MEDICINE AND NEURO INTENSIVE CARE UNIT

INTRODUCTION:

An intensive care unit (ICU), critical care unit (CCU), intensive therapy unit or intensive treatment unit (ITU) is a specialized department which combines physicians, nurses and allied health professionals in the co-ordinated and collaborative management of patients with life-threatening single or multiple organ failure, including stabilization after severe surgical interventions. It is a continuous (ie.24 hours) management including monitoring, diagnostics, support of falling vital functions as well as the treatment of the underlying diseases.

The main rationale behind having a separate department is to provide utmost care to the most serious patients. It requires specific interventions and equipments such as ventilators, defibrillators for its normal functioning. Intensive care unit involves high acuity, high risk of death, high turnover, high stress for family and health care worker, high danger of infection and very high costs.

MNICU of KEM hospital is a level 3 ICU according to Indian Society of Critical Care Medicine. Since it has bed strength of 10, multisystem care is available for 24 hours, CRRT is available, supported by blood bank, bed area is 110 square feet, all radiological facilities like X-ray, USG, 2D Echo, CT, MRI facilities are available and there is enough space for storage and nursing station.

However it does not fulfill some of its criteria like it is an open ICU, Nurse/patient ratio is not 1:1 in ventilated patients, no laid down protocols for infection control in ICU.

PHYSICAL STRUCTURE:

Location:

It is located on the 2nd floor of main hospital building above the radiology department. It is accessible to vertical transport like elevator, stairs. The MICU is protected from the external hospital environment by the presence of a long passage leading to it.

Layout of MNICU unit:

The department has 3 sections MNICU 1, MNICU 2 and ward 22. The ICU unit has a single entry and exit point. Also there are 2 barriers to the entry of ICU. The patients from MNICU 1 are shifted to an Intermediate ICU/ MNICU 2 when the patient has been stabilized. This has 7 beds. The patient after recovery from Intermediate ICU/ MNICU 2 is shifted to a Ward 22 which is attached to MNICU. This has 10 beds. The patient is later shifted to the respective Ward or discharged when a patient’s physiologic status has stabilized and the need for ICU monitoring is no longer required. This facility gives better patient care.

Layout of MNICU 1:

As we enter MNICU 1, on the left hand side is a store room and on the right hand side is the physician’s room (staffs lounge), further ahead is the MNICU. Its basic shape is rectangular and it is an open type of ICU. It has 10 beds and a nursing station at the entrance. 6 beds face the nursing station and 2 beds each are on its left and right side. There is a 5-6 feet distance between 2 beds.

Area:

Area of the department is 3000 square feet which includes MNICU 1, MNICU 2, and Ward 22.

Area of MNICU 1 is 1200 square feet.

Structure of MNICU 1:

Floor and walls- tiled. Lighting and ventilation: The MNICU has widows on the three sides, which provides

natural daylight. There are no curtains on the windows. There are enough tube lights to give good lighting at night. Doors have self closing devices.

Beds: Manual movable beds having crank at foot end of bed. Curtains: There are 2 curtain separators. But there are no curtains around each bed

because of no central monitoring system.

Air conditioning: MNICU has its own air conditioning unit. Temperature of MNICU ranges from 22-24 degree Celsius.

Technology available:

MAJOR EQUIPMENT TOTAL NUMBER WORKINGINFUSION PUMP 32 5MULTI PARA MONITOR 16 16PULSE OXYMETER 19 19VENTILATORS

versamed vella+bear neumovent siemens (servo)

12524

1252

4(not used)BLOOD PUMP 1 1CRRT (continuous renal replacement therapy)

1 1

2 D ECHO MACHINE 1 1DEFIBRILATOR 1 1

MINOR EQUIPMENT NUMBER MINOR EQUIPMENT NUMBERLARYNGIOSCOPE

ADULT PEADRIATRICS

41

TRACHEOSTIOMY DRUM TRAY

22

AMBUBAGAMBUBAG’S MASK

33

ICD BOTTLE TRAY 1

TORCH WITH CELL 1 LIVER BIOPSY TRAY 1HAMMER 1 GLOVES TRAY 3BP APPARATUS 2 DRESSING TROLLEY 2BLOOD KLAMMER 1 BONE MARROW TRAY 1NEBULIZER 1 URINOMETER 1

