ICU Procedures Manual

ICU MANUAL
DDH CARE CARDIAC CENTER

VIDYANAGAR
DDH CARDIAC CARE CENTER ICU Manual
VIDYANAGAR Rev. 01, 01.08.2019
QMS: NABH
ICU Manual
REVIEWED BY APPROVED BY
NAME
DESIGNATION HOD, ICU Medical Director
SIGNATURE
REVIEW DATE
APPROVAL DATE
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Amendment Record & Revision History

The issue, distribution and control of this Manual are vested with the NABH coordinator.
Amendments to this Manual are incorporated by the Head of the Department and approved by
Medical Director / Chief Hospital Administrator.
All the controlled copies have to numbered & documented.
Any revision in the Manual or SOPs has to be informed to all concern and Signature has to be
documented
Designation & Version /
S. No Name Date Signature
Department Revision Info
Admission and Policy on Admission and
1 HOD, ICU
Discharge criteria Discharge criteria in ICU
List of Code Blue
2 HOD, ICU Code Blue Members
Members
BLS and ACLS
3 guidelines HOD, ICU
/Algorithm
ICU QA Quality Assurance
4 HOD, ICU
Programme Program for ICU
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Table of Contents
S. No Topic Page No.
1 Introduction 5
2 Level of Care in ICU 5
3 Infection Control Practices in ICU 7
4 Work Instructions 18
5 Cardio version 30
6 Unsynchronized Cardio version/Defibrillation 30
7 Lumen Usage 33
8 CPAP face masks 35
9 Drawing ABGs/analysis 35
10 Emergency intubation 37
11 Enteral feeding 38
12 Humidification - aerosol and nebulizers 39
13 Pulse oximetry 40
14 Removal of arterial line 41
15 Removal of central venous line 42
16 Tracheotomy dressing 44
17 Non availability of ICU beds
18 Quality assurance in ICU
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1. Introduction
1.1 Definition
An intensive care unit, or ICU, is a specialized section of a hospital that provides comprehensive
and continuous care for persons who are critically ill and who can benefit from treatment.
1.2 Purpose
The purpose of the intensive care unit (ICU) is simple even though the practice is complex.
Healthcare professionals who work in the ICU or rotate through it during their training provide
around-the-clock intensive monitoring and treatment of patients seven days a week. Patients are
generally admitted to an ICU if they are likely to benefit from the level of care provided.
Intensive care has been shown to benefit patients who are severely ill and medically unstable—
that is, they have a potentially life-threatening disease or disorder.
2. Level of care in ICU
The following three levels of care are recommended for the ICU
2.1 LEVEL I
Patient should be categorized as level I care if the following criteria are satisfied
 Monitoring – Continuous monitoring like CVP, invasive arterial line, arterial
blood gases, pulmonary artery (Swan Ganz) catheter
 Unconscious patient
 Patient on invasive/ non-invasive ventilator.
 Patient on inotropes (dopamine, dobutamine, adrenaline, noradrenaline).
 Patient on IABP – intra-aortic balloon pump.
 Patient on pacemaker.
 Patient – nurse ratio 1:1.
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2.2 LEVEL II (High Dependency Unit/ Step Down ICU)
Patient should be categorized as level II care if the following criteria are satisfied:
 Needing additional monitoring like CVP, invasive arterial line.

 Patient conscious, accepting oral or tube feeding (Ryle’s tube/ Jejunostomy tube) or
nil by mouth.
 Patient receiving medications through infusion pumps like – NTG, insulin, heparin,
analgesics, epidural infusions.
 Post-angioplasty, post surgical patients not needing ventilator support.
 Patient-nurse ratio 2:1
2.3 LEVEL III
Patient should be categorized as level III care patient if the following criteria are satisfied:
 On basic non-invasive monitor – ECG, NIBP, pulse oximetry.

 ICU stay < 12 hours.
 Patient conscious, accepting oral fluids/ diet.
 Not on infusion pumps for any continuous medication like NTG, inotropes, insulin,
heparin, etc.
 Post-angiography
 Patient nurse ratio 3:1
Note: C – PAP extra in all levels. The charges applicable are Rs.125/- per hour or Rs. 2500/- per
day beyond 10 hours of usage. Minimum charges will be R. 125/-
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3.0 INFECTION CONTROL PROTOCOL FOR INTENSIVE CARE UNIT:-

Components of Protocols
3.1 Care of the ICU
A) Role of ICU In charge
- Active in infection control committee
- Regular surveillance of infection trends
- Limit traffic in ICU
- Antibiotic policies and prevention of antibiotic abuse
- Training and awareness on part of all ICU personal
- Compliance with protocols by visiting consultants
B) General cleaning of ICU

a) Clean thrice daily
- Through machine cleaning once weekly
b) Clean with disinfectant
- Bacilloid (formaldehyde and Glutaraldehyde)
C) Dirty utility room

- Cold + Hot water and disinfectant availability
- Adequate dry stands and shelf space
- Cups, bed pans, urinals to be kept dry
D) Sterilizing solutions
a) For sterilizing airway equipments
- 2% Glutaraldehyde (cidex)
b) For cleaning contaminated material (sputum cups, bed pans, urinals etc)
- Hypochlorite (clicks) 5% solution
- 75 ml of this diluted in 12 lit. of water
- This gives 325 PPM of CL
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- Recommendation is 7100 PPM

- Checked for potency with Cl sticks
- Fresh solution prepared daily
3.2 Care of the bed space

a) Hand wash solution at each bedside
b) Separate AMBU bag, face mask and stethoscope per bed
- Clean with spirit for each new patient
c) Bed space cleaned before arrival of new admission
d) Bed cleaned with clicks for every new patient and SOS
e) Clean floor X 3 times daily (with bacillocid)
f) Walls cleaned weekly
g) Curtains (partitions) changed weekly
h) Curtains (windows) changed every two weeks
i) Linen changed daily + SOS
3.3 Hand washing solution

- Self drying solution
- Alcohol (70%) +/- Chlorhexidine (0.5%) i.e. sterilium or microshield
3.4 Care of patient contact

 Wash hands before patient contact
 Rewash when contact with
o Vascular catheter and its connections
o Tracheal tube and its connections
o ICP monitor
Stericath for tracheal tube suction
Plastic sheath for PAC, ICP and pacing wires
Change patients position regularly
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- Prevents hypostatic pneumonia, bedsores

Air bed if longer than 2 days of immobility
3.5 Doing a procedure

a) Separate trolly
- Do not move a common trolley from bed to bed
- Separate trolley cleaned and loaded before a bedside procedure is done
b) Surface cleaned with disinfectant
- Microshield or sterilium
c) Surface completely covered with a sterile drape
3.6 Insertion of vascular catheters

Insert all central venous and arterial catheters with full sterile precautions
a) Wide cover with sterile drapes
b) Mask, cap, gown, gloves (sterile)
c) Do not allow gloves, guide wires etc to get touch contamination outside the sterile
field
d) Cleaning solution : Chlorhexidine (2%) with alcohol (70%) or 10% Betadine
3.7 Protocols for prevention of infection associated with the use of vascular catheters
A) General measures to reduce risk of CRBSI (Catheter related blood stream infection)
1) Systemic antibiotics not to be used for the prevention of CRBSI
2) All vascular catheters to be removed when there is no clinical indication for their
continuation.
B) Hand hygiene
1) Strict hand hygiene with alcohol based hand rubs before and after every contact
with the patient
2) Hand hygiene is mandatory even with the use of gloves
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C) Central venous catheters

1) Site preference
a) Subclavian vein cannulation is preferred over jugular or femoral sites to
reduce risk of infection.
b) In the selection of site, weigh the non infectious risk (haemorrhage,
pneumothorax) against benefits of reducing CRBSI
2) Catheter material and type

a) Use polyurethane / Teflon catheters rather than PVC / Polyethelene
catheters.
3) Hand hygiene
a) Hand hygiene procedures must be followed strictly before and after every
contact with line or insertion site
b) For insertion of CVCs full scrub (up to the elbows) with an antiseptic
solution
4) Aseptic techniques
a) Maximum sterile barriers precautions for the insertion of CVC. (it
includes use of cap, mask, sterile gloves, full sleeved sterile gown, large
sterile drapes)
b) PA catheters / pacing wires should have a sterile protective sleeve.
5) Skin preparation
a) Aqueous alcoholic chlorhexidine (2%) to be used in preference to
povidone iodine for cleaning skin prior to CVC insertion
b) 10% povidone iodine is acceptable alternative
c) Allow antiseptic solution to dry before insertion of CVC.
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6) Dressing, types, frequency of change

i. Use either sterile gauze or sterile transparent, semi permeable dressing to
cover CVC site
ii. Gauze dressing to be replaced every 2 days or if moist loosened or soiled
iii. Transplant dressings to be changed every 7 days
iv. Topical antibiotic ointments or creams should not be used at insertion site.
7) Monitoring & Surveillance of site

