THE DESIGN AND FUNCTION OF AN INTENSIVE CARE UNIT · 2017. 4. 13. · not requiring the apparatus and special skills of the intensive care unit. Patients whose diseases are defined

Brit. J. Anaesth. (1966), 38, 132

THE DESIGN AND FUNCTION OF AN INTENSIVE CARE UNIT

BY

JOHN S. ROBINSON

Department of Anaesthesia, University of Liverpool, and Whiston HospitalPrescot, Lancashire, England

In 1962 the Ministry of Health circulated a reporton progressive patient care which was largelyconcerned with intensive patient care. Since thisreport, Regional Hospital Boards have been sym-pathetic to the establishment of intensive careunits, and because of their special skill and know-ledge anaesthetists have usually been concernedwith the planning and establishment of suchunits.

Over a year ago a new intensive care unit wasbuilt at this hospital (Lancet, 1964) based uponexperience gained over two years work in a unitof three beds situated in the existing cubicles atthe entrance to a general medical ward. Work inthe new unit has revealed very few mistakes thatwere not already known before conversion of anexisting ward; furthermore, the number of visitorsinspecting the facilities suggested that a descrip-tion of the planning and running of the unitmight be of interest. The scanty literature avail-able on this subject shows that such units servemany purposes; some can be regarded as beingconcerned with little more than postoperative care,and in some hospitals there is the duplication ofboth a medical and a surgical intensive care unit.It is contended that such concepts are in errorand are possibly due to the inadequacy of avail-able definitions of the criteria for intensive care.

If the patient requiring intensive care is dennedas one requiring mechanical aid to support vitalfunction until the disease process is arrested orameliorated, then the aims, the planning and con-trol of such units become much simpler. Further-more, there is no lowering of nursing standards inthe acute wards by removal of seriously ill patientsnot requiring the apparatus and special skills ofthe intensive care unit. Patients whose diseasesare defined in this way may require artificial pul-monary ventilation, haemo- or peritoneal dialysis,cardiac pacemaking, or biochemical correction of

severe metabolic disorder; they do not suffer fromderangement of but one system. Respiratoryfailure is often associated with renal impairment,and cardiogenic shock brings both renal and pul-monary ventilation/perfusion ratio defects. Thepatients can, therefore, no longer be treated satis-factorily in the conventional specialist wards inhospitals, and the greatest chance of survival isprovided when treatment is undertaken by a teamof medical and nursing staff, with the necessaryapparatus and skill, advised as necessary by theconsultant referring the patient.

PLANNING CONSIDERATIONS

Patients with conditions so desperate as to requireintensive care, withstand movement extremelybadly, and considerations such as the siting of theintensive care unit near to the operating theatres,radiographic or other facilities, have been foundto be immaterial. The unit should be equippedto deal with the relatively minor procedures—tracheostomy, dialysis, etc., or, on occasions, moremajor procedures such as Caesarean section—with little inconvenience. The essential require-ment is that the unit should be readily accessiblefrom all parts of the hospital.

The load likely to be placed upon such a unit,and therefore the required size, is difficult toassess, for it is directly related to the type of thehospital in which it is located. Estimates have beenas low as 2 per cent of medical and surgicalpatients (Progressive patient care, 1962) or as highas 10 per cent (Saklad, 1964). Experience in thisgeneral hospital over three years gives a figure ofless than 2 per cent, but this is rising as researchreveals more disease conditions amenable to thisform of treatment. Although the size of the unitmay be conventionally described in terms of"beds", the essential concept is "space", for equip-ment and manoeuvre. The present unit for a

THE DESIGN AND FUNCTION OF AN INTENSIVE CARE UNIT 133

hospital of 516 acute beds has eight beds but alsoserves other hospitals which lack similar facilities.The total number of beds in the unit must belimited and most units which fall within the realdefinition of intensive care are limited in numberto between eight and twelve beds. The reason forthis must be obvious; there cannot be in one hos-pital enough staff with the proper skills, or enoughapparatus, diagnostic or therapeutic, to care forthese patients, and one can only assume that unitsof forty-eight beds (Darcy, 1964) admit patientswho are not in need of or do not receive intensivecare. Bates's (1964) surprise that the averagepatient's stay in some so-called intensive care unitsis but a few days, is in agreement with experiencein this unit, in which the average stay is close tothree weeks.

