Guidelines for Organization and Delivery of Intensive Care Services

Directorate General of Health Services Ministry of Health & Family Welfare Government of India

2026

Abbreviations:

ABG Arterial Blood Gas

AMC Annual Maintenance Contract

CAUTI Catheter Associated Urinary Tract Infection CLABSI Central Line-Associated Bloodstream Infection CT Computed Tomography

DNB Diplomate of National Board

DVT Deep Vein Thrombosis

ECG Electrocardiography

ECMO Extracorporeal membrane oxygenation

EMR Emergency Medical Response

FNB Fellowship of National Board

HDU High Dependency Units

HFNC High flow nasal canula

ICU Intensive Care Unit

MBBS Bachelor of Medicine, Bachelor of Surgery MRI Magnetic resonance imaging

MD Doctor of Medicine

MoHFW Ministry of Health and Family Welfare

NMC National Medical Council

PACU Postoperative Care Units

PDCC Post-Doctoral Certificate Course

RRT Renal replacement therapy

UPS Uninterruptible Power Supply

VAP Ventilator-Associated Pneumonia

Guidelines for the Organization and Delivery of Intensive Care Services Section1: Introduction

1.1 Definition

An intensive care unit (ICU) is a dedicated area within a hospital that provides intensive and specialized medical and nursing care, enhanced monitoring, and multiple forms of physiologic organ support to sustain life in patients with acute, life-threatening organ dysfunction.

The hallmarks of an Intensive Care Unit (ICU) are the defining features that distinguish it from routine hospital care. They can be summarized as follows:

1.2 Hallmarks of an ICU

Care for critically ill patients

An ICU provides care to patients with, or at risk of, acute life-threatening organ dysfunction.

Dedicated physical space

A defined geographic area within a hospital designed to concentrate expertise, equipment, and monitoring, for care of critically ill patients.

Intensive and specialized staffing

Care in an ICU is delivered by a skilled, interprofessional team, including specially trained physicians, nurses, and allied health professionals, with higher staff-to-patient ratios than general wards.

Enhanced monitoring capability

An ICU has continuous and advanced physiologic monitoring capability, which may include noninvasive and invasive monitoring of cardiovascular, respiratory, neurologic, and other organ systems.

Organ support technologies

An ICU is equipped with multiple modalities of organ support, such as mechanical ventilation, vasoactive medications, renal replacement therapy, and other life-sustaining interventions.

Capacity for rapid intervention

An ICU provides infrastructure and equipment for immediate assessment, resuscitation, and support in rapidly changing clinical situations.

Integration within the broader health system

ICUs often extend services to the emergency department, hospital wards, operation theaters and post-ICU follow-up areas.

Commitment to quality, education, and improvement

An ICU should be committed to quality improvement, and where resources allow, engagement in education and research, aimed at continually improving outcomes for critically ill patients.

These hallmarks collectively define the ICU as an organized, resource-intensive system focused on sustaining life during periods of severe physiologic instability.

Section 2: Methodology

The following document summarizes the recommendations on various aspects of ICU structure, function and care based on national and international guidelines and recommendations. The expert committee undertook a structured, iterative guideline development process that included multiple face-to-face meetings of a small working group who reviewed the existing guidelines and available medical scientific literature and formulated an initial consensus draft. The draft was subsequently reviewed, modified and edited through further deliberations by other members of the expert committee.

Section 3: Results

This document is intended to help clinicians across various parts of India and across various health care setups to deliver the best possible care to patients in need of intensive care, based on best available resources, and not to replace the clinician’s decision-making capability.

In accordance with the available guidelines, different levels of ICU have been described based on availability of infrastructure, health care personnel and severity of illness to be catered to. An ICU can be classified into three levels (Level 1, 2 or 3). Level 1 caters to patients with not more than single organ dysfunction requiring short term care to level 3 meant for critically ill patients requiring multiple organ support. Each section has been classified into mandatory requirements and desirable ones according to the level of ICU described. It is important to emphasize that clinical judgement should be used to determine which level of care would be the most appropriate for a critically ill patient. Also, upon clinical stabilization, when further organ support and/or close physiological monitoring are not required, patients should be stepped down to lower levels of care like ward, high dependency unit or discharged, as deemed appropriate by the treating physician.

3.1 Level 1 ICU

Level 1 Intensive Care Units are intended to provide short-term stabilization, basic monitoring and basic limited support for an organ system.

3.1.1 Infrastructure Requirements Location

The location of an ICU should preferably be in proximity to the emergency department and operation theatres and should have easy and fast access to imaging and laboratory facilities.

