ST.

PAUL’S HOSPITAL MILLENNIUM MEDICAL

COLLEGE

ADDIS ABABA, ETHIOPIA

INTENSIVE CARE UNIT MANAGEMENT MANUAL

Prepared by: ICU committee

2019
 1. Scope

The ICU provides care for patients in a critical condition requiring continuous, specialized
medical care. This is an area where highly complex equipment is used, and skilled medical and
constant nursing care is provided to patients which cannot be provided on a regular ward. The St.
Paul’s ICU will have a responsibility to handle in vast varieties of critically ill patients and be a
role model to strength the capacity of Ethiopian ICUs.

The content of this manual should be of great help for the following reasons:

1. For the hospital administration to acknowledge the quality standards necessary to help
establish a good ICU service.

2. To detail the specific requirements of the ICU in regard to manpower, training &
qualifications, and the necessary sophisticated equipment required and its technical
support and medical supplies.

3. This manual in its entirety details the Standards, Operational Policies & Practical
Procedure Guidelines to be implemented in the Intensive Care Units (ICU’s). It is the
responsibility of each Department that other operational standards in operation do not
conflict with the policies and protocols laid down in this document.

Disclaimer:

This document is not entirely original. Part of it is adopted from freely available
resources.

ICU Consultants in this document are intensivists, associate professors or assistant

professors in critical care related fields.

As the vision is to be a department in the future the phrases intensive care unit and
intensive care department are used interchangeably in this document.
 2. The Vision

To be a department with excellent, evidence based ICU services in East Africa by 2021.G.C

3. The Mission

To provide high quality critical care services and to train competent, compassionate critical care
professional and perform problem based research.

The short term activities to achieve the vision may include.

1. Decrease mortality and morbidity by delivering quality critical care in all available ICUs.
2. Improving management of critical ill patients in Ethiopian ICU through well designed
ICU manuals.
3. Efficient utilization of ICU equipment.
4. Efficient utilization of ICU beds.
5. Support the growing subspecialty and specialty medical education through organized
critical care service.
6. Increase availability of organ support devises including dialysis machine, and ECMO
7. Start critical care fellow ship in SPHMMC
8. Develop a workable locally appropriate ICU case management and monitoring guide line.
9. Be the short term training center for doctors and nurses who will stay and manage
critically ill patients in other hospitals.
10. Develop critical care nursing manuals for the improved care of critically ill patients.
 4. How many ICUS and Beds

It is recommended that total bed strength in specific ICU should be between 8 and 12 and not <6
or not >14 in any case.

Considering the current situation in St Paul’s the following ICU will be designed.

1. Adults general ICU at St Paul’s hospitals and Neuro and trauma ICU in AaBET hospital

2. Developing any other new ICU with more than 6 beds in St. Paul’s under the department
of main ICU but different staff and ICU director.

3. Neonatology and pediatric ICU under the department of pediatrics and child health.

4. Coronary care unit (CCU) at St. Peter hospital under cardiology unit.

5. Developing separate HDU/ ITU under internal medicine, nephrology, Gynecology and
obstetrics, neurology, surgery, burn and any other discipline with high case load of
critically ill patients.
5. Organogram
 6. Job Descriptions

6.1. ICU director

a. Responsible for the total functioning of the department.

b. Maintaining adequate staffing levels.
c. Participate in all ICU quality improvement, Educational sessions and patient care
d. Maintain the staffing, equipment and quality of HDU
e. Support the development of St. Peter ICU
f. Managing the equipment and supplies. Ensuring that appropriate equipment is acquired.
g. Conducting academic and research activities.
h. Supervising junior faculty and residents.
i. Handling complaints from patients and other departments.
j. Attending meetings in senior management session, academic sessions and others.
k. Collecting various quality indicator data, doing root cause analysis of the identified
problems and to report and to improve the functioning of the department.

6.2. Lead consultants

a. Supervision of all the junior staff during patient assessment, management and emergency
procedures.
b. Leading the daily round
c. On call consultation to all ICUs
d. Daily counseling of families and attendees of patients
e. Defuse difficult or unpleasant situations which may arise between staff and patients or
patients’ relatives.
f. Organization of teaching program according to accepted curriculum and allotment of
topics for lectures/ research to juniors.
g. Allotment of duties to consultants.
h. Following duty roster for residents.
i. Initiate new research projects and guide dissertations of junior residents
j. Academic activity in the form of lectures and presentations at workshops and
conferences.
k. Organizing research activity in the department.
 l. Ensuring appropriate distribution of staff in all areas of activity including teaching
sessions.
m. Visit Peripheral ICUs and follow-up of patients in the wards.

6.3. Consultants

In addition to the responsibilities outlined for fellows and residents, Consultants shall have the
following responsibilities.
They also may have responsibilities in their respective departments
They should be in ICU in the assigned time period (at list one week)

a. Helping in establishing and confirming correct diagnosis, and initiating immediate

management of patients.
b. Performing daily rounds
c. Doing night shifts
d. Guiding and mentoring of residents and fellows both at the bedside and in the classroom.
e. Participation in audits and quality indicator programs of the department.
f. Participate in the administration of the department through assumption of responsibility
for specified activities.
g. Taking part in the academic activities of the department.
h. Visiting HDUs and training of resident patient care.
i. Actively participating in and organizing regular interdepartmental activities.
j. Performing duties entrusted by the institution like supervising examinations and setting of
question papers.
k. Performing all official duties assigned by the head of the unit VPMS, VPAS, OR
PRROVOST.
l. Being part of departmental research activities and initiate new research projects.
m. Ensuring publication of research output in indexed journals.

6.4. Critical care fellow:

a. Accurate assessment of all patients attending the department and arriving at a

provisional diagnosis, in conjunction with the junior residents.
b. Supervision of junior residents at all times, including in patient management, during
performance of procedures and during counseling of relatives.
c. Allotting tasks to the junior residents and interns and preparing the duty roster for
 residents.
d. Triaging patients, ensuring that nursing staff carry out instructions, ensuring accurate
and timely advocation of treatment to patients.
e. Periodic updation of medical records to reflect all aspects of care.
f. Bedside teaching of juniors to improve their skills in patient assessment, management
and emergency procedures.
g. Classroom teaching during the department’s teaching program
h. Taking part in undergraduate and postgraduate teaching
i. Conducting training programs for better patient care for the nursing aids and to staff in
the OPD and ward.

6.5. Residents responsibility

a. Performing Initial assessment and undertaking immediate management of all patients

attending the EMCC department or inpatient wards during consultation.
b. Arranging for / performing urgent investigations and collecting reports, and promptly
conveying critical reports to the consultants in charge.
c. Starting intravenous access and administering emergency drugs and fluids.
d. Formulating a management plan for each patient after discussion their senior.
e. Performing emergency procedures under supervision .
f. Liaising with other appropriate departments depending on the needs of each patient,
discussing the patient’s problem with them and performing necessary investigations as
advised by them.
g. Close monitoring of all patients as long as they stay in the emergency department.
h. Counseling of patient’s relatives regarding the diagnosis, prognosis and effective
timely management of the patient in accordance with the overall plan of care.
i. Documentation of all patient related information including history, examination
findings, dietary preferences, etc. in the patients’ folder.
j. Planning the required diagnostic procedure(s) and safely performing the same.
k. Instituting the treatment as decided by the supervising seniors.
l. Performing procedures indicated during follow up/revisit of patients.
m. Taking part in academic activities such as seminar presentations and case
presentations.
n. Taking part in undergraduate teaching; bedside teaching and tutorials.
 7. OPERATIONAL POLICIES

7.1. Physician Operational policies:

Patients admitted to the ICU are admitted under the name of the ICU consultant or under the
admitting consultant as per operational policies of St Paul’s Hospital.

 Management of each patient is carried out by the ICU staff and, if appropriate, in
combination with the referring Team.

 Doctors’ Orders and Drug Charts are to be written up only by the ICU physicians.

 Doctor’s rounds will take place twice daily. These rounds can also have staff from other
departments.

 A major round will take place in the morning and at the end of the working day to prepare
the patient care plan for both day and night.

 A consultant plan will be recorded within 24 hours of admission.

 The progress sheet will record issues and care plans (diagnostic & therapeutic) twice
daily after each shift in the progress charts.

 Issues and plans discussed with relatives will be documented in the progress charts.

7.2. Nursing operational Policy:

Nurses should be able to demonstrate the ability to:

 Assess and manage the psychological needs and physical care of patient suffering sudden
and chronic trauma and crisis.

 Demonstrate skilled use of equipment for monitoring and therapy.

 Detect and manage sudden and dramatic changes in the patient's condition.

 Know about all relevant psychological, physiological and therapeutic aspects of ICU
treatment.
 Involve the patient and relatives in relevant aspects of care.

 Document nursing progress, care plan after every shift in progress records

Nursing staff will:

 Collaborate with colleagues to identify, agree and monitor standards of care.

 Identify education needs for all staff.

 Provide information for patients on the principles, objectives and outcomes of the ICU.

 Contribute to audit.

 Know about ethical issues underlying ICU treatment and contribute to the ethical decisions.

 Have knowledge of current policy statements regarding ICU.

 Support the patient with full information about details of care and be aware of legal
implications in regard to consent.
 8. Work flow pattern:

The day starts at 08 00 where the doctors who have done night will hand over to the morning
staff in morning session. There are two teams with non-overlapping functions who share the ICU
workspace and patient load. More than one ICU team may share the residents in ICU. After
handing over, the ICU staff will discuss with the family the events and plan for the day
(counseling). The ICU social worker often provides support in this process. The senior ICU staff
will do rounds and the residents are expected to keep the work plan and developments. During
night time EMCC and anesthesia specialists will be covering the care.

Rota

 An ICU director should dedicate himself in ICU without any other additional clinical
responsibilities. He will be in ICU the whole day.

 ICU consultants and lead consultants will be rotating to ICU from their respective
departments. The departments can decide for how long they are going to stay in ICU. But
it should be at least for one week without any other responsibilities.

 ICU consultants and lead consultants will be in ICU during assigned time unless replased

 At least two lead consultants will be assigned in ICU at a time. They have to be in ICU
during the whole working hour at least for one week.

 During holly days and weekends lead consultants will be assigned for day duty coverage.

 Consultants will cover ICU night shift

The designated member who takes care of organizing the Rota should always be aware of
the following points

 Uninterrupted provision of ICU coverage.

 Even distribution of workload amongst each rank of physicians.

 Avoidance of over exhaustion of physicians so that patient care is not jeopardized.

  Continued coverage of after hours, nights, weekends and holidays.

9. Verbal order and communication Policy:

A number of situations which require urgent verbal orders to be carried out are common in ICU.
The following principles should be borne in mind and followed:
PURPOSE:
 To enhance safe practices around treating orders and ensure verbal/telephone orders are
authenticated.
 To reduce errors associated with misinterpreted verbal or telephone communications of
medication orders or test results.
a) A Verbal order should be acknowledged by repeating the order, executing the order, and
communicating back the order and noting that it has been acknowledged: Give 50 mg X,
50 mg X?, Yes 50 mg X, 50 mg X given, Thank you.
b) This verbal order has to be written and signed by physician and nurse.
c) Abnormal/Unusual doses should be double checked by two nursing staff verbally and
documented.
d) Verbal orders will be given only by qualified physicians or other persons authorized to
prescribe.
e) Verbal communication of prescription or medication orders and test results is limited to
urgent situations in which immediate written or electronic communication is not feasible.
f) Verbal orders and test results are not allowed when the prescriber is present, and the
patient’s chart is available, except during a sterile procedure or in an emergency, in which
case a repeat-back is acceptable.
g) Verbal orders are not permitted for non-formulary drugs, except during a sterile
procedure or in an emergency, in which case a repeat-back is acceptable.
h) Verbal orders are not permitted for chemotherapy and high-risk medications.
i) Verbal orders and test results are not permitted via voice mail.
PROCEDURES:

 Recipients of verbal orders will sign, date, time, and note the order at the time it is written
 For medication orders, the prescriber will spell the name of any unfamiliar medication, if
either party feels this is necessary.
 For medication orders, prescribers will include the purpose of the drug to ensure that the
order makes sense in the context of the patient’s condition.
  Due to the risk for medication errors associated with verbal/telephone communication of
orders, it is expected that the following components of the order will be verbalized and
transcribed:

 Date and time of order

 Generic and brand name of drug

 Drug dosage (strength and concentration, formulation – tabs, pills, solution mg/cc)

 Dosage, pronouncing it in single digits (e.g. 15 mg should be read as one five)

 Quantity and duration

 Route of administration

 Frequency of administration, (e.g. three times daily, not TID)

 Name of Prescriber

 Signature of Order Recipient.

 Prescribers will verify, sign, and date orders within 24 hours.
 Abbreviations should be avoided when an order is given or received.
 A record of the verbal order must be documented in the patient’s clinical record

Verbal orders are not acceptable for the following

 Blood and Blood Product
 Chemotherapy drug
 Narcotic drug
 Antithrombotic agent
 Anti-arrhythmic agent
 Neuro-muscular blocking drug
 Epidural or intrathecal medication
 Electrolytes
 Radio contrast agent
 10. Admission& discharge policy:

10.1. Guidelines for the Admission of Patients to ICU.

Introduction:

Appropriate utilization of ICU resources is an important issue in poor resource settings.

