Management

ICU Design: Basics

The requirement of ICU beds has increased from the traditional 1-4 beds per 100 hospital beds to 10-20 per cent of the total hospital beds

The old concept of identifying ICU as just a separate area with high-tech gadgets no longer holds true. One should take cognizance of the recent developments and the various recommendations by bodies like the Society of Critical Care Medicine (SCCM), Indian Society of Critical Care Medicine (ISCCM) and the published literature on the subject. An important dimension is the concerns of the patients and their families, who often complain about overwhelming feelings of insecurity, disorientation, anxiety, fear and anger. The sheer volume of technology, the unfamiliar, sterile surroundings, lack of privacy, constantly revolving medical teams, incessant noise and glaring light, and the lack of natural forms, materials, and sensory experiences all add to this traumatic experience. As a result, the patients feel trapped in an environment they dislike and cannot control, and their families feel helpless.

Comfort: Top Priority

The focus, therefore, is on ICU designs that provide comfort to patients, reduce hospital acquired infections and cost of ICU stay. On one hand the severity of the interventions requires the utmost in technology, methodology and sterility, while on the other hand, the patients and their families who are experiencing some of the most traumatic moments of their lives need a natural feel and look environment that is comforting and de-stressing.

There is also increasing awareness about quality in healthcare and institutions are keen to comply with the standards laid down by agencies like the Joint Commission on Accreditation of Healthcare organisations (JCAHO), Joint Commission International (JCI), National Fire Prevention Association (NFPA), National Accreditation Board for Healthcare Organisations (NABH), for upgrading their facilities to promote safety as well as business.
These organisations have developed minimum standards for healthcare institutions independently and although these standards by these non-State agencies are technically considered non-binding, many governmental and private reimbursement organisations require compliance with them to qualify for reimbursement. As a result, more and more hospitals in India are opting voluntarily for accreditation by these agencies.

Prime Factors

"A direct elevator is an excellent idea to transfer sick patients to and fro from the ICU, reducing transport time and avoiding the visitors" - Dr Rajesh Pande Chairman Department of Critical care and Emergency Medicine BLK Memorial Hospital New Delhi

The various factors that need to be considered while designing an ICU are sources of patients, admission and discharge criteria, expected rate of occupancy, economic investment, financial viability, personnel required as well as the technological resources. One has to also consider the level of ICU care required. Level I provide monitoring, observation and short term ventilation. Level II provides observation, monitoring and long term ventilation with resident doctors. Level III provides all aspects of intensive care including invasive hemodynamic monitoring and dialysis.

The Team

The designing team should consist of an ICU specialist, nursing administrators and supervisors, hospital administrators, architect, engineers, environmental engineers, interior designers with considerable input from patients and their families. ICU floor plan should be based on patient admission pattern, staff and visitor traffic pattern. It should be centrally located close to the operation theatres, HDUs, Imaging and the Emergency Departments. Some hospitals have amalgated the ER triage with the ICU, so-called shock labs, increasing the preparedness and eliminating the duplication of resources and manpower. But to achieve these both facilities should be located on the same floor.

An Ideal ICU

There should not be any thorough traffic to other departments from the ICU. It is a good idea to separate the supply and professional traffic from public/ visitor traffic. A direct elevator is an excellent idea to transfer sick patients to and fro from the ICU, reducing transport time and avoiding the visitors. The patient transport corridors should be separate than those used by the visiting public. Patient privacy should be preserved and transportation should be rapid and unobstructed. The elevators should be oversized keyed elevators, separate from public access. The support facilities should include nursing stations, storage, clerical space, administrative and educational requirements, and other services unique to the institution.

Call for a Change

The requirement of ICU beds has increased from the traditional 1-4 beds per 100 hospital beds to 10-20 per cent of the total hospital beds, but this depends on the type as well as on the role of an ICU. ICUs with less than four beds are not seen as cost-effective and from a functional point of view 8-12 beds per unit is best, if a large ICU is planned. ICU should have positive and negative pressure isolation rooms within the unit. Each ICU should be a geographically distinct area with controlled access. Regarding the subspecialty ICUs, it's for the Institution to decide whether to organise its ICU into multiple units, e.g., medical and surgical ICUs etc. under separate management or to make a general multidisciplinary ICU managed by the Intensive care specialists.