ICU size and infrastructure

Size of an ICU and bed strength can be variable and would vary depending on variables such as number of beds in the hospital; type of services the hospital delivers (such as surgical specialties, medical specialties, trauma services, emergency services etc) and number of operation theaters etc.

A level 1 ICU is suggested to have 6-8 beds to permit operational efficiency. The physical space around an ICU bed should be sufficient to provide comfortable access to the patient and permit unhindered movement of diagnostic equipment and nursing services.

The facility should meet general infrastructure requirements for an ICU as per standard guidelines issued by the Ministry of Health and Family Welfare (MOHFW).

There should be provision for generator/ UPS back up for emergency power supply.

Proper housekeeping with an emphasis on sanitation should be implemented in the ICU. Storage must be clearly defined to permit easy and quick access to relevant supplies. Such areas should be temperature controlled.

3.1.2 Medical Utilities Bedside Utilities

a. Multipara monitor- Each patient bed must have a multiparameter monitor. The monitor should be able to display heart rate, ECG, non-invasive blood pressure, oxygen saturation and temperature.

b. Medical gas- There should be provision for oxygen supply at the patient bed. There should be at least 2 oxygen outlets per bed.

c. Suction facility – There should be at least one suction outlet per bed.

d. Electrical outlets

There should be provision for multiple electrical outlets (both 15 ampere and 5 ampere) at each patient bed to allow multiple equipment to be used in case of emergency. Some of these outlets should be on UPS backup.

e. IV Pumps

a. Infusion pumps

It is desirable to have 2 infusion pumps in a Level 1 ICU.

b. Syringe pumps

There must be a minimum of 1 syringe pumps per bed.

Emergency Equipment

a. Crash Cart

There should be a crash cart with emergency medications, airway support equipment along with equipment for manual ventilation.

b. Defibrillator

There should be a defibrillator available in the ICU for monitoring and management of patients.

c. Suction apparatus

There should be provision for a portable suction machine.

d. Invasive Ventilator

There should be provision for at least one ventilator to assist patients needing short term respiratory support. There should be provision for at least one back up ventilator.

e. Noninvasive ventilator

There should be provision for non-invasive ventilation.

f. Emergency oxygen cylinder

There should be provision for supplemental oxygen delivery through an oxygen cylinder.

g. Glucometer

Point of care glucometer should be available.

h. ECG machine (12 channel)

A 12 channel ECG machine should be available.

3.1.3

3.1.4

3.1.5

3.1.6

3.1.7

3.1.8

3.1.9

All equipment should be functional and regularly serviced and maintained as per manufacturers’ recommendations. Staff should be trained and competent to use the medical equipment. Appropriate decontamination and sterilization processes should be adopted as per standard guidelines.

Nursing Station

An ICU should have a dedicated space for organizing nursing care services including preparation and dispensation of medications, making treatment and nursing care plans, etc.

Imaging Services

There should be access to imaging services such as x-ray and ultrasound. Non-Emergency Equipment

a. Wheelchair

b. Patient transport trolley with portable oxygen cylinder

c. Transport ventilator with portable multiparameter monitors, including EtCO2

monitoring.

d. Over bed table (desirable)

Laboratory Services

Infection Control

The ICU should implement strict infection control protocols to prevent hospital acquired infections. Relevant guidelines issued by Ministry of Health and Family Welfare and Indian Council of Medical Research should be used to guide infection control policy of the facility and biomedical waste management. There should be hand hygiene stations.

Additional Services

The following services would be required for the working of a level 1 ICU

a. Pharmacy services: There should be access to a pharmacy

b. Should have a 24×7 access to blood bank and ambulance services.

Safety

Fire and safety systems and emergency exits should be functional

3.2 Healthcare Personnel 3.2.1 Doctors

ICU specialist

An ICU can be under the care of the following physicians:

1. A level 1 ICU should preferably be under the care of a specialist with a National Medical Council recognized (NMC) postgraduate degree (MD or DNB) in Anesthesiology/ Medicine/ Pulmonary Medicine/ Pediatrics / Emergency Medicine and with training in intensive care (DM/DrNB) of at least three years with a structured exit exam and certification process.

2. An ICU can also be under the care of a specialist with a NMC recognized postgraduate degree (MD or DNB) in Anesthesiology/ Medicine/ Pulmonary Medicine/ Pediatrics / Emergency Medicine and a 2 year Post Doctoral Certificate Course or Fellowship in intensive care (PDCC / PDF) or Fellowship of National Board (FNB) in intensive care.

3. A specialist with a NMC recognized postgraduate degree (MD or DNB) in Anesthesiology/ Medicine/ Pulmonary Medicine/ Pediatrics/ Emergency Medicine/ General Surgery and a one-year training in Intensive Care can be in-charge.