Therefore, SPHMMC ICU guideline will help to guide the admission, discharge, transfer,
management and conflict resolution in the ICU.
Objectives:
➢ To aid physicians in determining patient appropriateness for ICU admission and
discharge.
➢ To avoid unnecessary delayed admission and discharge.
➢ To acquaint the ICU staffs with the specific criteria for admission and discharge
➢ To coordinate the departments and units and develop equity among them in use of ICU
➢ To improve ICU management
Admission Policy
 Critically ill patients may be admitted to the ICU from any department of the hospital.
 Admission to ICU can be requested by any consultant in the hospital but admission of a
patient to the ICU must be accepted by ICU consultant after priotization from available
patients.
 If a decision is made to admit a patient to the ICU, the nurses must be informed
beforehand to get prepared.
 All patients admitted to the ICU have to be under a Consultant in the hospital or an ICU
consultant. This non-ICU consultant will not be directly responsible for the medical care
of the patient while in the ICU. However daily communication between the ICU medical
staff and the referring consultant will be encouraged.
 Patients admitted directly through the Emergency Unit come under the name of the
admitting surgical department of the day for surgical cases and ICU consultant for non
surgical cases.
 Patients sent to the ICU from the wards must have their beds reserved whenever possible.
 Transfer from another hospital to ICU will be organized by EMCC. This is to avoid
blocking of ICU beds by patients from other hospitals when Emergency Medicine needs
to transfer patients from emergency to ICU.
Admission Criteria

The ICU admission decision may be based in two models utilizing prioritizing and diagnosis.
These admission criteria are meant to guide the physician and don’t replace physician’s
judgment.

1 .Prioritization Model for ICU admission

This system defines those that will benefit most from the ICU to those that will not benefit at all
from ICU admission.

Priority 1 – Unstable

Requires intensive treatment and monitoring that cannot be provided outside of the critical care
unit (respiratory support, continuous vasoactive drug infusions, etc). Admission should take
place as soon as possible.

Priority 2 – High risk of sudden deterioration

Requires invasive monitoring and may potentially need immediate intervention. E.g. a patient
with chronic co-morbid conditions who develops acute severe medical or surgical illness

Priority 3 – Reduced likelihood for recovery due to underlying illness

May receive intensive treatment to relieve acute illness but limits on therapeutic intervention may
be set, such as no intubation or cardiopulmonary resuscitation.

Priority 4 – Little or no anticipated benefit (too well to benefit) from critical care or patients with
terminal and irreversible illness (too sick to benefit from ICU care) facing imminent death.
Required care and monitoring can be administered in a ward setting. Admission of this type of
patient to the ICU is generally not considered appropriate.
2. Diagnosis Model for ICU admission

1. Respiratory

ARDS, acute pulmonary embolism with hemodynamic instability, massive haemoptysis,

pneumothorax (with hemodynamic instability), upper airway obstruction, after
emergency/elective procedure, bronchoscope patient arrest

2. Cardiovascular

Shock states, life-threatening dysrhythmias, dissecting aortic aneurysms ,hypertensive

emergencies ,AMI,acute pulmonary edema, post cardiac arrest , cardiac tamponade or
constriction with hemodynamic instability ,complete heart block, need for continuous invasive
monitoring of cardiovascular system (arterial pressure, central venous pressure, cardiac output)

3. Infectious diseases

Complicated malaria, relapsing fever with severe complication, severe tetanus, and severe sepsis
with multi-organ failure

4. Neurological

Severe head trauma ,status epilepticus ,meningitis with altered mental status or respiratory
compromise, acutely altered sensorial with the potential for airway compromise, progressive
neuromuscular dysfunction(myasthenia gravis, GBS),acute spinal cord compression ,acute
Subarachnoid hemorrhage, acute stroke with raised ICP, comatose patient.

5. Hematology

Severe coagulopathy and/or bleeding diathesis, severe anemia resulting in hemodynamic and/or
respiratory compromise, tumors or masses compressing or threatening to compress vital vessels,
organs, or airway, DIC

6. Endocrine

DKA complicated by hemodynamic instability, altered mental status , severe metabolic acidosis
states ,thyroid storm or myxedema coma with hemodynamic instability ,HHS or hemodynamic
instability, adrenal crises with hemodynamic instability, pituitary apoplexy with
neurohemodynamic instability, Other severe electrolyte abnormalities, such as: Hypo or
hyperkalemia with dysrhythmias or muscular weakness ,severe hypo or hypernatremia, severe
hypocalcaemia with altered mental status, requiring hemodynamic monitoring

7. Gastrointestinal :

Life threatening gastrointestinal bleeding, acute hepatic failure leading to coma, hemodynamic
instability, severe acute pancreatitis, after emergency/elective procedure

8. Renal

Acute Renal failure, requirement for acute renal replacement therapies in an unstable patient,
acute rhabdomyolysis with renal insufficiency

9. Acute poisoning: Insecticide poisoning, snake bite, CO poisoning, Drug overdose (e.g.
phenobarbitone, antidepressant etc)

10. Surgical

High risk patients in the peri-operative period ,post-operative patients requiring continuous
hemodynamic monitoring/ ventilator support, usually following: vascular , thoracic,
airway ,craniofacial, major orthopedic and spine surgeries, general surgery with major blood
loss/ fluid shift, neurosurgical procedures, post organ transplant

11. Multisystem and Other

Patients with life-threatening or unstable multisystem disease: Toxic ingestions and drug
overdose with potential acute decomposition of major organ systems, multiple organ dysfunction
syndrome, suspected or documented malignant hyperthermia, electrical or other household or
environmental (e.g., lightning) injuries, burns covering >10% of body surface ,anaphylaxis

12. Obstetric

Medical conditions complicating pregnancy, severe pregnancy induced hypertension/ eclampsia,

obstetric hemorrhage with severe hemodynamic instability (APH, PPH), amniotic fluid
embolism, septic abortion with severe hemodynamic instability.
 10.2. DISCHARGE/TRANSFER POLICY

Patients in the ICU will be evaluated and considered for discharge based on the reversal of the
indication for admission or resolution of the unstable physiologic condition, and it is determined
that the need for complex intervention exceeding general patient care unit capabilities is no
longer needed.

Discharge Policy:

a) All discharges must be approved by the on call ICU consultant.

b) Patients are discharged when the reason for admission has resolved.

c) At discharge from ICU the patient will be immediately accepted by the parent team.

d) Primary care teams must be informed of all patient discharges and any potential or continuing
problems.

e) If appropriate, limitation/non-escalation of treatment must be clearly documented and

discussed with the parent team prior to discharge.

f) A discharge summary must be completed in the case notes prior to discharge.

Transfer / Discharge Criteria:

Transfer/discharge will be based on the following criteria:

1. Stable hemodynamic parameters

2. Stable respiratory status (patient extubated with stable VS, AND arterial blood gases if
available) and airway patency;

3. Minimal oxygen requirements that do not exceed patient care unit guidelines;

4. Intravenous inotropic support, vasodilators, and antiarrhythmic drugs are no longer

required or, when applicable, low doses of these medications can be administered safely in
otherwise stable patients in a designated patient care unit;

5. Cardiac dysrhythmias are controlled;

6. Intracranial pressure monitoring equipment has been removed;

 7. Neurologic stability with control of seizures;

8. Removal of all hemodynamic monitoring catheters;

9. Chronically mechanically ventilated patients whose critical illness has been reversed or
resolved and who are otherwise stable may be discharged to a designated patient care unit
that routinely manages chronically ventilated patients, when applicable, or to home;

10. Routine peritoneal or hemodialysis with resolution of critical illness not exceeding
general patient care unit guidelines;

11. Patients with mature artificial airways (tracheotomies) who no longer require excessive
suctioning;

12. Patient is vegetative or neurological recovery is not expected soon, but maintains his/her
airway
The health care team and the patient's family, after careful assessment, determine that
there is no benefit in keeping the patient in the ICU or that the course of treatment is
medically futile.

10.3. Out of Hours Admission

The request for admission must be made by one of the referring Team on-call. Every request for
admission by a junior physician is deemed to imply his Consultant's consent for admission.

Once the decision to admit a patient has been made by the Intensivist they will:

1. Inform the ICU In-Charge Nurse.

2. Ensure that the In-Charge Nurse of the ward currently holding the patient is informed.

3. When a new patient is expected the bed area is prepared according to their clinical condition.

5. On arrival the patient is attached to the cardiac monitor and all the vital signs are taken and
recorded. A member of the ICU Team, as well as the referring Team sees the patient, and a plan
of management discussed. The Senior Nurse on night duty should be informed of an admission
as well as the patient's relatives if not already aware.

6. On entering the ICU patients require constant explanation and reassurance, as they are often
understandably anxious and apprehensive. The same is true of the relatives accompanying them.
 10.4. Discharge

Decision

• Patients are discharged from ICU when the need for treatment is no longer needed or treatment
has failed and/or consent for ICU treatment is witheld. (eg patients not for active ICU treatment
should not come back to the ICU unless there is a change in mangement status).

• The ICU will generally rotate patients from ICU through HDU/ITU prior to transfer to the
general wards.

• The decision to discharge/transfer a patient finally rests with the ICU consultant or his / her
representative.

Once a decision to discharge a patient has been made the ICU physician must:

1. Inform and discuss with the referring Team.

2. Inform the ICU nursing staff.

3. Ensure a ward bed is available.

4. Complete a short discharge summary in the patient's notes.

In addition, Medical Transfer note and Nursing Transfer forms are completed with the patient's
diagnosis, history, treatment, problems and drugs.

1. The appropriate ward will be notified.

2. The referring Department will be informed about the patient being discharged
from ICU.

3. The decision to transfer to any appropriate department rests with the ICU
Consultant or her representative.The patient's relatives and, if possible, the patient
will be informed of the transfer.

4. Ward charts, investigations, x-rays and ECG strips are put together with the
patient's history.
Physiological Criteria for Discharge from ICU:
1) Neurological: Alert and conscious and able to protect airway, or tracheostomy done, or pt
being transferred for palliation/comfort care. No worsening GCS last 72 hrs(exception see
above)
2) Cardiovascular: BP Map>=65 mmHg and a rhythm which is stable and does not need
cardiac monitoring.
3) Respiratory: RR <35 or >12/min, sats clinically acceptable(92%) and Indication for
invasive ventilation unlikely in next 24 hrs. Bipap with Fio2<0.5
4) Hr>40 or <120 bpm.
10.5. Transfer within the Hospital

To improve ease of transport of critically ill patients the following guidelines should be followed
(transport to OT/CT/procedures)

1. Fully sedate and paralyses all ventilated patients before transport (desirable). Drugs for
paralyses and sedation should be available as syringes for bolus administration.

2. All infusions, which are not essential (e.g. maintenance IV, TPN, etc, should be closed off and
pumps removed. Take only the minimum infusions needed.

3. Syringe drivers or volumetric pumps only allowed for essential drugs, e.g. inotropes.

4. Monitoring equipment for pulse rate, SaO2, ECG +Portable monitor (MMS)

5. Check that request forms & essential x-rays are available.

6. Transports will preferably not occur during rounds.

7. An ICU nurse should accompany all patients.

8. An ICU doctor should accompany all unstable and critical patients and should have airway
skills

9. Oxylog + two O2-tank used for ventilation of transported patients

10. AMBU bag for manual ventilation and essential drugs/equipment.

11. Emergency drugs and drugs for sedation, analgesia and muscle paralysis should be available.
 11. SOP for bed shortage:

1) ICU consultant will communicate with liaison, ward consultant and ward
nurse and identify patient who can be exchanged for the incoming patient.

2) In case of no suitable bed consultant can co-ordinate with supervisor to

expedite transfer/creation of ward/ITU bed.

3) Areas in order of priority which can create beds: different ICUs, ITU/HDU
other hospital ICU, wards.

4) Last resort-patient can be kept in emergency until bed is available.

 12.Levels of Critical Care for terminally ill patients
Policy
The ICU is committed to the attempt of preserving life while:
1. Respecting individual's dignity.
2. Determining the competent patient's informed acceptance or rejection of treatment, including
cardiopulmonary resuscitation.
3. Recognizing that in certain cases of irreversible and irreparable terminal illness heroic
measures are unwarranted.

12.1. Procedure

In harmony with this commitment, the following definitions and care guidelines are provided to
assure appropriate care for patients while in the ICU.

1. Category 1 Total Support: All patients are assumed to be at this level upon admission to the
ICU unless, or until, otherwise documented.

Description: A critically ill or injured patient, without irreversibly damaged vital organ systems,
in whom survival without brain failure is expected.

Care Guidelines: Everything possible is done to reduce mortality and morbidity.

1. Category 2 Limited support (no CPR or dialysis or escalation as per patient/family

decisions which are extensively and appropriately discussed and documented).

Description: Patients who deserve support but certain boundaries have been determined.
(Formal documentation is essential on hospital forms).

Care Guidelines: Everything possible is done to reduce mortality and morbidity within the
stated boundaries.

2. Category 3 Basic Care/Comfort care: Patients in whom aggressive treatment is

meaningless, ie seems to delay death rather than prolong life.( Formal documentation on
hospital forms).

Care Guidelines: Every aspect of therapeutic regimen is determined by the criteria of overall
welfare and comfort of the patient. Certain procedures may cease to be justifiable and thus be
contra-indicated (CPR, Escalation of drugs etc). Therapeutic measures are not instituted, or
 are discontinued, unless discontinuation is expected to result in immediate demise. It is
important that the intensivist specify for nursing and junior physicians what modalities of
treatment will be excluded.

