Chapter 76
Intensive care unit
Almir Badnjevića,b, Lejla Gurbeta Pokvića,b
a
Department of Genetics and Bioengineering, Faculty of Engineering and Natural Sciences, International
Burch University, Sarajevo, Bosnia and Herzegovina, bMedical Device Inspection Laboratory Verlab Ltd.,
Sarajevo, Bosnia and Herzegovina
Intensive care units are run and staffed by specialists
trained in intensive care. Once a patient is admitted to the
unit, the intensive care team will manage the care of the
patient in consultation with the original team that admit-
ted the patient to the hospital and any other specialists
that they think can help to aid the patient’s recovery. The
intensive care doctors and nurses will give the best over-
view and general update on the patient, but they may refer
relatives to the specialist teams for discussion of certain
aspects of care.
Patients need to be sedated to tolerate the help they
need with their breathing. This level of sedation is much
less than is needed for an operation and patients are often
partially awake. The nurses and doctors will keep reas-
suring the patient and make sure that they have plenty
of pain relief to minimize any uncomfortable procedures
that need to be done. Relatives often want to know if they
can talk to the patient or touch them and this is usually en-
couraged. Reassuring voices and contact can really help
patients.
Noise levels are likely to be higher than on a general
hospital ward largely because of the operation of the equip-
ment, often beeping or sounding an alarm. If you do hear
an alarm, it does not necessarily mean something’s wrong,
just that there’s something the staff need to be aware of.
Staff will be able to explain the equipment and noises to you
should you have concerns about the alarms.
It is common for patients to be connected to a number of
different machines or devices while in the ICU.
● Breathing machines or ventilators
Many patients need help with breathing and to do this
they usually need to be sedated and have a breathing
tube put into their windpipe or through the neck. Such
tubes are attached to a breathing machine known as ven-
tilator. Modern ventilators use complex computers to
enable patients to breath as much as possible for them-
selves with variable amounts of help from the machine.
Sometimes, patients’ breathing might be supported with
Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00077-8
Copyright © 2020 Elsevier Inc. All rights reserved.
tight-fitting masks which look uncomfortable at first,
but many patients get used to them very quickly and this
means they do not need to be deeply sedated and do not
need a tube putting into their windpipe.
● Kidney dialysis machines
Some patients’ kidneys stop working due to their illness.
The kidneys work to filter the blood and remove waste
products (and in doing so produce urine); so, if they fail,
it is important that the machines take over this work. To
do this, a special large tube is inserted into one of the
large veins in the leg or neck.
● Monitors
Patients in intensive care are constantly monitored to
track their condition and alert medical staff to changes.
This monitoring routinely includes the measurement
of:
● Heart rate and heart electrical tracing (ECG)
● Oxygen levels in the blood
● Blood pressure
● Pressure in the veins (CVP)
● Urine output
● Temperature
● All the fluids, food, and drugs.
Lines
These are plastic catheters or tubes sometimes referred to
as “drips” or “lines” and are inserted by the doctors and
nurses into the patient’s blood vessels. These lines help
to give fluids and medications, are used in monitoring
blood pressure, and for taking blood samples for regular
investigations. Common lines used in the ICU are listed
below.
● Arterial line
A very thin tube is inserted into one of the patient’s ar-
teries (usually in the arm) to allow direct measurement
of the blood pressure and to measure the concentration
of oxygen and carbon dioxide in the blood.
503
504  Section | 8  Medical devices: Utilization and service
● Central line
A thin tube is inserted into a large vein usually in the neck,
shoulder, or groin to measure the pressure, take blood sam-
ples and to administer concentrated medications and fluids.
● Dialysis line or vascath
These lines are similar to central lines and are inserted
into a big vein. However, they are bigger in diameter en-
abling to attach to a kidney machine in order to perform
the work of the kidneys.
● PICC lines
These lines are inserted in one of the veins in the upper
arm and are long enough to reach the big veins close to the
heart. They have the advantage of having less chance of in-
fection, thereby could be used for a long duration of time.
How are lines inserted?
All lines inserted are done by doctors or nurses experienced
in doing the procedure. A local anesthetic will be injected into
the site to numb the area before performing the procedure to
ensure patient comfort. Sometimes, a strong painkiller might
be given through a venous line. All lines are inserted in the
safest manner. Complications do occur although these are
rare. The common ones are bleeding, bruising, and infection.