The physical dimensions of the unit are deter-mined by one of two factors. An area may bedesignated for adaptation in the best way possible.More rarely, the area required can be estimatedin advance during a building programme. As aworking rule it has been found that the total spaceassigned for beds in the unit should equal thesum of space for working area and for utilityrooms. Two overall designs of units are in use.In one type normal ward bed type of accommod-ation is provided over a large area (Puddicombe,1964), with perhaps a limited number of closedsingle rooms (Edwards, Richardson and Ashworth,1965). In the second type, the design is based al-most entirely on single-room accommodation(Richards, 1964), with another area with sectionsof two or three beds wherein patients, whose re-quirements are rather less, can be intensivelycared for by fewer nurses.

We are in complete agreement with the viewexpressed by Bates (1964) that the adoption ofthe first type of design—"a sort of barn full ofexpensive machinery"—is a most retrograde step.This "recovery room" approach to intensivepatient care is very common and leads to pro-longed care of acutely ill patients in large openareas separated only by septic curtains. Thereasons usually given in support of this approachare that it is less expensive to build and that moreeffective surveillance of the patients is possiblewith fewer nurses. Seldom does one hear it statedthat such open areas facilitate cross-infection andmake likely a decrease in the available level ofintensive care. Patients being treated intensively

require constant surveillance and some nursing ormedical procedure every minute of every hour ofevery day. This is best achieved by the use ofsingle rooms. Such an arrangement requires morenursing staff, but effectively prevents depletion ofsuch staff for other purposes.

In experience at this unit, it has been foundthat the greatest hazard of intensive patient careis cross-infection within the unit. This problemhas been most ably reviewed by Kinney (1964),yet cognizance is not always taken of such views.Although some have suggested that an intensivecare unit need not be "purpose designed" (Puddi-combe, 1964), our own experience proves this tobe in error. Thus, in the old temporary unit, deathwas attributable to cross-infection in nine ofeighty-four patients admitted in one year, whereaswith largely the same staff in a specifically de-signed unit this had fallen to two cases out of afirst-year total of 168 cases. This adds support tothe statement of Kinney (1964) that "in an inten-sive area not only the grossly septic patient butevery patient is an exercise in bacteriologicalcontrol. Standard procedures for asepsis are sel-dom effective in a poorly designed unit". Theview held by Edwards, Richardson and Ashworth(1965) that septic cases should be excluded fromtheir ward hardly comes within the concept ofintensive care, nor does their design allow con-tainment or exclusion of indigenous or airbornebacteria.

Most workers with long experience of intensivecare (e.g., Saklad, 1964; Bates, 1964; Kinney,1964) favour multiple single large rooms, and itwas upon this layout that the unit described herewas designed. The unit, converted from an exist-ing wartime Emergency Medical Service ward,was designed by the consultant staff and built bythe hospital group works department in six weeksat a capital cost of conversion of £5,280.

PLANNING AND DESIGN

It was found that patients generally needed a pro-gressively diminishing amount of intensive careand therefore separate areas were set out for theirdifferent needs. Thus, patients are initially ad-mitted to the operating room where facilities foranaesthesia, bronchoscopy, tracheostomy, dialysisor other operative procedures are available. Aftercompletion of these procedures the patient can bemoved to an intensive treatment room, the design

FIG. 1Ground plan of Intensive Care Unit.

Scale 1 in. = 18 ft.


allowing for patients to be moved within the con-fines of the unit on their own beds (figs. 1-5).

The floor space of this operating room is 351square feet, of which an area of 81 square feet isset aside for storage racks, cupboards and sinkswith working top areas. It is essential that allequipment and instruments needed in this areashould be immediately and visibly available. Thetwo single-bedded intensive treatment roomseach have a floor space of 216 square feet whichis now recognized to be inadequate; 300 squarefeet would be better. These rooms have an inter-communicating folding plastic door for patientmovement only.

