Design, organization and staffing of the intensive care unit

CritiCal illness and intensive Care i

Design, organization and staffing of the intensive care unitsean Bennett

Abstractthe location, size, organization and staffing of crtical care facilties

should be carefully planned to take into account the types of patients

it will serve, the levels of care required, existing demand and likely

future demands. Health Building note (HBn) no. 57 gives precise detail

of the functional, design and engineering requirements for new critical

care facilities. Comprehensive Critical Care, published in 2000, provides

direction and advice on issues around organization and staffing. though

not produced as a national service Framework, it makes key recom-

mendations about the need for a ‘critical care delivery group’, medical

staff trained in intensive care medicine, levels of patient dependency,

collection of data for audit purposes and other operational aspects of

intensive care. it also gives a time frame for the introduction of these

measures.

Keywords consultant work pattern; critical care; mortality

The intensive care unit (ICU) should be large, airy, offer privacy, be located close to admitting areas, have easy access to imaging, be quickly evacuated and allow patients to be observed at all times. It should have a leader well versed in all aspects of care which should follow patterns dictated by evidence-based prac-tice and be administered in a full-proof way. Everyone should know all about the patients and there should be robust plans for admissions as required. Fully trained medical staff should be available at all times.The design, construction, organization and staffing of the inten-sive care unit should include consideration of the following: • Functional requirements • Design requirements • Engineering requirements • Human resources • Standard operating policies

Design

Published in 2005 by NHS Estates, the third edition of Health Build-ing Note (HBN) No. 57 describes in detail the functional, design and engineering requirements for new critical care facilities.1

The document presents patient-centred design concepts and has drawn on the experiences of patients, visitors and staff. Where possible, issues such as inadequate space, insufficient

Sean Bennett MB ChB FRCA is a Consultant Anaesthetist at Castle Hill

Hospital, Hull, UK. Conflicts of interest: none declared.

sUrGerY 27:5 19

numbers of single rooms, high levels of ambient noise and lack of privacy are addressed during the design process.

Location

Critical care facilities should be centrally located within a hos-pital, with ready access to and from operating theatres, the emergency department and imaging facilities. The availabil-ity of point-of-care testing (e.g. blood gas analysis), pneumatic specimen transport systems and electronic reporting have largely removed the requirement for pathology services to be located nearby (Figure 1).

How many beds?

Before a brick is laid it is important to consider the current and future demands for critical care from within the hospital and from the population it serves. Changes in demand may occur as a result of demographic shifts (e.g. an aging population), or secondary to local and regional reorganization of services such as Accident and Emergency, oncology, neurosciences and cardi-acthoracic surgery. Deciding how much capacity (i.e. the number of beds) a critical care unit should have is an imprecise science but may be calculated from: • Trends in emergency department workload. • The number of acute hospital beds and operating theatres. • Historical data on the number admissions, refused admissions and premature discharges. • Historical data on bed occupancy and average length of stay. • Critical care admission policy. • The availability of critical care facilities at neighbouring hos-pitals and specialist centres. • Mathematical models of clinical activity.2

It is recommended that calculations be based on an ideal occu-pancy level of around 75% and an admission refusal rate of no greater than 5%. Despite an expansion of critical care facilities in the last decade (Figure 2), most UK hospital critical care facilities operate at or above maximum capacity.

Schematic layout for an ICU from HBN 57

Criticalcare area

In-patientacute

servicesInfectioncontrol

Pathology

Pharmacy

Sterilesupplies

Operatingtheatre

Emergencycare

Adjacent Easily accessible

Located within same building

HBN, Health Building Note

Radiology

Figure 1

0 © 2009 elsevier ltd. all rights reserved.


What sort of bed?

While HBN 57 states that, ideally, every patient be nursed in an individual room, it recognises that most clinicians consider this to be an unrealistic and undesirable aspiration. Nevertheless, at least half of the beds should be located in single occupancy rooms; preferably with negative and positive pressure airflow systems to permit isolation of infectious and immunocompro-mised patients respectively. The benefits of privacy and quiet have to be balanced against the additional number of nurses required to care for isolated patients. By contrast, an open area, accommodating 4 or more beds, may be safely managed with a nurse:patient ratio <1.

General requirements (Tables 1 & 2)

ICU design should consider the needs of its users; patients, staff and visitors. It is recommended that each bed space has a floor area of at least 25.5 m2, sufficient to permit all bedside interven-tions (e.g. intercostal drain insertion, tracheostomy) and accom-modate monitoring and life-support equipment. Cubicles for isolation need an ‘air-lock’ room for gowning, which requires an additional 7 m2 floor space. All clinical areas, corridors and door-ways must be large enough to permit unimpeded bed movement. Anyone visiting such a unit will be impressed by how vast it looks compared with previous designs. Additional space is required for the storage of bedding, disposables, drugs, fluids, cleaning supplies and unused equipment; and the temporary storage of clinical waste and soiled linen prior to disposal. Natural daylight and outside views – not always achievable in a central location – should be provided where possible, whilst preserving patient privacy and dignity.