Breathing tubes
Some of the patients in intensive care will need support with
their breathing. This is achieved by passing a plastic breathing
tube into the windpipe. There are two types of breathing tubes:
● Endotracheal (ET) tube
This is a plastic tube placed through the patient’s mouth
or rarely through the nose into the windpipe (trachea).
Most patients will need sedation to keep them comfort-
able while this breathing tube is in place.
● Tracheostomy
This is a plastic tube placed into the patient’s windpipe
through a small incision in the front of the patient’s neck.
Tracheostomy is usually performed where there is a need
for breathing support for a prolonged period of time.
Breathing tubes are placed by doctors skilled in anesthe-
sia or critical care and are always done using a general
anesthetic. Rarely, the patient may need a surgical tra-
cheostomy, which is done in the operating theater—more
information will be given if this operation is needed.
Tracheostomy is far more comfortable than a breathing
tube passing through the mouth/nose. Patients need less
or no sedation after a tracheostomy, which means that
they are more awake and this will help in the process
of reducing the breathing support needed by the patient.
Most of the tracheostomies performed in the intensive
care are safe. Complications include bleeding, bruising,
infection, and rarely a collapsed lung (pneumothorax).
Feeding in the intensive care
Patients in the intensive care unit are at risk of malnutri-
tion because of their illness. It is essential to maintain an
adequate nutrition and calorie intake in order to fight the
infection and aid recovery after prolonged illness.
● Nasogastric tube
A nasogastric tube is the most common type of feeding
tube used in the critical care. These are long thin tubes
which are inserted by the nurse or the doctor, which goes
into the nose, down the esophagus (food pipe) until it
reaches the stomach. Nasogastric tubes are used to feed
the patients in the intensive care who are unable to eat or
drink. In addition to this, these tubes could be used to drain
the stomach contents. Complications with nasogastric
tubes are rare. Common ones include bleeding from the
nose, inflammation of the sinuses and occasionally these
tubes might go into the lungs instead of the stomach. The
position of the tube is checked either by X-ray or by a pH
test in order to ensure that it is in the right position.
● Intravenous feeding
If there are problems with absorption of the feed through
the stomach, nutrition is provided through a central line
into the veins. This route is usually not the first choice
for feeding as it poses the risk of infection and feeding
through the stomach is more physiological.
● Nasojejunal tube
If there are problems with the nasogastric tube due to ab-
sorption of the feed, a nasojejunal tube might be inserted.
These are similar to nasogastric tubes but the tip of the tube
is positioned in the small intestine (jejunum) instead of be-
ing in the stomach. Special X-rays or other imaging may
be needed to ensure the adequate positioning of the tube.
● Percutaneous endoscopic gastrostomy (PEG) tube
A PEG tube is inserted through the skin on the abdo-
men leading into the stomach. These tubes are inserted
if the patient need feeding for a long time, or they are a
high risk of aspirated food contents into the lung. The
procedure is technically challenging and the surgeon
performing the procedure will update you with further
information.
Urinary catheter
A urinary catheter is a flexible tube that is inserted into the
bladder to drain urine. This is essential to drain the bladder
of urine while the patient is unable to use the toilet nor-
mally. In addition to this, it is essential to check the amount
of urine produced by the patient to ensure that the kidneys
are functioning alright.
The tube is inserted by a doctor or a nurse via the urethra
until it reaches the bladder and a balloon is inflated to keep
the tube within the bladder. Urinary catheters carry a risk

of urinary tract infection (UTI) in the urethra, bladder, or
the kidneys. Care will be taken to prevent such infections;
however, this might need treating with antibiotics.
There is a great demand for ICU beds in a hospital, which
costs three times more per day than an acute ward bed. The
ICU uses 8% of the total hospital budget and in USA it is
14%–20%. The total ICU costs per patient of US$22,000 in
USA (1978) and A$1375 in Australia (1986) have been re-
ported. Batra et al. have worked out cost per patient per day
from a major teaching hospital in India to be Rs. 3200 ($
167.7). A similar pattern was observed in our own ICU in the
year 1997 and the cost worked out in the year 2000 is around
Rs. 5000 ($106) per patient per day (personal communica-
tion). The costs in our country vary tremendously between the
corporate and teaching institutions. The costs are higher in pa-
tients requiring parenteral nutrition, sepsis with usage of more
antibiotics, requiring imaging modalities for investigations.
