GUIDELINES FOR HIGH DEPENDENCY UNIT (HDU) & INTENSIVE CARE UNIT (ICU)

March 2022

2 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

4 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

6 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

8 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

ABG

AC ACPH AED AHU AIIMS ALS AMBU AMC ARDS ARF

AS & MD ASV

BHP BLS BMW BT

CBSI CCF CFT CMC COPD CPAP CPK-MB CSSD CT

DKA

e/o

ECG

ECHO

EMT

EPABX

EPDM

EtCO2

FB Aspiration F&E

FRUs GCS GoI HDU HEPA

Abbreviations

– Arterial Blood Gas

– Air Conditioner

– Air Changes Per Hour

– Automated External Defibrillator

– Air Handling Unit

– All India Institute of Medical Sciences

– Advanced Life Support

– Artificial Manual Breathing Unit

– Annual Maintenance Contract

– Acute Respiratory Distress Syndrome

– Acute Renal Failure

– Additional Secretary and Mission Director

– Anti-Snake Venom

– Bed Head Panel

– Basic Life Support

– Biomedical Waste Management

– Blood Transfusion

– Candida Blood Stream Infections

– Congestive Cardiac Failure

– Capillary Filling Time

– Comprehensive Maintenance Contract

– Chronic Obstructive Pulmonary Disease

– Continuous Positive Airway Pressure

– Creatine Kinase Myocardial Band

– Central Sterile Services Department

– Computed Tomography

– Clean Utility

– Decibel

– District Hospital

– Diabetic Ketoacidosis

– Dirty Utility

– Evidence of

– Electrocardiogram

– Echocardiograph

– Emergency Medicine Technician

– Electronic Private Automatic Branch Exchange – Ethylene Propylene Diene Monomer Rubber

– End Tidal Carbon Dioxide

– Foreign Body Aspiration

– Fluid and Electrolyte

– First Referral Units

– Glasgow Coma Scale

– Government of India

– High Dependency Unit

– High Efficiency Particulate Air

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 9

HIV

HMIS – HR – HVAC –

ICT –

ICU –

IMR – INC – IPHS – LCD – LED – LMA – LR – MGIMS – MI – MMR – MoHFW – MO – MRI – NEIGRIHMS –

NHM – NHSRC – NIBP – OOPE – OT – PEEP – PEM – PGIMER – PMSSY – RH – RKSK – SBP – SDH – s/o – SOP

SpO2 – SSIs – UPHSSP – USG – UTI – VAP – WHO –

Human Immuno Deficiency Virus

Health Management Information System

Human Resource

Heating, Ventilation and Air Conditioning

Information and Communication Technology

Intensive Care Unit

Infant Mortality Rate

International Noise Council

Indian Public Health Standards

Liquid Crystal Diode

Light Emitting Diode

Laryngeal Mask Airway

Labour Room

Mahatma Gandhi Institute of Medical Sciences

Myocardial Infarction

Maternal Mortality Rate

Ministry of Health and Family Welfare

Medical Officer

Magnetic Resonance Imaging

Northeastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong

National Health Mission

National Health Systems Resource Centre

Non Invasive Blood Pressure

Out of Pocket Expenditure

Operation Theatre

Positive End Expiratory Pressure

Protein Energy malnutrition

Postgraduate Institute of Medical Education and Research Pradhan Mantri Swasthya Suraksha Yojana

Relative Humidity

Rashtriya Kishor Swasthya Karyakram

Systolic Blood Pressure

Sub District Hospital

Suggestive of

Standard Operating Protocol

Peripheral Capillary Oxygen Saturation

Surgical Site Infections

Uttar Pradesh Health System Strengthening Project Ultrasonography

Urinary tract infections

Ventilator Associated Pneumonia

World Health Organization

10 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

CONTENTS

Background ………………………………………………………………………………………………………………………………………………………….12 Objectives …………………………………………………………………………………………………………………………………………………………….13 Introduction ………………………………………………………………………………………………………………………………………………………….14 Need for Intensive Care Unit ………………………………………………………………………………………………………………………………15 Hybrid Model………………………………………………………………………………………………………………………………………………………..16 Admission and step up/down criteria ………………………………………………………………………………………………………………17 Physical Infrastructure ………………………………………………………………………………………………………………………………………..23 Human Resource …………………………………………………………………………………………………………………………………………………26 Operationalizing ICU through Teleconsultation and Tele ICU Equipment ………………………………………………….30 Quality policy ……………………………………………………………………………………………………………………………………………………….31 Monitoring and supportive supervision…………………………………………………………………………………………………………..33

Annexure-I ……………………………………………………………………………………………………………………………………………………………35

General High Dependency Unit Critical Care Block 100 Bedded Critical Care Block 75 Bedded Critical Care Block 50 Bedded

Annexure-II ……………………………………………………………………………………………………………………………………………………………46

Equipment for ICU/HDU

Annexure-III ………………………………………………………………………………………………………………………………………………………….47

Quality Checklist for HDU/ICU

Annexure-IV …………………………………………………………………………………………………………………………………………………………49

Sample Format For HDU/ICU

List of Contributors ……………………………………………………………………………………………………………………………………………..50

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 11

BACKGROUND

With the launch of NHM, recent years have seen renewed efforts towards strengthening public health in India. Upgradation of health care infrastructure as per IPHS and addition of specialists, doctors, nurses, paramedics, giving financial flexibility etc. have helped in making facilities operational.

These efforts have contributed to major improvements in public health since 1950s. Life expectancy has increased from 36.5 years in 1951 to 68.8 years in 2016. Commensurate progress has been achieved in infant (Infant Mortality Rate declined from 146 per 1000 live births in 1951 to 28 per 1000 live births in 2020 (SRS, 2020 report) and maternal (Maternal Mortality Rate declined from 398 per 100,000 live births in 1997-98 to 103 per 100,000 live births in 2017-19 (SRS Data) survival over the years. Free medicines and diagnostics are now available in public health facilities which are highly effective in reducing morbidity and mortality.

Despite these efforts, public health facilities across India are facing challenges regarding increasing burden of disease, deficient infrastructure, insufficient manpower, non-adherence to protocols, high out of pocket expenditure etc.

District Hospitals form the crux of public health system as they provide secondary health care facilities ranging from preventive, promotive, curative, rehabilitative and palliative to the community within the District. Patients with severe complications that are not life threatening can be managed under existing medical/ surgical specialty with round the clock care and can be monitored in High Dependency Units.

However, in a patient with life-threatening conditions, the first goal is to save the life of the patient for which one to one care, monitoring and regular follow-up by an Intensivist/specialist trained in Intensive Care is required. They may also require support from specialists like Cardiologist/ Pulmonologist/ Nephrologist etc. Such patients should be treated in Intensive Care Units.

With no clear protocols at times defined, there is a high likelihood that patients who need regular monitoring are still continued to be observed in the wards. HDUs will be specifically equipped and staffed to provide the intermediate level of care that such patients often require if their condition deteriorates during their stay in the ward or after discharge from the ICU as a stepdown approach, before being shifting to the ward. Moreover, as compared to ICUs, HDUs are also intermediate in the consumption of valuable resources in terms of infrastructure and human resource, thereby helping in optimizing the resources and bringing in efficiency in critical care.

INTRODUCTION

HDUs/ICUs in public health facilities need to be better equipped both in terms of manpower as well as resources to provide assured and quality intensive care, as required, to the patients. During the COVID – 19 pandemic, the need for assured critical care facilities providing close monitoring was quiet evident. Efforts were taken both at central and state level to create and operationalize infrastructure as per the basic needs and protocols for intensive care by provision of equipment and adequate HR. These initiatives need to sustain so that the population gets assured critical services at district level.

So, there is a need to develop general High Dependency Units for better monitoring and prompt care to the patients requiring critical care. Once HDUs are established, ICUs also need to be developed, preferably in the vicinity of HDUs or a hybrid HDU can be developed having both invasive and/or non-invasive ventilator supported beds.

These Guidelines on High Dependency Units/ Intensive Care Units provide protocols for operationalizing HDUs and ICUs in secondary care facilities. These guidelines define admission criteria, infrastructural, human resource, equipment requirements, infection prevention protocols, and monitoring protocols.

12 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

OBJECTIVES

To define protocols for operationalization of HDU & ICU.

To define criteria for admission, monitoring, transfer and discharge of patients.

To ensure that High Dependency/Intensive Care setups are customized to the requirements based on the size of the hospital, patient turnover and specific specialty available.

To develop standards required for a high dependency/intensive care unit, both for the care of patients and training of staff.

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 13

KEY COMPONENTS

A critical care unit is defined as a separate, specially staffed, and equipped area dedicated for management and monitoring of patients with potential life-threatening illnesses, injuries, and complications. It comprises of Emergency/ Casualty, Intensive Care Units, High Dependency Units, or a hybrid HDU along with isolation beds.

In emergency and casualty, all medical, surgical, or accidental cases which need immediate interventions are coming for life saving and other emergency interventions. Some of them may require constant monitoring so, such cases are transferred to either HDU, ICU or hybrid HDU for further monitoring and treatment.

An Intensive Care is an area in a critical care unit where patients are managed and monitored extensively for life threatening illnesses and injuries. Patients in ICUs may require invasive ventilatory support.

A high dependency unit is an area of a critical care unit, where patients can be cared for in a more extensive manner than that in a normal ward, but not to the extent as provided in an intensive care unit. Such units will have non-invasive ventilatory support to the patients. Those admitted in HDU may require ICU admission later (step up) or, those admitted in ICU who have improved, may be shifted to HDU (step down), before being shifted to the general ward.

The critical care units will also require isolation rooms with a negative pressure ventilation for admitting and monitoring such infectious cases which are highly virulent and may spread infection to others. These rooms are supported with monitoring equipment and oxygen.

Basic characteristics of both HDU and ICU are mentioned below:

High Dependency Unit:

Intensive Care Unit:

Acts as a “step-up” or “step-down” unit between the level of care (intermediary care) delivered on a general ward and intensive care.

Acts as a “step-up” unit, since the highest level of care is delivered in intensive care unit

In general, HDU aims to manage cases where patients do not require invasive ventilatory support, are not in shock with significant amounts of vasoactive medications, or are not in multi organ failure, but have complications that necessitate close monitoring and supervision and are treated at the secondary care level (DH).

Provides invasive ventilation, constant monitoring, and support to patients with, or at risk of developing, acute (or acute on chronic) single or multiple organ failure.

HDU also aims to be a facility where severely sick patients who require ICU care can be stabilised before being transported to the nearest Intensive Care Unit for further treatment.

Patients with severe complications or organ failure can be managed in the intensive care unit with the facility of Invasive ventilation and vasopressor assistance.

Does not admit patients who only require nursing care on a regular basis.

–

14 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Need for Intensive Care Unit

Intensive care units cater to patients with severe and life-threatening illnesses and injuries, that require, close and continuous monitoring and support for maintaining functionality of vital organs. This needs close one to one observation and support of highly trained doctors and nurses who specialize in managing critically ill patients. ICUs are also distinguished from HDUs and wards by a higher staff-to-patient ratio and access to advanced medical resources and equipment that are not routinely available elsewhere.

Since, Intensive Care Units also monitor and manage cases of organ failures, so, it is desirable to either have in-house or established linkages with certain specialties like urology, oncology , neurology (mentioned in IPHS 2022)

Patients who have eminent threat to life or have multi-organ failure or are in severely serious general condition need to be admitted to ICUs. Patients may also be transferred directly to an intensive care unit from an emergency department if required, or from a ward/ high dependency unit if they rapidly deteriorate, or immediately after surgery, if the surgery is very invasive and the patient is at high risk of complications.

Availability of an Intensivist/ specialist trained in intensive care, adequate infrastructure and equipment are essential for smooth functioning of an ICU. So, only those District Hospitals that have such Specialties, HR and Equipment should develop ICUs. ICU would employ nurses who are trained in Intensive Care. since this a technical guidelines, do we need to mention this.

Hybrid Model

Ideally, district hospitals should have a hybrid HDU having both invasive and non-invasive ventilator supported beds. The hybrid model HDU can function under intensivist or specialists such as a MD Medicine or MS Surgery or an Anesthesiologist/Emergency medicine specialist with support from other MOs, Nurses, and other staff as per IPHS. Such health facilities where we have a space crunch or shortage of specialists and HR, the hybrid model is more suitable and cost-effective.