a) When gauze dressings are changed, site must be inspected for purulence & erythema
& palpated for tenderness & indurations
b) In patients with transparent dressings, daily surveillance of the site should be
performed without the removal of the dressing
8) Systemic antibiotics –
o Not to be used to prevent colonization / CRBSI ( either prior to CVC
insertion or even during catheter maintenance )
o Anticoagulant flush / lock Heparin flushes and locks not to be used
9) Catheter Replacement
a) Routine (timed) replacement of CVC not be done (as a method of
infection control)
b) If fever is explained by another focus of infection or non
Infections cause, CVC should no be replaced
c) CVC, placed with less than maximal sterile precautions (in
Emergency) are to be replaced as soon as possible no later than
48 hrs after insertion
d) Replace CVC if CRBSI is suspected.
e) Remove catheters as soon as they are not needed
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10) Over the guide wire exchanges

a) Routine replacement of CVCs over a guide wire should not be done
b) A CVC may be changed over a guide wire to replace a malfunctioning
catheter or to convert existing catheter (eg. CVC to PA catheter or vice
versa), if there is no evidence of infection at the insertion site.
D) Arterial lines
1) Site – preferred sites are radial, dorsalis pedis and femoral artery.
2) Hand hygiene
Same as in CVC insertion
3) Skin preparation
Same as in CVC
4) Dressing, types, frequency of change
Same as in CVC
5) Monitoring and surveillance
Same as in CVC
6) Duration and catheter change
Arterial catheters can be left safely for 96 hrs
7) Selection and replacement of pressure monitoring system.
- Disposable transducer monitoring system is to be used
- Replace the entire disposable transducer system at 96 hrs interval.
- Replace reusable transducer systems every 48 hrs
8) Care of pressure monitoring systems
- Patency to be maintained using a closed continuous flush system
- Dextrose containing solutions not to be administered through the
pressure monitoring system.
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E) Short peripheral intravenous catheters

- IV cannula should not be inserted in lower extremity
- Antiseptic hand rub and clean gloves to be used
- Prepare skin with 70% alcohol
- Once prepared the site of insertion should not be palpated
- Daily palpation over the intact dressing at the catheter site for the signs of
phlebitis is essential.
- IVs are to be replaced after 96 hrs or earlier if signs of phlebitis, infection
and malfunction are present.
- Cap all stopcocks which are not being used
- Clean infection ports with 70% alcohol before access.
- Use of that chart which we are using should be mentioned.
3.8 A Protocol for hand hygiene

A. Routine hand hygiene
a) This process is mandatory for all medical, nursing and paramedical
personel who come in contact with the patient.
b) All such individuals should wash their hands and distal forearm with water
and 2% Chlorhexidine surgical scrub solution at the beginning of their
duty hours and after every break away from the unit.
c) No watches or jewellary must be worn during this wash. This wash must
last for a minimum of two minutes.
d) The hands must be dried with a sterile, dry towel or with disposable paper
tissue.
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e) The process must be repeated after any accidental, unprotected contact

with the body fluids of the patient.
f) A hand rub (with alcohol or chlorhexidine with alcohol) should

subsequently be used.
- Before and after every contact with the patient
- While moving from one bed to another
- While moving to common areas (refrigerator / store / telephone)
g) The hand rub is also required before gloving and after degloving for any
non procedural contact that involves handing off IV lines of fluids, blood
draws or contact with body fluids or wounds.
h) The use of gloves doesn’t preclude the need for the hand hygiene
techniques described above.
B. Procedural hand hygiene

a) This process is indicated before every procedure including but not limited
to central venous access, PA catheter and arterial line placements,
tracheostomy, ICD catheter placement.
b) The process is a full surgical scrub using running water and 4%

Chlorhexidine scrub solution from fingertips to elbows.
c) Care must be taken to ensure drainage of water away from the finger and
hands, towards the elbows.
d) No watches, rings or jewellary must be worn during the scrub.
e) The scrub to be performed for a minimum of two to three minutes.
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f) Hand drying should be only with the use of sterile (autoclaved) towels.
g) This scrub always proceeds gowning and gloving for the procedure.
3.9 Replacement of Administration sets, needle less system and parenteral fluids.
I. Administration sets
A. Replace IV administration sets including secondary sets and add on devices at 72

hrs intervals, unless CRIBSI is suspected or documented.
B. Replace tubing used to administer blood, blood products or lipid emulsions.

(Those combined with amino acids and glucose in a 3 in 1 admixture or infused
separately) within 24 hrs of initiating infusion.
If the solution contains only dextrose / amino acids, the administration set does
not need to be replaced more frequently than every 72 hrs.
C. Replace tubing used to administer propotol infusions every 6 or 12 hours,

depending on its use, as per the manufacturer’s recommendations.
2. Needle less intravascular devices

Replace intravenous plastic cannulas every 96 hrs or earlier if there is evidence
of phlebitis / infection
3.10 Care of indwelling devices

- Appropriate sterile precautions for insertion
- Wash hands before and after contact
- Minimal disconnection
- Protective plastic sheaths if appropriate
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- Appropriate dressing and care protocol

- Avoid routine changes of
 Vascular catheters
 Urinary catheters
 Tracheal tubes
 ICP catheters
3.11 Care of external devices

1. Care of intravenous infusion sets
1) TPN through dedicated port
2) Fluids, drug infusions changed after 24 hrs
3) Infusion set changed every 24 hrs for TPN and every 3 days for other fluids
2. Care of transducers
1) Use of disposable equipment
3. Ventilator circuit
1) Ventilator and tubing
- Disposable circuits
- No routine change of circuit, catheter mount or stericath
2) HMEF at connection for all patients

- HMEF to be changed 24 – 48 hrs.
- HMEF not to be removed from circuit except at time of changing
3) MDI’s may be better than nebulizers

- In line port of space preferable
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3.12 Preventing Endogenous infection

1) Daily awakening with sedation break
2) Early weaning and extubation with established protocol
3) Semi recumbent position for all ventilated patients and those who are on feeding tube.
4) Early external nutrition
5) No use of TPN / PPN unless justified
6) To maintain euglycemia
3.13 Prevention of VAP

1) Orotracheal intubation route should be used when intubation is necessary
2) New ventilatory circuit for each patient and changes if the circuit becomes soiled. But no
scheduled ventilator circuit changes.
3) Use of HMF filters in patients who have no contra indication, instead of heated
humidifier.
4) Use of closed endotracheal suction systems that are changed for each new patient and as
clinically indicated.
5) Kinetic beds to be used
6) Use of semirecumbent positioning with a goal at 450 in patients without contraindication.
7) Use H2 blockers / PPI instead of sucralphate for stress ulcer prophylaxis.
8) No oral / IV antibiotics to be used for prevention of VAP.
9) Mention about ventilator bundle chart.
3.14 Protocols for other procedure

e.g. Tracheostomy
ICD placement
Infection control protocols are same as that of CVC insertion
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3.15 PROTOCOLS FOR SHOE REMOVAL

All ICU staff should wear ICU slippers
Consultants also should remove shoes while entering in ICU
Same rule applies to relatives
4.0 Work Instruction
4.1 Work instruction – Taking Consent for treatment / procedure / surgery:

1. Make the patient comfortable
2. Explain procedure to patient he / she will be undergoing along with the relatives write
Age, sex, IP No. date of admission diagnosis of patient, name of consultant,
procedure to be done Handover all the ornaments & valuables to the relative with
signature in valuable handover form take signature of patient, relative with name &
relation Signature of staff who is explaining as a witness
3. File the consent form in patient’s file
4.2 Work instruction – Recording Vital parameters
1. TPR
T – Temperature in Fahrenheit
P – Pulse per minute, with rhythm & volume
R- Respiration per minute
2. B.P – Blood pressure in mm / hg
3. Enter all vital parameter in respective chart
4.3 Work Instruction – Medication Chart

1. On Duty doctor prepares the medication chart for the patient.
2. Indent the medicines in the medication chart nursing module.
3. Give the medicines to the patient in right time, through right route
4. Make an entry in the medication chart & the nurse’s record about the dosage & time
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4.4 Work Instruction – Nurses Notes

1. Write all the particulars of the patient with date
2. Time of receiving the patient with condition
3. Write the vital parameters in each shift
4. Any verbal/ written instruction carried out to be written with time & date
5. Any investigation carried out in / outside the hospital or pending investigation is to be
recorded in the notes.
6. Sign the process during Handing over.
4.5 Work instruction – Pre operative procedures

1. OT booking form is filled by on duty RMO & sent to OT.
2. Vitals are checked and noted down in the file.
3. Handover patient’s ornaments (white/yellow) or any valuable things (Dentures,
spectacles etc.) & signature of the relative are taken in valuable handover form.
4. Before transferring the patient to OT / cathlab confirm about the schedule of the
surgery.
5. Transfer the patient with file, necessary documents, medicine / blood.
6. On duty sister accompanies the patient to OT / Cathlab and will handover the
patient to OT staff/ nurse.
7. SHAVING – The area to be incised needs to be shaved, preferably on the day of
surgery.
8. Patient scalp hair needs to be capped by a disposable cap before shifting to OT
4.6 Work Instruction – Method for DISCHARGE
1. All case sheets shall be completed and discharge cards prepared before discharging
patients. Written order for discharge is a MUST.
2. A written order for discharge against medical advice should be obtained.
3. Pharmacy Clearance to be obtained before billing process
4. Check the status of discharge summary with the PREs.
5. send the patient file to billing department
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6. Check the check out slip, handover the patient file to relative
7. Take signature from relative in admission register in remark column
4.6.1 Discharge Process of DAMA
1. Patient & relative asks for discharge without the approval of consultant.
2. On duty RMO informs the consultant & takes DAMA consent form is taken from
patient’s relative
3. On duty RMO explains the condition of patient & informs about the consequences
patient may face in future without medical supervision.
4. DAMA consent form is attached to the Medical Records file (hospital file)
5. Follow discharge process as per 4.6
4.6.2 Discharge Process of Expired Patients
1. In case of death, the resident doctor shall issue death declaration certificate in triplicate.
2. The consent of the relative is also attested in the Death Declaration certificate.
3. The certificate is signed by the resident doctor and a copy is given to the relative.
4. One copy is sent to the municipal authorities for their records
5. Follow the discharge process as per 4.6
6. Handover the patient body to the relative
4.7 Work Instruction - Nursing In Intensive Care Unit