ICUs have a definite role and it should be well defined.
In general and district hospitals, the ICU is somewhat like
a high dependency where close observation and monitoring
is carried out. When one uses complex management, and all
systems are supported, it should be located in a large tertiary
hospital. Therefore, ICUs can be classified accordingly:
Level I: This can be referred as high dependency are
where close monitoring, resuscitation, and short-term
ventilation <24 h has to be performed.
Level II: It can be located in general hospitals, undertake
more prolonged ventilation. It must have resident doc-
tors, nurses, access to pathology, radiology, etc.
Level III: Located in a major tertiary hospital, which is
a referral hospital. It should provide all aspects of inten-
sive care. All complex procedures should be undertaken.
Specialist intensivists, critical care fellows, nurses, ther-
apists, support of complex investigations and specialists
of from other disciplines to be available at all times.
Organization of the ICU
It requires intelligent planning. One must keep in mind the
need of the hospital and its location. One ICU may not cater
to all needs. An institute may plan beds into multiple units
under separate management by single discipline specialist
viz. medical ICU, surgical ICU, CCU, burns ICU, trauma
ICU, etc. It may be useful but experience in Australia has
favored multidisciplinary ICUs, which are managed by spe-
cialist intensivists. Duplication of services and equipment is
to be avoided. Critically ill patients develop the same patho-
physiological process no matter whether they are classified
as medical or surgical. They require the same approaches
to support the organs. The problems of critically ill patients
are not confine to their primary disease and the single disci-
pline doctor lacks the experience and expertise to deal with
the complexities of the multiorgan failure.
Intensive care unit Chapter | 76  505
The number of ICU beds in a hospital ranges from 1 to
10 per 100 total hospital beds. Multidisciplinary requires
more beds than single specialty. ICUs with fewer than four
beds are not cost effective and over 20 beds are unmanage-
able. ICU should be sited in close proximity to relevant areas
viz. operating rooms, imageology, acute wards, emergency
department. There should be sufficient number of lifts avail-
able to carry these critically ill patients to different areas.
Design of ICU
There should be a single entry and exit. There should not
be any through traffic of goods or hospital staff. ICU must
have areas and rooms for public reception, patient manage-
ment, and support services. Full commitment must be given
from the administration and a designated team to work on
various tasks.
Patient areas
Each patient requires a floor space of 18.5 m2 (200 ft2) with
a single room being larger about 26–30 m2 to accommodate
patients, staff, and equipment without overcrowding. There
should be at least 3–3.67 m between the bed centers. Single
rooms are essential for isolation and privacy. The ratio of
single room beds to open ward beds depends on the role and
type of ICU. Service outlets could conform to local standards
(electrical safety, and emergency supply). Three oxygen, two
air, four suction, and 16 power outlets and bedside lamp are
optimum for level III ICU. They can be either wall mounted,
or bed pendants. Many of the charts, syringes, sampling tubes
and pillows should be kept in bed dividers. Lead lining these
dividers will help minimize X-ray radiation risk to staff and
patients. There should be source of natural light coming from
the windows. Lack of natural light has shown to cause patient
disorientation and increased stress to the staff. A central sta-
tion will have the central monitor, drug cupboard, telephone,
refrigerator, and patient records. Nursing in ICU is always at
the bedside. Sufficient hand wash areas should be provided.
X-ray views are needed in multibed wards. Proper facilities
for hemodialysis such as filtered water should be incorpo-
rated at the time of ICU planning.
Storage areas/service areas
Most ICUs lack storage space. They should have a total of
25%–30% of all patient and central station areas for stor-
age. Clean and dirty utility rooms should be separate each
with its own access. Disposal of soiled linen and waste
must be catered for. A lab, which estimates blood gases,
electrolytes, hemoglobin, is a must. Good communication
systems, staff lounge, and food areas must be marked out.
There should be an area to teach and train students. This
completes the design.
506  Section | 8  Medical devices: Utilization and service
Medical staff
Carrier intensivists are the best senior medical staff to be
appointed to the ICU. He/she will be the director. Less pre-
ferred are other specialists viz. from anesthesia, medicine,
and chest who have clinical commitment elsewhere. Junior
staff are intensive care trainees and trainees on deputation
from other disciplines.
