialysis
requirement should include water treatment or an
alternative.
Doors and Windows
The door should accommodate the largest ICU
bed together with portable equipment and caregivers and transporters. Single entry is recommended. The room should get adequate natural
light and ventilation. Ground oor ICUs should
have the environmental view of a garden, if possible. Upstair rooms should provide a mirror
image of nature. This helps to relieve anxiety and
fastens recovery.
Walls and Ceilings
Green and blue paints have been previously
shown to be favorable for tranquility. Most of the
bedridden patients stare at the ceiling so that the
interior design should consider non-abstract
drawings and neutral lighting system. Pediatric
units should have conducive wall arts with appropriate fairy tale gures.
Furniture
Bedside chair for both patients and family, waste
containers, television, wall images, and clocks
can be considered to create conducive
environment.
Family Accommodations
Allowing families inside a patient’s room should
have a time limit to allow the patient to rest and
the staff to deliver care in a timely manner.
Considering the strong social bond and an
extended family, early morning and late evening
assignment of visitor hour is mandatory. For conscious patients who need frequent family support, allowing one family member extended stay
might be warranted. ICU dressing code for IPC
should always be in place.
Temperature Control
Depending on weather conditions air cooling and
warming system should be available. In pediatric
ICUs external temperature control is mandatory.
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Hygiene and Sanitation
Hand hygiene should follow the WHO protocol.
Water, soap, and alcohol should be readily available. There should be two sinks at entry to a room
and near disposal system. A separate toilet for
staff and mobile patients should be available
inside the ICU. Caregivers can use bedpans or
containers (for males) for uid and urine collection for bedridden patients.
Waste Disposal System
All used equipment should be segregated in categories and disposed appropriately. Reusable
materials, especially airway and mechanical ventilator equipment, should have a separate place
for cleaning and storage. Sharp materials and
needles should have a separate container than
other wastes. All types of body uids should be
disposed of in a separate room. Strict follow-up
of IPC protocol ensures appropriate waste
management.
Isolation
Isolation rooms are mandatory for infected
patients, patients who are prone to acquire infection, and patients who have phono- or photophobias. Creating negative pressure helps in
preventing the spread of airborne pathogens but
is very costly and not mandatory but ideal.
Clinical Support Zone
This area functions as storage space for equipment and supplies which are related to diagnosis
and treatment of patients. Some of these may be
located inside the ICU, while others may be
located in more remote sites.
Team Work Areas
There is a need for sites for discussions among
the members of the care team or with consultants,
as well as a site for regular rounds in a separate
and quiet environment. This is especially important in teaching hospitals. This should also be the
location for maintenance of ICU guidelines, protocols, activity schedules, staff rosters, and standard manuals for everyone’s use.
Centralized Monitoring: for electronic point
of care, ICUs may have remote site centralized
monitoring system. For others, documentations
and order carryout can be done on site in the ICU.
Tele-ICU: For ICUs with few trained physicians, a single critical care physician can oversee
several ICUs via digital supervision and continuous consultation. Such remote site consultation is
also possible with direct patient visualization. It
may also serve as an important tool for teaching
new staff.
Pharmacy Services
There should be a separate ICU pharmacy inside
an ICU with appropriate security and accountability. This permits rapid access to emergency
drugs in urgent situations. Many of ICU medications need further preparation according to the
prescription. A discrete sterile area in the pharmacy should be reserved for this activity and contain a refrigerator, laboratory scale, and
centrifuge, and, if possible, a fume hood. After
preparing the medication it should be clearly
labeled with the name of the patient, hospital
number, date, time, and duration of
administration.
Laboratory Services
ICUs must have access to 24-h clinical laboratory
services. Simple tests can be done in a satellite
laboratory near or in the ICU equipped with a
centrifuge, a microscope, and an incubator. There
must be easy access for blood gas analysis, chemistry, hematology, uid analysis, and cultures,
while more extensive investigations should be
performed in a central laboratory.
Imaging Services
Portable ultrasound and X-ray should be available in the ICU.Since transportation of critically
ill patients attached to multiple devices is often a
challenge, other services like CT and MRI should
be easily accessible, preferably on the same oor.
The equipment should be inspected on a regular
basis as proscribed by the manufacturer and
repaired promptly when needed.
Respiratory Therapy
A respiratory support area with storage space for
mechanical ventilators, circuits, tubes, airway
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equipment, and oxygen tanks should be separate
from the main storage area. Since a respiratory
therapist may not always be available, a trained
professional physician or nurse should be in
charge of this unit. The team should include
nurses, physicians, and biomedical technicians.
