Neobook — clinical reference

Bed numbers

The number of critical care beds required in a hospital or per capita is not clearly defined and is influenced by many factors. The recommended number of ICU beds per hospital varies according to the level of hospital and the services offered at the hospital. In general, the following targets for critical care beds are recommended:

District hospitals: 1% of beds
Regional hospitals or equivalent: 3-5% of beds
Tertiary hospitals or equivalent: 8-12% of beds

The distribution of these beds will vary by hospital, but the following general principles should apply:

District hospitals: all beds are Level 1 ICU beds
Regional hospitals: 2/3 of beds are Level 1 ICU beds and 1/3 are Level 2 beds
Tertiary and Central hospitals: 2/3 of beds are Level 1 ICU beds and 1/3 are Level 2 and 3 beds

With respect to ICU beds per capita, the number of ICU beds in the public sector needs to increase. A reasonable target would be 5-8 beds per 100 000.

An ICU of less than six beds is unlikely to be resource effective and it may be worth consolidating smaller units into larger referral units.

It must be noted that optimising ICU bed utilisation is as important as increasing ICU bed capacity in terms of delivering quality critical care services to a patient population. In this regard, intensivist run ICUs and equitable admission and discharge criteria will improve utilisation of current ICU beds. An ICU bed occupancy of >80% in an intensivist-run unit suggests that ICU bed capacity for that institution is inadequate and should be increased. A recommended bed occupancy in ICU is 70-80%. This allows for effective surge capacity. An increase in ICU bed capacity may be warranted even in settings with apparently optimal bed occupancy. In these settings’ optimal occupancy may be due to strict triage decisions, and thus, the ICU director must periodically be consulted regarding increasing ICU bed capacity as this may allow the director to relax stringent triage criteria and expand critical care services.

ICU design

General

Details of ICU design are available in documents such as the Infrastructure Unit Support Systems (IUSS) Health Facility Guide for Adult Critical Care of 30 June 2014. Specific issues and requirements are highlighted below.

When developing new critical care areas or renovating existing critical care areas, an intensivist must be included in the design team.

New critical care areas should meet current IUSS standards. When renovating existing critical care areas, attempts should be made to meet IUSS standards, and where not feasible, this must be justified and approved by the intensivist on the design team.

New ICUs should ensure that provision is made for natural lighting in the unit during the day. Daylight is important for both patient and staff wellbeing.

All appropriate fire and other safety regulations should be adhered to. Furthermore, an evacuation route able to accommodate the patient’s bed, accompanying staff and life support systems must be incorporated into the development of an ICU.

Non-clinical areas

The entrance to the ICU should be accessed controlled. There should ideally be separate visitors and patient/staff entrances and separate clinical and supply entrances. Access control systems should utilise proximity sensors rather than systems that require physical contact.

A visitor waiting area should be provided either before or after the access control. This should include 1.5 seats per ICU bed. Visitors should have access to restroom facilities.

A counselling room should be available within or in close proximity to the ICU. This must be private and provide a conducive environment for counselling of family members.

Adequate rest facilities should be available to staff members in close proximity to the ICU. These include “tearooms” for breaks and doctors call rooms where the ICU model requires a full-time on-site doctor.

Designated areas with adequate privacy should be available for staff to complete administrative tasks.

Office space should be available in proximity to the unit for senior staff e.g. nursing manager, medical director, permanent consultant staff.

Clinical care areas

The clinical care area may be “open plan” where beds are separated by curtains or may consist of individual cubicles separated by permanent partitions. Whichever design is chosen, provision needs to be made for both patient privacy and to allow for clear visibility of the patient and monitors from the nursing station when privacy is not required. One nursing station is required per “pod” of 8 beds (as a minimum).

Bed space

A Level 1 ICU requires a minimum bed space of 3.5 x 4.5m, a Level 2 ICU 4 x 5m, and a Level 3 ICU 5 x 5m per bed. The space should allow for all necessary equipment to be placed at the patient’s bedside; for clinical staff to be able to access the patient from all sides (including the head end of the bed); for diagnostic radiology procedures to be performed, for five staff members to be able to access the patient during an emergency; and to allow for adequate infection prevention and control practices. The floor to ceiling height should be at least 3m. The ceiling must be adequate to support the weight of devices/pendants that are to be mounted to the ceiling.