Nursing staff
The major teaching tertiary care ICU will require trained
nurses in critical care. In our setups it may be ideal to have
an in house training program for critical care nursing. The
number of nurses ideally required for such units is 1:1 ra-
tio, however, it may not be possible to have such numbers
in our setup. One nurse for two patients is acceptable. In
complex situations they may require two nurses per patient.
The number of trained nurses should be also worked out by
the type of ICU, the workload and work statistics and type
of patient load.
Allied services
Physiotherapy, social workers, dieticians, radiology
services, and respiratory therapists are a useful work
force responsible for patient management and equip-
ment maintenance. Biomedical department services are
required on a regular basis to service and repair and de-
velop equipment. Adequate secretarial assistance and
reception category makes the functioning smooth. For
transport of patients it is ideal if one can have separate
teams to lift critically ill patients and transport them to
different areas. Trained staff in this area would be very
valuable contribution.
Type of ICU
There are two types of ICUs, open and closed. In the for-
mer physicians admit, treat and discharge and in the latter
the admission, discharge, and referral policies are under the
control of intensivists. The patient outcome and cost ben-
efit is noted to be better if intensivists have full clinical re-
sponsibility. In our country where the specialist intensivist
has not evolved completely, specialists interested in ICU
care management, be it from anesthesia, chest, or intensiv-
ist, when there is no provision for intensivists the persons,
usually anesthesiologist looks after on a day-to-day basis.
The concerned specialists must spend all their time in the
ICU and get totally trained in the area. The director should
be a full-time intensivist. The lines of management have to
be delineated, protocols should be well documented, and
responsibilities should be shared correctly. The policies
should be formulated, periodically reviewed, for example,
antibiotic policies and hand washing. A microbiologist as
an additional member of the team is welcome to not only
prevent and treat infections and also to involve in infection
control, antibiotic policies, etc.
Data collection, continuing education,
and research
Data should be collected and computerized so that it fol-
lows the set guidelines and conforms to the policies laid
out. It gives idea about the caseload. Audits should be con-
ducted regularly, the results should be discussed, critical in-
cident should be reported from time to time and should be
recorded. The various critical incidents are analyzed over a
period of time and published from our ICU. A critical in-
cident is an event, which has or would have led to morbid-
ity or mortality. Analyzing these will alter the practices and
improve care.
The outcomes can be judged by using APACHE II
scores. Its multivariate analysis model has been used to
compare performance of actual versus predicted death
rates. Ongoing academic programs should be a part of ICU.
Journal reviews, mortality conference, teaching program for
nurses, trainees, respiratory therapists must be encouraged
to develop their quality assurance program. Research has to
be pursued at all levels.
Critical care in its various forms plays a central role
in access to medical care. Because of its dramatic display
of medical intervention at its best, it is viewed as part of a
medical system that is expected to contribute its share of
service for welfare of entire society. Quality assurance and
continuous quality improvement is an important aspect of
any critical care unit. The constant thrust for improvement
of quality can provide significant for all who care for the
critically ill.
Ethics in intensive care
These should be scrupulously upheld over enthusiastic
treatment. Euthanasia has to be addressed and discussed.
These can cause problems due to public misconception, dif-
ferent interpretation of terminology and irresponsible me-
dia. There should be strict guidelines on all ethical issues
and frequent discussion with hospital administration.
Brain death
The term “brain death” is accepted by healthcare profession-
als, physicians, and general public in the most parts of the
world. This should be thoroughly discussed with relatives,
for the termination of life support systems. A coordinator
added to the team may be a useful member, particularly for
organ donation. Brain death declaration is part of the trans-
plantation procedure of the Organs Act 1995 in our country.

Although in some countries, legal or ethical implications
are there for euthanasia, there is no legislation regarding its
usage. The only way is explanation to the relatives and ob-
taining consent from them to terminate life support, which
is to withdraw or withhold treatment, which sustains or
prolongs life. Persistent vegetative state patients should be
discharged to the ward after establishing spontaneous respi-
ration and are not to be managed in the ICU.
Withdrawal of treatment has to be discerned at length
with all relatives in our setups. Treatment is not being aban-
doned but reduced from time to time. Discontinuing oxy-
gen, reducing inotropes, and withholding antibiotics are a
few steps. Sudden disconnection from ventilation should be
avoided. Effective communication between the ICU team
and family is key in difficult circumstances.