4. If an ICU specialist with the above qualifications is not available, then an Anesthesiologist, Internal medicine physician, Pulmonary medicine physician, Pediatrician (for care of pediatric critically ill patients), Emergency medicine physician or general surgeon can be in-charge of a level 1 ICU. This is ONLY applicable to level 1 ICU, and not for higher levels of ICU.

5. If an ICU specialist with the above qualifications is not available, then a NMC recognized diploma holder in any of the specialties of Anaesthesia (DA), Thoracic and Respiratory diseases (DTCD) or Pediatric (DCH) with ICU experience of 2 years can be in-charge of a level 1 ICU. This is ONLY applicable to level 1 ICU, and not for higher levels of ICU.

The ICU specialists should devote at least 50% of their professional time in the ICU.

ICU shift duties

The ICU should be manned round the clock by doctors working in shifts. These doctors should have an NMC recognized MBBS degree or more, preferably along with experience of working in an ICU.

Interdisciplinary consultation i.e. access to specialist as per the clinical needs must be available. It would be desirable to have the telemedicine support of an ICU specialist if ICU specialist is unavailable onsite.

3.2.2 Nursing Personnel

Nursing care is an essential and key component of any ICU. Nursing care should be higher than delivered in a ward with a higher nurse: patient ratio. It should be 1:2 to 1:3 for monitored patients depending upon the medical acuity of the patient. It would be desirable to enhance nurse: patient ratio to 1:1 for patients who are unstable or on ventilator. It may be noted that the nurse: patient ratio maybe adapted according to competencies of other allied health personnel as well. Nurses should also be familiar with infection control practices to reduce hospital acquired ICU infections.

3.2.3 Allied Healthcare Personnel

The ICU should have support from various technical support staff as required according to the facility/ hospital such as technician for ABG, portable X-ray along with other machinery and equipment.

3.2.4 Documentation

The ICU should maintain the medical record of the patients including doctor’s notes, nursing records, investigation records, consultation records, treatment records etc.

3.2.5 Audit

Periodic audits are desirable.

3.3 Desirable Equipment and Services

While the requirements mentioned above are considered essential, it may be noted that many additional therapeutic and monitoring equipment along with clinical care services may be required for the care of some patients admitted to a level 1 ICU. It would be desirable to have these additional equipment available for use when feasible. A list of some suggested equipment is enclosed below. This list not exhaustive and requirements of many of these equipment in a hospital may vary depending upon the size of the facility, its workload and the clinical expertise and specialty the hospital ICU handles. It is recognized that certain ICUs may be located in remote areas where the scope of services maybe limited due to various logistic and manpower constraints.

Additional Desirable Equipment and facilities for Level 1 ICU • High flow nasal canula (HFNC)

• Body warming devices

• Sequential compression device [Deep Vein Thrombosis (DVT) prevention pump]

• Access to endoscope, flexible bronchoscope

• Imaging services such as a Computed Tomography (CT) Scan

• Dietician services

• Access to physiotherapy services

Whenever there is a need for enhancing care which requires additional resources that are unavailable in a level 1 ICU, the patient should be transferred to a higher level of care (level 2 or 3 ICU as needed) in ambulances/ transport systems capable of delivering appropriate care to acutely ill patients.

Who should be managed in a Level 1 ICU?

• Patients requiring short-term stabilization and basic support for a single organ system

• Patients who require initial resuscitation before transfer to higher level of care

• Patients with illness requiring close monitoring and greater degree of observation that

cannot be done in a ward

• Patients requiring basic interventions to prevent further deterioration in organ function

4.1 Level 2 ICU

Patients requiring more detailed assessment, monitoring and interventions beyond that possible in level 1 ICU should be managed in a level 2 ICU. A level 2 ICU admission is justified for patients with potentially reversible critical illness who require continuous monitoring and active organ support, but do not require advanced extracorporeal or highly specialized tertiary interventions. This can include patients requiring basic monitoring and support of two or more organ systems or advanced support of one organ system or those requiring long-term respiratory support. A level 2 ICU should meet all the requirements of a level 1 ICU and provide additional facilities for advanced levels of care.

4.1.1 Infrastructure Requirements Location

The location of an ICU should preferably be in proximity / with easy accessibility to emergency department and operation theatres and should have easy and fast access to imaging and laboratory facilities. It should be such that it facilitates interdisciplinary teamwork between various specialties such as medicine, surgery, anesthesiology and radiology. The corridors in the hospital should permit easy patient movement along with equipment both horizontally on a floor and vertically between floors through appropriate lift(s).