The design process also needs to incorporate the needs of nursing, medical and other staff. One or more central moni-toring ‘stations’ provides space for administrative tasks whilst maintaining patient observation. In addition, thought must be given to staff changing rooms, rest rooms, and training and meet-ing rooms. Relatives and visitors – often last to be considered

0

500

1000

1500

2000

2500

3000

3500

4000

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

Level 3 Level 2

Figure 2 Biannual census of open and staffed adult intensive care

(level 3) and high dependency (level 2) beds in england. Following

publication of Comprehensive Critical Care in 2000, 77% of the step

increase in critical care beds was due to an increase in the number of

level 2 beds. Between 2000 and 2009 the number of level 3 beds has

increased by 31%, whereas the number of level 2 beds has increased

by 107%. (source: dh.gov.uk)

sUrGerY 27:5 19

– require comfortable waiting rooms, private interview rooms and toilet facilities.

Whilst constrained by building regulations the physical lay-out should create an efficient working environment. Nowadays, architects and designers use computer simulations or ‘virtual-izations’ of their designs to demonstrate functionality and avoid costly mistakes. Scott gives a good account of how HBN 57 was used in the design of a new ICU in Sheffield.3

Equipment

In addition to initial and ongoing maintenance costs, con-sideration should be given to reliability, ease of use and compatibility with equipment already in use within the hos-pital. In many instances standardization within hospitals and across regions, and use of national purchasing agreements can yield considerable cost benefits. A more detailed discussion of

General design considerations (HBN 57)

Location and departmental

relationships

User requirements

space requirements increasing the number of

single bedrooms

Moving and handling

equipment

separate treatment/

procedure rooms

storage areas education and training areas

reducing healthcare associated

infections

decontamination of

equipment

noise reduction strategies lighting

telecommunications internal environment

Finishes and floors Walls and ceilings

doors, frames and windows Maintenance and cleaning

Corridors security and access control

Fire safety access for the disabled

environmental protection Health and safety regulations

Table 1

Specific design considerations (HBN 57)

entrance and waiting areas reception/clerical office

Communications base Bed areas

assisted bathroom/toilet Patients’ pantry

Clean utility and blood storage dirty utility and disposal

holding area

Bulk supplies and linen storage imaging equipment bays

Cardiac arrest/emergency trolleys Medical gas cylinder storage

Furniture store Clinical equipment storage

and service rooms

Point-of-care testing laboratory staff facilities

visitor facilities Office accommodation

Housekeeping Uninterruptible power supply

Table 2



the processes involved in the procurement of equipment (e.g. patient monitors, clinical information systems, ventilators, infusion pumps, haemofilters, defibrillators) and disposables (e.g. breathing systems, syringes) is beyond the scope of this article.

Engineering considerations

It is essential that the ICU design process gives consideration to the provision of essential services. HBN 57 provides guidance on lighting, heating and energy recovery, ventilation, refrigera-tion, hot and cold water systems, drainage, cabling (electrical, communication, digital), the supply of electricity, piped medical gases and vacuum. Further discussion of these is beyond the scope of this article.

Organization

Critical care without wallsPublished in 2000 by the Department of Health, a review of adult critical care services entitled Comprehensive Critical Care detailed a series of proposals for the organization of critical care, workforce planning, standards and guidelines.4 The Expert Group recommended the creation of hospital-wide ‘critical care delivery groups’ to deliver integrated and flexible services. Replacing the traditional classification of patients according to their place of care (i.e. intensive care or high dependency unit) by a classification based on patient need regardless of location, led to the concept of ‘critical care without walls’ (Table 3). This model underpins the recom-mendation that critical care services need to extend beyond the physical boundaries of critical care units. Within regions, the creation of critical care networks was seen as a way of providing comprehensive critical care and setting common standards.

Levels of acute care recommended in Comprehensive Critical Care

level 0 Patients whose needs can be met through

normal ward care in an acute hospital.

level 1 Patients at risk of their condition deteriorating,

or those recently relocated from higher levels of

care, whose needs can be met on an acute ward

with additional advice and support from the

critical acre team.

level 2 Patients requiring more detailed observation or

intervention including support for a single failing

organ system or post-operative care and those

‘stepping down’ from higher levels of care.

level 3 Patients requiring advanced respiratory support

alone or basic respiratory support together with

support of at least two organ systems. this level

includes all complex patients requiring support

for multi-organ-failure.

