Concepts of Critical Care: Gamar Akalal Sugala Clinical Resource Nurse

CONCEPTS OF CRITICAL CARE
GAMAR AKALAL SUGALA

Clinical Resource Nurse
Introduction :
Critical / Intensive Care Unit

is a specially designed and
equipped facility staffed by
skilled personnel to provide
effective and safe care for
dependent patients with a life
threatening problem
It is the Home of an Organization

Critical Care Nursing Critical Care Nurses
A licensed Professional
Nurse
Certified CCN
Job Training CCN
specialty within nursing

that deals specifically with
human responses to life-
threatening problems.
Seven Cs OF CRITICAL CARE
1.Compassion
2.Communication
3.Consideration
4.Comfort
5.Carefulness
6.Consistency
7.Closure
Aim of an Intensive / Critical Care
To provide care such that patient improves and survives

the acute illness or tides over the acute exacerbation of
the chronic illness.
Evolution of Critical Care
Historical Perspectives
Florence Nightingale recognized the need to

consider the severity of illness in bed allocation of
patients and placed the seriously ill patients near
the nurses’ station.
1923:
• John Hopkins University Hospital developed a
special care unit for neurosurgical patients
• Recovery room started
1950:
• The epidemic of poliomyelitis necessitated thousands of
patients requiring respiratory assist devices and intensive
nursing care
1953:
• Manchester Memorial Hospital opened a four bedded unit
at Philadelphia was started.
1957:
• 20 units in USA
1958
• Number increased to 150.
During 1970’s, the term critical care unit came

into existence which covered all types of
special care
Union Benevolent Association on the corner of Lyon Street and College
Avenue, 1886
1970’s
Types of Critical / Intensive
An Open :
Physicians admit, treat and discharge
A Closed:
The admission, discharge and referral policies
are under the control of intensivists.
CORE COMPONENTS OF AN ICU
1. CONSTANT MONITORING
2. RAPID SKILLED INTERVENTION
3. MULTI DISCIPLINARY TEAM

WORK
LEVELS OF ICU CARE
• LEVEL I
Provides monitoring, observation and
short term ventilation.
• Level II
Provides observation, monitoring &
long term ventilation with resident
doctors.
• LEVEL III
Provides all aspects of intensive
care including invasive haemo
dynamic monitoring & dialysis.
DESIGNING AN ICU
Critical Care Team
Who ?
 Medical Staff
 Nursing Staff
 Head Nurse
 Head of Department
 Respiratory Therapist
 Physician Subspecialists
 Support Collaboration
Staff
 Infection Control Team
 Quality Team
 Others
PERSONNEL
• NURSE PATIENT RATIO – 1: 1.
Critical Care Nurse

1. RN (registered nurse) with a BSN or
preferably an MSN degree.
2. Certification in critical care or equivalent
graduate education with at least 2 yrs.
experience working in a critical care unit.
Critical Care Nurse
• EXPERIENCE WITH HEALTH
INFORMATION SYSTEMS, QUALITY
IMPROVEMENT/RISK MANAGEMENT
ACTIVITIES, AND HEALTHCARE
ECONOMICS.
• ABILITY TO ENSURE THAT

CRITICAL CARE NURSING PRACTICE
MEETS APPROPRIATE STANDARDS.
Critical Care Nurse
• ABILITY TO FOSTER A COOPERATIVE

ATMOSPHERE WITH REGARD TO THE
MULTIDISCIPLINARY TRAINING
PERSONNEL INVOLVED IN THE CARE
OF CRITICAL CARE UNIT PATIENTS.
Critical Care Nurse
• REGULAR PARTICIPATION IN ONGOING
CONTINUING NURSING EDUCATION.
• KNOWLEDGE ABOUT CURRENT

ADVANCES IN THE FIELD OF CRITICAL
CARE NURSING.
• PARTICIPATION IN STRATEGIC
PLANNING AND REDESIGN EFFORTS
MEDICAL STAFFING – COVER FOR EVERY
SHIFT WITH COMPETENCE TO HANDLE
ANY EMERGENCY.
ANCILLARY STAFF – THERAPISTS,