Specialized Procedure Areas
One designated patient room in the ICU should
be equipped to accommodate imaging or invasive
procedures. Areas for specialized medical
procedures, such as biopsies, or line insertions,
must be available adjacent to or near the ICU
(e.g., a cardiac catheterization laboratory adjacent to a cardiac ICU).
The functional requirements for the unit will
dictate the need for specialized procedure rooms.
Due to equipment and stafng costs, a costbenet analysis should assess the probable number of cases requiring these highly specialized
rooms over the lifespan of the unit.
Emergency Equipment and Supplies
Crash cart lled with emergency life-support
equipment and supplies should be always available and be inspected on a regular basis, and be
replenished after each use. Charge nurse should
check that it is properly resupplied at least once a
day. There should be written hand-over protocol
conrmation of its inventory between shifts.
Nutrition Preparation Area
Kitchen appliances should be available to prepare
food for patients based on their dietary need.
Unit Support Zone
The unit support zone encompasses areas where
administrative, logistic, and staff support functions are performed. Multipurpose conference
room is useful for clinical audits, seminars,
change of shift reports, and case discussions. A
Clean Utility room is necessary for storage of
clean materials and a Soiled Utility room is used
for decontamination of soiled materials. Staff
lounge with full kitchen appliance decreases staff
absences from the ICU during service hours.
On-call rooms with beds, television, internet, and
table facilitate staff to have adequate rest when it
is possible. ICU director and shift head need an
ofce space. Toilet and shower services must also
be available on the unit.
Family Support Zone
The Family Support Zone should consist of
spaces which would be outside of the patient
rooms to serve both family and visitors. This will
also permit consultations, rest, visitor nourishment, and prayer activities in an isolated walledoff section. Chairs should recline sufciently for
the family and/or visitors to rest and nap.
ICU Classication
The ICU may be classied based on the following alternate basis: (1) Level (Level 1, Level 2,
Level 3); (2) Purpose—(a) Standard (ideal or
standard), (b) General (used for all purposes), (c)
Specialized (medical, neurological, or surgical),
(d). Age group (adult ICU, pediatrics, neonates);
(3) Specic organ system (cardiovascular, neuro,
renal, respiratory); (4) Clinical syndrome (burn,
trauma, stroke, poisoning); and (5) based on
Client (neonatal, pediatric, obstetric) [1, 5].
Level I ICU is also referred to as high dependency unit. This can be located in primary district
hospitals, where close monitoring, resuscitation,
and short-term ventilation for less than 24h have
to be performed. Trained general practitioners
and nurses work in this unit. Specialist physicians might be in charge of the critical patients
based on their expertise and availability. Teleconsultation with critical care physicians elsewhere is available at all times.
Level II ICU can be located in a general
regional hospital. Here trained professionals
including residents, doctors, nurses, and specialists supervise patient care and are able to undertake more prolonged patient ventilation and
maintenance. Laboratory, radiology, and pathology accesses are modest but are available and are
mandatory.
Level III ICU is a highly specialized unit
located in a major tertiary hospital. It provides
dialysis, cardiac catheterization laboratory, clinical pharmacy, physiotherapy, and rehabilitation
services. This unit is overseen by intensivists,
emergency, and critical care physicians and anes-
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thesiologists. Further availability of nephrologists, gastroenterologists, neurologists, and other
sub-specialists is almost always available on call.
General Intensive Care Unit
This represents a multi-disciplinary care unit. In
consideration of critical complications of all disease entities, this type of unit offers specialized
care to acute stabilization of the presenting lifethreatening condition. A closely interacting team
of Emergency and Critical Care specialists,
Anesthesiologists, and Intensivists provides joint
diagnostic and therapeutic interventions as they
are needed. Consultations with other specialty
areas, including surgeons, are made based on the
individual patient’s needs. This is a cost-effective
strategy for LMICs since it permits a centralized
system of resource management.
Medical Intensive Care Unit
The medical intensive care unit is dedicated to
the care of adult patients with life-threatening
medical conditions requiring frequent observation, specialized monitoring, and medical treatment. These include illnesses such as diabetic
ketoacidosis, gastrointestinal bleeding, drug
overdose, respiratory failure, sepsis, stroke, and
metastatic cancer.
Surgical Intensive Care Unit
The surgical intensive care unit is dedicated primarily to the management of postoperative
patients, including patients who have undergone
major abdominal surgeries, craniotomies, thoracotomies, unstable multiple traumas, and any
preoperative or acutely ill patient with a presumed surgical disease who requires continuous
monitoring or organ support, regardless of cause.
Pediatric Intensive Care Unit
All critically ill children are managed in the pediatric intensive care units. Children who have
recently undergone surgery and are at risk of
deterioration are also managed in the pediatric
intensive care unit.
