Operational Guidelines For Hybrid CCU Version 1.0

Memo No. HFW-13099/1/2022-SPSRC SEC-Dept. of H&FW/410 Dated:-27.06.
2022
Department ofGuideline
Operational Health & Family
for W
Hybrid Critical Care Unit
(HCCU)
(Version1.0)
Department of Health & Family

Welfare
Government of West Bengal
000001
File No. HFW-13099/1/2022-SPSRC SEC-Dept. of H&FW (Computer No. 494973 )
Contents
Sl. Subject Page No.
Forwarding iii - iv
Preface v - vi
I. Overview 1
II. Goal 1
III. Strategies 2
IV. Operational steps for planning & rolling out New Hybrid CCUs 2
V. Design Team 3
VI. Human Resources Standards 3
VII. Job responsibilities of Different Human Resources 5
i. Medical Officer in Charge 5
ii. Medical Officers 5
iii. Nursing –in-Charge 5
iv. Nursing Personnel 5
v. MT (Critical Care) 6
vi. Hospital Assistant 7
vii. General Duty Attendant 8
viii. Karmabandhu 8
ix. MT(Physiotherapy) 9
x. MT(Dialysis) 9
xi. MT(X-ray) 9
xii. Pharmacist 9
xiii. Bio-Medical Engineers 9
VIII. General Instruction regarding patient management 9
IX. Hospital Level Supervision & Monitoring 10
X. Equipment Management 11
XI. Reporting 12
XII. Training of HR for CCU 13
A Primary Training plan for Medical officers 14
B. Short term training for Specialist Medical Officers 17
C. Plan of training of Nursing Staff on CCU 18
XIII. Technical Aspects for 24 bedded Hybrid CCU 21
A. Civil Construction 21
B. Electrical Construction 23
C. Environmental 24
D. Centralised laminar flow 24
E. Centralised Medical Oxygen Supply System (Either through mini-manifold
25
or PSA or Liquid oxygen supply system)
F. Centralised Suction System 25
G. Compressed Medical Air 25
H. Lighting 25
I. Noise Control 26
i
J. Bio- Medical Waste, Municipal Solid waste Disposal & Pollution Control 26
XIV. Standard list of equipment 27
1. Major equipment recommended for each Critical Care Unit 27
2. Ancillary equipment (CMS Items) recommended for each unit (Number de-
30
pending on the bed strength as per following list):
3. Furniture (CMS Items) recommended for each unit (Number depending on the
32
bed strength as per following list):
XV. Standard List of Medicine & Consumables 33
1. Basic Requirement of Medicines 33
2. Basic Requirement of Consumables 40
XVI. Essential Tests to be done in CCU 24x7 44
XVII. Protocol for Infection control in Critical Care settings 46
A. Patient at risk of nosocomial infections 46
B. Factors related to inappropriate practices in CCU 46
C. Common CCU acquired infections 47
D. Sources of Cross –Infection in the CCU 47
E. Strategies to Reduce Infections in CCU/HDU 47
1. Room Sterilization 48
2. Isolation 48
3. Universal Protocol: Hand Hygiene & Barrier protection 48
4. Device related protocol 52
5. Equipment Sterilization 53
6. Transport of Sterilized equipment from CSSD to CCU 55
7. Disposal of Waste 55
8. Procedural Care 56
F. Specific strategies focused on prevention of transmissions of infections to pa-
58
tient cared for in the CCU/ HDUs
G. Specific Strategies focused on prevention of specific no socomial infections 62
1. Strategies to reduced ventilator –associated pneumonia (VAP) 62
2. Strategies to reduce Catheter- Related Blood Stream Infection or CRBSI 63
3. Strategies to reduce CAUTI 64
H. Patients needing ICU care should be assessed for 64
I. Regarding Health Care Workers in CCU 64
J. Environmental Factors and CCU Design Related issues for prevention of
65
transmission of Infections
1. Space 65
2. Ventilation of the unit 66
3. Traffic Flow 67
4. Non ICU Staff 67.
ii
Preface
Government of West Bengal has prioritized to minimize out of pocket expendi-

ture of common people related to medical care. Priority is also given to mini-
mize the delay of every critically ill patient to reach appropriate institution in
an emergency situation. To fulfil this priority, one of the premier achievement
of Department of Health & FW is to set up Critical Care Units and High De-
pendency Units where critically ill patients of the remote areas of West Bengal
would get sophisticated high end management for critical life threatening dis-
eases completely free at their doorstep. These units are targeted to be estab-
lished within 50 km of distance from each other to minimize the delay to
reach appropriate institution in any emergency and life threatening situation,
so that every patient can be treated in “golden hour”.
Accordingly, it was decided to set up 42 Critical Care Units and 30 High De-
pendency Units at Medical College & Hospitals and District and Sub District
levels within the year 2015-16. Among these units, 37 CCUs have been made
functional till date in 14 Medical Colleges, 20 District Hospitals and 3 Sub Di-
visional Hospitals having a total bed strength of 552 beds and 18 HDUs also
have been made functional in 17 different Sub-divisional hospitals and 1 Ru-
ral Hospital having a total bed strength of 108.
Critical Care Unit (CCU) is a general or multispecialty unit to care critically ill
patients in general (older terminology for the same is Intensive Therapy Unit
or ITU). To facilitate planning, establishment, operation and monitoring of
critical care units at various levels of Public Health facilities an operational
guideline was developed and published in August 2014. That guideline was
provided to assist program managers and service providers at state and dis-
trict level in planning and delivering critical care. The guidelines have been
put together based on recommendations of a State Level Advisory Commit-
tee (SLAC-CCU) and a Technical Assistance and Support Team (TAST-CCU)
set up by the GoWB and included experts from public and private sectors.
Subsequent versions 2.0 and 3.0 were published after thorough DATA analy-
sis generated by all the functional units and situational analysis regarding pa-
tient management, Human resource and inventories some changes were in-
cluded in the Operational Guideline for CCUs & HDUs. During COVID pan-
v
demic there were increased number of critically ill patients requiring admis-
sion in CCU and HDU. To accommodate such surge of any other epidemic/
pandemic in future, it was decided to establish 24 bedded hybrid CCUs in 76
Hospitals.
Version 1.0 of Hybrid CCU Guideline is introduced with a number of changes

in running the Hybrid Critical Care Units in different level of hospitals like
Medical Colleges, District Hospitals, sub-divisional Hospitals, State General
hospitals and Super Speciality Hospitals.
This operational guideline includes information on various aspects that

needs to be addressed for ensuring quality critical care services and is or-
ganized into different sections.
This guideline will also act as a ready reckoner regarding different HCCU re-
lated activities like equipment procurement & maintenance and help to sup-
port the Medical Officers & Nursing Personnel of HCCUs as well as Hospital
authority to run these highly specialized units smoothly.
This guideline also helps the trainers to conduct training programme for the
Medical Officers, Nursing Personnel and paramedical personnel.
This guideline is developed by the members of Expert committee for Hybrid
CCU under active guidance and support of Shri Narayan Swaroop Nigam,
Secretary to the Department of Health & FW, Shri Soumitra Mohan, IAS; Sec-
retary & Mission Director, NHM, Shri Y. Ratnakara Rao IAS; Director, SPSRC
& Secretary to the Department of Health & FW, Dr. Siddhartha Neogyi, Direc-
tor of Health Service & Dr. Debashis Bandopadhyay, Director of Medical Edu-
cation.
vi
I. Overview
One of the premier achievements of Department of Health & FW is to set up Critical

Care Units in the District & Sub-District level Hospitals, where critically ill patients of the
remote areas of West Bengal would get sophisticated high end management for criti-
cal life threatening diseases at no cost at their doorstep. These units are targeted to
be established within 50 km of distance from each other to minimize the delay to
reach appropriate institution in an emergency situation, so that every patient can be
treated in “golden hour”
Accordingly, 53 Critical Care Units and 27 High Dependency Units are already made
functional at Medical College & Hospitals and District and Sub District level Hospitals
(including Super specialty Hospitals & selected State General Hospitals, rural Hospitals
& PHCs) between 2012 to 2019. Among which 61 units (34 CCUs & 27 HDUs) units are
establish in District and Below District level Hospital.
Now, in view of the management of Covid-19 affected patients and post covid com-
plication management, Department has decided to establish 24 bedded Critical care
unit at 79 units. These units mainly plan to be established in the hospitals where Critical
Care Unit / High Dependency Unit / Trauma Care Units are already functional or
planned (non-Covid). These units will be additional or supplementation of the already
established & functional units.
These 24 bedded Hybrid Critical Care Units will be planned where 6-12 bedded Criti-
cal care Unit or High Dependency Units or Trauma care units or Burn units are already
present or planned. If place for extension is not available adjacent to the existing
CCUs or HDUs, then a separate built up place with an minimum area of 3500 sq ft
may be selected for the establishment of these Hybrid CCUs. Any ward including the
wards dedicated for Covid HDUs with this specified area may be converted to hybrid
CCU.
II. Goal
Set up of Hybrid Critical Care Units at different Medical College Hospitals, District Hos-
pitals, Sub Division Hospitals, Multi/Super Speciality Hospitals and selected State Gen-
eral Hospitals, Rural Hospitals & PHC to provide quality Critical Care services with the
help of Critical Care trained Human Resources across the state to provide emergency
lifesaving treatment within the ‘Golden Hour’.
1
III. Strategies
(i) Each 24 bedded CCU planned with 1 eight bedded ICU and 1 sixteen bedded
HDU.
(ii) These units are planned to be established as an extension unit of the existing 6
bedded High Dependency Unit or 12 bedded critical care unit or ICU attached
to Trauma care unit. In few hospitals, where already 24 bedded CCU is already
established, there this unit will act as a new 24 bedded extension.
(iii) If extension will not be possible adjacent to the existing CCU / HDU; then a sep-
arate built up place with a minimum area of 3500 sq ft will be selected within
the hospital for the establishment of these Hybrid CCUs.
(iv) As far as possible, new construction will be avoided.
(v) These Hybrid Critical Care Unit (CCU) will act as a multispecialty unit catering to
all critically ill adult patients.
(vi) In all District Hospitals and other Sub District level hospital, Hybrid CCU will serve
as sole unit for critical care. In these hospitals, these CCUs may be extended to
care pediatric patients also.
IV. Operational steps for planning & rolling out new Hybrid CCUs
i. Identification of location, no. of units and category of development

(new/augmentation)
ii. Policy decision and issuance of GO regarding unit & HR
iii. Timeline determination
iv. Source of Funding determination: (a) Non-recurrent& (b) Recurrent
v. Detailed planning for required Infrastructural development
vi. Fund allocation for Infrastructural development
vii. Administrative action taking for Infrastructural development
viii. Recruitment & allocation of Human Resources
ix. Procurement of Equipments and installation
x. Procurement of Drugs
xi. Initiation of the unit
xii. Operation and maintenance
xiii. HMIS including networking
2
V. Design Team
1. At State Level –
1.1. State Level Expert Committee – Critical Care (SLEC-CC)
2. At Facility Level –
2.1. Medical Superintendent (MSVP) / Superintendent
2.2. Deputy Superintendent (in Medical Colleges)
2.3. Physician
2.4. Anesthetist
2.5. Engineers (Civil & Electrical)
2.6. Nursing Superintendent
2.7. Deputy / Assistant Superintendent (Non-Medical)
VI. Human Resource Standards

1. Patient admitted in Critical care unit (CCU) and High Dependency Unit (HDU)
will be treated following a multi- disciplinary approach but a particular patient
will be admitted under a particular Specialist Doctor/Faculty (Consultant) of
concerned discipline who is the bed in- charge (BIC).
2. Each unit will be manned by a dedicated earmarked core team of person-
nel consisting of; (i) Trained Medical Officer (CCU); (ii) Trained nursing staff
(CCU); (iii) Medical Technologist (MT-CCU); (iv) Hospital assistant (if available)
and (v) GDA / sweeper. The core team will be supported by the Anesthetists
and Physicians, who will act as Supervising Officer of CCU (as selected by re-
spective Hospital authority).
3. Each unit should be manned preferably by two Critical care trained Medical
Officer in each of the three daily eight hour shift. In case of Nursing Personnel
provision should be made for presence of preferably three trained Nursing Per-
sonnel per eight hour shift. Unit should be manned by at least one MT-CCU in
each shift.
4. Hybrid CCUs situated in Medical College Hospitals should involve the Senior res-
idents / RMO/ PGTs of Medicine, Chest medicine, Tropical medicine& Anesthe-
sia Department.
5. One of the Critical care trained Medical Officers of CCU will be in-charge and
will assist the Medical Superintendent-cum-vice-principal (MSVP) / Superinten-
3
dent in CCU related administrative matters.