Single bed areas or so-called “isolation cubicles”: A Level 1 ICU should have at least 1 single bed area per 12 beds and Level 2 and 3 ICUs should have at least 1 single bed area per 6 beds. These cubicles should have a dedicated hand basin within the cubicle. In general, these single rooms will be used to separate patients with potential or confirmed infectious diseases from the rest of the ICU. In this case, these single rooms should have negative pressure ventilation. If the rooms are being used to isolate patients from potential infectious diseases (e.g. immunocompromised or burns patients), the single rooms should have positive pressure ventilation at a higher pressure than the exterior of the room. The single rooms should have “no-touch” sliding glass doors. As with all single rooms in the ICU, ensure that there is adequate visibility into the room and provision is made for patient privacy when required. A true “isolation” room will require an anteroom with one door between the exterior and the anteroom and a second door between the anteroom and the isolation room. The anteroom should have a sluice.

Ventilation

The main patient care area should have positive pressure ventilation in the range of 40 to 100kPa. Single bed areas should have negative pressure ventilation in Level 3 ICUs and where feasible, in Level 1 and Level 2 ICUs. General critical care areas should have at least six air changes per hour, while airborne infection isolation areas should have at least twelve air changes per hour. Airconditioning should be adequate to maintain a unit temperature between 24°C and 26°C independent of the external ambient temperature.

Toilets and disposal of bodily waste

Patients who are able to mobilise should have ready access to an enclosed toilet. All patient clinical areas should have ready access to a soiled utility room with a flushing rim sink for the disposal of bodily waste.

Hand basins

Hand basins must be readily accessible from every bed in the ICU to ensure adequate infection prevention and control practices. In an open-plan ICU there should be a minimum of 1 hand basin per 4 beds. In units with enclosed cubicles, each cubicle should have a hand basin. The hand basin should have elbow taps or no-touch electronic sensors controlling water flow. The tap must be high enough above the basin to allow for hand washing without accidentally touching the tap and without water splashing from the basin onto the person’s hands. The tap should not discharge directly over the drain outlet. Each basin should have a soap dispenser and a paper towel dispenser.

Lighting

Lighting must be bright enough to allow for adequate clinical assessment and management of patients. A minimum of 400 lux is required for clinical areas. Additional lighting of at least 10 000 lux must be available for procedures. Lighting in patient care areas must be dimmable to allow for patient rest/sleep periods. Adequate daylight should be available in all patient care areas and staff restrooms.

Services

A Level 1 ICU should have the following services for each bed:

2 oxygen outlets
1 medical air outlet
1 vacuum outlet
8 unswitched 15-amp socket outlets
An emergency nurse call system

The above may be mounted on the wall at the head end of the bed or on ceiling- or floor-mounted pendants. Strong consideration should be given to providing adequate data points at each bed to allow for connection to hospital information systems, even if these are not currently utilised in the institution. One water outlet and one drainage point for dialysis should be available for every 8 beds.

Level 2 and 3 ICUs should have the following services for each bed:

4 oxygen outlets
2 medical air outlets
2 vacuum outlets
14 unswitched 15-amp socket outlets
An emergency nurse call system

Electrical supply: All patient care areas, clinical areas, and areas where vital equipment (blood fridges, blood gas analysers) is stored should be fully covered by an uninterruptable power supply (UPS) with a minimum backup period of one hour. Furthermore, all the above areas should have generator backup to provide backup power for longer power outages.