ICU size and infrastructure

A level 2 ICU is suggested to have 8-12 beds to permit operational efficiency. The physical space around an ICU bed should be sufficient to provide comfortable access to the patient and permit unhindered movement of diagnostic equipment and nursing services. A bed space of at least 150-175 sq ft per bed is recommended. ICU beds with features such as adjustability for height, back, legs, side rails, pressure relieving mattress is essential.

One or more isolation rooms would also be desirable in level 2 ICU.

The facility should meet general infrastructure requirements for an ICU as per standard guidelines issued by the Ministry of Health and Family Welfare (MOHFW).

There should be provision for generator/ UPS back up for emergency power supply.

4.1.2 Medical Utilities

Bedside Utilities

a. Multiparameter monitor- Each patient bed must have a multiparameter monitor. The

monitor should be able to display heart rate, ECG, non-invasive and invasive arterial/ venous pressure, oxygen saturation, respiratory rate, temperature and end tidal carbon dioxide.

b. Medical gas- There should be provision for central oxygen supply through manifold/ pipeline at the patient bed. There should be at least 2 oxygen outlets per bed. There should be provision for emergency oxygen cylinders as back up.

c. Vacuum – There should be at least one vacuum outlet per bed.

d. Compressed air – There should be at least one compressed air outlet at each patient

bed.

e. Electrical outlets

There should be provision for multiple electrical outlets (both 15 ampere and

5 ampere) at each patient bed.

f. IV Pumps

i. Syringe Pumps

There must be provision to permit use of multiple syringe pumps for patient care during emergency. A minimum of 3 syringe pumps per patient bed should be available.

ii. Infusion Pumps

There must be availability of a minimum of 1 infusion pump per patient bed.

Emergency Equipment a. Crash Cart

There should be a crash cart with emergency medications, airway support equipment along with equipment for manual ventilation. Availability of difficult airway equipment such as bougie, stylet, supraglottic airway devices and flexible bronchoscope are required. Access to a video-laryngoscope is desirable.

b. Defibrillator

There should be at least two defibrillators available in the ICU for monitoring and management of patients. The defibrillator must have facility for transcutaneous pacing.

c. Suction apparatus

There should be provision for a portable suction machine in an ICU.

d. Invasive ventilator

Provision of invasive ventilation should be available for at least 50% of the total bed strength.

e. Noninvasive ventilator

There should be provision for non-invasive ventilator for at least 50% of the total bed strength.

f. Emergency oxygen cylinder

There should be provision for supplemental oxygen delivery through oxygen cylinders.

g. Glucometer

Point of care glucometer should be available in an ICU.

h. ECG machine (12 channel)

A 12 channel ECG machine should be available in an ICU.

i. Transport ventilator and transport monitor

It should have a transport ventilator and multiparameter transport monitor with EtCO2 for transfer of patients.

j. Sterile trays with instruments for various procedures

There should be sterile trays with instruments for various ICU procedures like pigtail insertion, chest tube drainage, wound dressing sets, central venous catheter and hemodialysis catheter insertion sets, cricothyrotomy, percutaneous tracheostomy and others as necessary (as needed by the case mix and type of ICU)..

k. High flow nasal cannula device

One or more high flow nasal cannula devices should be available in a level 2 ICU.

l. Gastro-intestinal (GI) endoscopy

A level 2 ICU should have access to GI endoscopy services.

4.1.3 Nursing Station

An ICU should have a dedicated space for organizing nursing care services including preparation and dispensation of medications, making treatment and nursing care plans, etc. It would be preferable to have a central monitoring station.

4.1.4 Imaging Services

The ICU should have access to imaging services. These include

a. Portable X ray

There should be 24X7 access to a portable x ray machine within the premises.

b. Ultrasound

There should be 24X7 access to ultrasound machine with appropriate probes capable of point of care examination at the bedside.

c. Access to additional imaging services such as CT scan/ Magnetic Resonance Imaging (MRI).

4.1.5 Non-emergency Equipments

a. Wheelchair

b. Patient transport trolley with portable oxygen cylinder

c. monitoring.

d. Over bed table

e. Air mattress

f. Patient warmers

g. DVT prevention pump

4.1.6 Laboratory Services

The ICU should have access to laboratory services for biochemistry investigations (such as hemogram, kidney and liver function tests, blood glucose, serum electrolytes) and microbiology testing. Arterial blood gases and point of care blood glucose testing should be available on round-the-clock basis. Additional point of care tests appropriate for clinical management are desirable.

