Federal Democratic Republic of Ethiopia

Ministry of Health

ICU Admission & Discharge

Protocol

EMERGENCY AND CRITICAL CARE DIRECTORATE

May 2018

St.Paul’s Hospital Millennium Medical College Printing press

 Federal Democratic Republic of Ethiopia
Ministry of Health

ICU Admission, Transfer & Discharge Protocol

EMERGENCY AND CRITICAL CARE DIRECTORATE

May, 2018
16
I
 14. References ACKNOWLEDGEMENTS

1. FMOH 2015, Health Sector Transformation Plan HSTP2015/16 - 2019/20 The Federal Ministry of Health would like to acknowledge the
following individuals and organizations in technical working
2. FMHACA , First edition, Hospital standardization in Ethiopia 2014 groups and for their contribution to the workshop and in order to
the complete this protocol.
3. Policy for admission to adult critical care services CCaNNI Admission
Policy Dec 2009
Name Organization
4. AAU-MF Feb, 2010, Guideline for deciding on admission of patients to
the i ntensive care unit, office of the chief resident department of 1. Dr. Assefu W/Tsadik AAU- Black lion hospital
internal medicine, Addis Ababa 2. Dr. Aklilu Azazh AAU- Black lion hospital
3. Dr. Amsalu Bekele AAU- Black lion hospital
5. Tikur Anbesa Specialized referral teaching hospital common intensive 4. Dr. Rediet Shimeles Ethiopian society of
care unit (CICU) admission and discharge criteria Nov,2014 Anesthesiologists Association
5. Dr. Yewondsone Tadesse AAU- Black lion hospital
6. National reference manual for establishment of Intensive Care Unit (ICU) 6. Dr. Tewodros Haile AAU- Black lion hospital
March, 2014 7. Dr. Tigist Bacha AAU- Black lion hospital
8. Dr. Ishmael Shemsdin St. Paul Hospital
7. American College of Critical Care Medicine of the Society of Critical
9. Dr. Tola Bayisa St. Paul Hospital
Care Medicine, Guidelines for ICU Admission, Discharge, and Triage.
10. Ato Tolosa Dida St. Paul Hospital
8. Saudi Critical Care Society. Admission Criteria for ICU. 11. Dr. Abraham Endeshaw FMOH- MSD
12. Dr. Desalegn Tigabu FMOH-MSD
13. Dr. Helena Hailu FMOH- MSD
14. Dr. Feven Girma FMOH-MSD
15. Sr. Emebet Teshager FMOH-MSD
16. Sr. Fatuma Ibrahim FMOH-MSD
17. Tenaye Demissie FMOH-MSD
18. Dr. Nicola Ayers FMOH- Clinical Service Directorate
19 . Yenegeta Walelign FMOH-MSD
20. Fekadu Yadeta FMOH-MSD

