2 In Practice FOCUS November 2016

Planning, managing and equipping an intensive care unit within a veterinary facility

Caroline Smith, Holly Witchell

MANAGING A UNIT

An intensive care unit (ICU) is a specially staffed and equipped, separate and self-contained area of a hospital dedicated to the management and monitoring of patients with life-threatening conditions. Patient demands require staff with special expertise and facilities for the support of vital functions. Careful thought is essential when creating an ICU facility, as each hospital will have its own individual needs and expectations for what should be offered. This article gives an overview of the main points to consider when planning, managing and equipping an ICU.

Planning and managementLocationLayout of the intensive care unit (ICU) should allow rapid access to and from the reception area and consulting rooms for incoming emergency patients, the surgical theatres and the imaging department. This facilitates the rapid movement of patients between these areas for investigations and treatment as necessary. An easily accessible, secure outdoor space for walking canine patients is useful and consideration for disinfection of this area essential.

SizeThe size of the ICU is dependent upon the caseload and the type of cases seen by the hospital. Typically, ICUs in large multidisciplinary hospitals treating dogs and cats can accommodate between 20 and 30 patients. The split between dog- and cat-housing facilities will be dictated by the caseload; however, in most instances, two thirds of the kennel space will accommodate canine patients of various sizes and one third will be allocated to feline patients. Ideally, feline kennels should be within their own space, with noise-restricting windows and doors to minimise the stress associated with being in close proximity to dogs (Fig 1).

The ICU should be equipped with two or more patient examination and procedure tables. Dog hooks on the walls are a useful addition for patient restraint.

Caroline Smith, Holly Witchell, School of Veterinary Sciences, University of Bristol, Langford House, Langford, Bristol BS40 5DU, UKe-mail: caroline.smith@bristol.ac.uk

Depending upon the hospital caseload, a high-dependency unit may be included in the design. This area is dedicated to the care of the most critical patients, such as those requiring one-to-one intensive nursing, mechanical ventilation or dialysis. A raised bed, incubator or cot allows easy access to the patient from all sides. This area requires a dedicated oxygen source and the ability to provide advanced monitoring (Fig 2). A wall-mounted or mobile suction unit is essential for clearing patient airways. Placement should allow use of the suction unit in both the high dependency unit and crash areas where it is most likely to be required

An area for performing cardiopulmonary cerebral resuscitation with a hydraulic table and ‘crash trolley’ supplies is essential in a busy ICU. This area must have an oxygen supply and monitoring equipment, including an electrocardiograph and capnograph placed locally. Typical contents of an ICU crash trolley are listed in Table 1. After every use, the contents of the trolley will need restocking. Additionally, date checking of the contents can

be assigned to one of the ICU staff members to be performed on a weekly basis. After every breach, it is useful to seal the crash trolley or box with dated tape or ties as confirmation that restocking and checking has been completed.

StaffingICUs can be run on an open or closed basis. Both offer advantages and disadvantages. Open ICUs allow clinicians from any part of the hospital to place patients within the ICU and continue managing the patient’s care as their own. Patients in a closed ICU have their care directed by an ICU-based clinician typically with specialist training in emergency and critical care, with ongoing input from the clinician or service through which the patient was originally admitted to the hospital. In most instances, some middle ground can be reached whereby ICU-based staff manage both their own patients and provide support and advice for patients under the direct care of other services.

Successful ICU patient management relies heavily upon a collaborative team approach and open, clear communication between all staff. Case rounds form an important part of this communication and should be undertaken at the beginning and end of each working day. This is an opportunity for case discussion and planning with input from all members of the team; its importance cannot be emphasised enough.

The nursing team is essential to the smooth running and success of the unit. ICU nurses have a huge responsibility in caring for the sickest patients, so developing a well-motivated and

Fig 1: Dedicated feline kennelling area, with noise-restricting doors and windows to minimise the stress for hospitalised cats

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efficient team with a strong desire to provide the highest level of care is paramount. Nurses with a special interest, or further qualification, in emergency and critical care make a valuable addition in this regard. Encouragement and support in pursuing further education and qualifications within the field of emergency and critical care fosters a forward-thinking and passionate team.