3. Category 4 Ventilation Discontinuation. Description: Formal withdrawal of care when

further treatment is deemed futile. We recommend communication and request of same by
the next of keen, intensivists and at list two ICU consultant before deciding for this path way.

4. Category 5: Brain death pathway. As of now we do not have Braine death and organ
donation criteria in Ethiopia. Hence this category is not applicable.

12.2. WITHHOLDING AND / OR WITHDRAWAL OF ACTIVE TREATMENT

• There are no specific “tests” that can be applied to identify patients who have no hope of
survival and to aid in the decision to withhold and / or withdraw treatment. Formal
documentation of the process, discussions with the family and plan should be documented in
detail in the ICU document (progress).
• However, there are certain guidelines which can be considered helpful in supporting a clinical
decision to withhold and / or withdraw active management.
• Patients with terminal conditions e.g. end stage organ failure with no medical treatment
available, i.e. terminal liver failure and terminal malignancies will be among the patients
considered appropriate for withholding of active treatment.
• Active management includes: inotropic support, renal dialysis / haemofiltration, blood & blood
products, TPN and ventilatory support.
Basic care includes: sedation & analgesia, IV fluids, maintenance of a free airway with room air,
enteral feeding and personal hygiene, and will be continued.
• Any decision made to withdraw treatment will be a team decision. The team will be made up of
the health care professionals involved in the patient's treatment and next of keen for the patient.
Any disagreement regarding the decision to withdraw treatment will result in treatment being
continued.
• Relatives should be told of the poor prognosis and their contribution to the discussion, if any,
should be considered and recorded.
 12.3. Care of the dying patient.

The quality of ICU care is judged as much by the care of dying patients as by the care of patients
who have been just admitted.

In the majority of cases in ICU, death is not sudden and unexpected, and appropriate counseling
should prepare the family for the terminal events.

The following practice pointers are indicative of the best practices:

• Restrictions on patient’s access by family can be eased whenever possible if it does not impact
on care.

• Privacy of patients can be increased by shifting such patients to quieter areas and providing
privacy to family.

• Reduce number of intrusive visits and tests.

• Ensure that patient is pain free and comfortable.

• Culturally appropriate support should be provided.

• Culturally sound religious leaders can be called to provide support and services.

• Family can bring “Holley water” or “Zam-Zam pani” which can be used to help them pay their
final respects to patient.

• If family wishes they can be at the bedside during the final moments.

• Discuss arrangements with family and inform them about hospital facilities for storage,
embalming and paperwork and documentation.
 13. Access control

The following policy is designed to maintain reasonable access to the ICU for visitors, while
maintaining good medical care and the privacy of the patient. 24-hour security, sufficient for the
individual ICUs, should be provided.

Visitors include: Family members & friends of patients, Professional visitors from within the
Hospital, Professional visitors from outside the Hospital

All Visits to the ICU

1. All requests for visiting or touring the ICU both by professionals and non-professionals who
are not directly related to patient care must be coordinated and cleared by VPMS, or his
representative, and / or the Nurse in Charge.

2. The ICU staff has ultimate and absolute authority over visiting and touring. Any visit in
progress may be terminated if conditions warrant.

3. Family members and friends are allowed to visit the patients while in the ICU. Certain
restrictions, however, must be placed on the visiting in order to give the best possible care to all
patients in ICU.

4. All visitors should be informed by the physician of the patient's condition and what equipment
is currently being used for treatment

5. A limit of 2 visitors per day per patient is permitted with only two visitors at the bedside at any
time. The Nurse will limit the time of each visit.

6. No information will be given to anyone other than close family members.

7. During the following times, visiting will not be permitted:

1. Nursing Report or handover time.

2. Physician rounds.

3. Emergencies.

4. At the Nurse's discretion.

 14. Noise Control.

ICU patients require rest. All alarms, QRS beeps should be appropriately adjusted to minimize
noise pollution.

The ICU is designed to care for critically ill patients. Every effort should be made to keep
extraneous noise to a minimum.

15. Departmental stock

All essential drugs must be kept in the ICU. The list of such drugs is determined by the ICU
team. See annexes for recommended ICU medications and equipments to be available at
SPHMMC ICU.

STORAGE

1. IV stocks are kept in clean room.

2. Drugs which need refrigeration should be kept in a refrigerator.

3. Lists should be clearly posted outside the drug cupboard.

4. Emergency drugs should be kept in prominent position.

6 .LASA: look alike/Sound Alike and high risk medication protocols are in place and staff are
aware about them
 16. Communication and consent

16.1. What information should be provided?

Patients and their families should receive information which is appropriate to the stage of the
disease. Information should also be given if requested or deemed to be useful in making
decisions or to make choices.

Information offered could include;

 Information about the stage of the disease

 Information about goals of care and outcomes
 Information about treatment and care options available
 Medications and their possible effects
 Availability and scope of services in the institution
 Any other help with documentation, insurance, healthcare benefits etc.

Information provided should be sensitive to the needs and preferences of patients and their
families. Those who do not wish to have the information should be respected.

16.2. Presumption of capacity:

It is to be presumed that every patient is capable of making decisions about their care and
treatment. It is improper to assume that patient has no capacity based on their language, age,
disability, appearance, behavior, medical conditions, beliefs or apparent inability to communicate
or if they make a decision that others disagree or consider unwise.

16.3. Maximizing capacity to make decisions:

It is important to provide all the support, explanations and reassurance to patients to support the
patient in maximizing their ability to understand, retain, use, or weigh up the information so as to
enable them to make decisions.

16.4. Decision making in patients who have capacity to decide:

After an assessment by a specialist of the overall clinical condition of the patients and
understanding by the patient of his clinical prospects, doctors should explain the therapeutic
options available to patient, their benefits, risks, burdens etc for each option.
Patient has a right to choose the treatment or refuse the treatment. If patients requests for
clinically inappropriate treatment, doctors should explain the reasons why the options are not
beneficial. Doctors have a right to refuse inappropriate treatment and advise the patient regarding
second opinions and legal redress if any.

16.5. Decision making in patients who lack capacity to decide:

This situation initially involves identification of a next of kin or a legal representative.

 Initially the doctors should be clear about what decisions need to be made regarding care.
It is important to ensure if the patient has refused consent for certain aspects of care and
has it been documented.
 Next, the doctors should ascertain who holds the authority for making decisions. Is it next
of kin or a legal authority. Next of kin, family, or any other well wishers etc usually
represent patient’s interest in majority of clinical situations in Ethiopia.
 Legal authorization and representation is needed for inmates of prisons, orphanages etc.
Also, it will be important to know the scope of their authority. In absence of legal
authority, the institution legal and ethical offices will be communicated.
 After an assessment by a specialist of the overall clinical condition of the patients and
understanding by legal representative or next of kin, of his clinical prospects, doctors
should explain the investigations and therapeutic options available to patient, their
benefits, risks, burdens etc for each option.
 Patient’s caregivers have a right to choose the treatment or refuse the treatment. If the
caregivers request for clinically inappropriate treatment, doctors should explain the
reasons why the options are not beneficial
 17. Ethics& Pts rights/safety:

17.1. Patient rights:

It is the patient's right to receive enough information regarding all treatments, procedures and
anesthetic techniques to allow them to make decisions regarding treatment. The patient’s wishes
should be respected as much as possible. It should be emphasized that the patient wishes are
paramount and only if she is incompetent should the wishes of the next of kin be ascertained.
Interactions with patient and family should involve nursing staff and social workers, and
adequate documentation of events should reflect the spirit of discussions and not merely the
decisions taken. This will include the following in the ICU.

17.2. Confidentiality:

All patient related information is confidential. Information will only be provided to third parties
after specific consent has been obtained. Specific consent will be obtained from surrogates prior
to disclosing status. In the case of intra-family disputes the doctor will identify the legal next of
kin and provide a consensus by which disputes can be mediated.

17.3. Refusal of treatment:

ICU staff will respect the patient or surrogates wishes to refuse or defer decisions regarding
specific treatments. This will be documented appropriately and updated on a regular basis.

17.4. Privacy, safety and dignity:

ICU patients are very vulnerable and ICU staff will be trained to respect privacy in each and
every patient related activity. Verbal consent will be obtained and attempts made to
communicate prior to each and every patient interaction however trivial ( eg: nasogastric
feeding, back care…)

17.5. Consent:

Standard consent and information is already available in the ICU admission document. Consent
will be taken and documented for special procedures:
 17.6. Research:

The protocols governing clinical research of the hospital along with the statements of the Ethical
Review Board will have to be followed in letter and spirit. No studies cannot be undertaken
without explicit consent and formal documentation of all relevant processes.

17.7. Right to information:

Patient and legally empowered next of kin have full access to all patient related records. Copies
of these will be made available to them on request. Discussions with patients will be done in a
language best understood by patient

17.8. Social and Cultural needs:

ICU staff should be aware of the cultural needs of family especially at end of life care. Every
attempt will be made to recognize and fulfill cultural needs of the patients.

18. AUDIT

It is necessary to appreciate the importance of audit. Providers of intensive care should

understand the distinctions between audit and research. Audit means the process of monitoring
and assessing performance. Quality Assurance is a system to ensure high quality performance of
care.

18.1. Audit Activity

The presence of a systematic and comprehensive clinical audit program should be demonstrated.
Clinicians must accept that administrators will have a legitimate interest in the audit and, with its
application, improve practice. Audit activity should be:
1. Incorporated into the general activity of the unit.
2. Designed to provide a program for quality assessment, which will lead to improvements in
performance and the quality of patient care.
3. Implemented to measure practice against activity and clinical standards.
4. Carried out regularly in identified areas of concern.
5. Able to compare assessment of the delivery of care with agreed protocols.
6. Involved with collaborative audit between areas to improve care.
 19. Quality Assurance

1. Quality Assurance is an essential function and regular reviews are necessary to ensure that
good care is given. Constant improvement in quality of care should be the goal.

2. Monitoring that records are being correctly completed in duplicate.

3. A mechanism must be established to ensure that when important matters are neglected,
appropriate corrective measures are implemented.

5. The factors that are monitored in audit should be carefully selected and regularly reviewed to
ensure they are appropriate.

6. This should be an ongoing, dynamic process, with appropriate responses to feedback

mechanisms.

7. Within a department a more formal, closed meeting should occur regularly to discuss candidly
mortality &morbidity, difficult cases and critical incidents.
QUALITY IMPROVEMENT PLAN OF THE DEPARTMENT (KEY PERFORMANCE INDICATORS)
KPI Code KPI Description Frequency Domain
KPI-001 Reintubation within 24 hrs Weekly Structure
Monthly Process
Quarterly Outcome
Half yearly
Yearly

Readmission within 48 hrs Weekly Structure

Monthly Process
Quarterly Outcome
Half yearly
Yearly

Iatrogenic pneumothorax Weekly Structure

Monthly Process
Quarterly Outcome
Half yearly
Yearly

HICC: CAUTI/CLABSI/VAE Weekly

Monthly
Quarterly
Half yearly
Yearly

20. DATA MANAGEMENT:

It is essential that all staff of the ICU contribute in a meaningful manner for full rollout and
utilization of the data management. Database will be is installed on all ICU computers. The user
id's and password will be available with the ICU director. Formal teaching on usage of the app
will be done at the bedside.

Following are the duties of each category of staff:

1. Consultant and fellow: Ultimately responsible for maintaining database up to date. Daily they
will enter health issues in a standard manner. Residents are encouraged to enter health issues as
and when a new issue occurs. They are responsible for updating sentinel events in health issues
like a) pressure sore/falls, b) unplanned events c) VAC's etc.

2. Head of unit Responsible for informing faculty about number of new admissions an entering
health issues like fever and labs on a daily basis for all patients.

3. ICU registration assistant: Responsible for maintaining lab values and vitals.

4. Staff nurses: maintaining procedures and medications in database.

21. ACADEMIC

21.1. CONTINUING MEDICAL EDUCATION (CME)

1. The department of Critical Care should have time set-aside during working hours for weekly
lectures, journal clubs, tutorials and case presentation.
2. This teaching should be aimed at physicians, nurses &technician from both inside and outside
the Department of Intensive Care.
3. Rotation of intensivists, nurses and paramedical staff to other areas of the hospital is allowed
as per curriculum.
4. Journal Club: Regular meetings are to be encouraged and provision made to acquire the major
journals.
5. Cardiopulmonary Resuscitation-It is mandatory that all physicians are certified ACLS.
6. RESEARCH: All staff members are encouraged to do meaningful research within the
guidelines laid down by the Ethics committee.
7. Faculty and Staff are encouraged to take active part in training by the unit

21.2. TRAINING

The training of ICU staff is time consuming and requires the acquisition of knowledge and skills
as a teacher.
Training can take the form of:

 Continuous presentations and lecturers presented by junior and senior physicians. (Time
should be allocated during the working day for the preparation and delivery of lectures.

 Daily physicians rounds, these should have a strong teaching element.

 Supervision in the ICU, this would ideally, be one-to-one.

This training would be appropriate for:

 Junior physicians wishing to specialize in ICU. These physicians should have a teaching
session / tutorial once a week.

 Physicians from other departments who require a rotation in ICU to complete their
training. They should be able to deal with a critical patient, i.e. critical airway and
assessment of hemodynamic.

Physicians in training:

• Should be actively involved in patient care including admission from the emergency room,
consultation and ongoing care until discharge.

• Should be exposed to all ICU procedures and skills to master intubations, central line insertions,
venous and arterial cannulations, chest drainage, etc.

