Planning and designing guidelines for Intensive Care Unit Design for future as per Indian prospective

Through this article Hospaccx is trying to help the organization who want to build a new hospital or renovating their existing ICU. if you have any query or design confusion please mail it us on hospaccx.india@gmail.com or visit our Hospaccx website on www.hhbc.in

Introduction

Designing an intensive care unit (ICU) to handle the needs of critically ill patients in the future requires both an ability to predict which of today’s healthcare trends will still be influential 20 years from now and the flexibility to adapt to these trends.

Two current trends that are likely to remain current are: using resources efficiently and meeting the expectations and needs of patients’ families.

ICU is highly specified and sophisticated area of a hospital which is specifically designed, staffed, located, furnished and equipped, dedicated to management of critically sick patient, injuries or complications. It is a department with dedicated medical, nursing and allied staff. It operates with defined policies; protocols and procedures should have its own quality control, education, training and research programs. It is emerging as a separate specialty and can no longer be regarded purely as part of anaesthesia, Medicine, surgery or any other specialty. It has to have its own separate team in terms of doctors, nursing personnel and other staff who are tuned to the requirement of the specialty .

Why Build a New ICU or Renovate an Old One?

Hospitals undertake ICU construction for many reasons: to adapt to changing patient demographics or disease patterns; to upgrade or add services; and to accommodate changes in the ow of information, materials, or patients. New construction may become cost effective when an older ICU requires expensive repairs or upkeep to remain viable, or simply ceases to function well.

Changes in performance standards and new issues in reimbursement and risk management may suggest alterations. Designing for infection control by separating patients, adding isolation facilities, adding hand hygiene stations, upgrading mechanical ventilation and ltration, re- vising provisions for disposal of human waste, or introduction of antimicrobial materials can lower infection rates and therefore morbidity and mortality, cost per case, and length of stay.

How many ICUS and Beds are needed?

Before going for planning and designing of ICU we need to understand first how many ICU units are required with how many beds each unit. how many ICU beds are needed and how many ICUs should be made which may include Advanced ICU, HDU, PICU and Specialty related ICU like Neuro-intensive care, Cardiac Intensive Care and Trauma.

The number of Intensive Care beds will depend on the data available from the hospital and current/future requirements of the hospital. Some ICUs particularly in Private set ups in India may be main specialty in the hospital and they should be very careful in deciding about the number of beds and budgetary provisions and viability issues are very important in such cases.

Numbers of ICU Beds recommended in a hospital are usually 1 to 4 per 100 hospital beds

ICUs having <6 beds are not cost effective and also, they may not provide enough clinical experience and exposure to skilled HR of the ICU. At the same ICU with bed strength of >24 are difficult to manage and major problems may be encountered in management and outcome.

Recommendations suggest that efficiency may be compromised once total number of beds crosses 12 in ICU.

The Canadian Department of National Health and Welfare has developed a formula for calculating the number of ICU beds required based on the average census in the existing unit and the desired probability of having an ICU bed immediately available for a new admission. Therefore, it is recommended that total bed strength in ICU should be between 8 to 12 and not <6 or not >14 in any case
ICU Bed Designing and Space required
Space per bed has been recommended from 125 to 150 sq ft area per bed in the patient care area or the room of the patient. Some recommendation has placed it even higher up to 250 sq ft per bed. In addition, there should be 100 to 150% extra space to accommodate nursing station, storage, patient movement area, equipment area, doctors and nurse’s rooms and toilet.
ICUs in India it may be satisfactory to suggest an area of 100 to 125 sq ft be provided in patient care area for comfortable working with a critically sick patient where all the paraphernalia including monitoring systems, Ventilators & other machines like bedside X-ray will have to be placed around the patient. Bedside procedures like Central lines, Intubation, Tracheostomy, ICD insertion and RRT are common. It may be prudent to make one or two bigger rooms or area which may be utilized for patients who may undergo big bedside procedures like ECMO, RRT etc. and has large number Gadgets attached to them.10 % (one to two) rooms may be designated isolation rooms where immuno- compromised patients may be kept, these rooms may have 20% extra space than other rooms.
We should be thinking of introducing newer technologies in their ICU like ECMO, Nitric Oxide and Xenon clearance etc. Do they need Lamellar flow for specific patient population in their ICUs? This will be highly specific for High end up ICUs and is not recommended in routine Provisions may be kept open for such options in future.