Some thought must be given to the number of nurses required to staff the ICU as the level of care needed by patients is typically much higher than for those in wards. The nurse to patient ratio should be no more than 1:8, but sometimes patients will need 1:1 care. Additionally, 24-hour staffing is considered standard of care in most ICUs and a nurse should be in attendance at all times.

Due to the high patient turnover and importance of exceptional levels of cleanliness, dedicated cleaning and patient care staff are

hugely advantageous to the smooth running of the ICU.

CommunicationBeing a central hub for the hospital, the ICU must be well equipped for communication. In a large unit, a central nurses’ station with at least one telephone point for both incoming and outgoing calls is essential (Fig 3).

Typically, some form of alarm system is also required to alert staff in all areas of the hospital if there is a problem in the ICU. This may be in the form of an overhead paging or alarm system, or pocket-carried pagers that can be activated from the ICU.

One or more computers both for medical record keeping and internet access facilitates efficient record keeping and patient care.

Record keepingCritically ill patients typically require more frequent observations, monitoring and interventions than stable ones. For this reason, an ICU hospital sheet that allows at least hourly recordings of pulse and respiratory rates, temperature and blood pressure, with additional space for further monitoring parameters, fluid therapy instructions, feeding and walking instructions, and medications is recommended. Importantly, the hospital sheet must clearly

display the patient’s name and its owner’s contact details, the patient’s problem list, a plan for the day and a list of concerns or notifiers so that nursing staff are clear as to when the primary clinician needs to be contacted about a problem with the patient. A large space for free text allows observations to be recorded. Useful additions include pain score and modified Glasgow coma score guidelines, calculation space for resting energy requirement, resuscitation codes and areas for recording fluid ins and outs, blood type and transfusion history. An example of an ICU hospital sheet is shown in Fig 4.

StorageWhen planning an ICU, consideration must be given to storage space. It is advisable to have a small area to keep stocks of frequently used items such as intravenous catheters, bandaging materials, syringes, needles, and so on. Patient files, belongings, bedding, food and bowls may also need to be stored in a location that can be accessed easily. Some hospitals may wish to stock frequently used medications, controlled drugs and fluids within the ICU or the layout may mean storage within a separate pharmacy is more practical.

Fig 2: High dependency area, allowing easy patient access and advanced monitoring and interventions. This area is used for the most critical patients requiring direct continuous observation

Table 1: Essential and desirable items for an intensive care unit-based crash trolleyEssential Desirable

Laryngoscope Intravenous catheter supplies

Endotracheal tubes in small, medium and large sizes

Drugs (may include atropine, adrenaline and reversal agents)

Endotracheal tube ties

Large-volume saline flush syringes

Cuff-inflation syringe Syringes and needles

Urinary catheter for difficult intubations

Defibrillator

Dry swabs Mini surgical kits for venous cut down, tracheostomy, entering the chest

Ambu-bag (Ambu) or anaesthetic circuit

Fig 3: A central nurses’ station facilitates efficiency and communication while allowing ongoing patient monitoring

Table 2: Laboratory equipment considered essential and desirable for an intensive care unitEssential Desirable

Centrifuge Cross-matching kits

Spectrometer Prothrombin time and activated partial thromboplastin time analyser

Packed cell volume/haematocrit reader

Haematology machine

Microscope and Diff-Quik

Serum biochemistry machine

Blood glucose monitor

Blood gas analyser

Urine dipsticks

Blood-typing kits

Fig 4: Example of an ICU hospital sheet with space for hourly observations and drug administration, a problem list and a notifier list for clinician concerns

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LaboratoryThe ICU should be equipped with basic laboratory facilities to allow rapid bedside patient assessment (Fig 5). Suggested essential equipment is given in Table 2.

The laboratory area requires numerous power outlets and clean, clear benchtop workspace. For infection control purposes, it should ideally be in an area separate from the ICU kennelling facilities.