6. One of the Nursing Personnel (Critical care trained) posted at CCU will act as
Nursing-in-charge and will maintain the nursing related administrative matters,
inventory management & assist the MO in Charge – CCU / HDU in daily admin-
istrative matters.
7. In case of acute scarcity of trained Medical Officers, Emergency Medical Of-
ficers who already have undergone training for “Advance Life Support and
Management of commonly encountered emergency situation (cardio-
respiratory & Head Injury)” may be given duty in the HDU area in case of emer-
gent situation under active supervision of on duty Physician & Anesthetist of that
period of time.
8. Essential requirement may be varied depending on the performance of the in-
dividual unit. More number of human resources may be required in case of
admission of more critical cases in the individual unit. Human resources from
underperforming CCUs may be relocated to over burdened CCUs for optimal
utilization of manpower.
9. This norm is applicable for any type of hospitals.
10. In case of selection, any candidate with any kind of training/experience in
CCU/ OT will be given preference but the Medical Officer / Nursing Personnel
should undergo the requisite training for CCUs as per norms.
11. Provision of male nurse is also recommended.
12. GDA / Sweeper may be outsourced depending on the issuance of respective
Government order. In case of unavailability of GDA, housekeeping staffs may
be engaged from outsourced agency.
13. MT (Physiotherapy) from existing pool may be deployed by rotation at CCU at
regular basis. Such roster will be prepared by designated Deputy/ Assistant Su-
perintendent (Non-medical).
14. One MT (X-ray) from existing pool may be deployed by rotation at CCU as and
when required. Such roster will be prepared by designated Deputy/ Assistant
Superintendent (Non-medical).
15. If available, MT (Dialysis) from existing pool may be deployed by rotation at
CCU as and when required. Such roster will be prepared by designated Depu-
ty/ Assistant Superintendent (Non-medical).
16. One pharmacist from existing pool may be deployed by rotation. Duration of
such deployment should be for at least 6 months at a stretch. Such roster will be
prepared by designated Deputy/ Assistant Superintendent (Non-medical).
4
VII. Job responsibilities of different Human Resources
i. Medical Officer in Charge:

One of the Critical Care trained Medical Officers of CCU will act as In Charge
and will discharge additional administrative duties. MO-in Charge is the overall
in charge of the unit.
 Besides providing medical management during his/her duty shift, he/she
is also responsible for all types of administrative matters of the respective
CCU.
 Responsible for duty roster of Medical Officers, MT-CCUs &Hospital Assis-
tants(if available) and overall responsibilities for regular duties of other
staffs also.
 Ensure regular medical data entry & reporting.
ii. Medical Officers:

 Supportive care and disease specific management on 8 hour shifting du-
ty including equipment handling and basic pathological/ biochemical
tests utilizing equipment present in the CCU.
 Ensure regular medical data entry & reporting.
iii. Nursing- in-charge:

 Supervisory, Logistics management,
 Duty roster of Nursing staffs.
 Duty roster of Hospital Assistants, if available(if delegated by the MSVP/
Superintendent/ MOIC).
 Ensure regular medical data entry & reporting through Critical Care
Management Information System (CCMIS).
iv. Nursing Personnel:

Patient care on 8 hour shifting duty including equipment handling and basic
pathological / biochemical tests utilizing equipment present in the CCU as fol-
lowing,
 General Nursing Care
5
 Basic Life Support

 Assisting Advanced Life Support
 Airway Suction &Nebulization
 Simple blood test like Capillary Blood Glucose by glucometer and basic
pathological / biochemical tests utilizing equipment present in the CCU.
 ECG.
 Monitoring – a) Clinical parameters, b) Multichannel monitors, c) Ventilator
parameters, d) others.
 Assisting in transport of critically ill and ventilated patients to CT/ MRI suite
or dialysis unit if needed.
 Maintenance of different charts.
 Maintenance of records, statistics & reporting.
 Sampling body fluids.
 Managing requisitions for tests.
 Maintenance and keeping ready stocks of drugs, equipment, consu-
mables etc.
 Ensure regular nursing related data entry & reporting through CCMIS.
 Any other work to manage any emergent situation within the unit.
v. MT (Critical Care)
Assisting on duty Medical Officers & Nursing Personnel in patient care on 8 hour
shifting duty including equipment handling and basic pathological / biochemi-
cal tests utilizing equipment present in the CCU / HDU as following:
 Preventive maintenance of all equipment present in the CCU– preventive
and to certain extent remedial.
 Basic Life Support.
 Chest physiotherapy (in absence of MT-Physiotherapy).
 Oxygen therapy including handling oxygen manifold & centralized oxygen
supply.
 Assisting Advanced life support.
 Assisting MOs & Nursing Personnel performing different procedures.
 Assisting bedside dialysis (where available) in collaboration with MT (Dialy-
sis).
 Blood sampling by peripheral venipuncture.
 Assisting USG / Echocardiography (if available) / X-ray
 Assisting in transport of critically ill and ventilated patients to CT/ MRI suite or
6
dialysis unit if needed.

 Basic blood test by Biochemical analyzer / Cell counter / Glucometer / Ar-
terial blood gas analyzer / Electrolyte analyzer/ any other point-of-care test
and other equipment present in the CCU / HDU.
 Monitoring – a) Clinical parameters, b) Multichannel monitors, c) Ventilator
parameters, d) others
 Regular data entry under supervision of on duty MOs & Nursing Personnel
 Computation & clerking
 Any other work to manage any emergent situation within the unit
 Any other work assigned by on duty MO / Nursing Personnel for emergency
patients’ service
vi. Hospital Assistant:

Assisting on duty Medical Officers & Nursing Personnel in patient care on 8 hr
shifting duty including equipment handling and basic pathological / biochemi-
cal tests utilizing equipment present in the CCU / HDU in addition with the fol-
lowing activities,
 Basic life support.
 Assisting in Advanced life support.
 Draw up Nursing care plan in his/her Unit in consultation with the on duty
Nursing Personnel /Nursing in charge.
 Perform the routine Nursing activities for Admission, Discharge and Transfer
of the patients.
 Prepare and assist for Diagnostic procedure for the patients.
 Take part in intending of drugs, Diet and other supplies and maintaining the
inventory of each item.
 Assist the Nursing Personnel /Nursing in charge in maintenance of the Sub
store and buffer stock of drugs, linen, consumables and other equipments.
 Responsible for maintenance, sterilization and disinfection of articles and
equipments as necessary.
 Assisting in transport of critically ill and ventilated patients to CT/ MRI suite or
dialysis unit if needed.
 Responsible for overall cleanliness of the ward/unit. Will segregate and en-
sure proper disposal of Bio Medial Waste and Municipal solid waste.
 Make rounds with doctors and Sr. Nursing Officers.
 Keep the Patient’s record up-to-date.
 Make communication with Patients and patient’s party.
7
 Responsible for collection and file up reports and making detail bed to bed
round at the time and changing of ‘shift’.
 Sign the ‘Night report’ after checking.
 Must have knowledge on “Quality Assurance” and “Safety Measures” with
standards and protocols.
 Acquainted with all the monitors, machines and equipments particularly
ECG machine of the above said units for their operation and maintenance.
 Responsible for continuous monitoring/observation of the patients and will
take prompt action/measures in CCU.
 Responsible for implementation of Infection Control measures in CCU under
guidance of Hospital infection control committee.
 Acquainted with Hospital Corneal Retrieval programme and ‘Transplanta-
tion of Human organs bill’ and ability in “Grief counseling”. He must know
the various Legal and Ethical issues in ‘Critical Care Unit’ like “Brain death”.
 Able to manage the patient with impaired Respiratory function.
 Intervene with Triage, assist in documentation and take resuscitation tech-
niques for critically ill and participating in managing crowd and counsel pa-
tients and party.
 Implementation of Swasthy Sathi in respective unit.
 Implementation of Financial assistance schemes (e.g. SIAF/ RBSK/ RSBY etc.)
under guidance of nodal Assistant Superintendent (NM).
 Arrangement of referral of patient to higher centre or any other unit of same
hospital.
 Supervision of quality and quantity of supplied cooked diet/ feed to pa-
tients.
 Any other work assigned by on duty MO / Nursing Personnel for emergency
patients’ service.
vii. General Duty Attendant:

 General duty, housekeeping, loading/unloading, stretcher bearer, mes-
senger and any other work assigned by on duty MO / Nursing Personnel
for emergency patients’ service.
viii. Karmabandhu:
All type of cleaning & sweeping.
8
ix. MT (Physiotherapy)
 Perform bedside physiotherapy for CCU patients as and when required.
x. MT (Dialysis)
 Perform bedside dialysis in CCU as and when required (if available).
xi. MT (X-ray)
o Perform bedside X-ray when required.
o Routine maintenance of portable X-ray and C-arm of CCU.
o Operating image intensifier (C-arm) during temporary transvenous pac-
ing (as and when required).
xii. Pharmacist
Conduct quarterly internal audit and physical verification of drugs and medical
oxygen supply and consumption in CCU.
xiii. Bio-medical engineers:

District level / Hospital level Bio-medical engineers will be responsible for regular
follow up of the status of the equipment under their jurisdiction along with ar-
rangement of regular maintenance with the help of the MT-CCUs posted at the
respective units.
VIII. General Instruction regarding Patient management:
i. Patients in the CCU should be admitted under respective Bed-in-charges of dif-

ferent Departments of the hospital (Unit in Charges in case of Medical College
Hospitals). CCU Trained Medical Officers will be responsible for initial critical
care management and daily and Emergency medical management of the
admitted patients in consultation with the respective BICs.
ii. On duty specialist, one each from Medicine and Anesthesiology will be given
extra responsibility as Supervising Officer to supervise patient care of the entire
unit and they will be consulted upon by the MOs as & when required.
iii. MSVPs / Superintendents will allot the duty of the specialists and keep liaison
with the entire unit.
iv. Specialists of different disciplines will take care of patients admitted in CCU
under them as Visiting and on referral during day–on-call, as they do usually in
other wards.
v. In case of Tertiary care hospitals Staff pattern is same except specialists will be
9
replaced by faculty and Postgraduate trainees of Medicine & Anesthesiology

will also be given duty at Critical Care Units on a rotation basis as part of their
training for the respective courses.
IX. Hospital level Supervision & Monitoring
1. One trained MO among the MOs working at CCU will act as Medical Officer In
charge of the unit and responsible for all the duty as mentioned above.
2. One Nursing personnel will be designated as Nursing – in – charge by hospital
authority. She will be responsible for all the duty as mentioned above.
3. One specialist each from the Dept. of Medicine and Anesthesiology of the re-
spective hospital, selected by respective MSVPs / Superintendents, will act as
Supervising Officer and make overall supervision regarding patient care &
technical issues.
4. One Deputy Superintendent / Assistant Superintendent (Non-Medical) will act
as Hospital level liaison officer for respective CCU. They are responsible for daily
logistics management, regular updating of patient related information elec-
tronically and regular monthly reporting.
5. Deputy Superintendent / Assistant Superintendent (Non-Medical) should physi-
cally visit CCU at least once daily.
6. One Deputy Nursing Superintendent will supervise nursing related matters of
CCU. She should visit CCU at least once daily along with Assistant Superinten-
dent (NM).
7. MSVP / Superintendent of the respective hospital should give at least once
weekly round with respective Supervising Officers; Deputy Superintendent / As-
sistant Superintendent (Non-Medical) responsible for CCU related activities,
Nursing Superintendent and designated Deputy Nursing Superintendent.
8. Regular round (at least twice daily) by Bed-in-charges in the CCU is mandatory,
if patients present under their treatment.
9. A Hospital level monitoring committee will be formed in each Hospital / Medi-
cal College Hospital with functional CCU / HDU for periodic monitoring of CCU
/ HDU activity with the following persons,
a. MSVP / Superintendent of the hospital as Chairman of the committee,
b. MO in charge of the respective CCU as Convener,
c. Supervising Officer (Physician) of that unit as member,
10
d. Supervising Officer (Anesthetist) of the unit as member,

e. Nursing Superintendent as member,
f. Deputy Nursing Superintendent designated for CCU as member,
g. Nursing in charge of the respective CCU as member,
h. All CCU trained MOs attached to the unit as member,
i. Deputy Superintendent (non-medical) / Assistant superintendent (non-
medical) responsible for CCU / HDU related activity as member,
j. Deputy Superintendent (medical) as member (in case of Medical Col-
lege Hospitals),
k. Dy. CMOH 1 (as District Nodal Officer for CCU) of that District as invitee
member.
10. This Hospital level monitoring committee will meet monthly (preferably at a pre-
fixed date in every month) and analyses all CCU related activities including
monthly report analysis, logistics review, gap analysis and problem identification
and possible corrective measures.
X. Equipment Management
1. Equipment including Laboratory equipment present in the CCU should be pri-

marily handled by MT-CCU in consultation with on duty Medical Officer & Nurs-
ing staffs.
2. Laboratory equipment, designated for CCU should be kept in the respective
CCU only and not in the general laboratory of the hospital as these equipment
should be available 24 x 7 for the patients admitted in CCU.
3. Laboratory equipment, kept at CCU, may also be utilized for the other patients
of the hospital. In that case, respective laboratory technician of that hospital
may perform the tests with permission of the on duty Medical Officer of the
CCU.
4. Portable X-ray present in the CCU will be operated by MT (X-ray) or MT-CCU,
present in that hospital.
5. Maintenance of the equipments and indent for repairing these equipments will
be the joint responsibility of the MO in Charge & Nursing in charge with the help
of MT-CCU. Necessary feedback regarding the malfunctioning of the equip-
ment will be the responsibility of MT-CCUs.
6. In case of malfunctioning of any equipment, MT-CCU should inform the respec-
11
tive companies in prescribed format at the earliest and properly follow up the
repairing work. This is also the responsibility of Nursing in charge to inform the
hospital authority regarding the renewal of Annual Maintenance Contract well
prior to the expiry of the ongoing contract.
7. Arrangement of maintaining environmental specification required for optimal
working condition of an equipment as specified by manufacturer (e.g. tem-
perature, humidity, damp-proof, moisture-free, pipeline pressure of medical
gasses, vacuum etc.) is responsibility of designated Deputy Superintendent
(NM) / Assistant Superintendent (NM) who will keep liaison with the agency
(e.g. PWD-Civil, PWD-electrical, WBMSCL etc.) for regular maintenance.
8. Biomedical Engineer will supervise relocation of equipment from one CCU to
another CCU within the district, if required. No equipment should be relocated
without relocation order issued by appropriate authority (CMOH in DH, SSH,
SDH, SGH and MSVP/ Principal in medical Colleges).
XI. Reporting
1. A web based e management & information software programme named ‘Crit-

ical Care Management and Information System (CCMIS)’ has already been in-
troduced to ensure – e-admission, e-patient management, e-prescription, e-
discharge, e-inventory management, e-programme analysis & e-monitoring of
all functional Critical Care Units.
2. All patient data should be keyed in / entered in real time. Regular data entry
should be updated by Medical Officers on duty, Nursing Personnel on duty, MT
(CCU) or any other persons engaged for this purpose by respective hospital au-
thority.
3. All patient admission and discharge should be recorded in on line software.
Recording should be the responsibility of on duty Medical Officers, Nursing Per-
sonnel and MT-CCUs. Data entry operator is not required, as all the data en-
tered here are solely medical & technical data.
4. MO in charge and Nursing in charge of the respective CCU / HDU are given re-
sponsibility to monitor regular entry & update of treatment related matters and
nursing related matters respectively in CCMIS of their own unit.
5. All Medical Officers, Nursing Personnel including Nursing in charge posted in the
respective CCUs & HDUs and other personnel who are regularly engaged in the
12
CCU related Data entry process should be individually registered in this system
and generated their individual user Id & password through CCMIS.
6. Dy. CMOH 1 of the respective District on behalf of CMOH, Deputy / Assistant
Superintendent (NM) in charge of respective CCU / HDU on behalf of Superin-
tendent / MSVP will look after the CCMIS related matters and ensure regular
and updated data entry.
7. State Level Monitoring Officers will also look after the CCMIS related matters of
the units under their supervision and provide regular feedback to them after
analysing the data entered in CCMIS.
8. At the end of each month, report through CCMIS should be analysed by the
Hospital authority & Hospital level Monitoring Committee and share the neces-
sary feedback with the CCUs.
9. All CCU should be provided at least two computer, two printer and suitable In-
ternet connection for this purpose. Provision may be done by the local hospital
authority or centrally.
10. All units and patient related data including maintenance of stock (medicine,
equipment and other logistics) should be entered electronically in CCMIS and
all the related manual register will be replaced by e-register through CCMIS.
XII. Training of HR for CCU
i. Medical Officer will be imparted a short course training on Critical Care of 8

weeks (48 working day), covering major fundamentals before started working
at any CCU/HDU.
Recently Department already starts a Post Graduate Certification course in crit-
ical care under WBUHS.
ii. Nursing Staff will be imparted a Short training of 3 weeks (18 working days) at dif-
ferent training centre covering major fundamentals before started working at
any CCU/HDU.
iii. MT-CCU: For posting as MT-CCU, minimum qualification will be a recognized Dip-
loma in Critical Care Technology. After joining, MT-CCUs will be provided a
week long (6 working days) sensitization programme in different training cen-
tres.
Detailed training plans are given below,
13
A. Primary Training Plan for Medical Officers
1. Training Centers for Medical Officers: At present, Department of Critical Care