Partition between two room and maintaining privacy of patients

It is recommended that there should be a partition/separation between rooms when patient privacy is desired which is not unusual. Standard curtains soften the look and can be placed between two patients which is very common in most Indian ICUs, however they are displaced and become unclean easily and patient’s privacy is disturbed Therefore, two rooms may be separated by unbreakable fixed or removable partisans, which may be aluminum, wood or fiber.
However permanent partitions take away the flexibility of increasing floor space temporarily (In Special circumstances) for a particular patient even when the adjoining bed/room may not be in use. There are also electronic windows which are transparent when the switch is off and are opaque when the switch is on, although expensive now, the cost of this option may come down over time.

MEP design Constrain: Pendant vs Head End Panel

One of the most important decisions is to how to plan bedside design Two approaches are usually practiced
1. Head wall Panel
2. Free standing systems (power columns) usually from the ceiling Each can be fixed or
3. moveable and flexible can be on one or both sides of the patient.
4. Flexibility is usually desirable,
5. Panels on head wall systems allow for free movements
6. Adaptable power columns can move side to side or rotate,
7. Mounts on power columns are also usually adjustable,
8. Flexible systems are expensive and counterproductive if the staff never move or adjust them,
9. Head wall systems can be oriented to one side of the patient or to both sides, some units use two power columns, one
on each side of the patient,
10. Other units use a power column on one side in combination with some fixed side wall options on the opposite side,
11. Ceiling mounted moveable rotary systems may reduce clutter on the floor and make a lot of working space available,
However, this may not be possible if the weight cannot be structurally supported
12. Power columns may not be possible in smaller rooms or units.
13. Each room should be designed to accommodate portable bedside x-ray, Ultrasound and other equipment such as
ventilators and IA Balloon pumps; in addition, the patient’s window view (If available) to the outside should be
preserved.

Height of Monitoring System
Excessive height may be a drawback to the way monitoring screens are typically well above eye level and display more parameters. Doctors and nurses may have chronic head tilting leading to cervical neck discomfort and disorders, Therefore, the levels of monitors should be at comfortable height for doctors and nurses.

Keep Bed 2 ft. away from Head Wall

A usual problem observed in ICU is getting access to the head of the bed in times of emergency and weaving through various tangled lines. And at the same time patient also should not feel enclosed and surrounded by equipment and induced uncalled for fear
About 6 inches high and 2 ft. deep step (Made of wood) usually temporary/removable (which would otherwise would stay there only) is placed between the headwall and the bed lt will keep the bed away from the wall and automatically gives caregivers a place to stand in emergencies without too much of problems. Lines may be routed through a fixed band of lines tied together.

Provision for RRT

Two beds should be specially designated for RRT (HD/CRRT) where outlets should be available for RO/de-iodinated water supply for HD machines. Self-contained HD machines are also available (Cost may be high)

Isolation Rooms

10% of beds (1 or 2) rooms may be used exclusively as isolation cases like for burns, serious contagious infected patients.

Alarms. music. phone etc.