Infection controlInfection control forms an important part in the planning of an ICU facility, both in terms of protecting immunocompromised patients from being exposed to pathogens and preventing spread from patients with infectious agents. Infection control involves minimising the ‘traffic’ of both people and animals through the ICU facility and includes rules about ICU attire. Adoption of a ‘bare below the elbows’ rule has reduced infection transmission in human hospitals and is thought to offer the same benefits in veterinary practice. Similarly, jewellery and nail varnish should be discouraged. Gloves and plastic aprons should be readily available for patient examination (Fig 6).

Multiple sink units with hand soap and paper towels should be located around the ICU and sanitising hand gel stations should be placed prominently, particularly near the entrance and exit doors (Fig 7).

Occasionally, significantly immuno-compromised patients or infectious patients will require ICU care. Barrier-nursing techniques, with the creation of a temporary isolation area within the ICU ward, is effective. Clear floor marking can be laid out, with gloves and aprons stationed at the periphery. Equipment required by that patient for its care should remain within the barrier mark. This may include monitoring equipment, medications, hospital records, food, bowls and bedding materials. Similarly, dirty bedding and waste must be cleanly bagged before exiting the barrier mark.

CleaningThere should be minimal equipment and storage on the work surfaces to facilitate

maintenance of a clean environment. High-contact areas, such as phones, keyboards, desk surfaces and door handles, should be cleaned with disinfectant F10 wipes (F10 Products) every few hours. Daily cleaning should consist of wiping down all surfaces and monitoring equipment, vacuuming and mopping the floors with disinfectant solution. Kennels should be cleaned as needed when dirtied by the occupant and completely disinfected between patients. Deep cleaning should take place on a monthly basis – this includes walls, fridges, cupboards and shelves.

Microfibre cloths have been shown to clean surfaces more effectively than plain cloths (Moore and Griffith 2006). Using detergent before disinfectant also increases the removal of organic matter and bacteria.

A daily, weekly and monthly cleaning schedule ensures that no job gets missed.

Standard operating proceduresStandard operating procedures (SOPs) are essential to the smooth running of the ICU, as they ensure that common procedures are performed in the same way every time. SOPs can be applied to both clinical and non-clinical tasks. Each hospital will have differing needs for SOPs and they can be created for cleaning protocols, controlled drug handling, ‘infection control procedures, peripheral or central catheter placement, blood collection or transfusion administration, the management of certain diseases such as diabetic ketoacidosis or seizures, and so on.

The SOPs should be kept in a centralised location in electronic or paper form and clearly labelled.

EquipmentWhen considering an ICU, thought must be given to both the necessity and proximity of the relevant equipment in context of the number and types of patients that will be cared for.

Medical gas supplyThere should be medical gas supply built into the ICU to supply piped oxygen, surgical air,

suction and scavenging. Suspended ceiling columns could also be considered, as these can add accessibility to specific areas for triage or high-dependence cases.

OxygenSeveral kennels should be equipped with oxygen outlet ports nearby. This allows oxygen delivery to the patient within that kennel either by creating an oxygen kennel or providing nasal cannulae or prongs. There should be about two oxygen kennels for every 10 kennels, dependant upon the size of the ICU and caseload. If oxygen is administered via nasal prongs or catheters, humidifiers should be placed between the oxygen and the patient. These usually come with the purchase of the oxygen kennel and can also be purchased individually.

Surgical airSurgical air is necessary for patients that are on long-term oxygen therapy, for example, patients that are being ventilated.

SuctionSuction equipment is important in an ICU and is useful for cleaning endotracheal and tracheostomy tubes, clearing airways in patients that have regurgitated acutely and aiding oral hygiene in ventilated patients.

ScavengingScavenging is necessary for any gaseous anaesthesia within the ICU.

Electrical supplyElectrical sockets should be abundant within the ICU. There must be two sockets to every kennel and also at certain points around the room. Ceiling columns with integrated electrical sockets are useful in providing centralised access points.