16
21 II
Contents Annex- 3 ICU admission decision making consultation sheet
ACKNOWLEDGEMENTS------------------------------------------------------i
Abbreviations----------------------------------------------------------------------v ICU Consultation Location
1. Introduction---------------------------------------------------------------------1
2.Definition------------------------------------------------------------------------2 1. Reassess 1. Emergency
3.Scope-----------------------------------------------------------------------------3
4.Rationale-------------------------------------------------------------------------3 2. Elective
2. Resuscitation
5.Objectives------------------------------------------------------------------------3
5.1General Objective-----------------------------------------------------------3 3. Trauma 3. Ward
5.2 Specific objectives---------------------------------------------------------3
6.ICU Setting----------------------------------------------------------------------4 4. Opinion 4. Other ICU same
7.Category of ICU Care----------------------------------------------------------5 hospital
7.1 Level of care I (LOC-I):/ICU 5. Other hospital
care in Emergency Department--------------------------------------------5 6. Other hospital ICU
7.2 Level of Care II (Loc-II):
Can be located ICU in general hospital-----------------------------------6 Premorbid 1. Dependent 2. Independent 3. Partial dependant Problems
7.3 Level of Care III (Loc-III): ICU decision 1. Admit to ICU
Located in a major tertiary hospital----------------------------------------6
8.Admission-----------------------------------------------------------------------7 2. Not for ICU admission, consult again if required
8.1 General principle of ICU admission-------------------------------------7
8.2 Source of Admission to ICU----------------------------------------------8 3. ICU admission inappropriate, unlikely to benefit
8.3 Admission Policy-----------------------------------------------------------8
4. Other (details): -----------------------------------------------
8.4 Admission Criteria---------------------------------------------------------9
8.5 Prioritization Model for ICU Admission-------------------------------9
Triage priority 1. . Need ICU treatment
8.6 Diagnosis Model for ICU Admission----------------------------------10
9.Special Intensive Technologic Needs--------------------------------------14 2. Need close monitoring
10.Discharge---------------------------------------------------------------------14
10.1 Discharge/Transfer Policy--------------------------------------------14 3. Poor prognosis
10.2 Discharge policy:-------------------------------------------------------14
10.3 Transfer/Discharge Criteria:-------------------------------------------15 4. Stable
11.Remark------------------------------------------------------------------------16
12.Summary----------------------------------------------------------------------17 5. Treatment irreversible illness
13.Annexed-----------------------------------------------------------------------18 Date:--------------------------------------------------------------------------------------
14.References--------------------------------------------------------------------21 Decision Time: ------------------------------------------------------------------------
Name: -----------------------------------------------------------------------------------
Senior:
III 20
 Acronyms
AAU-FM Addis Ababa University Faculty of Medicine

APH Ante Partum Hemorrhage

ARDS Acute Respiratory Distress Syndrome

CCANNI Critical Care Network Northern Ireland

CICU Common Intensive Care Unit

CVP Central Venous Pressure

DIC Disseminated Intravascular Coagulation

ECMO Extra Corporeal Membrane Oxygenation

EMSS Emergency Medical Service System

ERCP Endoscopic Retrograde Cholangio Pancreatography

ESA A Ethiopian society of Anesthesiologists Association

FMHACA Food ,Medicine and Health care Adminstration and

control Authorty
FMOH Federal Ministry of Health

HSDP Health System Development Program

HSTP Health Sector Transformation Plan

ICU Intensive Care Unit

ICP Intra Cranial Pressure

NSTEMI Non ST Segment Elevated Myocardial Infarction

PPH Post Partum Hemorrhage

STEMI ST Segment Elevated Myocardial Infarction

16 SOP Standard Operational Procedure

19 V/S Vital Sign v

1.Introduction 13. Annexed
An Intensive Care Unit (ICU) is a hospital facility for care of critically
ill patients at a more intensive level than is needed by other patients. Annex.1- ICU colour coded ICU triage
In many developed countries, it is usually staffed by specialized
personnel & the unit also contains various kinds of monitors & life
support equipment that can sustain life.
2 Orange 3 Yellow less 4 green not
1 Red
The patient population in ICU may present with a large variety of Urgent Urgent urgent
resuscitation
pathologies but shares the potential reversibility of one or more (15 min) (60 min) (180 min)
(0 min )
threatened vital functions.

Appropriate utilization of Intensive care unit (ICU) resources is an Obstructed Threatened

important issue in poor resource settings like our country where A airway stridor airway
there is a national struggle to contain health expenditure.
SPO2 <80 SPO2: 80-90 SPO2: 90-94 SPO2: >95
Generally, ICU uses 8% of the total hospital budget, but in countries B RR>35 or <8 RR:31-35 RR: 26-30 RR: 26-30
like USA it consumes14-20% of total hospital budget.
HR; 121-130
Due to the rapid urbanization, motorization, industrialization, and c HR>130
BPsys <80
HR<40
HR; 111-120
HR:40 -49
HR; 50-110
rapid population growth, the Ethiopia health sector is facing a double BTsys: 80-89
burden of diseases, although infectious diseases still account for the
major part of the burden. Even though the medical care facilities are GCS ≤8 GCS: 9-13 GCS= 14 GCS= 15
progressively growing in number and in capacity, obtaining timely and
optimal emergency and critical care has been practically difficult. The Tp>40 Tp: 38.1-40.0 Tp: 34.1-38.0
Emergency Medical Service System (EMSS) as a system, and acute care Tp<32 Tp: 32-34
medical practices, are found in rudimentary state. Due to this situation,
patients with acute illness, mothers with complicated delivery and victims
of different accidents have been managed sub-optimally. Due to such
problems, morbidity and mortality associated with accidents, acute
illnesses and a complicated delivery are high. To decrease such
mortality and morbidities the FMOH has been in the process of
strengthening EMSS and acute care units or intensive care units by
providing necessary training, equipment, different operational guidelines
and protocols.