Each group should decide if they want to provide the patient access to music (audio), telephone etc. However, an alarm bell which has both indicators by sound and light must be provided to each patient and he be taught about it, how to use it when needed

STORAGE

It is important to decide what is to be stored by the bedside
• At the Nursing station
• Nursing stores
• Remote central store
Those supplies used repeatedly and in emergencies should be readily available and easy to find, storing a large inventory can be costly, but so is wasting personnel time, Making supplies more available may increase their use. Some over cautious or clever staff may decide to hoard or hide them. Cost effective and efficient designs are needed.
Staff nurses can always give useful ideas about improvement of systems, which they develop while working with patients. Their opinion can be invaluable.
When medications are kept at the bedside, JCAHO currently requires that the storage be lockable, these stores can store medicines, disposables, records, injections, tabs etc. Bedside supply carts that are stocked for different subsets of patients can make storage in the room more efficient, for example, surgical, medical, trauma patients, cardiac patients where needs are different. Staff nurses may be specifically trained for such care and work
Determining what supplies are placed near but not at the bedside is based on the size of the unit, the grouping of patients and the patterns of practice, although many units organize supplies by the department that restocks them (central services, nutrition, pharmacy, respiratory therapy, etc.,)
it is worth considering grouping supply by activity, like Chest tray, Central line tray, skin care tray, catheterization tray, Intracranial pressure tray etc. They may be labelled by name or color code.

Heating, Ventilation and Air-conditioning (HVAC) system of ICU

The ICU should be fully air-conditioned which allows control of temperature, humidity and air change. If this not be possible then one should have windows which can be opened (‘Tilt and turn’ windows are a useful design.).
Suitable and safe air quality must be maintained always. Air movement should always be from clean to dirty areas. It is recommended to have a minimum of six total air changes per room per hour, with two air changes per hour composed of outside air. Where air-conditioning is not universal, cubicles should have fifteen air changes per hour and other patient areas at least three per hour.
The dirty utility, sluice and laboratory need five changes per hour, but two per hour are sufficient for other staff areas.
Central air-conditioning systems and re-circulated air must pass through appropriate filters.
It is recommended that all air should be filtered to 99% efficiency down to 5 microns. Smoking should not be allowed in the ICU complex.
Heating should be provided with an emphasis on the comfort of the patients and the ICU personnel.
For critical care units having enclosed patient modules, the temperature should be adjustable within each module to allow a choice of temperatures from 16 to 25 degrees Celsius.
A few cubicles may have a choice of positive or negative operating pressures (relative to the open area). Cubicles usually act as isolation facilities, and their lobby areas must be appropriately ventilated in line with the function of an isolation area (i.e. pressure must lie between that in the multi-bed area and the side ward).
Power back up in ICU is a serious issue. The ICU should have its own power back, which should start automatically in the event of a power failure. This power should be sufficient to maintain temperature and run the ICU equipment (even though most of the essential ICU equipment has a battery backup). Voltage stabilization is also mandatory. An Uninterrupted Power Supply (UPS) system is preferred for the ICU

Negative pressure isolation rooms

(Isolation of patients infected/suspected to be Infected with organisms spread via airborne droplet nuclei <5 μm in diameter) In these rooms the windows do not open. They have greater exhaust than supply air volume. Pressure differential of 2.5 Pa. Clean to dirty airflow i.e. direction of the air flow is from the outside adjacent space (i.e. corridor, anteroom) into the room. Air from room preferably exhausted to the outside, but may be re-circulated provided is through HEPA filter NB: re-circulating air taken from areas intended to isolate a patient with TB is a risk not worth taking and is not recommended

Positive pressure isolation rooms

(To provide protective environment for patients at Highest risk of infection e.g. Neutropenia, post-transplant) These rooms should have greater supply than exhaust air. Pressure differential of 2.5 – 8 Pa, preferably 8 Pa. Positive air flow relative to the corridor (i.e. air flows from the room to the outside adjacent space). HEPA filtration is required if air is returned.

CONCLUSION

Design of critical care facilities has an impact on organizational performance, clinical outcomes, and cost of care delivery. Organizations involved in design and construction projects are advised to engage experienced consultants who will collaborate with the users and make key design decisions on the basis of best current evidence.
Through this article them Hospaccx is trying to help the organization who want to build a new hospital or renovation there existing ICU . if you have any query or design confusion please mail it us on hospaccx.india@gmail.com or visit our Hospaccx website on www.hhbc.in

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