Each bed of MNICU having:

Area: 110 sq feet Electrical points: 7 Ventilator: 1 3 outlets of: oxygen, air, vacuum Multi Para monitor: 1 Infusion pump:1

ORGANIZATIONAL STRUCTURE:

HOD MEDICINE

HOD MNICU

DOCTORS NURSES

Doctors:

HEAD OF DEPARTMENT- PROFESSOR (1)

ASSOCIATE PROFESSOR (1)

ASSISTANT PROFESSOR (2)

REGISTRARS (3) (1-on call)

HOUSEMAN (2/3) (8am-8pm)

INTERN (1)

Nursing Staff:

SISTER INCHARGE (1)

SENIOR STAFF NURSES (2)

STAFF NURSES (15)

Class 4 Employees:

SISTER INCHARGE

SWEEPERS (male, 7) SWEEPERS (female, 3) MUKADAM (male, 2) WARDBOYS (male, 6)

TIMINGS OF STAFF:

Doctors: 9am-4pm (except houseman whose duty is from 8am-8pm)

Nurses:

Sister in charge (1): 7am-3pm Senior staff nurses (2):

1. 7am-3pm2. 12:30pm-7:30pm

Staff nurses:1. Morning: 7am-3pm2. Evening: 3pm-11pm3. Night: 11pm-7am

Class 4 employees:

Morning 7am-3pm (2) Ward Boys

(1/3) Sweeper Male

(1) Sweeper Female

(2) Mukadam

Evening 3pm-11pm (1/2) Ward Boys

(2) Sweeper Male

(1) Sweeper Female

-

Night 11pm-7am (2) Ward Boys

(2) Sweeper Male

(1) Sweeper Female

-

SYSTEMS AND PROCEDURES:

Admission procedure:

Sources of admissions: Casualty/ emergency ward 20 Shift from General wards (female ward, male ward) Obstetrics Neurology and neurosurgery

Type of disease pattern seen in admissions of MNICU: Severe Malaria, Tetanus, Leptospirosis, Poisoning,

Snakebite, Scorpion Sting, Ecclampsia and Other Obstetrics Emergencies.  Guillain Barre Syndrome, Myasthenia Gravis, Subarachnoid Hemorrhage, Status Epilepticus Cerebral Cortical Venous Thrombosis,

Discharge and Transfer procedure:

Decision regarding discharge of the patient is taken by the attending physician. Once the doctor makes a decision regarding discharge, he/she has to write in the case papers. Discharge from ICU can be of following forms:

1. Shift to MICU 22. Shift to Ward 223. Shift to other wards4. Death 5. Discharge against medical advice (DAMA)

Handing over and taking over procedure:

It is extremely important for duty medical officers to tell their replacement doctors all the information regarding the patient. The information is passed verbally as well in written form. All the information is written in a doctors’ register maintained for it. The information that is passed is the patient status since morning, any laboratory report to collect, any procedure conducted or to be conducted, etc.

Similarly, the nursing staff also has to inform their replacements regarding patient status. They also do it verbally as well in written form. They also maintain a register similar to the one like doctors’.

Billing procedure:

Per day charge of MNICU is 200 Rs. The patient is asked to pay a sum of 800 Rs at the billing counter number 56 every 4 days. The relatives are asked to pay at these intervals of days, so that they won’t have to pay a large amount when the patient gets discharged.

Procedure followed with regard to patient’s belongings and valuables:

After the stabilization of patient in MNICU, patient’s clothes and valuables are removed and handed over to the nearest relative with his/her sign in the admission book.

Procedure of visiting hours:

Visiting hours are from 4:30pm-6:30pm. No visitors are allowed to stay with the patient in MNICU 1 and 2 either in the day or at night.

Procedure for infection control, (Cleaning and Disinfection of MNICU):

Hand sterilizer, Sterilium is used by the doctors. No dry dusting is done in MNICU. The floor is wiped in morning and after visiting hours with 1% CSPS or 1% Na hypochlorite and allowed to dry. Once a month floor washing is done on the floor washing day. Beds are wiped with 1% CSPS or 1% Na hypochlorite once patient is discharged (Bed carbolyze). Fumigation of MNICU 1 is done 2 time a year. (Diluted disinfectants especially sodium hypochlorite are not stored. From the concentrated disinfectant provided fresh working solutions are prepared every day).

