HIGH-DEPENDENCY UNIT (HDU)^9,10

An HDU is a specially staffed and equipped area of a hospital that provides a level of care intermediate between intensive care and general ward care. Although HDUs may be located in or near specialty wards, increasingly they are located within or immediately adjacent to an ICU complex and are often staffed by the ICU personnel.

The HDU provides invasive monitoring and support for patients with or at risk of developing acute (or acute on chronic) single-organ failure, particularly where the predicted risk of clinical deterioration is high or unknown. It may act as a ‘step-up’ or ‘step-down’ unit between the level of care delivered on a general ward and intensive care, but does not normally accept patients requiring mechanical ventilation. Several older studies have shown benefits to outcome associated with the introduction of HDUs,⁹ whereas a more recent study has questioned these findings.¹¹

PAEDIATRIC ICU (PICU)²

A PICU is a separate area in the hospital capable of providing complex, multisystem life support for indefinite periods to infants and children less than 16 years of age. It is a tertiary referral centre for children needing intensive care and has extensive back-up laboratory and clinical services to support this tertiary role. Consultants in a PICU are paediatric intensive care specialists with expertise different from their adult intensive care colleagues. All patients admitted to the PICU are referred to the attending PICU specialists for management.

PATIENT AREAS

Each patient bed area in an adult ICU requires a minimum floor space of 20 m² (215 ft²), with single rooms being larger (at least 25 m²), to accommodate patient, staff and equipment without overcrowding. The ratio of single-room beds to open-ward beds will depend on the role and type of the ICU, but with a recommended range of between 1:6 and 1:2. They should be equipped with an anteroom of 2.5 m². Single rooms are essential for isolation and, less importantly, privacy for conscious long-stay patients. The emergence of resistant bacterial strains in ICUs around the world has increased the need for isolation facilities in recent years. A non-splash hand wash basin with elbow- or foot-operated taps should be close to each bed and a hand disinfection facility at each bed.

Bedside service outlets should conform to local standards and requirements (including electrical safety and emergency supply, such as to the Australian Standard, Cardiac Protected Status AS3003).

Utilities per bed space as recommended for a level III ICU are:

Adequate and appropriate lighting for clinical observation must be available. How the services are supplied (e.g. from floor column, wall-mounted, or ceiling-pendant) depends on individual preferences. There should be room to place or attach additional portable monitoring equipment and, as much as possible, equipment should be kept off the floor. Space for charts, syringes, sampling tubes, pillows, suction catheters and patient personal belongings should be available, often in a moveable bedside trolley.

All central staff and patient areas must have large clear windows. Lack of natural light and windowless ICUs give rise to patient disorientation and increased stress to all. Efforts should be made to reduce sound transmission and therefore noise levels, e.g. walls and ceilings should be constructed of materials with high sound-absorbing capability. Suitable and safe air quality should be maintained at all times. Air conditioning and heating should be provided with an emphasis on patient comfort.

Since critical care nursing is at the bedside, staffing of a central nurse station is less important than in a CCU. Nevertheless, the central station and other work areas should have adequate space for staff to work in comfort and situated so that patients can be seen. This central station usually houses a central monitor, satellite pharmacy and drug preparation area, satellite storage of sterile and non-sterile items, telephones, computers with internet connections, patient records, reference books and policy and procedure manuals. A dedicated computer for the picture archive and communication system (PACS) or a multidisplay X-ray viewer should be located within the patient care area.

STORAGE AND SUPPORTING SERVICES AREAS

Storage areas should take up a total floor space of about 25–30% of all the patient and central station areas. They should have separate access remote from the patient area for deliveries and be no farther than 30 m from the patient area. Frequently used items (e.g. intravenous fluids and giving sets, sheets and dressing trays) should be located closer to patients than infrequently used or non-patient items. There should be an area for storing emergency and transport equipment within the patient area with easy access to all beds.

Floor areas for supporting services should make up about 20–25% of the patient and central station areas. Utility rooms must be clean and separate, each with its own access. Disposal of soiled linen and waste must be catered for, including contaminated items from infectious patients, using one-way traffic schemes. Facilities for estimating blood gases, glucose, electrolytes, haemoglobin, lactate and sometimes clotting status are usually sufficient for the unit’s laboratory. There should be a pneumatic tube or other system to transfer specimens to pathology. A good communication network of phones/intercoms is vital to locate and inform staff quickly. Adequate arrangements for offices, doctor-on-call rooms, staff lounge (with food/drinks facilities), wash rooms, education (seminar room) and a waiting room (see below) complete the unit.

RELATIVES AREA

Apart from a waiting room, levels II and III ICUs should have a separate room to interview and comfort distressed relatives. There should be facilities for tea/coffee making and a water dispenser and toilets should be located close by. Television and/or music should be provided.

