ICU Infrastructure

This section of the toolkit addresses the infrastructure needed to provide safe and effective care in the ICU. Infrastructure includes people (staff), equipment and supplies and the physical environment. The ICU nurse manager and medical director are responsible for assessing the adequacy of the ICU’s infrastructure.

ICU Caregivers and Support Staff

The people who support the function of an ICU can be divided into two main groups: people who provide direct hands-on care to patients and people who serve in supportive roles but do not provide direct patient care.

Direct caregivers who work in the ICU include physicians, nurses, therapists and others. Physician caregivers include ICU medical directors, intensivists and others. Hospitals that do not employ an intensivist or an appropriately certified physician as discussed under Section 6 of the toolkit should employ a hospitalist to serve as the ICU medical director. The medical director is responsible for admissions and discharges into the unit and for generating protocols of care. Hospitals may also employ various types of technology to obtain the services of an intensivist. Please note that the technology-based and hospitalist models of care do not meet the MH&SC ICU Physician Staffing Guideline.

Nurses are a major category of direct ICU caregiver. Nursing staff includes the nurse manager and staff nurses. It also includes certain types of ancillary support staff including nurse aides, patient care technicians and patient lift teams. Given the critical shortage of ICU nurses, hospitals should implement programs that contribute to the health and satisfaction of nurses. One example of such a program would be to employ a lift team. Lift teams free nurses to perform activities that do not require nursing skills. They also decrease back injuries and workers' compensation claims, increase nurse satisfaction and aid in recruiting.

Other direct ICU caregivers include mid-level practitioners including nurse practitioners and physician assistants. Additionally, other important components of direct ICU caregivers include various types of therapists, especially respiratory therapists, and specialty teams including IV and phlebotomy. Critical to the success of the ICU are the services provided by pharmacists.

Support staff includes a wide variety of very important resources that buttress the work of the direct ICU caregivers. Given the shortage of ICU staff nurses, support staff should be used as appropriate and feasible to permit nurses to focus on direct patient bedside care rather than a variety of duties that do not require their skills. To that end, unit clerks and secretaries, as well as transportation services, should be employed as appropriate.

Staffing Levels

Hospitals should staff their ICUs so they have all the health professionals required to provide safe and effective care for critically ill patients. ICUs should regularly conduct a staffing assessment and develop and implement a plan to correct all identified inadequacies. It is assumed that staffing assessments will be conducted and tracked on a quarterly, if not monthly, basis.

Each ICU must determine the appropriate ratio of staff members to ICU patients, based on the type of patients admitted to the ICU and other structural aspects of the ICU. The appropriate ratio of staff to patients should be considered on a caregiver-by-caregiver basis. In other words, the ratio of registered nurses to patients should be considered independent of the ratio of respiratory therapists to patients. Generally, ICUs should have at least one registered nurse for every two to three patients, but there may be some circumstances where certain ICUs need to have one registered nurse for each patient. The unit staff — usually the ICU charge nurse — on a shift-by-shift basis should monitor the conditions and complexity of patients, seek feedback from the staff regarding workload and make staffing decisions accordingly. Similar methods for determining staffing needs should be used by all other caregivers and their managers. Managerial staff should work collaboratively to make sure that all staffing needs are communicated and addressed appropriately.

Monitoring and Information Technologies

All ICUs use numerous types of equipment and information technologies to monitor the patient’s condition, support vital life functions and communicate changes in the patient plan of care to other members of the team. All equipment must be appropriate to properly care for the ICU's patient population and be properly maintained and replaced as needed. In addition, to communicate the patient’s condition and changes in the plan of care, ICUs should include computerized physician order entry (CPOE) systems. CPOE should be implemented in the ICU only after it has been tested and is working well in other areas of the hospital.

Supplies and the Physical Environment

Hospitals must have sufficient inventory on hand to provide safe and effective care for critically ill patients. Inventory includes the disposable products, medications and intravenous fluids, linens and equipment used in routine and emergency care. As with the staffing assessment, ICUs should determine what supplies are required to provide safe and effective care and then regularly conduct a supplies and equipment assessment. It should be assumed that on a daily basis stock is replenished as necessary.

© 2004 Michigan Health and Safety Coalition