• Should be familiar with haemodynamic monitoring and interpretation for the purpose of patient
treatment, ventilatory modes, troubleshooting and other aspects of medical support in ICU, e.g.
nutrition.

• Are expected to attend conferences, symposia and meetings, and are encouraged to present
papers.

21.3. NURSING

A Clinical Mentor (currently Mr. Mark) who is dedicated to the ICU, trains nursing staff.

Each member of the nursing staff will complete an extensive education program that aims to
advance their knowledge and skills to a point where they can work independently in the ICU.
 Nurses training:

1. There should be skill sharing between the staff of other specialized units and ICU staff.

2. All nurses joining the ICU must undergo training for a period of at least one month before
they are allotted independent patient care for 2 patients.

3. They will be put along with a senior staff nurse where they will perform procedures under
supervision.

4. Classes will be scheduled for the new staffs and they must take responsibility to attend
the classes.

5. Program list of procedures will be given to all staffs that will be the basis of guidance for
their learning at the bed side.

6. There will be classes organized periodically by doctors and staff nurses and students in
the ICU which all staff nurses must attend.

7. the staffs nurses will have periodic performance appraisals

22. Annexes

A. Recommended Crash cart medications

S.No

Stoc

Names
k

3 Inj. Magnesium sulphate 6

1 Inj. Adrenaline – 1 mg 15 4 Inj. Soda Bicarb – 25 ml 10
2 Inj. Amiodarone – 150 mg 6 5 Inj. Xylocard 2% 2
 41 Surgical gloves no -6.5, 7, 7.5 2 each
6 Inj. Atropine – 0.6 mg 10 42 ECG electrodes 6
7 Inj. Midazolam 2 43 Kidney tray 1
8 Inj. Adenosine – 6 mg 5 44 Voluven – 500 ml 2
9 Inj. Dobutamine – 250mg 1 45 0.9 % NS – 500 ml (Viaflex) 2
10 Inj. Dopamine – 200 mg 2 46 RL 500ml 2
11 Inj. Hydrocortisone - 100mg 5 47 Dextrose 50% - 100 ml 2
12 Inj. Lasix 2 ml 6 48 Dextrose 5%- 100 ml 10
13 Inj. Eptoin 2 ml (100 mg) 10 49 2CC / 5 CC/ 10 CC Syringes 5 each
14 Inj. Potassium Chloride 5 50 20 CC/ 50 CC Syringes 2
15 Inj. Calcium gluconate 5 51 IV extension 100 cc 2
16 Inj. Noradrenaline 6 52 18G / 20G / 22G Venflows 2
17 Inj. Avil 2 ml 2 53 18G needle 2
18 Inj. Vecuronium 10 mg 2 54 ABG syringe 2
19 Inj. Propofol 50ml 2 55 3 way 2
20 Inj. Ketamine 2
21 Oxygen mask 1
22 Ambu bag with mask, O2 tubing 1
23 Airways - no 2 / 3 1 each
24 Laryngoscope with blades 3,4 1 each
25 ET tubes (cuffed) (6, 6.5, 7, 7.5,
8,8.5) 2 each
26 Intubating stylet 1
27 Xyclocaine Jelly 1
28 Dynaplast 1
29 Cotton tape 1
30 1
Tracheostomy tube no –7,7.5,8,8.5 each
31 Suction catheter 14 with
connector 1
32 Magill forceps 1
33 Nasal prongs 1
34 Ryles tube no 14 2
35 IV fluids set (macro set) 5
36 Blood set 2
37 Micropore 2
38 Tourniquet , Spirit swab 1
39 Xylocaine 2% 2
40 Gloves (unsterile) (Box) 1
 B. Recommended ICU Inventory
Items Stethoscope
Ventilators Blue T.piece
Connections Spacer
Nebulizer Peepvalve
Test lungs Knee hammer
Test tubes (Blue) Tuning fork
Heater guide wire Bronchoscopic schivel connector
Humidifier (Adult) Boogi (new)
Humidifier (Paed) Laryngeal mask
Test lungs (Paed) Check valve
NIV fisher packet Bone marrow needle
NIV Resmed Cricothyroid set
NIV Ordinary (Adult) Mask Megles forceps
NIV Ordinary (Paed) Mask Stillets
NIV Metal connections Flexitip laryngoscope with blade
Drager porta vent tubings Fibreoptic laryngoscope+B
Drager flow sensor Laryngoscope(ordinary)
Expiratory cassetes Laryngoscope No:4
Ordinary NIV belt Laryngoscope no: 3
Blood warmer Laryngoscope No:2/ No:1
Kelly’s forceps Ambu bag’s (adult)
Catheter mount Steam inhaler
Hand splints Hair drier
Leg splints Stapler
Heater wire Nail cutter
IBP Module Scales
IBP cables Extension board
Pulse oxymeter Cordless phone
ECG machine Bath basins
Cautery machine with probe Double stands
Doppler Cardiac tables
Opthalmoscope Heater, plate and kettle
Torch Dressing trolly
Glucometer O2 trolly’s
Protoscope Wheel chair
Shaving set Fumigation pump
Tongue depressor Ladder
Needle holder Hand pressure gauge
Suture removal scissors Room heater
Scissors s-2,c-8 Punching machine
Stapler remover Philips monitor
Plaster cutting Ecg cable
Tin cutter SPO2 cables + ear probes
Inch. Tape NIBP Cable +cuff
ICD milker Philips – Agilent monitor
ECG Cables + Modules Shoe racks
Spo2 Module + cables Transport cot with mattress
NIBP module + cables Sofa set
Picco ECG Module + cables Couch (staff resting bed)
Spo2 Module + cable Benkar cot (double bed)
Temp Module + cable Godrej Cupboard
ETCO2 Module Glass cupboard
ETCO2 sensor cable Office chaires
Adapters Plastic chairs
Co modules Reclining chairs
Co cables Crash cant trolley
Temp module Rounds trolley
Temp probes Operation trolley with mattress
Bath trap probes Bed side trolley
Skin probes IV stand steel
MMS extension Co2 – capno / Co2 haemo Cot with rails
Otoscope Wall suction unit
Defibrillator Fridges
Manometer Teapoy wooden
Tracheal dilator Notice boards
Trochar & Cannula Wooden stools
Sand bags Fire extinguisher
ICD wooden box single Mopping machine
ICD wooden box double Aquaguard
ICD wooden box triple Fax machine
Foot blocks Music system
Ordinary phones Lap top
Steel vessel with lid Computers
Feeding cup Pillows
Aluminium trays Podium
Steel kidney trays ABG GEM machine
Steel bowl Knife
Plastic kidney trays Wall clock
Steel tray with lid X – ray illuminator (wall)
Soap dish EEG machine with laptop
Bread box Diginfusa
Flask Infusion Pump
Calling bell Syringe Pump
Hot water bag Rectal thermometer
Water mattress Curved artery forceps
Enema can CVP scales
Bed pan O2 flow meter
Urinal Thermometer
Measuring fax BP apparatus
Microven Pressure bags
Bed cradles White mask
Paed – laryngoscope Black mask
X – ray view machine Reservoir bags
 Ambu bag (paed) Plastic drums
Small plastic bowl Plastic mugs
Jugs Medium size buckets
Big medicine container Dustbins
Injection tray(box) TV with remote
Office tray(plastic medicine tray) Portable suction apparatus
Writing pad Drum SS bin
Chart holder Medicine box
Chart holder TPA seal
3-pin holder

C. Recommended PHARMACY LIST – INTENSIVE CARE

UNIT

01 ATROPINE 34 SERENACE
02 ADRINALINE 35 TRAMADOL
03 SOD. BICARBONATE 36 WATER FOR INJ 10ML
04 DOBUTAMINE 37 ATRACURIUM
05 LEBETOLOL IV 38 LORAZAPAM
06 XYLOCARD 50 ML 39 PAVULON
07 SENSORCAINE 20 % 40 DEXTROSE 5%
08 MENADIONE SODIUM 41 3 % SALINE
09 AVIL 42 DNS
10 CALCIUM GLUCONATE 43 NORMAL SALINE 500 ML
11 DEXTROSE 25% 100ML 44 RINGER LACTATE
12 DEXTROSE 50% 100ML 45 SODIUM CHLORIDE 0.45 %
13 DILANTIN 46 DEXTROSE 10 %
14 HYDROCORTISONE 47 ISOLYTE M
15 DEXAMETHASONE 48 NORMAL SALINE 100 ML
16 QUININE 49 HAEMACOEL
17 HEPARIN 5000 IU 50 HESTERIL 6 %
18 HEPARIN 25000IU 51 NOR ADRENALINE
19 LASIX 52 XYLOCAINE 2% 30 ML
20 POTASSIUM CHLORIDE 53 ½ GNS
21 PARACETAMOL 54 AMPHOTERICIN B 50 MG
22 MVI 55 NITROGLYCERINE
23 MANNITAL 100ML 56 VECCURONIUM
24 MIDAZOLAM AMPOULES 57 ROCURONIUM
25 MAGNESIUM SULPHATE 50% 58 PETHEDINE
26 NORMAL SALINE 25ML 59 MORPHINE
27 PHENERGAN 60 FENTANYL
28 METHYL PREDNISOLONE 500 MG 61 THIOPENTONE
29 VASOPRESSIN ANT
30 T.T 0.5 ML IBIO
31 ANTI SNAKE VENOM TIC
32 PERINORM S
33 RANITIDINE 62 CEFAPERAZONE SULBACTUM 2
 MG 97 RYLES TUBE 14
63 CEFAPERAZONE 2 MG 98 CVC UROCOM
64 PIPERACELLIN TAZOBACTUM 4.5 99 DISPOSABLE SYRINGE 5 CC
MG 100 DISPOSABLE SYRINGE 10 CC
65 CEFTRIAXONE 1MG 101 DISPOSABLE SYRINGE 20 CC
66 CEFAZOLIN 1 MG 102 DISPOSABLE SYRINGE 50 CC
67 IMIPENEM 500 MG 103 DISPOSABLE SYRINGE 1CC
68 ARTESUNATE 60 MG 104 DISPOSABLE SYRINGE 2CC
69 VANCOMYCIN 500 MG 105 NEEDLE 23
70 TIGYCYCLINE 50 MG 106 NEEDLE 18 G
71 PROPOFOL 20 ml 107 NEEDLE 26 G
SO 108 VACUETTE PLAIN 4 ML
LU 109 VACUETTE EDTA
110 VACUETTE COAGULATION
TI
111 VACUETTE ESR
ON SURGICAL GLOVES 6.5”
112
S 113 SURGICAL GLOVES 7
72 IPRAVENT SOLUTION 114 SURGICAL GLOVES 7.5
73 ASTHALIN SOLUTION 115 CERTOFIX TRIO
74 WOKADINE MOUTHWASH 116 CERTOFIX MONO
75 XYLOCAINE VISCOUS 117 ARTERIAL LINE KIT
76 VOVERAN 118 TEGADERM 10 X 12
77 BUSCOPAN 119 SWAB STICK
78 KETAMINE 100 MG 120 AIRWAY 3.0
79 SCOLINE 100 MG 121 AIRWAY 2.0
80 PROPOFOL 50 ML 122 ET TUBE’ 9
81 CORDARONE 123 ET TUBE 8.5MM
82 ADENOSIDE 124 ET TUBE 8
SUT 125 ET TUBE 7.5
URE 126 ET TUBE 7
S:
MA
83 MERSILK 3.0 CUTTING TER
MA IAL
TER S:
IAL 127 ET TUBE 6.5
S:
128 ET TUBE 6
84 DYNAPLAST 10 CM
129 ECG ELECTRODES
85 DYNAPLAST 8 CM
130 TRACHEOSTOMY TUBE 8
86 IV SET PRIME LINE
131 TRACHEOSTOMY TUBE 8.5
87 BLOOD SET
132 FOLEYS CATHETER 14 CH
88 3 WAY
133 FOLEYS CATHETER 16
89 IV EXTENSION LINE
134 TRI FLOW
90 OXYGEN MASK - A
135 DUAL LINE MONITORING KIT
91 NEBU MASK - A
136 UROCONDOM MEDIUM
92 VENTURI MASK
137 SPINOCAINE NEEDLE NO 22
93 NASAL OXYGEN CANNULA
138 SPINOCAINE NEEDLE NO 20
94 VASOFIX 20 G
139 COTTON 200GM
95 VASOFIX 18 G
140 GAUZE BANDAGE 6”
96 JELCO 20 G
141 INTRODUCER GUIDEWIRE
142 SUCTION CATHETER 14
143 THORACIC CATHETER 28
144 THORACIC CATHETER 32
145 HAEMODIALYSER
146 VENTILATOR CONNECTIONS
147 OXYGEN RECOVERY KIT
148 CATHETER MOUNT
149 BACTERIAL +HME FILTER
150 STERI CATHETER
151 SUB CLAVIAN KIT
EXT
ERN
ALS
:
152 HEALEX SPRAY
153 XYLOCAINE JELLY
154 BETADINE 500 ML
154 IRRIGATION SALINE 500 ML
156 DISTILLED WATER
157 HYDROGEN PEROXIDE
158 EUSOL
159 GLYCERIN 400 GM
160 SURGICAL SPIRIT 1L
161 BETADINE OINTMENT 250 GM
162 OIL TURPENTINE
163 POLYSAN 0.5% 5 LTR
164 MERCUROCHROME
165 GLYCERIN MAGSULF
166 VASELINE
167 STERILIUM 500 ML
168 MICRO SHIELD HAND SCRUB 500 ML
OIN
TME
NTS
169 THROMBOPHOB
170 LACRIGEL EYE OINTMENT
DR
OPS
171 MOISOL EYE DROPS
172 TROPICAMIDE EYE DROPS
NARCOTICS
1 INJ. FENTANYL 2ML
2 INJ. FENTANYL 10ML
3 INJ. PETHIDINE
4 INJ. MORPHINE
5 INJ. TRAMADOL (1ML)
6 INJ. THIOPENTONE 500MG
 D. Equipment and medications for transportation of ICU patients on
ventilator
Names Recommended 7.5 1
no 7.0 1
Inj. Adrenaline 5 6.5 1
Inj. Atropine 5 TT 8.5 1
Inj. 8 8.0 1
Noradrenaline 7.5 1
Inj. Ca gluconate 2 7.0 1
Inj. KCL 2 Airway NO 2 2
Inj. Bicarb 3 Suction catheter 3
Inj. Lasix 2 ET tie 2
Inj. Avil 2 ET plaster 2
Inj. Lorazepam 2 Ambu with 1
Inj. Vecuronim 2 reservoir
Inj. Amiodarone 2 O2 connection 1
Inj. Propofol 1 O2 flow meter 1
NS 500ml 2 HME filter 1
DNS 500 ml 2 Catheter mount 1
NS 100 ml 1 Laryngescope 1
NS 25% D100ml 2 with blade
5% D 100ml 2 Cardiac monitor 1
IV set 2 with 4 cables
100 cm 1 Portavent with 1
extension tubings and
20cc syringe 1 sensors
10cc syringe 3 Defibrillator 1
5cc syringe 3
2cc syringe 3
Jelco 20G 2
18g.Needle 5
Inj. Midazolam 2

