Entry Level COP4

COP 4: Documented procedures guide the care of patients as per the scope of services provided by the hospital in intensive care and high dependency units.

• Intensive care admission and / or discharge shall be decided by treating doctor. Each patient shall be under the care of a nurse, always maintaining the patient to nurse ratio of 2:1. Intensive care areas shall follow infection control practices as per procedure. (Ref: Infection control manual). Intensive care units shall follow the quality assurance program.
• Visitors shall not be allowed in high dependency areas, except in special situations wherein restricted entry of one or two close relatives shall be permitted during visiting hours only.
• As and when there is a shortage of beds, patients those who are normal will be shifted to the wards and priority will be given to the emergency patients.
• One empty bed shall be kept reserved for all the time for receiving emergency patients who need ICU admission.
• Quality assurance system is implemented and followed in ICU’s.

Patients needed emergency care is shifted to Intensive Care Unit depending up on the cases.

Admission Criteria in ICU: Admission criteria are used to select patients who are likely to benefit from care in ICUs. Patients who meet any of the following criteria shall be admitted to the ICUs at the request of the consultant. While we make every effort to strictly adhere to admission criteria, we accommodate requests from consultants who clinically feel that a patient would benefit from close monitoring in the critical care unit even through not strictly meeting the criteria stated below:

Respiratory:

• Acute respiratory failure (PaO2 < 60 mm Hg).
• Respiratory rate > 30 breaths/minute and <8 breath/mt.
• Patients requiring ventilator support (invasive or non-invasive).
• Pulmonary emboli with hemodynamic instability.
• Massive Haemoptysis
• Post-operative patients requiring hemodynamic monitoring, ventilator support or extensive nursing care.
• Patients with surgical abdomen requiring preoperative fluid and/or electrolyte resuscitation.
• Polytrauma with significant injury to thoracic / abdominal organs requiring surgical intervention.

Renal:

• Patient who has acute renal failure with accompanying respiratory or hemodynamic components require close monitoring & respiratory/ hemodynamic support.
• Significant acidosis or alkalosis.
• Hypo or hyper kalemia with dysarhythmias or muscular weakness.
• Hypo or hyper natremia with seizures, altered mental status.
• Severe hyper calcemia with altered mental status, requiring close neurological monitoring.
• Hypo or hyper magnesemia with hemodynamic compromise or dysarrhythmias or muscular weakness

Drug Ingestion and overdose:

• Drug ingestion with significantly altered mental status & inadequate airway protection / hemodynamic instability.
• Seizures following drug ingestion

Endocrine:

Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status, respiratory insufficiency, or severe acidosis.

Thyroid storm or myxedema coma with hemodynamic instability. Other endocrine problems such as adrenal crisis with hemodynamic instability

Miscellaneous:

• Environmental injuries (lighting, near drowning, hyperthermia or hypothermia).
• Any other clinical conditions requiring ICU level nursing care
• Suicidal gestures including partial hanging, drug overdoses and other self-inflicted injuries.

Discharge Criteria:

1)   Written discharge order by the attending physician.

2)   Substantial resolution of the problems responsible for admission.

3)   Anticipation of prolonged medical stability.

4)   Elimination of need for mechanical ventilation/ airway protection.

The admission of a patient to these units shall be done by the RMO who in turn shall inform the specialists / doctors who are trained to handle emergency care in Intensive Care Units.

The specialist shall give written instructions to trained nursing staff for the management and treatment of a particular patient in such units.

Each patient shall be under the care of a nurse, always maintaining the patient to nurse ratio of 2:1 / as advised by ICU doctor in-charge.

Emergency medicines with resuscitative equipments shall always be kept ready for use. (Ref: Checklist for emergency medicines and equipments).

Specialized life support equipments like, ventilators, defibrillators, infusion pumps, Central oxygen supply and suction, etc., are readily available.

The staff on duty is trained to handle and use this highly technical equipment properly and at the right time.

All staff shall be trained periodically on how to handle critical care equipments so as to minimize break down and loss.

Staff in charge of these units shall check that these equipment's are kept in proper working condition at all times.

Bio medical engineer shall also take care of the maintenance and calibration of equipment's of the intensive care units.

This shall be reviewed by the head nurse of the intensive care units.

In the event of a large number of patients arriving to these units which exceed the capacity of the established beds, the nursing superintendent shall be contacted and she shall arrange for extra beds to be placed in the areas and provide more staff to meet the demand.

Sterility of these units shall be strictly maintained.

Restricted entry of attendants, only one or two close relatives shall be permitted during visiting hours only. Whenever such visitors are allowed inside, measures shall be taken to maintain the sterility of the area. Foot wear shall not be allowed, and they shall wear only the foot wears provided for exclusive use inside the area. Cap, masks, shoe covers are also to be worn by the visitor/relative.

Transfer of the patients to the normal ward or the patient’s home is done after the treating doctor gives specific orders for the same.

Proper instructions on further treatment, advice on preventive aspects and follow up are given to the patient / attendee by the doctor or senior staff nurse.

In order to maintain the quality of care in these departments, the recipients of these services are interviewed from time to time and their satisfaction in the treatment provided is assessed.

When a patient is discharged, details about the investigation, treatment given, condition on discharge, advice on discharge, medications, diet, exercise, follow up, when and how to seek care in case of emergency and details visit schedule shall be written in the discharge card duly named, signed, dated and time by the treating doctor.

A copy of all reports shall be given to the patient along with the discharge summary.

Infectious cases need isolation.

Handling shortage of beds:

1)            In case of bed shortages, this information is given to the Chief Medical Officer immediately.

2)            All stable patients will be transferred out to other wards with their or the attend consent and the same will be intimated to the patient attendant.

3)            On arrival the patient /attendant will be informed about the non-availability of beds, if the patient is stable he will be transferred to other hospital of patient choices.

4)            In case of minor injury or unstable will be stabilized and transferred with the help of hospital ambulance to a hospital of patient choice.

5)            At the time of transfer, transfer protocol is followed.

Quality Assurance Program in ICU:

S.No	Quality objective	Performance indicator	Responsibility	Measurement criteria
				Criteria	Frequency
1.	Service Quality	Staff availability - doctors ,nurses and support staff nurses patient ratio 2:1	ICU incharge staff	Duty Roster / Attendance Record	Monthly
		Bed Availability and turnaround time for making bed	ICU incharge staff	Ward census book ,front office	Monthly
		Reporting time of investigations	ICU incharge staff	HMS / investigations register	Monthly
		Medication administration (route, dose and frequency)	ICU incharge staff	Drug chart	Once in two months
		Coordination between staff in ICU	ICU incharge staff	Feedback form	Monthly
2.	Hospital Infection Control	Infection rates	Hospital infection control committee	UTI, Intra vascular device related infection, Respiratory tract infections, surgical site infections , VAP	Monthly