Neobook — clinical reference

There is no universally accepted method of classifying intensive care units. For the purposes of classifying the services offered, and resources required by different levels of ICUs, a system proposed by the (then) World Federation of Societies of Intensive and Critical Care Medicine has been modified for local circumstances ⁶:

Level 1 ICU (High care)

A Level 1 ICU has traditionally been described as a high care but classifying it as an ICU highlights the importance of these units in providing critical care in our healthcare system. Level 1 ICUs may be run as an open or closed model and by critical-care trained or non-critical-care trained medical personnel.

Level 1 ICUs include coronary care units. A Level 1 ICU is ideally located in a geographically distinct ward, infrastructure constraints may however require a Level 1 ICU to be located within a general ward. Irrespective of the geographical location the following are required for a Level 1 ICU:

Monitoring: A Level 1 ICU must have the ability to provide intensive non-invasive monitoring. This includes continuous ECG, respiratory rate and SpO₂ monitoring and hourly NIBP, urine output, glucose, temperature, airway, and neurological monitoring, including Glasgow Coma Scale (GCS) monitoring. Level 1 ICUs should be able to offer invasive blood pressure monitoring. Certain level 1 ICUs will offer additional specialised monitoring.

Organ support: A Level 1 ICU should be able to provide single-organ support, other than mechanical ventilation. This includes supplemental oxygen therapy, inotrope/vasopressor support, parenteral antihypertensives, renal replacement therapy (RRT) (usually intermittent haemodialysis (IHD) but may include continuous renal replacement therapy (CRRT) where expertise exists), plasma exchange, airway support (including care of intubated patients and those with tracheostomies who do not require invasive ventilation) and external ventricular drain monitoring and drainage. Non-invasive ventilation (NIV) or high-flow nasal cannula oxygen (HFNCO) therapy may be offered where the facilities are available. Invasive mechanical ventilation in a Level 1 ICU is not recommended except as a bridge to referral to an appropriate setting, during stabilisation, or during evaluation for admission by a higher-level unit.

Staffing: Level 1 ICUs should have a designated doctor and nurse in charge of the unit. These personnel should have appropriate experience to run the unit and should ideally have critical care experience, not necessarily at the level of a specialist. Each patient must have a designated doctor responsible for responding to emergencies. The doctor responsible for each patient must be readily contactable, but a dedicated medical practitioner does not need to be available on site in the unit. A medical practitioner (or equivalently trained personnel: see below) must be immediately available in the hospital to attend to life-threatening emergencies (e.g. accidental extubations, cardiac arrest) until the patient’s physician arrives, if required. In hospitals without a doctor on site (including many private hospitals), an alternative would be to have an appropriately trained emergency care practitioner (or equivalent) on site who could provide the above-mentioned emergency management in the ICU. A registered nurse with appropriate training for the functioning of that unit should be rostered for each shift. The ratio of nursing staff to patients rostered for each shift should not be less than less than 1:2.

Level 2 ICU

A Level 2 ICU, in general, refers to an ICU at a regional public hospital or equivalent level private hospital. Level 2 ICUs may be run as open or closed units. Level 2 ICUs must be located in a geographically distinct ward. The following are the minimum required for a Level 2 ICU:

Monitoring: A Level 2 ICU must be able to provide the monitoring offered in a Level 1 ICU, and in addition must be able to provide continuous invasive arterial pressure monitoring (and if required central venous pressure monitoring). Intraabdominal pressure must be able to be monitored, either intermittently or continuously. A blood gas machine must be immediately available.

Organ support: A Level 2 ICU must be able to offer invasive and non-invasive mechanical ventilation, and inotropic/vasopressor support. A Level 2 ICU must be able to offer RRT in the form of either IHD or CRRT.