Number of beds in a critical care unit

Number of beds in a critical care unit will depend on the number of beds in a hospital. As per IPHS 2022 norms 8-10% of the total beds should ideally be a critical care beds. States/Districts are free to add more critical care beds depending on disease prevalence and local needs.

Additional number of critical care beds have also been sanctioned for district hospitals under Pradhan Mantri Ayushman Bharat Healthcare Infrastructure Mission. Whatever be the source of funds for establishing critical care beds, the processes and protocols given in the guidelines need to be followed.

Number of Beds in HDU and ICU

Type of Hospital

SDH 100 Beds

DH 50 Beds

DH 100 Beds

DH 200 Beds

DH 300 Beds

DH 400 Beds

DH 500 Beds

General HDU Beds

Isolation Beds

Pediatric HDU Beds

–

General ICU Beds

–

Pediatric ICU Beds

–

Obstetrics HDU Beds

–

Isolation Beds in Obs. Unit

–

Obstetrics ICU Beds

–

Polytrauma Unit Beds

–

Total Number of Beds

Critical Care Blocks

Apart from the critical care beds identified and recommended under IPHS 2022, every district in the country have also been sanctioned Critical Care Blocks (CCB) under PM-ABHIM. Critical care wing or block will be an integral part of the existing District Hospital (DH) or Medical College Hospital (MCH) to ensure optimum

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 15

utilization of resources. However, it must be ensured that there are separate entry and exit for the critical care block and it should be constructed in such a manner that it can be isolated and used as a dedicated facility for management of infectious diseases.

The purpose of establishing these blocks is to augment the capacity of the district for assured treatment and management of patients with infectious diseases and managing outbreaks. The separate entry/exit will help in isolating it from the main hospital building so that, the routine patient care does not suffer. However, in normal situations the hospital will utilize this wing for managing all types of critical patients.

Under PM-ABHIM, support is being provided to 602 districts across all states/ UTs to establish critical care blocks. For the 102 districts having more than 20 lakh population, the bed capacity for CCBs will be as follows:

For 274 districts with 5-20 lakhs population, it is envisaged to set- up 50 bedded critical care hospital block/ wing. Apart from the above, 226 districts, with government medical colleges, would also be supported to establish a 50 bedded critical care hospital block/wing.

Bed Strength at each level of CCB

Bed Strength of Critical Care Blocks

Sr. No.

Existing Bed Strength

Bed Strength of Critical Care Block

Less Than 200

200-300

More than 300

100

Beds

100 Beds

75 Beds

50 Beds

ICU

20 (including 4 Pediatric Beds)

12 (including 2 Pediatric Beds)

10 (including 2 Pediatric Beds)

HDU

20 (including 4 Pediatric Beds)

12 (including 2 Pediatric Beds)

6 (including 2 Pediatric Beds)

Isolation Ward

Isolation room

Dialysis

MCH

Emergency

10 (4 Red+ 4 Yellow+2 Triage)

5 (2 Red+ 2 Yellow+1 Triage)

Total Beds

100 +2 Triage Beds

75 +2 Triage Beds

50 +1 Triage Beds

LDR

Point of Care Lab

Planning & Location

CCBs need to have distinct identity for easy access but simultaneously, the infrastructure should be closely integrated with existing hospital through a connecting corridor at all floors. A suggestive layout plan is annexed, and the soft copy can also be downloaded through QR code given in the guidelines.

The 100, 75 and 50-bedded Critical Care Hospital Blocks/Wings would be functionally integrated with the respective DH or MCH. During the time of an outbreak such as COVID-19, the block/ wing can be isolated from the main building to ensure adherence to infection prevention practices, while during regular time, the critical care block can function as an integral part of the district hospital.

The block would have functional units for critical care including emergency area and ICU, isolation wards, OT, Labour-Delivery-Recovery rooms (LDRs) with New-born Care Corner, etc. The support services like Imaging facility, Dietary services, CSSD with Mechanized Laundry, etc. needs to be linked with existing DH or to be created if not available. These blocks/wings would also be supported with Medical Gas Pipeline System, Oxygen generation plants/ Oxygen supply, Air Handling Units (AHUs), etc., and mechanism for Infection, Prevention and Control.

The HRH norms for CCBs will be as per the IPHS 2022 norms for critical care areas.

16 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

ADMISSION AND STEP UP/DOWN CRITERIA

Admission Criteria for HDU

Irrespective of the dependency, (system-wise) patients would be identified by applying an objective physiologic criterion to decide whether and where the admission is required. Neonatal, Obstetric and Trauma patients have specifically been excluded since separate units for such patients are to be established for which Government of India guidelines are available2.

Admission criteria can be prepared in two ways-

1. A system-based list of various conditions that require intensive care and monitoring. However, such a list will be very exhaustive. This will also require an extensive training of staff in various definitions of the conditions listed in the admission criteria.

2. Objective physiologic status to make it consistent with the skills list, supplemented with some examples and objective criteria that will be representative but not limited to exhaustive / all-inclusive list as indicated below-

Note: Despite above, individual clinical skills and expertise should be weighed in against the individual patient conditions with the above being guiding principles.

Patients with the following symptoms, signs, findings or requiring following interventions will need HDU admissions. The possible criteria according to the physiologic status as well as organ specific diseases and few possible clinical conditions are enumerated. However, it must be remembered that this list is not exhaustive and in real life many other diseases may present with the same physiologic status which may need HDU admission.

Physiological parameters / Organ specific dysfunction

Symptoms

Signs

Investigations

Interventions

Airway

1. Threatened

2. Not maintainable/ Obstructed

Possible diseases causing airway problems-

FB aspiration, Status asthmaticus, Decreased consciousness, Inhalation of Toxic substances/fumes etc., Anaphylaxis, Trauma

• Breathlessness

• Choking sensation

• Air hunger

• Hampered phonation

• Symptoms s/o toxidromes

• Cyanosis

• Abnormal airway sounds like

stridor, wheeze, or significant gurgling sounds.

• Silent chest

• Absent air entry

• Severe chest / intercostal

retractions

• Signs s/o toxidromes

• SpO2 < 94% on room air

• X ray showing signs of acute croup

• Investigations s/o toxidrome exposure

• Suctioning

• Airway patency restoration

maneuvers as following*

• Head Tilt & Chin lift or Jaw thrust

maneuver

• Nasopharyngeal airway

• Oropharyngeal airway

• Supraglottic airway insertion (e.g LMA)

• Endotracheal intubation

• Emergency Cricothyrotomy /

• Tracheostomy

• FB removal

• Bronchoscopy

2https://nhm.gov.in/images/pdf/programmes/child-health/guidelines/Strenghtening_Facility_Based_Paediatric_Care-Operational_Guidelines.pdf https://nhm.gov.in/images/pdf/programmes/maternal-health/guidelines/Guidelines_for_Obstetric_HDU_and_ICU.pdf

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 17

Physiological parameters / Organ specific dysfunction

Symptoms

Signs

Investigations

Interventions

Breathing

1. Respiratory distress 2. Respiratory failure

Possible diseases causing breathing problems-

Pneumonia, Pulmonary

edema, Kerosene poisoning, ARDS, COPD, Neuromuscular depression, Pleural pathology ( e.g. effusion Pneumothorax etc. ), interstitial lung diseases.

• Breathlessness

• Air hunger

• Inability to lie down flat

• Fast respirations

• Symptoms secondary to hypoxia – altered mentation

• Tachypnea, Bradypnea, Apnea

• Abnormal lung sounds

like grunting, crepitations

• Differential lung sounds

• Decreased or Absent air entry

• Shallow breathing (low tidal volume)

• Chest / Inter- coastal retractions

• Cyanosis

• SpO2 < 94% on room air

• ABG with PaO2/FiO2 < 300

• ABG with PaCO2 > 50 and pH < 7.25

• X-ray Chest showing signs of lung

parenchymal or interstitial or pleural disease

• May show increased lactate

as a generalized marker of anaerobic metabolism.

• Raised Creatine Kinase in blood

• Oxygen therapy

• Nasal canula, face

mask, Venturi Mask,

Non rebreathing

mask with

administration of

different range of

FiO2 as appropriate

to maintain SpO2 > 94%**

• Bag and mask ventilation with

oxygen

• Non-invasive mechanical

ventilation (CPAP, BiPAP etc.)

• Needle thoraco- centesis

• Invasive mechanical ventilation

• Chest tube insertion

• Medical management of

diseases process underneath

Circulation

1. Congestive cardiac failure 2. Shock ( all different types )

3. Suspected Myocardial Ischemia / Infarction

4. Pericardial Effusion/ Tamponade

5. Sepsis with shock

6. Severe Bleeding

Possible diseases causing circulatory problems-

All types of Shocks, Myocardial Infarction, Cardiomyopathies, Valvular heart diseases, Myocarditis.

• Palpitation

• Chest pain

• Breathlessness

• Excessive sweating due to shock

• Sudden onset pallor

• Giddiness

• Persistent tachycardia, bradycardia,

irregular pulse perceived to be pathological

• Hypotension with SBP < 5th

percentile

• Weak peripheral pulses

• Signs of poor perfusion like-

delayed CFT,

cold clammy extremities, depressed mentation, decreased urine output <1 ml/kg/h

• New onset murmur

• X-Ray chest- cardiomegaly /

evidence of CCF

• ECG- Any e/o ischemia or infarcts

• ECG- e/o any arrhythmias with

hemodynamic instability

• Elevated cardiac biomarkers like

Troponin, CPK MB

• Echo- e/o any systolic / diastolic dysfunction, significant regional wall motion abnormalities, pericardial abnormalities.

• Increased lactate levels suggestive

of generalized anaerobic metabolism

• Metabolic acidosis might be present

• Fluid bolus requirement

beyond 10 ml / kg – crystalloids preferable.

• Vasopressor and inotropic

requirement

• Use of defibrillator, AED

& Transcutaneous Pacing

• Fibrinolysis for MI

• Treatment of arrythmia

(Pharmacological or electrical therapy)

• Blood transfusion (Massive BT)

18 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Physiological parameters / Organ specific dysfunction

Symptoms

Signs

Investigations

Interventions

Disability

1. Traumatic brain injury

2. Acute focal neuro-deficits

3.Hemiparalysis/Hemiplegia due to various causes e.g. Stroke

4.Paraparalysis/Paraplegia

5. Pott’s Spine, Bacterial/TB Meningitis

6. Hepatic/Uremic encephalopathy

Possible diseases causing disability

Neuro-infections, metabolic encephalopathies, toxidromes, structural brain disease, neuro- skeletal issues, myopathies etc.

• Altered consciousness • Convulsions

• Focal neurologic deficits

• Vomiting, Headache

• Decreased GCS ( or Poor AVPU scale )

• Hypoglycemia

• S/o Raised ICT

• Focal neurologic deficits

• Abnormal pupillary

examination

• Ongoing convulsions

• High BP

• Low backache

• No sensation in paralyzed limb

• Signs of respective system failure

• CT or MRI showing any abnormalities

• Fundoscopic examination

• abnormal LP puncture report

• Abnormal basic lab test reports, USG

• Interventions for low GCS (suctioning, airway insertions etc.)

• Interventions for raised ICT

(Medicines for raised ICT, neurosurgical interventions)

• Intervention to treat injuries caused by trauma

• Anti-hypertensives, Antibiotics, AKT

• Surgery as required

• Stroke treatment pathway

Exposure

Heat Stroke

Heat Exhaustion Frost Bite

Bites e.g. Snake bite

• Throbbing headache

• Coma

• Hallucination

• Lack of sweating despite heat

• Excessive Sweating

• Fever, temp >103 C

• Red, hot, dry skin

• Tingling, numbness, changes in colour of skin

• Rashes, Hives

• Hypotension

• Lower lime loss of power or sensation

• Snake bite mark

• Bullae on finger/

toes

• edema

• injury on back – spine injury if

visible

• gluteal region injury

• Abnormal electrolytes

• Acid base imbalance

• ECG- rhythm

disturbances

• X-ray spine at appropriate levels

• Log rolling

• Interventions to prevent

hypothermia

• ASV

• Symptomatic treatment

• Reduce fever in case of high body temperature

Organ Specific Dysfunction

Hepatic

Possible diseases causing hepatic problems-

Acute viral hepatitis, Acute hepatitis of other etiologies, Decompensated chronic liver disease

Portal hypertension

• Severe Jaundice

• Abdominal distension

• Bleeding manifestations such as UGI bleed

• Other symptoms of hepatic encephalopathy

• Altered sensorium

• Severe Jaundice

• Signs of hepatic

encephalopathy

• Signs of Portal hypertension

• Low GCS

• Hypoglycemia

• Deranged

coagulation profile

• Increased bilirubin

• Elevated liver enzymes

• Elevated ammonia

• Abnormal USG & other radiological test reports

• Interventions for low GCS (suctioning, airway insertions etc.)