1 1 18
 12. SUMMARY The success in this strategic theme will be measured by increased
The Intensive Care Unit can provide efficient and effective care to Knowledge, Attitude & Practice of the community including utilization
the critically ill patients by implementing well thought out of services; According to the national regulatory standards for general
admission and discharge criteria and procedures. Not all hospitals and specialized hospitals, a general hospital should have a well-staffed
will develop their ICU facilities in the same way, with the same and equipped ICU set-up which addreses the needs of the patients.
competencies and identical structures and equipment; nevertheless FMHCA has also standardized number and qualification of staff in ICU
they have to fulfill the minimum national standards and operate as well as the necessary equipment required.
based on national adm ission and discharge criteria. The current challenge of not having an admission and discharge criteria
All facilities should develop their own standard operational protocol, lead to unnecessary or inappropriate admissions and to the
procedures (SOP) for smooth and efficient management process ICUS Having. Critical patients’ admission and discharge criteria is
of critically ill patients after involving all concerned departments, crucial for an efficient of useing ICU. Admission and discharge criteria
liaison office, inpatient section head, matron, emergency services should also recognize patient’s autonomy, including advanced directives,
directorate and other concerned bodies. living wills, or durable powers of attorney for health care decisions.
It also should indicate who can admit patients to the ICU.
Specification credentialing procedures should be in place.

Through well-organized Emergeng units for early recognition and timely

effective intervention, and through well prepared and equipped ICU or
acute care units with basic equipment and by appropriate utilization of
Intensive care unit (ICU), the critically ill patients survival rate will be
improved The protocol proposed here provides models which ICUs
may use in formulating admission and discharge criteria.

2.Definition
An Intensive Care Unit (ICU) is a specially staffed and equipped,
separate and self-contained area of a hospital dedicated to the
management and monitoring of patients with life threatening conditions.
It provides special expertise and the facilities for the support of vital
functions and uses the skills of medical, nursing and other personnel
experienced in the management of these problems. It encompasses all
areas that provide Level 2 (high dependency) and/or Level 3
(intensive care) care as defined by the Intensive Care Society
document Levels of Critical Care for Adult Patients (2009).

16 2
17 2
 Multidisciplinary rounds are a patient-centered model of care, 9. Chronically mechanically ventilated patients whose critical
emphasizing safety and Efficiency, that enables all members of illness has been reversed or resolved and who are other wise
the team caring for patients to offer individual expertise and contribute stable may be discharged to a designated patient care unit
to patient care in a concerted fashion. that routinely manages chronically ventilated patients, when
3.Scope applicable, or to home;
This protocol provides guide for all health professionals who play 10. Routine peritoneal or hemodialysis with resolution of critical
a role in the admission and discharge of patients from intensive care illness not exceeding general patient care unit guidelines;
units. 11. Patients with mature artificial airways (tracheostomies) who no
4.Rationale longer require excessive suctioning;
Admissions to critical care unit are often unplanned. Immediate 12. Patient is vegetative or neurological recovery is not expected
access to resuscitation and critical care is fundamental in the management soon, but maintains his/her airway
of many life threatening disease conditions. Delayed admission to intensive 13. The health care team and the patient's family, after careful
care is associated with a significant increase in mortality. Lack of access assessment, determine that there is no benefit in keeping the
to critical care management has been identified as a major contributor patient in the ICU or that the course of treatment is medically futile.
to post surgical mortality.
11.Remark
Any patient in hospital may become high risk for suden deterioration
However, the recognition of acute illness may be delayed or its - Cases to be admitted for the medico-legal issues and out of
subsequent management may be inappropriate. This may result in late the protocols should be done only in consultation with ICU
referral and/or avoidable admissions to critical care, and may lead consultant and/ pertinent unit consultant.
to prolonged critical care stay and increased morbidity and mortality. - Any kind of feedback can be given to the director of ICU.
Patients in the ICU will be evaluated and considered for discharge - Each Institution develops their own ICU SOP.
based on the reversal of the disease process or resolution of the
unstable physiologic condition that prompted admission to the unit.

