ICU Design: Basics
The requirement of ICU beds has increased from the traditional
1-4 beds per 100 hospital beds to 10-20 per cent of the total hospital beds
old concept of identifying ICU as just a separate area with high-tech gadgets
no longer holds true. One should take cognizance of the recent developments
and the various recommendations by bodies like the Society of Critical Care
Medicine (SCCM), Indian Society of Critical Care Medicine (ISCCM) and the published
literature on the subject. An important dimension is the concerns of the patients
and their families, who often complain about overwhelming feelings of insecurity,
disorientation, anxiety, fear and anger. The sheer volume of technology, the
unfamiliar, sterile surroundings, lack of privacy, constantly revolving medical
teams, incessant noise and glaring light, and the lack of natural forms, materials,
and sensory experiences all add to this traumatic experience. As a result, the
patients feel trapped in an environment they dislike and cannot control, and
their families feel helpless.
Comfort: Top Priority
The focus, therefore, is on ICU designs that provide comfort
to patients, reduce hospital acquired infections and cost of ICU stay. On one
hand the severity of the interventions requires the utmost in technology, methodology
and sterility, while on the other hand, the patients and their families who
are experiencing some of the most traumatic moments of their lives need a natural
feel and look environment that is comforting and de-stressing.
There is also increasing awareness about quality in healthcare
and institutions are keen to comply with the standards laid down by agencies
like the Joint Commission on Accreditation of Healthcare organisations (JCAHO),
Joint Commission International (JCI), National Fire Prevention Association (NFPA),
National Accreditation Board for Healthcare Organisations (NABH), for upgrading
their facilities to promote safety as well as business.
These organisations have developed minimum standards for healthcare institutions
independently and although these standards by these non-State agencies are technically
considered non-binding, many governmental and private reimbursement organisations
require compliance with them to qualify for reimbursement. As a result, more
and more hospitals in India are opting voluntarily for accreditation by these
direct elevator is an excellent idea to transfer sick patients to and fro
from the ICU, reducing
transport time and avoiding the visitors"
- Dr Rajesh Pande
Department of Critical care and Emergency Medicine
BLK Memorial Hospital
The various factors that need to be considered while designing
an ICU are sources of patients, admission and discharge criteria, expected rate
of occupancy, economic investment, financial viability, personnel required as
well as the technological resources. One has to also consider the level of ICU
care required. Level I provide monitoring, observation and short term ventilation.
Level II provides observation, monitoring and long term ventilation with resident
doctors. Level III provides all aspects of intensive care including invasive
hemodynamic monitoring and dialysis.
The designing team should consist of an ICU specialist, nursing
administrators and supervisors, hospital administrators, architect, engineers,
environmental engineers, interior designers with considerable input from patients
and their families. ICU floor plan should be based on patient admission pattern,
staff and visitor traffic pattern. It should be centrally located close to the
operation theatres, HDUs, Imaging and the Emergency Departments. Some hospitals
have amalgated the ER triage with the ICU, so-called shock labs, increasing
the preparedness and eliminating the duplication of resources and manpower.
But to achieve these both facilities should be located on the same floor.
An Ideal ICU
There should not be any thorough traffic to other departments
from the ICU. It is a good idea to separate the supply and professional traffic
from public/ visitor traffic. A direct elevator is an excellent idea to transfer
sick patients to and fro from the ICU, reducing transport time and avoiding
the visitors. The patient transport corridors should be separate than those
used by the visiting public. Patient privacy should be preserved and transportation
should be rapid and unobstructed. The elevators should be oversized keyed elevators,
separate from public access. The support facilities should include nursing stations,
storage, clerical space, administrative and educational requirements, and other
services unique to the institution.
Call for a Change
The requirement of ICU beds has increased from the traditional
1-4 beds per 100 hospital beds to 10-20 per cent of the total hospital beds,
but this depends on the type as well as on the role of an ICU. ICUs with less
than four beds are not seen as cost-effective and from a functional point of
view 8-12 beds per unit is best, if a large ICU is planned. ICU should have
positive and negative pressure isolation rooms within the unit. Each ICU should
be a geographically distinct area with controlled access. Regarding the subspecialty
ICUs, it's for the Institution to decide whether to organise its ICU into multiple
units, e.g., medical and surgical ICUs etc. under separate management or to
make a general multidisciplinary ICU managed by the Intensive care specialists.