Vasofix22,20G 2
3way 1
Blade no 11 1
ETT no 8.5 1
8.0 1
PART TWO
ICU
PROCEDURS
 Routine ICU Procedures

1. ENDOTRACHEAL INTUBATION.

Endotracheal intubation in ICU patients is a high risk but vital procedure. Usually it is an

emergency procedure, with limited time. Usually indicated for acute respiratory failure, or

associated with limited respiratory reserve. Patients may have cardiovascular instability and

significant co morbidities. Patients may have cervical spine or oropharyngeal trauma/surgery.

Patients are at risk of vomiting and aspirating. Positioning is difficult. Familiarization with the

intubation trolleys, equipment and drugs in essential. Intubation should ideally not be done as a

sole operator procedure. Skilled assistance should always be sought. If you are alone (ie after

hours): → Call for Help!

Expertise in intubation is always available. Remember EMCC/ OR staff. The majority of ICU

patients mandate rapid sequence induction.

1.2 Indications

a) Institution of mechanical ventilation.

b) To maintain an airway

c) Upper airway obstruction.

d) Potential deterioration like early burns, epiglottitis, trauma Patient transportation.

f) To protect an airway
 g) Patients at risk of aspiration.

h) Altered conscious state.

i) Loss of glottis reflexes.

j) Tracheal toilet

1.3 Techniques

Orotracheal intubation is the standard method of intubation in this unit.

Nasotracheal intubation may be indicated where:

Patients require short-term ventilation and are intolerant of oral ET tubes.

Fibreoptic intubation is indicated: Following head and neck surgery, Inability to open

the mouth: eg intermaxillary fixation, TMJ trauma, rheumatoid arthritis and Upper air

obstruction.

Contraindicated in base of skull & Leforte facial fractures.

Methods:

I. Direct visualization under rapid sequence induction.

II. Fibreoptic bronchoscopic awake intubation.

III. Intubating laryngeal mask – LMA (Fastrac).

1.4 Endotracheal Tubes

a. Standard tubes: low pressure, high volume PVC oral tube.

i. Males 8 – 8.5mm: secure at 21-23cm to incisors.

ii. Females 7– 7.5 mm: secure at 19-21cm incisors.

iii. Do not cut tubes to less than 26cm long.

a. Mark tooth level with tape.

b. Double lumen tubes rarely indicated in ICU:

i. Unilateral lung isolation for broncho pulmonary fistula, abscess or hemorrhage.

ii. These tubes should be inserted as a temporary maneuver prior to a definitive

procedure.

iii. Allow differential lung ventilation.

c. Intubated patients from theatre may have the following tubes that are not recommended

prolonged intubation. These tubes must be changed if intubation anticipated > 48hours if safe

and feasible.

i. Plain PVC tubes: change to standard EVAC trans-laryngeal tube.

ii. Armored tubes: problems:

a. High pressure low volume cuff.

b. Once kinked, remain kinked: beware in patients who bite tubes.

iii. RAE tubes: problems

a. Difficulty in suction due to bend.

b. Fixed length from bend: frequently advance downright main bronchus.

c. High pressure, low volume cuff.

1.5 Protocol for endotracheal intubation in ICU

a. Personnel: Intubation is a 4 person procedure: skilled assistance is mandatory:

i. “Top End” intubator who coordinates the intubation.

ii. One person to administer drugs.

iii. One person to apply cricoid pressure once induction commences:

a. This is recommended as a routine for emergency intubations.

b. The intubator should direct the person who is applying cricoid pressure so that pressure is

correctly applied and removed if distortion of the larynx or difficulty in intubation occurs as a

result.

C. One person to provide in line cervical spine immobilisation (trauma and spinal patients only).

D. Consider the use of Fastrach( intubating) LMA for spinal patients to minimise neck

movements.

E. Secure adequate IV access.

F. Equipment (kept in intubation trolleys).

Ensure the following equipment is available and functional:

i. Adequate light.

ii. Oropharyngeal airways.

iii. Working suction with a rigid (Yankauer) sucker.

iv. Self-inflating hand ventilating assembly and mask.

v. 100% oxygen, i.e. working flow meter at 151/min

vi. 2 working laryngoscopes.

vii. Magill forceps

viii. Malleable introducer and gum elastic bougie.

ix. 2 Endotracheal tubes

a. Normal size + 1 size smaller.

b. Check cuff competence.

x. Access to difficult intubation equipment.

 a. Be aware of Failed Intubation Drill.

b. Cricothyroidotomy equipment (#15 scalpel / #6.0 cuffed ETT).

d. Monitoring (on all patients):

i. Pulse oximetry.

ii. Capnography.

iii. Arterial blood pressure if possible.

iv. Electrocardiograph.

e. Drugs

i. Induction agent (thiopentone, fentanyl, ketamine, midazolam).

ii. Suxamethonium (1-2 mg/kg) is the muscle relaxant of choice.

a. Contraindicated in:

1. Burns > 3 days.

2. Chronic spinal injuries (i.e. spastic paraplegia).

3. Chronic neuromuscular disease (eg Guillain Barre, motor neurone disease).

4. Hyperkalaemia states. (K+>5.5).

b. Consider Rocuronium (1-2 mg/kg) if suxamethonium is contraindicated.

iii. Atropine (0.6-1.2 mg).

iv. Adrenaline (10 ml 1:10000 solution).

1.6 Procedure: Rapid sequence indication and orotracheal intubation

i. Pre oxygenate with 100% oxygen for 3-4 minutes.

ii. Preload with 250-500ml saline intravenously.

iii. Induction agent + suxamethonium.

 iv. Cricoid pressure applied.

v. Direct visualisation of vocal cords and tracheal intubation.

vi. Inflation of cuff until sealed.

vii. Confirmation of end tidal CO2 and chest auscultation with manual ventilation.

viii. Cricoid pressure released.

ix. Secure tube at correct length.

x. Connect patient to ventilator (see default ventilator parameters).

xi. Ensure adequate sedation ± muscle relaxant.

xii. Consider insertion of a naso/oro-gastric tube.

xiii. Chest X-ray, blood gas analysis and adjust F1O2 accordingly.

Xvi. Post intubation sedation: Morphine ± midazolam, propofol, fentanyl diazepam as

indicated by the clinical scenario.

1.7 Maintenance of endotracheal tubes

a. Tapes

i. Secure tubes with white tape after insertion.

ii. Ensure that loop of tape is snug around back of neck but not too tight to occlude

venous drainage. Should allow 2 fingers under tape.

iii. Retape with adhesive tape once X-ray check done.

b. Cuff Checks

i. Volumetric (sufficient air to obtain a seal + 1 ml) tests are done following insertion and

whenever a leak is detected with a manual hyperinflation once per nursing shift.

ii. Seal is assessed by auscultation over trachea during normal ventilation.

 iii. Manometric tests are inaccurate and do not correlate with mucosal pressure. These are

an adjunct only if cuff malfunction is suspended.

c. Persistant cuff leaks

i. Tubes requiring more then 5ml of air to obtain a seal or if there is a persistent cuff leak must be

examined by direct laryngoscopy as soon as possible even if the tube appears to be taped at the

correct distance at the teeth.

ii. Ensure that:

a.The cuff has not herniated above the cords.

b. Tube has not ballooned inside the oral cavity and “pulled” the cuff above the cords.

iii. High risk patients for cuff leaks:

a. Inappropriately cut tubes: do not cut tubes <26cm

b. Facial swelling (burns, facial trauma).

1.8 c. Patients requiring high airway pressures during ventilation.

d. Aspirate EVAC tubes 2 hourly, or more frequently (hourly) if>10ml supraglottic.

1.9 Endotracheal tube change protocol

a. Ensure adequate skilled assistance, equipment, drugs and monitoring as for de novo

intubation.

b. Procedure

i. Set the FIO2 = 1.0 and change SV modes to SIMV.

ii. Ensure sufficient anesthesia and muscle relaxation (fentanyl / propofol + neuro-

muscularblockade).
 iii. Perform laryngoscopy and carefully identify patency of upper airway after suction,

anatomy of larynx, degree of laryngeal exposure and swelling.

iv. Clear view of larynx and no or minimal laryngeal swelling:

a. Application of cricoid pressure by assistant and careful, graded extubation

under direct laryngoscopic vision.

b. Maintain laryngoscopy and replace tube under direct vision.

v. Impaired visualization of larynx:

a. Use gum elastic or ventilating bougie (cook).

b. Place bougie through tube under direct vision and insert to a length that would

be just distal to the end of the ETT (approximately 30cm from end of tube).

c. Have an assistant control the bougie so that it does not move during movement

of the endotracheal tube.

d. Application of cricoid pressure by assistant and careful, graded extubation.

e. Maintain laryngoscopy and ensure bougie is through the cords on extubation.

f. Replace tube over bougie and guide through larynx under available vision.

vi. Inflate cuff, check end tidal capnography, auscultation, expired tidal volume

and then release cricoid pressure.

vii. Secure tube with tape.

 1.10 Extubation protocol

a. Ensure equipment, monitoring and adequate assistant as for intubation.

b. Preferentially done during daylight hours and is a medical responsibility.

c. Extubation criteria:

i. Return of adequate conscious state to maintain adequate protective laryngeal reflexes

and secretion clearance.

ii. Adequate pulmonary reserve Resp rate: <30bpm. a. Tv/Frequency <100 b. Fio2<0.4 &

Stats>95%, Peep<5 and PSV<10.

iii. In patients with upper airway surgery or swelling the demonstration of an adequate air

leak around the deflated endotracheal tube cuff.

iv. Plastic surgical and ENT patients require consultation with the Parent Clinic.

d. All patients should receive supplemental oxygen post extubation.

 2. Peripheral venous catheterisation.

1. Indications: First line IV access for resuscitation including blood transfusion and Stable

ICU/HDU patients where a CVC is no longer necessary.

2. Management protocol: Remove all resuscitation lines inserted in unsterile conditions as soon

as possible.

3. Generally remove if not in use.

4. Aseptic techniques:

i. Handwash with (chlorhexidine/alcohol) + gloves.

ii. Skin prep. (chlorhexidine 1%/75% alcohol)

5. Dressing: adhesive occlusive .

6. Change / remove all peripheral lines after 48 hours.

8. Complications

a. Infection.

b. Thrombosis.

c. Extravasation in tissues.
 3. Central venous catheterisation.

CENTRAL VENOUS CATHETERS: Residents and fellows should be familiar with the

limitations of central catheters in critically ill patients.

1. Indications:

a. Standard IV access in ICU patients:

i. Fluid administration (including elective transfusion).

ii. TPN, hypertonic solutions (amiodarone, nimodipine, etc)

iii. Vasoactive infusions.

2. Monitoring of right atrial pressure (CVP) Currently out of favour due to lack of evidence for

the same

3. Venous access for:

i. Pulmonary artery catheterisation (PAC)

ii. Continuous renal replacement therapy (CVVHDF), plasmapheresis.

iii. Jugular bulb oximetry.

iv. Transvenous pacing.

4. Resuscitation: for acute volume resuscitation considers a PAC sheath.

5. Management protocol: (applies to all types of CVC):

a. Types:

i. The standard CVC for all ICU patients is a 20cm triple lumen catheter.

ii. Vascath catheters are used for CVVHDF and plasmapheresis.

iii. Pulmonary artery catheter sheath (part of the PAC kit)

6. Subclavian is the preferred site for routine stable patients, followed by internal jugular.

Femoral access is preferred where:

• Limited IV access (burns, multiple previous CVC’s).

• Thoracic approach is considered hazardous.

• Severe respiratory failure from any cause (PaO²/FiO²<150)

• Hyperexpanded lung fields (severe asthma, bullous lung disease).

• Coagulopathy and inexperienced staff requiring urgent access, where supervision is not

immediately available.

Technique Policy:

 Local anaesthesia in awake patients.