Therefore, a protocol for admitting and subsequently discharging

critically ill patients is essential. In addition for continuous developments
in critical care, periodic review of these criteria is necessary.
5.Objectives
5.1 The general objectives of this protocol are:
to ensure quality of care for acute critical conditions, through
appropriate, transparent and timely admission and discharge of patients
to or from critical care, and to bring accountability for the system and to
facilitate the proper utilization of limited resources

3 16
 10.2 Discharge policy: 5.2 The Specific Objectives of this Protocolare:
to aid physicians and nursing staff in determining patient
a) All discharges must be approved by the ICU consultant/ICU
appropriateness for Adult ICU admission and discharge.
responsible physician.
to decrease significant delayed admission to intensive care.
b) A discharge summary must be completed in the case notes prior
to admit patients to the intensive care units based on clinically
to discharge.
based criteria.
c) At discharge from ICU the patient (must) be immediately
to improve ICU bed utilization by addressing overflow placement of
accepted by the ward treating team.
ICU patients.
d) Primary/parent teams must be informed of all patient discharges to coordinate appropriate patient discharge from the ICU with relevant
and any potential or continuing problems. units.
e) If appropriate, limitation/non-escalation of treatment must be
clearly documented and discussed with the parent/ primary 6.ICU Setting
team prior to discharge. ICU should be organized in health institutions based on their capacity,
human resources, facility and equipment as FMHACA standards;
10.3 Transfer/Discharge Criteria: 1. ICU should be organized in a health institution that could
provide the necessary services and it should be located so
Transfer/discharge will be based on the following criteria: it is easily accessible to all departments and laboratory, with
1. Stable hemodynamic parameters; adequate spaces, and outlet.
2. Stable respiratory status (patient extubated with stable VS, AND
arterial blood gases if available) and airway patency; 2. Health institution/hospitals that provide general service may have
3. Minimal oxygen requirements that do not exceed patient care one or more ICU with different levels of care depending on the
unit guidelines; facilities, at least one of which must be a common ICU.
Specialized hospitals on the other hand can have specialized ICU,
4. Intravenous inotropic support, vasodilators, and anti arrhythmic human resources and equipments available at the institution.
drugs are no longer required or, when applicable, low doses of
3. The ICU system may be open or closed depending on
these medications can be administered safely in otherwise stable
institutional capacity and preference.
patients in a designated patient care unit;
4. The ICUs may be common or specialized, depending on
institutional need and capacity. Common ICUs are recommended
5. Cardiac dysrhythmias are controlled; for most of the general hospitals.
6. Intracranial pressure monitoring equipment has been removed; 5. A physician director must be appointed, who can give clinical,
7. Neurologic stability with control of seizures; administrative and educational direction to the ICU. The physician
8. Removal of all hemodynamic monitoring catheters; director could be an intensivist, pulmonary critical care specialist,
anesthesiologist, emergency medicine specialist or a physician
16 2
15 4
trained in providing critical care. The director should assume 5. Burns covering >10% of body surface (institutions with burn
responsibility for ensuring quality, safety, and appropriateness of care units only; institutions without such units will have transfer
in the ICU. The ultimate authority for admission, discharge and policy to cover such patients)
triage rests with the ICU director or delegated consultant in charge.
6. Anaphylaxis
6. There should be a multi professional ICU team/ committee.
The team should meet on a regular basis to identify and solve 8.6.12 Obstetric
problems through quality assurance and continuous quality
improvement activities. The team shall comprise representative 1. Medical conditions complicating pregnancy
from the departments, ICU director, head nurse, pharmacist, 2. Severe pregnancy induced hypertension/eclampsia
dietitian, CEO, and hospital director. The committee will be 3. Obstetric hemorrhage with severe hemodynamic instability
chaired by hospital director and the ICU director will be the (APH, PPH)
secretary. 4. Amniotic fluid embolism
7. ICU should be staffed with appropriately trained and skilled 5. Septic abortion with severe hemodynamic instability.
staff and might include intensivists, pulmonary critical care
specialists, emergency specialists, trained physicians and nurses, 9.Special Intensive Technologic Needs
physiotherapists and clinical pharmacists.
Conditions that necessitate the application of special technologic
8. A national ICU training curriculum for physicians and nurses needs, monitoring, complex intervention, or treatment including
should be developed and delivered intensively. medications associated with the disease that exceed individual
patient care unit policy limitations.
9. ICU should have a regular performance review.
10. DISCHARGE
A. the performance evaluation and review should include its admission, 10.1 DISCHARGE/TRANSFER POLICY
and discharge guidelines. It should be done by a multi professional
ICU committee. Patients in the ICU will be evaluated and considered for discharge
based on the reversal of the indication for admission disease or
B. A database to track admissions, outcomes and other variables should resolution of the unstable physiologic condition that prompted
be established. admission to the unit, and it is determined that the need for complex
intervention exceeding general patient care unit capabilities is no
C. A mechanism to review requested admissions that were denied should longer needed.
be in place to assure the appropriateness of both guidelines and decision
making process.