• Interventions for bleeding

complications

• Paracentesis

• Interventions to control GI bleed

• Interventions to reduce ammonia/ urea in blood e.g. dialysis

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 19

Physiological parameters / Organ specific dysfunction

Symptoms

Signs

Investigations

Interventions

Hematological

Possible diseases causing hematologic problems-

Hemoglobinopathies, Thalassemias, Anemias

of various etiologies, Hematological malignancies, Infections,

Acute Haemorrhage, Autoimmune diseases affecting blood e.g. ITP

Clotting factors diseases etc.

• Signs of vaso-occlusive crises

• Acute Dyspnea

• Fever & other signs of

infection

• Easy bruising

• Severe pallor

• Bleeding

manifestations

• Cola urine (Hb- uria)

• Severe anemia

• Severe

thrombocytopenia

• Severe Leucopenia

• Clotting factors deficiency

• Blood component therapies

• Interventions for haematological

crises

• Interventions for febrile neutropenia

• Specific therapy

for autoimmune & malignant disorders

Fluid & electrolytes

Possible diseases causing F&E problems-

Diarrheas, PEM, Cholera, SIADH, Kidney diseases, Diabetes Insipidus,

Dysentery

• Symptoms s/o dyselectrolytemia (e.g. Abdominal distension, convulsions etc.)

• Irregular heart beat/ fast heart rate

• Fatigue/lethargy

• Nausea, vomiting,

diarrhea or constipation

• Abdominal cramping, muscle cramping

• Muscle weakness

• Irritability/confusion

• Headache,

numbness and tingling

• Signs compatible with

dyselectrolytemia (eg. arrhythmias floppiness, hypotonia, raised ICT, decreased consciousness)

• Coma, Cardiac arrest

• Abnormalities in electrolytes (Na, K, Ca, Mg, Chloride, Phosphate, Bicarbonate, Lactate etc.)

• ECG abnormalities consistent with

dyselectrolytemia

• Interventions for dyselectrolytemia

Endocrine / Metabolic

Possible diseases causing Endocrine /Metabolic problems-

Thyroid disorders, Adrenal Insufficiencies, Pituitary hyposecretion, Diabetes mellitus etc.

• Symptoms compatible with thyroid

emergencies

• Symptoms compatible with diabetic

emergencies

• Adrenal crisis

• Signs compatible with thyroid emergencies

• Signs compatible with diabetic emergencies

• Abnormalities in thyroid function tests

• ABG suggestive of DKA

• Severe metabolic acidosis

• Interventions for DKA / metabolic

acidosis

Renal

Possible diseases causing renal problems-

Acute kidney injury,

Acute over chronic kidney diseases, Pyelonephritis, UTI, Nephrolithiasis etc.

• Oliguria / anuria

• Generalized edema

• Symptoms s/o compatible with acute renal failure

• Severe weakness, fever, lower backache

• Hematuria

• Signs compatible with acute

renal failure & uremia (e.g. Fluid overload, uremic encephalopathy)

• Loin Pain with features of

infection

• Deranged Creatinine, urea etc.

• Dyselectrolytemia

• Severe metabolic

acidosis

• Raised cell counts

• Urine c/s positive

• Renal stones in KUB etc.

• Medical management

of uremia, Dyselectrolytemia, fluid overload due to ARF

• Renal replacement therapy

20 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Physiological parameters / Organ specific dysfunction

Symptoms

Signs

Investigations

Interventions

Malignancies

• Symptoms compatible with tumor lysis

syndrome

• Coma

• Altered sensorium, intractable headache

• Bleeding PR

• Sudden passage of blood in Urine

• Signs compatible with tumor lysis

syndrome

• Neurological signs reflecting possible presence of a Space Occupying Lesion

• Family history or life-style history

indicating towards a possible cancer etiology

• Hypercalcemia

• Hyperkalemia

• Hyperphosphatemia

• Hyperuricemia

• Metabolic acidosis

• Urine analysis

• CT/MRI

• Interventions for complications

of tumor lysis syndrome

• Interventions to detect the primary cancer and the secondary deposits, if any.

Surgical

• All post-operative patients requiring intensive monitoring either due to pre-morbid conditions, due to complexity of surgery or due to intra-operative complications.

Miscellaneous

e.g. amnesia, acute psychosis etc.

• Sudden onset of erratic behavior

• Sudden loss of memory

• CT/MRI brain changes compatible with Alzheimer

• Interventions to control the

acute attack and then long-term management

Note:

1. Criteria for admission should be considered only in correlation with the clinical and physiological

parameters and/or lab reports interpreted together.

2. Exclusion criteria- Gynecology/Obstetrics/Newborn emergencies and Trauma

Step-up Criteria for transfer from HDU to ICU

Patients either admitted to HDU or qualifying for admission to HDU with either presence of or anticipation of the following must be considered for shifting / direct admission to ICU-

1. Requiring invasive ventilatory support.

2. Hemodynamic instability requiring significant / increasing vasopressor / inotrope support. 3. Multi-organ failure syndrome involving 2 or more organ system dysfunctions.

4. Continuous or intensive monitoring required for any reason/condition.

Step-down Criteria for transfer out from ICU to HDU

Resolution of the above criteria with reasonable clinical stability for at least 12-24 hours can be taken as criteria to step down / transfer the patient from ICU to HDU. However, the clinicians must keep in mind that strict vigilance will be required for such transferred patient in the HDU as the clinical condition may again worsen and some patients may again need to be shifted back to ICU.

Step-down Criteria for transfer out from HDU to ward

Once the underlying physiologic condition that necessitated admission to HDU gets resolved or stabilized for a reasonable period of time, the patient can be considered for transfer from HDU to ward.

Minimum transfer criteria for intra- and inter- facility transports

Patients who need to be transferred to an ICU within the same hospital or in another hospital’s ICU need a proper transport system in place. In ideal settings, oxygen, Monitor (ECG, NIBP & SPO2), and transport ventilator (for patients requiring IPPV) should be available. However, if transport ventilator is unavailable, at least a manual bag resuscitator or Bag-Mask assembly with oxygen for giving ventilation with or without

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 21

PEEP valve and is needed for transporting a patient from HDU to ICU.

Such transfer will require the following systems to work but not limited to these-

1. After initial stabilization of the physiological parameters to the best possible over a short period of time, the benefits of making an early transfer of the patient to a definitive care facility must be weighed against the risk of holding the patient back to the current facility. This can be considered even with the ongoing resuscitation and stabilization during the transport. The transport capabilities in terms of infrastructure ( advanced ambulance ) , manpower (Trained paramedics ) needs to be weighed-in, while making above decision.

2. Pre transport coordination and communication with the receiving facility and information and counselling with patient’s relatives should be done.

3. Personnel required for transport: wherever feasible and available, some personnel trained in advanced life support or similar skills should accompany the patient.

4. Equipment: Monitoring equipment should measure non-invasive parameters like SpO2, NIBP, ECG and preferably EtCO2. Along with defibrillator, resuscitative equipment should contain oxygen source, oxygen delivery devices including AMBU bag with O2 reservoir, Bag-Mask assembly (Bain’s or T-piece circuit) transport ventilator, fluid resuscitation devices like syringe pump, difficult airway device cart including laryngoscope, bougie, endo tracheal tube, supraglottic airway, oropharyngeal and nasopharyngeal airway, adhesive tape or cotton tape to secure airway device etc.

5. Drugs: Following Emergency lifesaving drugs (but not limited to)-

Cardiac Drugs: Adrenaline, Nor-adrenaline, Dobutamine, Atropine, Amiodarone, Preservative free lignocaine, Nitroglycerine injections.

Others: – Calcium gluconate, Sodium bicarbonate, Potassium chloride, 25% dextrose, Bronchodilators, Hydrocortisone, Dexamethasone.

Sedative – Neuromuscular – Anti-convulsant: Midazolam, Propofol, Succinylcholine, Atracurium, fosphenytoin / phenytoin.

6. Documentation: Should include indications, consent, pre, intra and post transport vitals recording, handover notes, critical findings of laboratory tests, imaging, ECG, etc., and their significance course of treatment (plan of care) and likelihood of life-threatening deterioration without intervention.

Referrals from outside to HDU / from ICU to HDU (inter or intra-hospital transfers):

Ensure attaching completely filled referral slips mentioning summary of illness, provisional diagnosis, reasons for referral, investigations done, treatment given and vitals at the time of referral. Ensure availability of emergency medications, assured transport and a trained paramedic to accompany while transferring.

Transfer of a Corpse

In case of death, the deceased should be given a dignified transfer to the mortuary or any other designated area. While transferring such deceased bodies, precautions need to be taken to follow a separate route than the one used by the patients, such as fire exit gate. It must be ensured that valuables or any important belongings of the deceased must be handed over to the family member before shifting the body from the /wards/HDU/ICU.

22 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

PHYSICAL INFRASTRUCTURE

A. Where to set up Critical Care Unit?

• To start with, it is suggested that all District Hospitals should have a general, paediatric and an obstetric HDU. Later on, based on the availability of resources, the states can set up HDUs at SDH and other high load FRUs.

• Two rooms of approx. 171.6 sq. ft. each shall be designated as Isolation Room at one end in the HDU for management of patients requiring isolation

B. Location

• For efficient utilization of infrastructure and manpower services, HDU / ICU should be co-located at one location. If the district hospital is small (50-100 bedded), it can be linked to an external ICU of nearby District hospital / medical college or other as appropriate to ensure availability of critical care services within ‘golden (one) hour’.

• Within the facility, it should ideally be located near the operation theatre.

• Proximity to other areas and essential support services such as the main wards, Radiology,

Laboratory, Blood bank etc.

• Preferably on First floor as at the ground floor dust contamination & chances of infection are more. An electric elevator/ramp is must for patient transportation.

• There should be unidirectional flow for entry and exit to/from HDU and ICU.

• There should be provision of separate fire safety exit. In case of disasters or any other emergency,

these “exits” to be used with spring loaded flap type doors.

C. Space

As per IPHS, the following space requirements are essential for a hybrid critical care unit:

D. Privacy

• There should be single-piece curtains and not split into parts between the rooms for ensuring

privacy of the patients.

• The curtain fabric should be fire and waterproof, washable, clean, light colored, inherently stain resistant and non‐ allergic.

• Preferably 3 colors i.e., blue, yellow and red/pink should not be used in HDU/ICU as they interfere with identifying cyanosis, icterus and pallor respectively.