After an initial period of treatment, patientshave usually recovered sufficiently to be nursedin an open area where observation can be madefrom the ubiquitous nurse's station, although evenin this area activity is frequent enough to allowlittle time for seated observation. In commonwith other workers (Saklad, 1964) it is found thatthere is need for more single rooms and it would beadvantageous if the two intensive care rooms werelarger. Apart from the serious cross-infectionhazard, the bright lighting, activity and noise ateach bed dictate single rooms. Bright lighting isnecessary to facilitate therapeutic procedures andobservations, the actual value being 35 lumensper square foot in the operating room (withoutthe operating light) and 25 lumens per squarefoot in the intensive treatment rooms. The striplighting in all parts of the unit has the same coloursource so that no false impressions of tissue bloodperfusion can be given to staff moving within theunit.

It is known (Clarkson and Robinson, 1962) thatacutely ill or curarized patients find their inabilityto look away from a single light source to be in-tolerably painful; therefore, a unique form ofover-bed strip lighting was designed which couldbe converted from direct to diffuse by rotatingthe tube housing to the ceiling.

Much of intensive care equipment is electricaland a large number of socket outlets per bed isessential; there are twelve in the operating room,seven being suspended from the ceiling (so thatcables do not trail across the floor), and seven atevery other bed. Good chest radiographs areessential to intensive care and this requires at least90 kV, which is obtained from a Deans mobileunit which requires a separate 30-amp socket.

These are easy to install during building of theunit but very expensive to put in as an after-thought. A standby emergency generator ishoused near the unit and has been employed twicein the last year. Even so, all ventilation and suc-tion apparatus is capable of hand or foot opera-tion. Piped oxygen was made available throughoutthe unit, but piped suction was not. This wasdictated partly on grounds of cost but alsobecause of the cross-infection hazard. If settleplates are left under unconnected wall suctioninlets, colonies of pathogens can be grown. Thiscan be lessened by interposing bacterial filters be-tween the suction bottles on the inlet, but indivi-dual electrically operated vacuum pumps arepreferred. The individual vacuum pumps usedfor each patient are changed twice daily and arethen cleaned and sterilized with bacteriocide(Sudol, Prince Regent Tar Co.), the tubing beingchanged for an autoclaved set, The positive oreffluent side of the vacuum pump has a cottonwool bacterial filter and, provided this does notget wet and is changed twice daily, bacterial con-tamination of the discharged air has not beenobserved. Although, as in the unit described byRosen and Secher (1963), an electrical conduit isavailable at each bed for electronic monitoring toa central console at the nurse's station, feelingis now against such an installation. Electricalthermometers, blood pressure and pulse monitors,electrocardiographic and electroencephalographicdevices are used but these are situated at the bed-side. In this type of work the only possible andreliable monitor is a highly trained nurse at eachbedside, aided as necessary by electronic devices.

It is obligatory, if there is to be success withintensive care, that blood gas analysis, acid-base,metabolic balance and electrolyte values should beimmediately available at any hour. There is acertain urgency in these analyses during the hoursof darkness. If the possible answer to a probleminvolves many hours of work, then the analysismay be delayed until the rule-of-thumb clinicalassessment and correction has been tried. Thismethod is seldom successful in such a complexand scientific field.

A laboratory is situated at the end of the unittherefore, and apparatus was provided and was,if necessary, designed to enable the junior medi-cal staff themselves to carry out blood gas analysisand similar procedures within 10 minutes. This

136 BRITISH JOURNAL OF ANAESTHESIA

FIG. 2Operating room.

nmtiFIG. 3

Intensive treatment room. The overbed strip lighting can be seen.


FIG. 4View of the intensive care unit, showing the division into separate roomsby the use of Thermoplastic covered walls and the racks for barrier gowns.