1. IP reception PRE / Ward sister informs the ICU staff about the patient.
2. Information about the patient is given to on duty RMO
3. Patient is received in ICU by on duty nurse and transferred to bed immediately.
4. Patient is settled down in proper position.
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5. Nurses to monitor the patient condition form time to time shall inform the consultant/
resident doctor when required.
4.8 Work Instruction - Method for Initial assessment of patient in ICU

1. On arrival, all routine investigations are done.
2. For patients admitted for any Invasive procedures like Broncos copy, CAG, HbsAG
& HIV- ELISA is done.
3. History & clinical examination is done by the duty doctor.
4. Working diagnosis is made and treatment is started
5. Condition of the patient is assessed & decision taken whether patient needs intensive
care management or ward.
6. The consulting physician assesses the patient within 2-3 hours of admission in ICU
7. Decision regarding the diet of the patient is taken by the dietician on admission and
accordingly informed to the patient’s relatives.
4.9 Work Instruction - Preparation of Patient file.
 Nurse shall record the services done as per the instruction of the consultant in the activity
chart and billing record which shall include
 Data Sheet for Consultant Visit
 Data Sheet for Diagnostics
 Data Sheet for Pharmacy
 Data Sheet for Billing Miscellaneous Services
 The course of treatment, observation and progress time to time is written by the
consultant / Resident doctor in the Case Sheet.
 Lab and Diagnostics reports to be received by the respective wards, and to be kept in the
case sheet record, for verification and observation by the consultant.
 Nurse shall write in the activity chart patients bed transfers form ward to OT or ICU.
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 Pertinent Records
1. Case Sheet 4. Pharmacy/Drugs Tariff
2. Diagnostic Tariff 5. Doctor Duty Roster
3. Consultant Tariff
References
1) In-Patient data Form 2) Requisition form 3) Indents
4) Registration form 5) Admission form 6) Nurses Record
7) Activity Chart 8) Clearance for drugs & disposable 10) Hospital Billing
Record
11) Discharge Summary 12) Consolidated Billing Statement
13) Death declaration certificate
4.10 Work Instruction – Method for shifting Patient
4.10.1. Method for shifting of patient from ICU to Wards:

i. Consultant informs to shift the patient.
ii. Ask the room preference to the patient’s relatives. Check for the availability of the
room and ask the PRE to show the room opted.
iii. Inform the concerned ward about the patient shifting and bed preparation.
iv. Check all the entries in the patient’s case sheet, billing record and entries in the
system.
v. Transfer the patient from the system.
vi. Transfer the patient to the respective ward with a ward boy.
vii. Give hand over of the patient to the ward staff nurse along with the current
medication and other instructions.
4.10. 2 Method for shifting patient from wards to ICU
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i. Monitor the patient as per the protocol.

ii. If any irregularity in patients condition, immediately inform the RMO.
iii. If the condition of the patient is critical, and ICU shifting is required (according to
the instructions of the Consultant or RMO), shift the patient immediately.
iv. Check that all the entries in the patient’s case sheet and system are correct.
v. Transfer the patient from the system.
vi. Give complete handover of the patient to ICU staff nurse along with the current
medication and other instructions.
4.11 Work Instruction -DEATH CARE
4.11.1 Care of the Dying & Dead
- To care for patient who has expired and the after care of the body before leaving the
hospital with consent of the attendants.
- To prepare the body.
- To show respect to the human body.
4.11.2 METHOD:
1. No preparation of the body is permitted until after the patient has been declared
dead by the doctor.
2. Notify the attendants and allow them to see the body.
3. Straighten the body, place in dorsal position and remove pillows. Insert dentures
(if any) and clean eyes. Place a small piece of damp cotton on the upper lid to
keep the eyes closed.
4. Remove all catheters and appliances.
5. Remove gown, sponge the body and arrange the hair neatly.
6. If the patient has a discharging wound, put on a clean dressing.
7. Prevent the jaw from falling by holding a bandage around the chin and tying it on
the top of the head.
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8. Pack the body cavities with cotton – rectum, nose and vagina, as far as possible
out of view.
9. Remove any casts or splints, cover patient with a sheet.
10. Attach a label of sticking plaster with the Patient’s Name, Room No. and IP No.,
date and time of death to the body/sheet.
11. When the relatives come for the body ask them for a sheet so that it will not be
necessary to take the hospital sheet. If the hospital sheet is used to cover the dead
body, billing department to be informed.
12. Before releasing, ask the patient’s relatives to sign the necessary documents and a
copy is kept with the hospital..
13. Record the time that the patient is pronounced dead, by whom and notification of
the
Attending doctor.
14. Death certificate to be prepared by the attending doctor.
4.11.3. Management of Patients Following Death:

1. Patient to be examined by Senior Resident on duty and confirmed dead.
2. Certificate of death is signed; date and time of death are written.
3. Relatives, if not present are to be notified of patient’s deterioration and advised to
come to the hospital. Not to be told of death over telephone except in situations
where this is being awaited. Try and obtain autopsy permission.
4. Relatives are to be seen by Senior Resident on arrival at hospital.
5. Patient is shown to the relatives after the death is declared. All belongings are
handed over to family members.
6. Patient is to be attended to in the following manner:
7. All tubes, drains, I.V. lines to be removed.
8. Orifices to be packed only if necessary.
9. Ankles and toes to be tied together with bandage.
10. Wrists to be tied together with bandage over the chest.
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11. Chin to be neatly tied.

12. Body packed in a clean sheet.
13. Labels to be stuck in the following positions:
14. Over the right wrist and,
15. Over the packing, mentioning name, age, sex, I P no., date of admission, date and
time of death, ward & bed number.
16. Body is transferred to mortuary by ward boys.
17. Death certificates are sent with the body.
18. Death is notified to the hospital authorities.
19. In M.L.C. cases, police constable on duty is to be informed and copy of death
certificate to be forwarded to him.
4.12 Work Instruction – Method for HIV & HbsAG Positive Cases:
1. Receive the patient in comfortable Bed
2. Check & record vital Parameters
3. Carry out the doctor’s instruction
4. Send all investigations according to hospital protocol
5. Wear gloves & take sample
6. Send the specimen to pathology
7. Keep cap, mask, gown, outside the patient’s room
8. Separate all the equipments that is been used for patient care in the room itself
9. Dispose all the waste according to Biomedical Waste protocols & label the bag with
colour coding
10. Linens used for the patient to be soaked in 1% hypochlorite solution for 10 minutes
for disinfecting
11. Wash the linen in clean water, put in the colour bag and send it for washing.
12. If there is blood spills pour 1% hypochlorite solution in to the blood spill, keep it foe
10 min & then mop the area & destroy the mop.
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13. All the staff caring for the patient must use disposable cap, mask & gloves during any
procedure.
14. During operative procedure, all disposable items are used and discarded in a separate
bag & 1% hypochlorite solution is poured in that bag.
15. In case of needle prick injury during nursing care, immediately inform nurse
Superintendent & infection control doctor.
16. Patient should be provided food in disposable Plates.
17. All the instruments used for the operation are soaked in 10% Hypochlorite solution
for 24 hrs, then cleaned & packed followed by double autoclaving.
4.13 Work Instruction – Method for Medico Legal Patients

1. Receive the patient in Comfortable bed.
2. Nursing will be informed about the medico legal status of the patient by PRE
3. Patient file to be labeled as MLC
4. Injury report will be sent to police station
5. MLC report will be made by on duty RMO
6. During Discharge patient will be given only the photocopied discharge summary &
photocopied investigation reports if asked by patient
7. X-ray files & all investigation reports will be kept with the hospital as record
4.14 Work Instruction for fumigation: OT / ICU Fumigation Plan