 Strict aseptic technique at insertion.

 Hand disinfection: surgical scrub with chlorhexidine for >1minute.

 Sterile barrier: gown, glove, cap and mask and sterile drapes.

 Skin prep (chlorhexidine 1%/75% alcohol).

 Seldinger technique only.

 Suture all lines.

 Dressing: non occlusive dressing.

 4. ARTERIAL CANNULAE

1. Indications:

a. Routine measurement of systemic blood pressure in ICU.

b. Multiple blood gas and laboratory analysis.

c. Measurement of BP during transport of patients in hostile environments (e.g. during

retrieval)

2. Management protocol:

a. Remove and replace lines inserted in unsterile conditions as soon as possible.

b. Brachial and femoral arterial lines must be changed as soon as possible when radial or

dorsalis pedis arteries are available.

c. Aseptic techniques:

i. Handwash with (chlorhexidine/alcohol) + gloves.

ii. Skin prep. With (chlorhexidine 1%/75% alcohol)

d. Local anaesthesia in awake patients.

e. Cannulae:

i. Arrow (Seldinger technique): radial or femoral kits.

ii. 20G cannula.

iii. Single lumen 18G for femoral arterial lines.

f. Sites: (order of preference): radial, dorsalis pedis, ulna, brachial, femoral.

g. The femoral artery may be the sole option in the acutely shocked patient.

h. Dressing: occlusive Opsite® + sutured.

i. There is no optimal time for an arterial line to be removed or changed.

 j. IA cannulae are changed/removed only in the following settings:

i. Distal ischaemia.

ii. Mechanical failure (over damped waveform, inability to aspirate blood)

iii. Evidence of unexplained systemic or local infection (cf CVC lines).

iv. Invasive pressure measurement or frequent blood sampling is no longer

necessary.

k. Measurement of pressure:

i. Transducers should be ‘zeroed’ to the mid-axillary line

ii. Continuous pressurized (Intraflo®) saline flush at 3ml/hr.

3. Complications

a. Infection.

b. Thrombosis.

c. Digital ischaemia.

d. Vessel damage / aneurysm e. HITS (secondary to heparin infusion)

 5. URINARY CATHETERS.

1. Standard in all ICU patients.

2. Management Protocol:

a. Aseptic technique at insertion.

i. Hand disinfection: surgical scrub with chlorhexidine for>1 minute.

ii. Sterile barrier: gloves, and sterile drapes.

iii. Skin prep: chlorhexidine 1%.

b. Local anesthesia gel in all patients.

c. Foley catheters for 7 days and change to silastic thereafter if prolonged catheterisation

is anticipated (i.e. >14days).

d. Remove catheters in anuric patients and perform intermittent catheterisation weekly, or

as indicated.
 6. Lumbar puncture epidural catheters

1. Indications

a. Post operative pain relief (usually placed in theatre).

b. Analgesia in chest trauma

2. Management protocol:

a. Notify the acute Pain Service of any epidural placed in ICU.

b. Epidural cocktails should follow theAcute Pain Service protocols.

c. Strict aseptic technique at insertion.

d. Daily inspection of the insertion site. The catheter should not be routinely redressed,

except under the advice of the APS.

e. Leave in for a maximum of 5 days and thenremove.

f. Remove if not in use for >24 hours or clinical evidence of unexplained sepsis or

positive blood culture by venipuncture with likely organisms (s. epidermidis, candida).

g. Heparin/Warfarin Protocol.

3. Complications

a. Hypotension from sympathetic blockade / relative hypovolaemia.

i. This usually responds to adequate Intravascular volume replacement.

b. Pruritis, nausea &vomiting, or urinary retention (opioid effects).

c. Post-dural puncture headache.

d. Infection: epidural abscess.

e. Pneumothorax (rarely).

4. NB: Further guideline for the management of epidural catheters can be obtained from

contacting the duty anesthesia registrar

.
 7. Chest drains insertion.

1. Indications:

a. Pneumothorax.

b. Tension Pneumothorax may require urgent needle thoracostomy.

c. Haemothorax.

d. Large symptomatic pleural effusion.

2. Management protocol:

a. Needle thoracostomy (tension Pneumothorax)

i. 16G cannula placed in mid clavicular line, 2nd intercostals space.

ii. Always place an UWSD following this procedure.

b. Pleurocentesis: (pleural effusion)

i. Local anaesthesia and sterile technique.

ii. Cannula technique:

a. 3 way tape attached to 12 – 14 G IV cannula, syringe and rubber hose (closed system).

b. Remove needle from cannula and aspirate pleural effusion until dry.

iii. Seldinger technique

a. Pigtail pericardial catheter (preferred) or single lumen CVC kit.

b. Insert guidewire through needle into pleural space.

c. Insert catheter into pleural space over wire.

d. Aspirate intermittently with closer system or attach to an underwater-seal

drainage system.

iv. Record volume removed and send for MC&S, cytology & biochemistry
 v. Check CXR post-procedure.

3. Underwater seal drainage:

i. Local Anaesthesia in awake patients.

ii. Strict aseptic technique at insertion: i.e. full gown/mask/glove and cap; chlorhexidine

skin preparation.

iii.Site: mid axillary line, 3 – intercostals space.

iv. ICU patients need large drains: 28F catheter or larger.

v. Remove trochar from catheter: do not use trochar for insertion of tube.

vi. 2-3cm skin incision parallel to the ribs (#10 or #15 scapel).

vii. Blunt dissection to and through intercostals space with index finger or Kelly forceps

until within pleural space.

viii. Insert finger into pleural space to enlarge hole and insert tube directly into pleural

space or with forceps.

ix. Connect to underwater seal apparatus.

x. Insert 2 purse string sutures: 1 to fasten the tube, and 1 (untied) to close the incision on

removal.

xi. Dressing: occlusive dressing (Hypafix).

xii. Check CXR.

xiii. Maintenance

a. Remove or replace drains inserted in unsterile conditions as soon as possible.

b. Leave drain in situ until radiological resolution, no further bubbling, or

drainage (<150 ml/24 hours).

 c. In ventilated patients, drains should be clamped for ≥ 4 hours and removed if

none of the above are present.

d. Surgically placed drains (ie intraoperative placement) are the responsibility of

the surgeon.

3. Complications: (Minimised using the blunt technique).

a. Incorrect placement (extrapleural, intrapulmonary, subdiaphramatic).

b. Pulmonary laceration (haemorrhage, fistula).

c. Pneumothorax.

d. Bleeding

i. Local incision, intercostals vessels.

ii. Lung.

iii. IMA (with anterior placement).

iv. Great vessels (rare).

e. Infection: empyema. f. Mechanical (kinking, luminal obstruction).

• Pleurocentesis.

• Peritoneocentesis.
 8. EMERGENCY SURGICAL AIRWAY ACCESS.

1. Policy

a. Cricothyroidotomy and jet ventilation are recommended procedures for urgent surgical

airway access and emergency oxygenation.

b. Call for help & skilled assistance then proceed without delay.

c. Precutaneous tracheostomy is not an emergency procedure.

2. Indications:

a. Refer to the failed intubation drill in the clinical protocols section.

b. Inability to maintain an airway despite basic manoeuvres – ie jaw thrust, chin lift + oral

/ nasal airways + inability to hand ventilate

3. Cricothyroidotomy

a. Surgical technique i. Equipment a. Size 15 scalpel + handle

b. Size 6.0 cuffed endotracheal tube

c. Oxygen delivery circuit:

i. Laerdal bag.

ii. Procedure

a. Palpate cricothyroid membrane.

b. 2cm horizontal incision through skin and membrane

c. Insert blade handle into wound and turn vertically to enlarge wound.

d. Insert endotracheal tube directly into trachea.

e. Connect oxygen circuit.

f. Confirm correct placement with end-tidal CO2 auscultation and check CXR.
 g. Perform catheter suction as soon as possible after adequate oxygenation.

h. Cricothyroidotomy is a temporary airway:

a. arrange a definitive surgical airway as soon as possible.

b. Percutaneous technique

i. Equipment : Emergency Cricothyrotomy Catheter kit.

ii. Procedure

a. Palpate cricothyroid membrane with well extended neck.

b. 1cm horizontal incision through skin.

c. Locate tracheal air column with fluid filled syringe & needle/cannulae.

d. Insert wire through cannulae and thread cannulae off wire.

e. Thread dilator over wire & dilate puncture site.

f. Feed introduce &tube over wire.

g. Remove wire & introducer.

4. Jet ventilation

a. Equipment

i. Jet Ventilation kit .

ii.Oxygen flow meter set to highest flow rate.

b. Procedure

i. Palpate cricoid membrane with well extended neck.

ii. Locate tracheal air column with fluid filled syringe &needle/cannulae.

iii. Feed cennulae off needle down the trachea.

iv. Attach oxygen delivery tubing from flowmeter to cannula.

v. Occlude lumens in tubing to produce the jet of oxygen.

 vi. Jet ventilation is a temporary airway: arrange a definitive surgical

9. Percutaneous tracheostomy.

1. Policy

a. Percutaneous tracheostomy is the preferred method for tracheostomy in suitable

critically ill patients.

b. This procedure is only to be performed by experienced consultant staff or advanced

vocational trainees under supervision.

c. Patients must have the option of surgical tracheostomy cleared by the parent clinic

(either medical or surgical). This is basic courtesy.

d. The decision to do a percutaneous tracheostomy is at the discretion of the Duty ICU

consultant.

e. Percutaneous tracheostomy is an elective procedure and has no place in urgent airway

access.

2. Indications:

a. The indications for PCT are the same as surgical tracheostomy:

b. Airway maintenance

i. Prolonged intubation (>7-10 days)

ii. Prolonged upper airway obstruction (eg craniofacial #).

iii. Laryngeal pathology.

iv. Subglottic stenosis.

 c. Airway protection

i. Delayed return of glottic reflexes.

ii. Tracheal toilet.

3. Contraindications to PCT

a. Coagulopathy

i. Platelets: <100,000.

ii. APTT: >40.

iii. INR: >2.0.

b. Previous neck surgery.

c. Difficult anatomy, ie short fat neck.

4. Procedures

a. Ensure consent has been obtained and documented.

b. Equipment, monitoring an drugs as per endotracheal intubation available.

c. Coagulation screen prior to procedure.

d. Bedside procedure light essential.

e. General Anaesthesia: the person controlling the airway must be appropriately trained.

f. Ventialte the patients on 100% oxygen.

g.Tracheostomy equipment:

i. A modified Cook Ciaglia kit using “Blue Rhino” dilatational technique is standard for

this unit. ii. Tracheostomy tubes:

a) aspirating tubes are standard for all trachiostomies.

 b) This includes patients who have surgical trachiostomies: ensure that an EVAC tube

goes with the patient to theatre.

c) Patients who have non-aspirating tracheostomy tubes in place (ie from CTSU or other

hospitals) must havethese tubes changed to EVAC tubes as soon as safe and feasible.This

is usually 4-5 days post tracheostomy.

d) Other tubes:

(1) Foam cuffed tubes: indicated in patients with tracheomalacia or persistent air leaks.

(2) Uncuffed tubes (usually size 6.0) as part of weaning of tracheostomised patients to

facilitate secretion clearance.

(3) Fenestrated tube: these are either cuffed or uncuffed tube with a fenestration that

allow patients to talk.

(4) Adjustable flange tubes: useful for patients with marked neck or soft tissue swelling.

(5) Shiley long-term tubes: these tubes have a removable inner tube for tube changes.

5. Insertion technique:

i. Strict aseptic technique (goggles essential for operator and anaesthetist).

ii. Local anaesthetic infiltration (2% lignocaine + 1:200000 adrenaline) over pretracheal

rings.

iii. Check the tube cuff, lubricate and insert the dilator into the tube.

iv. 2cm horizontal incision over 1st and 2nd tracheal ring.

v. Pretracheal tissue dissection to fascia: look for anterior jugular vein and ligate if

identified.
 vi. Insert a 14G IV cannula mounted on a syringe with saline into trachea and aspirate

through saline/water to confirm intratracheal placement.

vii. Reconfirm intratracheal placement by aspirating the IV cannula after removal of the

stylet.

viii. Insert the guide-wire through the IV cannula and remove the cannula.

ix. Inert a small dilator over the wire into the trachea and make a hole large enough to

accommodate the main dilating instrument.

x. “Blue Rhino” graduated 1-step dilator:

a) Place dilator nd guide cannula (white) over the wire.

b) Slowly insert to required ETT size, ensuring the marker (black line) on the guide

cannula remains at the distal end of the dilating tube.

xi. Remove the dilator leaving the white guide cannula on the wire and insert

tracheostomy tube &dilator over the wire/guide into the trachea.

xii. Remove the dilator and wire, inflate the cuff and suction the trachea.

xiii. Attach to a ventilator and confirm end tidal CO2.

xiv. Secure tracheostomy tube with tapes. xv. Obtain a CXR post procedure.

xvi. Document the procedure in the case notes can complete separate operation note.

6. Complications (of tracheostomy)

a. Bleeding

b. False passage.

c. Loss of the airway: immediately re-intubate the patient orally.

d. Pneumothorax.

e. Cricoid cartilage fracture.

 f. Laryngeal dysfunction.

g. Tracheal stenosis.

h. Infection.