FIG. 5Open area containing two beds and the nurse's station.


laboratory is also involved with the many researchproblems posed by intensive care. Thus, estima-tions of cardiac output, chest compliance, tissueperfusion, external metabolic and electrolytebalance, ventilation/perfusion defects, forexample, are all undertaken by this laboratory onpatients admitted to the unit. This is an essentialpart of the philosophy of intensive care. Nowherecan it be more true that the research of today isthe routine of tomorrow.

When the unit was built, storage space wasknown to be inadequate, but as money becameavailable two more rooms were added. One is alarge room (600 sq. ft.) for storage of the mass ofbulky equipment, and has service benches; theother room (300 sq. ft.) is capable of being keptat 70 °F and has a water supply which gives thefacilities for ethylene oxide sterilization (Boultbeeet al., 1964).

The existing rooms at the entrance to the wardwere converted to provide a comfortable waitingroom for relatives (many of whom wait for longperiods) and a preparation room in which instru-ments, suction, cardiac and pacemaker catheters,endotracheal and tracheostomy tubes are packedfor sterilization.

The patients' kitchen is largely wasted; patientsable to be fed normally have no place in an inten-sive care unit. The kitchen is used to prepare theintragastric feeds and the staff beverages.

STAFFING STRUCTURE

The administration of the unit is often a subjectof controversy (Keats, 1964; Boyd, 1964; Cher-niak, 1964); it is believed that patients admittedunder the definition given here can only beproperly managed by a highly specialized team,and the suggestion that the referring physicians orsurgeons could be trained to use the facilities ofthe unit is ridiculous; these patients require con-stant surveillance which cannot be undertaken ona part-time basis. The unit team should beprimarily responsible for the acute situation whichwhen resolved allows transfer of the patient backto the referring consultant.

Medical staff.The team consists of a physician and an anaes-

thetist, either of whom have the sole responsibilityfor admission of patients. It is sometimes sug-gested that units of this kind perform a sort of

geriatric resuscitation. This is far from the truth;none of us tries to confer immortality nor, on theother hand, is age a bar to admission, providedthe condition is remediable and useful patientfunction can be restored.

There is no doubt that in this work the anaes-thesia department is pre-eminent. Respiratoryfailure is almost always one of the conditionspresent in patients needing admission to the unit.Other resuscitation techniques are familiar to theanaesthetist, and the ready availability of the 24-hour service of the department ensures that theadministrative team must include an anaesthetist.

No resuscitation is worth while without carefuldiagnosis and control. It is here that the physicianon the team is invaluable. There have sometimesbeen questions as to the advisability of giving"beds" to an anaesthetist. This is difficult to com-prehend. Patients alone have beds in this unit,and it is considered that such deliberations as towho has the ultimate clinical responsibility areVictorian and unrealistic. If intensive care is tosucceed it requires a working team with patients,and not personalities, in mind. Both of the consul-tants of the team are always available and hold acombined ward round at noon every day whentreatment policy is made or changed. At thisround, referring consultants give advice whennecessary on the admitting condition, but thehandling of the patients within the unit properlyremains with the team.

The day-to-day medical control of the patientsis undertaken by a senior house officer who hasvery few other duties. An anaesthetic and medicalregistrar have a daily duty for the unit, and per-form tasks outside the training and competenceof the senior house officer. A surgical colleagueis always available to perform tracheostomy, peri-toneal or haemodialysis, etc.

Some of the success of the unit has been due toinsistence that intensive care should be madelargely a nursing procedure. If not, lives can belost as the medical burden becomes intolerable.It has been found that the principles of endo-tracheal intubation, relaxant therapy in convulsivestates, tracheostomy care, pulmonary ventilationand its defects, haemodialysis and cardiac pace-making, can all be profitably taught to nurses.For this reason, unlike Edwards, Richardson andAshworth (1964) it is believed that there is no placefor a medical officer's bedroom; if one of the


medical staff is in the unit he is working and hasno time for sleep. Nurses have been very ade-quately trained to deal with the rare emergency.More usually, careful monitoring and data col-lection give ample warning of impending trouble.

