The guiding principle when considering ICU admission should be the timely use of resources on patients who have a realistic prospect of recovery, to achieve a quality of life that would be valued by them.

The following criteria are based on internationally acceptable guidelines for ICU admissions.

 

1.       Diagnosis: All patients must have a diagnosis; however, some specific conditions automatically qualify patients for ICU admission. E.g., patients with severe head injury, Inhalational injury etc.

2.       Ventilatory support: The need for mechanical ventilatory support. E.g., Respiratory failure, ARDS, Acute exacerbated COPD etc.

3.      Cardiac support: Patients whose cardiovascular function needs to be supported. These are patients who require inotropic support while their primary problem is being treated. e.g., Sepsis, Shock etc.

4.      Compromised airway: These are patients who need urgent anaesthesiologist intervention such as Inhalational injury, Status Asthmaticus, Tetanus, Unstable Post-operative patients etc.

5.      Active invasive/advanced monitoring:

Examples includes; unstable cardiac parameters on continuous invasive cardiac monitoring such as in post cardiac-arrest, myocardial infarction, Polytraumatised patient, patients that need serial ABG monitoring; such as in severe metabolic derangement etc.

6.        Exclusions: Potential for the patient to benefit from interventions are considered in all patients. All patients must have a reversible pathology to be considered i.e., potentially salvageable. This excludes patients with conditions such as; brain death, irreversible organ damage, severe chronic disease with limited life expectancy, acute illness with limited life expectancy, acute complication of severe but potentially incurable diseases.

7.        Prognosis: The patient who stands to benefit the most, and has the better chance of survival will always be considered first; e.g., paediatrics before the elderly

8.       Bed availability. The existence of an empty bed does not justify an ICU admission. Each patient will be evaluated on his/her own merits. However, in the absence of pressure for ICU beds, a patient with uncertain primary diagnosis but with active medical problems who meets the above criteria may be considered for admission.

Note:

·        The above guidelines are required to avoid unnecessary suffering, and the waste of valuable resources caused by admitting patients who have nothing to gain from intensive care because they are either too well; or have no realistic prospect of recovery.

·        Patients in persistent vegetative state must not be admitted into intensive care unit.

·        Interventional ventilation (elective ventilation) shall not be done in patients who are expected not to benefit at all.

·        Elective ventilation or mechanical ventilation for purpose of cadaveric organ transplantation is not permissible.

·        Organ System support in ICU often defers death but does not always prevent death.

·        Intensive care can infringe on the dignity of the patient, and where the outcome is poor; it increases the physical, mental, and financial sufferings of the patient as well as the families.

 

TRANSFER PROCEDURE

a.       Consultation requests for potential ICU admission should be attended to within 30 minutes to 1 hour of receipt of the consult; which can either be by letter or phone calls.

b.      Review of the patients must be done by a competent Doctor designated by the Anaesthesia team on call.

 

c.        It is the duty of the Anaesthesia team to apply the admission CRITERIA in reviewing, and admitting the patient.

d.      The Anaesthesia Doctor sees the patient, makes a clinical assessment, and confirms that the patient requires ICU admission.

e.       The reviewing Doctor discusses the patient's need for ICU admission with the Consultant Anaesthetist on call, and confirms the availability of bed space in ICU

f.        The Doctor in charge at the ward/emergency room should communicate with his team, meanwhile the anaesthesia team on call should continue interaction with the managing team.

g.       The Anaesthetist on call should inform the ICU Nurse of his decision to admit the patient.

h.       The patient's diagnosis, and the level of dependency should be stated clearly by the Anaesthetist; i.e., ventilator support, cardiac support, or close monitoring.

I.        The Nurse currently managing the patient (in the ward or A&E) informs the patient's relatives to pay for ICU admission after he/she has RE-CONFIRMED THE AVAILABILITY OF BED SPACE WITH THE ICU NURSES, AND THEIR READINESS TO RECEIVE THE PATIENT.

j.       If ICU bed space is available, the Nurse also informs the Doctor on call in the ward/A&E, who then informs the Consultant in charge of his own team of the Anaesthetists' decision to transfer the patient to ICU.

k.       The bed and necessary equipment should be prepared by the ICU Nurses before the arrival of the patient.

l.        Movement of the patient to ICU is done by the Nurse from the ward/A&E

m.     The patient is received by the ICU Nurse; who  takes the baseline vital signs, and informs the Anaesthetist.

n.       Appropriate documentation, and timing, by those concerned is very crucial. The whole process of transfer should be done within 20 minutes from the time the decision to admit is taken.

o.       If bed space is unavailable, or patients have financial difficulty; and unable to pay for critical care, the medical officer should inform his/ her Consultant, as well as the Anaesthesia department of this difficulty.

p.       The primary managing team should escalate to the HCS for a possible waiver, or permission to refer out of the hospital; and document the final decision by the management.

q.       In the situation of NO bed space:

i.     Inform the patient/relative about the unavailability of bed space in the ICU.

ii.    Give option of referral to another facility outside the hospital.

iii. The managing team/primary physician to be informed.

iv. The Consultant Anaesthetist on call to be informed.

v. The HCS to be informed; requesting for authorization for movement outside the hospital.