5 14
 8.6.9 Acute poisoning 7. Category of ICU Care

7.1 Level of care I (LOC-I):/ICU care in Emergency Department

(With altered mental status, systemic complications or/&deranged
vital signs)
● Are where close monitoring, resuscitation, and short term ventilation
1. Insecticide poisoning e.g. organophosphate poisoning
for(less than) (<)24hrs has to be performed. Can be organized in
2. Snake bite poisoning (if antivenom is available)
emergency departments to resuscitate and monitor patients till proper
3. Carbon monoxide poisoning
referral/transfer for definitive care and specialist care is arranged.
4. Drug overdose (e.g. phenobarbitone poisoning, antidepressant
poisoning etc.) ● Minimum requirement:

8.6.10 Surgical ● Human resources:

1. High risk patients in the peri-operative period Trained physician and nurses. Nurse: patient ratio should be 1:1
2. Post-operative patients requiring continuous hemodynamic
monitoring/ ventilator support, usually following: ● Medical equipment:
o Vascular surgery Oxygen sources, oxygen regulators, chest tube set, pig tails,
o Thoracic surgery tracheotomy sets, cardiac monitors, suction machines, Non
o Airway surgery invasive ventilators, intubation kits, different masks, cardio verter ,
o Craniofacial surgery defibrillator, nebulizer, infusion pumps, ECG machine, pulse
o Major orthopedic and spine surgery oxymeters, LP set, X-ray view box, blood warmer, suture set,
o General surgery with major blood loss/ fluid shift dressing set, glucometer
o Neurosurgical procedures
7.2 Level OF Care II (LOC-II): Can be located in general hospital ICU
3. Post organ transplant
● Undertake more prolonged ventilation. Must have senior specialists,
8.6.11 Multisystem and Other general practitioners and emergency and critical care trained nurses,
Patients with life-threatening or unstable multisystem disease; biomedical technicians and a dietician. Have access to pathology,
Conditions include, but are not limited to: radiology, etc.
1. Toxic ingestions and drug overdose with potential acute
decomposition of major organ systems; ● Minimum requirement:
2. Multiple organ dysfunction syndrome;
3. Suspected or documented malignant hyperthermia; -Human resources:
4. Electrical or other household or environmental (e.g., lightning)
injuries; Anesthesiologist or intensivists or pulmonary critical care or
emergency medicine specialist or trained physician and nurses,
16 Nurse: patient ratio should be 1:1