Nursing staff.Originally, it was calculated that it would re-

quire thirty-five trained nursing staff to allow fullcover for the eight beds for eight-hour shifts withallowances for vacations and sickness. It wasquickly appreciated that this was unrealistic;such a number of trained staff could not be ob-tained and eventually proved unnecessary. A shiftsystem was essential, and an almost equal numberof trained staff are required at night as during theday; intensive care is a continous procedure. Itproved only necessary however, to have the majorproportion of the nursing staff trained and to pro-vide assistance to these by having enrolled nursesand auxiliaries. It is wasteful to use highly trainedsisters to change beds and attend to toilet requi-sites. Furthermore, it has been found perfectlypracticable to use enrolled nurses and auxiliariesto watch and record the monitoring of ventilation,compliance, systemic and venous blood pressure,and dialysis. The nursing staff now consists oftwelve fully trained sisters, three staff nurses, twoenrolled nurses and four auxiliaries. A four-monthpostgraduate nursing course is held in the unitand these students work in the unit and are paidby the Management Committee. Student nurseshave little place in the unit because their know-ledge of physiology is usually inadequate tounderstand the procedures in use, nor are theywith the unit long enough to be taught. It is con-sidered that the full four-month course of lectures,demonstrations and experience is needed beforesisters are capable of independent judgementwithin the unit.

The nursing superintendent is male and has twofemale deputies. In many ways the work of the in-tensive care ward is ideally suited to the malenurse.

There has been some discussion in the litera-ture on the grave psychological strain this workplaces upon nursing staff. In our experience thereis evidence of some strain, but we think we haveovercome this by the tremendous spirit of integ-rity and comradeship which has arisen. Further-more, if nurses are taught to understand and are

given the responsibility of personally correctingderanged physiology then many of their fears dis-appear. Most of the nursing staff have workedhere for three years.

Other staff.To help with the cross-infection hazard, the

unit floors and walls are continually being cleaned,and for this reason the unit has four orderlies andcleaners who also share night duty when the samestandards of cleanliness are expected. A technicianis employed to look after the mechanical equip-ment and also to take charge of the ethylencoxide sterilization.

In the last twelve months this unit has treated168 patients of whom thirty-eight died. By defi-nition of criteria for treatment, without admissionevery one of these patients would have died;furthermore, of the thirty-eight deaths, elevenwere proved at autopsy to have irremediable con-ditions. It is difficult, therefore, to conceive howEdwards, Richardson and Ashworth (1964) couldquestion whether lives have been saved by theestablishment of an intensive care ward. There arecertain procedures which have been foundessential for success, and perhaps they may beworth recording.

CONTROL OF CROSS-INFECTION

In these seriously ill patients with diminished re-sistance and often a tracheostomy, lung infectionwith antibiotic-resistant organisms is a real hazard.This has been diminished by the use of singlerooms the construction of which did not proveexpensive, because the walls are light structurescovered with thermoplastic. This design allowsthorough cleaning of the rooms and spraying ofthe walls and floor with a bacteriocide C^ego;Hough-Hoseason Ltd.). Barrier nursing is prac-tised and each member of the nursing staff onlycarries out sterile procedures on their own desig-nated patient during their duty shift. Jackets andwhite coats must be removed on entering theunit; individual gowns and footwear arc worn foreach room. The removal of outer clothing ensuresthat such clothes are not placed on racks next tobarrier gowns and ensures that visitors arc awarethat this is a special area with a cross-infectionhazard.

Each room in the unit is a complete entity withall the requisite instruments, drugs and solutions.


Traffic between the rooms is prevented as muchas possible and for this reason an intercommuni-cation system is being installed.

The major route of cross-infection is via thetracheostomy to the lungs. Attempts have beenmade to control this route in the following ways:

(1) A most careful asceptic technique must beadopted for aspiration of sputum; this consists ofpacking the sterile Pinkerton catheters in a nylonenvelope which allows the catheter to be fed intothe trachea by a "no touch" technique using theoutside of the envelope and by the user wearingdisposable polyethylene gloves for the manoeuvresof aspiration—e.g., disconnecting the ventilator.Lubrication of aspiration catheters is with a 1/50Tego solution in saline, each vial of Tego andcatheter being discarded after use.