Medicine of IPGMER and SSKMH Kolkata is designated as main training center.
Different Medical College Hospitals are designated as Critical care training
centers under the guidance of main training center. Some District Hospitals like
M R Bangur Hospital, Howrah District Hospital, Hooghly District Hospitals are also
designated as training centers under the guidance of main training centre.
2. Duration: Eight weeks (48 working days)
3. Number of trainees: 10 - 15 per batch
4. Learning objectives: After completion the trainee will achieve (a) Proficiency
in recognition and initial management of problems commonly encountered in
an CCU; (b) Efficiency in resuscitation of critically ill patient; (c) Appropriate
monitoring of different parameters & their interpretation; and (d) Capacity to
identify troubles- both patient and device related and perform basic trouble-
shooting
5. Training methodologies: Lectures, Demonstrations, Practical (Hands-on Train-

ing). Trainee will have to perform shifting duty at each training center.
6. Curriculum:
6.1. Specific credentials (Training method: Hands-on): (a) CPR – BLS (Basic Life
Support); (b) CPR – ALS (Advanced Life Support) : Intubation/ Mechanical
Ventilation / Defibrillation / Temporary pacing / Application of cardiovascu-
lar drugs- Antiarrythmics / Vasopressors /Inotropes etc.
6.2. Procedural skills (Training method: Hands-on): (a) Maintenance of open

airway in a non-intubated patient; (b) AMBU Mask ventilation; (c) Tracheal
intubation : Trans-oral, Trans-nasal; (d) ICTD ( Chest Drain ); (e) Cardiover-
sion; (f) Transcutaneous temporary pacing; (g) Insertion of CV cath.(Central
Venous Catheter); (h) Tracheostomy (i) Changing Tracheostomy Tube.
14
During training, hands on training will be given preceded by a lecture and fol-
lowed by a test.
7. Following subjects will be incorporated in the 48 days’ training session.

7.1. An overview of critical care: The basic do’s and don’ts and Basic Idea re-
garding the whole Training programme
7.2. Approach to respiratory failure
7.3. Cardiopulmonary resuscitation (BLS)
7.4. Cardiopulmonary Resuscitation (ACLS)
7.5. Haemodynamic drugs in critical care
7.6. Maintenance of an open airway (Chin lift / jaw thrust / Suction / Oropha-
ryngeal & nasopharyngeal tubes) / Mask ventilation / Using AMBU / Using
Breathing Circuit in emergency
7.7. Tracheal intubation using direct laryngoscope (Endotracheal Tube / Laryn-
goscope)
7.8. Rescue oxygenation (LMA / Combitube / Cricothyrotomy)
7.9. Arterial Blood Gas analysis – approach, interpretation & application
7.10. Oxygen therapy, Humidification and inhalational therapies
7.11. Invasive Ventilation: Basic concepts & Basic modes
7.12. Invasive Ventilation: Indication, Criteria, Monitoring & Troubleshooting
7.13. Invasive Ventilation: Weaning and tracheostomy
7.14. Disease specific ventilation : ARDS and restrictive diseases
7.15. Disease specific ventilation : Severe Obstructive Airway diseases
7.16. Management of commonly encountered arrhythmias in the general Critical
Care Unit (including defibrillation)
7.17. Acute Coronary Syndrome
7.18. Approach to cardiogenic shock & acute heart failure
7.19. Noninvasive ventilation
7.20. Principle of Renal Replacement Therapy
7.21. Approach to shock
7.22. Central venous pressure and arterial blood pressure monitoring
7.23. Intravenous fluids in critical care (Including evidence based comparison be-
tween colloids & crystalloids)
7.24. Transfusion practices in critical care
7.25. Pulse oximetry & Capnometry: its implications in critical care
7.26. Surviving sepsis campaign for management of severe sepsis and septic
15
shock
7.27. Hospital acquired infections and infection control practices in critical care
7.28. Antibiotic policies in Critical care Unit
7.29. Management of seizures
7.30. Diagnosis and management of cerebrovascular accidents (CVA)
7.31. Approach to peripheral neuropathic and neuromuscular diseases in critical
care
7.32. Meningitis and encephalitis
7.33. Approach to liver failure
7.34. Approach to acute pancreatitis
7.35. Pneumonia
7.36. COPD and Asthma exacerbations
7.37. Venous thromboembolism and Thromboprophylaxis in CCU
7.38. Sedation and analgesia in Critical Care
7.39. Glycaemic control in Critical Care (along with management of hypergly-
cemic crises)
7.40. Approach to common obstetric complications encountered in CCU
7.41. General management of major trauma including head injury (with special
reference to District Hospitals)
7.42. General management of burns (with special reference to District Hospitals)
7.43. Practical aspects of renal replacement therapy
7.44. Approach to acute and acute on chronic renal failure
7.45. Critical care Nutrition
7.46. Approach to poisonings and drug overdoses
7.47. Snake bite
7.48. End of life, Brain death and medicolegal issues in critical care
7.49. PRACTICAL HANDS ON TRAINING - GROUPWISE
During this period, trainee of all training centers will be given training (both theoretical
& hands-on) at a state level training centre. Critical care Training Centre of Bijoygarh
SGH may also be utilized for this purpose.
Preferably, maximum 1-2 topics will be covered in a single day along with practical
session covering at least 50% of the total working days. Trainee MOs will be given rota-
tional duty in the respective CCUs of the training centers in presence of regular MOs of
that CCU for better sensitization and training in real time scenario.
16
8. Logbook: Each trainee will have to maintain a log book recording perfor-
mance of duty, specific credentials, lectures & demonstrations attended, pro-
cedures performed and rotational training as performed. It is to be signed by
the Unit / Departmental Head / Training in charge.
9. Post training evaluation & Certification: Only oral and practical tests. On com-
pletion of successful training, duly signed by the Head of the Institute and
DME/DHS.
B. Short Term Training for Specialist Medical Officers
1. A short term sensitization training may be planned for Specialist Medical Offic-
ers who already have degree / diploma in Anaesthesia & General Medicine /
Bed-in-charges (under local order).
2. Duration: 12 working days divided in two phases (6 day each) at a interval of 3-
4 wks.
3. Number of trainees: 5-10 per batch
4. Training Centre: Preferably training will be given at Department of Critical Care
Medicine of IPGMER and SSKMH, North Bengal MCH, R. G. Kar MCH and Critical
Care Training Center of Bijoygarh SGH
5. Learning objectives: After completion the trainee will achieve (a) Efficiency in
resuscitation of critically ill patient; (b) Capacity to handle different CCU re-
lated devices, (c) Capacity to identify troubles- both patient and device re-
lated and perform basic troubleshooting, (d) Capacity to give technical sup-
port to Medical Officers & Nursing personnel present in CCU & HDU and (e)
Capacity to give sensitization training to other Medical Officers and Nursing
personnel.
6. Training methodologies: Lectures, Demonstrations, Practical (Hands-on Train-
ing).
7. Curriculum:
The following topics will be covered in whole training programme. Maximum 3-4
topics will be covered in a single day. 50% of the topics will be covered in 1 st
part of the training programme and rest of the topics will be covered in 2 nd
part.
17
7.1. BLS and ACLS

7.2. Shock
7.3. Colloid and Crystalloid resuscitation
7.4. Hemodynamic drugs
7.5. Hemodynamic monitoring (Arterial blood pressure and central venous
pressure)
7.6. Acute respiratory failure
7.7. Pulse oximetry and Capnometry
7.8. Oxygen, Humidification and Inhalational therapies
7.9. Noninvasive Ventilation
7.10. Invasive Ventilation (Basic concepts + Basic modes + Weaning)
7.11. Disease specific ventilation (ARDS + Severe airway obstructive disorders)
7.12. Arterial Blood Gas analysis
7.13. Acute Kidney Injury
7.14. Dyselectrolytemias in critical care
7.15. Transfusion practices in critical care
7.16. Sepsis
7.17. Hospital acquired infections and infection control practices in critical
care
7.18. Antibiotic policies in critical care
7.19. Sedation and analgesia in critical care
7.20. Glycaemic control in Critical care
7.21. Venous thromboembolism and thromboprophylaxis in Critical Care
7.22. Major trauma including Traumatic brain injury
7.23. Critical Care Nutrition
7.24. Hands on training of different equipment used in CCUs & HDUs
C. Plan of training for Nursing Staff on CCU
1. Training Centers: Department of Critical Care Medicine of IPGMER and SSKMH

Kolkata is designated as Main training center. Different Medical College Hos-
pitals are designated as CCU training centers for Nursing staffs under the guid-
ance of main training center. Some District Hospitals like M R Bangur Hospital,
Howrah District Hospital, Hooghly District Hospital are also designated as train-
ing centers under the guidance of main training centre. Rotational exposure for
2 days each at pediatric ICU where available.
18
2. Duration: Three weeks (18 working days) at the Training Centre and three weeks
post-placement consolidation under guidance of trained MOs in the individual
CCU / HDUs.
3. Number of trainees: 15 - 20 per batch
4. Learning objectives: After completion, in addition to routine usual nursing care

the trainee will be able to perform (a) Appropriate monitoring of critically ill pa-
tients (Including ECG interpretation and ventilator parameters monitoring),
detect troubles, report it to on duty MOs and troubleshoot themselves to cer-
tain extent. They will maintain all charts at bedside; (b) Feeding patients (Enter-
al / Parenteral) properly avoiding aspiration lung injury in case of enteral feed;
(c) Preventing pressure sore; (d) Capacity to assist / perform chest physiothera-
py including airway toileting & aerosol therapy; (e) Continuous infusion of dif-
ferent lifesaving medicines; (f) Implement infection prevention protocols includ-
ing sterilization of instruments & devices; (g) Performing ECG and (h) Assist or
cooperate patient care activities with that of Medical Technologist (MT) (Criti-
cal Care) and MOs.
5. Training methodologies: Lectures, Demonstrations, practical (Hands-on Train-

ing). Trainee will have to perform shifting duty at each training centre. Grand
round with consultant, MOs and medical technologists
6. Curriculum:
A. Specific credentials (Training method: Hands-on): Basic Life Support (BLS)

B. Procedural skills (Training method: Hands-on): (a) Insertion of peripheral ven-
ous catheter; (b) Endotracheal suction & collecting sample for microbiologi-
cal study
C. Cognitive skills:
(a) Recognition of (12 sessions of Lecture/Demonstration): (i) Respiratory Failure;

(ii) Oxygen therapy; (iii) Mechanical Ventilation – Invasive; (iv) Mechanical
ventilation – Noninvasive; (v) Fluid and Electrolyte Disorders; (vi) Sepsis; (vii)
Shock / Hypotension; (viii) Normal ECG interpretation & pattern identification
19
of common ECG abnormalities in intensive care; (ix) Cardiovascular medi-

cines – Vasopressors, inotropes, common antiarrhythmics, antihypertensives,
antiischaemic drugs, antiplatelets, anticoagulants; (x) Aspiration Lung Injury,
ARDS, Cardiogenic pulmonary edema; (xi) Communication skill : with CCU
staff, patient, relatives of patients and administrators
(b) Application of (10 sessions of Lecture/Demonstration): (i) Bedside assess-

ment – Clinical/ on multichannel monitor / ventilator parameters/ glucome-
try / common lab reports and maintaining charts; (ii)Troubleshooting & re-
porting to MOs and MT. Detection of problems include clinical, blood gas
related (SPO2, ETCO2), mechanical ventilatory, electrocardiographic, he-
modynamic – CVP/ NIBP ) and identification of true & false alarms; (iii) Chest
physiotherapy including airway toileting &nebulisation; (iv) Application of in-
fusion pump – both syringe and rapid; (v) Nutrition : Different diets, enteral
and parenteral feeding , methods of feeding, prevention of aspiration; (vi)
Prevention of infection in CCU : Application of protocols – universal, room
sterilization, disposal of wastes, sterilization of instruments and device related
policies; (vii) Prevention of bedsore or pressure sore; (viii) ECG machine
handling and performing ECG; (ix) Appraisal of errors.
7. Logbook: Each trainee will have to maintain a log book recording performance
of duty, specific credentials, lectures & demonstrations attended, procedures
performed and rotational training as performed. It is to be signed by the Unit /
Dept. Head.
8. Post training evaluation & Certification: Only oral and practical tests. On comple-
tion of successful training, duly signed by the Head of the Institute and DME/DHS.
20
XIII. Technical aspects for 24 bedded Hybrid CCU
Following specifications are for the establishment of 24 bedded Critical care Unit and
will be followed while doing infrastructural up gradation work.
A. CIVIL CONSTRUCTION:
• Unit is preferably on Ground floor; otherwise Electric elevator is must for patient
transportation. On the ground floor dust contamination & chance of infection
are more.
• Front Gate – Single entry/exit, 2 barriers before patient care area. One emer-
gency exit – separate as appropriate, No thoroughfare.
• All the doors should have self-closing property. Door at the entry point of main
patient care area preferably of no touch auto-sliding door.
• Floor space for Patient care area: 100 – 125 Sq. Ft. / Bed. 20% extra space for
cubicle type.
• Distance between two adjacent beds should be at least 4 ft and a free space
of 2 ft should be provided at head end & foot end.
• Isolation cubicle: 2 in HDU area, This cubicle will be glass walled with clear glass.
• Additional Space: 100 – 150% of Pt. care area
• Approximate area requirement for establish a 6 bedded unit is 1500 sq ft, for a
12 bedded unit is 2500 sq ft, and for a 24 bedded unit is 3500 sq ft.
• Additional Rooms
• Inside the sterile zone:
• MO’s Room, Nurses Room, Room for paramedical staffs – all 3 rooms with
attached toilet & AC facility
• Outside the sterile zone but within the CCU complex
• Room for Nurse In-charge, Room for sweepers, Store rooms (medicine,
linen, equipment and consumables), Laboratory, Hand Wash area, Linen
wash area, common toilet (2 in no), Reception area, Pantry, shoe rack,
Donning& doffing area.
 Wall Rack @ height of 5 ft from floor for keeping Multichannel Monitors size 1½ ft
X 1 ft (if rack not provided with the Multi-channel Monitors).
21
 Wall fixed rack in lab room ‘L’ shaped to keep machines.