E. Civil construction and other necessary requirements

Critical Care Unit is divided into four major areas: a. Waiting Area:

i. A comfortable waiting area in the hospital should be located in the vicinity of critical care areas including HDUs and ICUs. Waiting area for the patients’ attendants should be provided, with facility

Type of bed

Floor space per bed

Space between head end and wall

Space between Foot end and wall

Space between center of two adjacent beds

ICU bed

25-30 m2

0.9 m

1.2 m

3.5 m

HDU bed

20-24 m2

Pediatric ICU Bed

12m2

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 23

for seating capacity for at least 2 relatives per patient, facility of drinking water, a large TV with LCD display, toilets, and educational/IEC material etc. The waiting area can be shared with waiting area for other important areas such as LR and/or OT. An efficient electronic communication system should be ensured in waiting area. Crowd management in the waiting area is the responsibility of the guard on duty. S/He must ensure that only one attendant per person is allowed in the patient interaction room. A communication system should be suitably accommodated to establish communication with the patients’ attendants.

ii. Counselling Area: Since the attendants of the admitted patients remain anxious about the status of the patient, the waiting area should have a space demarcated for interaction with doctors regarding patient’s condition.

iii. Trolley Area: Layout of critical care area prescribes one time trolley change while moving patients from ward/operation theatre/ emergency to the complex. After each use, the trolleys need to be brought back into trolley area after cleaning by wet mop with disinfectant/chemical/soap water.

b. Changing Room

i. Patient’s attendants changing room: This area will be used for patients’ attendants and relatives who have been permitted to visit the patients. This will be located close to the reception area. Provision for shoe cover/sandal change to be ensured.

ii. Staff Changing Room: This area will be used for staff. Provision for shoe cover/sandal change and personal protective equipment (PPE) to be ensured.

c. Critical Care Complex

i. Nursing Station: The location of nursing station inside the unit should be such that the nurses can see each patient conveniently. Nursing station should be equipped with Central Monitoring Station, Nurse Call system, Desktop Computer, Telephone/EPABX system, File Cabinets, Cupboards and Drawers.

ii. Linen Store : A Linen storeroom should be made to keep bed linen, personal protective attire like caps and masks, slippers, etc.

iii. Critical Equipment Store: A separate room should be made to keep critical equipment as placed in Annexure II.

iv. Therapeutic Diet Preparation Area: A separate room for preparing therapeutic diet as per patient’s chart to be made available.

v. Isolation Area: To provide protective environment for patients at highest risk of infection, e.g., neutropenic, and post-transplant. Positive airflow relative to the corridor (i.e., air flows from the room to the outside adjacent space) should be maintained.

vi. ICU and HDU beds:

1. Flooring: The floor should be made of large vitrified, antiskid, stain proof and easy to clean tiles with seamless joints. The tiles should be of light color (preferably white or off‐white). The floor tiles should be able to withstand abuse and absorb sound while enhancing the overall look and feel of the environment. Carts and beds equipped with large wheels should roll easily over it. Vinyl flooring should be avoided as the durability of this material are low and a small damage in one corner may trigger damage of entire flooring and make it accident prone.

24 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

2. Walls: The walls should be of durable glazed tiles which are easy to clean, stain resistant, flame retardant and have a visual appeal. It will be preferable to have finishing of wall up to 6‐7 ft. height with the tiles that are similar to floor tiles. Colors should be chosen carefully to avoid interference with clinical assessment in certain clinical presentation. On the skin Light colors (white or off‐white) is preferable.

3. Coving: All corners of the unit should be coved.

4. Ceiling: The ceiling should be leak proof. It is suggested that no electric lines or wires should run over the ceiling or be kept underground. The lines should be easy to explore, in case repair is required, as damages are common and may occur any time.

5. Window: Window should be hermetically sealed with toughened glass and flushed to the inside wall of the room. The Window frame should be of powder coated Aluminum flush mounted with wall. The entire assembly should be completely sealed with Silicon/EPDM gasket and fitted with proper Aluminum profile. Window should be constructed of two toughened glass wrapped with film/Frosted toughened glass/ Motorized Venetian blinds sandwiched with toughened glass.

6. Heating, Ventilation and Air conditioning system (HVAC)- HVAC system should be such that 10-12 Air Changes Per Hour (ACPH) with 4 – 5 fresh air changes can be provided in the unit. AHU should be equipped with fine filters and continuous air circulation system (24×7). A Temperature of about 23±20C and Relative Humidity of 45 -65% throughout the year should be maintained inside ICU/HDU

7. Light: Clean LED light fitting should be used for lighting. Light should be sealed and flushed to the ceiling. Illumination at bedside must be at least 300 lux. All switches and sockets inside unit should be antimicrobial.

8. Bed Head Panel (BHP)/Pendant: Each bed in the unit should have a Bed Head Panel/Pendant equipped with antimicrobial switches. It should be planned in such a way that clutter of wires is avoided, thereby enabling free movement around patient’s bed

9. Gas Pipelines: Gas pipelines should be laid in the unit with Oxygen Outlet & Flow meter, Vacuum Outlet & Ward Vacuum unit and Medical air (4 bar) outlet. Each unit should have an individual Valve Box and Alarm system. Gas Outlets shall be fixed to the BHP/Pendant

10. As per INC (International Noise Council) recommendation, the noise levels in hospital acute care areas should not exceed 45 dB (A) in the daytime, 40 dB (A) in the evening, and 20 dB (A) at night.

11. Back-up for power supply for running of all electric operated equipment.

a. Cleaning Area

i. Toilets: Toilets as per the sample layout annexed in this guideline should be made.

ii. Bed Pan Cleaning area: A separate area to clean used bed bans should be designated

For all the above-mentioned areas, provision for fire safety, preferably through automatic water sprinkling system or normal fire extinguishers.

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 25

HUMAN RESOURCE

The Human Resource in HDU and ICU shall be as per Indian Public Health Standards. The Human Resource trained in critical care should not be deployed/transferred to other areas. While establishing or operationalizing HDUs/Hybrid HDUs/ICUs, following ratio should be adhered to:

S. No.

Type of Staff

Staffing Norms

Medical Officer

1 : 10

Nurses (General HDU)

1 :2

Nurses (Pediatric HDU)

1 :3

Nurses (General ICU including pediatric)

1:1 for General ICU & 1:2 for Pediatric ICU

Sanitation Staff

1 : 10

Note: Besides above norms for HR, these critical units will also need a senior supervisory staff like Nursing Superintendent or Asst. Nursing Superintendent for logistic and supervisory support. Similarly, technicians are needed for assisting in USG/Echo/X-ray etc. and other diagnostic procedures. They will also undertake correction of day-to-day faults and maintenance of equipment. Adequately trained sufficient number of housekeeping staff should be available round the clock either in house or through outsourcing.

Sufficient number of security guards should be available round the clock either in house or through outsourcing for managing entry/exit points in OT.

Job Description

Sl. No.

Category

Brief Job description

Security

Security guards should be made available round the clock for ensuring safety of staff, property and essential commodities.

Security is also needed for restricted access.

Security guards should be trained in crowd management, empathy during grief counselling, infection control practices and shifting of patients during emergency

Dietician

These are not specially for the critical care complex but to be taken from pool of hospital’s human resource.

Dietician: Therapeutic diet of patients will be determined by the dietician during their daily rounds in consultation with concerned doctor based on the clinical condition of the patient and after assessing the food habits.

Physiotherapist: Physiotherapist will also undertake daily rounds to advise patients admitted in critical care areas, for stroke, respiratory distress and/or those on chronic bed rest).

Bio-medical Engineer: Oversee Equipment Maintenance

10.

Physiotherapist

11.

Bio-medical Engineer

Capacity building

Maintaining and running a critical care unit is a specialized and skillful job. The staff working in the Critical Care Unit is exposed to long stressful environment with critical cases. Hence, it is of utmost importance that the staff of unit is trained and motivated for leading healthy lifestyle with low/zero mental stress. They should also be trained and oriented in various technical processes, that are pre-requisite to providing high quality services in the unit. Unit’s in-charge should be a specialist, or a doctor trained in emergency medicine. The unit should be managed round the clock by the MBBS doctors and the nurses. They should ideally be qualified in relevant critical care courses. In case this is not the case, they must be trained for providing critical care in critical care departments of a tertiary care hospitals where they are posted along with the regular staff to be able to learn the required knowledge and skills.

A few short duration trainings have been advised below, that can be conducted for capacity building in critical care.

• Training on Clinical parameters, ventilation, resuscitation, monitoring of vitals, emergency drug usage, side effect, adverse event training, anaphylactic shocks can also be provided under supervision of medical college for a minimum of seven days.

• Medical Officers and nurses working in these units need to be trained and oriented on various technical parameters, practices required for identification and management of critical illnesses. They also need to be oriented on various monitoring parameters like diagnostics and lab reports, clinical condition of the patient and the protocols for their management. It is a good practice to have them posted at least for a week at a critical care unit of medical college to acquire these knowledge and skills.

All MOs/nurses should be trained in ALS/BLS/ BCLS / CCLS / Trauma Life support courses / NELS. Besides the above, following short trainings are also advised:

28 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Training Plan

Name of Training and duration

Components of training

Target Participants

Trainers

Quality check of training

Organizational behavior and management of critical care unit

Duration: 3 hours

Teamwork, Stress management, Room wise protocol

All staff working in unit

NHSRC, Medical colleges, Paramedical institutes and Supporting institutes

Pre and Post training test – Knowledge and Skill test

How to maintain sterilization of critical care unit – monitoring & quality check

Duration: 3 hours

Hand hygiene, AHU maintenance, Cleaning protocol, BMW practices, Microbiological sampling

Unit in-charge, nurses, Ward boy, Guard and Cleaning staff

NHSRC , Medical colleges, Paramedical institutes and Supporting institutes

Pre and Post training test – Knowledge and Skill test

Equipment maintenance & Record keeping

Duration: 3 hours

Indenting, AMC, CMC, Calculation of downtime and cleaning, handing and taking over of critical equipment, Record maintenance and Reporting

Unit in-charge and Unit nurses, Technician

NHSRC , Medical colleges, Paramedical institutes and Supporting institutes

Monthly monitoring of records

Other Trainings Duration: 1 day

Orientation for Step up and Step down process and disaster management

Doctors and Staff nurses. All staff for disaster management

NHSRC , Medical colleges, Paramedical institutes and Supporting institutes

Pre and Post training test – Knowledge and Skill test

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 29

OPERATIONALIZING ICUS THROUGH TELECONSULTATION AND TELE-ICU

Availability of specialists and trained HR is critical for operationalizing ICUs/HDUs. Till the time availability of trained specialists in adequate number is ensured while keeping them as priority in a long term plan, there is a need to augment the knowledge and skills of existing doctors and specialists providing clinical care for efficiently managing critical care units at public health facilities.

Capacity building for clinical staff posted at HDU/ICU is of paramount importance but practically bringing all of them for skill building is sometimes a tedious task since, as primarily they will have to leave the clinical services at their own facilities and then join for a training, even if its duration is short. Even if available, the type of specialties is very limited. Therefore, e-trainings/virtual trainings is promoted where knowledge can be imparted through a tele consultation hub, even skill demonstration on mannequins can be undertaken by the hub.

Tele ICU services are not designed to replace the local health care services provided at secondary care level , but to augment care through leveraging of technical, informational, and clinical resources and standardization of processes.

In this model, a team of Intensivists and other healthcare professionals may assemble in a central location (hub) and be connected to different locations (spoke) at a predetermined schedule. They can thus serve multiple locations in the same day. A separate smaller team may also be constituted to attend to emergency calls emanating from any location. This will help in orderly delivery of services. The actual number of hubs and spokes will depend upon the ICU beds and their occupancy, acuity of care required and availability of human resources.

The tertiary care institutions may form teams of PG students and faculties to provide support to the recently established ICUs in the district hospitals/general hospitals. Once the teams in the spoke hospitals are confident, they will perform the procedures in ICUs by seeking tele- consultation, if needed.

The health work force of spoke may be trained at hub which can be located at a medical college. Such hubs will support DH/SDH as a spoke for:

1. Capacity building by case-based discussion

2. Schematic planning for upgradation of spoke facilities by temporary posting of ICU staff

3. For other specialists identifying the areas which requires skill upgradation, skill practice by on-site training at hub facility

The details of telemedicine practice, emergency consultations and its applications at HUB and SPOKE is defined in telemedicine practice guidelines (enabling registered medical practitioners to provide healthcare using telemedicine, released by board of Governors in suppression of the Medical Council of India on 25th March 2020) (link: https://www.mohfw.gov.in/pdf/Telemedicine.pdf ).

Equipment

For effective functioning of HDU/ICU, a particular set of equipment will be required. The list of such equipment is placed at Annexure-II. All the equipment purchased should be covered under comprehensive equipment maintenance programme or under 3-5 years Annual Maintenance Contract (AMC). And all the areas having critical and electric equipment to have conductive flooring with proper earthing.

30 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Quality Policy

Statutory requirements

The design and planning of critical care unit will need compliance with mandatory regulations related to local administration such as State Government, Municipal Corporation Pollution Control Board, Fire Safety Department, PWD etc. While planning HDU/ICU complex, provision for future expansion of the complex should be kept in mind.

Operational Management of HDU/ICU

Policies and Procedures:

1. Administration: A Standard Operating Procedure (SOP) should be laid down on functioning of critical care unit, duties & responsibilities of staff members, infection control measures and cleaning & sterilization policy in the unit. Management of the unit is team work wherein all- Clinicians, Nurses and Allied Health Professionals work together for long duration in a closed & stressful environment. Thus, a high level of motivation is needed for maintaining high output, high degree of asepsis and quality assurance. Normally, a senior Anesthesiologist is designated as Officer In-Charge of HDU/ICU for day- to-day administration, coordination and regular maintenance. The admission/discharge to/from HDU/ ICU should be done strictly as per protocol and laid down criteria, by the doctor on duty with the consultation of HDU/ICU in-charge.