Handling relatives
The physician should talk to them on a regular basis in a
calm manner. The physician should build rapport, identify
one or two relatives to talk to on a regular basis. Relatives
feel comfortable when a nurse is also around. Any misinfor-
mation or misconception must be cleared in simple, clear,
consistent terms.
The comments made at the NIH consensus conference
are as follows. Critical care medicine (CCM) is a multidis-
ciplinary and multiprofessional medical/nursing field con-
cerned with patients who have sustained or are at risk of
sustaining acutely life-threatening single or multiple organ
system failure due to disease or injury. These require pro-
longed minute-to-minute therapy or observation in ICU,
which is capable of a high level of intensive therapy in
terms of quality and care. It includes management at the
scene of onset of critical illness or injury, transportation in
the emergency department, during surgical intervention in
the operating room and finally in the ICU.
The ability of specially trained critical care physicians to
lower mortality in ICU was shown by two studies. Reynolds
et  al. showed that mortality from septic shock decreased
from 74% to 23% when specially trained physician super-
vised care. Mortality decreased by 52% when full-time a
critical care specialist was recruited.
Improvement can be defined as attainment of an un-
precedented level of performance. In the healthcare sector,
performance can be measured in terms of critical outcome,
patient satisfaction, error rates, waste, costs to produce a
given product, products, market share, and much more con-
tinuous improvement requires rejection of the current level
of performance the status quo. Grounded in the present,
continuous improvement has its eye on the future. It is not a
technique that concerns itself simply with putting out fires
or solving sporadic problems. Instead, the goal is better
long-term performance, improving basic design to achieve
a superior product.
Intensive care unit Chapter | 76  507
The level III ICU is an extended operating room where
very sick patients are catered for. Overall care should be
given such that even the most critically ill patients with high
risk of death survive. Tremendous commitment, team effort
from each and every member, scientifically based and ethi-
cally correct practices and regular audits go a long way in
establishing an ideal critical care unit.
Predicting outcome in critical illness
Clinical outcome is the most important measure of critical care
activity. It is the end result of therapeutic interventions applied
to the patients. It encompasses the entire range of activities of
the ICU forming the basis of performance appraisal in its wid-
est meaning. It can be short term or long term. It can be mea-
sured in the perspective of the patients, care takers and various
other healthcare personnel. It is the end point for research,
audit benchmark, performance, and making comparisons. It
helps allocating the funding and demonstrates efficiency, as
the resources are scanty in relation to the number of patients.
From the perspective of the staff, the short- and long-
term outcomes are important. As a large quantity of re-
sources are expended on patients who do not survive in
intensive care (intensive care given to nonsurvivors costs
twice as much as survivors), attempts to identify potentially
ineffective care are constantly under review. Prognostic
tools may help physicians in the difficult task of direct-
ing ICU resources to those patients who are more likely to
benefit with the best chance of long-term survival. The ef-
fects of disease and the consequences of medical interven-
tions on mortality are important. New therapeutic options
are frequently introduced with the expectation of reduced
ICU mortality. Accurate and reliable data helps the health
managers, economists, and politicians to resolve conflicts
concerning areas of health care, not only within the hospital
but also establish appropriate balance between the primary
and secondary health care as their task involves distributive
justice to maximize good for the whole of society.
Measurement of outcome
All outcome measures have limitations, as the results from
outcome structures and data concerning outcome could be
over interpreted. The most important clinical outcome mea-
sures from the patient’s perspectives are:
1. Survival—Long-term survival is most important to the
patient, but individuals undergoing major surgical pro-
cedures will also want to know the risks of intervention
and hence the short-term mortality.
2. Functional outcome—Depicts the physical and mental
capabilities after recovery. Most patients will want to
return to an independent existence to at least their previ-
ous level of activity.
508  Section | 8  Medical devices: Utilization and service
3. Quality of life—Includes patient’s sense of well-being
and satisfaction, which are the important components of
quality of life.
ICU survival
ICU mortality provides a global impression of the ICU per-
formance but is affected by the factors such as case mix,
severity of illness, comorbidity, and the age of the patients.
Discharge policy whereby no terminal care is given in ICU
with hopelessly ill patients being discharged to the general
wards or if the ICU workload has a large elective surgical
component (low-risk patients) will depress the overall mor-
tality figure.