patient bed area in an adult ICU requires a minimum floor space of 20 m2 (215
ft2), with single rooms being larger (~ 250 ft2) to accommodate patient, staff,
and equipment without overcrowding. The ratio of single rooms to open beds is
usually recommended as 1:6 for multidisciplinary ICUs, though it also depends
on the role and type of the ICU. Utilities per bed space as recommended are:
3 oxygen, 2 air, 3 suction, 16 power outlets, and an adequate appropriate bedside
light. All beds should have uninterrupted supply and battery backup to run life
saving equipment. Centrally supplied oxygen and compressed air must be provided
at 50 to 55 psi from main and reserve tanks, and installation must follow NFPA
standards. The vacuum system must maintain a vacuum of at least 290 mm Hg at
the outlet farthest away from the vacuum pump. Audible and visual alarms must
indicate a decrease in vacuum below 194 mm Hg. Total luminance should not exceed
30 foot-candles (fc). Night lighting should not exceed 6.5 fc for continuous
use or 19 fc for short periods. Separate lighting for emergencies and procedures
should be located in the ceiling directly above the patient and should fully
illuminate the patient with at least 150 fc shadow-free. How the services are
provided, from floor columns, bed pendants, wall mounted depends on individual
preferences as each design has its pros and cons.
Signals from patient call systems, alarms from monitoring
equipment, and telephones add to the sensory overload in critical care units.
Without reducing their importance or sense of urgency, such signals should be
modulated to a level that will alert staff members, yet be rendered less noxious.
The International Noise Council has recommended that noise levels in hospital
acute care areas not exceed 45 dB (A) in the daytime, 40 dB (A) in the evening,
and 20 dB (A) at night. To achieve this, the floor covering that absorb sound,
walls and ceilings should be constructed of material with high sound absorption
capability and the doorways should be offset rather than being placed in symmetrically
opposed positions to reduce sound transmission.
Space and surfaces for computer terminals and patient charting
should be incorporated into the design of each patient module. Storage must
be provided for each patient's personal belongings, patient care supplies, linen
and toiletries. Locking drawers and cabinets must be used if syringes and pharmaceuticals
are stored at the bedside. Personal valuables should not be kept in the ICU.
Rather, these can be either handed over to the family or held by hospital security
until patient discharge.
Patient areas must have large clear windows so that natural
light can access the room easily. Additional approaches to improving sensory
orientation for patients may include the provision of a clock, calendar, bulletin
board, and/ or pillow, speaker connected to radio and television. Televisions
must be out-of-reach of patients and operated by remote control. If possible,
telephone service should be provided in each room.
The clinical areas must be situated so that direct or indirect (video monitor)
visualisation by healthcare providers is possible at all times. This permits
monitoring of patient status under both routine and emergency circumstances.
If possible, the design should allow a direct line of vision between the patient
and central nursing station. The presence of sliding glass doors, partition
facilitate this arrangement and increase access to the room in emergency situations.
For the Nurses
The central nursing station should be of sufficient size
to accommodate all necessary staff functions. Adequate space should be provided
for computer terminals and printers with good overhead and task lighting. A
wall mounted clock should be present. The patient records should be easily accessible.
Adequate surface space and seating for medical record charting by both physicians
and nurses should be provided. The shelving, file cabinets and other storage
for medical record forms must be located so that they are readily accessible
by all personnel requiring their use. The secretarial area may be located separately
from the central station but should be easily accessible.
There should be a designated area near the ICU for the viewing
and storage of patient radiographs. An illuminated viewing box of appropriate
size should be present to see serial X-ray, CT and MR scans. The work areas
should be well planned so that the critical supplies can be located within or
immediately adjacent to the ICU. Work areas and storage for critical supplies
should be located within or immediately adjacent to the ICU.
For storage and rapid retrieval of crash carts and portable monitors/ defibrillators,
alcove should be provided. Space should be earmarked for keeping ventilators
not in use. A separate medication area containing a refrigerator for pharmaceuticals,
a double locking safe for narcotics and controlled substances must be provided.
There should be cabinets available for storage of medication and supplies and
countertops for medication preparation. This area should be earmarked as injection
loading area. If this area is enclosed, a glass wall should permit visualisation
of patient and ICU activities during medication preparation, and to permit monitoring
of area itself from outside to assure that only authorised personnel are within.
A sink with hot and cold water supply should be provided in this area.
Each ICU should have a reception to control visitor access.
The preferred location is where the visitors must pass this area to enter the
ICU. The receptionist should be linked to the ICU's by telephone and or communication
system. Ideally visitor's entrance should be separate from that used by healthcare
professionals and should be securable if the need arises. It is a good idea
to have one room/ corner labeled as a procedure room. It avoids interference
during visiting hours and ensures privacy during the procedure. The ward ICU
procedures like decanulation, CVP insertion, bronchoscopy etc can be done here.
The facility should be at par with the ICU with sufficient storage cupboards
and should have free access and exit.
Air Supply Matters
Air supply to the ICU merits special attention. It is preferable
to have triple filtration including High Efficiency Particulate Air (HEPA) filters
to improve the quality of air. In fact the air quality should be at par with
the OR. The clean and dirty areas should be separate without inter-connection.
The air supply from the dirty utility and isolation rooms must be exhausted.
The floor should be covered with seamless materials to facilitate cleaning.