Table 3

sUrGerY 27:5 19

Specialization and ‘ring-fencing’It is not unusual for large teaching hospitals in the USA to have seven or more separate critical care facilities, each accommo-dating a specific group of patients – trauma, general surgical, neurosurgical, cardiac surgical, cardiology, general medicine, respiratory care, paediatric and neonatal. Although this degree of segregation is not evident in the UK, services such as car-diothoracic and neurosurgery tend to have access to their own specialty critical care units, whereas medical and surgical patients are typically managed on a single ‘general’ unit. The rationale for this approach is based, principally, on the observa-tion that concentrating patients in high-volume specialties, all with similar needs, improves outcomes.5 An additional benefit is that these specialties do not have to compete with others for critical care beds.

Where activity within a particular specialty is insufficient to justify a separate ICU, the centralization of services, particu-larly thoracic and major vascular surgery, across a network can benefit patients.6 The improvement in outcomes accrued is not solely the result of the increased experience of an individual surgeon, but the familiarity of critical care staff with this type of patient.7

In some centres – such as Cornell University, New York – all adult critical care is delivered within a single facility comprising 60 or more beds. By dividing the facility in to distinct, specialty-based autonomous sections (6–12 beds) high quality care can be delivered whilst the institution benefits from flexibility and economies of scale. Beds within each section are notionally pro-tected or ‘ring-fenced’ for use by that specialty and, at least in theory, clinical activity must be adjusted according to bed occu-pancy. Apart from the inevitable ‘overspill’ of patients from one area to another, the greatest risk posed by this design is that of cross infection. One approach to managing the problems of mix-ing long-term critical care patients with those in high-volume, elective specialties requiring admission for <24 hours is the con-cept of ‘overnight intensive recovery’ in a post-anaesthesia care unit (PACU).8

Open versus closedCritical care units in which the supervision of a patient’s care is the responsibility of the admitting physician are termed ‘open units’. Evidence suggests that this model of organization results in inappropriate admissions and variable levels of critical care. Increasingly, critical care units operate a ‘closed’ model of orga-nization in which patients are transferred to the care of special-ists in intensive care. Despite concerns about loss of continuity of care, closed units appear to offer more uniform levels of care and deliver improved clinical outcomes. Whilst closed units are the norm in Australia and the USA, maintaining this strict regime in the UK has proved to be difficult – particularly in surgical specialities – and a shared care or semi-closed approach emerges as the pragmatic solution. In a study of an open unit, daily input by an intensivist resulted in a 3-fold reduction in mortality.6 Other studies have demonstrated reductions in length of stay and complications.9,10

StaffingIn addition to nurses and doctors, a critical care unit can-not function without the services of allied professionals



(e.g. physiotherapists, dieticians), support staff (e.g. pharma-cists), housekeeping staff, porters and clerical staff. Comprehen-sive Critical Care provides a foundation on which the current organization and staffing of intensive care in the UK is built.4

Nursing staffNurses are the largest staff group and arguably the greatest resource in any ICU. Assuming an average nurse:patient ratio of 1:1 and a 40 hour working week, as many as six whole-time nurses are required to staff each bed. The number of nurses required at any particular time is dictated by the level of patient need (dependency) and the mix of senior and junior grades. It is common to have one or more nurses in overall charge and, in large units, divide beds into smaller functional areas, each with its own leader. Despite the adoption of flexible working patterns, which allow staffing levels to be adjusted to meet clinical demand and cover annual leave and sickness, it is not uncommon for beds to be closed due to a lack of staff.

The level of investment required to maintain a large group of ICU nurses should not be underestimated. Chronically inad-equate staffing levels leads to increased levels of staff sickness and turnover, and may result in increased patient mortality.11 Allowing nurses with young children to work part-time, offer-ing training and career advancement opportunities, and provid-ing a pleasant working environment improve recruitment and retention.

Medical staffConsultant medical staff have overall responsibility for direct-ing clinical care, supervising and teaching trainees, management and leadership. For historical reasons the majority of ICUs in the UK have been run by anaesthetists with an ‘interest’ in critical care. However, since the creation of the Intercollegiate Board for Training in Intensive Care Medicine (ICBTICM) in 1999, trainees in anaesthesia, surgery and medicine have been able to obtain dual accreditation. The Board now recommends that all newly appointed consultants with >50% commitment to criti-cal care have the Certificate of Completion of Training (CCT) in Intensive Care Medicine (ICM).12 An equivalent system of Board certification for anaesthestists, surgeons, internists and paediatricians has been in operation in the USA for many years. In Australasia, the Faculty of Intensive Care has overseen train-ing in ICM since 1993. Since 2002, completion of training in ICM is now recognized by the award of the diploma of Fellowship of the Joint Faculty of Intensive Care Medicine (FJFICM). Despite an increase in the number of ICM consultants in the UK, achiev-ing all of the ICBTICM recommendations may prove difficult (Table 4).