1. Clean & wash the area thoroughly (as per 4.20 Cleaning OT – after procedure)
2. close all the windows, ventilators, doors & services
3. Add 150 gms of potassium permanganate to 280 ml of formalin for 1000cubic feet
area
4. Calculate the desired amount of fumigation as per the size of the Operation theatre &
ICU
5. Areas of the OTs & ICU are as follows
 G OT 1 – 264 sq feet ,
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 G OT 2 – 360 sq feet,
 CT OT – 420 sq feet,
 Neuro OT – 420 Sq feet ,
 ICU – 1700 sq feet
 Labour Room – 225 sq feet
6. Place the bowl in the centre of the room.
7. Hours of fumigation
routine fumigation – 24 hrs
New construction of OT/ Renovation – 48 hrs
If fumigation by fumigation apparatus, (Automist) – 12 hrs
8. Subsequent to fumigation, before opening start the exhaust fan to remove vapors and then
open the OT
9. Weekly fumigation to be done in OT , ICU – as required (if patients are less in No. 1/2
patients
10. If there is any infected case operated OTs to be fumigated
11. If the report comes positive re fumigation to be done till the time report is negative
4.15 Work instruction for collection of Swabs: - Swab collection after fumigation
1. Change the uniform, wear cap, mask & gown
2. Collect the swabs from the following sites
a. OT
b. Overhead table,
c. Overhead Lamp
d. Boyle’s apparatus
e. Instrument Trolley
f. Floor near the OT table,
g. AC Duct
3. Swabs are collected one for aerobic culture and the other for clostridium tetani.
4. Send them to laboratory after labeling them properly
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5. If the reports are positive OT must be re-fumigated
4.16 Work Instruction for Vasofix: - To incorporate Vasofix

1. Disinfect your hand with sterlium
2. Clean the area with spirit
3. Wait for the spirit to dry,
4. Open the vasofix,
5. Do not touch the tip of the cannula
6. Insert the cannual in to the vein,
7. Fix the vasofix with dynaplast
8. Flush the vasofix with normal Saline
9. Cork the vasofix, write the date on which it was incorporated with a sticker
10. Change the vasofix after 72 hours / SOS if redness / swelling appear at the tip.
4.17 Work Instruction for usage IV Set:-Process for IV Set Usage.

1. Disinfect your hand with sterlium.
2. Open the new IV Set; Write the date of incorporation on the set.
3. Incorporate it into the IV bottle; expel the air out of the tubing.
4. Fill up the fluid chamber 3/4th & connect with the vasofix.
5. Let the fluid run according to the instruction of the doctor.
6. If the fluid is continuously running for 48 hrs, IV set can be used for 48 hrs.
7. If the medication to be given TDS change the IV set on the next day.
8. Whenever the set is changed the date must be written on the set.
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4.18 Work Instruction: Air viva/laerdal bag assembly and cleaning
STANDARDS:
* All registered nurses working in ICU/CCU familiar with and competent at assembling
laerdel bag and heads, can assemble and dismantle the equipment prior to and after cleaning.
* Safety for patient by the correct assembly of laerdel head and bag.
* Prevention of contamination of laerdel unit during assembly.
* Clean hands by washing.
* Use clean technique and assemble on cleaned bench in respiratory room.
* All assembled units to be checked by 2 registered nurses to prevent error in assembly and
promote patient safety.
EQUIPMENT:
Laerdel head (spare units are stored in respiratory room after assembly, on return from
CSSD.
PROCEDURE:
* Assembly of parts may be viewed (in photography) in respiratory book.
* All air-viva laerdel heads to be sent to CSSD for cleaning after patient transferred from
ICU or extubation.
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1. Cardioversion
INTRODUCTION: Synchronised Cardio version:
INDICATIONS:
- Atrial fibrillation
- Atrial flutter
- Atrial tachycardia
- Supraventricular tachycardias
2. Unsynchronised Cardio version/Defibrillation:
INDICATIONS:
- Ventricular tachycardia - compromising
- Ventricular fibrillation
both compromising causing loss of consciousness.
STANDARDS:
* Management and care of cardioversion procedure is to be undertaken by:
- Medical officers of either ICU.
- Procedure should be carried out by authorised medical personnel.
* Should be done under close monitoring continuous ECG and recording facilities.
* Elective Cardioversion requires an anaesthetist and anaesthetic agents, laerdel bag and oxygen
equipment to maintain airway with induced unconsciousness.
* The defibrillator should be checked prior to use and the emergency trolley should also be
checked and placed in patients room.
* Ensure patient has been on NBM for 4-6 hours prior to elective cardioversion.
* Ensure patient has an IV cannula.
* Ensure a recent 12 lead ECG is available and recording of a baseline observation.
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* Patient should have procedure explained to them by medical officer and in elective
cardioversion a consent form signed.
* All cardioversion being elective are to be attended in ICU or CCU.
OUTCOMES: The procedure will be terminated either by a successful reversion to sinus rhythm
or when the medical officer determines that cardioversion will not revert the rhythm.
SPECIAL CONSIDERATIONS:
In elective cardioversion the delivery of a synchronised external electrical impulse via the chest
wall in order to revert an arrhythmia to sinus rhythm. The current is delivered at a pre-
determined point in the cardiac cycle (the peak of the R wave) so as to avoid discharging during
the relative refractory stage of the cycle (the end of the T wave), as this may result in the
development of ventricular fibrillation.
EQUIPMENT:
Defibrillator with a synchronising button Emergency trolley with emergency drugs; lignocaine
atropine and adrenaline
Intubation equipment
Oxygen mask, laerdel bag - Guides airway
Hudson mask
Monitor and continuous recording facilities
PRE PROCEDURE:
PATIENT PREPARATION:
* Baseline observations - BP pulse and ECG for post procedure comparison.
* Be aware of the patients serum K+ level or whether the patient has been digitalised. Notify
medical officer.
NB: Digitalis is usually discontinued 24-36 hours prior cardioversion; its presence may result in
an increased risk of cardioversion induced arrhythmias.
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* Ensure patient IV access.

* The patient is connected to the monitoring function of the defibrillator baseline rhythm
recorded; Lead selected for recording, Lead II.
PROCEDURE:
* The anaesthetic agents are chosen by the Anaesthetist; short acting general anaesthetics. The
patient will require recovery nursing care.
* Once the patient is anaesthetised get gel pad interface or defibrillator pads are applied to the
chest. The correct positions are to the right of the upper sternum for the sternal pad and paddle
and between the left midclavicular line and the left mid axillary line for the apical pad and
paddle.
* Place defibrillator paddles over the gel or defibrillator pads apply 10-12kg of weight; charge
machine to the joule level selected by the medical officer. Commencement at 50-150j increasing
to 300-360j.
* Ensure bed is clear; no one is in contact.
* Press the discharge buttons and maintain pressure on the paddles for one second following
electrical discharge.
POST PROCEDURE:
* The procedure will be terminated either by a successful reversion to sinus rhythm or when the
medical officer determines that cardioversion will not revert the rhythm.
* Ensure the patient’s airway is patent.
* Patient nursed in the left lateral position until fully conscious. Oxygen administration c/-
hudson mask.
* BP record immediately post procedure at 5 minute intervals for 15 minutes then 15 minute
intervals for 2 hours.
* A 12 lead ECG is recorded within _ an hour of the procedure.
* Documentation should include:
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- pre and post procedure ECG

- pre and post procedure rhythm strip
- pre and post procedure observations
- the number of shocks and joules used
- the condition of the skin following cardioversion
3. LUMEN USAGE
Proximal Blood Sampling
Medial Total Parenteral Nutrition (TPN)
Medication ( Only if TPN is not anticipated)
Distal CVP Monitoring
Blood Administration
High Volume or Viscous Fluids
Colloids
Medication
4 th Lumen Infusion
Medication
STANDARDS:
* Management and care of Central Venous Catheters (CVC) may only be undertaken by
Registered Nurses accredited to give intravenous medication and Registered Nurses
accredited to give intravenous medication may undertake training to care for CVC.
* Central Venous Catheter dressings must be changed at least every 72 hours or when dressing
becomes soiled.
* Area around catheter insertion site will remain free from any signs or symptoms of possible
infections.
* Area around catheter insertion site will remain aseptic to decrease chances of possible
infection.
* Any sign of infection or possible infection will be reported to the Physician for assessment at
the earliest possible moment.
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OUTCOMES:
* The area around the catheter insertion site is to remain infection free during the hospital stay of
the patient.
* If infection does occur, arrangement must be made with the Physician for earliest possible site
change to be carried out.
Patients with long term Central Catheters in place may carry out the procedures they
are familiar with under supervision of a qualified Nurse from DDH Cardiac Care Center,
while in hospital. Management of the Central Line by the patient must meet the standards set
down by Hospital.
EQUIPMENT:
Dressing pack x 1 Hansapor (wound dressing) 15 cm x 8 cm x 1
Hibitane solution
Rubbish bin
PROCEDURE:
* Explain procedure to patient prior to commencement.

