MEDICINE AND NEURO INTENSIVE CARE UNIT

INTRODUCTION:

An intensive care unit (ICU), critical care unit (CCU), intensive therapy unit or intensive

treatment unit (ITU) is a specialized department which combines physicians, nurses and allied
health professionals in the co-ordinated and collaborative management of patients with life-
threatening single or multiple organ failure, including stabilization after severe surgical
interventions. It is a continuous (ie.24 hours) management including monitoring, diagnostics,
support of falling vital functions as well as the treatment of the underlying diseases.

The main rationale behind having a separate department is to provide utmost care to the most
serious patients. It requires specific interventions and equipments such as ventilators,
defibrillators for its normal functioning. Intensive care unit involves high acuity, high risk of
death, high turnover, high stress for family and health care worker, high danger of infection and
very high costs.

MNICU of KEM hospital is a level 3 ICU according to Indian Society of Critical Care Medicine.
Since it has bed strength of 10, multisystem care is available for 24 hours, CRRT is available,
supported by blood bank, bed area is 110 square feet, all radiological facilities like X-ray, USG,
2D Echo, CT, MRI facilities are available and there is enough space for storage and nursing
station.

However it does not fulfill some of its criteria like it is an open ICU, Nurse/patient ratio is not
1:1 in ventilated patients, no laid down protocols for infection control in ICU.
PHYSICAL STRUCTURE:

Location:

It is located on the 2nd floor of main hospital building above the radiology department. It is
accessible to vertical transport like elevator, stairs. The MICU is protected from the external
hospital environment by the presence of a long passage leading to it.

Layout of MNICU unit:

The department has 3 sections MNICU 1, MNICU 2 and ward 22. The ICU unit has a single
entry and exit point. Also there are 2 barriers to the entry of ICU. The patients from MNICU 1
are shifted to an Intermediate ICU/ MNICU 2 when the patient has been stabilized. This has 7
beds. The patient after recovery from Intermediate ICU/ MNICU 2 is shifted to a Ward 22 which
is attached to MNICU. This has 10 beds. The patient is later shifted to the respective Ward or
discharged when a patient’s physiologic status has stabilized and the need for ICU monitoring is
no longer required. This facility gives better patient care.

Layout of MNICU 1:
As we enter MNICU 1, on the left hand side is a store room and on the right hand side is the
physician’s room (staffs lounge), further ahead is the MNICU. Its basic shape is rectangular and
it is an open type of ICU. It has 10 beds and a nursing station at the entrance. 6 beds face the
nursing station and 2 beds each are on its left and right side. There is a 5-6 feet distance between
2 beds.

Area:

Area of the department is 3000 square feet which includes MNICU 1, MNICU 2, and Ward 22.

Area of MNICU 1 is 1200 square feet.

Structure of MNICU 1:

 Floor and walls- tiled.

 Lighting and ventilation: The MNICU has widows on the three sides, which provides
natural daylight. There are no curtains on the windows. There are enough tube lights to
give good lighting at night. Doors have self closing devices.
 Beds: Manual movable beds having crank at foot end of bed.
 Curtains: There are 2 curtain separators. But there are no curtains around each bed
because of no central monitoring system.
 Air conditioning: MNICU has its own air conditioning unit. Temperature of MNICU
ranges from 22-24 degree Celsius.
Technology available:

MAJOR EQUIPMENT TOTAL NUMBER WORKING

INFUSION PUMP 32 5
MULTI PARA MONITOR 16 16
PULSE OXYMETER 19 19
VENTILATORS
 versamed 12 12
 vella+bear 5 5
 neumovent 2 2
 siemens (servo) 4 4(not used)
BLOOD PUMP 1 1
CRRT (continuous renal replacement 1 1
therapy)
2 D ECHO MACHINE 1 1
DEFIBRILATOR 1 1

MINOR EQUIPMENT NUMBER MINOR EQUIPMENT NUMBER

LARYNGIOSCOPE TRACHEOSTIOMY
 ADULT 4  DRUM 2
 PEADRIATRICS 1  TRAY 2
AMBUBAG 3 ICD BOTTLE TRAY 1
AMBUBAG’S MASK 3
TORCH WITH CELL 1 LIVER BIOPSY TRAY 1
HAMMER 1 GLOVES TRAY 3
BP APPARATUS 2 DRESSING TROLLEY 2
BLOOD KLAMMER 1 BONE MARROW TRAY 1
NEBULIZER 1 URINOMETER 1