Minimum Requirements

Each patient bed area in an adult ICU requires a minimum floor space of 20 m2 (215 ft2), with single rooms being larger (~ 250 ft2) to accommodate patient, staff, and equipment without overcrowding. The ratio of single rooms to open beds is usually recommended as 1:6 for multidisciplinary ICUs, though it also depends on the role and type of the ICU. Utilities per bed space as recommended are: 3 oxygen, 2 air, 3 suction, 16 power outlets, and an adequate appropriate bedside light. All beds should have uninterrupted supply and battery backup to run life saving equipment. Centrally supplied oxygen and compressed air must be provided at 50 to 55 psi from main and reserve tanks, and installation must follow NFPA standards. The vacuum system must maintain a vacuum of at least 290 mm Hg at the outlet farthest away from the vacuum pump. Audible and visual alarms must indicate a decrease in vacuum below 194 mm Hg. Total luminance should not exceed 30 foot-candles (fc). Night lighting should not exceed 6.5 fc for continuous use or 19 fc for short periods. Separate lighting for emergencies and procedures should be located in the ceiling directly above the patient and should fully illuminate the patient with at least 150 fc shadow-free. How the services are provided, from floor columns, bed pendants, wall mounted depends on individual preferences as each design has its pros and cons.

Silent Noise!

Signals from patient call systems, alarms from monitoring equipment, and telephones add to the sensory overload in critical care units. Without reducing their importance or sense of urgency, such signals should be modulated to a level that will alert staff members, yet be rendered less noxious. 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, and 20 dB (A) at night. To achieve this, the floor covering that absorb sound, walls and ceilings should be constructed of material with high sound absorption capability and the doorways should be offset rather than being placed in symmetrically opposed positions to reduce sound transmission.

Personal Space

Space and surfaces for computer terminals and patient charting should be incorporated into the design of each patient module. Storage must be provided for each patient's personal belongings, patient care supplies, linen and toiletries. Locking drawers and cabinets must be used if syringes and pharmaceuticals are stored at the bedside. Personal valuables should not be kept in the ICU. Rather, these can be either handed over to the family or held by hospital security until patient discharge.

Patient areas must have large clear windows so that natural light can access the room easily. Additional approaches to improving sensory orientation for patients may include the provision of a clock, calendar, bulletin board, and/ or pillow, speaker connected to radio and television. Televisions must be out-of-reach of patients and operated by remote control. If possible, telephone service should be provided in each room.
The clinical areas must be situated so that direct or indirect (video monitor) visualisation by healthcare providers is possible at all times. This permits monitoring of patient status under both routine and emergency circumstances. If possible, the design should allow a direct line of vision between the patient and central nursing station. The presence of sliding glass doors, partition facilitate this arrangement and increase access to the room in emergency situations.

For the Nurses

The central nursing station should be of sufficient size to accommodate all necessary staff functions. Adequate space should be provided for computer terminals and printers with good overhead and task lighting. A wall mounted clock should be present. The patient records should be easily accessible. Adequate surface space and seating for medical record charting by both physicians and nurses should be provided. The shelving, file cabinets and other storage for medical record forms must be located so that they are readily accessible by all personnel requiring their use. The secretarial area may be located separately from the central station but should be easily accessible.

Special Focus

There should be a designated area near the ICU for the viewing and storage of patient radiographs. An illuminated viewing box of appropriate size should be present to see serial X-ray, CT and MR scans. The work areas should be well planned so that the critical supplies can be located within or immediately adjacent to the ICU. Work areas and storage for critical supplies should be located within or immediately adjacent to the ICU.
For storage and rapid retrieval of crash carts and portable monitors/ defibrillators, alcove should be provided. Space should be earmarked for keeping ventilators not in use. A separate medication area containing a refrigerator for pharmaceuticals, a double locking safe for narcotics and controlled substances must be provided. There should be cabinets available for storage of medication and supplies and countertops for medication preparation. This area should be earmarked as injection loading area. If this area is enclosed, a glass wall should permit visualisation of patient and ICU activities during medication preparation, and to permit monitoring of area itself from outside to assure that only authorised personnel are within. A sink with hot and cold water supply should be provided in this area.

Each ICU should have a reception to control visitor access. The preferred location is where the visitors must pass this area to enter the ICU. The receptionist should be linked to the ICU's by telephone and or communication system. Ideally visitor's entrance should be separate from that used by healthcare professionals and should be securable if the need arises. It is a good idea to have one room/ corner labeled as a procedure room. It avoids interference during visiting hours and ensures privacy during the procedure. The ward ICU procedures like decanulation, CVP insertion, bronchoscopy etc can be done here. The facility should be at par with the ICU with sufficient storage cupboards and should have free access and exit.

Air Supply Matters

Air supply to the ICU merits special attention. It is preferable to have triple filtration including High Efficiency Particulate Air (HEPA) filters to improve the quality of air. In fact the air quality should be at par with the OR. The clean and dirty areas should be separate without inter-connection. The air supply from the dirty utility and isolation rooms must be exhausted. The floor should be covered with seamless materials to facilitate cleaning. Similarly, dialysis (CRRT) is often required in the critical patients, therefore, provision must be made to have RO water recirculation system installed in a few beds in the ICU.