13 6
2
 ● Medical equipment: 8.6.5 Hematology
● All of the LOC 1 equipment and ventilators, portable X-ray, 1. Severe coagulopathy and/ or bleeding diasthesis
telemetry, central monitors, ultrasound with Doppler and cardiac 2. Severe anemia resulting in haemodynamic and/or respiratory
probes, capnometer, ABG analyzer, ICU beds, glidioscope , compromise
Pericardiocentesis set, other consumables 3. Tumors or masses compressing or threatening to compress vital
vessels, organs, or airway
7.3 Level OF CARE III (LOC-III): Located in a major tertiary hospital 4. Disseminated Intravascular Coagulation (DIC)
8.6.6 Endocrine
It should provide all aspects of intensive care required. All complex 1. Diabetic ketoacidosis complicated by hemodynamic instability,
procedures should be undertaken. Specialist intensivist or physician altered mental status
anesthesiologist, Pulmonary & critical care specialist, nurses, therapists,
support of complex investigations and specialists from other disciplines 2. Severe metabolic acidotic states
Should be available at all times. 3. Thyroid storm or myxedema coma with haemodynamic
instability
Minimum requirement: 4. Hyperosmolar state with coma and/or haemodynamic
• Human resources instability
5. Adrenal crises with haemodynamic instability
6. Pituitary apoplexy with neurohemodynamic instability
Anesthesiologist, intensivists, pulmonary critical care, emergency
7. Other severe electrolyte abnormalities, such as:
medicine specialist, trained physician and nurses plus
- Hypo or hyperkalemia with dysrhythmias or muscular weakness
physiotherapist, clinical pharmacist, nutritionist , Nurse:
- Severe hypo or hypernatremia with seizures, altered mental status
patient ratio should be 1:1
- Severe hypercalcemia with altered mental status, requiring
haemodynamic monitoring.
• Medical equipment:
o All of LOC 1 and 2 plus special care ECMO (optional), renal 8.6.7 Gastrointestinal
replacement therapy, bronchoscope, esophageal tubes (Minnesota 1. Life threatening gastrointestinal bleeding
and Black More tubes), intracranial monitors, CVP catheter, 2. Acute hepatic failure leading to coma, haemodynamic instability
arterial lines, feeding tubes. 3. Severe acute pancreatitis
8. Admission 4. After emergency/Elective procedure,
Endoscopy/Colonoscopy/ERCP patient arrest
8.1 General principle of ICU admission
8.6.8 Renal
• ICU beds are very few in number in any country. However, the
1. Acute renal failure
number of patients who compete for ICU admission & care is very
2. Requirement for acute renal replacement therapies in an
high. For this reason, admission of patients to the ICU must be
unstable patient
based on a guideline.
3. Acute rhabdomyolysis with renal insufficiency