MEDICAL STAFF¹⁷

An intensive care department should have a medical director who is qualified in intensive care medicine and who coordinates the clinical, administrative and educational activities of the department. The duties of the director should involve patient care, supervision of trainees/other junior doctors, the drafting of diagnostic and therapeutic protocols, responsibility for the quality, safety and appropriateness of care provided and education, training and research. It is recommended that the director be full-time in the department.

The director should be supported by a group of other specialists trained in intensive care medicine who provide patient care and contribute to non-clinical activities. In an ICU of level II or III there must be at least one specialist exclusively rostered to the unit at all times. Specialists should have a significant or full-time commitment to the ICU ahead of clinical commitments elsewhere. There should be sufficient numbers to allow reasonable working hours, protected non-clinical time and leave of all types. The recent increase in ICU outreach activities (medical emergency team calls, outpatient review: see Chapter 2) has increased the workload of intensive care specialists as well as junior staff in many hospitals, resulting in the need to increase the size of the medical team.

There should also be at least one junior doctor with an appropriate level of experience rostered exclusively to level II and III units at all times. Junior medical staff in the ICU may be intensive care trainees, but should ideally also include trainees of other acute disciplines (e.g. anaesthesia, medicine and surgery). It is imperative that junior doctors are adequately supervised, with specialists being readily available at all times.

This physician staffing model has been used in Australia and New Zealand for many years, but has not been common in the USA. A systematic review¹⁸ has shown that when there has been mandatory intensivist consultation (or closed ICU – see below) compared with no or elective intensivist consultation or open ICU, both ICU and hospital survival were improved and there was a reduced length of stay in ICU and in hospital.

NURSING STAFF

Critical care nursing is covered in Chapter 6. The bedside nurse conducts the majority of patient assessment, evaluation and care in an ICU. In ICUs supporting tertiary hospitals 1:1 nursing is required for all ventilated patients, whereas one nurse per two patients is appropriate for HDU patients. Some complex patients with multiple supports may require more than one nurse. When leave of all kinds is factored in, long-term 24-hour cover of a single bed requires a staff complement of six nurses. Nurse shortages have been shown to be associated with increased patient mortality and nurse burnout and adversely affect outcome and job satisfaction in the ICU.^19,20

There should be a nurse manager who is appointed with authority and responsibility for the appropriateness of nursing care and who has extensive experience in intensive care nursing as well as managerial experience. In tertiary units the nurse manager should participate in teaching, continuing education and research. Ideally, all nurses working in an ICU should have training and certification in critical care nursing.

ALLIED HEALTH

Major ICUs must have 24-hour access to pathology and radiological services. Access to physiotherapists, dieticians, social workers and other therapists should also be available. A dedicated ward clinical pharmacist is invaluable and participation of a pharmacist on ward rounds has been associated with a reduction in adverse drug events.²¹ Respiratory therapists are allied health personnel trained in and responsible for the equipment and clinical aspects of respiratory therapy, a concept well established in North America, but not the UK, continental Europe and Australasia. Technical support staff,²² either as members of the ICU staff, or seconded from biomedical departments, are necessary to service, repair and develop equipment.

OTHER STAFF

Provision should be made for adequate secretarial support.²³ Transport and ‘lifting’ orderly teams will reduce physical stress and possible injuries to nurses and doctors. If no mechanical system is available to transport specimens to the laboratories (e.g. air-pressurised chutes), sufficient and reliable couriers must be provided to do this day and night. The cleaning personnel should be familiar with the ICU environment and infection control protocols. There should also be a point of contact for local interpreters, chaplains, priests or officials of all religions, when there is need for their services.

OPERATIONAL POLICIES²

Clear-cut administrative policies are vital to the functioning of an ICU. An open ICU has unlimited access to multiple doctors who are free to admit and manage their patients. A closed ICU has admission, discharge and referral policies under the control of intensivists. Improved cost benefits are likely with a closed ICU and patient outcomes are better, especially if the intensivists have full clinical responsibilities.^18,24 Consequently ICUs today, especially levels II and III, should be closed under the charge of a medical specialist director. All patients admitted to the ICU are referred to the director and his/her specialist staff for management, although it is important for the ICU team to communicate regularly with the parent unit and to make referrals to specialised services when appropriate.

There must be clearly defined policies for admission, discharge, management and referral of patients. Lines of responsibilities must be delineated for all staff members and their job descriptions defined. The director must have final overall authority for all staff and their actions, although in other respects each group may be responsible to respective hospital heads, for example, director of nursing.

Policies for the care of patients should be formulated and standardised. They should be unambiguous, periodically reviewed and familiarised by all staff. Examples include infection control and isolation policies, policies for intra- and interfacility transport, end-of-life policies (e.g. do not resuscitate (DNR) procedure) and sedation and restraint protocols. It should be noted, however, that when protocols involve complex issues (such as weaning from mechanical ventilation) they may be less efficient than the judgement of experienced clinicians.²⁵ Clinical management protocols, e.g. for feeding and bowel care, can be laminated and placed in a folder at each bed or loaded on to the intranet.