(2) All ventilators are sterilized by ethyleneoxide, and when in use are changed for a freshsterile machine every 48 hours.

(3) All ventilators, except pressure-cycledmachines run off the oxygen pipeline, have bac-terial intake filters fitted.

(4) Urine collection is by a closed system con-sisting of a urethral catheter led to a polyethy-lene container in which is 5 ml of a powerfulbacteriodde (Racasan; Racasan Ltd.); this doesnot interfere with the daily estimations on eachpatient of urinary electrolytes and total nitrogen.

There have been cases of pneumonia due toPseudomonas pyocyaneus, which organism is al-most certainly a tracheostomy contaminant fromthe urine collection, but urine collection andanalysis is an essential part of the monitoring ofintensive care cases. Acute renal failure, so com-mon in these desperate conditions, is, in thewriter's experience, largely preventable.

WORKING LOAD

It is firm policy that the bed capacity and the unitstaff should not be overloaded. If a patient is ad-mitted to the unit and the staff cannot maintainthe strict barrier nursing and give the patient thecare and attention necessary for successful resus-citation, then this patient may succumb or becomecross-infected; worse still, the patient may infector diminish the care given to other cases whoseprogress in the unit had hitherto been satisfac-tory. This tragic, set of circumstances has beenseen to occur on several occasions, and this is the

reason for the belief that true intensive care unitsmust be limited to eight or ten beds, and theharsh rule of non-admission must be enforced ifnursing staffing is inadequate.

During the brief periods when the number ofpatients in the unit is small, the nursing staff areoccupied by review and repair of equipment. Thestaff are never moved to other work; this leads todiscontent. The idea, prevalent in some units, thata nucleus of trained staff should man the unit andthat when the working load is high this should beaugmented by other nurses, is quite wrong;nurses untrained and inexperienced in this workare much more of a hazard than a help.

TABLE I

Primary condition Admissions

Cardiorespiratory-renal failuredue to cor pulmonale

Respiratory failure due to pneu-monic consolidation and collapse(including postoperative cases)

Poisonings—barbiturate, narcoticor industrial accidents

Status asthmaticusCritically crushed chestsMetabolic and electrolyte im-

balance including diabeticcoma and postoperative casesnot requiring dialysis

Renal failure requiring eitherperitoneal or haemodialysis

Coma due to head injury, meningitisor subarachnoid haemorrhage

Pulmonary infarctionStatus epilepticusCoronary infarctionPolyneuritisEclampsiaCongestive cardiac failure due to

primary cardiac conditions—mitral stenosis, bacterialendocarditis

Tetanus

Total

48

29

221411

9

9

554432

21

168

Deaths

9

6

323

2

4

221310

00

38

In this table an attempt is made to classify the con-ditions leading to admission to the Unit in one year(1964-65). This classification cannot be regarded asrigid, as it is usual for more than one system to failand require mechanical support—e.g., the cardio-respiratory-renal failure of cor pulmonale.


FIG. 6View of one of the equipment rooms, cthylene oxide sterilization of a Cape

ventilator in progress in the bag.

METABOLIC BALANCE

In this country starvation is rare outside hospitalsbut within hospitals it is most common in theseriously ill patient in need of intensive care. Theloss of the lean body cell mass (wasting), whichoccurs on account of the patient's inability tomaintain a proper dietary intake, is an insultwhich, on top of their already deranged physio-logy they cannot sustain. There seems to bea popular misconception that an intake of 5 percent dextrose, normal saline and Darrow's solu-tion given intravenously provides the dailyrequirement of calories and electrolytes. Dextrosesolutions were introduced to provide water, notcalories. Jones and Peaston (1965), working in theunit, have been able to restore a positive nitrogenbalance by giving their formulation for intra-gastric feeding or intravenously by the use ofamino acids, fructose and fat emulsions. It is sur-prising that at least 2,500 calories per day arerequired to maintain desperately ill patients in apositive balance, and even curarized patients,although totally inactive, then gain weight duringtheir illness. There is no doubt that intragastricfeeding is the easiest route and provides a bettermetabolic balance; it should be used unlesscontraindicated by alimentary disorder.