TECHNICIANS, RADIOGRAPHERS etc.
RECEPTIONIST, CHAPLAIN /
COUNSELLOR.
 Recruitment Process
 Screening Staff Qualification
 Competency Checklist
 ICU/CCU Preparation
- ICU Organization – Set Strategy Plan
/ Goal and Values
- Development of Scope of Service
- Develop Policy and Procedure
Guide / Protocol
- ICU /CCU Admission /
Discharge
Newly Hired Staff –
Orientation Program
Probationary / Annual
Appraisal
Staff Continue Education
Council Registration and
Licensing
PERSONNEL DEVELOPMENT
IN SERVICE EDUCATION PROGRAMMES
DEBRIEF SESSIONS – TO BURN OUT
TEAM BUILDING EXERCISES
INVOLVEMENT IN POLICY
DEVELOPMENT
LOCATION ???
• Should be a geographically distinct

area within the hospital, with
controlled access.
• No through traffic to other
departments should occur. Supply
and professional traffic should be
separated from public/visitor
traffic.
• Location should be chosen so that
the unit is adjacent to, or within
direct elevator travel to and from,
the Emergency Department,
Operating Room, Intermediate care
units, and the Radiology
Department.
BED STRENGTH
• IDEALLY 8 TO 12 BEDS (14) 5 10-14 (ccu) 1-
9 (
• 3 TO 5 BEDS PER 100 HOSPITAL BEDS

FOR A LEVEL III ICU / 2 TO 20% OF THE
TOTAL NUMBER OF HOSPITAL BEDS
• 1 ISOLATION BED FOR EVERY 10 ICU BEDS

BED SPACE & BEDS
• 150 – 200 SQUARE FEET PER OPEN BED
WITH 8 FEET IN BETWEEN BEDS.
• 225 – 250 SQUARE FEET PER BED IF IN A

SINGLE ROOM.
• SINGLE ROOM – WITH AN ANTEROOM (20

FEET) FOR HAND WASHING, GOWNING etc
• BEDS - ADJUSTABLE, NO HEAD BOARD,

SIDE RAILS AND WITH WHEELS.
• HAND RINSE SOLUTION BY EACH
BEDSIDE.
• EQUIPMENT SHELF AT THE HEAD

END (MIND THE HEIGHT OF THE
CARE GIVER).
INFRASTRUCTURE
• Patients must be situated so that direct or
indirect visualization by healthcare providers is
possible at all times.
• The preferred design is to allow a direct line

of vision between the patient and the central
nursing station.
• Modular design – sliding glass doors &

partitions to facilitate visibility.
ENVIRONMENT
PREVENTING SENSORY OVERLOAD
•SIGNALS & ALARMS

• Needs to be modulated.
•FLOOR COVERINGS AND CEILING

• With sound absorption properties.
•DOORWAYS – OFFSET TO MINIMISE SOUND

TRANSMISSION.
•LIGHT & SOFT MUSIC

• Focused and central lighting
NATURAL ILLUMINATION AND VIEW
1. Windows are an important aspect of

sensory orientation; helps to
reinforce day/night orientation.
2. Window treatments should be durable
and easy to clean, and a schedule for
their cleaning must be established.
ADDITIONAL APPROACHES TO
IMPROVING SENSORY
ORIENTATION FOR PATIENTS
1. May include the provision of a
clock, calendar, bulletin board,
and/or pillow speaker connected
to radio and television.
UTILITIES
• ELECTRICAL – ADEQUATE SOCKETS (5AMPS &
15 AMPS), GENERATOR SUPPLY & BATTERY
BACK UP.
• MEDICAL GAS & VACUUM PIPELINE – COLOUR

CODED AND NOT INTERCHANGEABLE.
• HANDWASHING AREAS –
UNINTERRUPTED WATER SUPPLY,
DISPOSABLE PAPER TOWELS / HAND
DRIER. (NO CLOTH TOWELS PLEASE)
• TELEPHONES & COMPUTERS FOR

COMMUNICATION.
• CLEAN AND A DIRTY UTILITY WITH
NO INTERCONNECTION.
• SHELVING & CABINETS OFF THE

GROUND FOR STORAGE.
• WASTE & SHARPS DISPOSAL.

