Tracer Tool
Adapted from Islamabad Health Regulatory
Authority (IHRA)
INSTRUCTIONS: Work on a copy of this template.
- Select Score from the dropdown list.
- Press "Delete" to erase a selection.
- RE-SAVE FILE after making selections
OVERALL RESULTS
# of items met: 0
# of items not met: 0
STRENGTHS
AREAS FOR IMPROVEMENT
9 INTENSIVE CARE UNIT
9.1 Service Management
Standard 22: The Intensive Care Unit is managed by suitably qualified staff and organized
to provide safe and efficient care for seriously ill patients who need to be continuously
monitored.
Indicator 230: A qualified professional with relevant training in intensive care is responsible for
overall co-ordination of the unit and is accessible for specialist advice.
Indicator 231: A designated deputy is responsible for the management of the ICU in the absence
of the manager.
Indicator 232: An appropriately qualified, registered and experienced nurse is responsible for the
day-to-day management of nursing care in the unit.
Indicator 233: Staff are allocated on the basis of a systematic analysis of patient dependency and
number of patients.
Indicator 234: All staff working in the unit are appropriately qualified and experienced for the work
they do and have attended specialist high dependency care courses and continuous medical
education for updating their skills.
Indicator 235: Registered nurses in the unit have completed formal in-service training or a
recognised course in intensive care and at least one is present on allshifts.
Indicator 236: A suitably experienced doctor is immediately available at all times.
Indicator 237: The Unit has a person who leads on infection control issues.
Indicator 238: Relevant current texts are available for all staff for reference on the unit.
Indicator 239: The expenditure/cost of procedures in the ICU is clearly defined, and available.
9.2 Policies and Procedures
Standard 23: Operational policies and procedures which clearly describe the key
processes of the ICU, the responsibility of the staff and expected results are followed by
staff.
Indicator 240: Specific policies and procedures include emergency admission to ICU from:
- Theatres
- Wards
- Other departments
- Outside
Indicator 241: Management policies and/or procedures are available and followed by staff for the
following:
- Airway management
- Conscious Sedation
- Ventilators/respirators
- Central oxygen supply and oxygen cylinders
- CVP readings (central venous pressure)
- Infusion pump management
- Pulse oximeters
- Cardiac monitors
- Arterial lines
- X-ray and other imaging investigations
- Epidural care
- Recovery facilities for all surgical cases where there is no dedicated recovery unit
- Recovery care of major surgical cases
Indicator 243: There are written criteria defining who is authorised to perform the following
emergency clinical activities:
- Intubation
- Tracheotomy
- Insertion of central lines
- Defibrillation
Indicator 244: There are written policies and procedures agreed and followed for the following:
- Clothing of staff and visitors
- Filtering of patients’ respired air
- Changing of catheters, humidifiers and ventilator tubing
- Isolation of at-risk or infected patients
- Cleaning of the unit
Indicator 245: Regular meetings take place to review cases and patient management, both within
the unit and in conjunction with other departments.
Indicator 246: The Unit will have defined visiting hours.
9.3 Facilities and Equipment
Standard 24: Safe and adequate facilities and equipment are provided to meet the needs
and volume of patients in the ICU.
Indicator 247: There is sufficient space for storing disposable and consumable items.
Indicator 248: A functional resuscitation trolley and defibrillator are available on the unit
Indicator 249: Within the Unit, a designated member of staff is responsible for checking and
recording daily and after each use:
- Resuscitation equipment
- Stockholding and date of resuscitation drugs
Indicator 250: Each bed has a central line facility for:
Indicator 251: Beds in the unit are arranged to allow ready access for routine and emergency
procedures and are within direct vision of supervising staff at all times.
Indicator 252: Adequate (at least three) numbers of power sockets are available for each bed.
Indicator 253: Facilities in the unit include:
- CVP monitoring
- Pulse oximetry
- Blood pressure monitoring (automatic)
- Urometry
- Ambient and patient temperature monitoring
- Arterial blood gases
- Glucometer
- Electrolyte machine
Unit:
Dept.: Quality Department
Date:
Tracer Team:
# of items completed: 0
% of applicable questions scored MET: #DIV/0!
Findings/ Recommendations
Findings/ Recommendations
Findings/ Recommendations