LightingIt is important to be able to control the lighting within the ICU and ideally it should be dimmable. This allows provision of a low-stimulus environment for sound- and light-

Fig 6: Gloves and aprons should be available around the room, with easy accessFig 5: Basic laboratory area within an intensive care unit

Fig 7: Sinks should be kept clean and clear, and there should be access to both hand wash and sanitising spray or gel. Paper towels prevent cross-contamination from hand drying

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sensitive patients and patient rest periods, during which patient checks should be kept to a minimum. Spotlights located above examination tables provide a focused light source for intravenous catheter placement, and so on (Fig 8).

KennelsKennels should be easy to clean and maintain, and numbered and correlated to a numbered drawer for in-patient medications and a numbered file for in-patient records. Steel kennels are ideal for small to medium patients and walk-in kennels with non-slip flooring are suitable for large or recumbent patients.

Each kennel should be furnished with a clipboard to which the daily hospital sheet can be attached (Fig 9).

Other equipmentThe caseload and kennel space will dictate how much other equipment is required. Items of equipment that are considered essential and desirable for the smooth running of the ICU are listed in Table 3.

Blood productsGenerally, a hospital large enough to require an ICU will be treating patients that may require blood products. Storage of these products

does not have to be within the ICU but the ease of access in a crisis can be lifesaving. A dedicated fridge and freezer with the ability to monitor maximum and minimum temperatures

are required for appropriate blood product storage. A logbook of products received and recipients forms part of the medical record and allows auditing of blood product administration within the hospital.

The administration of blood products necessitates blood typing; therefore, blood-typing kits should be added to the ICU inventory. Benchtop cross-matching kits are also available and useful for out of hours cross-matching when required for blood administration and when external laboratories are closed.

SummaryPlanning and equipping an ICU is a multifaceted and challenging task. Each hospital will have its own individual needs and expectations for what the ICU should offer and these will influence the design, layout and management. There are plenty of resources online and numerous publications within the human field that can guide the planning of a new facility. Above all, the success of the ICU rests upon the ability of the team to work and communicate together to achieve the highest level of patient care.

ReferenceMOORE, G. & GRIFFITH, C. (2006) A laboratory evaluation of the decontamination properties of microfibre cloths. Journal of Hospital Infection 64, 379-385

doi: 10.1136/inp.i5579

Fig 8: Intensive care units can benefit from a centrally located ceiling column with both gas and electrical outlets. Spotlights are helpful for performing tasks in low light conditions. Walk-in kennels (shown in the background) are useful for large or recumbent patients

Fig 9: Kennels should be easy to access and clean, and allow direct patient observation from most aspects of the room

Table 3: Items of equipment considered essential and desirable for the provision of intensive patient careEssential Desirable

Intravenous fluid pumps Capnograph

Syringe drivers Chest drainage unit (eg, Thora-Seal, Medtronic Minimally Invasive Therapies)

Oscillometric blood pressure device

Electrocardiograph

Doppler blood pressure device

Heat mats

Blood pressure cuffs in multiple sizes

Temperature management system (eg, Bair Hugger, 3M)

Pulse oximeter Incubator

Multiparameter monitors

Pressure bag

Mobile ultrasound

Holly Witchell qualified as a veterinary nurse in 2008. She worked in small animal practice for four years followed by two years in a mixed practice veterinary hospital. She joined Langford Veterinary Referral Services in March 2011, where she began her role as a night nurse and went on to work in the ICU. She gained the certificate in emergency and critical care in 2013 and became head ICU nurse in 2014. She gained the AVECCT Veterinary Technician Specialist (Emergency and Critical Care) in 2015.

Caroline Smith graduated from the Royal Veterinary College (RVC). After a short period in general practice she decided to pursue a career in emergency and critical care. She undertook an internship in a large referral hospital in Rochester, USA, and stayed on as an emergency veterinarian. After returning to the UK, she worked for an out-of-hour’s provider before embarking upon a residency in emergency and critical care back at the RVC. She spent two years in private referral clinics before moving to Langford Veterinary Services to help develop and expand the critical care service already offered. She particularly enjoys management of emergency trauma cases, sepsis control and fluid therapy.

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