7. Prolonged care of tracheostomy

a. Cuff checks

i. Volumetric (sufficient air to obtain a seal) tests are done following insertion and

whenever a leak is detected with a manual hyperinflation once per nursing shift.

ii. Manometric tests are inaccurate and do not correlate with mucosal pressure. These are

an adjunct only if cuff malfunction is suspected.

b. Tube changes

i. Routine change at 14 days.

c. Aspirate tube 2 hourly or more frequently (hourly) if >10ml supraglottic secretion per

hour.
 10. Fibreoptic bronchoscopy.

1. Policy:

a. This is only to be used by skilled personnel and authorised by the duty consultant.

b. Expertise with the bronchoscope takes time: registrars are recommended to attend all

bronchoscopic procedures by the consultant intensivist to become familiar with the

anatomy of the tracheobonchial tree and use of the flexible fibreoptic bronchoscope.

2. Indications:

a. Difficult intubation (trained staff only): not used as aid to failed intubation.

b. Persistent lobar collapse that is refractory to physiotherapy.

c. Foreign bodies.

d. Diagnostic bronchoalveolar lavage (BAL) i.e. if atypical pneumonia is suspected.

3. Protocol for fibreoptic intubation

a. Indication as per endotracheal intubation.

b. Procedure.

i. All equipment, drug and monitoring as for any intubation.

ii. Supplemental oxygen must be given via a mask and may also be given via the suction

channel of the bronchoscope.

iii. Usually performed nasally: preparation of the nasal mucosa woth topical 10%

ligocaine or 2% amethocaine spray.

iv. Anaesthetise pharynx with viscous lignocaine & larynx with transtracheal injection,

direct application through the scope or nerve blockade.

v. Check tube cuff.

vi. Place warmed appropriately sized tube (7-7.5mm tube for either sex) into posterior

nasal space.

vii. Insert scope through tube under direct supervision.

viii. Advance the scope into trachea under supervision

ix. Advance tube over scope into trachea and then remove scope.

x. Confirm ETT placement ETCO2, auscultation and CXR.

xi. NB: Suction at least 500ml water or saline through scope immediately following use

and notify the equipment nurse that the scope has been used ASAP.
 11. Protocol for BAL

a. Diagnosis of nosocomial pneumonia in selected patients.

i. Determination of colonisation vs infection in chronically ventilated patients.

ii. These patients should ideally be off antibiotics for 24-48 hours.

iii. Sufficient reserve to tolerate procedure:

a. Ideally PaO2>70 and FiO2<0.7 b. BAL will commonly result in a 10% reduction in PaO2 for

up to 24hours after procedure.

b. Procedure

i. Ensure sufficient sedation.

ii. Place patient on 100% oxygen.

iii. Select lobe to be lavaged from morning CXR.

iv. Local anaesthetic gel is contra-indicated (interferers with culture media).

v. If possible do not suction through scope prior to lavage (upper airway bacterial

contaminiation).

vi. Pass scope directly into the selected lobe.

vii. Wedge scope as far as possible – ideally to 3rd generation bronchi.

viii. Lavage with 4-6 x 20-40ml aliquot’s of sterile normal saline.

ix. Aspirate between aliquots and label aliquots accordingly.

x. Send aspirate for quantitive culture and atypical pneumonia screen as directed.
 12. Pericardiocentesis.

1. Policy

a. This procedure must be authorised by the duty ICU consultant and performed by

consultant staff, trainees under supervision, or cardiology. b. Confirmation of pericardial

effusion or tamponade must be made with echocardiography prior to procedure. Liaison

with cardiology is essential.

2. Indications

a. Symptomatic pericardial effusion (tamponade).

b. Local anaesthetic infiltration if awake patient.

c. This procedure is greatly facilitated using echocardiography guidance.

d. Technique: Seldinger technique and insertion of a pigtail catheter.

i. Small incision under xiphisternum.

ii. Insert needle on syringe at 45º from the horizontal axis and aim for tip of left

shoulder.

iii. Advance slowly and aspirate until confirmation by aspirating blood or serous

fluid.

iv. Insert catheter using Seldinger technique over Guidewire.

v. Confirm placement by aspiration and/or echocardiography.

vi.Check CXR (Pneumothorax)

vii. Suture and occlusive dressing if leaving for >24 hours.

vii. UPDATE 2016:Real time US guided pigtail insertion is preferred rather than

siting under fluoroscopy in cath lab.

3. Complications
a. Arrhythmias.

b. Cardiac tamponade!

c. Myocardial laceration.

d. Pneumothorax, pneumopericardium.

e. Liver laceration.
 13. Oesophageal tamponade tube insertion.

1. Policy

a. All patients with tamponade tubes should be intubated prior to insertion and managed

in Intensive Care.

b. As a result, ICUstaff may be requested to insert oesophageal tamponade tubes for acute

upper GI bleeding.

c. The decision to insert a tube is made in conjunction with the gastroenterologist. There

are a number of tamponade tubes available: ensure that the operation, balloon inflations

are discussed with the gastroenterologist.

d. Become familiar with the theory of insertion, indications, and complications of these

tubes.

2. Indications:

a. Variceal haemorrhage:

i. Where endoscopy cannot be done due to bleeding.

ii. Failure of sclerotherapy, banding and/or octreotide.

3. Types of tubes:

a. Minnesota: oesophageal and gastric balloons and aspirating ports.

b. Sengstaken: oesophageal and gastric balloons and gastric aspirating port.

c. Linton: gastric balloon and aspirating port.

4. Procedure:

a. Prior to insertion

i. Check both balloons for leaks.

ii. Inflate the gastric balloon with 300ml of air and check pressure reading.
 iii. Deflate balloons completely and lubricate the tube.

b. Insert well in under direct vision using a laryngoscope then x-ray to ensure the tube is

not folded up in the oesophagus.

NB: inflating the gastric balloon in the oesophagus is virtually 100% fatal!

c. Inflate the gastric balloon in 50ml increments up to 300ml while monitoring the

balloon pressure.

NB: If the balloon pressure exceeds 5mmHg above the pre-insertion pressure then

incorrect (oesophageal) placement is probable and this mandates deflation of the balloon

and reinsertion of the tube.

d. Pull back until resistance is felt as the balloon rests against the gastric fundus.

e. Note the measurement at the lips, and fix securely with gentle traction:

i. Rope and pulley system with 500ml bag of fluid, or

ii. Adhesive tape to face.

f. Connect a pressure gauge to the oesophageal balloon, and inflate to a pressure of

40mmHg. (Inflation of the oesophageal balloon is usually not required).

g. Recheck position on x-ray. h. After 12-24 hours, the balloon should be let down and if

bleeding does not recur the tube may be removed (liaise with the gastroenterologist).i.

Scerotherapy is usually performed: (50% patients will re-bleed otherwise).

 14. JUGULAR BULB OXIMETRY .

1. Policy

a. The decision to insert a jugular bulb catheter is made in conjunction with the parent

neurosurgical consultant and authorised by the duty ICU consultant.

b. This procedure is only to be performed by consultant staff or advanced vocational

trainees under supervision.

c. Become familiar with the theory of insertion, indications, interpretation and

complications of SjO2: this monitor is used in conjunction with the cerebral perfusion

pressure (CPP) algorithm.

2. Indications:

The titration of CPP by maintaining SjO2>55% in moderate to severe head injury (ie,

GCS ≤ 8 where the injury ≤ 24hours old) where:

i. Haemodynamic instability exists (eg extracranial trauma, hypovolaemic or cardiogenic

shock), or ii. Haemodynamically stable, but requiring high dose catecholamines

(>30ml/hr) to achieve a CPP>70mmHg, despite euvolaemia and resultant catecholamine

induced polyuria.

3. Procedure:

a. Site selection:

i. Cannulate side of maximal parenchymal trauma on CT.

ii. If diffuse axonal injury, cannulate left IJ.

 iii.The jugular compression test (compressing each jugular vein and cannulation of the

side of maximal ICP) is unreliable and is not used.

b. Insertion

i. Full surgical scrub and drape.

ii. Perform a pre-insertion calibration of the SjO2 catheter to tests integrity of the optical system.

a) Open package but leave catheter attached to optical cuvette; connect to optic cable.

b) Press “cal”

c) Press lid of reference cuvette until clicks (in catheter package).

d) Select “P” for pre insertion calibration.

e) Wait until “CAL OK” message appears before inserting catheter.

f) Remove catheter from Cuvette.

iii. Connect 3 way tap and flush catheter with heparinised saline.

iv. Retrgrade cannulation &insertion through the internal jugular

v.: a) Use an 23G seeker needle to locate the IJV:

b) Insert Cook needle in peel away kit adjacent to the seeker needle and remove he latter once

the IJV is located with the Cook needle: note this needle is relatively blunt of the seeker needle.

c) Insert the J-wire until moderate resistance is felt.

d) Insert the paediatric “peel away” sheath and introducer.

e) Remove the wire and introducer, leaving the sheath.

f) Insert the catheter until level with the external auditory meatus (usually 15cm: indicated as the

third marker on the catheter).

v. Aspirate and flush the catheter.

vi. Chack the light intensity monitor. vii.Remove the “peel away” sheath.
viii. Secure with Tegaderm: do not uture, bend or coil the catheter.

ix. Do a lateral or AP cervical spine x-ray to confirm the tip of the catheter is at the level of C1.

x. Continuous pressurised (Intraflo®) heparinised saline flush (1u/ml) at 3ml/hr.

c. In vivo calibration: to be done 12 hourly.

i. Press “cal”.

ii. Select “I” for vivo calibration.

iii. Aspirate blood in AGA syringe (the monitor will store the value).

iv. Measured oxygen saturation from blood gas machine or lab.

v. Adjust the stored value to the lab value using the or keys.

vi. Press OK when correct.

4. Troubleshooting

a. Poor light intensity:

i. Maintain head in neutral position.

ii. Flush or gently advance or withdraw catheter.

b. Unstable baseline or sudden unexplained desaturation:

i. Perform in vivo calibration.

 15. CARDIAC PACING .

1. Policy

a. The decision to use transcenous pacing (TVP) is made in conjunction with the duty

cardiologist and authorised by the duty ICU consultant.

b. If inserted by ICU staff, the procedure is only to be performed by consultant staff or

advanced vocational trainees under supervision.

c. Become familiar with the theory of insertion, indications, interpretations and

complications of TVP.

2. Indications

a. Medical pacing with adrenaline or transthoracic pacing may be adequate to treat many

symptomatic bradycardias.

Note: this is particularly relevant for retrievals and has obviated the need for prophylactic

pacing in some high-risk patients.

b. Any sustained symptomatic bradycardias which does not respond to medical treatment,

or predisposes to a malignant ventricular arrhythmia. Note: pacing is indicated by the

haemodynamic consequences of the rhythum, not the arrhythmia perse.

c. Ventricular tachycardias (especially polyphasic) may respond to overdrive suppression

pacing.

d. Following cardiac surgery in high risk patients (epicardial leads):

i. Valve replacement / repair: especially mitral.

ii. VSD repair / papillary muscle rupture.

iii. Acute myocardial infarction.

3. Types:
 a. Bipolar pacing lead (VVI): insert under image intensification (standard TVP at RAH).

b. Balloon flotation leads: may be inserted under ECG or pressure guidance.

c. Paceport PA catheters: these have little utility.

d. Epicardial leads:

i. Placed during cardiac surgery in high-risk patients.

ii. Usually unipolar ventricular, but may be bipolar, atrial or ventricular: Check

the operative note and liaise with the surgeon.

4. Procedure protocol: (VVI lead)

a. Strict aseptic technique.

b. Image intensification.

c. Local Anesthesia where appropriate.

d. Insertion protocol.

i. 6F peel away sheath or PAC introducer.

ii. Right IJ vein is the preferred route, then left subclavian.

NB: if permanent pacing is likely then avoid subclavian placement.

iii. Under I-I control, feed the wire through the RA until the tip just stops on the right ventricular

wall.

iv. Connect to the control box (switched off).

v. Set output and sense to their minimum value, and rate 20bpm faster than the patient’s own rate

(or 70bpm, whichever is greater).

vi. Turn the generator on and gradually increase the output while watching the ECG for capture.

vii. If there is no capture or a high output is required:

a) Place on demand mode.

b) Turn output right dwn, advance or reposition the wire slightly.

c) Try to capture again. An ideal capture setting is ~ 2mA

d) Ensure wires are not exposed and tape both sides.

viii. Suture the wire and apply an occlusive dressing.

ix. Arrange a post-insertion CXR.

e. Daily check:

i. Battery strength.

ii. Capture: set the output 2x higher than threshold for safety.

5. Floatation Catheter Insertion

a. These may be inserted either “blind”, under ECG guidance (standard recommendation), or via

pressure guidance for catheters having an infusion lumen (cf. PA catheter insertion).

b. Aseptic technique & local anaesthesia where appropriate.

c. Insertion protocol:

i. 6F peel away sheath, do not use a PAC introducer as these will leak.

ii. Attach V5 lead of an ECG to the distal electrode of catheter & monitor.

iii. Note P then QRS wave-form changes as the catheter advances to the RV.

iv. Advance catheter another 2cm, deflate the balloon and advance 1cm.

v. Connect to the pulse generator (switched off).

vi. Set output and sense to their minimum value, and rate 20bpm faster than the patient’s own

rate.

vii. Turn the generator on and gradually increase output while watching the ECG for capture.
viii. If there is no capture or a high output is required – see (4.d.vii) above .

ix. Suture the wire and apply an occlusive dressing.

x. Arrange a post-insertion CXR.

 16. Cervical spine clearance following trauma

1. In sedated and intubated polytraumatized patients radiological clearance involves confirmation

of a normal 3 static film series (e.g. lateral, anteroposterior and odontoid views).

