ICU Operational Procedures
In contrast to the structures of care that address infrastructure and
multidisciplinary teams, ICU operational procedures address the processes
of care used to manage ICU patients. Operational procedures include
the criteria for admitting patients to the ICU and discharging them
from the ICU. Operational procedures also include the criteria by which
decisions are made regarding transferring patients from one facility
to another. Additionally, operational procedures include various safety
practices used during the provision of direct patient care at the bedside
Decisions related to admission and discharge from the ICU are crucial
safety concerns and have been discussed at length in an article published
in Critical Care Medicine. 22 The MH&SC ICU physician
staffing guideline recommends that these decisions be made by the intensivist
or appropriately qualified physician responsible for the ICU.
Protocols for ICU Admission and Discharge
Every ICU should have and use admission and discharge criteria. The
criteria should be endorsed by the intensivist or other appropriately
qualified physician. In hospitals where there is no intensivist or appropriately
qualified physician, the Medical Executive Committee should endorse
the criteria. ICU admission and discharge criteria should address the
following: 23 24
- In hospitals where physicians other than the intensivist or appropriately
qualified physician have admitting privileges into the ICU, the hospital
should have a plan for decertifying physicians.
- An interim step for hospitals where physicians other than the intensivist
have admitting privileges is to have the intensivist or other appropriately
qualified physician review all admissions within 24 hours to determine
if the patient was admitted appropriately or should be transferred
to another unit.
- Hospitals should have in place plans and protocols for transferring
patients as needed.
- Hospitals should have in place regional referral networks for complex
cases so every hospital (and critically ill patient) has access to
the specialty and subspecialty care required by critically ill patients
with complex illnesses. Every hospital should assess its ability to
provide a complete range of care, identify the gaps in care that it
can provide and develop plans for referring patients to other hospitals
for care it cannot provide.
Protocols for Patient Care
Every ICU should have protocols for patient care that have been developed
by the intensivist or other appropriately qualified physician and other
multidisciplinary team members. The protocols should establish procedure
as it relates to:
Daily rounds. Protocols should stipulate when and how multidisciplinary
team rounds should be conducted; that daily multidisciplinary team
rounds should be conducted; and that the rounding team member constituency
should include the intensivist or appropriately qualified physician,
nurse, pharmacist, respiratory therapist, social worker, physical
therapist and other ancillary staff as needed (e.g., chaplain).
When an intensivist or appropriately qualified physician is not
available, the rounds should include the primary or attending physician.
The structure and schedule for multidisciplinary team rounds should
be established by ICU and hospital leadership as appropriate.
Patient plans of care. Protocols should stipulate how plans of
care and goals are established and evaluated, the way in which protocols
for care reflect local concerns and circumstances and daily goals
for each patient.
Protocol compliance. Protocols should include a measure to monitor
compliance with protocols. One method for accomplishing this criteria
could be done in meetings where staff are encouraged to focus on
protocols, rather than outcomes by using rapid-cycle
improvement methods and to update protocols when circumstances
Protocol topics. The following clinical care areas have well-tested
protocols of care and should be adopted by all ICUs.
- Central Line-Associated Bloodstream Infection (JCAHO)
- Central Line Utilization (JCAHO)
- Deep Vein Thrombosis Prevention
- Enteral Nutrition
- Low Tidal Volume Ventilation/Acute Respiratory Distress Syndrome
- Management of Agitation and Use of Sedation
- Stress Gastritis Prevention
- Tight Glycemic Control
- Ventilator Weaning
ICU Safety Tips
The MH&SC recommends that all ICUs adopt the safety tips developed
by the Society of Critical Care Medicine.
The following list of items are recommended strategies for improving
patient safety in the ICU.
- Open communication among all staff is a key element for successful
- Ask questions and avoid making assumptions.
- Clearly label patient beds; consider having a removable sign at
the foot of the bed with the patient's name and bed number.
- Verify patient identification by verbally communicating with the
patient and/or check patient's identification band.
- Institute a standard change of shift policy, where nurses handing
off patients personally review orders during their shift with oncoming
nurses to clarify complete and incomplete orders.
- Perform a medication audit on each patient once during each shift,
which could be performed at change of shift.
- Create a mentoring culture for medical students, residents, nurses
and other ICU staff where every question is welcomed and proper supervision
- Check the Pyxis machines daily to ensure medications and doses
are stored in appropriate bins.
- Incorporate "check backs" during provider team and patient
interactions, where providers repeat an order during a handoff to
help verify information transfer.
- Remove concentrated esmolol from Pyxis and replace it with prefilled
- Incorporate independent redundancies into patient care. An independent
redundancy is when more than one person checks to make sure a clinical
process is executed properly. For example, when a physician orders
a medication, a nurse checks the medication order (first redundancy)
for patient allergies and other drug interactions. This action is
followed by a pharmacist who also checks the medication order (second
redundancy) for patient allergies and multiple drug interactions.
- Reconcile drugs at the time a patient is discharged. Specifically,
a nurse should complete a standardized form and confirm allergies
and home medications, and resolve discrepancies before the patient
- Use a rolling line cart to keep all sterile supplies needed for
insertion and maintenance of central line catheters.
22 Task Force of the American College of
Critical Care Medicine, Society of Critical Care Medicine. (1999). Guidelines
for intensive care unit admission, discharge, and triage. Crit Care Med
23 Task Force of the American College of Critical
Care Medicine, Society of Critical Care Medicine. (1999). Guidelines for
intensive care unit admission, discharge, and triage. Crit Care Med 27(3)
24 Thompson DR, Clemmer TP, Applefeld JJ,
et al. (1994). Regionalization of critical care medicine: Task force report
of the American College of Critical Care Medicine. Crit Care Med 22(8)
© 2004 Michigan Health and Safety Coalition