Neonatal Intensive Care Unit
The neonatal intensive care unit (NICU) is dedicated to the management of premature, high-risk,
and critically ill neonates. NewbornsInfants undergoing urgent operations following delivery (e.g.,
Diaphragmatic hernia, TE stula) are cared for in
NICU. Neonates with congenital disorders and
birth complications are also managed in the NICU.
ICU Organizational Models
Intensive care services are an important and
costly resource, which once established must be
consistent, safe, and efcient [10].
Open Model
This organizational model allows many members
from various specialties in the hospital to manage
their patients in the ICU.This leads to inconsistencies in management, confuses and misleads
the staff, and is unreliable and inefcient. It introduces many errors in judgment and in patient
mismanagement [13].
Closed Model
In this model a limited number of ICU-certied
physicians are responsible for the overall activities in the ICU.Based on the need judged by the
full-time staff other specialists can be consulted.
In most cases, patient’s own physician or surgeon
can assist in the care of their patients through
suggestions and advice to the responsible ICU
staff. This model leads to favorable outcomes and
improved patient survival [13].
Hybrid Model
This model combines aspects of open and closed
models in a systematic manner, usually combining responsibilities in patient management by
joint rounds at which decisions are made.
Availing many specialists at a time is not cost
effective for LMICs.
ICU Standards
The number of ICU beds typically comprise 1 to
10% of a hospital’s total bed capacity.
Multidisciplinary ICUs require more beds than
does a single specialty ICU. ICUs with fewer
than four beds are not nancially viable, and
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those with more than 20 beds may be difcult to
manage. An ICU should be situated close to one
or more important locations, such as the operating room, radiology department, acute wards,
and emergency room. There should be a sufcient number of elevators available to transport
seriously ill patients to various locations quickly
and without delay. An ICU should have only a
single entrance and exit point. Any trafc of medical personnel or supplies through an ICU should
be prohibited.
ICU must feature places and/or rooms for
support services, patient management talks,
and public reception. A central station should
be equipped with one or more telephones, two
refrigerators, one for medications, the other for
samples, and a central monitor for EKG and
vital signs connected to each patient’s bed.
Patient records, if not electronic, or supplemental should also be maintained in this area.
Each patient requires a oor area of 18.5 m2
(200 sq.), with single rooms needing a greater
area of 26–30 m2 to comfortably t patients,
personnel, and equipment. All space restrictions listed above and in the comments are
arbitrary and determined by the rules of the relevant health authorities. The distance between
the bed centers should be at least 3 to 3.67
meters. Single rooms are essential for isolation
purposes and for privacy. Three oxygen, two
air, four suction, and 16 power outlets including a bedside lamp are optimal for level III
ICU beds depending on size and function of
the ICU.
The overall management should be led by a
director who is a full-time physician and responsible to the chief executive director or medical
director. Institution-based protocols on
admission- discharge, IPC, sedation, enteral–parenteral feeding, lung protective ventilation,
weaning, venous thrombo-embolism prophylaxis, and drug administration hospital should be
clearly strictly adhered to.
A multidisciplinary committee should be
established with main role of conducting clinical
oversight and audits and an Ethics Committee
should be available to help resolve ethical
dilemmas.
ICU Stang
The ICU structure depends on institutional
human resource capacity.
Medical Staff
Large hospitals require larger teams. Intensivists
are the most effective senior medical staff
appointed to the leadership roles in ICUs. They
can share their supervisory functions with other
intensivists or specialists in various elds depending on the medical focus of the ICU. Other
Emergency and Critical Care physicians and
Pulmonologists or Anesthesiologists can also fulll the supervisory ICU role. In very limited
resource areas critical care trained physicians
like surgeons, internists and pediatricians can
also assume leadership ICU function (Fig.11.1).
Nursing Staff
The head nurse should be an Emergency and/or
Critical Care trained and experienced nurse.
Alternatives include BSc critical care nurses. He/
she should be experienced in the use of health
information systems, in guiding quality improvement projects, and be familiar with enforcing IPC
standards. The head nurse’s duty extends to creating conducive environment among the nurses,
physicians, and various working units in the ICU
like pharmacy, laboratory, and physiotherapy.
The major hospital’s teaching tertiary care
ICUs require trained and critical care certied
nurses. Nurse-to-patient ratio in tertiary units
should aim for a ratio of, 1:1in all mechanically
ventilated patients, and not accept anything lower
than 1:2 ratio. A ratio of 1:2 is acceptable for
those patients who need only close observation
and are not supported by a mechanical
ventilator.
Allied Service Staff
Physiotherapy, social workers, dieticians, radiology services, and respiratory therapists are an
important and essential workforce responsible
for the overall effective and safe patient management. Biomedical department services are also
required on a regular basis to service, repair, and
install old and new equipment.
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