Journal of Pediatric Critical Care

P - ISSN : 2349-6592    |    E - ISSN : 2455-7099

Special Article
Year : 2019 | Volume : 6 | Issue : 3 | Page : 45 - 50

Pediatric Intensive Care Unit: Planning & Design

Kundan Mittal1

1Senior Professor and Incharge Pediatric Intensive Care Unit & Respiratory Clinic, Pt B D Sharma, PGIMS Rohtak, Haryana,India

Correspondence Address:

Dr. Kundan Mittal, Senior Professor Pediatrics
Pt B D Sharma, PGIMS, Rohtak, Haryana, India,
Phone : +919416514111, Email : kundanmittal@gmail.com
Received: 24-Apr-19/ Accepted: 22-May-19/Published Online:05-Jun-19

Source of Funding:None Conflict of Interest:None

DOI:10.21304/2019.0603.00503


ABSTRACT
Intensive care unit is specialised unit providing care to critically ill patients. Level of intensive care unit depends on the requirement of the particular hospital. Outcome is always better if care is provided, the team specially trained in emergency and critical care. Equipment requirement is also different to some extent for children being developmentally and anatomically different at earlier age. Requirement for number of equipment is also slightly different.

Key words:
Pediatric Intensive care unit, design, planning
Children constitute 40% of total population in India and they have different developmental physiology, anatomy, pattern of developmental progression, diseases pattern, and instrument requirement in intensive care management planning. Moreover, children are dependent on care-givers for their requirement. Certain diseases are specifi c to adult population like ischaemic heart disease while respiratory, diarrhoeal and infectious diseases are common in pediatric population. This makes to understand us that while planning pediatric intensive care unit (PICU) what kind of arrangement should be given priority.
Intensive care or critical care unit is the specialised geographic area of the hospital to provide support to patients with potentially recoverable disorders who can benefi t from close observation with or without invasive monitoring and some short appropriate intervention. This may be because of impending or established organ(s) failure as a result of disease or therapeutic intervention. Certain procedures are also carried out in PICU which are not possible in wards. At occasion, patient may be kept for palliative care and waiting for organ donation or transplant. It involves multidisciplinary and interprofessional approach to provide the comprehensive care.
Primary focus of intensive care is to support the organ and prevent further deterioration while underlying disease process resolves. Intensive care unit is not always meant for therapeutic intervention only. Intensive care is multi-speciality involving physicians of different sub-speciality, nurses, respiratory therapists, physiotherapists, clinical pharmacists, nutritionist, microbiologists, biochemist, social & psychological workers, ethicists, spiritual care, and many others.

Intensive Care Unit (ICU):
It is health care delivery system providing specialized care using available resources and technological support. Medical, nursing and allied health staff work with defi ned policy and procedure and has its own way of quality improvement, teaching and research. ICU should be Accessible, optimal Safe, and has healing touch.

Why separate physical space for PICU?
Care can be provided anywhere but if given in specifi c area designed and allocated to PICU results in better outcome. PICU should be located close to acute areas like emergency department, pediatric fl oor area & supportive services like investigative and radiology section. Ideally it should be centrally located with adequate space for transport of patients, equipments and other items etc (size of gate, corridor, lift).
The space should be accommodating desired number of beds in PICU depending on geographic location, level of care, type of subspecialties or discipline or multidisciplinary and requirement. All beds must be accessible from all side, adequate space for head side of bed and leg side, adjust all monitoring devices and adequate space for intervention, and infection control measures, space for family, accessibility to central nursing station (CNS) should be available. Ideally single room is suggested but due to some constrains in our developing countries like India,
this may not be possible hence a large dormitory will suffi ce. Adequate space should be available for team incharge, teaching and research, retiring cum dinning room, storage of equipments, staff changing room, IT, waiting area, counselling room. Patient zone should have facility for natural light and sound level should be kept below 45 dBA. The ceiling and wall be able to absorb sounds. Monitoring and other devices should not be placed on fl oor. Caregiver or clinical support zone is dedicated zone for staff nurse primarily on bedside but may also be placed at central nursing station (space for monitoring, satellite pharmacy, storage of items acutely required, drug preparation, computer, reference books, communication system). Unit support zone should have at least space of 10m2/bed (within range of 30m from patient area). Family support zone space of 10m2 for total ICU may be made available.The design must also focus on electrical, plumbing, lighting, fl ooring, connectivity and communications, bathrooms and sinks. Flooring is preferred of marble and corners to be rounded.