CONCLUSIONS

During the past twelve months 168 patients havebeen treated in this specifically designed unit, thediseases leading to admission being listed in tableI. It is certain that 130 of these were saved by thedesign and procedures outlined here. The unithas certain faults. There are not enough singlerooms and the working floor area in two of t ierooms is insufficient. When originally built theratio of equal storage floor space to workingspace had to be ignored, but has since been recti-fied with the addition of the annexe (fig. 6). Thereis no doubt that Rosen and Secher (1964) arecorrect in regarding plenum ventilation for an in-tensive care unit as essential. In the unit, as atpresent designed, the fight against cross-infectionwould be easier if air conditioning could have beenafforded with a positive pressure air gradientfrom intensive care rooms to corridor. Welch(1964) has commented on the expense of such aunit and its treatment. This is very real, but canbe reduced by a sensible approach to capital out-lay, useless long-range electronic monitoringgadgetry being disregarded and pleas made foradequate trained staff who monitor and performthe procedures which get desperately ill patientswell again. This must be more expensive thanallowing such patients to die, but it is difficult to


see why the expense of such an organization isquestioned.

ACKNOWLEDGEMENTS

Some of the conclusions in this paper were reachedafter visiting intensive care units in the United Statesof America, Canada and Sweden. This was madepossible by the generosity of the Liverpool RegionalHospital Board and Vitmm Ltd., Stockholm.

REFERENCES

Bates, D. V. (1964). Workshop on intensive careunits. Anesthesiology, 25, 192.

Boultbee, P. J., Robinson, J. S., Leach, R., andThomas, E. (1964). Sterilization of intensive careequipment. Brit. J. Anaesth., 34, 531.

Boyd, R. G. (1964). Workshop on intensive care units.Anesthesiology, 25, 192.

Cherniak, R. M. (1964). Workshop on intensive careunits. Anesthesiology, 25, 192.

Clarkson, W. B., and Robinson, J. S. (1962). Deliberatehypcrventilation in the treatment of a crush injuryof the chest. Brit. J. Anaesth., 34, 471.

Darcy, M. (1964). Workshop on intensive care units.Anesthesiology, 25, 192.

Edwards, F. R., Richardson, J. C , and Ashworth,P. M. (1965). Experience with an intensive careward. Lancet, 1, 855.

Jones, E. S., and Peaston, M. J. T. (1966). Metaboliccare during acute illnesses. Practitioner, 196, 271.

Keats, A. S. (1964). Workshop on intensive careunits. Anesthesiology, 25, 192.

Kinney, J. M. (1964). Workshop on intensive careunits. Anesthesiology, 25, 192.

Lancet (1964). A unit for intensive patient care. (Cor-respondence.) 1, 657.

Progressive Patient Care: Interim Report of a Depart-mental Working Group (1962). Monthly Bull.Mmist. Hlth. Lab. Sen., 21, 218.

Puddicombc, M. W. (1964). Intensive care unit,Addenbrooke's Hospital. Nursing Times, 60, 1030.

Richards, N. (1964). New intensive care unit atWhiston Hospital. British Hospital Special ServiceJournal, 1, 624.

Rosen, J., and Secher, O. (1963). Intensive care unitat University Hospital, Copenhagen. Anesthesi-ology, 24, 855.

Saklad, M. (1964). Workshop on intensive care units.Anesthesiology, 25, 192.

Welch, C. E. (1964). Advances in surgery. Practitioner,193, 408.

Documents

THE DESIGN AND FUNCTION OF AN INTENSIVE CARE UNIT · 2017. 4. 13. · not requiring the apparatus and special skills of the intensive care unit. Patients whose diseases are defined