Medical personnel: Each unit must have a responsible medical director who should be an intensivist. Given the shortage of intensivists in South Africa the medical director may be a specialist with intensive care experience. Intensive care experience is defined as two years full-time experience (or equivalent part-time experience) working as a specialist in an academic ICU or working with an intensivist. The aforementioned recommendation will be reviewed in the next version of these guidelines in the context of availability of intensivists at the time of drafting the new guidelines. Patients remaining in a level 2 ICU for more than 72 hours should be reviewed by an intensivist every 3-5 days if one is available. The medical personnel responsible for the care of each patient may be an intensivist or a non-intensivist specialist who has received formal critical care training as part of their specialist training. The doctor responsible for each patient must be readily contactable, but a dedicated medical practitioner does not need to be available on site in the unit. A medical practitioner (or equivalently trained personnel: see below) must be immediately available in the hospital to attend to life-threatening emergencies (e.g. accidental extubations, cardiac arrest) until the patient’s physician arrives, if required. In hospitals without a doctor on site (including many private hospitals), an alternative would be to have an appropriately trained emergency care practitioner (or equivalent) on site who could provide the above-mentioned emergency management in the ICU.

Nursing personnel: Level 2 ICUs must have a critical care-trained nursing director. A registered nurse with critical care experience should be rostered for each shift. The ratio of nursing staff to patients rostered for each shift should not be less than 1:1 for ventilated patients or less than 1:2 for non-ventilated patients. Alternatively nursing ratios may be determined by established tools such as the Nursing Activities Score or Therapeutic Intervention Scoring System (TISS-76) using evidence-based cutoffs as long as the ratios are not less than the abovementioned ratios ^{(18, 19)}. Enrolled nurses may nurse patients in Level 2 ICUs but there must be at least one registered nurse per enrolled nurse rostered per shift.

Multidisciplinary team: A Level 2 ICU must have regular input from relevant members of a multidisciplinary team, including dieticians, microbiologists, pharmacists, physiotherapists, occupational therapists and speech therapists. A clinical microbiologist or infectious disease specialist should provide regular alerts on drug-resistant organisms and reports on antimicrobial susceptibility profiles that are relevant to the unit. A clinical technologist should be available assist in the ICU when required. A psychologist should be available to provide psychological support to patients, family, or staff members as required.

Administration: A Level 2 ICU must have established administrative and clinical protocols and must engage in quality improvement projects.

Education: A Level 2 ICU must ensure staff receive appropriate continuous professional development (CPD) training

Referral: A Level 2 ICU should act as a referral centre for referring hospitals that do not have an ICU on site.

Level 3 ICU

A Level 3 ICU, in general, refers to an ICU at a tertiary public hospital or equivalent level private hospital but may be established at other hospitals depending on specific local requirements. Level 3 ICUs offer modern, specialised critical care to complex critically ill patients. Level 3 ICUs must be located in a geographically distinct ward, with appropriate links to support services. The following are the minimum requirements for a Level 3 ICU:

Monitoring: A Level 3 ICU must be able to provide the monitoring offered in a Level 2 ICU, but in addition must be able to provide advanced cardiac output monitoring, continuous capnography and echocardiography. A Level 3 ICU may also offer advanced neuromonitoring. A blood gas machine must be available in the ICU complex.

Organ support: A Level 3 ICU must be able to offer invasive and non-invasive mechanical ventilation, including advanced ventilatory modes. A Level 3 ICU must be able to offer inotropic/vasopressor support, including therapies that may not be available in Level 2 hospitals (e.g., vasopressin or noradrenaline). A Level 3 ICU must be able to offer RRT in the form of IHD and CRRT. Level 3 ICUs may also offer additional therapies such as extracorporeal membrane oxygenation (ECMO).

Medical personnel: Level 3 ICUs must be managed as closed units. Each unit must have an intensivist as the medical director. An intensivist (or a specialist intensive care trainee under the supervision of an intensivist) must be responsible for the care of every patient in the ICU. The responsible intensivist must be readily contactable by ICU staff and must not be assigned other clinical duties when on duty for the ICU. A medical practitioner (medical officer, registrar, specialist trainee) with no other clinical duties must be immediately available to attend to emergencies in the ICU at all times. At least a core of these medical staff should be permanent staff members in the ICU.