* Aseptic preparation prior to commencing procedure.
* Prepare dressing pack at bedside prior to positioning patient.
* Place patient in supine position.
* Remove old dressing and check site for discomfort, redness, inflammation and/ or leakage of
fluids from around insertion site.
* Clean area around insertion site with Hibitane solution, allow area to dry before applying
Hansapor dressing.
* Label dressing with time and date of change.
* Record date and time of dressing change on flow chart.
* Note in patient's chart condition of insertion site and inform Physician of signs
of infection.
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4. CPAP FACE MASKS

STANDARDS: * All trained registered nurses working in the ICU/CCU will ensure that a clean,
correct sized mask is used for CPAP on each patient.
* Correct care and use of mask during the duration of patient's stay in ICU/CCU will minimise
risk of nosocomial infection.
* Correct use will maximise mask's usability for individual patient during ICU/CCU stay.
OUTCOMES: * The patient will experience no infection through contaminated mask.
* Progressive recovery from effective and correct use of CPAP mask.
EQUIPMENT: * Sizes available - large and medium.
* Each mask will stay with the patient for duration of stay in ICU/CCU or duration of CPAP
therapy. On discharge/transfer mask is disposable.
* Mask cushion is made of soft silicon for comfortable fit.
PROCEDURE: * During fitting of mask, explain to the patient aim of treatment and that the
mask can easily be removed.
* Place mask for optimal comfort and effective CPAP.
* Single Patient Use Only - Kept at bedside until patient is discharged or transferred from unit.
- Replace if mask cushion hardens or tears, air leakage increases around mask, the valve
dysfunctions or O2 ports block with patient secretions.
5. DRAWING ABGs/ANALYSIS
STANDARDS:
* All registered nurses working in the ICU/CCU area may collect arterial samples from arterial
lines if familiar with the management of arterial lines.
* Radial puncture should only be attempted by registered nurses familiar with or experienced in
technique, or under supervision of same persons.
* Goals to be achieved are to obtain accurate and satisfactory sample without undue stress or
discomfort for patient.
* Prevention of contamination into arterial infusion/monitoring set.
* Minimise possible risk of haematoma formation.
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OUTCOMES:
* Maintenance of patient safety.
* Prevention of introduced infection in the critically ill patient.
PROCEDURE:
* Wash hands before collecting sample.
* Assemble equipment; blood gas syringe, swabs, 5ml syringe, gauze to evacuate blood line
onto.
* Swab area on and around port.
* Remove cap.
* Attach syringe and open line to air.
* Draw off line fluid and initial blood - approximately 5mls.
* Discard 5ml syringe after closing 3 way stop cock _ way to both air and patient.
* Draw off sample.
* Close stop cock to air.
* Remove sample syringe.
* Flush line.
* Close stop cock to patient and flush blood line into gauze.
* Discard.
* Close stop cock to air.
* Replace port cap.
* Sample should be taken to gas analysis machine at earliest possible moment, as results may be
altered.
* Agitate sample between palms of hands to mix blood and syringe content well before putting
sample into machine.
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* Samples that are being sent to the lab need to be transported on ice to prevent deterioration.
* Ensure correct labelling information is on blood sampling and form.
6. EMERGENCY INTUBATION (E. I.)
STANDARDS:
* Emergency intubation to be undertaken by the medical officer skilled in this procedure.
* Persons warranting E.I. must have a registered nurse in constant attendance.
* IV access made available.
* Cricoid pressure to be applied prior to intubation and removed only after cuff inflation.
* Cuff inflated to 200mmHg and no more than 30mmHg.
* Positioning of the ETT is verified by observing chest movement.
- Auscultation of the chest and stomach.
- Chest x-ray (reviewed by medical officer).
* ETT sizes ranging from 2.5mm to 9.5mm. Selection appropriate to patient size.
* Necessary drugs are prescribed and administered at medical officers request.
OUTCOMES: Patient airway available with means to maximise respiratory function.
EQUIPMENT: Oxygen
Suction
10ml syringe attached to buffered artery forcep
Laryngoscope
Magills forceps
Lubricant (H20 solution or L.A.)
1m white tape
Scissors
Geudel airway
R: 1.1
Laerdal resuscitation and mask
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Yankeur sucker
Drugs as ordered
Stethoscope
Leucoplast tape
PROCEDURE:
* Excess secretions/foreign bodies removed from oropharynx prior to procedure.
* Patient pre-oxygenated with 100% oxygen.
* Patient placed in supine position with adequate access to the head.
* Drugs prepared and available close to IV access.
* Manual of mechanical ventialtion comenced when ETT in situ.
* Record size of ETT and placement at the lips.
* Observe and record respiratory observations.
7. ENTERAL FEEDING
STANDARDS:
* Enteral feeding is ordered by medical officers.
* Trained registered nurses and medical officers may insert salem sump/fine bore gastric tubes in
the * * Radiological verification of tube position may be done before enteral feeding.
* Patients must be on a fluid balance chart whilst receiving enteral feeding.
* The tube must be securely anchored to the patients nose.
* The tube should be flushed with 10-20ml of H2O before and after administration of medication.
* Enteral feed giving set to be changed at 2000hrs daily.
EQUIPMENT: Enteral feeding bottle

Enteral feeding set
Enteral food solution and opener
Alcohol swabs
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Label for feeding bottle

Kangaroo pump
PROCEDURE:
* Check and verify type and rate of enteral feeds to be used. Check expiry date.
* Collect all equipment at bedside.
* Assemble feeding bag and lines.
* Verify feeding tube placement.
* Prime line and connect to patients enteral feeding tube; ensure tight connection.
* Attach label to bag detailing feed type, amount, patients identification and your signature.
8. HUMIDIFICATION - AEROSOL AND NEBULISER
o STANDARDS:
* Nebulisers to be ordered by medical officer and to be administered by a Registered
Nurse.
* Nebulisation of saline will be given same priority as any other prescribed medication.
* Nebuliser will be rinsed and left to dry following each use.
* Nebuliser mask will be fitted and medication must be administered in such a way as to
ensure a comfortable, efficient exercise.
* Nebulisation will be given with air or oxygen according to medical officer's orders.
OUTCOMES:
* Patient will obtain medication in a form that requires less coordination and effort.
* Patient will receive medication; saline to assist with bronchial dilatation and
expectoration of sputum.
EQUIPMENT: Nebuliser, mask and O2 tubing

O2 or air supply
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Medication or saline
PROCEDURE:
* Add prescribed medication to nebuliser.
* Attach nebuliser to mask and then attach mask to patient.
* Turn on O2/air to give fine mist.
* Remove when misting ceases.
9. PULSE OXIMETRY
STANDARDS:
* All registered nurses working in the ICU/CCU and general wards may record pulse oximetry to
assess respiratory function and oxygen therapeutical needs.
* Registered nurses using this equipment should have a basic understanding of pulse oximeters
and the need to obtain an adequate waveform.
* Pulse oximetry is a vital tool for providing continuous observation in a safe and non invasive
way.
* Goals to be achieved are to obtain accurate and satisfactory information from pulse oximetry to
asses in effective management of oxygen therapy needs.
OUTCOMES:
* Maintenance of adequate oxygen therapy and prevention of respiratory difficulty.
* Maintenance of patient safety.
PROCEDURE:
* Fingernail bed should be clean and free of nail polish.
* Probe light source should be place on finger or ear.
* Monitor visual and audible displays should be observed to assess if a strong pulse is achieved.
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* Use of oximetry increases patient safety both intra and post operatively.
* Falling percentiles in oximetry readings should be brought to the medical officers attention as
soon as possible to enable adequate oxygen therapy be maintained.
10. REMOVAL OF ARTERIAL LINE
STANDARDS:
* Arterial Lines are to be removed prior to transferring patients to the ward * Arterial Lines
sites should be rotated at least every seven (7) days or sooner if infection occurs
* Post removal Arterial Line site must be observed for bleeding, bruising and swelling
frequently over the next 24 hours
* Upon removal of the arterial Line, Universal precautions must be maintained to avoid
contamination of the health care worker through exposure to blood borne pathogens.
* Aseptic technique is used at the insertion site to decrease chances of infection to the patient.
OUTCOMES:
* The area around the catheter insertion site is to remain infection free during the hospital
stay of the patient.
* If signs of infection do occur, arrangements must be made with the Physician for earliest
possible site changed to be carried out.
* There will be no excessive blood lose, swelling or bruising post removal of Arterial Line
EQUIPMENT: Dressing pack x 1 Elastoplast dressing
PROCEDURE:
* Explain the procedure to patient prior to commencement.
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* Prepare dressing pack at bedside on over bed table prior to positioning patient.
* Remove armband and place arm on bed with dressing facing up.
If patient restless have second nurse to secure limb to avoid accidental removal of arterial line.
* Ensure pressure bag is clamped off to Arterial Line
* Remove old dressing and check site for erythema, drainage, tenderness, suture integrity and
catheter position.
* Clean area around insertion site with Hibitane solution.
* Remove sutures holding in Arterial Line. Protect against accidental removal of the Arterial
Line at this point to avoid unnecessary blood lose from artery * Place sterile gauze over insertion
site and apply pressure too site while withdrawing Arterial Line
* Pressure should be maintained at least 5 minutes over site to prevent blood lose and excess
bruising and swelling. * Longer periods of applied pressure will be necessary if the patient has
been anti-coagulated * Observer site and when bleeding and swelling have stopped remove old
gauze. Applied new sterile gauze over insertion site and secure with Elastoplast dressing. *
Continue to observe site for bleeding
* Chart that Arterial line has been removed time, date and condition of catheter. Chart condition
of patients’ skin i.e. swelling, redness or discharge
*ALERT*
Arterial Lines are a direct access to the patients arterial blood circulation hence if contaminated
in any way may lead to severe systemic infection.
11. REMOVAL OF CENTRAL VENOUS LINE
STANDARDS:
* Management and care of CVC may be undertaken by a registered nurse accredited to give
intravenous medication.
* Upon removal of the CVC, Universal precautions must be maintained to avoid
contamination of the health care worker through exposure to blood borne pathogens.
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* Aseptic technique is used at the insertion site to decrease chances of infection to the
patient.
* Dressing is to remain in place 24-72 hours according to lenght of time that catheter was in
place.
* Observe patient post removal for the following i.e S&S of bleeding, air embolism or
infection of at the site.
OUTCOMES:
* The patient will experience no infection through contamination of the CVC site during his
or her stay in LBH.
EQUIPMENT: Sterile dressing pack Air occlusive dressing i.e. tela gauze with antimicrobial
ointment
Hibitane solution one pair sterile gloves
Rubbish bin Sterile jar to collect catheter tip is infection is suspected
Stitch cutter for removing sutures Sterile scissors
PROCEDURE:
* Explain the procedure to the patient prior to procedure.
* Turn off all infusions
* Place patient in Trendelburg or supine position.
* Instruct patient to preform Valsalva maneuver or to hold breath on command.
* If tip of catheter to be sent for cultures have sterile equipement ready.
* If tip to be cultured prep skin around site with aseptic solution and remove catheter at 90
degree angle
* Remove suture holding in CVC while insuring CVC does not accidently migrate out.
Ensure all suture material has been removed.
* As catheter is removed ask patient to preform Valsalva maneuver or to hold breath.
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* Immediately cover area with sterile guaze to apply pressure to area.