2. Infection Control Measures

There should be regular and strict monitoring by the infection control team on infection control practices in HDU/ICU.

• Detailed cleaning protocols specifying frequency, cleaning agent and processes for the HDU/ICU are annexed.

• Fumigation is not recommended if infection control protocols are strictly adhered to and humidity and temperature are adequately maintained.

• Use of aldehyde containing compounds for fumigation are contraindicated in hospitals., infection control measures should be adhered to as per the annexure attached.

There should be clearly laid down policy guidelines for sepsis control in HDU/ICU. Some of these include:

(a) Strict environmental control – Temperature, humidity, and ventilation. Pressure gauze and thermometer should be installed for daily checking of these parameters.

(b) HEPA filters should be used in AC and checked for efficiency.

the air pressure.

(d) Swabs should be collected from AC ducts and sent for culture for checking microbial growth at periodic intervals.

(e) Disinfection of equipment, beds and other mobile items should be ensured while maintaining its record.

(f) Timetable should be maintained and one day in a week should be set aside for cleaning and maintenance.

(g) Designated Infection Control Nurse should visit the critical care unit regularly to check compliance with infection control measures.

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 31

(h) Routine sampling of air or surfaces for culture is not recommended. In special circumstances, air culture using slit sampler can be performed in the operation theatres (OTs) instead of settle plate test.

(i) Wearing of caps, masks, and gown, change of footwear should be made compulsory and be strictly enforced.

(j) All staff members should be periodically sensitized in hand hygiene and surgical site infection and measures to avoid it.

(k) Any staff member with any respiratory infection or any infectious disease should not be allowed to enter inside the unit

(l) Adherence to the latest Bio Medical Waste Management Rules.

For an efficient functioning of High Dependency Unit, there is a need to reinforce effective communication skills and adherence to standard patient monitoring protocols, infection control protocols, hand hygiene practices & Biomedical Waste management. Documentation, record keeping, and certification required for various medico legal purposes along with knowledge and skills to identify conditions that need referral and adherence to standard referral protocols is needed.

Quality Policy

Type of indicator

Indicator

Formula

Rationale

Efficiency of HR

Daily rounds by in- charge

(Total No. of daily rounds/total no. of days in the month) *100

Continual quality care of patient is monitored

Skills of nursing staff

(Total no. of nurses skilled(trained in intensive care)/total no. of nurses) *100

For provision of efficient quality care

Equipment

Downtime of machine/ equipment

(Downtime of the equipment/the time the equipment was functional)*100

Productivity of the equipment

Process

Bed occupancy rate

(Inpatient Days of Care/Bed Days Available) x 100

Utilization of available beds

Bed turnover rate

(Total no. of discharges+ total no. of deaths in the month/no. of beds)

Calculation of rate if discharged

Average length of Stay

Total sum of Length of stay/Total no. of patients in a month

Efficiency of the functions of critical care unit

Outputs

Refer rate

(Total no. of patients referred in the month/total no. of patient admission in a month)*100

Determinant for tertiary care utilization

Death rate

(Total no. of deaths in a month/Total no, of admissions in the month)*100

Efficiency of quality care provided

Hospital Acquired infections

#(Total no. of cases with CBSI +VAPs + SSIs + Decubitus ulcers in the month/Total no. of patients admitted in the month)*100

Delivery of safe and quality care

Patient satisfaction Survey Score

Analysis of Likert scale score

Measurement for improving on the quality care provision

#CBSI: Candida Blood Stream Infections VAPs: Ventilator Associated Pneumonia

32 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

SSIs: Surgical Site Infections

Cleaning Protocols

Activities Frequency Agent Used

Cleaning of high touch surfaces At the beginning of each shift Cleaning with soap & detergent plus disinfection with alcohol compound or

hydrogen peroxide

Cleaning of procedure Instruments After every procedure Disinfection with detergent & water followed by sterilization

Cleaning of clean areas and corridors Twice a day (as & when Damp Mop with detergent and water/ required) 0.5% chlorine

Floor Mopping Thrice a day and after each Damp mop with detergent and water / procedure 0.5% chlorine

Cleaning of dressing trolleys, Clean after each use Damp mop with detergent/alcohol and medication trolleys water

Cleaning of equipment like anaesthesia machines, monitors, ventilators, infant warmers/ baby cribs etc. (wiping of entire machine)

Twice a day/ as & when required

Damp Mopping, dry, Disinfect with 70% isopropyl alcohol / 2% glutaraldehyde(Refer to swachhta guidelines for more details)

Doctor’s / nurses / technician room/ Twice a day Detergent & water feeding room/equipment room/stores

Washroom & wash basins cleaning / Thrice a day and as & when Wash with Soap & water, then dry, wipe Bed pan cleaning area/dirty utility area required 0.5% chlorine

Washing of slippers Once a day and when required Detergent & water

Shoe change area Once every shift Detergent and water

Cleaning of Mops After every use Soak in clean water with bleaching powder 0.5% for 30 minutes. Wash again with detergent and water to

remove the bleach

Cleaning of patient trolleys, stretchers Daily morning Damp mop with detergent/alcohol and water

Cleaning of general furniture Twice a day Damp mop with detergent/alcohol and water

Removal of soiled linen and sluicing As and when required Soak in clean water with bleaching powder 0.5% for 30 min. Wash again

with detergent and water to remove the bleach OR ; launder in hot water (70-80 degree C) if possible.

Cleaning of patient beds, Crash Cart Once a day and between Damp mop with detergent/alcohol and trolleys change of patients in case of water

discharge/death etc.

Cleaning of bedpans and urine pots After every use Wash with detergent and water/0.5% chlorine

Bio Medical Waste Management Thrice a day and more when As per BMW rules, 2018 bags are 3/4th full present in

Dirty Utility area

Monitoring and supervision

Various functions and infrastructure suggested in the guideline need to be maintained for ensuring quality in service delivery; this can only be ensured through regular rounds for monitoring and surveillance. Daily rounds of the unit need to be taken by Matron, Hospital manager and the unit in-charge (doctors and nurses) for ensuring adherence to various protocols. While periodic rounds by Hospital In-charge/ MS for general overview on functioning and adherence to quality parameter.

Every unit needs to run with zero tolerance for non-adherence of all the above, so maintaining discipline is of prime importance. Even during rounds, all the staff needs to adhere to the protocol of changing dress/

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 33

gown. This exclusive responsibility of ensuring adherence to the protocols lies with the in-charge. The designated doctor on duty at ICU/HDU should be available round the clock for providing prompt and on the spot clinical care, however, specialists and other designated doctors need to undertake morning, evening and need based clinical rounds. During their rounds, they should also monitor the other quality parameters and give some time for mentoring of staff on various protocols.

During rounds, unnecessary entry, adherence for PPE, hand-hygiene, shoe change, and availability of on duty staff needs to be checked by supervisors. A monitoring checklist for ensuring quality, maintaining records and registers, HR posted etc. is also annexed for review.

Records and Registers

The HDU/ICU needs to be managed systematically and professionally for which maintaining proper records is one of the vital activities. This helps in analyzing and reviewing the performance, maintaining cleanliness, ensuring adherence to clinical and technical protocols, monitoring functionality of equipment, ensuring availability of equipment/drugs and in finding the gaps for corrective actions. HDU/ICU data should be linked with Health or hospital management information system (HIMS). This will help in decision making by the hospital management for improving health care services.

Health Management and Information System (HMIS): –

Facility should provide a designated area for data collection, data transmission, data storage, data processing, data analysis and data presentation. This will help in decision making by the hospital management for improving health care services.

34 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

ANNEXURES

HYBRID UNIT (8 Bedded HDU & 4 BEDDED ICU & 2 BEDDED ISOLATION AREA) PROPOSED COVERED AREA – 6400SQFT

Annexure-I

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 35

6MTR WIDE ROAD

SERVICES

AHU

6′-3″ 22′-3″ 16′-9″ 23′ LDR-2 15′-9″

NEWBORN CARE CORNER

23′-3″

11′ ONE STOP CENTRE

LDR-1

DUTY ROOM

STORE

CH. ROOMS

6MTR WIDE ROAD

23′

MAIN ENTRYEIT

PORCH

6MTR WIDE ROAD

NURSING STATION

15′-3″

22′-3″

PUBLIC WAITING

6MTR WIDE ROAD

11′-3″

TOILET

ISOLATION 11′-9″ ROOM-1

13′-9″

ISOLATION ROOM-2

10′

STAFF LIFT LIFT LOBBY

100 BEDDED CRITICAL BLOCK

SUGGESTIVE DISTRIBUTION OF BEDS

WHEELCHAIR/ STRETCHER BAY

33′-3″

TOILET

TRIAGE

SCREENING 23′-3″

SERVICES AHU

ENTRANCE 51′-3″ LOBBY

11′-3″

FIRE CONTROL ROOM

I ONE

20 BEDS (including 4 paediatric beds)

SEOND LOOR 20 BEDS (including 4 paediatric beds)

SEOND LOOR D ONE

ISOLATION WARD

IRST LOOR 30 BEDS

ISOLATION ROOM

IRST LOOR 12 ROOMS

DIALYSIS

IRST LOOR 04 BEDS

GROND LOOR M

06 BEDS

10 BEDS (04 RED+04 YELLOW+2 TRIAGE)

GROND LOOR EMERGENY

TOTAL

100 BEDS +2 TRIAGE

LDR OINT O ARE

02 NOS 02 NOS 01 NO

TIRD LOOR GROND LOOR GROND LOOR

7′-3″

RADIOLOGY ROOM 23′-3″

ROOM

10′-6″ 23′-3″ STAFF TOILET(M)

6′ TOILET

POINT OF

11′-6″ CARE LAB

ULTRASOUND 10′-6″ ROOM

PLASTER ROOM

RED& YELLOW ZONE

23′-3″

NURSING

STATION EQUIPEMNT AREA

BUFFER/PREP.

GREEN ZONE

9′

19′ MATERNITY WARD 06 BEDDED

23′-3″

EXAMINATION ROOM

14′-9″

14′-9″ PROCEDURE MINOR ROOM

8′ INJECTION ROOM

12′-6″

ROOM DUTY

3550 MM WIDE CORRIDOR

POLICE POST

11′-3″

11′

3550 MM WIDE CORRIDOR

TOILET TOILET

OPEN TO SKY

GOODS

BED

BED LIFT

LIFT LIFT

LIFT LOBBY LIFT LOBBY

GOODS

17′

Critical Care Block 100 Bedded

36 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

11′ STAFF TOILET(F)

DIRTY DW

TOILET

8′

6MTR WIDE ROAD

TOILET

NURSING STATION

ROOMS

CH.