The clean utility should be used for storage of all clean and sterile supplies including linen. Shelving and cabinets for storage must be located high enough off the floor to allow easy access to the floor underneath for cleaning. The Dirty Utility (DU) must contain a clinical sink and a hopper both with hot and cold mixing faucets. Separate containers should be provided for soiled linen and waste materials. There should be designated mechanism for the disposal of items contaminated by body fluids and special containers should be provided for disposal of needles and sharps. It is also a good idea to have a dedicated area for the storage and securing of large patient care equipment items not in active use. This space should be adequate to provide easy access, easy location of desired equipment and easy retrieval. Grounded electrical outlets should be provided within the storage area in sufficient numbers to permit recharging of battery operated items.

Comfy Ambience

Due consideration should be given to the comfort of ICU staff and a staff lounge must be available on or near the ICU, to provide a comfortable and relaxing environment with secured locker facilities, showers and toilets. This area should include comfortable seating and adequate nourishment storage and preparation facilities including a refrigerator and a microwave. The lounge must be linked to the ICU by telephone or the intercommunication system and emergency cardiac alarms should be audible within.

In order to provide service on a 24-hour basis, on-call rooms should be available close to the ICU. Toilet and shower facilities should be provided. On-call rooms must be linked to the ICU by telephone and/ or voice inter-communication system. In addition, cardiac arrest/ emergency alarms must be audible in these rooms. It is often desirable to have office space available adjacent to the ICU(s) for medical and nursing management and administrative personnel. These offices should be large enough to permit meetings and consultations with ICU team members and/ or patients' families. Additional office space may be allocated for staff development personnel, clinical specialists and social services, as applicable. The ability to place these individuals in close proximity to an ICU may facilitate an integrated and broad-based team approach to patient management.

Well Connected

Similarly, a conference room should be present conveniently near the ICU area for ICU physician and staff use. This room must be linked to ICU by telephone or other communication systems and emergency cardiac alarms should be audible in the room. It will be a multi-purpose room for organising CME, house staff education, or multidisciplinary patient care conferences. It can also be used to store medical and nursing reference materials and resources. VCR, computers and other self learning equipment including mannequins can be placed here. If the conference room is not large enough, a separate class room should be provided for teaching and training. A separate family consultation room is strongly recommended for daily counseling as well as grief counseling.

Cannot Afford to Ignore

One of the most important areas is the visitors lounge or the waiting area, located near the ICU. The visitor access should be controlled from the receptionist area. The recommendations are to have one and one-half to two seats per bed. Public telephones and dining facilities must be available to the visitors besides television and soft music. The public toilet facilities and a drinking fountain should be located within the lounge area or immediately adjacent. It is desirable to have warm colours, carpeting, indirect soft lighting, and windows. A variety of seating, including upright, lounge and reclining chairs is also desirable. The educational material and lists of hospital and community based support and resources can be displayed here. The ICU has to be customised to meet the need of the hospital and should take future expansion plans of the hospital into consideration.

IT is the Way Forward

Computerised patient charting is becoming increasingly popular in ICUs. These systems provide for 'paperless' data management, order entry and nurse and physician charting. If and when a decision is made to utilise this technology, it is important to integrate such a system fully with all ICU activities. Bedside terminals facilitate patient management by permitting nurses and physicians to remain at the bedside during the charting process. To minimise errors, monitored data can be recorded automatically.

In addition, when these systems are properly interfaced with existing hospital Information System (HIS), Laboratory Information System (LIS) as well as Picture Archiving and Communication System (PACS) for X-ray, CT scans etc facilitating data retrieval at bedside. Remote data transmission capabilities (to offices, on-call rooms, etc.) are desirable to facilitate continuity in patient management. It is also a good idea to have an intercommunication system in ICU that provides voice linkage between the central nursing station, patient modules, physician on-call rooms, conference rooms, and staff lounge. Supply areas and the visitors' lounge/ waiting room may also be included in the system. When appropriate, linkage to key departments such as blood-bank, pharmacy and clinical laboratories should be included. Some types of communication, such as personnel tracking and non-emergency calls, may best be accomplished using visual displays (for instance, numerics or colour-coded lights) that eliminate unnecessary noise.

Communication is the Key

In addition to standard telephone service for each ICU, which should provide hospital-wide and external communications capabilities, there should be a mechanism for emergency internal and external communications when normal systems fail (for example, during power failures). All ICUs must have access to 24-hour clinical laboratory services. There should be provision to provide minimum chemistry and haematology testing, including arterial blood gas analysis in the ICU.

ICUs in near future will be need based, well planned, equipped with advanced technology, fulfilling all dimensions of the patient's needs.

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