4.1.7 Infection Control

The ICU should implement strict infection control protocols to prevent hospital acquired infections. Relevant guidelines issued by Ministry of Health and Family Welfare and Indian

Council of Medical Research should be used to guide infection control policy of the facility and biomedical waste management. There should be hand hygiene stations.

4.1.8 Safety

Fire and safety systems and emergency exits should be functional

4.1.9 Additional Services

The following services would be required for the working of a level 2 ICU

a. Pharmacy Services: There should be access to a pharmacy

b. Blood Bank and ambulance services – It should have access to 24×7 blood bank

services and ambulance services for transfer of patients.

c. Renal Replacement Therapy: Access to renal replacement therapy should be

available

4.2 Healthcare Personnel 4.2.1 Doctors

ICU specialist

An ICU can be under the care of the following physicians:

1. A level 2 ICU should preferably be under the care of a specialist with a National Medical Council recognized (NMC) post graduate degree (MD or DNB) in Anesthesiology/ Medicine/ Pulmonary Medicine/ Pediatrics / Emergency Medicine and with training in intensive care (DM/DRNB) of at least three years with a structured exit exam and certification process.

2. An ICU can also be under the care of a specialist with a NMC recognized post graduate degree (MD or DNB) in Anesthesiology/ Medicine/ Pulmonary Medicine/ Pediatrics / Emergency Medicine and a 2 year Post Doctoral Certificate Course or Fellowship in intensive care (PDCC / PDF) or Fellowship of National Board (FNB) in intensive care can be in charge.

3. A specialist with a NMC recognized post graduate degree (MD or DNB) in Anesthesiology/ Medicine/ Pulmonary Medicine/ Pediatrics / Emergency Medicine/ General Surgery and a one year training in Intensive Care can be in charge.

4. An Anesthesiologist, Internal medicine physician, pulmonary physician/ Pediatrician / Emergency medicine physician having a NMC recognized postgraduate degree (MD or DNB), with an ICU experience of 3 years or more may be considered as an ICU specialist.

5. If an ICU specialist with the above qualifications is not available, then a NMC recognized diploma holder in Anesthesiology (DA), Thoracic & Chest disease (DTCD), or Pediatrics (DCH) with ICU experience of at least 10 years, who spend more than 50% of their professional time in a multidisciplinary ICU may also be considered as ICU specialists, and can be in-charge of a level 2 ICU.

6. Medical professionals trained in super-specialties (NMC recognized) in pulmonary and critical care medicine, anesthesia organ transplant and critical care, or other super- specialties, who spend more than 50% of their professional time in a multidisciplinary ICU may also be considered ICU specialists. Physicians with a super specialty degree practicing exclusively within a single super-specialty ICU may be regarded as ICU specialist for that subspecialty.

All ICU specialists should devote at least 50% of their professional time in the ICU.

ICU shift duties

An ICU should be manned round the clock by resident doctors working in shifts. These doctors should be postgraduates (NMC recognized degree) from anesthesia, medicine, pulmonary medicine, emergency medicine, pediatrics or surgical specialties. Doctors with NMC recognized MBBS degree working under supervision of post graduate doctors can also be posted in shifts along with them. There should be a roster for duties.

It is desirable that 1 postgraduate ICU resident along with a graduate ICU resident should care for not more than 12 critically ill patients in ICU.

The ICU specialist should preferably be the administrative in charge of an ICU. An intensivist led ICU is labeled as closed ICU. It is recommended that over a period of time the concept of open ICU should go in favor of closed ICUs.

Interdisciplinary consultation i.e. access to specialist as per the clinical needs must be available.

4.2.2 Nursing Personnel

Nurse: patient ratio in a level 2 ICU should be a minimum of 1:2 to 1:3. It would be desirable to have nurse: patient ratio of 1:1 for patients who are unstable or on ventilator. It may be noted that the nurse: patient ratio maybe adapted according to competencies of other allied health personnel as well. Nurses should also be familiar with infection control practices to prevent and reduce hospital acquired ICU infections. Nurses should preferably be trained and certified in critical care skills such as Basic and Advanced Life Support.

4.2.3 Allied Healthcare Staff

4.2.4 Training and Competency

Staff should be trained in resuscitation, infection control protocols and should receive training for continued professional development. Documentation of staff competencies are desirable.

4.2.5 Documentation

The ICU should maintain all records of the patient pertaining to the ICU care including doctors notes, nursing records, investigation records, consultation records, treatment records, etc.

4.2.6 Audit

Periodic audits are desirable.

Whenever there is a need for enhancing care which requires additional resources that are unavailable in a level 2 ICU, the patient should be transferred to a higher level of care (level 3 ICU as needed) in ambulances/ transport systems capable of delivering appropriate care to acutely ill patients.