Other points to be taken care are
● Light 100lux per bed
● Scrub area 150sq ft
● Temperature 24
● Humidity 60%
● Air exchange 14-16/hour
● Soothing wall color
● Concealed type lighting
● Ceiling noise reduction coeffi cient 0.6519
● One room for ECMO and dialysis/CRRT
● Double door
● Ceiling height 3meter
● Corridor 2.5m
● Isolation room 10% with 20% extra space
● Separate pathway from contaminated material
● Negative pressure room for airborne infection <5u
● One shower 8m and one toilet 4.5m2
● Drug preparation area
● Laboratory area
● Office space
● Procedure room

Space requirement for an 8 bedded PICU
● In cubicle patient space 20m2 and room size 25m2/ (1.2m head and foot side and 1.8m on each side clear area, 2.5m traffi c area beyond bed space), bed space 200-250sq.ft./bed
● One isolation room [3m2 area for hand washing (non-splash hand wash basin with elbow- or footoperated taps and a hand disinfection), gowning and storage of isolation material], negative pressure ventilation for contagious diseases
● Bulk supplies (21m2)
● Clinical Equipment (30m2)
● X-ray/ imaging equipment area (5m2)
● Linen Store (4m2)
● Furniture (15m2)
● Gas cylinders (4m2)
● Dirty utility room (18m2)
● Clean utility room (17m2)
● Laboratory (8.5m2)
● Procedures/treatment room (20m2)
● Emergency trolley bay (1m2)
● Total of 1000m2 (8 beds, storage, staff and relative facilities area)

Staff facilities
● Offi ce: Team leader 10.5m2
● Offi ce: Clinical staff/IT resource room 24.0m2/
● Meeting/interview/counselling room (6 person) 14.0 m2
● Staff restroom/dinning: 20.0 m2
● Staff changing/shower/wash room: 11.5 m2
● Seminar/training room: 37.5 m2

Utility items
● 12-16 single electrical outlets with connection to UPS (distributed on both side of head end of bed)
● 2 Oxygen outlets (ideal is four)
● 2 Vacuum outlets (ideal three)
● 2 Compressed air outlets (ideal three)
● One light source
● Nitrous Oxide outlet
● Data sockets for multiparameter monitoring, and PC for Clinical Information System (four data outlet)
● TV, radio and telephone sockets
● Chart for recording observation and if skilled manpower is present, system may be made paperless, Emergency bell, Nurse Call

2. Support and monitoring
Continuous monitoring of various physiological parameters related to various bodily organ using different non-invasive and invasive methods and supporting them using various methods and technique are another function of intensive care unit. We may need various equipment’s/devices beside human resource for this and are listed below. Specifi c requirements may be met accordingly.

List of Equipment’s (Ideal for Eight Beds PICU)





3. Human resources
● Level III PICU should be manned by fulltime formally trained in critical care supported by resident or junior doctor while level II may be controlled by trained paediatrician.
● Nurse:
Trained in critical is ideal choice. Ration preferred is 1:1 (Nurse: Patient) but due to aging and burnout of staff 1:2 is acceptable.
● Respiratory Therapist:
Duty of RRT is to prepare, intubation, extubation, connection, maintain mechanical ventilation, spontaneous breathing trail, NIV, inhalation therapy, part of transport team when child is being transferred for procedure, and monitoring of respiratory system.

● Clinical Pharmacist
● Physiotherapist:
Critical care polyneuropathy and myopathy are common in critical care illnesses. Early mobilization is essential and hence a physiotherapist is required.

● Biomedical Engineer
● Perfusionist:
Unit providing ECMO/ELS service requires service of perfusionist in PICU.

● Microbiologist
● Other allied professionals (social worker, psychological support, occupational therapist}
● Biochemist

4. Critical Care Services
● Admit all category of patients
● Provides Follow up care
● Counsel the family
● Coordination with other departments
● Outreach consultation
● Copying with death

5. Research, education/training and quality improvement
Coordinate with other department and professional bodies for accreditation and other educational activities. Main areas are;
● Evaluation of care and program
● Research in critical care
● Training and education
● Steps for quality improvement

6. Budget and Finance
Team leader and management have to plan the budget for current affairs and expansion and arrange timely fi nancial assistance for smooth running (patient care, pay of health care professionals, new equipment’s, maintenance, consumables, transport, donation for poor, emergency expenditure and preparedness, source of funding, stationary, etc.)