 Wall fixed rack in Store.
 Coving at the junction of wall with floor for better cleaning.
 Wall should be fitted with tiles up to the minimum height of 8ft. ; preferably upto
roof height
 Hole in the walls for cleaning purpose is essential with proper drainage system.
 Wash basins one each in the rooms of Medical Officer & Nursing Personnel.
 One sink with elbow operated tap is required in Lab room.
 A common hand wash area is to be provided with 2-3 bay 304 grade stainless
steel scrub sink or deep ceramic sink fitted with automatic sensor taps or elbow
operated taps.
 Floor with large marble plates (No visible junction in between) / Vitrified anti-skid
floor tiles.
 Granite/ Marble / wooden top semicircular or half squire or L-shaped Central
Work station with inside rack. Wooden work station with drawers is preferred as
its position can be shifted if needed.
 Rack beside Nursing Station for emergency medicine cum equipment store.
 False ceiling should be avoided as far as possible. If required, false ceiling will
be made of fire proof material to conceal central A/C ducts and certain other
cables.
 Windows 2 piece Sliding with clear glasses.
 Screen made with easy washable materials (avoid cotton material) should be
available for all Doors and Windows.
 Drinking water supply is must (may be through water purifiers).
 Granite/ Marble top rack with sink in pantry.
 In wash area an area of 5ft X 3 ft should be guarded with ½ ft high cement wall
with proper drainage system for linen cleaning purpose.
 Colour of the ceiling should be white.
 Colours of the walls are either light cream or off-white or light pesta or any light
colour except white (colour of ceiling).
 Beds are separated by Screen fitted stands. The screen also should be light co-
loured and preferably made by easily washable material.
 Annual Maintenance of the whole Unit from civil part is must.
 Arrangement of Pipeline for dialysis with two portals (out of which one should
be in isolation cubicle) in CCU should be provided for future use.
22
B. ELECTRICAL CONSTRUCTION:
 Patient care area should be provided with Negative pressure ventilation facility
with the following minimum criteria:
o Negative-pressure room has at least 12 air changes per hour and controlled
direction of airflow.
o Negative-pressure differential greater than 2.5 Pa (0.01 inch water gauge),
or an airflow differential greater than 56 l/s (125 cfm) exhaust versus supply
o Clean-to-dirty airflow
o Sealing of the room, allowing approximately 0.046 m2 (0.5 square feet)
leakage
o An exhaust to the outside, or a high-efficiency particulate air (HEPA) filter if
room air is re-circulated
o Air curtain at the entry and exit of the patient care area.
o All related duct should be covered from the roof.
 12 Electric Points of which 4 may be near the floor, 4 on each side of the pa-
tient.
 Electric outlets/Inlets should be common 5/15 amp pins. Should have pins to
accommodate all standard electric pins /sockets. Adapters should be discour-
aged.
 UPS Power back-up is essential for at least 50% of bed side Electrical points and
at least one emergency light per bed.
 Voltage stabiliser for the entire unit.
 Total load per bed is approximate 1.5 KV.
 AC should be of split type. Centralised AC should be avoided as far as possible.
No duct of AC is allowed inside the room. If unavoidable, it should be strictly
fixed to the roof and length should be minimised as far as applicable.
 Laboratory room requires 4 electrical boards in equidistance with 3 plug points
in each of whom 1 must be of 15 amps.
 At least one electrical extension board with earthing should be supplied to each
room.
 Wall mounted fan is essential on the head end of the patient on the wall at 8 ft
height from floor.
 Wearing preferably be of concealed type with fire retardant wires.
 One calling bell in each room with switch outside the complex (outside Buffer
23
zone) should be there.
 Calling bell from each bed with visible and audible alarm at nurses’ station is
recommended.
 Additional electric board to be established on the wall at the back of central
work station for charging equipment. That board will be of same specification as
earlier, number of boards should be at least 2 with 4 plug points on each board.
 At least one computer board is must in nursing station and MO room with provi-
sion for teleconferencing.
 Annual Maintenance of the whole Unit from electrical part is must.
C. ENVIRONMENTAL:
 Fully A/C – Controlling – Temp. / Humidity. Preferably Split A/C.
 Temperature maintained = 16 – 250 Celsius
 Humidity should be <70%.
 Minimum of 12 total air changes /room/hour with two changes/ hour by outside
air.
 Re-circulated air must pass through appropriate filter : HEPA filter
 Provision of regular maintenance and replacement of HEPA filter should be
available.
D. CENTRALISED LAMINAR FLOW:
 Compressed air outlet = 1 per bed (Lacking compressed air supply – Ventila-
tors will run by inbuilt compressor or turbine)
 Oxygen outlet = 1 per bed (preferably 2)
 Vacuum outlet= 1 per bed for suction
 Alarm system: At main plant, manifold and locally (inside nurses; station).
 Area valve service unit: Desirable to avoid total shut down of CCU during pre-
ventive maintenance or repair in one part.
24
E. CENTRALISED MEDICAL OXYGEN SUPPLY SYSTEM (either through mini-manifold

or PSA or liquid oxygen supply system):
i) Oxygen:
• Preferably through pipeline with manifold room at the same floor or attached
to the Central Medical Gas Pipeline system (MGPS) of the hospital.
• If separate manifold system is required to establish for CCU, manifold should
contain at least 6 cylinders in two rows (10x10) for 24 bedded units.
• Two point at head end of each bed.
• Oxygen supply key is to be established on the pipeline at least two in number,

one just outside CCU and other at manifold room.
• Additional 2 Jumbo Cylinders with MOX Adapter are to be supplied to each

room as back-up for ventilators. Additional medium/ small size cylinders are to be
supplied as back up for non-ventilated patients.
• Flow meter with Humidifier is essential for one outlet per bed.
F. CENTRALISED SUCTION SYSTEM:
Suction:
 Central vacuum system is preferable. 1 vacuum outlet per bed is advised. Two
vacuum outlets will be required in CCU of all Trauma Care Facilities and in some
beds of Hybrid CCUs.
 Can be performed by suction machine in CMS Category too. (1/4 H.P.)
 In case of suction machine, ratio should be 1 / bed.
G. COMPRESSED MEDICAL AIR

 Compressed medical air may be required to run ventilators without compressors.
H. LIGHTING:
• Spot light for procedures will be required over each bed.
• Overhead lighting of at least 20 Candle ft.
• Overhead lighting by one twin tube set, box covered with transparent glass
• In conference room lighting should be concealed type.
25
I. NOISE CONTROL:
• Noise level is to be ideally under 45 dB - daytime, 40 dB - evening and 20 dB -

night
J. BIO-MEDICAL WASTE, MUNICIPAL SOLID WASTE DISPOSAL & POLLUTION CON-

TROL:
• Three foot operated covered bins – colour coded –(Yellow, Red, Black) X 2 sets.
 Blue and white puncture proof containers as per requirement.

 Two Perforated buckets in foot operated closed containers.
• Adequate wash basins, preferably in the washing area. Wash basin inside the
Critical care area should be avoided as far as possible.
• Adequate no. of toilets.
Main Patient care area
Entrance Pre-sterile First steri- HDU 1 HDU 2 ICU

area learea (8 bedded) (8 bedded) (8 bedded)
26
XIV. Standard List of Equipment
Equipment required in each CCU will be divided in two groups – Major equipment &
Ancillary equipment. Equipment belonging to CMS Category will be purchased from
CMS approved firms by respective hospital authority or District authority or WBMSCL.
Major Non CMS category items will be purchased by WBMSCL or Individual hospital
authority (if permitted by financial power and fund availability) and Ancillary Non CMS
category items will be purchased by respective CMOH or Hospital authority.
The standard list of equipment & furniture are given below.
Respective units should check CMS list before placing order.
[These are the essential requirement required to make a unit functional smoothly de-
pending on the bed strength of the respective units. This is an indicative list only; the
requirement may vary depending on the functionality of the respective unit. Hospital
authority may take decision to make available requisite number & nature of equip-
ment depending on the functional status of the unit and periodic assessment by unit
level or District level or State level monitoring teams.]
1. Major equipment recommended for each Critical Care Units
Sl Name of Equipment Required no. of equipment
For every 12 bed 1 no is required i.e. Total 2 (Extra 1

Biphasic External Defibril-
1. may be required, if any part of the unit is situated at a
lator
separate place)
2. Blood Gas & Electrolyte

1 no. for whole unit
Analyzer
Requirement as per total no. of functional beds
3. Ripple Mattress
available.
Requirement is equal to the no. of functional ICU
4. Ventilator- Standard beds available and 25% of functional beds available
at Step down area or HDU area
5. Portable Ventilator At least 1 no. for each unit
Non-Invasive BI-PAP Venti- Requirement is 25% of the total functional beds
6.
lator available.
7. High Frequency Nasal Requirement is 25% of the total functional beds avail-
27
Canula (HFNC) able.
8. Portable X Ray Machine 1 no. for whole unit
9. Automated Cell Counter 1 no. for whole unit
10. Fogger Machine 7 no. for whole unit

Requirement is 25% of the total functional beds
11. Rapid Infusion Pump
available.
Pulse Generator
12. 2 no. for whole unit
(Optional)
13. Electrolyte Analyser 1 no. for whole unit
14. Nebulizer
available.
Syringe Infusion Pump for
15. sustained and slow injec-
available.
tion of drugs
ECG Machine (portable)
16. 12 channel with auto- 2 no. for whole unit
mated analysis
17. Semi Auto Analyzer 1 no. for whole unit

18. Over bed Table
available.
19. ICU Bed
available.
20. Multi-Channel Monitor
available.
Automated analyzer for
detection of D-dimer, CK-
21. 1 no. for whole unit
MB, NT Pro BNP, Pro-
calcitonin
1 no. for whole unit with provision of ECHO compati-
22. USG Machine (Optional) ble probe and related software (depending on the
requirement assessed for individual unit)
Microbial Culture Ma- 1 no. for the unit established at Medical College Hos-
23.
chine(Optional) pital and District Hospital
28
Automated system for 1 no. for the unit established at Medical College Hos-
identification and Antimi- pitaland District Hospital – this equipment preferably
24.
crobial Sensitivity Test to be established at the Microbiology Department of
(AST)(Optional) MCH and in laboratory of DH
25. Central monitor 1 For every 12 bed i.e. Total 2
Sequential intermittent
26. pneumatic compression 5 for whole unit
device
Sleeves for Sequential in-
27. termittent pneumatic 20 for whole unit
compression device
Videolaryngoscope (op-
28. 1 for whole unit
tional)
Videoendoscope (4 mm 1 for whole unit(depending on the availability of the
29.
OD) (Optional) respective specialist)
Endotracheal tube cuff
pressure manometer
Continuous cardiac out-
put monitor (Optional)
32. Coagulometer 1 for whole unit
33. Image intensifier (C-arm) 1 (if not available in hospital)
CPR manikin (for training

centres only)
Airway manikin (for train-
ing centres only)
29
2. Ancillary equipment (CMS Items) recommended for each unit

(Number depending on the bed strength as per following list):
Requirement for whole 24 bedded unit

Sl no. Item Description
(should be maintained as buffer stock)
1. Trolley (with side rails) 5
2. Bed-cum-trolley 2
3. AMBU – Bag & Mask (Adult) 6
4. AMBU – Bag & Mask (Child) 2
5. Laryngoscope with Blade (1,2,3,4) 3
6. Glucometer 4
7. Emergency Medicine tray 4
8. Refrigerator 2
9. Instrument sterilizer 2
10. Emergency light 6
11. X- Ray View box 2
12. Suction machine 8
13. Portable spot light 4
14. Stethoscope Equal to no. of beds
15. Instrument tray 12
16. Scissors 4
17. Drip Stand Double to no. of beds
18. Needle Destroyer 2
19. Cut Down Set 4
i. Instrument tray 4
ii. Sponge Holding Forceps 4
iii. Mosquito Artery Forceps 12
iv. Scissors 4
v. Venesection Hook 4
vi. Allies' Tissue Forceps 8
vii. Needle Holder 4
viii. Scalpel Blade No 15 4
ix. B. P. Handle 4
x. Silk 50
30

Sl no. Item Description
xi. 2-0 Synthetic non-absorbable nylon 50
20. Tracheostomy Set 3
i. Instrument tray 3
ii. Sponge Holding Forceps 3
iii. Mosquito Artery Forceps 6
iv. Scissors 3
v. Allies' Tissue Forceps 6
vi. Needle Holder 3
vii. B. P. Handle 3
viii. Tracheostomy tube 5
ix. Tracheostomy Hook (Double) 6
x. Tracheostomy Hook (Single) 6
xi. Scalpel Blade No 15 3
21. L. P. Set 2
i. L. P. Needle 2
ii. Instrument tray 4
iii. Sponge Holding Forceps 2
22. Oxygen Cylinder Medium 30
23. Oxygen Cylinder Large (‘D’ type) 30
24. Ophthalmoscope 1
25. Heater 1
26. Computer 2
27. Tablet Crusher 1
28. Magnifying glass 1
29. Sleepers 50
30. Hand wash dispenser Equal to no. of beds
31. Medicine Box Equal to no. of beds
32. Torch 2
33. Kidney Tray 30
34. Tracheostomy Set 3
35. Per cutaneous Tracheostomy Set 3
31
3. Furniture (CMS Items) recommended for each unit (Number de-

pending on the bed strength as per following list):