5.1 Level 3 ICU

Level 3 ICUs are intended to provide comprehensive multisystem organ support, advanced monitoring and preferably to act as referral centers. Such an ICU should be in hospitals that have multiple medical and surgical disciplines included in its services so that it can provide consultations with various specialties as needed in ICU care. They should have all the facilities of a level 2 ICU along with providing infrastructure for more advanced critical care services. Patients with multi-organ failure requiring advanced invasive monitoring, multisystem organ support and complex critical care therapies, with potential need for long term ICU care should be managed in level 3 ICUs. The following section describes the requirements for infrastructure, devices, staffing and patient-care capabilities required to operate a level 3 ICU safely, which are in addition to the capabilities of a level 2 ICU.

5.1.1 Infrastructure Requirements ICU Bed and Space

Location

The location of a level 3 ICU should preferably be in proximity/ with easy accessibility to emergency department and operation theatres and should have easy and fast access to imaging and laboratory facilities. It should be such that it facilitates interdisciplinary teamwork between various specialties such as medicine, surgery, anesthesiology and radiology. The corridors in the hospital should permit easy patient movement along with equipment both horizontally on a floor and vertically between floors through appropriate lift(s).

ICU size and infrastructure

A level 3 ICU is suggested to have a 8-12 beds to permit operational efficiency. The physical space around an ICU bed should be sufficient to provide comfortable access to the patient and permit unhindered movement of diagnostic equipment and nursing services. A bed space of 150-250 sq ft per bed is recommended for ease of using different devices at bedside. ICU beds with features such as adjustability for height, back, legs, side rails, pressure relieving mattress would be essential. It would be desirable to have body weight monitoring feature in the ICU bed.

One or more isolation rooms should be available.

5.1.2

The facility should meet general infrastructure requirements for an ICU as per standard guidelines issued by the Ministry of Health and Family Welfare (MOHFW).

There should be provision for generator/ UPS back up for emergency power supply.

Proper Housekeeping with an emphasis on sanitation should be implemented. Storage must be clearly defined to permit easy and quick access to relevant supplies. Such areas should be temperature controlled for all medications.

Medical Utilities

All equipment should be regularly serviced and maintained as per manufacturers recommendations. Staff should be trained and competent to use the medical equipment. Appropriate decontamination and sterilization processes should be adopted as per guidelines.

Bedside Utilities

a. Multipara monitor- Each patient bed must have a multiparameter monitor. The monitor should be able to display heart rate, ECG, non-invasive blood pressure, oxygen saturation, respiratory rate, end tidal carbon dioxide and temperature along with invasive hemodynamic monitoring and other advanced monitoring as required. There should be provision for cardiac output monitoring.

b. Medical gas- There should be provision for central oxygen supply through manifold at the patient bed. There should be at least 2 oxygen outlets per bed. There should be provision for emergency oxygen cylinders as back up.

c. Vacuum – There should be at least one vacuum outlet per bed.

d. Compressed Air – There should be two compressed air outlets at each patient bed.

e. Electrical outlets

i. There should be provision for multiple electrical outlets (both 15 ampere and 5 ampere) at each patient bed to allow multiple equipment to be used in case of emergency.

f. IV Pumps

i. Syringe Pumps

There must be provision to permit use of multiple syringe pumps for patient care during emergency. At least 4 syringe pumps per patient bed should be available

ii. Infusion Pumps

There must be provision to use multiple infusion pumps if needed for a patient. At least 3 infusion pumps per patient bed should be available

Emergency Equipment

a. Crash Cart

There should be an crash cart with emergency medications, airway support equipment along with equipment for hand ventilation. Availability of difficult airway equipment such as bougie, stylet, supraglottic airway devices, flexible bronchoscope and video-laryngoscope are required.

b. Defibrillator

There should be at least 2 defibrillators available in the ICU for monitoring and management of patients. The defibrillators must have facility for transcutaneous pacing.

c. Suction apparatus

There should be provision for a portable suction machine in an ICU.

d. Invasive ventilation

Provision of advanced invasive ventilation with adult/ pediatric modes is suggested for 60 – 100% of the total bed strength depending on case mix. There should be a provision for back up ventilator.

e. Noninvasive ventilation

There should be provision for non-invasive ventilation for 60-100% of the total bed strength.

f. Emergency oxygen cylinder

There should be provision for supplemental oxygen delivery through oxygen cylinders.

g. Glucometer

Point of care glucometer should be available in an ICU.

h. ECG Machine (12 channel)

A 12 channel ECG machine should be available in an ICU.

i. Transport Ventilator and Transport Monitor

A level 3 ICU should have a transport ventilator and transport monitor for intrahospital transfer of patients. The transport monitor should include EtCO2 monitoring.

j. Sterile trays with instruments for various procedures

k. High Flow nasal cannula device

High flow nasal cannula devices should be available in a level 3 ICU.