 

DISCHARGE PROTOCOL FROM ICU

a.       The Anaesthetist documents, and informs ICU Nurse of his decision to transfer the patient to the ward or HDU.

b.      The primary managing team may also document their satisfaction and fitness of patient for transfer to the ward.

c.      In the event of (b) above, the ICU Nurse should inform the Anaesthetist who takes the final decision.

d.       The receiving ward is contacted to secure a bed space.

e.      The patient (or his family) is informed of the decision to transfer their him/her to the ward.

f.      The receiving ward Nurses are invited to move the patient from the ICU.

g.     The handing-over, and necessary documents are carried out in the ICU.

h.      The vacated bed is then cleaned and carbolized by the ICU Nurse on duty.

I.       The ventilator, tubing, and other equipment are then decontaminated and sterilized chemically; in preparation for the next patient.

 

ROUTINE PROCEDURE IN ICU:

1.       All patients in ICU must have a Central line inserted within the first 24 hours. Patients (or their relatives) must consent to this at the point of admission to the ICU.

2.       The Intensivist/lCU doctor shall give legibly written instructions to the ICU nursing staff; outlining the management, and treatment, of a patient in the unit. The level of dependency may be quantified by the Therapeutic Intervention Scoring System (TISS).

 

3.        Each patient shall be under the care of a particular Nurse. The patient to Nurse ratio at any point in time should be 1 :1 . The Nurse responsible for a particular patient must always be present by the bed side during ward rounds, and visitation.

4.       Emergency medicines with resuscitative equipment shall always be kept ready for use. Nurses should take stock of these daily.

5.      The ICU Nurse in-charge along with other staff must carry out rounds in the mornings and evenings. Additional rounds can be undertaken according to the type, and condition, of the patients.

6.      Specialized life support equipment like; ventilators, defibrillators, infusion pumps, central oxygen supply, and suction, etc.; must be readily available for use by the staff on duty. It is expected that the ICU staff should handle and use this highly technical equipment properly, and with the right caution. Evaluation must be done at one-hour intervals; whether the intensive care support is successful or not.

7.        Paralysing the patients for giving life-support like ventilation shall be avoided unless otherwise indicated.

8.       Weaning-off the ventilators; whether pressure support or through 'T' piece should be by Rapid Shallow Breathing Index guidelines.

9.      All intubated patients will be sedated; and Sedation assessment in ICU will be by RAMSEY sedation scale. This should be documented daily and at each ward round.

10.    All staff shall be trained periodically on how to handle critical care equipment to minimize break down, and damage.

11.    Staff in charge of the ICU shall regularly check that all equipment are kept in proper working condition. The department of Bio-Medical Engineering shall on a daily basis check the equipment of the intensive care unit, and maintain a log book and shall also take care of the maintenance and calibration of the equipment in the intensive care unit. This shall be reviewed by the head Nurse of the intensive care unit and Intensivist/Anaesthetist.

 

OXYGEN USAGE PROTOCOL

1.        Sources of oxygen in ICU include:

a.         Central Pipeline

b.        Backup cylinder

c.         Oxygen concentrator

2.        100% Oxygen should not be administered to any patient beyond 30 minutes except indicated by ABG.

3.        Any patient requiring oxygen > 60% should have ABG done 6-hourlv.

4.        Oxygen therapy should always be humidified.

5.        Nurses should always document Fi02 for each patient at the point of taking over and handing over.

6.        In the event of central oxygen pipeline failure:

a. Change to backup oxygen cylinder immediately; this should be done under 2 minutes.

b. Inform the Anaesthetist.

c. Oxygen store should always be contacted to urgently refill any empty cylinder whenever the backup Oxygen finishes.

7.        In the event of increasing oxygen dependency necessitating higher level of Fi02. Inform the Intensivist/Anaesthetist.

8.        All oxygen sources should be turned off when not in use

 

BLOOD TRANSFUSION PROTOCOL IN ICU

1          . Blood transfusion should be administered with utmost care

2.        The blood component to be transfused should be clearly stated by the Doctor e.g., packed cell, whole blood, Platelet concentrate, etc.

3.        The Nurse should send the porter to the blood bank with the blood bank slip to collect the blood.

4.        Put blood under running water to warm the blood to room temperature.

5.        Take the baseline vital signs.

6.        Confirm the name of the patient, hospital number, blood bag number, collection date, expiry date, blood group. This should be checked by at least two medical staffs.

7.        Document the information above.

8.        Prime the blood giving set by allowing blood to fill up the tube and the filter.

9.        Connect the blood to the patient and run for about 10 minutes while monitoring actively.

10.      Monitor vital signs every 1 5 minutes in the first hour, then every 30 minutes thereafter until completion of transfusion.

11.      Target to transfuse a unit of blood over 3 hours; unless otherwise stated in the prescription.

12.      Discontinue transfusion, and call the anaesthetist, if;

a. There is a rise in temperature > 30C.

b. Development of rashes

 c. Restlessness

d. Coughing/Breathlessness

e. Fresh development/complain

f. Reduce the rate of transfusion if patient develops chills or rigor.