Sl No Item Description
1. Steel Rack 8
2. Chair with arms 12
3. High stool Equal to no. of beds
4. Stool Equal to no. of beds
5. Towel Rack 3
6. Long Table for wards 2
7. Bench without arms 4
8. Table small wooden 3
9. F. C. Armed Chair 4
10. Composite computer unit 2
11. Ward locker Equal to no. of beds
12. Ward Screen Equal to no. of beds
13. Instrument cabinet 4
14. Strecher Trolley 4
15. Steel Almirah without locker 6
16. Steel Almirah with locker 1
17. Rack open all sides 6
18. Steel Locker Cabinet 8 chamber 6
32
XV. Standard List of Medicine & Consumables
The standard medicines & consumables should be available in each Critical

Care Unit and High Dependency Units. Medicine belong to CMS Category
(CAT items) will be purchased from CMS approved firms. Non CMS category
items will be purchased from outside preferably through Fair price Medicine
Shop.
The standard list of medicine & consumables are given below. Some are in-
cluded in CMS catalogue and some are non-CMS. Respective units should
check CAT no from CMS list before procurement.
The amount of medicines & consumables given here are based on assumption
and to help budgeting, it may vary from unit to unit depending on the Bed oc-
cupancy Rate, Bed Turnover Rate, Av. Length of Stay and type of patient ad-
mitted. Proper requirement will be ascertained after functioning of the respec-
tive CCU & proper medicine audit done by the hospital authority.
The following drugs and consumables should be available in every unit and the
amount mentioned in the following lists may be maintained as buffer stock as
far as possible. These are the essential requirement required to make a unit
functional smoothly depending on the bed strength of the respective units. This
is an indicative list only; authority of the individual unit may take local decision
to make inclusion of new drugs and consumables depending on the patient
status, treatment modality and periodic assessment of the requirement by unit
level or State level monitoring teams.
1. Basic Requirement of Medicines:
Requirement for 24
Sl No Name of Medicine bedded unit as
buffer stock
1. Tab Aceclofenac - Paracetamol (Strip of 10) 5
2. Tab Acyclovir 200 (Strip of 10) 10
3. Tab Acyclovir 400 (Strip of 10) 10
4. Tab Alprazolam 0.25 mg (Strip of 10) 5
33
Requirement for 24
buffer stock
5. Tab Amlodipine 5 mg (Strip of 10) 20
6. Tab Apixaban 2.5 mg 20
7. Tab Aspirin 75 mg (Strip of 10) 10
8. Tab Atenolol 50 mg (Strip of 10) 10
9. Tab Atorvastatin 10 mg (Strip of 10) 30
10. Tab Carbimazole 5 mg (Cont of 100) 1
11. Tab Cefpodoxime Proxetil 200 mg (Strip of 10) 5
12. Tab Cefuroxime Axetil 500 mg (Strip of 10) 10
13. Tab Chloroquine Sulphate 500 mg (Strip of 10) 1
14. Tab Clarythromycin 500 (Strip 0f 5) 10
15. Tab Clopidogrel 75 mg (Strip of 10) 10
16. Tab Digoxin (Strip of 10) 1
17. Tab Doxophylline 400 mg (Strip of 10) 10
18. Tab Fluconazole 200 (Strip of 10) 2
19. Tab Frusemide 40 mg (Strip of 10) 1
20. Tab Ivermectin 6 mg 20
21. Tab Levodopa + Carbidopa (Strip of 10) 1
22. Tab Linezolide (Strip of 10) 5
23. Tab Losartan Pot 25 (Strip of 10) 1
24. Tab Losartan Pot 50 (Strip of 10) 1
25. Tab Methyledopa 250 mg (Strip of 10) 1
26. Tab Metoprolol 25mg (Strip of 10) 10
27. Tab Morphine (strip of 10) 1
28. Tab Moxifloxacin 400 mg (Strip of 10) 2
29. Tab Nutrofurantoin 100 mg (Strip of 10) 1
30. Tab Primaquine 7.5 mg (Strip of 10) 1
31. Tab Propranolol (strip of 10) 1
32. Tab Quetiapine 100 mg (Strop of 10) 1
33. Tab Rivaroxaban 10 mg 10
34. Tab Telmisartan (40 mg) 100
35. Tab Thyroxin Na 50 mcg (phial of 100) 2
36. Tab Trihexyphenydil 2 mg (Strip of 10) 1
34
Requirement for 24
buffer stock
37. Syr KCl (50 ml bottle) 30
38. Syr Lactulose 60ml bot 30
39. Syr Sucralfate Suspension (100ml Ph) 30
40. Powder Pre + probiotic (Strip of 10) 30
41. Oin Clotrimazole Mouth Paint 1% (10ml) 20
42. Oin Mupirocin 2% 20
43. Oin Povidone Iodine 5% 5
44. Neb Budesonide (Box of 10) 20
45. Neb Ipratroprium (Box of 10) NebuliserSoln 20
46. Neb Salbutamol (Box of 10) NebuliserSoln 20
47. Lot Chlorhexidine Hand Rub (500ml) 50
48. Lot Chlorhexidine surgical Scrub (100ml) 100
49. Lot Glutaraldehyde 2% (Jar of 5 lt) 10
50. Lot Glutaraldehyde 2.5% (Jar of 5 lt) 10
51. Lot Glutaraldehyde 5% 500 ml (Surface disinfectant) 20
52. Lot Hydrogen Peroxide + Ag Nitrate (Jar of 1 lt) 10
53. Lot Liquid Soap Solution (Jar of 5lt) 5
54. Lot Povidone Iodine 5% (100 ml bottle) 40
Lot Surface Disinfectant formaline / H2O2 based 50

55.
500ml
56. Inj Acetylcystein (vial of 5ml) 10
57. Inj Adenosine (Box of 10) 1
58. Inj Adrenaline (Box of 12) 50
59. Inj Amikacin 500mg 50
60. Inj Aminophylline 250 (Box of 10) 1
61. Inj Amoxyclav 1.2 (Box of 10) 5
62. Inj Amphotericin B 50 mg vial 4
63. Inj Artisunate 60 mg (Box of 10) 1
64. Inj Atracurium (Box of 10) 2
65. Inj Atropine (Box of 100) 5
66. Inj AVS (Box of 10) 5
67. Inj Calcium Gluconate (Box of 50) 4
68. Inj Caspofungin 70 mg 10
35
Requirement for 24
buffer stock
69. Inj Cefepime 1 gm (Box of 10) 5
70. Inj Cefepime 1 gm+Tazobactum 125 mg (Box of 10) 5

71. Inj Cefotaxime 1 gm (Box of 10) 10
72. Inj Ceftazidime 1 gm 20
73. Inj Ceftriaxone 1 gm (Box of 10) 10
74. Inj Cefuroxime Axetil 750 mg (Box of 10) 5
75. Inj Chloroquine Phosphate 200 mg (Box of 10) 1
76. Inj Chlorpromazine (Box of 10) 1
77. Inj Ciprofloxacin 100ml bottle 20
78. Inj Citicoline 500mg 20
79. Inj Clindamycin 600mg (Box of 10) 5
80. Inj Colistin 1 MIU 50
81. Inj Dexamethasone (Box of 10) 5
82. Inj Dextrose 10% 10
85. Inj Diazepam (Box of 10) 1
86. Inj Diclofenac Sodium (Box of 10) 1
87. Inj Dicyclomine (Box of 10) 1
88. Inj Digoxin (Box of 10) 1
89. Inj DNS 50
90. Inj Dobutamine 250 5
91. Inj Dopamine 200 (Box of 10) 10
92. Inj Drotavarine (Box of 10) 1
93. Inj Enoxaparin60 U (Box of 10) 4
94. Inj Enoxaparin 40 U (Box of 10) 5
95. Inj Fentanyl 100 mcg (Box of 10) 5
96. Inj Fluconazole 200 mg/100 ml 10
97. Inj Frusemide (Box of 10) 10
98. Inj GCSF 300 mcg 5
99. Inj Gentamycin (Box of 10) 5
100. Inj Haloperidol (Box of 10) 1
36
Requirement for 24
buffer stock
101. Inj Heparin 5000 (5ml) 100
102. Inj Human Albumin 20% 100ml 10
103. Inj Hydrocortisone Na Succinate (Box of 10) 20
104. Inj Imipenem 1 gm + Cilastatin 1 gm (Box of 10) 10
105. Inj Insulin Mixtard 30:70 (Box of 20 vials) 2
106. Inj Insulin Soluble (Box of 20) 8
107. Inj KCl (Box of 10) 50
108. Inj Labetalol 20mg/2ml (Box of 10) 6
109. Inj Lacosamide 200 mg/20 ml 6
110. Inj Levofloxacin 100ml 40
111. Inj Lignocaine + Adrenaline 1
112. Inj Lignocaine 2% 5
113. Inj Lignocaine 4% 1
114. Inj Lignocard 2% (50ml) (Box of 10) 1
115. Inj Linezolide 10
116. Inj LMWH 2500 (UFH) (Box of 10) 1
117. Inj Mag Sulph 50% (Box of 10) 20
118. Inj Mannitol 20% 50
119. Inj Meropenem 1 gm (Box of 10) 10
120. Inj Meropenem 1 gm Salbactum 0.5 gm (Box of 10) 20
121. Inj Methyl Prednisolone 1 gm (Box of 10) 4
122. Inj Metronidazole 100ml 50
123. Inj Midazolam 10mg/2ml (Box of 10) 20
124. Inj Morphine (Box of 10) 1
125. Inj Nalaxone HCl (box of 10) 1
126. Inj Neostigmine (Box of 12) 1
127. Inj Nitroglycerine 25 mg/5 ml(Box of 10) 4
128. Inj Noradrenaline (box of 10) 100
129. Inj NS 0.9% 200
130. Inj NS 0.9% 100ml 200
131. Inj NS 3% 50
132. Inj Octreotide 100mcg 20
37
Requirement for 24
buffer stock
133. Inj Ondansetron 4 mg / 2 ml (Box of 10) 5
134. Inj Ondansetron 8 mg / 4 ml (Box of 10) 5
135. Inj Pantoprazole 40 mg (Box of 10) 30
136. Inj Paracetamol 100 ml 100
137. Inj Phenobarbitone (Box of 10) 10
138. Inj Phenytoin Na (Box of 10) 30
139. Inj Piperacillin + Tazobactum 4.5 gm (Box of 10) 10
140. Inj Propofol 1% 5
141. Inj Ranitidine (Box of 10) 50
142. Inj RL 20
143. Inj Succinyl choline 1
144. Inj Teicoplanin 200 mg (Box of 10) 5
145. Inj Tenecteplase 40 mg 10
146. Inj Theophylline + Etophylline (Box of 10) 1
147. Inj Tigecycline 50 mg 20
148. Inj Total Parenteral Nutrition (3 chamber) 2000 ml per 15

bag
149. Inj Tramadol (Box of 10) 5
150. Inj Tranexamic Acid (Box of 10) 10
151. Inj Vancomycin (Box of 10) 2
152. Inj Vit B Complex (Box of 20) 10
153. Inj Vit-K 10 mg (Box of 10) 5
154. Inh Levosalbutamol + Ipratropium 20
155. Inh Salmeterol + Fluticasone 10
156. Drp Ciprofloxacin Eye Drop 10
157. Drp Haloperidol 2
158. Drp Normal saline nasal drop 10
159. Drp Oxymetazoline Nasal Drop 10
160. Cap Anti-oxidants (Strip of 10) 1
161. Cap Calcium Carbonate + Vit D3 (Strip of 10) 10
162. Cap Ganciclovir 500 mg (Strip of 10) 2
163. Cap Itraconazole 100 mg (Strip of 10) 10
164. Cap Ramipril 1.25 (Strip of 10) 10
38
Requirement for 24
buffer stock
165. Cap Rifaximin 550 mg (Strip of 10) 2
166. Drp Haemostatic (10ml) 10
167. Drp Methyl Cellulose Eye Drops (10ml) 5
168. Drp Steroid Eye Drop (10ml) 5
169. Gel Enema Practoclys 30
170. Gel Hypochlorite + Hypochloric Acid 2
171. Inf NS 0.45% (Bottle of 500 ml) 25
172. Inj Amiodarone (Amp of 3 ml) 30
173. Inj Cerebrolysate Hydrochloride 60 mg 30
174. Inj Levetiracetam 500 mg 50
175. Inj LOLA (L-Ornithine L-Aspartate) 10 ml 25
176. Inj Methyl prednisolone 40mg 40
177. Inj Methylcobalamin 500mcg 10
178. Inj Sodium Bi Carbonate (Amp of 25 ml) 100
179. Inj Thiamine 100 mg (amp of 2 ml) 10
180. Inj Vasopressin 40 IU 10
181. Liq Waterless Body Bath (100 ml) 5
182. Liq Waterless Shampoo (100 ml) 1
183. Gel Lignocaine 2% 5
184. Gel Water soluble lubricating gel 5
185. Powder Calcium Polystyrene Sulphonate Powder 50
186. Powder Food Supplement (Albumin) (200 gm) 25
187. Powder Food Supplement (Balanced) (400 gm) 25
188. Powder Food Supplement (Diabetic) (400gm) 25
189. Powder Food Supplement (Hepatic) (400 gm) 25
190. Powder Food Supplement (High Calorie) (400 gm) 25
191. Powder Food Supplement (High Protein) (400 gm) 25
192. Powder Food Supplement (Renal) (400 gm) 25
193. Spray Hypochlorite + Hypochloric Acid 2
194. Spray Lignocaine Spray 50ml 2
195. Tab Bisoprolol 2.5mg (Strip of 10) 2
196. Tab Hydralazine 25 mg (Strip of 10) 10
39
Requirement for 24
buffer stock
197. Tab Ivabradine 5 mg (Strip of 15) 10
198. Tab Lasilactone 50 mg (Strip of 10) 10
199. Tab LOLA (L-Ornithine L-Aspartate) (Box of 10) 10
200. Tab Glyceryl Tri Nitrate 2.6 mg (Phial of 30 tabs) 4
201. Tab Sodium Bi Carbonate (Strip of 15) 5
202. Tab Tolvaptan 15 (Strip of 6) 1
203. Tab Vitamin C 500 mg (Strip of 15) 4
204. Cap Nintedanib 100 mg 10
205. Tab Pirfenidone 200 mg 20
2. Basic Requirement of Consumables:
Sl No Name of Consumables Requirement for 24 bedded

unit as buffer stock
1. 3 way I.V. Connector 10cm 60
2. ABG Cal. Solution 2
3. ABG Cassette 80
4. ABG Paper Roll (Pack of 6) 2
5. Adhesive Plaster 10
6. Adult Diaper (Pack of 10) 10
7. Arterial Line 50
8. B. T. Set 60
9. Bed Pan Equal to no. of beds
10. Bed Sheet 14 x no. of beds
11. Binasal Oxygen Cannula (Pack of 100) 1
Bi-pap Mask (Reusable) (Small, medium and