In addition to consultant staff, the ICU requires a resident med-ical presence 24 hours a day, 7 days a week. In most instances this is provided by Foundation year trainees (i.e. interns) and trainees in specialty training (e.g. anaesthesia, surgery, medi-cine). Compliance with the European Working Time Directive means that no less than five trainees are required to provide this level of cover.

Continuity of care is a vital component of critical care and effective communication between staff members is essential. The adoption of novel patterns of work goes a long way to preserve continuity and protect patients.13

sUrGerY 27:5 19

Policies and proceduresCare delivered to critically ill patients should, wherever possible, be evidence-based and comply with guidelines produced by governmental (e.g. the National Institute for Health and Clini-cal Excellence, NICE) and national professional (e.g. Royal Col-leges, Intensive Care Society, ICBTICM) bodies. In an attempt to standardize care and facilitate training and audit, most ICUs maintain an extensive portfolio of policies, procedures, stan-dards an monographs describing all aspects of care delivery. The involvement of all staff groups and public interest groups in the production of standard operating policies promotes inclusion and underpins multidisciplinary team working. ◆

REFERENCES

1 nHs estates. Facilities for critical care HBN 57. london: the

stationery Office. May 2005.

2 Costa aX, ridley sa, shahani aK, et al. Mathematical modeling and

simulation for planning critical care capacity. Anaesthesia 2003;

58(4): 320–7.

3 scott CJ. Building a critical care unit for sheffield using a new nHs

estates building strategy-ProCure 21: partnership approach to nHs

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4 department of Health. Comprehensive critical care: a review of adult

critical care services. london: the stationery Office. May 2000.

available from: http://www.doh.gov.uk/nhsexec/compcritcare.htm.

5 Halm ea, lee C, Chassin Mr. is volume related to outcome in

health care? a systematic review and methodologic critique of the

literature. Ann Intern Med 2002; 137: 511–20.

6 Pronovost PJ, Jenkes MW, dorman t, et al. Organizational

characteristics of intensive care units related to outcomes of

abdominal aortic surgery. J Am Med Assoc 1999; 281: 1310–7.

7 Hillner Be, smith tJ, desch Ce. Hospital and physician volume or

specialization and outcomes in cancer treatment: importance in

quality of cancer care. J Clin Oncol 2000; 18: 2327–40.

Recommendations for consultant staffing in ICU (Intercollegiate Board for Training in Intensive Care Medicine, 2008)

all units must have a minimum of 15 programmed activities

(60 hours) of consultant time totally committed to intensive care

medicine each week per eight level 3 beds.

all consultants providing an on call service must have

programmed activities committed to intensive care medicine.

Consultants should not have any other clinical commitments

when covering the iCU during daytime hours.

during working hours the consultant in charge of the iCU should

spend the majority of his or her time on the iCU and must be

immediately available on the iCU.

there must be 24 hour cover of the iCU by a named consultant

with appropriate experience and competencies.

a consultant in intensive care medicine must see all admissions

to the iCU within 12 hours.

Table 4


http://www.doh.gov.uk/nhsexec/compcritcare.htm


8 aps C. adopting a fast track approach to cardiac surgery. Br J

Cardiac Nurs 2006; 1(4): 174–9.

9 dimick JB, Pronovost PJ, Heitmiller rF, et al. intensive care unit

physician staffing is associated with decreased length of stay,

hospital cost and complications after esophageal resection. Crit Care

Med 2001; 29: 753–8.

10 Hanson CW, deutschman Cs, anderson Hl. effects of an organized

critical care service on outcomes and resource utilization: a cohort

study. Crit Care Med 1999; 27: 270–4.

11 Pronovost PJ, angus dC, dorman t, et al. Physician staffing patterns

and clinical outcomes in critically ill patients: a systematic review.

J Am Med Assoc 2002; 288: 2151–62.

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12 intercollegiate Board for training in intensive Care Medicine.

standards for consultant staffing in intensive care units. available

from: http://www.ica.ac.uk, august 2008.

13 royle P, Bramall J, norrington a. the effect of introducing a

consultant weekly working pattern on mortality in a critical care

unit. J Int Coll Surg 2008; 9(1): 26–9.

CROSS REFERENCE

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with reality in the iCU. Surgery 2003; 21(11): i–ii.


http://www.ica.ac.uk

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Design, organization and staffing of the intensive care unit