A 50-year-old male patient was brought to the emergency department in a shock state. After initial resuscitation, the emergency physician wanted to admit this patient in the intensive care unit (ICU), but there were no beds available. The duty resident in the ICU was unable to shift any patient to make room for the patient in the emergency department.

Organizational issues, anticipating problem areas, and prior planning are of utmost importance for smooth functioning of any intensive care unit (ICU). These organizational aspects may be looked from human resources, infrastructure, and processes of care viewpoint (Table 82.1).

Step 1: Designate the level of care that can be provided by the ICU

•ICUs are usually designated by three levels of care provided, with a varying nomenclature for these levels.

•In essence, they are the basic, intermediate, and advanced level of ICU care.

•Minimum requirements for a basic level ICU care:

–Resuscitation and short-term cardiorespiratory support including mechanical ventilation

–Noninvasive ventilation

N. Rungta, M.D., F.C.C.M. (*)

Critical Care Medicine, Rungta Hospital, Jaipur, India e-mail: drnrungta@yahoo.com

M. Munjal, M.D.

Department of Anaesthesia & Critical Care, Rungta Hospital, Jaipur, India

K. Mittal, M.D.

Department of Pediatrics, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, India

–Closed ICU care: Patient care is transferred to consultant intensivist, who makes all major decisions including transferring out of patients. Once the patient is transferred out of ICU, the primary physician takes over the care.

–Open ICU care: Patient care remains under the primary physician who may not be an intensivist. Intensivist, if available, consults only on request and can suggest treatment which is not binding.

–Semiclosed or transitional ICU care: This is a hybrid model where the consultant intensivist rounds on every patient as a mandatory consultation. Patient management is a shared decision between the primary physician and the intensivist.

•There is an increasing body of literature that the closed ICU system is a better model of delivery of care in the ICU.

Step 3: Construct a multidisciplinary team

•The principal ingredients of a multidisciplinary team in an advanced ICU should consist of the following:

–Consultant intensivists

•Conduct daily rounds of all ICU patients preferably twice

•Available on call or in-house for emergencies

•Supervise residents in writing clinical notes and during procedures

•Coordinate admissions and discharges

•Coordinate with the primary physician

•Communicate with the patient and the family

•Coordinate end-of-life decisions (see Chap. 81)

•Maintain policies and protocols (see Chap. 80)

•Perform quality control and audit (see Chap. 84)

•Play an active role in teaching and research

–Resident doctors

•One qualified resident doctor for five ICU beds

•Rotate at 8- or 12-h shift

•Present cases in rounds, write clinical notes, and perform procedures and proper handover (see Chap. 79)

–Nurses

•1:1 Nursing for patients on the ventilator

•1:2 or 1:3 Nursing for less sicker patients

–Health assistants

•Assist nurses in patient care activities such as feeding, giving bath, bed making, etc.

–Respiratory/physiotherapists

•Help in early mobilization

–Nutritionists

•Assess calories and protein goal every day and ensure adequacy of nutrition delivery

•Coordinate with the physician and nurses to ensure early enteral nutrition delivery

–Biomedical technicians

•Maintain, calibrate, and troubleshoot different biomedical devices such as monitors and defibrillators

•Ensure safe transport of these equipments

•Ensure proper disinfection of the equipments

–Clinical pharmacists

•Coordinate with nurses and doctors to identify adverse drug reaction, drug dosing, and drug–drug interaction

•Ensures compliance with the hospital antibiotic policy

–Social workers

•Liaise with family members and coordinate between them and ICU staff

–Secretarial staff

•Keep proper medical records, billing, computer entry of drugs, etc.

•Answer phone calls and check the laboratory and radiology report.

–Cleaning and housekeeping personnel

•Clean the ICU (see Chap. 48)

•Help in transporting the patient and blood samples

•Help with catering services

Step 4: Understand important elements of an ICU design

•Location

–The ICU should be located ideally near the emergency department and operation theater.

•Number of beds

–General recommendation for number of ICU beds is usually 10 ICU beds per 100 hospital beds.

–Bed strength in one ICU should be between 8 and 12.

•Layout

–The ICU could have separate rooms, two or four bed cubicles, or an open ward with curtains or partition between patients.

–The isolation room should be present for immunosuppressed patients (positive pressure) or infectious patients (negative pressure).

–Space per bed has been recommended from 125 to 150 square feet.

–Each bed should have compressed air, oxygen, vacuum source, and adequate electrical sockets for power source.

–Beds should have removable headboards and adjustable position ideally motorized.

–Beds should be equipped with the cardiopulmonary resuscitation (CPR) facility knob.

•Adequate lighting, preferably natural light, and minimum noise level should be maintained.

•Bedside hemodialysis facility should be available in some beds.

•There should be ample storage area and clean and dirty utility rooms.

•Proper hand hygiene, waste disposal, and adequate CSSD facilities should be available.

•Disaster preparedness should be maintained.

•Family counseling room and doctors and nurse resting rooms should be provided.

•Adequate toilet facilities for the patient and staff should be provided.

Step 5: Equip the ICU with the following services

•Continuous electrocardiogram monitoring (with high/low alarm) in all beds

•Pulse oximetry monitoring capability in all beds

•Continuous arterial pressure monitoring (noninvasive and invasive)

•Continuous central venous pressure monitoring

•Emergency resuscitative equipment including defibrillators

•Airway maintenance equipment including laryngoscopes and endotracheal tubes

•Adequate number of ventilators depending on case mix

•Equipment to support hemodynamically unstable patients including infusion pumps, blood warmers, pressure bags, and blood filters

•Hypo-/hyperthermia blankets

•Core temperature monitoring devices

•Temporary pacemakers

•Cardiac output monitoring facility

•Pulmonary artery pressure monitoring

•Glucometer

•Continuous or intermittent hemodialysis

•Peritoneal dialysis

•Capnography

•Fiber-optic bronchoscopy

•Intracranial pressure monitoring

•Continuous EEG monitoring

•Portable X-ray facilities

•Computerized access to laboratories, pharmacy, and imaging

•Immediate access to information—paging numbers, hospital directory, duty roster, online search facility, medical textbooks and journal, and poison center contact number

Step 6: Define ICU policies and protocols

•An updated policy and protocol of the ICU should be available to all ICU personnel.

•These policies should be formed with consultation of all stakeholders and approved by the ICU director and hospital management.

•A few examples of such policies are as follows:

–Interhospital and intrahospital transport

–End-of-life policies

–Guidelines for determining brain death

–Restraint and sedation protocols

–Organ donation policies

–Infection control policies

–Antibiotic policies