* Cover the site with occulsive drsging while patient is still reforming Valsalva maneuver.
* Reposition patient.
* Chart that central line has been removed time, date and condition of catheter. Chart type of
catheter removed. Chart condition of patients’ skin i.e. swelling, redness or discharge.
12. TRACHEOSTOMY DRESSING

STANDARDS:
* The tracheal tube will be secured in the midline position.
* Aseptic technique to be used when changing tracheostomy dressing.
* Dressing to be changed for the first time 24hrs post procedure.
* Dressing to be changed thereafter once a shift or PRN when soiled.
* Tie tapes holding tracheostomy tube will not be secured so tight around neck as to occluded
patients circulation.
OUTCOMES:
* Complication of tracheal stenosis and erosion are minimised by securing the tracheal tube in
midline position.
* The patient tracheostomy site will remain infection free during his or her stay in hospital.
EQUIPMENT: Basic dressing pack Normal saline

2 pack sterile gauze 10x10cm 2 x _ in white cotton tape x 1m lengths
PROCEDURE:
* Explain the procedure to the patient prior to procedure.
* Suction patient (refer to Suctioning of patient with tracheostomy tube).
* Arrange for second nurse to hold the tracheostomy tube.
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* Remove old dressing and ties.

* Swab around tracheal stoma with normal saline until the area is cleaned.
* Fold sterile gauze squares in half and place on under each flange of the tracheostomy tube.
* Attach cotton tape to tracheostomy tube flange by passing doubled cotton tape up through
opening in flange then threading loose ends up through loop. The end result should have two
tails extending out from flange, one tail being 15cm of the one metre length. Repeat procedure
for the side of the flange.
* Threat the two long portions of the cotton tape behind the patients head.
* The long cotton tape are then to be tied to the shorter tied leaving at least a two finger space
between patient and tie tapes.
* Ensure patients comfort with new dressing.
* Test cuff press with cuffed tracheostomy tubes. Pressure should be <25cm H2O.
Non availability of ICU beds
In case of non availability of ICU beds , patents will be immediately transported in a Well
equipped ambulance to either “CARE Banjara” or “CARE Nampally”
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QUALITY ASSURANCE
QUALITY ASSURANCE PROGRAM IN ICU
S
Indicator Evidence Remarks Frequency
NO
Service level
Staff availability
(Doctors, Nurses & ICU QA (Nursing and doctor ratios as per
1 Monthly
Support) register International ICU criteria)
Average of time taken for ICU bed

Bed availability & ICU QA
2 to be re-occupied after patient is Monthly
Turnover time register
discharged from hospital
Number of discharges +deaths
ICU QA
3 Bed turn over rate during a period/Total number of Monthly
register
beds
Investigation Reporting ICU QA Average time taken for reporting of
4 Monthly
time register investigations (Test specific)
Total number of IP deaths during
ICU QA
5 Death rate period/Total number of discharges Monthly
register
+Deaths
Total number of days of all ICU
ICU QA
6 Average Length of stay occupants/Total number of Monthly
register
discharges +death
Total deaths (within 10 days of
surgery) /
Total number of patients who
Post operative death ICU QA
7 were operated on for the period Monthly
rates register
*100
Clinical level
ICU QA
8 % Medication errors AS per NABH QI Monthly
register
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Number of adverse drug ICU QA

9 AS per NABH QI Monthly
reactions register
% of case accidental
ICU QA
10 removal of tubes and AS per NABH QI Monthly
register
catheters
Incidence of haematoma ICU QA
at puncture site. register
ICU QA
12 % of transfusion reactions AS per NABH QI Monthly
register
Surgical site infection rate ICU QA
(Only in SICU) register
Respiratory tract infection
ICU QA
14 rate/ Ventilator AS per NABH QI Monthly
register
associated pneumonia
Urinary Tract infection ICU QA
rates register
Intravenous device ICU QA
related infection rates register
ICU QA
17 Incidence of Bed sores AS per NABH QI Monthly
register
ICU QA
18 ICU utilization rate AS per NABH QI Monthly
register
Number of re-admitted
ICU QA
19 ICU re-admission rate patients/Total number of patients Monthly
register
managed in ICU
ICU QA Number of patients re-intubated
20 Re-Intubation rate Monthly
register /Number extubated
Other measures
1)Patient received in ICU
 ICU staff informed about shifting of patient and nature of illness from
 ER
 OT
 Ward
 Direct ICU referral from outside hospital
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 Patient shifted into ICU as per ICU entry and exit protocols as present in the ICU protocols
manual
 Shifting of unstable patients done with appropriate support and monitoring measures as
per Hospital policy
 Handing over of patient with cross checking patient ID, patient file, reports, treatment
already given, and treatment to be continued
2) Initiating ICU treatment
 Patient connected to required monitors and organizing of requested lines and tubes –
patient settled comfortably
 Care of ventilated patient as per ICU protocols
 Patient treatment instituted as advised
 All systems’ examination done and recorded in case file – i.e. patient status on receiving
in ICU and preparation of ICU charts
 Patient status and treatment instituted recorded in Nurse’s notes
3) Continuing treatment in ICU
 Bedside monitoring of periodically as per ICU protocols

o Hemodynamic parameters
o Respiratory parameters
o Temperature
o Urine Output
o Drainage (from tubes)
o Blood sugar
 Entry made in patient ICU chart
 Entry of treatment given and nursing care recorded in ICU chart periodically as per ICU
protocol
 Informing other specialist doctors involved in treatment of co-morbid conditions
Routine care of patient is continued like

o Medications & feeds
o Giving IV fluids
o Tracheo bronchial toilet ( by Physiotherapist )
o Position change
o Patient hygiene
o Hydrotherapy
 Changing Dressing & line care
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 Supervising patient’s management and continuous evaluation of patient’s condition to

provide necessary curative care
 A blanket consent for procedures like central line insertion, endotracheal intubation,
Ryle’s tube and catheterization at the time of shifting into ICU and a separate consent for
specific procedures when deemed necessary
4) Investigations in the ICU
 Daily routine investigations as per ICU protocols

 Other investigations as written in patient case notes daily
 Investigations as per protocol are ordered the previous night, so that all
investigations are done early morning and results / reports available before 9 am.
 Investigations from ICUs given priority during the day also.
 Routine X ray films (done early morning) are made available in the ICU before xxx am
for consultant review. Previous days’ films are then sent back to Radiology for
reporting in the afternoon.
 Requisition form for the investigation filled
 Specimen collected and labeled
 Specimen sent to respective labs as soon as sample is ready
 Requisition for Radiology investigation filled out sent to Radiology as and when
generated
 Portable investigation done at bedside
 All reports dispatched to ICU
 Reviewing reports, altering supportive therapy and treatment
5) Drugs procurement
 Pharmacy register maintained in ICU for entry of daily patient medication

 Daily requirement of drugs and disposables list drawn out and dispatched to Pharmacy
 The patient’s relative then procures the drugs and disposables from hospital pharmacy
as cash purchase and given to the ICU.
 In case of company or insurance patient, Billing department in charge of ensuring bills
are raised for pharmacy.
 If patient on package, then no pharmacy billing is done for the first xxx number of days
6) Family Counseling
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 On admission to ICU – patient’s condition, visiting hours, likely prognosis and course and
duration of treatment, probable expenditure explained to patient family
 Daily patient’s clinical condition and prognosis
7) ICU Routine & Maintenance Processes
 Maintenance of crash cart as per checklist – emergency drugs, tracheal intubation

equipment & defibrillator (as in ICU protocol)
 Disinfection of floor / walls; reusable equipment coming in patient contact (as per
written ICU protocol)
 Maintenance of Oxygen, air, vacuum wall outlets
 Maintenance of electronic equipment like ventilators, monitors, infusion pumps,
breathing circuits, anesthesia circuits (in SICU) flow meters, nebulisers, etc.
 Isolation precautions as per ICU protocols
 Infection control protocols are followed as per policy
 ICU instruments, dressing trays, etc. washed and sent to CSSD for sterilization (refer
CSSD process flow)
8) Patient transferred for investigations, surgery, etc
 Patient transferred out of ICU as per ICU exit protocols that judge patient condition for
shifting out
9) Patient death
 Patient declared dead