Each bed of MNICU having:

 Area: 110 sq feet

 Electrical points: 7
 Ventilator: 1
 3 outlets of: oxygen, air, vacuum
 Multi Para monitor: 1
 Infusion pump:1

ORGANIZATIONAL STRUCTURE:
 HOD MEDICINE

HOD MNICU

DOCTORS NURSES

 Doctors:

HEAD OF DEPARTMENT- PROFESSOR (1)

ASSOCIATE PROFESSOR (1)

ASSISTANT PROFESSOR (2)

REGISTRARS (3) (1-on call)

HOUSEMAN (2/3) (8am-8pm)

INTERN (1)

 Nursing Staff:

SISTER INCHARGE (1)

SENIOR STAFF NURSES (2)

STAFF NURSES (15)

 Class 4 Employees:

SISTER INCHARGE

SWEEPERS (male, 7) SWEEPERS (female, 3) MUKADAM (male, 2) WARDBOYS (male, 6)

TIMINGS OF STAFF:

Doctors: 9am-4pm (except houseman whose duty is from 8am-8pm)

Nurses:

 Sister in charge (1): 7am-3pm

 Senior staff nurses (2):
1. 7am-3pm
2. 12:30pm-7:30pm
 Staff nurses:
1. Morning: 7am-3pm
2. Evening: 3pm-11pm
3. Night: 11pm-7am

Class 4 employees:

Morning 7am-3pm (2) Ward (1/3) Sweeper (1) Sweeper (2) Mukadam
Boys Male Female
Evening 3pm-11pm (1/2) Ward (2) Sweeper (1) Sweeper -
Boys Male Female
Night 11pm-7am (2) Ward (2) Sweeper (1) Sweeper -
Boys Male Female

SYSTEMS AND PROCEDURES:

Admission procedure:

 Sources of admissions:
 Casualty/ emergency ward 20
 Shift from General wards (female ward, male ward)
 Obstetrics
 Neurology and neurosurgery
 Type of disease pattern seen in admissions of MNICU:
 Severe Malaria,
 Tetanus,
 Leptospirosis,
 Poisoning,
  Snakebite,
 Scorpion Sting,
 Ecclampsia and Other Obstetrics Emergencies. 
 Guillain Barre Syndrome,
 Myasthenia Gravis,
 Subarachnoid Hemorrhage,
 Status Epilepticus
 Cerebral Cortical Venous Thrombosis,

Discharge and Transfer procedure:

Decision regarding discharge of the patient is taken by the attending physician. Once the doctor
makes a decision regarding discharge, he/she has to write in the case papers. Discharge from
ICU can be of following forms:
1. Shift to MICU 2
2. Shift to Ward 22
3. Shift to other wards
4. Death
5. Discharge against medical advice (DAMA)

Handing over and taking over procedure:

It is extremely important for duty medical officers to tell their replacement doctors all the
information regarding the patient. The information is passed verbally as well in written form. All
the information is written in a doctors’ register maintained for it. The information that is passed
is the patient status since morning, any laboratory report to collect, any procedure conducted or
to be conducted, etc.

Similarly, the nursing staff also has to inform their replacements regarding patient status. They
also do it verbally as well in written form. They also maintain a register similar to the one like
doctors’.

Billing procedure:

Per day charge of MNICU is 200 Rs. The patient is asked to pay a sum of 800 Rs at the billing
counter number 56 every 4 days. The relatives are asked to pay at these intervals of days, so
that they won’t have to pay a large amount when the patient gets discharged.

Procedure followed with regard to patient’s belongings and valuables:

After the stabilization of patient in MNICU, patient’s clothes and valuables are removed and
handed over to the nearest relative with his/her sign in the admission book.

Procedure of visiting hours:

Visiting hours are from 4:30pm-6:30pm. No visitors are allowed to stay with the patient in
MNICU 1 and 2 either in the day or at night.

Procedure for infection control, (Cleaning and Disinfection of MNICU):

Hand sterilizer, Sterilium is used by the doctors. No dry dusting is done in MNICU. The floor is
wiped in morning and after visiting hours with 1% CSPS or 1% Na hypochlorite and allowed to
dry. Once a month floor washing is done on the floor washing day. Beds are wiped with 1%
CSPS or 1% Na hypochlorite once patient is discharged (Bed carbolyze). Fumigation of MNICU
1 is done 2 time a year. (Diluted disinfectants especially sodium hypochlorite are not stored.
From the concentrated disinfectant provided fresh working solutions are prepared every day).