CH. ROOMS

23′ PUBLIC TOILET(M)

PUBLIC TOILET(F) 16′-6″

SCREENING/ TRIAGE

M  LDR

RECEPTION/ REGISTRATION

DOUBLE HEIGHT PORCH

35′-3″

18′

47′-6″

23′

GROUND FLOOR LAYOUT PLAN

9′

Critical Care Block 100 Bedded

60′-6″

TOILET(F) TOILET(M)

11′-6″ 11′

23′-3″

ROOM

13′-6″

NURSES ROOM

23′-9″

8′

21′-6″

DIRTY DW 9′-3″

TOILET(M)

STAFF

6′

9′

9′-3″

TOILET

11′-6″

10′-6″

STAFF TOILET(F)

13′-9″

ISOLATION ROOM-12

ISOLATION ROOM-11

13′-9″

ISOLATION ROOM-10

ISOLATION ROOM-09

ISOLATION ROOM-08

13′-6″

NURSES 7′-9″ ROOM

STORE 7′-9″

7′-9″

PASSAGE

3550 MM WIDE CORRIDOR

6′

59′ 21′-6″

30 BEDDED ISOLATION WARD

PASSAGE

10′-3″

11′-9″

7′-9″

ISOLATION ROOM-01

ISOLATION ROOM-02

ISOLATION ROOM-03

13′-9″

ISOLATION ROOM-04

ISOLATION ROOM-05

11′ ISOLATION ROOM-06

91′

GOODS

BED

BED LIFT

LIFT LIFT

LIFT LOBBY

7′-9″

TOILET TOILET

4′-6″

TOILET TOILET

TOILET

TOILET TOILET

NURSING STATION

68′

NURSING STATION

139′-6″

11′

23′-3″

51′-3″

21′-6″ ( OXYGEN SUPPLY) 6 BEDDED UNIT (F)

6 BEDDED UNIT

( OXYGEN SUPPLY) (M)

THERAPEUTIC DIET

23′-3″

ATTE1N1’D-6A”NT CHANGE ATTENDANT CHANGE

9′-9″ (F)

(M)

11′-6″

8′-6″

162′-3″

UPS ROOM

LOBBY

CH. ROOMS (STAFF)

ISOLATION ROOM-07

CH. ROOMS

12′-6″ COUNSELLING (PUBLIC)

10′-6″ ROOM

10′

5′-6″ TOILET 5′-6″ TOILET

STAFF LIFT LIFT LOBBY

22′-3″

11′-6″

32′-3″

SUPPORT OF DIALYSIS

23′-3″

DIALYSIS

22′-3″

THERAPEUTIC DIET

PROCEDURE ROOM

10′-6″

37′-3″

51′-3″

SECURITY

10′-3″

23′-3″

10′ DUTY ROOM 15′

10′ ROOM DUTY

3550 MM WIDE CORRIDOR

11′-9″

60′-6″

STAFF CHANGE

STAFF ROOM+PANTRY

23′-3″

AHU SERVICES

11′-6″

10′-6″

23′-3″

111′-9″

100 BEDDED CRITICAL BLOCK

SUGGESTIVE DISTRIBUTION OF BEDS

I ONE

20 BEDS (including 4 paediatric beds)

SEOND LOOR

D ONE

20 BEDS (including 4 paediatric beds)

SEOND LOOR

ISOLATION WARD

30 BEDS

IRST LOOR

ISOLATION ROOM

12 ROOMS

IRST LOOR

DIALYSIS

04 BEDS

IRST LOOR

M

06 BEDS

GROND LOOR

EMERGENY

10 BEDS (04 RED+04 YELLOW+2 TRIAGE)

GROND LOOR

TOTAL

100 BEDS +2 TRIAGE

02 NOS

TIRD LOOR

LDR

02 NOS

GROND LOOR

OINT O ARE

01 NO

GROND LOOR

FIRST FLOOR LAYOUT PLAN

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 37

Critical Care Block 100 Bedded

AHU SERVICES

DIRTY DW

BED PAN WASH

18′

TOILET(M)

TOILET(F)

BUFFER

HDU 20 BEDS

8′-6″ THERAPEUTIC DIET

8′-6″

7′

BED PAN WASH 23′-3″

10′ 6′ TOILET(M)

22′-3″

11′-6″

BUFFER

12′-6″

11′-9″

TOILET(F)

6′

8′

59′-3″

13′-6″ ROOM NURSES 6′-6″

8′-9″

NURSING STATION

ICU 20 BEDS

3550 MM WIDE CORRIDOR

68′-6″

UPS ROOM

GOODS

BED BED LIFT

LIFT LIFT

LIFT LOBBY

COUNSELLING 14′-6″ ROOM

EXAMINATION/ PROCEDURE ROOM

23′-3″

11′-6″

11′-6″ ROOMS

CH.

12′-9″

CH. ROOMS (STAFF) (STAFF)

22′-3″

69′-6″

THERAPEUTIC DIET

23′-3″

EXAMINATION/PROCEDURE ROOM

10′-6″

11′-9″ ROOM DUTY

TOILET 15′

10′-6″

CH. ROOMS

COUNSELLING 11′-6″ ROOM (PUBLIC)

22′-3″

51′-3″

LOBBY

SECURITY

NURSES ROOM

14′-6″

COUNTER

NURSING STATION

59′

13′-3″

LOBBY

13′-9″

4′

9′-9″ ATTENDANT CHANGE (M) 11′-9″

ATTENDANT CHANGE (F)

11′-6″ 35′-9″

4′

TOILET

10′-6″

15′

ROOM DUTY

STAFF CH.

10′-6″ 11′-9″ 9′-6″ ROOMS

STAFF ROOM+ PANTRY

STAFF LIFT LIFT LOBBY

23′-3″

AHU SERVICES

23′-3″

100 BEDDED CRITICAL BLOCK

SUGGESTIVE DISTRIBUTION OF BEDS

I ONE 20 BEDS (including 4 paediatric beds)

D ONE

20 BEDS (including 4 paediatric beds)

SEOND LOOR

ISOLATION WARD

30 BEDS

IRST LOOR

ISOLATION ROOM

12 ROOMS

SEOND LOOR

IRST LOOR

DIALYSIS

04 BEDS

IRST LOOR

M

06 BEDS

GROND LOOR

EMERGENY

10 BEDS (04 RED+04 YELLOW+2 TRIAGE)

GROND LOOR

TOTAL

100 BEDS +2 TRIAGE

02 NOS

TIRD LOOR

LDR

02 NOS

GROND LOOR

OINT O ARE

01 NO

GROND LOOR

SECOND FLOOR LAYOUT PLAN

38 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Critical Care Block 100 Bedded

23′ AHU SERVICES 23′-3″

23′

OPERATION THEATRES-1

DIRTY DW

11′-3″

13′-3″

10′-9″

13′-3″

DONNING ROOM 13′-3″

8′

TERRACE

FOR FUTURE EXPANSION

22′-3″

EMERGENCY DOOR

SCRUB

22′-3″ OPERATION THEATRES-2

23′

9′-9″ 3000 MM WIDE CORRIDOR

CLEAN STORE

11′-3″

CRITICAL EQUIPMENT 23′-3″

9′-9″ INCHARGE ROOM CONSUMABLE

3550 MM WIDE CORRIDOR

REPORT WRITING 11′-9″

12′-6″

22′-6″

UPS ROOM

LOBBY

51′-3″

7C’-H6″. ROOM

4′

GOODS BED BED LIFT

LIFT LIFT LIFT LOBBY

22′-3″

POST OP

15′

19′-3″

15′

11′-3″

7C’-H6″. DAUFFING ROOM ROOM

9′-9″ 9′-9″

SCRUB

7′

4′

9′-9″

C7H’-6.” ROOM

9′-3″

COUNSELLING ROOM

17′

TERRACE

16′-3″ 8′-3″

PRE-OP

NURSING 11′-9″ 11′-9″ STATION

9′-3″

6′

9′-6″

12′-6″ PROTECTED ZONE

36′-9″

TROLLEY OT RECEPTION AREA AREA

STAFF + PANTRY AREA

22′-3″

17′

PATIENT ATTENDANT 13′-6″ CHANGE ROOM

10′-9″

12′

100 BEDDED CRITICAL BLOCK

SUGGESTIVE DISTRIBUTION OF BEDS

I ONE 20 BEDS (including 4 paediatric beds)

D ONE

20 BEDS (including 4 paediatric beds)

SEOND LOOR

ISOLATION WARD

30 BEDS

IRST LOOR

ISOLATION ROOM

12 ROOMS

SEOND LOOR

IRST LOOR

DIALYSIS

04 BEDS

IRST LOOR

M

06 BEDS

GROND LOOR

EMERGENY

10 BEDS (04 RED+04 YELLOW+2 TRIAGE)

GROND LOOR

TOTAL

100 BEDS +2 TRIAGE

02 NOS

TIRD LOOR

LDR

02 NOS

GROND LOOR

OINT O ARE

01 NO

GROND LOOR

THIRD FLOOR LAYOUT PLAN

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 39

Critical Care Block 75 Bedded

60′-6″

75 BEDDED CRITICAL BLOCK

18′-9″

20′-9″ AHU SERVICES

6′

DIRTY DW

15′

23′

LDR

59′-6″ 6′

5′-6″ 7′-3″ 6′

16′-9″

10′ POINT OF CARE

16′ 15′

4 BEDDED MATERNITY WARD

23′-3″

23′

LDR

NEWBORN CARE CORNER

17′-3″

11′-9″

16′-9″ ENTRY BUFFER

11′-9″

9′

ENTRY FOYER

NURSING

STORE

STATION

7′-3″ 6′ DUTY

8′-6″ ROOM

16′-9″

PASSAGE

6′-6″ 7′-3″ CH.

CH. CH. ROOM

ROOM ROOM

11′

6′

7′-6″

PASSAGE

10′-6″ EXAMINATION ROOM

SCREENING/ TRIAGE

23′-9″ 10′

10′-3″

NURSING STATION

23′ SERVICES

16′-6″

BED

LIFT BED LIFT

LIFT LOBBY

13′ 12′-6″

TOILET

24′ 12′

DUTY ROOM

24′

TRIAGE

6′-6″

6′ TOI.

8′

6′ TOI.

14′

MINOR PROCEDURE ROOM

19′

9′ BUFFER/PREP.

6′-9″

23′

14′

GREEN ZONE

38′

INJECTION 14′ ROOM

23′-9″

ULTRASOUND

POINT OF CARE LAB 17′

ROOM

DU 13′-3″ STAFF TOILET(F) 17′-6″ 23′

10′-3″

10′

BUFFER/PREP.

15′-6″

12′-6″

15′

22′-3″

25′ PUBLIC WAITING

MCH & LDR

11′-9″

21′-9″

11′-9″ EMERGENCY

22′-3″

8′-3″

RECEPTION/ REGISTRATION

12′-6″

12′-6″ POLICE POST

10′-3″ FIRE CONTROL ROOM

15′-9″ ENTRANCE

LOBBY 15′

22′-6″

7′-9″ 16′ WHEELCHAIR/ STRETCHER BAY

SCREENING

24′

11′-9″ 12′

10′

NURSING STATION

EQUIPEMNT AREA

23′-9″

15′

31′-6″

RED& YELLOW ZONE

23′-3″

15′

X-RAY ROOM

23′

BED PAN WASH

11′-9″

SERVICE PASSAGE 28′-3″

JANITOR’S CLOSET 10′

17′

STAFF TOILET(M)

10′-3″

3550MMWIDECORRIDOR

8′

10′

PUBLIC

Drinking

PUBLIC MWacahteinre

TOILET(M) TOILET(F)

Janitor’s Closet

7′

RAMP 1:10

MAIN ENTRY/EXIT

DOUBLE HEIGHT PORCH

RAMP 1:10

ICU ZONE

HDU ZONE

SUGGESTIVE DISTRIBUTION OF BEDS

1 EDS    

SECOND FLOOR

ISOLATION WARD

ISOLATION ROOM

1 EDS    

0 EDS

SECOND FLOOR

FIRST FLOOR

DIALYSIS

MCH

 ROOMS

0 EDS

FIRST FLOOR

EMERGENCY

TOTAL

0 EDS

10 EDS 0 RED0 YELLOW TRIAGE

GROUND FLOOR

69′

LDR

 EDS  TRIAGE

0 NOS

SECOND FLOOR

GROUND FLOOR

POINT OF CARE

0 NOS

01 NO

GROUND FLOOR

129′-6″

160′-9″

60′-6″

221′-6″

GROUND FLOOR LAYOUT PLAN

40 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Critical Care Block 75 Bedded

75 BEDDED CRITICAL BLOCK

18′-9″

20′-9″ AHU SERVICES

16′-9″

ISOLATION ROOM-3 12′ 12′ ISOLATION ROOM-2

12′

6′ DU DIRTY DW

16′-9″

ISOLATION ROOM-4 ISOLATION 12′ 12′ 12′ ROOM-5

12′

16′-9″

16′-9″ ISOLATION ROOM-1

23′-3″

THERAPEUTIC DIET

9′-3″

16′-9″

NURSES

15′ 7′-9″ ROOM

23′-6″ NURSING

12′

STATION

11′-3″

STORE

11′-3″ COUNSELING

CH. ROOMS ROOM

(PUBLIC)

14′

9′

10′-3″ 11′-3″ 24′-6″ PROCEDURE

ROOM

10′-6″

11′-9″

ENTRY FOYER

23′ SERVICES

16′-6″

BED

LIFT BED LIFT

LIFT LOBBY

13′ 12′-6″

TOILET

11′-3″

15′-6″

12′

ATTENDANT CHANGE (M)

ATTENDANT 11′-6″ CHANGE (F)

THERAPEUTIC DIET

13′-9″

15′-3″

11′-9″

CH.