• WORK AREAS AND STORAGE FOR
CRITICAL SUPPLIES SHOULD BE
LOCATED IMMEDIATELY ADJACENT
TO EACH ICU.
MEDICATION AREA
• AT LEAST 50 SQUARE FEET
CONTAINING A REFRIGERATOR FOR
PHARMACEUTICALS,
• WITH LOCKING SAFE FOR
CONTROLLED SUBSTANCES
• A TABLE TOP FOR PREPARATION OF
DRUGS AND INFUSIONS.
EQUIPMENT
MONITORING EQUIPMENT
THERAPEUTIC EQUIPMENT
DIGITAL & ANALOGUE DISPLAY
AUDIO & VISUAL ALARMS
BATTERY BACK UP & CHARGING

POLICIES & PROTOCOLS
• ADMISSION,
DISCHARGE &
WITHDRAWAL
OF SUPPORT.
• LEGAL & ETHICAL

GUIDELINES
• ORGAN
DONATION.
INFECTION CONTROL
• SURVEILLANCE
• STERILIZATION & DISINFECTION
• QUALITY CONTROL & AUDITING

DOCUMENTATION
• CONVENTIONAL
• ELECTRONIC MEDICAL RECORDS (EMR)
Bedside terminals
Interfaced with existing hospital data

Systems, data retrieval (laboratory
Results, x-ray reports, etc.).
Remote data transmission capabilities

(to offices, on-call rooms, etc.)
OTHER FACILITIES
• BEREAVEMENT & AFTER CARE
SERVICES
• COUNSELLING
• SUPPORT SYSTEMS FOR PATIENT

RELATIVES & STAFF
REFERENCES
Guidelines for Intensive Care Unit Design –
Crit Care Med 1995 Mar; 23(3):582-
588.
John, G. Essentials of Critical Care, Edition IV,

(2003), Shakti Prints, Vellore.
Worthley, L.I.G. Clinical Examination of the

Critically Ill Patient, Edition II, (2000), The
Australasian Academy of Critical Care Mediicne,
South Australia.

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CONCEPTS OF CRITICAL CARE

GAMAR AKALAL SUGALA

Critical / Intensive Care Unit

It is the Home of an Organization

specialty within nursing

To provide care such that patient improves and survives

Florence Nightingale recognized the need to

During 1970’s, the term critical care unit came

2. RAPID SKILLED INTERVENTION

3. MULTI DISCIPLINARY TEAM

Critical Care Nurse

• ABILITY TO ENSURE THAT

• ABILITY TO FOSTER A COOPERATIVE

• KNOWLEDGE ABOUT CURRENT

ANCILLARY STAFF – THERAPISTS,

DEBRIEF SESSIONS – TO BURN OUT

TEAM BUILDING EXERCISES

• Should be a geographically distinct

• 3 TO 5 BEDS PER 100 HOSPITAL BEDS

• 1 ISOLATION BED FOR EVERY 10 ICU BEDS

• 225 – 250 SQUARE FEET PER BED IF IN A

• SINGLE ROOM – WITH AN ANTEROOM (20

• BEDS - ADJUSTABLE, NO HEAD BOARD,

• EQUIPMENT SHELF AT THE HEAD

• The preferred design is to allow a direct line

• Modular design – sliding glass doors &

•SIGNALS & ALARMS

•FLOOR COVERINGS AND CEILING

•DOORWAYS – OFFSET TO MINIMISE SOUND

•LIGHT & SOFT MUSIC

1. Windows are an important aspect of

• MEDICAL GAS & VACUUM PIPELINE – COLOUR

• TELEPHONES & COMPUTERS FOR

• SHELVING & CABINETS OFF THE

• WASTE & SHARPS DISPOSAL.

DIGITAL & ANALOGUE DISPLAY

AUDIO & VISUAL ALARMS

BATTERY BACK UP & CHARGING

• LEGAL & ETHICAL

• STERILIZATION & DISINFECTION

• QUALITY CONTROL & AUDITING

• ELECTRONIC MEDICAL RECORDS (EMR)

Interfaced with existing hospital data

Remote data transmission capabilities

• SUPPORT SYSTEMS FOR PATIENT

John, G. Essentials of Critical Care, Edition IV,

Worthley, L.I.G. Clinical Examination of the

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