 Relatives informed and allowed time with the body
 Security and mortuary attendant informed
 All monitors, tubes, etc. removed; body cleaned; packed in sheet; handed over to
security
 Death certificate prepared
ADMISSION AND DISCHARGE CRITERIA FOR INTENSIVE CARE UNITS
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ADMISSION POLICY:
1. The ICU admits all adult patients

2. Admission is arranged by consultation with the on-call ICU consultant or their
nominated deputies Consultations are accepted 24 hours a day.
3. Patients admitted directly from the Accident and Emergency department or by transfer
from another hospital will always be recorded as under the care of the duty medical or
surgical team or other special unit (e.g. Orthopaedics, O&G) as appropriate.
4. Admission of patients from another hospital must be arranged with the ICU Medical
staff before transfer of the patient.
5. Resuscitation or admission must not be delayed where the presenting condition is
imminently life-threatening, (eg. profound shock or hypoxia), unless clear advanced
directives are available.
6. Patients are admitted under the parent team or unit while in the ICU and remain under
the long term care of the parent team consultant under whom they are admitted.
7. Admission disputes must be referred to the on-call ICU consultant.
8. Admission will be arranged by the ICU consultant or their nominated deputies provided
that a bed is available.
9. If admission is delayed or impossible due to bed unavailability the ICU staff will discuss
and if appropriate, assist in the process of alternative specialized care.
10. Until the patient enters the ICU his/her medical care remains the responsibility of the
referring physician.
ADMISSION CRITERIA
a) ICU provides services that include both intensive monitoring and intensive treatment for
patients with actual or potential vital system failures, which appear reversible with the
provision of ICU support. During times of high utilization and scarce beds, patients requiring
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intensive treatment (Priority 1) have priority over monitoring (Priority 2) and terminally or
critically ill patients with a poor prognosis for recovery (Priority 3)***. Eligibility for ICU
admission and discharge is also based upon reversibility of the clinical problem as well as the
likely benefits of ICU treatment and expectation of recovery.
b) It is the responsibility of the patient’s attending physician to request ICU admission and to
promptly accept back patients meeting discharge criteria.
c) It is the responsibility of the ICU consultant or their nominated deputies to decide if a patient
meets eligibility requirements for ICU. In case of conflict regarding admission or discharge
criteria, the ICU consultant will decide which patient should be given priority.
d) Some patients are admitted to the ICU only under unusual circumstances, at the discretion of
the ICU consultant, and they should be discharged if necessary to make room for priority 1, 2 or
3 patients. Examples of patients who do not meet routine admission criteria are:
 Competent patients who refuse life-support therapy.
 Patients with non traumatic coma causing a permanent vegetative state.
Priority 1 Patients: Critically ill, unstable patients in need of intensive treatment such as
ventilatory support or continuous vasoactive drug infusion. Examples of such admissions are
status asthmaticus patients, or patients in septic shock. Priority 1 patients have no limits placed
on therapy.
Priority 2 Patients: Patients who, at the time of admission, may not be critically ill but whose
condition requires the technologic monitoring services of the ICU. These patients would benefit
from intensive monitoring (e.g. peripheral or pulmonary arterial lines) and are at risk for
needing immediate intensive treatment. Examples of such admissions may include, but are not
limited to, patients with underlying heart, lung, or renal disease who have a severe medical
illness or have undergone major surgery. Priority 2 patients have no limits placed on therapy.
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Priority 3 Patients: Critically ill, unstable patients whose previous state of health, underlying
disease, or acute illness, either alone or in combination, severely reduces the likelihood of
recovery and benefit from ICU treatment. Priority 3 patients may receive intensive therapy to
relieve acute complications, but therapeutic efforts might stop short of other measures such as
endotracheal
intubation or cardiopulmonary resuscitation. After consultation with immediate relatives and
documentation.
DISCHARGE POLICY:
1. All discharges must be approved by the ICU consultant / on call ICU consultant.
2. Patients are discharged when the reason for admission has resolved.
3. At discharge from ICU the patient will be immediately accepted by the parent team.
4. Primary care teams must be informed of all patient discharges and any potential or
continuing problems.
5. If appropriate, limitation/non-escalation of treatment must be clearly documented and

discussed with the parent team prior to discharge.
6. A discharge summary must be completed in the case notes prior to discharge.
QUALITY ASSURANCE PROGRAM IN ICU
Objective:
Primary objective is to select suitable quality indicators for intensive care units.
Development of a data base and meaningful utilization of this data base is the final objective.
1. Select very common parameters mainly focusing on the outcome (mortality and
Morbidity ), process, infection, communication, human resource and safety.
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2. Generate data base for comparison with international bench marks.
Quality indicators monitored in ICU
1. ICU readmission rate
Indicator ICU readmission rate
Description Readmission to the ICU within 24 hrs of transfer during a single

hospital stay. This is an indicator of post ICU care
Rationality A zero readmission rate reflects more defensive approach by ICU

team which increases LOS in ICU causing risk of nosocomial
infection , iatrogenic complications, and non availability of bed for
the deserving patients Higher mortality rate of 1.5 to 10 times that of
controls and higher length of stay at least twice that of control
patients had been documented. A higher readmission rate indicates
premature decision to shift out.
Formula for calculation (Number of readmitted patients/Total patients managed in ICU)

X100
Benchmark ICU readmission rates are around 4%

McMillan TR, Hyzy RC. Bringing quality
References improvement into the intensive care unit
Crit Care Med 2007;35:S59–65.
2. Patient’s fall rate
Indicator Patient’s fall rate
Definition An untoward event which results in the patient coming to rest

unintentionally on the ground or on other lower surface.
Rationality Fall could be accidental, anticipated physiological or unanticipated

physiological. This is a safety issue for a patient in ICU. Accidental
fall could lead to morbidity, prolonged stay and customer
dissatisfaction.
Formula for calculation Fall rate = (no. of falls/no. of bed days) x 1000
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8.46 falls per thousand bed days with an injury rate of 12.85% in
Benchmark 2000-01[2]
Norton Hospital USA, 2008 Norton Healthcare statistics per 1000 in
patient days of the of the unit.[3]
3. Medication error
Indicator Medication error
Description Medication error could be due to wrong prescription, dosing and due
to communication gap (verbal or written)
Rationality Medication errors occur at a mean rate of 19% in hospitalized adults.

The need for assessing ICU medication error frequency is high
lightened by the finding that 78% of the serious medical errors that
occurred in the ICU were attributed to medications.
Formula for calculation Medication error rate = (no. of error / no. of bed days) x 1000
 Medication errors range from 1.2 to 947 per 1000 patient-days
Benchmark (median of 105.9 per 1000 patient-days) in adult ICUs and Median of
24.1 per 1000 patient days in neonatal/pediatric ICUs[1]
 Wrong dose: 105.9 errors per 1000 patient-days in ICU[2]
 Kane-Gill S, Weber RJ. Principles and Practices of Medication

References Safety in the ICU. Crit Care Clin 2006;22:273–90.
 Herout PM, Erstad BL. Medication errors involving continuously
infused medications in a surgical intensive care unit. Crit Care Med
2004;32:428–32.
4. Needle stick injury rate
Indicator Needle stick injury rate
Definition A penetrating stab wound from a needle (or other sharp objects) that
may or may not be associated with exposure to blood or other body
fluids.
Rationality Needlestick injuries can cause transmission of blood borne

pathogens. Needle stick injury can occur due to faulty handling of
needle syringe with needle, suture needle, recapping of needle and
faulty disposal.. It is a preventable injury therefore adequate training
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to health care provider is a must.
Formula for calculation Incidence per 1000 venepunctures
Benchmark 0.94 per 10,000 venipunctures USA national rate

 vailable from:.
Reference  Rosenstock L. Statement for the record on needle stick injuries.
Centers for disease control and prevention, Department of Health and
Human Services Available from:. [last accessed on 2000 Jun 2000].
 American nurses' association's needle stick injury prevention
guide. Washington, D.C: 2002-04.
5. Reintubation rate
Indicator Reintubation rate
Description Reintubation within 48 hrs of extubation
Rationality Accidental extubation and subsequent reintubation can held to

prolonged stay, longer ventilation and higher nosocomial pneumonia
and mortality.
Formula for calculation (Number reintubated / Number extubated) X 100
Benchmark 12%
Reference Delgado MC, Pericas LC, Moreno JR, et al. Quality indicators in
critically ill patients. SEMICYUC work groups. 1st ed. May 2005.
ISBN 609- 5974.
6. Ventilator associated pneumonia (VAP)
Indicator Ventilator associated pneumonia (VAP)
Description Ventilated patient developing new opacity and also fulfilling criteria of
VAP (developing 48-72 hrs after intubation)
Rationality Ventilator associated pneumonia increases morbidity and mortality. It

has cost implications as it increases days of ventilation. Reduction in
the incidence rate is desirable in ventilated patients. Reported crude
mortality rates in VAP exceed 50%, and the attributable cost of VAP
approaches $20000.
Radiologic signs
Diagnosis
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> 2 serial chest radiographs with at least one of the following