Similarly, dialysis (CRRT) is often required in the critical patients, therefore,
provision must be made to have RO water recirculation system installed in a
few beds in the ICU.
The clean utility should be used for storage of all clean
and sterile supplies including linen. Shelving and cabinets for storage must
be located high enough off the floor to allow easy access to the floor underneath
for cleaning. The Dirty Utility (DU) must contain a clinical sink and a hopper
both with hot and cold mixing faucets. Separate containers should be provided
for soiled linen and waste materials. There should be designated mechanism for
the disposal of items contaminated by body fluids and special containers should
be provided for disposal of needles and sharps. It is also a good idea to have
a dedicated area for the storage and securing of large patient care equipment
items not in active use. This space should be adequate to provide easy access,
easy location of desired equipment and easy retrieval. Grounded electrical outlets
should be provided within the storage area in sufficient numbers to permit recharging
of battery operated items.
Due consideration should be given to the comfort of ICU staff
and a staff lounge must be available on or near the ICU, to provide a comfortable
and relaxing environment with secured locker facilities, showers and toilets.
This area should include comfortable seating and adequate nourishment storage
and preparation facilities including a refrigerator and a microwave. The lounge
must be linked to the ICU by telephone or the intercommunication system and
emergency cardiac alarms should be audible within.
In order to provide service on a 24-hour basis, on-call rooms
should be available close to the ICU. Toilet and shower facilities should be
provided. On-call rooms must be linked to the ICU by telephone and/ or voice
inter-communication system. In addition, cardiac arrest/ emergency alarms must
be audible in these rooms. It is often desirable to have office space available
adjacent to the ICU(s) for medical and nursing management and administrative
personnel. These offices should be large enough to permit meetings and consultations
with ICU team members and/ or patients' families. Additional office space may
be allocated for staff development personnel, clinical specialists and social
services, as applicable. The ability to place these individuals in close proximity
to an ICU may facilitate an integrated and broad-based team approach to patient
Similarly, a conference room should be present conveniently near the ICU area
for ICU physician and staff use. This room must be linked to ICU by telephone
or other communication systems and emergency cardiac alarms should be audible
in the room. It will be a multi-purpose room for organising CME, house staff
education, or multidisciplinary patient care conferences. It can also be used
to store medical and nursing reference materials and resources. VCR, computers
and other self learning equipment including mannequins can be placed here. If
the conference room is not large enough, a separate class room should be provided
for teaching and training. A separate family consultation room is strongly recommended
for daily counseling as well as grief counseling.
Cannot Afford to Ignore
One of the most important areas is the visitors lounge or
the waiting area, located near the ICU. The visitor access should be controlled
from the receptionist area. The recommendations are to have one and one-half
to two seats per bed. Public telephones and dining facilities must be available
to the visitors besides television and soft music. The public toilet facilities
and a drinking fountain should be located within the lounge area or immediately
adjacent. It is desirable to have warm colours, carpeting, indirect soft lighting,
and windows. A variety of seating, including upright, lounge and reclining chairs
is also desirable. The educational material and lists of hospital and community
based support and resources can be displayed here. The ICU has to be customised
to meet the need of the hospital and should take future expansion plans of the
hospital into consideration.
IT is the Way Forward
Computerised patient charting is becoming increasingly popular
in ICUs. These systems provide for 'paperless' data management, order entry
and nurse and physician charting. If and when a decision is made to utilise
this technology, it is important to integrate such a system fully with all ICU
activities. Bedside terminals facilitate patient management by permitting nurses
and physicians to remain at the bedside during the charting process. To minimise
errors, monitored data can be recorded automatically.
In addition, when these systems are properly interfaced with
existing hospital Information System (HIS), Laboratory Information System (LIS)
as well as Picture Archiving and Communication System (PACS) for X-ray, CT scans
etc facilitating data retrieval at bedside. Remote data transmission capabilities
(to offices, on-call rooms, etc.) are desirable to facilitate continuity in
patient management. It is also a good idea to have an intercommunication system
in ICU that provides voice linkage between the central nursing station, patient
modules, physician on-call rooms, conference rooms, and staff lounge. Supply
areas and the visitors' lounge/ waiting room may also be included in the system.
When appropriate, linkage to key departments such as blood-bank, pharmacy and
clinical laboratories should be included. Some types of communication, such
as personnel tracking and non-emergency calls, may best be accomplished using
visual displays (for instance, numerics or colour-coded lights) that eliminate
Communication is the Key
In addition to standard telephone service for each ICU, which
should provide hospital-wide and external communications capabilities, there
should be a mechanism for emergency internal and external communications when
normal systems fail (for example, during power failures). All ICUs must have
access to 24-hour clinical laboratory services. There should be provision to
provide minimum chemistry and haematology testing, including arterial blood
gas analysis in the ICU.
ICUs in near future will be need based, well planned, equipped
with advanced technology, fulfilling all dimensions of the patient's needs.