7. Air handling
It is recommended to have a minimum of six total air changes per hour, with two air changes per hour composed of outside air. Central air-conditioning systems and re-circulated air must pass through appropriate fi lters. High Effi ciency Particulate Arrestance (HEPA) fi lters are recommended. It is recommended that all air should be fi ltered to 99% effi ciency down to 5 microns. Heating when indicated, should be provided with an emphasis on the comfort of the patients and the ICU personnel.

Critical care specialist / intensivist is more than sub-speciality clinicians with following characteristics;
● Person having specialized training in care of critically ill patients.
● Knowledgeable about the diagnosis and treatment of acute organ dysfunctions.
● Able to perform ICU procedures related to critical care.
● Comfortable liaising with other doctors/staff members.
● Comfortable in emergency situations and end-oflife issues.
● Advocates for quality assessment and improvement, culture of safety, multi disciplinary and interprofessional collaboration, and optimal resource allocation and utilization.
● Research activities
● Administrative duties
● Able to provide during critical care transport
● Educational duties
● Contributes to the growth of speciality at various level

8. Flexible
and comfortable arrangement through the creation of three distinct zones; the caregiver zone, the patient zone, and the family zone.

PICU Levels
Level I (Primary)
● Single organ support (basic respiratory monitoring and support, need vasoactive therapy, renal replacement therapy, neurological monitoring), cardiopulmonary resuscitation, non-invasive mechanical ventilation, recently extubated. postoperative patients, monitoring and prevention to further deterioration
● Suited to usually small hospitals
● Oxygen and NIV facility
● Patient: Nurse ratio 3:1 and fulltime equivalent per bed 6
● Long term chronic home ventilation (tracheostomy)
● Transport policy in place
      • Basic quality improvement program
      • Coordination with level II and III PICU
      • Staff should be BLS and APLS trained
      • Main role is monitoring, preventing complications in at risk

Level II (Secondary)
● Situated in larger hospitals, dealing children with multiorgan involvement but not handling or managing complex patients
● Intensivist and non-intensivist physician available
● Patient: Nurse ratio 2:1 and fulltime equivalent per bed 3
● Advanced respiratory monitoring and intervention
● May involve allied health professionals and access to other specialists
● Organised educational activity and quality improvement program

Level III (Tertiary):
● Mainly in tertiary care hospitals
● Deal with all type of complex cases
● Advanced monitoring system
● Facility for basic surgical procedures related to ICU
● Patient: Ideal nurse ratio 1:1 but may have 1:2 and fulltime equivalent per bed 6
● Trained nursing staff 24x7
● Governed by intensivist and other critical care trained allied staff
● Involved in education and research
● Disaster preparedness
● Isolation room facility

High-Dependency Unit
It is an equipped area located near intensive care units, which provides care between general ward and intensive care. Area provides care to children at risk or prone to have single organ failure.

Quality Indicators
It is essential to have quality control coordinator in PICU.
● Structure measures whether operational guidelines and policies followed or not (size, open or closed PICU, technology, level of supervision, role of staff)
● Clinical process measures ways the care is provided (hand washing prophylaxis, ventilation strategies, time of antibiotic administration)
● Outcome measuring results (patient or family satisfaction, mortality, quality of life in survivor, drug adverse events, VAP, catheter related infections)
● Critical event reporting
● Clinical audit
● Indicators of outcome assessment
● Risk identifi cation and management
● Educational activities
● Research activities

References
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2. Sarode VV and Hawker FH. Design and organisation of intensive care units. Oh’S Intensive Care Manual 2019. 8th edition: Elsevier:Pages 1-10
3. Valentin A and Ferdinande P. Recommendations on basic requirementsfor intensive care units: structuraland organizational aspects. Intensive Care Med. 2011; 37:1575– 1587.
4. Rosenberg DI,Michele M, Moss M. Guidelines and levels of care for pediatric intensive care units. Crit Care Med 2004; 32:2117–2127.
5. KeseciogluJ , Schneider MM , van der Kooi AW, Bion J. Structure and function: Planning a new ICU to optimize patient care. Curr Opin Crit Care.2012, 18:688–692