Procedure for linen change:

Bed sheets are changed once a day in MNICU 1. However the position change of bed sheet is done 4 times a day (morning 7:30am, evening 5pm and night 11:30pm and 6am). Bed sheets are also changed on discharge of patient.. All mattresses have an impervious cover of rexine or Macintosh sheet. All used bed sheets, linen etc are first be disinfected with 1% Na hypochlorite for 30 minutes and then washed, dried by aya bai (female sweeper) and then sent to laundry on Monday, Thursday, and Saturday. Linen is kept locked in a store room.

Procedure for biomedical waste disposal:

Biomedical waste is segregated into black and red bags. This biomedical waste is disposed 3 times a day in 3 shifts.

Books in MNICU:

• New Admission Book• MICU 1 (name + treatment)• MICU 2 (name + treatment)• Injection list book,• Injection account book• Refer book• S/N handing and taking over book• Garbage book• Tablet account book

• Day and night report • Servant roll call book• Doctors call book• Paying form book• Death dispatch book

Forms in MNICU:

• Investigation forms:• Biochemical investigations (RBS/LFT forms)• Pathological forms (bacteriology culture)• ECG form• X-Ray form

• Rx sheet• TPR chart• Intake and Output chart• Summary from (daily ward admission and discharge summary)• OPD continuation sheet• Pregnant women form• J/O chart

PERFORMANCE INDICATORS:

1. Chart showing number of admissions in MNICU from 1/01/2010 to 31/12/2010:

January

Febru

aryMarc

hApril

MayJune

July

August

Septem

ber

October

November

December

0

20

40

60

80

100

120

140

Number of Admissions in MNICU

Number of Admissions in 2010

2. Chart showing number of deaths in MNICU from 1/01/2010 to 31/12/2010

January

Febru

aryMarc

hApril

MayJune

July

August

Septem

ber

October

November

December

0

10

20

30

40

50

60

70

Number of Deaths in MNICU in 2010

Number of Deaths in MNICU in 2010

3. Death of patients in MNICU during monsoons

June July August0

1

2

3

4

5

6

7

8

9

10

MalariaLeptospirosisH1N1Dengue

4. List showing sources of admissions of patients in MNICU:

Month/2010

EMS Female ward

Male ward

Medical male ward

Endocrine Neurology/neurosurgery

Surgery ICU

others

January 20 18 4 5 1 1 0 11

February 18 9 3 7 1 3 0 12

March 24 12 6 9 1 1 1 17

April 20 3 5 8 1 3 1 11

May 20 19 3 11 0 2 1 15

June 20 7 3 12 0 0 2 17

July 9 19 9 19 0 1 1 24

August 36 17 5 19 2 0 1 35

September 45 26 10 22 3 3 2 22

October 44 21 2 6 4 1 1 19

November 31 15 3 13 1 1 0 14

December 36 14 2 15 1 1 0 13

5. List showing the quantitative indicators of MNICU:

Bed occupancy 100%

ALOS 6-7days

Bed turnover rate 56%

Doctor to patient ratio 1:2.5

Nurses to patient ratio:• Morning• Evening• Night

1:21:2.51:3.33

Mortality 40-45%

PROBLEMS AND RECOMMENDATIONS:

Problems RecommendationsNon availability of isolation beds Removable partition made of aluminum, wood or fiber can

be used. This will also provide flexibility of increasing floor space temporarily if required.

Frequent visiting of relatives Single entry and exit point of the ICU should be manned to control visiting traffic. Visiting policies should be explained to the relatives.

Shortage of class 4 staff and their lack of awareness about infection protocol. General housekeeping is also not good.

Vacancies of class 4 staff should be filled up so that infection control is not compromised. Proper training of class 4 staff regarding maintenance of infection control.

No central monitoring system, so no cubicle separation between beds.

Central monitoring system should be installed for effective monitoring of the patients.

Non availability of electrical backup

UPS should be installed for electrical backup.

No infection control protocols are laid down for ICU.

Infection control policies should be laid down and checked by appropriate authority.

Hand washing protocol not followed stringently

Hand washing protocol should be followed as a rule.