 

Then cover patient with warm blanket

g.         Return the discontinued blood bag to the blood bank

h.        Send fresh blood sample to the blood bank for grouping and cross matching.

VISITATION PROTOCOL IN ICU

1.        The ICU observes the hospital visiting time between the hours of 5 pm to 6 pm. Restricted entry of one or two close relatives only shall be permitted when visiting is allowed.

2.        Whenever such visitors are allowed inside, measures shall be taken to maintain the sterility of the area. They shall wear only the footwear provided for exclusive use inside the area. Cap, masks, shoe covers are also to be worn by the visitor/relative and; proper hand washing must be done.

3.        Nurses should regulate visitation of the patient relatives. Relatives are not allowed to visit ICU during ward round, or during clinical or surgical procedures; even when such falls within visiting hour.

4.        Relatives visiting ICU must observe all the rules and regulations:

a. No wearing of shoes into the ICU.

b. Must wear the ICU disposable gowns

c. No touching of patient.

d. No receiving of calls, or use of cameras in the ICU

e. Time is allocated to each visit

f. Only one relative is allowed at a visit

 

5.        In addition, the next-of-kin of the patient shall be briefed regarding the condition of the patient at regular intervals; so that the family is carried along as much as possible

 

INFECTION CONTROL

1.        The Nurses shall supervise the regular cleaning of the ICU to ensure that the sterility of the unit is strictly maintained. The floor, including the workstation should be cleaned with Sodium hypochlorite or Hydrogen peroxide + Ammonium nitrate composition disinfectant.

2.        Infection control protocol shall be strictly followed in critically ill patients who are highly vulnerable to health care associated infection, resulting in significant morbidity & prolonged length of hospital stay.

3.        It is the responsibility of every member of ICU team to ensure compliance with hospital and ICU infection control policies - like hand washing before & after examining a patient, use of alcohol hand rubs, use of sterile barriers & disposable gloves, safe disposal of all sharp objects & patient consumables, & traffic control.

4.        Checklist of care should be addressed daily. Checklist use reduces Average Length of Stay (ALOS) & improves infection control indices.

5.        Whenever a bed is vacated, it should be cleaned and carbolized immediately by the ICU nurse on duty. The attached gadgets to the bed; ventilator, tubing and other equipment are then decontaminated and sterilized chemically, in preparation for the next patient.

 

END OF LIFE CARE:

A.        Admission to the ICU is often a therapeutic trial. Only when the trial fails the patients and families consider a change from restorative care to palliative care. This change is a transition from cure to comfort.

B.        Patients and families must be given sufficient time to reach decisions at the end of life, and information should be delivered according to the patient's cultural, religious, and language needs regarding shifting the treatment from intensive care to palliative care. Emphasis must be given on shared decision-making and the importance of caring for patients' families.

C.        The consultant in-charge of the ICU must play a key role to make recommendations and guide families in ways that accord with their decision-making preferences for continuance, or to forgo life-sustaining treatment. The goal of care and what can be achieved must be clearly communicated to patient's relatives.

D.        While declaring death, plain language like; dead, dying, death, and die may be used which are rarely misunderstood. Family members must be reassured that everything appropriate was done to help the patient. News of a patient's death should be given in person, whenever possible. When families must be contacted by telephone, special care should be taken how the information is to be disclosed.

 

 

In all cases of change in transition from cure to comfort. The following procedures should be followed:

1.        Identify situations when EOL (End of Life) support needs to be initiated.

2.        Discuss with other team members including Nurses regarding EOL decision.

3.        Identify surrogate decision maker(s) and initiate discussion on EOL with surrogate decision maker.

4.        Understand ethical principles about withdrawing life-support measures in ICU.

a. Intensivist should initiate in an empathic and unhurried way

b. Senior Nurse, or family Doctor, or other family members may be present

c. Pain free palliative care.

5.        Hold multiple counselling sessions. Family should be given adequate time and opportunity to ask questions and to express views.

6.        Reach a consensus and discuss modalities of palliative care.

a. Do Not Intubate/Do Not Resuscitate

b. Do not escalate life support modalities

c. Withdrawal of life support - dialysis, ventilators.

7.        Document discussion in patient's records, also details of proceedings of the counselling sessions.

8.        Institute palliative care with proper sedation, analgesia and throat suction.

9.       Resolve areas of conflict by second opinion from another physician, multiple counselling sessions with help of the hospital administration and setting up of a committee and judicial review.

COMMUNICATION POLICY

1.       Communication must always be made quickly; after resuscitation, when there is an unexpected turn of events, every morning after rounds, and when an important investigation is contemplated.

2.        It is the responsibility of Intensivist, Primary physician, ICU doctor, attending nurse, attending resident psychologist, medical social worker & administrator to communicate in due time.

3.        All the issues related to the patient's plan of management, expected course of treatment, probable risks & outcomes, number of days that may be needed to recover, anticipated expenses, probable complications etc.; must be communicated.