Establishment of standards in intensive
care
Several international standards documents have been pub-
lished. These include those by the Task Force of European
Society of Intensive Care Medicine (1997), the American
Society of CCM (Task Force on Guidelines, 1988–1994),
and the World Federation of Societies of Intensive and
CCM (International Task Force, 1993).
In the UK, existing standards relate mainly to build-
ings, services, deployment of nurses, and for some items
of equipment. There have, however, been differences of
opinion about the organization, staffing, and structure
of what constitutes intensive care, and it is now becom-
ing increasingly important to draw together and direct
standards that match the needs of patients and their
caregivers.
The Department of Health (DoH) has produced guide-
lines about which patients and what therapies should be
found in the ICU. The importance of audit has also been
emphasized, for example by the Intensive Care National
Audit and Research Center (ICNARC) and the establish-
ment of standards in Guidelines for Purchasers (Royal
College of Anesthetists and The Intensive Care Society,
1994). The Intercollegiate Board on Training for Intensive
Care Medicine, a multidisciplinary body, is also driving
standards appropriate for those units that wish to provide
training for medical practitioners in the acute specialties (up
to and including ICU directors).
Further reading
Badnjevic, A., Gurbeta, L., Boskovic, D., Dzemic, Z., 2015. Medical
devices in legal metrology. In: IEEE 4th Mediterranean Conference
on Embedded Computing (MECO), pp. 365–367. 14–18 June 2015,
Budva, Montenegro.
Badnjevic, A., Gurbeta, L., Jimenez, E.R., Iadanza, E., 2017. Testing of
mechanical ventilators and infant incubators in healthcare institutions.
Technol. Health Care 25 (2), 237–250.
Badnjević, A., Cifrek, M., Magjarević, R., Džemić, Z., 2018. Inspection
of Medical Devices for Regulatory Purposes. Series in Biomedical
Engineering, Springer, ISBN: 978-981-10-6649-8.
Gurbeta, L., Badnjević, A., 2017. Inspection process of medical devices
in healthcare institutions: software solution. Health Technol. 7 (1),
109–117. https://doi.org/10.1007/s12553-016-0154-2.
Gurbeta, L., Badnjevic, A., Dzemic, Z., Jimenez, E.R., Jakupovic, A.,
2016. Testing of therapeutic ultrasound in healthcare institutions in
Bosnia and Herzegovina. In: 2nd EAI International Conference on
Future Access Enablers of Ubiquitous and Intelligent Infrastructures.
24–25 October 2016, Belgrade, Serbia.
Gurbeta, L., Alic, B., Dzemic, Z., Badnjevic, A., 2017a. Testing of infu-
sion pumps in healthcare institutions in Bosnia and Herzegovina.
In: Eskola, H., Väisänen, O., Viik, J., Hyttinen, J. (Eds.), EMBEC &
NBC 2017. EMBEC 2017, NBC 2017. IFMBE Proceedings. Vol. 65.
Springer, Singapore.
Gurbeta, L., Alic, B., Dzemic, Z., Badnjevic, A., 2017b. Testing of dialy-
sis machines in healthcare institutions in Bosnia and Herzegovina.
In: Eskola, H., Väisänen, O., Viik, J., Hyttinen, J. (Eds.), EMBEC &
NBC 2017. EMBEC 2017, NBC 2017. IFMBE Proceedings. Vol. 65.
Springer, Singapore.
Gurbeta, L., Dzemic, Z., Bego, T., Sejdic, E., Badnjevic, A., 2017c. Testing
of anesthesia machines and defibrillators in healthcare institutions. J.
Med. Syst. 41, 133. https://doi.org/10.1007/s10916-017-0783-7.
Gurbeta, L., Dzemic, Z., Badnjevic, A., 2018a. Establishing traceability
chain of infusion and perfusor pumps using legal metrology proce-
dures in Bosnia and Herzegovina. In: IUPESM—The World Congress
on Medical Physics & Biomedical Engineering in Prague. June 3–8,
2018.
Gurbeta, L., Vukovic, D., Dzemic, Z., Badnjevic, A., 2018b. Legal me-
trology procedures for increasing safety and performance character-
istics with cost benefits analysis: case study dialysis machines. In:
IUPESM—The World Congress on Medical Physics & Biomedical
Engineering in Prague. June 3–8, 2018.