5.1.3 Nursing Station

It should have a dedicated space for organizing nursing care services including preparation and dispensation of medications, making treatment and nursing care plans, etc. There should be a central monitoring station to view patient data.

5.1.4 Imaging Services

There should be access to imaging services. These include the following imaging modalities

i. Portable X ray

ii. Bedside point of care ultrasound with echocardiography (transthoracic and

preferably transesophageal echocardiography)

iii. Additional imaging services such as CT scan/ MRI should be available

iv. Advanced imaging technique such as mobile digital radiography and bedside

portable CT are desirable.

5.1.5 Non-Emergency Equipment

a. Wheelchair

b. Patient transport trolley with portable oxygen cylinder

c. Transport ventilator with portable multiparameter monitors, with EtCO2 monitoring.

d. Over bed table

e. Air mattress

f. Patient warmers

g. DVT Pumps

5.1.6 Laboratory Services

The ICU should have access to laboratory services for biochemistry investigations (such as hemogram, kidney and liver function tests, blood glucose, serum electrolytes) and microbiology testing including for fungi. Arterial blood gases and point of care blood glucose testing should be available on round-the-clock basis. Additional point of care tests appropriate for clinical management are recommended.

5.1.7

5.1.8

Infection Control and safety

Additional Services

The following services would be required for the working of a level 3 ICU

Pharmacy services: There should be access to a pharmacy

Blood Bank and ambulance services – It should have access to 24×7 blood bank services and ambulance services.

Renal replacement therapy (RRT): on-site hemodialysis should be available. CRRT capability is desirable.

Provision for both long-term acute care and palliative care.

Maintain policies for admission/discharge/escalation, infection control, equipment maintenance (such as Annual Maintenance Contract), antimicrobial stewardship, morbidity and mortality meetings, and regular audits of key quality indicators like ICU mortality, device-associated infection rates (VAP, CLABSI, CAUTI), etc.

Advanced respiratory support adjuncts such as nitric oxide delivery and high frequency oscillatory ventilation are desirable.

Centralized real-time patient surveillance (integrated EMR/monitoring) with alarm routing and alerts is desirable.

Access to Extracorporeal Membrane Oxygenator (ECMO) and ECCO2R services is desirable.

Provision to deliver other extracorporeal therapies like plasmapheresis, blood purification services if needed is desirable.

Gastro-intestinal (GI) endoscope- A level 3 ICU should have access to GI endoscopy services.

Safety

Fire and safety systems and emergency exits should be functional.

Healthcare Personnel Doctors

Medical leadership & physicians

5.1.9

5.2 5.2.1

a. b.

d. e.

f. g. h. i. j.

The ICU in-charge should be an experienced intensivist (preferably full-time) responsible for clinical governance, protocols, training and quality. The ICU should have 24×7 in-house physician coverage by senior residents/registrars and consultants on call (ensuring consultant/intensivist oversight available within defined response time) is needed. It is desirable to have a closed ICU model with intensivist-led care and formal multidisciplinary rounds (daily). For highest acuity centers, 24×7 in-house consultant intensivist presence is preferable.

ICU specialist

1. A level 3 ICU should preferably be under the care of a specialist with a National Medical Council recognized (NMC) post graduate degree (MD or DNB) in Anesthesiology/ Medicine/ Pulmonary Medicine/ Pediatrics / Emergency Medicine and with training in intensive care (DM/DRNB) of at least three years with a structured exit exam and certification process.

2. An ICU can also be under the care of a specialist with a NMC recognized post graduate degree (MD or DNB) in Anesthesiology/ Medicine/ Pulmonary Medicine/ Pediatrics / Emergency Medicine and a 2 year Post Doctoral Certificate Course or fellowship in intensive care (PDCC / PDF) or Fellowship of National Board (FNB) in intensive care can be in charge.

3. A specialist with a NMC recognized post graduate degree (MD or DNB) in Anesthesiology/ Medicine/ Pulmonary Medicine/ Pediatrics / Emergency Medicine/ Surgery and a one year training in Intensive Care can be in charge.

4. An Anesthesiologist, Internal medicine physician, Pulmonary physician/ Pediatrician / Emergency medicine physician having a NMC recognized postgraduate degree (MD or DNB), with an ICU experience of more than 3 yrs may be considered as an ICU specialist. The ICU specialist should practice predominantly in the ICU devoted to the care of critically ill patients.