12. Equal to no. of Bi-PAP
large size: vented and non-vented)
13. Blade Surgical No 11 (Box of 12) 2
14. Blade Surgical No 23 (Box of 12) 2
15. Blanket 2 x no. of beds
40

16. Blood collection vials (Plain & EDTA) (Box of100) 20
17. Canvas for Stretcher 6
18. Catheter Foley 50
19. Condom Catheter 50
20. Catheter mount with double swivel elbow 30

21. Chlorhexidine Hand Rub 12
22. Chlorhexidine Mouth Wash 40
23. Closed I. V. Catheter 100
24. Closed Suction Catheter System 30
25. Closed Suction System with MDI Adapter 30
26. Coaxial Bain Circuit 5
27. Cotton Absorbent (400gms) 60
28. Cotton Roll 2
29. Crepe Bandage 10 x 5 30
30. Crepe Bandage 15 x 5 30
31. CVP Manometer 40
32. CVP Transducer compatible with arterial pulse 30
33. Disposable blood Lancet (pack of 200) 2
34. Disposable Cap (Pack of 100) 20
35. Disposable Chest Drain Tube with Trocher 5
36. Disposable Chest Leads 500
37. Disposable Mask (Pack of 100) 10
38. Disposable Plastic Apron 40
39. Disposable Syringe 10ml (Pack of 100) 20
45. Dynaplast 8
41

46. E.T. Suction Catheter (10, 12. 14, 16) 100
47. ECG Gel 6
48. ECG Paper Roll 8

Endotracheal Tube cuffed No 6.0, 6.5, 7.0, 7.5,
49. 1
8.0, 8.5
50. Glucometer with strips (pack of 100) 10
51. Gum elastic bougie 10
52. Hand Care 200
53. Hand Towel 20
54. Hemodialysis catheter As per requirement
55. Humidifier + Bacterial Filter (Pack of 24) 5
56. I.V. Saline Set 300
57. Incentive Spirometer 30
58. Insulin Syringe (pack of 100) 5
59. Jelco No 16G 20

60. Jelco No 18G 50
61. Jelco No 20G 50
62. Jelco No 22G 10
63. Jelco No 24G 5
64. Laryngeal Mask airway (size 2, 3,4) 10
65. i-gel (set of size 2.5, 3, 4, 5) 2
66. Measuring Tape 4
67. Micropore Adhesive 20
68. Molly Sheet (Pack of 10) 20
69. Mucous Extractor 50
70. Nasopharyngeal airway (size 4, 5, 6, 7 mm ID) 5
71. Nebulization Kit 50
72. Nebulization Mask 50
73. Non-rebreathing Mask 30
74. Oropharyngeal Airway (size 1, 2, 3, 4) Equal to no. of beds
75. Oximetry CVC Catheter 4
76. Paraffin Gauge Sterilized 100
42

77. Pigtail Catheter 1
78. Pillow Equal to no. of beds
79. Plastic Bag For Waste Bin 400
80. PM Line 200
81. Radial or femoral artery sensor 10
82. Rolled Bandage (Dozen) 30
83. Rubber Cloth (in meter) 12 meters
84. Ryles Tube (Size 10, 12, 14, 16, 18 FG) 50
85. Sanitary Napkin (Pack of 10) 10
86. Sanitary Towels in PKTs of 10 10
87. Slipper (Pair) 20
88. Spinal Needle 5
89. Spirit 15 Bottle
90. Sputum Mug Equal to no. of beds
91. Sterile Gauge 400

92. Subclavian Catheter Introduction Set 20
93. Suction Tube Extension 10
94. Suprapubic Cystostomy Cannula with Trochar 2
95. Surgical Gloves 6.0 (Dozen Pair) 50
99. Suture Material Catgut 2.0 (Box of 12) 1
100. Suture Material Monofilament 2.0 (Box of 12) 2
101. Temporary Pacing Lead 6F 5
102. Temporary Pacing Sheath 6F/7F 5
103. Test Tube (Pack of 100) 1
104. T-Piece Connector 20
105. Tracheostomy Tube No 7.0, 8.0 20
106. Transperent IV Dressing 100
107. Transpulmonary Thermodilution Cath As per requirement
108. Urine Pot (Female) Equal to no. of beds
43

109. Urine Pot (Male) Equal to no. of beds
110. Urobag 50
111. Urometer 50
112. Ventilator Circuit 20
113. Venturi Mask 1
114. Vibratory Positive Airway Pressure System 10
115. Water Sealed Drain Bag 20
XVI. Essential Tests to be done in CCU 24x7

 Arrangement should be available in every CCU and HDU to perform the following
tests 24 x 7, as these tests are essential to treat a critically ill patient successfully.
These tests should be preferably done by the Laboratory equipment kept in the
CCU / HDU and if MT-CCU is not available, then these emergency tests should be
done by on-duty Medical Officer / Nursing Personnel.
 This list is not an exhaustive one and new tests may be included in this list depend-
ing on the local requirement and functional status of the respective unit.
 Hospital level committee should monitor this and make periodical review regarding
the inclusion of the new tests.
 Laboratory equipment supplied for the respective CCU / HDU should be kept at
the laboratory attached with CCU / HDU to ensure the 24x7 availability, not in the
other places of the hospital.
 Regular availability of the necessary consumables / reagents should be ensured by
the respective Hospital authority along with maintaining the necessary buffer
stocks (for at least15 days) and it is the responsibility of MO in charge & Nursing in
charge of the unit to make aware the respective hospital authority regarding the
stock position of the necessary consumables / reagents as well as the functional
status of the equipment.
 Appropriate quantity of consumables / reagents should be available in the store of
CCU / HDU, so that these are never out of stock at the time of emergency.
44
Name of the essential tests to be done 24x7,
1. Arterial Blood Gas Analysis

2. Complete Blood Count
3. Hemoglobin estimation
4. Sugar (Capillary Blood sugar)
5. Urea
6. Creatinine
7. Electrolytes (Na+, K+, Ca2+, Mg2+)
8. Liver function Test (optional)
9. Antigen Test for Malaria
10. ECG
11. Troponin-T
12. HIV
13. RAT for COVID19
14. Urine for β-hCG (UPT)
15. CRP
16. Procalcitonin (optional)
17. D-dimer
18. NT-Pro BNP (optional)
19. Coagulation profile (optional)
45
XVII. Protocol for Infection control in Critical

Care settings
Hospital acquired infections (HAIs) is a major safety concern for both health care pro-
viders and the patients. Considering morbidity, mortality, increased length of stay and
the cost, efforts should be made to make the Critical care Unit as safe as possible by
preventing such infections.
These short guidelines have been developed for health care personnel involved in pa-
tient care in critical care areas and for persons responsible for surveillance and control
of infections in hospital.
A. Patient at risk of nosocomial infections
There are patients, therapy and environment related risk factors for the development
of nosocomial infections.
i. Age more than 70 years

ii. High severity score
iii. Shock
iv. Major trauma
v. Surgery
vi. Renal failure
vii. Coma
viii. Prior antibiotics
ix. Mechanical ventilation
x. Immunocompromised – including drugs affecting the immune system (steroids,

chemotherapy)
xi. Indwelling catheters
xii. The exposure to multiple invasive devices and procedures
xiii. ICU stay >3 days
xiv. Malnutrition
B. Factors related to inappropriate practices in CCU
i. Inadequate Hand washing facilities.

ii. Frequent contact with patients by health-care personnel.
46
iii. Overcrowding in wards.
iv. Lack of isolation facilities.
v. No separation of clean & dirty areas.
vi. Excessive and non-judicious antibiotic use.
vii. Inadequate decontamination of items &equipments.
viii. Inadequate cleaning of environment.
C. Common CCU acquired infections
i. Ventilator Associated Pneuomonia (VAP) & Tracheobronchitis (VAT)

ii. Non VAP / VAT
iii. IV line associated or Catheter Related Blood Stream Infection( CRBSI)
iv. UTI associated with Foley’s Catheter (CAUTI)
v. Skin & skin structure related infections following necrosis of skin
vi. Surgical site infection (SSI)
vii. Nutritional therapy related Total Parenteral Nutrition (TPN)
D. Sources of Cross-Infection in the CCU
i. Hands of staff and attendants (via two-bowl handwashing and common towels
or no handwashing)
ii. Assisted ventilation equipment;
iii. Suction and drainage bottles
iv. I.V. lines – central and peripheral;
v. Urinary catheters
vi. Wounds and wound dressings;
vii. Disinfectant containers;
viii. Dressing trolleys (on which disinfectants jars/bottles are stored)
E. Strategies to Reduce Infections in CCU / HDU
1. Room sterilization
2. Isolation
3. Universal protocol
4. Device related protocol
5. Equipment sterilization
6. Disposal of waste
7. Procedural
47
1. Room sterilization :
i. Cleaning: Floor wash with available antiseptic ( e.g. Phenyl ) in the morning and
evening , if not once per shift.
ii. Fogging :
 For a general critical care unit it is not mandatory in idealsituation. But as we
are far from reaching ideal and clean condition, it isbetter to undergo fogging
i.e. sterilization by aerosolized disinfectant.
 Target frequency - at an interval of 1 month. Mostly difficult to get CCU/HDU
vacant because of continuous high turnover of patients. Alternative strategy is
to fumigate at the earliest possible time when it can be rendered vacant for a
short period. In CCU – each subunit is to be fumigated one by one. For exam-
ple, if HDU is rendered vacant first, patient care is continued in ICU being shut
off from HDU and vice versa.
 Materials used: Hydrogen Peroxide/ 5% Glutaraldehyde : Preferred, required
room closure for 2 hrs), Device used : Fogger machine.
Fogging by H2O2 11% w/v & Diluted Silver Nitrate 0.01% w/v is done by
mixing 200 ml solution with 800 ml of demineralized water to make 1 lit/
1000 cubic feet. Alternatively 1 ,6 Dihydroxy, 2-5 Dioxahexane 11.2g, Glu-
taraldehyde 5.0g, Benzalkonium Chloride 5.0g, Alkyl Urea Derivatives
3.0g per 100 gm, 10 ml is diluted to make 1 litre solution (1%). Fogging is
done for 60 minutes
2. Isolation:
Of highly infectious cases in isolation cubicle as constructed at least one in
HDU. Examples of cases – Chicken Pox, Measles, HIV, Influenza (particularly epi-
demic & pandemic cases e.g. Swine Flu, Bird Flu), Dengue.
3. Universal protocol : Hand hygiene & Barrier protection:

i. Hand hygiene:
 Hands are the most common vehicle of transmission of organisms and

therefore sinks should be provided for proper hand washing in every CCU /
HDU.
48
 All visitors and staff should wash their hands before direct contact with pa-
tients.
 Aseptic hand wash or alcohol based hand rub should be performed:
 Before entering the ICU.
 Before performing any invasive procedure including peripheral can-
nula insertion and removal.
 Before every use of multidose vials.
 Before administration of iv fluids or medications/drugs
 Routine hand wash should be performed:
 Before and after any contact with the patient
 After touching environmental surfaces
 Whenever soiled.
How to perform a successful hand wash
 Roll up sleeves above elbow.