Procedure for linen change:

Bed sheets are changed once a day in MNICU 1. However the position change of bed sheet is
done 4 times a day (morning 7:30am, evening 5pm and night 11:30pm and 6am). Bed sheets are
also changed on discharge of patient.. All mattresses have an impervious cover of rexine or
Macintosh sheet. All used bed sheets, linen etc are first be disinfected with 1% Na hypochlorite
for 30 minutes and then washed, dried by aya bai (female sweeper) and then sent to laundry on
Monday, Thursday, and Saturday. Linen is kept locked in a store room.

Procedure for biomedical waste disposal:

Biomedical waste is segregated into black and red bags. This biomedical waste is disposed 3
times a day in 3 shifts.

Books in MNICU:

• New Admission Book

• MICU 1 (name + treatment)
• MICU 2 (name + treatment)
• Injection list book,
• Injection account book
• Refer book
• S/N handing and taking over book
• Garbage book
• Tablet account book
 • Day and night report
• Servant roll call book
• Doctors call book
• Paying form book
• Death dispatch book

Forms in MNICU:

• Investigation forms:
• Biochemical investigations (RBS/LFT forms)
• Pathological forms (bacteriology culture)
• ECG form
• X-Ray form
• Rx sheet
• TPR chart
• Intake and Output chart
• Summary from (daily ward admission and discharge summary)
• OPD continuation sheet
• Pregnant women form
• J/O chart

PERFORMANCE INDICATORS:

1. Chart showing number of admissions in MNICU from 1/01/2010 to 31/12/2010:

 Number of Admissions in MNICU
140

120

100

80
Number of Admissions in 2010
60

40

20

0
y y h il y e y t r r r r
uar uar arc Apr Ma Jun Jul gus be obe be be
n r M u m t
A pte Oc ve ece m m
Ja Feb
Se No D

2. Chart showing number of deaths in MNICU from 1/01/2010 to 31/12/2010

Number of Deaths in MNICU in 2010

70

60

50

40
Number of Deaths in MNICU in
30 2010

20

10

0
y y h il y e y t r r r r
uar uar arc Apr Ma Jun Jul gus be obe be be
n r M u m t
A pte Oc ve ece m m
Ja Feb
Se No D

3. Death of patients in MNICU during monsoons

 10

6
Malaria
5 Leptospirosis
H1N1
4 Dengue
3

0
June July August

4. List showing sources of admissions of patients in MNICU:

Month/ EMS Female Male Medical Endocrine Neurology/ Surgery others

2010 ward ward male ward neurosurgery ICU
January 20 18 4 5 1 1 0 11
February 18 9 3 7 1 3 0 12
March 24 12 6 9 1 1 1 17
April 20 3 5 8 1 3 1 11
May 20 19 3 11 0 2 1 15
June 20 7 3 12 0 0 2 17
July 9 19 9 19 0 1 1 24
August 36 17 5 19 2 0 1 35
September 45 26 10 22 3 3 2 22
October 44 21 2 6 4 1 1 19
November 31 15 3 13 1 1 0 14
December 36 14 2 15 1 1 0 13

5. List showing the quantitative indicators of MNICU:

 Bed occupancy 100%
ALOS 6-7days
Bed turnover rate 56%
Doctor to patient ratio 1:2.5
Nurses to patient ratio: 1:2
• Morning 1:2.5
• Evening 1:3.33
• Night
Mortality 40-45%

PROBLEMS AND RECOMMENDATIONS:

Problems Recommendations
Non availability of isolation beds Removable partition made of aluminum, wood or fiber can
be used. This will also provide flexibility of increasing
floor space temporarily if required.
Frequent visiting of relatives Single entry and exit point of the ICU should be manned to
control visiting traffic. Visiting policies should be
explained to the relatives.
Shortage of class 4 staff and their Vacancies of class 4 staff should be filled up so that
lack of awareness about infection infection control is not compromised. Proper training of
protocol. General housekeeping is class 4 staff regarding maintenance of infection control.
also not good.
No central monitoring system, so Central monitoring system should be installed for effective
no cubicle separation between monitoring of the patients.
beds.
Non availability of electrical UPS should be installed for electrical backup.
backup
No infection control protocols are Infection control policies should be laid down and checked
laid down for ICU. by appropriate authority.
Hand washing protocol not Hand washing protocol should be followed as a rule.
followed stringently