ROOMS

(STAFF)

8′-3″

4′ 11′-6″ 11′-6″

CH. ROOMS (STAFF)

12′-6″

7′-3″

SERVICE PASSAGE

7′-9″ 7′-9″

7′-9″

NURSES ROOM ROOM

13′-6″

NURSING STATION 23′-9″

9′-9″

23′

14′

DUTY ROOM

ENTRY TO THE ATTENDANT CHANGING AREA

ISOLATION ROOMs

15′-9″ 47′

ISOLATION WARDS

ENTRY TO THE STAFF CHANGING ROOMS

7′

11′-9″

30 BEDDED ISOLATION WARD

9735

Drinking Water Machine

21′-6″

DUTY 15′-6″

ROOM

TOILET

47′

Janitor’s Closet 15′-3″ 7′-6″

STAFF TOILET(F)

BUFFER

11′-6″

STAFF TOILET(M)

DUTY ROOM

TOILET

23′

STAFF ROOM + PANTRY

19′

23′-9″ LOBBY AREA

20′-3″

23′-9″

BUFFER AREA

SUPPORT OF

NURSING STATION

DIALYSIS AREA

13′-6″

12′ 11′

DIALYSIS

15′-9″

26′

23′-9″

DOUBLE HEIGHT PORCH

I ONE

SUGGESTIVE DISTRIBUTION OF BEDS

SEOND LOOR

D ONE

ISOLATION WARD

12 BEDS (including 2 paediatric beds)

SEOND LOOR

IRST LOOR

ISOLATION ROOM

DIALYSIS

30 BEDS

5 ROOMS

04 BEDS

IRST LOOR

M

04 BEDS

GROND LOOR

EMERGENY

GROND LOOR

TOTAL

10 BEDS (04 RED+04 YELLOW+2 TRIAGE)

75 BEDS +2 TRIAGE

SEOND LOOR

LDR

02 NOS

GROND LOOR

OINT O ARE

02 NOS

01 NO

GROND LOOR

FIRST FLOOR LAYOUT PLAN

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 41

Critical Care Block 75 Bedded

75 BEDDED CRITICAL BLOCK

SUGGESTIVE DISTRIBUTION OF BEDS

18′-9″

20′-9″ AHU SERVICES

23′

22′-3″ OPERATION THEATRES-1

6′

23′

22′-3″ OPERATION THEATRES-2

DIRTY DW

CLEAN STORE

REPORT WRITING

12′

10′-9″ 11′-3″ 12′

6′ DONNING ROOM

10′

8′ SCRUB PASSAGE

6′ 5′-6″ CH.

6′

CH. CH. 9′-9″ 7′ 9′ ROOM ROOM ROOM

PASSAGE

6′

PROTECTTED ZONE

OT RECEPTION

AREA 43′-9″

12′-6″

11′-3″

16′-3″ 19′-3″

PRE-OP

TROLLEY AREA

13′-6″

6′-6″

11′-3″

11′-9″

CRITICAL EQUIPMENT CONSUMABLE INCHARGE ROOM

POST OP

BED

LIFT BED LIFT

LIFT LOBBY

13′ 12′-6″

CH. ROOMS (STAFF)

CH. ROOMS (STAFF) 11′-6″

11′-9″

ATTENDANT CHANGE (F)

ATTENDANT CHANGE

(M)

11′-6″

8′-6″ 12′

7′-3″

SERVICE PASSAGE

23′-3″ EXAMINATION/ PROCEDURE ROOM

8′-6″ THERAPEUTIC DIET

14′-3″

COUNSELLING ROOM

13′-9″

12 BEDDED HDU

9′-9″

9′-3″

17′-3″

15′

DAUFFING ROOM

10′

9′-3″

9′-9″

17′-6″

28′-3″

59′

NURSES CU NURSING ROOM

STATION

8′-3″

11′-9″ NURSING STATION

COUNSELLING ROOM 9′-3″

12′

16′-3″

12 BEDDED

ICU

85′

Drinking Water Machine

BED PAN WASH 15′-3″ 7′-6″

STAFF TOILET(F)

BUFFER

STAFF TOILET(M)

14′-6″

14′

8′ PATIENT ATTENDANT CHANGE ROOM

8′-6″ SECURITY

11′-6″

DOUBLE HEIGHT PORCH

ICU ZONE

HDU ZONE

12 BEDS  2  

SECOND FLOOR

ISOLATION WARD

12 BEDS  2  

 BEDS

FIRST FLOOR

ISOLATION ROOM

FIRST FLOOR

DIALYSIS

 ROOMS

FIRST FLOOR

MCH

EMERGENCY

 BEDS

1 BEDS  RED YELLOW2 TRIAGE

GROUND FLOOR

TOTAL

 BEDS 2 TRIAGE

2 NOS

SECOND FLOOR

LDR

GROUND FLOOR

POINT OF CARE

2 NOS

1 NO

GROUND FLOOR

SECOND FLOOR LAYOUT PLAN

42 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Critical Care Block 50 Bedded

I ONE

10 BEDS (including 2 paediatric beds)

SEOND LOOR

02 NOS

SEOND LOOR

D ONE

06 BEDS (including 2 paediatric beds)

SEOND LOOR

LDR

02 NOS

GROND LOOR

ISOLATION WARD

24 BEDS

IRST LOOR

OINT O ARE

01 NO

GROND LOOR

DIALYSIS

02 BEDS

IRST LOOR

ISOLATION ROOM

02 ROOMS

GROND LOOR

50 BEDDED CRITICAL BLOCK

SUGGESTIVE DISTRIBUTION OF BEDS

M

02 BEDS

GROND LOOR

EMERGENY

05 BEDS (02 RED+02 YELLOW+1 TRIAGE)

GROND LOOR

TOTAL

50 BEDS + 01 TRIAGE

11′-9″

ISOLATION ISOLATION 20′-6″ ROOM 1

ROOM 2

TOILET TOILET

12′ CORRIDOR 3650MM WIDE

24′-3″

12′

MINOR PROCEDURE

9′-9″

DOFFING

1500MM WIDE CORRIDOR

CHANGE ROOM

13′

ULTRASOUND 23′ ROOM

STAFF TOILET(F)

7′

NURSE STATION

13′-6″

TRIAGE

SCREENING

18′

29′-3″

7′-9″

INJECTION 10′ ROOM

RED ZONE (02 BEDS)

RED&YELLOW ZONE

20′

YELLOW ZONE (02 BEDS)

13′-3″

STAFF TOILET(M)

PLASTER ROOM

12′

CORRIDOR

MLDR 3650MMWIDECORRIDOR LVL.+600 24′-6″

DONNING

DUTY 16′-9″ ROOM

12′-3″

16′-9″

POINT OF CARE LAB

13′

CORRIDOR

GREEN ZONE

BED PAN WASH

36′-3″

BUFFER

DIRTY

DUMB WAITER

3650MMWIDECORRIDOR

RAMP UP

SLOPE 1:10

FHC

SCREENING/ TRIAGE

EXAMINATION ROOM

29′-3″

10′

NURSING STATION

17′-6″

WATER DRINKING

JANITOR

LOBBY

20′-3″

WAITING AREA ENTRANCE LOBBY

18′-6″

LIFT LOBBY

16′-9″

8′

10′ BED

LIFT

CORRIDOR

3000MM WIDE

12′

11′-9″

REGISTRATION AREA RECEPTION

17′-3″

22′-9″ 2 BEDDED MATERNITY WARD

LDR1

23′

41′-3″

NEWBORN CARE CORNER

NURSING STATION

15′

LDR2

23′

15′

10′-6″

9′

FHC

TOILET

TOILET F

BED LIFT

17′-3″

6′

8′

STORE

8′

10′

12′

SERVICES

13′-9″

6′

8′

PLANTER

RAMP UP SLOPE 1:10

LVL. +600

MAIN ENTRYEIT

DOUBLE HEIGHT PORCH

GROUND FLOOR LAYOUT PLAN

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 43

Critical Care Block 50 Bedded

I ONE

10 BEDS (including 2 paediatric beds)

SEOND LOOR

02 NOS

SEOND LOOR

D ONE

06 BEDS (including 2 paediatric beds)

SEOND LOOR

LDR

02 NOS

GROND LOOR

ISOLATION WARD

24 BEDS

IRST LOOR

OINT O ARE

01 NO

GROND LOOR

DIALYSIS

02 BEDS

IRST LOOR

50 BEDDED CRITICAL BLOCK

SUGGESTIVE DISTRIBUTION OF BEDS

ISOLATION ROOM

02 ROOMS

GROND LOOR

M

02 BEDS

GROND LOOR

EMERGENY

05 BEDS (02 RED+02 YELLOW+1 TRIAGE)

GROND LOOR

TOTAL

50 BEDS + 01 TRIAGE

CORRIDOR

8′

DOFFING 6′-6″

9′

CORRIDOR

22′

10′-9″

MALE TOILETS

29′-3″

10′-9″

18′-9″

FEMALE TOILETS

TOILET

29′-3″ DOCTORS DUTY ROOM

14′-6″

TOILET

13′-9″

22′-6″

NURSES DUTY ROOM

22′

DONNING 6′-6″

30′

20′

DIALYSIS AREA

15′-9″

SUPPORT OF DIALYSIS

12′ 16′-6″

BUFFER AREA

15′-6″

LOBBY

30′

CHANGE ROOM 6′-6″ 15′

NURSING STATION

17′

ATTENDANT CHANGE 7′-6″

10′-6″

DIRTY

DUMB WAITER

24 BEDDED ISOLATION WARD

18′-3″

3650MMWIDECORRIDOR

45′-3″ FHC BUFFER

3650MMWIDE

CORRIDOR

30′

22′-6″

22′

18′-9″

NURSING STATION

STORE

10′-9″

10′-6″

9′

SERVICES

18′-6″

13′-9″

FHC

DUTY

15′-6″

ROOM

14′

TOILET

DUTY ROOM

14′

TOILET

18′-6″

LIFT LOBBY

16′-9″

8′

10′ BED

LIFT

THERAPEUTIC DIET

8′-6″

30′

22′-3″

23′

STAFF ROOM + PANTRY

16′

BED LIFT

DOUBLE HEIGHT PORCH

FIRST FLOOR LAYOUT PLAN

44 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Critical Care Block 50 Bedded

I ONE

10 BEDS (including 2 paediatric beds)

SEOND LOOR

02 NOS

SEOND LOOR

D ONE

06 BEDS (including 2 paediatric beds)

SEOND LOOR

LDR

02 NOS

GROND LOOR

ISOLATION WARD

24 BEDS

IRST LOOR

OINT O ARE

01 NO

GROND LOOR

DIALYSIS

02 BEDS

IRST LOOR

50 BEDDED CRITICAL BLOCK

SUGGESTIVE DISTRIBUTION OF BEDS

ISOLATION ROOM

02 ROOMS

GROND LOOR

M

02 BEDS

GROND LOOR

EMERGENY

05 BEDS (02 RED+02 YELLOW+1 TRIAGE)

GROND LOOR

TOTAL

50 BEDS + 01 TRIAGE

12′

4′

9′-9″

BED PAN WASH

17′-3″

37′-6″

PRE-OP

25′-3″

1 POST OP

9′-9″

CRITICAL EQUIPMENT CONSUMABLE INCHARGE ROOM

STORE

CLEAN

11′-3″

22′

OPERATION THEATRES-1

25′

7′

10′

NURSING STATION

HDU/ICU

10′

45′-3″

TOILET

10′

13′ COUNSELLING 14′-6″ 14′ ROOM

9′-9″

REPORT WRITING

13′-6″

12′-6″

11′-3″

DAUFFING ROOM

8′

NURSES ROOM

19′ CHANGE 10′-6″

ROOMS

8′

AHU SERVICES

DIRTY

DUMB WAITER

15′-6″

PROTECTED ZONE 16′-3″

BUFFER

8′-6″ 9′-9″

PASSAGE

15′

9′-9″

71′-9″

11′

BUFFER ZONE

18′-6″

LIFT LOBBY

16′-9″

8′

10′ BED

LIFT

FHC

22′

OPERATION

29′-3″

THEATRES-2

FHC

9′-9″ 5′-9″

BUFFER

COUNSELLING 19′-6″ ROOM

10′-3″

8′ CH. ROOM

8′

8′ CH. ROOM

8′

CH.