2. If the 3 views are inadequate 'a non-contrast CT of the relevant cervical spine portion is

sufficient'.

3. In patients in whom the clinical suspicion of a cervical spine is low and the patient has been

radiologically cleared: place patient in a soft collar if endotracheal tube in situ or Philadelphia

collar in the case of a tracheotomized patient. Flexion/extension views arranged when patient is

extubated and orientated.

4. Document Neurosurgical clerance of the cervical spine.

 17. Hospital infection controlpractices & policies (HICC) for ICU

1) • HICC documents: Will be followed strictly in ICU

• Hand Hygiene ensure soap / Liquid Soap, Sterilium, hand towel / paper towel / tissue paper or

hand drier are provided.

• Hand wash basin is clean and not used for disposing body fluids. soap are kept on magnet,

which are cleaned properly and is kept dry. if hand towels are used, ensure it is changed when

wet (minimum 2 times in the morning and every shift) hand wash sinks are not littered with used

equipment or inappropriate items.

• Elbow operated / foot operated taps are available in the treatment rooms, post OP, ITU, ICU,

Isolation etc. Periodical orientation regarding hand washing and appropriate use of alcohol rub /

antibacterial solution etc. Provide alcohol rub (sterilium) on trolleys during Doctor’s rounds.

• Portable steilium to be provided for medicine trolley, procedure trolley / dressing trolley. Poster

promoting hand hygiene is displayed, wherever hand wash facilities are provided. Patients are to

be oriented about hand hygiene during admission, request them to get, soap, towel etc for hand

hygiene. Supervise and motivate hand hygiene.

• Ensure nursing staff and other staff use correct procedure and appropriate practices. Medical

staffs use the correct procedure for do contaminating hands and ensuring things are provided.

2) Personal protective equipment

• Every staff should follow universal / standard precautions. Ensure gloves and masks are worn

appropriately according to policy.

• Sterile gloves are used for sterile procedures. If any staff is sensitive to present gloves, kingly

report the same. Ensure hands are decontaminated following the renewal of glows.
• Disposable / reusable plastic aprons are provided and are to be worn, when there is a risk that

clothing or uniform may be exposed to body fluids.

• Gowns are to be worn where there is extensive splashing of body fluids on to the skin of health

care workers. Face mask and eye protection are to be worn where there is any risk of anybody

fulids splashing into the face and eyes. Masks are to be worn when there is risk for aerosole from

respirator secretion

3) Urethral Catheter management

• Ensure that catheterization is performed aseptically, and according the policy (hospital

procedure manual) indwelling urethral

• Catheter are connected to a sterile closed urinary drainage system hand hygiene is taken care of

before manipulating a patient’s Catheter while emptying the urinary drainage, gloves are used.

When emptying the urinary drainage bat a separated and clean container is used provide one for

each patient is private rooms, critical area, post-operative, ITU, septic area and isolated patient

room.

• Orientation to be given to patient’s relative and hospital aides if they are allowed to empty the

urinary drainage, about hand hygiene and taking care of the drainage system. Urinals and

measuring Jars are to be cleaned properly. Thorough cleaning scrubbing and disinfections to be

done weekly for bed pan, urinals and measuring Jars and to be documented. Number the urinals,

bed pan, and measuring Jars to ensure they are scrubbed and disinfected.
4) Enteral Feeding

Ensure hand hygiene is performed prior to preparing the feed or any manipulation of the enteral

feeding. Sterile water is used to flush the tube should be labeled with details of time and date

opened. Discard the water after 24 hours. Boiled / Aquaguard water can be used. Syringe used

for feeding to be changed after every 24 hours.

5) Care of peripheral intravenous lines

Insertion of intravascular devices is performed aseptically after hand hygiene Medicine trolley

should be taken to bedside with necessary accessories including waste disposal containers.

Suitable skin preparation and disinfection of the skin to be done. Insertion details related to the

canula have been documented. Canula and I.V. line should be labeled with date and to be

initiated. Injection ports and Catheter hubs are sterilized. Hubs are to be changed when it is

contaminated sterile hubs are sterilized. If patient get any infection (swelling pain, temperature,

discoloration, pus formation etc) to be documented and reported. Ensure used needles are not

recapped. Needle prick injury should be reported according to the policy. Orientation should be

given about the management of needle prick injury to all staff periodically and documented.

6) Care of central venous catheter

Ensure sterile gloves, sterile drape and sterile gown are used for insertion of central venous

Catheter Follow instruction of procedure, according to the procedure manual. Supervise the skin

preparation, skin disinfection and see that skin is allowed to dry before the procedure. Daily

inspection of the Catheter site, dressing, documentation are carried out. Date of insertion of
Catheter, I.V line etc to be documented. Hand hygiene is performed before and after the

manipulation of central venous Catheter or Catheter insertion site. If any infection occurs,

document in the nurses record, and report by hospital acquired infection from keep a record in

the ward also.

18. Infection prevention during Procedures

Procedures are to be done according the procedure manual Ensure aseptic technique, disinfection

and hygiene are followed Documentation according the hospital policy. Pre – operative and post-

operative checklist policy to be followed. All post -operative infections are to be reported.

Environment

• Ensure proper cleaning of patient unit including bed, bed frame, locker / table, stool, chair and

accessories, equipment etc.

• Ensure the ward furniture’s and equipment are in a good state of repair

• Floors including edges and corners are free from dust and grit.

• All high and low surgaces are free from dust and cobwebs.

• Curtains and blinds are free from stains, dust and cobwebs.

• Curtains are sent for wash biweekly.

• Curtains of septic / isolated cases after the discharge of the patient / weekly changing to be

done and documented.

• Provide enough curtains to spare while washing the curtains. Ensure fans and air vents are

clean and free from dust.

• Patient’s call bell, call light, table lamp etc are to be cleaned.

• Audiovisual system of patient, phone computer at nurses stations are visibly clean.
• Ensure waste are segregated correctly and kept covered and disposed according to the policy.

• Ensure windows including glass and window mesh are cleaned and documented.

Treatment room

• Area is clean and no in appropriate equipment / things are kept.

• Hand hygiene facilities are provided including provision for drying hand.

• Floor including edges and corners are to be cleaned properly. Through cleaning of cupboards,

racks, trays etc to be done weekly.

• Floor to be scrubbed, washed and fumigated weekly and documented

• Check the sterile items are autoclaved according to the instruction of hospital policy

• Trays including instruments, tubing’s etc should be cleared properly before sending to CSSD.

Medicine room

Expiry date of drug to be checked according to the policy.

Bath rooms

Both rooms, washing area, latrines, sluice, wash basin and other accessories are cleaned properly

and kept in working condition. Wall tiles and wall fixtures are clean and free from mould and

stain Foot mats are free from mould, clean and dry. Appropriate cleaning materials are made

available for the cleaning staff. Floors including edges and corners are cleaned properly daily.

Arrange for weekly scrubbing Bed pan, urinal, pint measure it should be cleaned properly and

kept in the appropriate stand / hook. Check for leaking tap, flush out tank, drainage, drainage

cover etc and repair on time if not functioning. There should be facility for disposal of sanitary

pad. Sluice fixed in bathroom should be cleaned free from stain and in working condition
Dirty utility rooms

Provision to be made for sluice with sluice hopper, of it is not provided in other area for disposal

of body fluids. Provide hand wash facility. Ensure room is clean and free from in-appropriate

items Floor including edges and corners to be free from dust and grit Products used for

disinfection to comply with policy and to be used at the right dilution Dilute products e.g.:

hypochlorite 1% sol is discarded after 24 hours.

19. Cleaning and disinfection of common ICU equipments:

 a) Patient area cleaning

• Single person cleaning / for a single patient unit is better than more person. This assures the

total unit cleaning.

• For a bed with single a person cleaning timing required is about 40 – 45 minutes. (Spot

checking supervision done).

• High risk area 3 times cleaning is advised.

• Articles required: trolleys containing: Cans solutions 2 buckets / small Waste receiver Kidney

tray Rag pieces / dusters – washed and dried in laundry clean gloves – mask as required

Measuring cap / oz glass to measure solutions

• Solutions required: Aarsha Quart 3% Bacillocid 0.5% Alcohol spray Ether / Turpentine / to

remove the plaster marks.

• Steps : All the time start with the cleaning from the most clean area, go towards most dirty area.

Start with oxygen suction and electronic equipment Follow with patient’s bed, railing and other

attachments to bed Follow with other items like IV stands, external ventilator Foot end trolleys /

medicines trolleys. Glass cabin Waste bins Flooring

• Note: Electronics items are sprayed with alcohol based solution. This prevents circuits

corrosions. Proper disposal of gloves,mask and the waste according to the waste management

Buckets used for solutions should be cleaned. And dusters or rags are changed regularly.

• Housekeeping Frequency of floor cleaning (Timing) wet vaccum preferred Check on dilution

of solutions Frequency of solution changing Use of Two Buckets Accidental spill management

(Body Fluid) Check on used cleaning equipment etc.

b) Disinfection of Ambu bags, Humidifiers and Suction bottle

• All part of the Ambu bag to be removed.

• To be cleaned first with soap solution to remove any organic matter

• All parts to be fully immersed in 2% solution of Bacillocid (100ml dissolved in 5 liters of

water) for at least 10 minutes.

• Rinse equipment thoroughly Dry equipment Send it in plastic bag for Ehylelen oxide

sterilization.

c) Humidifiers.

• All part of the humidifier to be removed.

• To be cleaned first with soap solution to remove any organic matter.

• All immersable internal and external surfaces to be immersed in 2% Bacillocid solution for 1

hour

• Rinse equipment thoroughly Dry equipment Send it for autoclaving

d) Suction bottles.

• Suction bottles to be opened and contents emptied.

• To be cleaned thoroughly with soap solution All parts to be fully immersed in 2% solution of

Bacillocid (100ml dissolved in 5 liters of water) for at least 10 minutes.

• Rinse equipment thoroughly Dry equipment Send it for autoclaving

e) Disinfection of tracheotomy inner cannula.

• Clean the device with a soap solution, followed by rinsing with water to remove organic

material.
• All immersible internal and external surfaces should be completely immersed in 2%

glutaraldehyde solution (plain Cidex solution undiluted) for 20 minutes.

• Rinse cannula thoroughly with sterile water.

• dry the cannula before re-use.

f) Disinfection Laryngoscopes/Bronchoscopes/blades.

For laryngoscope blades, bronchoscopes, stylet, tongue depressor etc (instruments coming in

contact with mucous membranes)

1. Clean the device with a soap solution, followed by rinsing with water to remove organic

material

2. All immersible internal and external surfaces should be completely immersed in 2%

glutaraldehyde solution (plain Cidex solution undiluted) for 20 minutes.

3. Rinse equipment thoroughly with sterile water followed by a 70- percent alcohol (spirit) rinse.

4. Non immersible parts/equipment should be physically cleaned with water and detergent, then

wiped with 70-percent alcohol

5. Dry the device with dry cotton.

g) Disinfection of Ventilator.

1. Wipe all parts with a soft lint-free cloth moistened in soap &water or detergent- based

disinfectant.

2. In case of more contaminated surfaces use ethyl alcohol (spirit) or isopropyl alcohol.

3. Discard: - Bacterial filter - Disposable patient tubing

4. The expiratory cassette: If using DUOgard do not clean cassette if it looks clean. If soiled:

Rinse the cassette in tap water (<350 C /950 F) immediately after use to remove organic matter

e.g blood and other residue .The water must have free passage through the cassette. Disinfectant

After all the organic matter is removed with tap water Let the parts soak in a disinfectant agent as

- Cidex OPA (for 20 minutes) .Rinse after disinfection. Rinse the parts thoroughly in water to

remove all traces of disinfectant Let the water flow through the parts It is important to rinse the

expiratory cassette thoroughly Rinse the expiratory cassette by dip it in water and carefully shake

and tilt the cassette holding it vertically in both directions, repeat this 3-4 times . See Diagram

pasted in cleaning areas.

Drager Ventilator.
1. Disinfection Clean the ventilator with Quaternary ammonium compounds (Ashar cot) .

2. When disinfecting contaminated parts, follow the hospital hygiene regulations (protective

clothing, eye protection, etc).

3. Dismantling Switch off the ventilator and breathing gas humidifier, and remove the power

plugs.

4. When removing the ventilation hoses, always grasp them by the sleeve, never by the hose

itself, to avoid possibly tearing the hose at the sleeve or ripping if out of the sleeves.

5. Flow sensor: Push the flow sensor to the left as far as it will go and pull out. The flow sensor

cannot be autoclaved or steam – sterilized The flow sensor can be re-used as long as automatic

calibration is carried out successfully .

6. Expiration valve: Remove collecting jar from water trap Turn knurled sleeve to the left

&remove expiration valve Remove diaphragm Remove rubber bushing(blue filter) The

expiration valve together with the rubber bushing and dismantled water trap collecting jar are

suitable for disinfection and cleaning by autoclaving or sterilizing .

7. Ventilation hoses: Discard the disposable connections after use Remove re-useable ventilation

hoses from the device ports Remove the water containers from water traps and the expiration

valve Prepare the ventilation hoses, water traps and associated water jars, and the Y-piece for
disinfection and autoclaving Soak the tubings in Bacillocid solution for 1 hour (Use 2% solution

– 100ml of Bacillocid to be added to 5lit of water) Wash the tubings under running water to rinse

it off the solution Keep the tubings for drying Send the tubings for autoclaving .