5. If an ICU specialist with the above qualifications is not available, then a NMC recognized diploma holder in Anesthesiology (DA), Thoracic & Chest disease (DTCD) or Pediatrics (DCH) with ICU experience of at least 10 years, who spend more than 50% of their professional time in a multidisciplinary ICU may also be considered as ICU specialists, and can be in-charge of a level 3 ICU.

may also be considered ICU specialists. Physicians with a super specialty degree practicing exclusively within a single super-specialty ICU may be regarded as ICU specialist for that subspecialty.

The ICU specialists should devote at least 50% of their professional time in the ICU.

ICU shift duties

5.2.2 Nursing Personnel

The nurse: patient ratio should be 1:1 for patients on invasive organ support; 1:2 acceptable for less acuity. Staffing must be adjusted by case-mix. It may be noted that the nurse: patient ratio maybe adapted according to competencies of other allied health personnel as well. Nurses should also be familiar with infection control practices to prevent and reduce hospital acquired ICU infections. Nurses should preferably be trained and certified in critical care skills such as Basic and Advanced Life Support.

5.2.3 Allied Health Care Personnel

The ICU should have support from various technical support staff including medical lab technicians, radiographers, physiotherapist and technical support for its medical equipment and devices from medical technicians/ engineers. Trained dialysis nurses for providing renal replacement therapy should be available. Trained housekeeping, transporters, security, clerical staff and dedicated infection control nurse are required. Availability of perfusionists is required for ECMO capable centers. Dedicated nutritionist, psychologist / access to palliative care and an ICU data-manager for quality metrics and research are desirable.

5.2.4 Training and Competency

A level 3 ICU should preferably act as a centre for research, training and teaching for intensive care medicine. It may serve as a centre for imparting teleconsultation services

5.2.5

5.2.6

6. 0

for level 1 or level 2 ICUs. Staff should be trained in resuscitation, infection control protocols and should receive training for continued professional development. Documentation of staff competencies & periodic audits are desirable

Documentation

It should maintain a record of the patient pertaining to his care including doctors notes, nursing records, investigation records, consultation records, treatment records, etc.

Audit

Periodic audits should be done.

Conclusions

These guidelines are intended to provide suggested minimum standards for intensive care unit infrastructure, equipment, and clinical services, based on the available guidelines and recommendations of national scientific societies and institutions like Ministry of Health and Family welfare, Indian Council of Medical Research, and guidelines and literature published by different national and international scientific societies. They are meant to serve as a general framework to support quality and safety in critical care delivery. While these guidelines broadly outline basic clinical and logistic requirements, institutions and practitioners are encouraged to exceed these minimums wherever feasible in the interest of optimal patient care. These recommendations should be subjected to periodic review and revision, to reflect evolving scientific evidence, technological advances, and best clinical practices. Adherence to these guidelines should be interpreted in the context of available resources, institutional capabilities, and individual patient needs.

References

• MoHFW / DGHS: Guidelines for ICU admission/discharge and clinical treatment pathways (DGHS / MoHFW operational guidance for ICU/HDU). (Clinical Establishments)

• ICMR: Hospital Infection Control Guidelines (ICMR technical guidance on infection prevention in hospitals/ICUs). (iamrsn.icmr.org.in)

• NHSC / PM-ABHIM & HFG India: Design / air-handling / facility guidance for critical-care areas (ACH / HVAC / isolation). (National Health Systems Resource Centre)

• Guidelines for High Dependency Unit (HDU) & Intensive Care Unit (ICU) 2022. Ministry of health & family welfare, Govt of India. National Health Mission. Available at: https://nhsrcindia.org/sites/default/files/Guidelines-on-HDU_ICU.pdf

Marshall JC, Bosco L, Adhikari NK, et al. What is an intensive care unit? A report of the

task force of the World Federation of Societies of Intensive and Critical Care Medicine.

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Rungta N, Zirpe KG, Dixit SB, et al. Indian Society of Critical Care Medicine Experts

Committee Consensus Statement on ICU Planning and Designing, 2020.

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• Guidelines for provision of Intensive Care Services, July 2022. Intensive Care Society. Available at https://ficm.ac.uk/sites/ficm/files/documents/2022- 07/GPICS%20V2.1%20%282%29.pdf.

• Hamilton et al. Society of Critical Care Medicine 2024 Guidelines on Adult ICU Design. Critical Care Medicine 53(3):p e690-e700, March 2025. | DOI: 10.1097/CCM.0000000000006572

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