 Take off wrist watch bangles and rings.
 Ensure no nail polish.
 Wet hands up to elbow with running water.
 Take 5 ml/ one full press of liquid soap in palm.
 Apply soap to cover hand surfaces.
 Rub right palm over left palm with fingers interlaced for 10 seconds.
 Rub left palm over right palm with fingers interlaced for 10 seconds.
 Fingers should remain interlaced during palm to palm rub.
 Palms should touch each other during palm to palm rub.
 Rub right palm over left dorsum for 10 seconds.
 Rub left palm over right dorsum for 10 seconds.
 Palm should touch dorsum during palm to dorsum rub.
 Rub knuckle of left hand with right palm for 10 seconds.
 Rub knuckle of right hand with left palm for 10 seconds.
 Rub thumb of left hand for 10 seconds.
 Rub thumb of right hand for 10 seconds.
 Thumbs should be directed downwards during thumb rub.
 Rub depressed part of left palm with clasped fingertips of right hand for 10
seconds.
49
 Rub depressed part of right palm with clasped fingertips of left hand for 10
seconds.
 Rub left wrist to elbow for 10 seconds.
 Rub right wrist to elbow for 10 seconds.
 Rinse hand with running water.
 Turn the tap off by elbow.
 Staff should count 10 seconds at each step.
Successful hand rubbing technique
 Use an alcohol-based handrube.g. 0.5% chlorhexidine with 70% w/v ethanol, if

hands are not visibly dirty and apply on hands in similar fashion mentioned in
hand wash over 20-30 seconds. A combination of chlorhexidine and alcohol is
ideal as they cover Gram-positive and Gram-negative organisms, viruses, my-
cobacteria and fungi. Chlorhexidine also has residual activity.
 Bare below elbow policy should be followed.
 Finger nails should be trimmed to <0.5 cm with no nail polish or artificial nails
 Avoid wearing long sleeves, ties should be tucked in, house coats are discou-
raged.
ii. Barrier protection
 Slippers, Shoe covers, Cap, Mask, Gown, safety goggles/ face shield.
 Recommended guideline for donning of PPE must be followed.
 Mandatory in isolation cubicle with additional protection in case of epidem-
ic / pandemic.
 Slippers although not required in ideal hospital situation, is to be followed out
in our CCUs/HDUs.
 Cap, mask and gown are mandatory while coming in close contact e.g.
airway toileting, airway procedures – intubation, tracheotomy, Putting a
central line, lumber puncture, putting a chest drain etc. when there is
chance of spillage of tissue of patient.
 Otherwise, all barrier protections are stringently followed in Surgical ICUs par-
ticularly specialty ICUS like NS – ICU, CTVS - ICU.
iii. Details of Personal protective equipments or barrier protection
50
a) Gloves:
 Never wear the same pair of gloves for the care of more than one patient.
 Remove gloves after caring for a patient.
 Practice hand hygiene whenever gloves are removed.
 Wear gloves for handling respiratory secretions or objects contaminated with
respiratory secretions of any patient.
 Wear puncture proof gloves while performing any surgical procedure or admi-
nistering injection to patients suffering from HIV, Hepatitis B, Hepatitis C.
 Change gloves and decontaminate hands, as above:
 Between contacts with different patients.
 After handling respiratory secretions or objects contaminated with secre-
tions from one patient.
 Before contact with object, or environmental surface.
51
 Between contacts with a contaminated body site and the respiratory

tract of, or respiratory device on, the same patient.
b) Gown:
 Wear a gown to prevent soiling of clothing and skin during procedures that are
likely to generate splashes of blood, body fluids, secretions or excretions; or
when exposure to respiratory secretions from a patient is anticipated, and
change it after soiling occurs and before providing care to another patient.
 Plastic aprons may be worn when contact with patient body fluids is antic-
ipated.
 The sterile gown is required only for aseptic procedures and for the rest, a clean,
non-sterile gown is sufficient.
 Remove the soiled gown as soon as possible, with care to avoid contamination.
c) Mask / Eye protection:
 Wear a mask (Disposable high-efficiency filter masks) and adequate eye pro-
tection to protect mucous membranes of the eyes, nose and mouth during pro-
cedures and patient care activities that are likely to generate splashes/sprays of
blood and body fluids, etc.
 Patients, relatives and health care workers (HCWs) presenting with respiratory
symptoms should also use masks (e.g. cough).
4. Device related protocol :
Daily check list is to be maintained in the format as enclosed in the Annexure.
 Peripheral venous catheter :

 Change after every 3 days. If patient comes with PV Cath – in case coming
from Emergency OPD – change immediately and if from the ward – 1st.
change after 24 hrs. Avoid insertion in legs.
 Central venous catheter :

 Not to be changed routinely. Fresh replacement is done in case of strongly
suspected / documented CV cath related infection by C/s test or mechan-
52
ical problems like blockage / kinking. When indicated fresh insertion is done
on the opposite side.
 IV Drip set :
 IV drip sets to be changed every 72 hours. Lipid containing and blood prod-
uct administration sets should be changed every 24 hours. Administration set
for propofol infusion should be changed every 6-12 hours.
 Ryle's tube :
 In case of malfunction or after every 5 – 7 days to avoid formation of biofilm
and thereby preventing pneumonia.
 Tracheostomy tube:
 1st change 48 hrs. of insertion and every after 24 hrs thereafter.
 Foley's catheter :
 Not to be changed routinely.
 It is suggested to change catheters and drainage bags based on clinical
indications such as infection, obstruction, or when the closed system is
compromised.
 Bladder wash is also abandoned except in selected uro-surgical conditions.
In case of catheter block by sediment, controlled catheter wash may be
cautiously tried avoiding bladder wash. These are to avoid vesico-ureteral
reflux and UTI – sepsis.
 Change is indicated in case of malfunctioning catheter or infection strongly
suspected / documented by culture.
 Closed system with two bags - Storage & collecting is preferred.
• Arterial Catheter and Pulmonary Arterial Catheter:

 These catheters need not to be changed routinely.
5. Equipment sterilization
i. Ventilator Circuit:
• For a particular patient on ventilator no tubing is routinely changed.
Changed only when it is visibly contaminated or malfunctioning.
• Disposable tubes are disposed after a single use.
53
• Reusable tubes & water traps are are first cleaned by immersing in detergent
solution for 10-15 minutes and then disinfected before applying on a new pa-
tient – by 2% Glutaraldehyde (Cidex) or 1% hypochlorite solution for ½ hour.
Next they are rinsed thoroughly by immersing in sterile water. No residual
germicide should remain inside circuit. After thorough rinsing, they are air
dried before use. It kills all microbes including HIV.
• Bacterial Filters - Disposables are for single use.
• Humidifier is sterilized along with reusable tubes in 2% Glutaraldehyde solution.
Autoclavable humidifier are sterilized by autoclaving (see manufacturer rec-
ommendation).
• High efficiency heat & Moisture Exchanger Filter(HMEF) when used as an al-
ternative to inbuilt humidifier, is to be changed after every 3 days or earlier if
soiled by secretions.
ii. Endotracheal suction Catheters:

• Closed suction catheters that incorporate a protective sleeve do not need to
be changed every 72 hours. Studies have demonstrated these can safely be
used on the same patient until the device is contaminated or malfunctions.
• More often, disposable suction catheters are used for respiratory tract suc-
tioning. This device should be discarded after each use.
• The water used for flushing the catheter after each suction must be sterile
and changed every time.
• Suction catheters must not be shared between patients.
iii. Endotracheal Tubes:

Disposable endotracheal tubes should be used.
iv. Ambu-bags:
These are used for resuscitation. Ambu-bags are extremely difficult to disinfect
and become contaminated very quickly:
 Parts of Ambu-bag are dismantled before cleaning.
 Cleaning is done by immersing in detergent solution for 10-15 minutes.
• Heat is the most reliable method of disinfection; 2% glutaraldehyde is a less ac-
ceptable method.
54
• The bags must be rinsed thoroughly in sterile water after immersion in glutaralde-
hyde. This will reduce the risk of chemical irritation, which can itself precipitate
respiratoryinfection.
iv. Oxygen Delivery masks:
These can be disposable or reusable;

• Disassemble before cleaning.
• Wash thoroughly using detergent solution.
• Soak in mask with 70% isopropyl alcohol for5 minutes or soak in hypochlorite (500
ppm) for 3 minutes or 3% H2O2 for 30 minutes; rinse, dry and store.
• Disposable oxygen delivery masks should be preferred in critical care settings.
v. Suction & drainage bottles:

These are usually disposable, with a self-sealing inner container held in a clear
plastic outer container.
Non-disposable bottles:
• Must be changed every 24 hours (or sooner if full).
• The contents may be emptied down the Effluent treatment plant.
• Must be rinsed and autoclaved.
• Do not leave fluids standing in suction bottles.
6. Transport of sterilized equipment from CSSD to CCU

Transport of instruments, equipments, linen, autoclave drums and trays be-
tween CCU and CSSD must be done by using covered CSSD trolleys only.
7. Disposal of waste :
 Disposal protocol should be followed differently for general waste (concern is

not more than household waste), cytotoxic waste, pharmaceutical waste,
chemical waste and radioactive waste.
 For blood spillage in the unit, cleaning should be done at the earliest with paper
towels followed by water and detergents.
 Laboratory spillage should be absorbed on to paper towels and disposed of as
clinical waste. Small blood spill should be disinfected with 1% hypochlorite and
55
left for 30 minutes. Large blood spill should be disinfected with 10% hypochlorite
and left for 30 minutes.
 It has been observed that HBV and HCV in dry blood remain infectious even
when exposed to external environment for up to a week and 16 h respectively.
 Implications remain the same even if blood is invisible or not present in sufficient
quantity. Considering this, glucometers should be cleaned and disinfected filter
every use to avoid contamination.
 Caution board for wet floor, mercury spill and blood spill should be made avail-
able in CCU.
8. Procedural Care :
Procedures requiring aseptic technique(Intravenous Therapy, Urinary Catheterization &
Respiratory Care Equipment /Practices)
i. IV care practices.
ii. Respiratory care - Patient-Based Interventions.
i. IV care practices:
 Clean injection ports with 70% alcohol or an iodophor before accessing the sys-
tem.
 Cap all stopcocks when not in use.
 Use aseptic technique including a cap, mask, sterile gown, sterile gloves and a
large sterile sheet for the insertion of central venous catheters (including Peri-
pherally Inserted Central Catheter or PICCs) or guidewire exchange.
 Do not routinely replace central venous catheters, hemodialysis catheters, or
pulmonary artery catheters.
 Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judg-
ment regarding the appropriateness of removing the catheter if infection is
evidenced elsewhere or if a noninfectious cause of fever is suspected.
 Do not routinely replace peripheral arterial catheters.
ii. Respiratory care - Patient-Based Interventions:
 If there is no medical contraindication, elevate the head of the bed of a pa-

tients who are at high risk for aspiration pneumonia, e.g., a person receiv-
56
ing mechanically assisted ventilation and/or who has an enteral tube in place,
at an angle of 30 degree.
 Periodically drain and discard any condensate that collects in the tubing of a
mechanical ventilator, taking precautions not to allow condensate to drain to-
ward the patient. Decontaminate hands with soap and water or a waterless
antiseptic agent after performing the procedure or after handling the fluid.
 If available, use an endotracheal tube with a dorsal lumen above the
endotracheal cuff to allow drainage (by continuous suctioning) of tracheal se-
cretions that accumulate in the patient's subglottic area.
 Use sucralfate, H2-blockers, PPIs and/or antacids interchangeably for stress-
bleeding prophylaxis in a patient receiving mechanically assisted ventilation
(H2-blockers alone decrease gastric acidity and increase gastric colonization
and increases the susceptibility to respiratory infections).
 Instruct preoperative patients, especially those at high risk of contracting
pneumonia, regarding taking deep breaths and ambulating as soon as medi-
cally indicated in the postoperative period. High-risk patients include those who
will have an abdominal, thoracic, head or neck operation or who have sub-
stantial pulmonary dysfunction.
 Follow manufacturers' instructions for use and maintenance of wall oxygen hu-
midifiers.
 Between patients, change the tubing, including any nasal prongs or mask used
to deliver oxygen from a wall outlet.
 Small-volume medication nebulizers: "in-line" and hand-held nebulizers: Be-
tween treatments on the same patient, disinfect; rinse with sterile or pasteurized
water; and air-dry small-volume in-line or hand-held medication nebulizers.
 Use only sterile or pasteurized fluid for nebulization and dispense the fluid into
the nebulizer aseptically.
 If multidose medication vials are used, then handle, dispense, and store them
according to manufacturers' instructions using sterile techniques.
 Total Parenteral Nutrition to be infused through central line and not beyond 12
hrs at a time.
57
F. Specific strategies focused on prevention of transmis-

sions of infections to patient cared for in the CCU / HDUs
I. Personnel
1. All personnel should follow the Standard Precautions policy.

2. Report all sharp injuries as described in the Management of healthcare workers
with blood exposure policy.
3. Admit only authorized personnel with a specific purpose.
4. Ensure personnel wear proper protective equipment during contact with pa-
tient, particularly when performing an invasive procedure. This includes the use
of disposable long sleeved gown or plastic aprons. masks, gloves and goggles,
if necessary.
5. Practice aseptic technique when performing a dressing change, or wound /
incision care. Dressings heavily soaked with blood should be properly bagged
and placed in the biohazard waste receptacle.
6. Prohibit eating, drinking and smoking in patient care areas.
7. Do not bring HCW's personal belongings into patient care areas. Deposit them
in lockers provided in the staff rooms.
8. Use stethoscopes that are provided for each bed.
9. Close doors leading to CCU / HDU and the patient's rooms.
II. Patients
1. Admit all patients according to the prevailing admission policy of the CCU /
HDU.
2. It is the responsibility of the attending physician to notify the Nurse in-charge of
the CCU / HDU if the patient has an infectious disease. He or she should also
decide on the isolation category and document this in the case notes.
3. If possible, keep the infected patient in isolated area / room.
4. Thoroughly clean and disinfect the beds and its contents when a patient with
an infectious disease is discharged from the CCU / HDU.
5. Limit personal belongings of patients in CCU / HDU.
6. Do not bring flowers and plants into cubicles or rooms.
III. Visitors
1. Visitors must report to the reception counter before seeing a patient.
58
2. Visitors should wash their hands with soap and water/ alcohol based hand rub
before entering CCU.
3. Design of the unit should permit staff to assess visitors for communicable disease
(eg, rash, respiratory infection) before permitted to enter unit.
4. Instruct visitors for patients nursed in isolation rooms on the appropriate precau-
tions such as hand hygiene, use of masks, and disposal long sleeve gown.
5. Encourage visitors of patients to adhere to the hospital's visiting hours. Excep-
tions to this include:
a. If death is imminent (as determined by the attending physician) the fam-
ily may be at the bedside
b. Patient is on the dangerously ill list ("DIL")
c. If the patient is a child, a parent may be permitted at the bedside.
6. All other visitors (e.g. medical students, sales representatives) to the unit must
obtain consent from the Nursing in charge. Identify such visitors with name tags
and instructed properly on Standard precautions, if necessary. Do not conduct
routine tours in the CCU / HDU.
7. Discourage children (<12 years of age) from frequent visitations in CCU / HDU,
particularly if the patient has an infectious disease.
8. Allow maximum one visitor for a patient at one time.
9. Discourage visitors who appear to be ill from visiting patients in CCU / HDU.
IV. Environment
1. Keep floors free of dirt, stains and spills at all times. Wet mop floors once a shift,
following housekeeping procedures.
2. Keep all large trash receptacles properly covered.
3. "Roll off' the bed all soiled linen to prevent unnecessary dispersal of organisms.
Properly bag soiled linen before sending them for laundry.
4. Do not transport central store and linen trolleys through patient care areas.
Store them in a designated clean area.
5. Clean preparation rooms at least once a day.
6. Keep store rooms neat and tidy and clean them on a regular basis.
7. Clean the clean and dirty utility rooms at least once a day. Store all housekeep-
ing equipment in a designated area in the dirty utility room.
8. Wipe down all counter tops once a day or when soiled.
9. Do all cleaning with a hospital-approved disinfectant solution.
59
10. Rodent and pest control should be arranged once every fortnight.
V. Equipment
1. Monitoring equipment should be personal to a patient for the duration of ICU