EQUIPMENT

The type and quantity of equipment will vary with the type, size and function of the ICU and must be appropriate to the workload of the unit. There must be a regular programme in place for checking its safety. Protocols and in-service training for medical and nursing staff must be available for the use of all equipment, including steps to be taken in the event of malfunction. There should also be a system in place for regular maintenance and service. The intensive care budget should include provision to replace old or obsolete equipment at appropriate times. A system of stock control should be in place to ensure consumables are always in adequate supply. The ICU director should have a major role in the purchase of new equipment to ensure it is appropriate for the activities of the unit.

PATIENT CARE

ICU patient management should be multidisciplinary, with medical, nursing and other staff working together to provide the best care for each patient. The critical care nurse is the primary carer at the bedside and monitors, manages and supports the critically ill patient (see Chapter 6). The medical team consists of one or more registrars, residents or fellows who direct medical care with an intensive care specialist. The patient should be assessed by a formal ward round of the multidisciplinary team twice daily, usually at a time when the junior medical staff are handing over from one shift to the next. The nurse coordinating the floor and in larger units allied health staff such as pharmacists and dieticians also take part. Each patient should be assessed clinically (examination, observations and pathology, radiological and other investigation results), the medication chart reviewed, progress determined and a management plan developed for the immediate and longer term. The ward round is also an opportunity to assess compliance with checklists such as Fast Hug.²⁶ Clearly, unstable patients will require much more frequent assessment and intervention.

It is crucial that all observations, examination findings, investigations, medical orders, management plans (including treatment limitations) and important communications with other medical teams and patients’ families are clearly documented in the appropriate chart or part of the medical record either electronically or in writing.

Wherever possible clinical management should be evidence-based and derived through consensus of the members of the ICU team, accepting, however, that evidence-based medicine has limitations when applied to intensive care medicine.²⁷

CARE OF FAMILIES²⁸

ICU care includes sensitive handling of relatives. It is important that there are early and repeated discussions with patients’ families to reduce family stress and improve consistency in communication. Ideally one senior doctor should be identified as the ICU representative to liaise with a particular family. Discussions should be interactive and honest and an attempt made to predict the likely course, especially with respect to outcome, potential complications and the duration of intensive care management required. The time, date and discussion of each interview should be recorded. Cultural factors should be acknowledged and spiritual support available, especially before, during and after a death. Open visiting hours allow families maximum contact with their loved one and promote an atmosphere of openness and transparency.

Education and debriefing may be necessary for staff, especially in relation to difficult and/or unexpected deaths and grieving families.

OUTREACH

ICU outreach activities are described in Chapter 2.

QUALITY IMPROVEMENT^30,31

It is essential that senior medical and nursing staff promote a culture of quality improvement (QI) within the ICU, whatever its size and role. All ICUs should have demonstrable and documented formal audit and review of its processes and outcomes in a regular multidisciplinary forum. Staff who collect and process the data should have dedicated QI time.

Quality indicators can be considered under three headings:

The QI process involves identification of the indicator to be improved (e.g. high ventilator-associated pneumonia (VAP) rate), development of a method to improve it (e.g. checklist such as Fast Hug²⁶), implementation of the method to improve it (e.g. requrement to tick off the checklist on the morning ward round), re-evaluation of the indicator (e.g. VAP rate) to ensure the intervention has improved the outcome and finally to ensure sustainability (e.g. print checklist on ICU chart).

Activities that assess processes include clinical audit (including morbidity and mortality meetings and delayed transfer out of ICU), compliance with protocols, guidelines and checklists and critical incident reporting.

Activities that assess outcomes are calculating risk-adjusted mortality using a scoring system such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) and calculation of standardised mortality ratios (see Chapter 3), measurement of rates of adverse events such as central venous catheter-associated blood stream infection rate or serious adverse drug event rate and surveys (e.g. patient or relative satisfaction, bad backs from lifting in ICU nurses).

Risk management is a closely related field. In the ICU, risks can be identified from critical incident reports, morbidity and mortality reviews and complaints from staff, patients or family members. Using similar methodology to the QI process risks must be identified, assessed and analysed, managed and re-evaluated. A major patient safety incident should result in a root cause analysis.³²

EDUCATION

All ICUs should have a documented orientation programme for new staff. There should be educational programmes for medical staff and a formal nursing education programme. Educational activities for intensive care trainees include lectures, tutorials, bedside teaching and trial examinations (written, clinical and viva). Apart from clinical reviews, meetings to review journals and new developments should be held regularly. Nurses are usually required to undergo annual assessment for advanced life support and sometimes other assessments (e.g. medication safety). Increasingly, simulation centres are used to teach and assess skills and teamwork in crisis scenarios.³³ A number of ICUs are also involved in undergraduate medical teaching. All staff should also participate in continuing education activities outside the hospital (e.g. local, national or international meetings).

RESEARCH

Level III ICUs should have an active research programme, preferably with dedicated research staff, but all units should attempt to undertake some research projects whether they be unit-based or contributions to multicentre trials.