Equipment

The following minimum equipment should be available: **TABLE DETAILS WILL BE INSERTED HERE***

	Level 1 ICU	Level 2 ICU	Level 3 ICU
Multi- parameter monitor	1.33/bed. Minimum requirements: 3-lead ECG, NIPB, SpO₂, 2x invasive pressure	1.33/bed. Minimum requirements: 3-lead ECG, NIPB, SpO₂, 3x invasive pressure	1.33/bed. Minimum requirements: 3-lead ECG, NIPB, SpO₂, 4x invasive pressure
Mechanical ventilator	1 transport ventilator or equivalent per 12 beds.	1.33/bed. Must include at least the following ventilation modes (or equivalent): VC-CMV, PC-CMV, SIMV-VC, SIMV-PC, PS, APRV, NIV. At least 50% of ventilators must include capnography.	1.33/bed. Must include at least the following ventilation modes (or equivalent): VC-CMV, PC-CMV, SIMV-VC, SIMV-PC, PS, APRV, NIV. At least 80% of ventilators must include capnography.
Transport ventilator	1 per 12 beds	1 per 6 beds	1 per 6 beds
MRI-compatible ventilator		1 per unit if MRI facilities available in the hospital	1 per unit if MRI facilities available in the hospital
Capnograph	1 per 12 beds	Optional	Optional
High flow nasal cannula oxygen devices	1 per 6 beds in general/surgical high care. 1 per 4 beds in medical high care.	1 per 6 beds or 16.7% of mechanical ventilators capable of delivering this modality.	1 per 6 beds or 16.7% of mechanical ventilators capable of delivering this modality.
12-lead ECG machine	1 per 12 beds	1 per 12 beds	1 per 12 beds
Defibrillator	1 per 12 beds	1 per 12 beds	1 per 12 beds
Emergency trolley	1 per 12 beds	1 per 12 beds	1 per 12 beds
Airway trolley with difficult airway equipment (may be incorporated into emergency trolley)	1 per 12 beds	1 per 12 beds	1 per 12 beds
Bag valve mask	1 per 6 beds	1 per bed	1 per bed
Volumetric infusion pump/syringe driver	4 per bed	10 per bed	12 per bed
Glucometer	1 per bed	1 per bed	1 per bed
Thermometer	1 per bed	1 per bed	1 per bed
Ultrasound machine	Optional	1 per 12 beds (with vascular and cardiac probes)	1 per 12 beds (with vascular and cardiac probes)
Advanced cardiac output monitor	Optional	Optional	1 per 6 beds
EEG	Optional	Optional	1 per 12 beds
Flexible bronchoscope	Optional	1 per 12 beds	1 per 12 beds
Intermittent haemodialysis machine (IHD)	1 per 12 beds	1 per 12 beds (either IHD or CRRT required but both preferable)	1 per 6 beds (both IHD and CRRT required)
Continuous renal replacement therapy machine (IHD)	Optional	1 per 12 beds (either IHD or CRRT required but both preferable)	1 per 6 beds (both IHD and CRRT required)
Extracorporeal membrane oxygenation	No	No	Optional
Arterial blood gas machine (at a minimum must include pH, PO₂, PCO₂, HCO₃/BE, Hb, lactate)	1 easily accessible	1 in unit (and easy access to another blood gas machine if required)	1 in unit (and easy access to another blood gas machine if required)
Point of care viscoelastic testing	Optional	1 easily accessible	1 in unit (with advanced coagulation monitoring capacity)
Emergency transport bag/box (a portable collection of resuscitation drugs and equipment that may be required during transport of critically ill patients). To accompany all critically ill patients during transport.	1 per 12 beds	1 per 12 beds	1 per 12 beds

*Ratios are a minimum. Higher ratios may be required depending on individual unit’s experience with equipment repair/replacement turnaround times.
**ECG: electrocardiogram, NIBP: non-invasive blood pressure, SpO₂: pulse oximetry, VC: volume control, PC: pressure control, CMC: continuous mandatory ventilation, SIMV: synchronised intermittent mandatory ventilation, PS: pressure support, APRV: airway pressure release ventilation, MRI: magnetic resonance imaging, EEG: electroencephalogram

Equipment should have a preventative maintenance plan and service certificates. Equipment manuals should be available for all equipment and training should be conducted by the supplier or appointed third party, with proof of training available on record. All equipment should be regularly checked as per a written unit protocol and the records of these checks should be maintained for at least five years.

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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