8′

ROOM

12′-6″

PASSAGE

DONNING ROOM

8′

14′-6″

9′

22′-9″

8′ 5′

10′

PASSAGE

BED LIFT

SCRUB 10′

15′

9′

SECOND FLOOR LAYOUT PLAN

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 45

EQUIPMENT FOR ICU/HDU

Annexure-II

List of Equipment – ICU/HDU

Furniture/ Description HDU ICU Equipment

Equipment Multi Para monitor – ECG, SPO2, NIBP (Non-invasive BP and Temperature) at the head end.  

Equipment Multi Para monitor with ETCO2 and invasive pressure lines  

Equipment Syringe Pump  

Equipment Micro- Infusion Pump  

Equipment Portable USG with compatible echo and vascular probe  

Equipment Portable x -ray machine  

Equipment ABG Analyzer with Lactate monitoring  

Equipment Bi-PAP/ CPAP mask ventilator  –

Equipment Defibrillator with AED & transcutaneous Pacing  

Equipment Suction machine (foot-operated) (as standby)  

Equipment Transport Ventilator – 

Equipment Mechanical Ventilator (Basic Invasive) – 

Equipment Computer with central monitoring system  

Equipment Laryngoscope- Adult & paediatric  

Equipment Nebulizer  

Equipment Glucometer  

Furniture Beds  

Furniture IV stands  

Furniture Crash cart with six drawers, writing / spine / CPR board / Oxygen cylinder holder / IV   stand / Space on the bottom (preferable in form of locked drawer) / and drug drawers on

top shelves for ease of access

Furniture LED view box- 4*2 ft.  

Furniture Stretcher  

Furniture Wheelchair  

Furniture Refrigerators  

—- Central pipelines for supply of Oxygen (3 outlets on each bed), Central Suction and   Medical Air

Instruments AMBU bag- adult & paediatric, Bag-Mask Assembly (Paediatric or Bain’s Circuit)  

Instruments Magill’s Forceps  

Instruments PEEP valve  

Equipment Pulse oximeter  

Equipment Thermometer  

Accessories NIBP with all cuff sizes  

Accessories Portable Inverter Battery set (for transport)  

Accessories Oxygen hood boxes  

46 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

SECTION A: STRUCTURE

QUALITY CHECKLIST FOR HDU/ICU

Annexure – III

CHECKPOINTS

YES

COMMENTS

(Mention which is not present in the facility)

1. HDU/ICU is in proximity to which area?

2. HDU/ICU has designated area

2.1 Waiting Area

2.2 Changing room

2.3 HDU/ICU main complex

2.4 Cleaning Area

3. The complex ensures a safe, comfortable environment and essential infrastructural components

3.1 Floor and walls of the complex is covered with vitrified tiles with seamless joints and easy to clean

3.2 Positive pressure, Humidity (45-65%) and temperature (23 ± 2oC) is regularly maintained with Air Handling Unit and is recorded

3.3 Adequate illumination for all work areas in the complex

3.4 (general area: 300 lux )

3.4 Piped medical gases (oxygen, suction and compressed air)

3.5 HDU/ICU has sufficient installed fire extinguisher (ABC

type) and has separate fire exit escape route planned.

3.6 Availability of color coded bins at point of waste genera- tion

3.7 Power back-up

4. The complex displays

4.1 Updated duty roster

4.2 Patient Hand Over/Take Over

5. Security arrangement at HDU/ICU (Security personnel, CCTV etc.)

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 47

SECTION B: PROCESS

CHECKPOINTS

YES

Comments

(Mention which is not present in the facility)

1. There is a defined SOP for entering the main HDU/ICU area

1.1 Changing of external foot-wear

1.2 Changing of clothes

1.3 Wearing personal protective equipment (face-mask, apron/ drape, gloves, head cap etc.)

1.4 Washing hands

2. There is an SOP to take informed consent

2.1 General consent

2.2 High risk consent

2.3 Anesthesia consent

3. Patient attendant is informed about the clinical condition and treatment provided at regular intervals

4. Treatment plan are written on BHT

5. There is an established SOP for documentation and reporting of various activities on daily basis, for the following:

5.1 Maintenance and breakdown of equipment.

5.2 Stock maintenance for the consumables

5.3 Periodic cleaning of the equipment

5.4 Spill management

6. Privacy and confidentiality is provided to all patients

6.1 Patients are properly draped/covered

6.2 Availability of screens between two beds

6.3 Patient records are kept at secure place

6.4 No unnecessary displaying of patient details

7. Any adverse event is also recorded and reported.

8. There is an established criteria for shifting patients

9. There is a designated infection control committee.

SECTION C: OUTCOME

CHECKPOINTS

COMMENTS

1. Average length of stay

2. Number of adverse events per thousand patients

3. Reintubation rate

4. Downtime of critical instruments

48 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Room No.

Employees

SAMPLE FORMAT FOR HDU/ICU

Annexure-IV

Designation (as applicable)

Name

In-charge

Medical officer

EMT

Staff Nurse

Staff Nurse for isolation room

Cleaning staff

Others

Registers/Records Maintained

S. No

Name of The Register

Key Information Recorded in The Register

Frequency of Updating

Person Responsible

Supervisor

Patient admission

Treatment register (all the diagnostic & investigation results)

Handing over & taking over

Blood Bank/Lab Investigation Book

Discharge

Stock and indent registers for medicines and consumables

Refer In/Out register

Cleaning Protocol

S. No

Sub areas

Number

Frequency Of Cleaning

Material Used To Clean

Person Responsible

Beds

Bed sheet

Equipment

Isolation room

Storeroom

Patient’s toilet

Change Rooms

Performance Chart

S. No

Indicators

Previous month

Current month

Average length of stay

Number of adverse events per thousand patients

Reintubation rate

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 49

List of Contributors

S. No.

Name

Ministry of Health and Family Welfare

Sh. Rajesh Bhushan, Secretary, MoHFW, Govt. of India

Ms. Preeti Sudan, Former-Secretary, MoHFW, Govt. of India

Ms. Roli Singh, AS & MD, MoHFW, Govt. of India

Ms. Vandana Gurnani, Former-AS&MD, MoHFW, Govt. of India

Mr. Manoj Jhalani, Former- SS&MD, MoHFW, Govt. of India

Dr. Manohar Agnani, Additional Secretary & Chairperson of the Expert Group

Mr. Vikas Sheel, Former AS&MD, Govt. of India

Mr. Vishal Chauhan, Joint Secretary Policy

Dr. Ajay Khera, Former Commissioner, RCH

Dr. Dinesh Baswal, Former Addl. Commissioner MH

Dr. S.K. Sikdar, Advisor, Maternal health and Family Planning

Dr. Yuvaraj NS, Former Director, NHM

Dr. Limatula Yaden, Former Director NHM

Mr. Jitendra Arora, Former Director, PMSSY

Dr. Arun Singh, National Advisor, RBSK & HoD, Dept. of Neonatology, AIIMS Jodhpur

Mr. Rajiv Kannaujia, Senior Architect, Central Design Bureau

Mr. Mukesh Bajpai, Senior Architect, Central Design Bureau

Mr. Sachin Mahindru, Architect Central Design Bureau

Dr. Sonali Bhardwaj- Senior Consultant NHM

State Experts

Dr. Satish Pawar, Add. Mission Director, NHM-Maharashtra

Dr K. Kolandaswamy, Ex-Director Public Health, Tamil Nadu

Dr. I.S. Thakur, CMHO, Sagar, Madhya Pradesh

Dr. Sanjiv Trehan, PMO, District Civil Hospital, Panchkula, Haryana

Dr. Simmy, PMO, Civil Hospital, Panchkula, Haryana

Dr. Ravinder Singh, Anesthetist, Civil Hospital, Panchkula, Haryana

Dr. Nymphia Kaul, ICU In-charge, Sanjay Gandhi Memorial Hospital, New Delhi

Mr. Ashish, Consultant for Laminar Flow, Bengaluru, Karnataka

Institutional Experts

Dr. Ravinder Kumar Batra, Ex-Professor, Department of Anesthesiology, Pain Medicine & Critical Care, AIIMS New Delhi

Dr. PP Kotwal, Chairman, PSRI Institute of Orthopaedics, New Delhi & Ex- Head of Department, Department of Orthopaedics, AIIMS, New Delhi

Prof. Atul Kumar, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi

Dr. Sidhartha Satpathy, Professor and Head, Department of Hospital Administration, AIIMS New Delhi

Prof. (Dr.) Noor Topno, Medical Superintendent &HoD, General Surgery, NEIGRIHMS, Shillong

Prof. A. K. Gupta, Professor of Hospital Administration cum Medical Superintendent, PGI Chandigarh

Dr. Sudha Jain, Professor, Department of Anesthesiology, MGIMS, Wardha

Dr. Manjunath, Retd. MS, KCGH, Malleshwaram, Bengaluru

Dr. Akash Bang, Additional Professor, Department of Pediatrics, AIIMS, Nagpur

Dr Bhavuk Garg, Associate Professor, Dept. of Orthopedics, AIIMS New Delhi

Dr. Angel Rajan Singh, Department of Hospital Administration, AIIMS New Delhi

Dr Sumedh Jajoo, Associate Professor, Department of Medicine, MGIMS Sewagram

Dr. Dhiraj B Bhandari, Associate Professor, Department of Anesthesiology, MGIMS Sewagram

Dr. Bhartendu Kumar, Associate Professor, Dept. of Surgery, SK Medical College, Muzzafarpur, Bihar

50 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Dr. Gk Thakur, MS, SKMCH, Muzzafarpur, Bihar

Major Dr. Munindra Srivastava, Founder Fellow, AHA

Dr. Avnindra Gupta, Senior Consultant, Centre for Sight, New Delhi

Dr. Namrata Sharma, Professor, Centre for Sight, New Delhi

Dr. Dilip Shinde, Professor, Centre for Sight, New Delhi

Dr. Ishita Sharma, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi

Ms. Indu Balasharma, DNS, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi

Ms. Sonu Rani, Infection Control In-charge, AIIMS New Delhi

Sh. Somraj, Chief Engineer, KCGH, Malleshwaram, Bengaluru

Dr. Harsh Sharma, APD, UPHSSP

Dr. Vivek Desai, HOSMAC India Pvt. Ltd.

Dr. Vinay Kothari, Hospital Planning, Design & Management Consultant

Mohd. Shoeb Alam, Architect, New Delhi

Dr. Paul Francis, Technical Officer, WHO Country Office for India

Dr. Somesh Kumar, Head of Programs, Deputy Country Director-India, Jhpiego-an affiliate of Johns Hop- kins University

Dr. Vikas Yadav, Associate Director, Maternal Newborn Health, Jhpiego-an affiliate of Johns Hopkins University

Dr. Saurabh Parmar, Programme officer, JHPIEGO

Dr. S.R. Jeevan Dass, Programme Director, JHPIEGO

Mr SN Sathu, Life Care, HLL

Mr. Gyanesh Pandey, CMD, HSCC Ltd..

Mr. Hari Kumar, South Asia Coordinator, Geohazards Society, New Delhi

Mr. R Pradeep, IIIT Hyderabad

Dr. Rakshita, Consultant – Health System Strengthening (SAMARTH), WHO

National Health Systems Resource Centre

Maj Gen (Prof ) Atul Kotwal, Executive Director

Dr. Rajani Ved, Former Executive Director

Dr Himanshu Bhushan – Member Secretary, Advisor, Public Health Administration, NHSRC

Dr. J.N. Srivastava, Advisor, Quality and Patient Safety

Ms. Mona Gupta, Advisor, HRH & HPIP

Dr. Nobhojit Roy, Former Advisor, Public Health Planning

Mr. Shashi Bhushan Sinha, Former Advisor, Health Care Technology

Mr. Prasanth KS, Senior Consultant

Mr. Parminder Gautam, Senior Consultant

Mr. Mohd. Ameel, Former Senior Consultant

Dr. Smita Srivastava, Senior Consultant

Mr. Ajit Kumar Singh, Former Senior Consultant

Dr. Aashima Bhatnagar, Senior consultant

Dr Kalpana Pawalia, Consultant

Dr Poonam, Consultant

Dr Ashutosh Kothari, Consultant

Ms. Neelam Tirkey, Consultant

Ms. Diksha, Consultant

Dr. Palak Dhiman, Consultant

Dr. Warisha Mariam, Former Consultant

Ms. Vasundhra Bharti, Former Short Term Consultant

Dr. Bhupinder Singh, Former Consultant

Ms. Ashu Ranga, Junior Consultant

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 51

52 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 53

54 Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU)

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