7 12
 5. Upper airway obstruction • Rigid rules to determine admission to ICU are destined to fail
6. after emergency/Elective procedure, Bronchoscopy patient arrest because every case must be evaluated on its own merits.
Nevertheless, broad guidelines are required to avoid unnecessary
8.6.2 Cardiovascular
suffering in the ICU & the waste of valuable resources caused
1. Shock states
by admitting patients who have nothing to gain from ICU care
2. Life-threatening dysrhythmias
because they either are well, have no realistic prospect of
3. Dissecting aortic aneurysms
recovery or the required treatment is not available.
4. Hypertensive emergencies
• The existence of an empty bed doesn’t justify admission of any
5. Acute Coronary Syndrome (Unstable angina, NSTEMI, STEMI)
patient to the ICU.
6. Acute pulmonary edema
7. Acute congestive heart failure with respiratory failure and/or • Admission should be allowed for those who have a realistic
requiring hemodynamic support prospect of recovery & are likely t o have a post-recovery
8. Post cardiac arrest quality of life that can be valued by the patient or relatives.
9. Cardiac tamponade or constriction with hemodynamic instability The wishes of the patient (if known) or relatives should also
10. Complete heart block be respected.
11. Need for continuous invasive monitoring of cardiovascular
system (arterial pressure, central venous pressure, cardiac output) • If the appropriateness of admission remains uncertain, the patient
should be given the benefit of the doubt & the indication for
8.6.3 Infectious diseases continuing treatment at the ICU must be reviewed through time.
1. Complicated falciparum malaria In our setup the following condition should be considered before
2. Relapsing fever with severe complication we admit a patient to ICU (policy statement)
3. Severe tetanus
4. Severe sepsis with multi-organ failure. Since the hospital has limited beds and ventilator machines
8.6.4 Neurological candidates for admission should be with reversible/treatable
1. Severe head trauma underlining disease.
2. Status epilepticus The state of acute illness during the request for admission has
3. Meningitis with altered mental status or respiratory compromise to be potentially reversible.
4. Acutely altered sensorium with the potential for airway compromise
5. Progressive neuromuscular dysfunction requiring respiratory 8.2 Source of Admission to ICU
support and / or cardiovascular monitoring (myasthenia gravis,
Gullain-Barre syndrome) Patients who are critically ill may be admitted to the ICU from;
6. Acute spinal cord compression or impending compression; Emergency department,
7. Acute subarachnoid hemorrhage Operating Theater and Procedure room
8. Acute stroke with raised ICP In-Patient Wards
9. Coma: metabolic, toxic, or anoxic Labor ward
16 2
11 8
 Other department of the hospital or other hospital for better 8.5.1 Priority 1 – Unstable
care with appropriate communication with ICU director. Requires intensive treatment and monitoring that cannot be
8.3 Admission Policy provided outside of the Critical care unit. E.g. Respiratory support,
Admission of a patient to the ICU must be decided by ICU continuous vasoactive drug infusions, etc. Admission should take
Director/Consultant in Charge/Physician in charge on duty. If the place as soon as possible.
case is difficult to make a decision by Physician in Charge,ICU 8.5.2 Priority 2 – High risk of sudden deterioration.
director will decide the admission. If a decision is made to admit Requires invasive monitoring and may potentially need immediate
a patient to the ICU, the nurses must be informed beforehand to intervention. E.g. a patient with chronic co-morbid conditions who
get prepared. Before accepting referral for admission to ICU from develops acute severe medical or surgical illness.
other hospital, there should be early communication and once
decision is made, the liaison office should be informed for 8.5.3 Priority 3 – Reduced likelihood for recovery due to
facilitation to transfer. If many patients are competing for underlying illness.
admission to the ICU, the following five questions must always be May receive intensive treatment to relieve acute illness but limits
addressed so that one may make an appropriate decision. on therapeutic intervention may be set, such as no intubation or
cardiopulmonary resuscitation.
Factors that must be considered in the assessment of a possible
admission to the ICU: 8.5.4 Priority 4 – Little or no anticipated benefit (too well to benefit)
from critical care or patients with terminal and irreversible illness
1. Primary diagnosis & the other active medical problems (too sick to benefit from ICU care) facing imminent death.
2. Prognosis of the underlying condition/ is recovery still possible? Required care and monitoring can be administered in a ward
3. Age, life expectancy & expected quality of life post discharge setting. Admission of this type of patient to the ICU is generally
4. Wishes of the patient &/ or relatives not considered appropriate.
5. Availability of the required treatment, technology & professiona
8.6 Diagnosis Model for ICU Admission
8.4 Admission Criteria This model uses specific conditions or diseases to determine
appropriateness of ICU admission. Patients with the following
The ICU admission decision may be based on two models utilizing conditions are candidates for admission to the ICU. The following
prioritizing and diagnosis. These admission criteria are meant to guide conditions include, but are not limited to:
the physician and does not replace the physician’s judgment.
8.6.1 Respiratory
8.5 Prioritization Model for ICU Admission 1. Acute respiratory failure requiring ventilatory support e.g. ARDS
This system defines those that will benefit most from the ICU 2. Acute pulmonary embolism with haemodynamic instability
(Priority 1) to those that will not benefit at all (Priority 4) from 3. Massive haemoptysis
ICU admission. 4. Pneumothorax (with hemodynamic instability)

9 10