 New or progressive and persistent infiltrate
 Consolidation
 Cavitation
Clinical signs
At least one of the following :
 Fever (temperature > 380C) with no other recognized cause
 Leukopenia (< 4.0 X 109cells/L) or Leukocytosis (>12.0 X 109
cells/L)
 For adults > 70 y of age, altered mental status with no other
recognized cause
Number of patients with VAP X 1000 days
Formula for
calculation Number of days mechanically ventilated with endotracheal tube
Benchmark 19.5/1000 ventilators days
Reference
7. Blood stream infection due to central line :
Indicator Blood stream infection due to central line
Description Blood stream infection rates = number of central line related BSI per
1000 central line days.
Rationality Blood stream infection (BSI) had emerged as a major killer. The
estimated death caused by BSI was 26250 deaths/year and it is ranked
as the eighth leading cause of death in the United States.
Number of central line associated BSI X 1000
Formula for calculation
Number of central line days
8. Urinary catheter related infection
Indicator Urinary catheter related infection
Description Incidence of UTI per 1000 catheterized day in patients catheterized in

the unit but were not infected on the day of catheterization.
Rationality Prevalence wise Urinary tract infection is most common. It increase

morbidity if not mortality, cost and stay.
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Number of UTI X 1000

Number of catheter days
9. Decubitus (Pressure) ulcer
Indicator Decubitus (Pressure) ulcer
Description Decubitus ulcer and pressure sore are synonyms. Decubitus is derived
from Latin word decumbere, means “to lie down”. Since pressure sore
can develop from other positions, it is called “Pressure Sore”.
Prolonged uninterrupted pressure over bony prominences causes
necrosis and ulceration. Depending upon tissue damage ulcers are
classified in 4 stages. Stage 1 indicates superficial colour change, stage
2 represents partial thickness skin loss, Stage 3 : full thickness skin
loss, and stage 4 denote deep and extensive tissue damage involving
muscle, tendon or bone. Hip and buttock sores represent 67% of all
pressure sores.
Rationality Annual cost of treatment in US exceeds $1 billion
Formula for calculation Number of pressure ulcers / Number of cases X 1000
Benchmark 22.71 / 1000 cases
Reference AHRQ national average. Sharphealth care 2007. Malcolm Baldrige

National Quality Award application 2007. p. 34.
10. Length of Stay (LOS)
Indicator Length of Stay (LOS)
Description Total hours and days patients managed in the unit with midnight bed
occupancy are more accurate than the number of calendar days a
patient spends in the ICU. Arithmetic mean overestimate LOS, as
outliers both ways influence the mean LOS very adversely. Medium
of LOS can circumvent this problem. LOS is also influenced by
factors such as the availability of aintermediary care, discharge
practices, and mortality rates. Appropriateness of using LOS as
outcome measure is therefore being reconsidered by Joint
Commission on Accreditation of Healthcare Organizations
(JCACHO). LOS properly stratified on the basis of diseases and
conditions and properly analysed could be a sensitive parameter
throwing up deficiency in process and techniques in ICU.
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Rationality ICU beds are limited in any hospital. Rationalized use for needy
patients therefore is necessary. LOS is therefore used to assess quality
of care and resource utilization.
Formula for calculation Total occupied bed days / number of patients in a given time frame
(weekly, monthly/yrly)
benchmark 4.36 days in general ICU;
Reference Pronovost PJ. Accelerating Change Today (A.C.T.) for America's

Health. Schoeni PQ, editor. © 2002 by the National Coalition on
Health Care and the Institute for Healthcare Improvement. The Robert
Wood Johnson Foundation supported report
11. CRUDE MORTALITY RATE
Indicator
Crude Mortality Rate
It is the number of mortality per 100 admissions in a given period of
Description time.
It gives an opportunity to individual ICU for improving the processes and
Rationality techniques.
Crude mortality rate = no. of deaths x 100
Formula for calculation no. of admissions
12. HOSPITAL ACQUIRED PNEUMONIA
Indicator Hospital Acquired Pneumonia
HAP is defined as the pneumonia that occurs more than 48 hrs after
Description admission but that was not incubating at the time of admission
It increases the cost and the length of stay
Rationality
Number of patients who developed HAP in a month
13. ADVERSE DRUG REACTION
Indicator Adverse Drug Reaction
An Adverse drug reaction is any noxious, unintended, undesirable, or
Description unexpected response to a drug that occurs at doses used in human for
prophylaxis, diagnosis or therapy, excluding therapeutic failure.
Rationality
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Number of Adverse drug reactions in a month

The rates per 1000 patient-days for all adverse events, preventable
Benchmark adverse events, and serious errors were 80.5, 36.2, and 149.7,
respectively. Among adverse events, 13% (16/120) were life-threatening
or fatal; and among serious errors, 11% (24/223) were potentially life-
threatening
Rothschild JM, Landrigan CP, Cronin JW, Kaushal R, Lockley SW,
Reference Burdick E, et al. The Critical Care Safety Study: The incidence and
nature of adverse events and serious medical errors in intensive care. Crit
Care Med 2005;33:1694–700.
14. HAEMATOMA PUNCTURE SITE
Indicator
HAEMATOMA PUNCTURE SITE
Haematoma related to percutaneous procedures
Description
Rationality
Number of patients who developed haematoma after percutaneous
Formula for calculation procedure eg. Central line, arterial line, CAG, etc.
15. THROMBOPHLEBITIS
Indicator THROMBOPHLEBITIS
Superficial venous inflammation developed in peripheral venous
Description cannulated patients
It increases morbidity
Rationality
No. of patients who developed thrombophlebitis in a month
Formula for
calculation
16. SENTINEL EVENT
Indicator SENTINEL EVENT
A sentinel event is an unexpected occurrence involving death or serious
Description physical or psychological injury or risk thereof. Serious injury specifically
includes loss of limb or function. Such events are called sentinel event
because they signal the need for immediate investigation and response.
Critically ill patients are at high risk for complications due to the
Rationality severity of medical conditions, complexity of treatments , poly
pharmacy, and technology based interventions. Nearly all ICU
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patients suffer from potentially harmful events. Nearly half

(45%) of the adverse events are preventable.
Number of sentinel events that occurred in a month
Formula for
calculation
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List of Code Blue Members:
 Anesthetist
 Cardiologist
 Critical Care
 DMO
 ER Technician
 Nursing Incharge
 Nursing Staff
 HA/MOD
 Security ASO
Minimum Time frame for completion of CPR/ code blue analysis: Within Next CPR
Analysis committee meeting
Reference:
1. Code Blue Running Sheet.

2. Code Blue Form
Page 64 of 64

ICU Procedures Manual

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What is the purpose of the ICU manual?

What is the purpose of the ICU manual?

What are the different levels of care provided in the ICU?

What are the different levels of care provided in the ICU?

ICU MANUAL

DDH CARE CARDIAC CENTER

DESIGNATION HOD, ICU Medical Director

Amendment Record & Revision History

All the controlled copies have to numbered & documented.

2. Level of care in ICU

2.2 LEVEL II (High Dependency Unit/ Step Down ICU)

 Needing additional monitoring like CVP, invasive arterial line.

2.3 LEVEL III

 On basic non-invasive monitor – ECG, NIBP, pulse oximetry.

3.0 INFECTION CONTROL PROTOCOL FOR INTENSIVE CARE UNIT:-

B) General cleaning of ICU

C) Dirty utility room

- Recommendation is 7100 PPM

3.2 Care of the bed space

3.3 Hand washing solution

3.4 Care of patient contact

- Prevents hypostatic pneumonia, bedsores

3.5 Doing a procedure

3.6 Insertion of vascular catheters

C) Central venous catheters

2) Catheter material and type

6) Dressing, types, frequency of change

7) Monitoring & Surveillance of site

10) Over the guide wire exchanges

E) Short peripheral intravenous catheters

3.8 A Protocol for hand hygiene

e) The process must be repeated after any accidental, unprotected contact

f) A hand rub (with alcohol or chlorhexidine with alcohol) should

B. Procedural hand hygiene

b) The process is a full surgical scrub using running water and 4%

d) No watches, rings or jewellary must be worn during the scrub.

e) The scrub to be performed for a minimum of two to three minutes.

A. Replace IV administration sets including secondary sets and add on devices at 72

B. Replace tubing used to administer blood, blood products or lipid emulsions.

C. Replace tubing used to administer propotol infusions every 6 or 12 hours,

2. Needle less intravascular devices

3.10 Care of indwelling devices

- Appropriate dressing and care protocol

3.11 Care of external devices

2) HMEF at connection for all patients

3) MDI’s may be better than nebulizers

3.12 Preventing Endogenous infection

3.13 Prevention of VAP

3.14 Protocols for other procedure

3.15 PROTOCOLS FOR SHOE REMOVAL

Consultants also should remove shoes while entering in ICU

Same rule applies to relatives

4.0 Work Instruction

4.1 Work instruction – Taking Consent for treatment / procedure / surgery:

4.3 Work Instruction – Medication Chart

4.4 Work Instruction – Nurses Notes

4.5 Work instruction – Pre operative procedures

4.6.1 Discharge Process of DAMA

5. Follow discharge process as per 4.6