stay.
2. Clean all blood pressure cuffs, ECG cables, pulse oximeter sensors etc. with a
hospital approved disinfectant after each patient use, or if they are contami-
nated.
3. Clean monitors, ventilators and other equipment once daily.
4. Transfer respiratory care consumables, such as masks, nasal prongs with each
patient as needed and discard them when they are no longer necessary.
5. Clean medication carts at least once a day.
6. Clean other equipment such as drug refrigerators, chairs and other furniture at
least once a week or more often when necessary. Defrost refrigerator once a
week.
7. Do all cleaning with a hospital-approved disinfectant.
VI. Endotracheal
1. Perform suctioning of intubated, mechanically ventilated patients only as

needed. Too frequent or excessive suctioning may irritate the tracheobronchial
tree and possibly lead to an infection.
2. Change the suction tubing every 24 hours.
3. Use closed suctioning system for selected patients e.g. TB, patients with multi-
resistant bacteria isolated from respiratory secretions.
4. Follow manufacturer's recommendation on frequency of change.
VII. Ventilator
1. Humidifier chamber
a. For humidifier chamber using close circuit dripping method, the partially
filled reservoir can be changed with the breathing circuit every 48 hours.
2. Ventilator circuit
a. Do not change the ventilator circuit routinely that is in use on an individ-
ual patient. The circuit should incorporate a bacterial-viral filter. Change
the circuit when it is visibly soiled or mechanically malfunctioning. Dis-
60
posable circuit is recommended for pulmonary tuberculosis and other

patients suffering from respiratory infections.
b. Place ventilator circuit used on infectious patient in orange coloured
bags before sending to CSSD.
c. Place ventilator circuit filters at the expiratory limb of the circuit.
3. Ventilator breathing circuits with HME
a. Change an HME that is in use on a patient when it malfunctions me-
chanically or become visibly soiled.
b. Do not routinely change more frequently than 48 hours an HME that is in
use on a patient or as per manufacture recommendation.
VIII. Infection control measures related to the use of disposable manual resuscitator
1. Prior to the first use, check that the seal is intact and that the resuscitator is not
expired.
2. When not in use, ensure manual resuscitator is kept clean.
3. Restrict the use to single patient. Do not share among patients. Do not send for
reprocessing.
4. Discard the resuscitator when
a. the resuscitator is no longer required
b. the resuscitator is grossly contaminated or the soils could not be cleaned
c. the patient is transferred out from isolation room
IX. Respirometer
1. Use extension piece to connect respirometer to Endotracheal tube. Do not

connect respirometer directly to Endotracheal tube.
2. Use filters for infectious patients e.g. MRSA.
3. Disinfect respirometer every 72 hours and between each patient's use.
X. Fluids and medications
1. Use only sterile fluid for nebulizer or humidifier.

2. Discard any unused sterile fluid after each use.
XI. Portable transport ventilator
1. Change circuit with filter after every patient's use.
61
2. Change the filter between patient's use if the circuit cannot be changed.
XII. Care of other equipment
1. Change/discard nasal prongs, venturi mask after each use.

2. Discard left over medication of nebulizers after each patient's use.
3. Humidifiers/Nebulizers.
a. Change every 24 hours or when the heat moisture exchanger gets con-
taminated with respiratory secretion e.g. Palls, Humivent.
b. Use only sterile fluid for humidifier.
c. Discard any unused sterile fluid in the bottle after 24 hours.
G.Specific strategies focused on prevention of specific no-

socomial infections
In addition to the standard and transmission-based precautions, there are several

strategies focused on prevention of specific nosocomial infections in critically ill pa-
tients. Of these, ventilator-associated pneumonia (VAP), catheter-related blood-
stream infection (CRBSI) and urinary tract infection (UTI) are the most important.
1. Strategies to reduce ventilator-associated pneumonia (VAP)
 Avoid intubation whenever possible.
 Consider noninvasive ventilation whenever possible.
 Prefer oral intubations to nasal unless contraindicated.
 Keep head elevated at 30-45° in the semi-recumbent body position.
 Daily oral care with chlorhexidine solution of strength 0.12%.
 Daily sedation vacation if feasible and assessment of readiness to extubate.
 Avoid re-intubation whenever possible.
 Routine change of ventilator circuits is not required.
 Monitor endotracheal tube cuff pressure (keep it 20-30 cm H2 O) to avoid air
leaks around the cuff, which can allow entry of bacterial pathogens into the
lower respiratory tract.
 Prefer endotracheal tubes with a subglottic suction port to prevent pooling of
secretions around the cuff leading to micro-aspiration.

 Closed endotracheal suction systems may be better than the open suction.
62
 Periodically drain and discard any condensate that collects in the tubing of a
mechanical ventilator.
2. Strategies to reduce Catheter-Related Blood Stream Infection or

CRBSI.
 Prefer the upper extremity for catheter insertion. Avoid femoral route for central
venous cannulation (CVC).

 If the catheter is inserted in a lower extremity site, replace to an upper extremity
site as soon as possible.

 Use maximal sterile barrier precautions (cap, mask, sterile gown and sterile
gloves) and a sterile full-body drape while inserting CVCs, peripherally inserted
central catheters, or guidewire exchange.
 Clean skin with more than 0.5% chlorhexidine preparation with alcohol (usually
2% chlorhexidine with 70% w/v ethanol) before CVC, arterial catheter insertion,
etc.
 Use chlorhexidine/silver sulfadiazine or minocycline/rifampin-impregnated
CVCs when the catheter is expected to remain in place for more than 5 days
and only if the bloodstream infection rates are high in the unit despite success-
ful implementation of measures to reduce CRBSI
 Use ultrasound-guided insertion if technology and expertise are available.
 Use either sterile gauze or sterile, transparent, semi permeable dressing to cover
the catheter site. Replace the catheter site dressing only when the dressing
becomes damp, loosened, or visibly soiled.
 Evaluate the catheter insertion site daily and check if a transparent dressing is
present and palpate through the dressing for any tenderness.

 Insertion date should be put on all vascular access devices.
 Use 2% chlorhexidine wash daily for skin cleansing to reduce CRBSI.
 Clean injection ports with an appropriate antiseptic (chlorhexidine, povidone-
iodine, an iodophor, or 70% alcohol), accessing the port only with sterile de-
vices. Cap stopcocks when not in use.
 Assess the need for the intravascular catheter daily and remove when not re-
quired.
 Peripheral lines should not be replaced more frequently than 72-96 hr (if not in-
dicated otherwise). Routine replacement of CVCs is not required.
63
 Replace administration sets, including secondary sets and add-on devices,
every day in patients receiving blood, blood products, or fat emulsions.

 If other intravenous fluids are used, change not <96-h intervals and at least
every 7 days.
 Needleless connectors should be changed frequently (every 72 h).
 Replace disposable or reusable transducers at 96-h intervals.
3. Strategies to reduce CAUTI
 Insert catheters only for appropriate indications.

 Follow aseptic insertion of the urinary catheter.
 Maintain a closed drainage system.
 Maintain unobstructed urine flow. At all times the urinary catheter should be
placed and taped above the thigh and the urinary bag should hang below the
level of the bladder.
 The urinary bag should never have floor contact.
 Changing indwelling catheters or drainage bags at fixed intervals is not rec-
ommended. Change only if there are clinical indications such as infection or
obstruction, or when the closed system is compromised.
 Remove the catheter when it is no longer needed.
H. Patients needing ICU care should be assessed for:

• Diarrhea,
• Rashes or skin conditions;
• Recognized communicable disease;
• Known carrier of an epidemic strain of bacterium;
• Isolation: Patients suspected or known to have communicable diseases should
be admitted directly to an isolation cubicle in the ICU or referred to a Fever
Hospital.
I. Regarding Health care workers in CCU:
 All staff working in the unit should be offered hepatitis B vaccine before begin-
ning work in the unit.
64
 PEP for HIV should be available round the clock.

 Orientation to the unit should include basic infection control concepts that in-
clude hand hygiene, management of sharps, and associated risks of disease
transmission.
 Training and education should include formal and informal infection control
lectures and assessment of practices through periodic observations.
 Annual health checkup of staffs should be arranged.
J. Environmental Factors and CCU Design Related Issues for

prevention of transmission of Infections:
Unit Design should consider the following
1. Space
2. Ventilation of the unit
3. Traffic flow
4. Visitors
5. Non-ICU Staff
1. Space
i. Beds:
 The beds should be adequately apart (at least 4’ space should be available
between adjacent beds and at least 3’ at the head and foot ends), to al-
low free movement of staff and equipment, reducing risk of cross contami-
nation.
ii. Partitions:
 Privacy partitions should be made of such type of material that is easily cleaned
and should be cleaned weekly and any time that it becomes soiled or contami-
nated. If curtains are used, they should be changed weekly.
iii. Toilets:
 Preferably be located outside the patient care area of ICU.
65
iv. Medication preparation:

 Medication preparation areas should be separate from patient care areas and
should be maintained as a clean area.
v. Clean storage:
 An area should be identified and maintained for clean storage and should
be separate from care and waste disposal areas.
vi. Soiled and waste storage:

 An area should be identified for storing collected bedside waste and should
be maintained separate from direct care and clean medication areas.
Ideally, this area should have aneffluent treatment plant for the disposal of
blood and body fluid waste. The area should include storage of filled sharps
containers until these containers can be removed.
 Daily removal of Municipal solid waste and biomedical waste from CCU is
recommended and process should be supervised by designated Assistant
Superintendent (NM).
vii. Surface & Floor Cleaning

 Frequency of cleaning should be as follows: Surface cleaning (walls) twice
weekly, floor cleaning at least once per shift and terminal cleaning (patient
bed area) after discharge or death. Cobweb and air-conditioners should be
cleaned weekly. Fans should be cleaned once a month.
viii. Waste disposal and spillage:

 Already discussed
2. Ventilation of the unit
i. Type:
 The source of clean air should be determined including central or through
- the –wall air conditioning units.
ii. Windows:
 Windows should remain closed in order to control all airborne risks; plants
and flowers should be kept outside the CCU.
66
• Sinks and alcohol based Handrub Dispensers:

 Sinks should be placed near the CCU entrance and if this is not feasible,
alcohol based handrub dispensers should be available at the CCU en-
trance and at each bedside. If the design permits scrub sinks, it should be
installed.
 An adequate number of easily accessible Elbow/Foot operated taps
should be available. Sinks should not be plugged or used for storage.
 Sinks assigned for hand washing should not be using for washing instru-
ments.
3. Traffic flow
i. The unit may be situated close to the operation theatre and to the emer-
gency department for accessibility with a dedicated separate entrance,
but should be separate from the main ward areas.
ii. Policies should consider controlling traffic flow to and from the unit in order
to reduce sources of contamination from visitors, staff and equipment.
4. Non-ICU Staff
Staff not assigned to the ICU should follow the following protocol:
i. Street coats and white coats must be removed;

ii. Hands should be washed on entering the ICU and before leaving the unit.
iii. The proper procedure should be followed when attending the patient.
67

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Memo No. HFW-13099/1/2022-SPSRC SEC-Dept. of H&FW/410 Dated:-27.06.

Department of Health & Family

Government of West Bengal has prioritized to minimize out of pocket expendi-

Version 1.0 of Hybrid CCU Guideline is introduced with a number of changes

This operational guideline includes information on various aspects that

One of the premier achievements of Department of Health & FW is to set up Critical

i. Identification of location, no. of units and category of development

VI. Human Resource Standards

dent in CCU related administrative matters.

VII. Job responsibilities of different Human Resources

i. Medical Officer in Charge:

ii. Medical Officers:

iii. Nursing- in-charge:

iv. Nursing Personnel:

 Basic Life Support

dialysis unit if needed.

vi. Hospital Assistant:

vii. General Duty Attendant:

xiii. Bio-medical engineers:

VIII. General Instruction regarding Patient management:

i. Patients in the CCU should be admitted under respective Bed-in-charges of dif-

replaced by faculty and Postgraduate trainees of Medicine & Anesthesiology

IX. Hospital level Supervision & Monitoring

d. Supervising Officer (Anesthetist) of the unit as member,

1. Equipment including Laboratory equipment present in the CCU should be pri-

1. A web based e management & information software programme named ‘Crit-

XII. Training of HR for CCU

i. Medical Officer will be imparted a short course training on Critical Care of 8

Detailed training plans are given below,

A. Primary Training Plan for Medical Officers

1. Training Centers for Medical Officers: At present, Department of Critical Care

2. Duration: Eight weeks (48 working days)

3. Number of trainees: 10 - 15 per batch

5. Training methodologies: Lectures, Demonstrations, Practical (Hands-on Train-

6.2. Procedural skills (Training method: Hands-on): (a) Maintenance of open

7. Following subjects will be incorporated in the 48 days’ training session.

B. Short Term Training for Specialist Medical Officers

7.1. BLS and ACLS

C. Plan of training for Nursing Staff on CCU

1. Training Centers: Department of Critical Care Medicine of IPGMER and SSKMH

3. Number of trainees: 15 - 20 per batch

4. Learning objectives: After completion, in addition to routine usual nursing care

5. Training methodologies: Lectures, Demonstrations, practical (Hands-on Train-

A. Specific credentials (Training method: Hands-on): Basic Life Support (BLS)

(a) Recognition of (12 sessions of Lecture/Demonstration): (i) Respiratory Failure;

of common ECG abnormalities in intensive care; (ix) Cardiovascular medi-

(b) Application of (10 sessions of Lecture/Demonstration): (i) Bedside assess-

XIII. Technical aspects for 24 bedded Hybrid CCU

• Additional Space: 100 – 150% of Pt. care area

• Inside the sterile zone:

• Outside the sterile zone but within the CCU complex

 Wall fixed rack in lab room ‘L’ shaped to keep machines.

zone) should be there.

 Additional electric board to be established on the wall at the back of central

sion for teleconferencing.

 Annual Maintenance of the whole Unit from electrical part is must.

 Fully A/C – Controlling – Temp. / Humidity. Preferably Split A/C.

 Temperature maintained = 16 – 250 Celsius

 Humidity should be <70%.