In hospitals without a doctor on site (including many private hospitals), an alternative would be to have an appropriately trained emergency care practitioner (or equivalent) on site who could provide the above-mentioned emergency management in the ICU.

While formal doctor-patient ratios are difficult to mandate, excessive doctor-patient ratios should be avoided to prevent risks to patients and medical personnel themselves. The minimum doctor-patient ratio needs to be determined for each unit and will depend on caseload, patient complexity, patient acuity and the experience of the medical personnel. The doctor to patient ratio should allow for adequate time away from the ICU and prevent excessively frequent night calls and should allow for the performance of the other non-clinical tasks required of medical personnel. The Critical Care Society of Southern Africa (CCSSA) may be approached to provide a recommendation on doctor-patient ratios for specific units. In general, one doctor should not be primarily responsible for > 6-8 Level 3 ICU patients at any one time, however, a doctor may supervise the management of up to 12-16 patients who are also being cared for by other practitioners. In the public sector/an academic unit a ratio of 1 medical officer or registrar to 8 patients is the maximum recommended ratio per shift. This may be reduced to 1:6 depending on patient complexity/acuity of illness. A ratio of one consultant to 12-16 patients (depending on complexity and acuity) per shift should not be exceeded. All non-intensivist consultants require a supervising intensivist. Junior and senior rosters should ensure adequate rest periods/off call periods and cater for annual leave, sickness and maternity leave and all administrative and academic duties.

Nursing personnel: Level 3 ICUs must have a registered nurse with formal critical care training as the nursing director. A registered nurse with formal critical care training must be rostered for each shift. The ratio of nursing staff to patients rostered for each shift should not be less than 1:1 for ventilated patients or less than 1:2 for non-ventilated patients. More intensive nurse to patient ratios may be required in patients with high nursing workloads e.g., patients undergoing CRRT or ECMO. Alternatively nursing ratios may be determined by established tools such as the Nursing Activities Score or Therapeutic Intervention Scoring System (TISS-76) using evidence-based cutoffs as long as the ratios are not less than the abovementioned ratios ^{(18, 19)}. All nurses in a Level 3 ICU must be registered nurses with ICU experience.

Multidisciplinary team: A Level 3 ICU must have regular input from relevant members of a multidisciplinary team, including dieticians, microbiologists, pharmacists, physiotherapists, occupational therapists and speech therapists. Physiotherapists should be available seven days a week to provide urgent physiotherapy. Daily input from a clinical microbiologist and dietician is strongly recommended. A clinical microbiologist or infectious disease specialist should provide regular alerts on drug-resistant organisms and reports on antimicrobial susceptibility profiles that are relevant to the unit. A dedicated clinical technologist should be assigned to the ICU. A psychologist should be available to provide psychological support to patients, family, or staff members as required.

Administration: A Level 3 ICU must have established administrative and clinical protocols and engage in quality improvement projects.

Research: A Level 3 ICU should be engaged in critical care research.

Education: A Level 3 ICU must ensure staff receive appropriate CPD training and should provide in-service training to other areas of the hospital as required. In addition, a Level 3 ICU must serve as a training centre and offer critical care training to nursing staff, specialist registrars and subspeciality trainees.

Referral: A Level 3 ICU acts as a regional referral centre for complex critically ill patients.

Outreach/Integration: A Level 3 ICU should offer assessment and support services for critically ill patients in the hospital and should offer post-ICU follow-up and support.

Surge capacity: A Level 3 ICU should have contingency plans in place to provide or coordinate expanded critical care services in the event of a natural disaster or pandemic.

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Critical Care Society of Southern Africa Guidelines for the Provision of Critical Care Services in South Africa - Critical Care Society of Southern Africa - Version 1: July 2022