Guidelines on Critical Care Services and Personnel: Recommendations Based on a System of Categorization into Two Levels of Care Copyright by the SCITY F CRITICAL CAR MICIN These guidelines can also be found in the February 1999 issue of Critical Care Medicine -- Crit Care Med 1999 Feb; 27(2):422-426 Society of Critical Care Medicine 701 Lee Street Suite 200 es Plaines, IL 60016 Phone: 847/827-6869
Guidelines on Critical Care Services and Personnel: Recommendations Based on a System of Categorization into Two Levels of Care American College of Critical Care Medicine of the Society of Critical Care Medicine ecisions to segregate critically ill patients into intensive care units (ICUs) by age, diagnosis, and acuity of illness are frequently difficult and complicated by economic and political considerations unique to the ICU s hospital setting. The characteristics of ICUs may therefore be determined by the population served by that institution, the proximity of and services provided by neighboring hospitals, and the number and subspecialities of physicians on the hospital staff. For example, large medical centers may have multiple ICUs separated and defined by specialty or subspecialty practices. Small hospitals may have only one intensive care unit designed to care for a large variety of critically ill patients. The use of intermediate care or step-down units in some hospital settings may provide a more efficient distribution of resources for patients whose critical illness requires less use of monitoring equipment and staffing than a high acuity ICU. Although the types and variety of ICUs may differ from hospital to hospital, all ICUs have the responsibility to provide services and personnel that assure optimal care to critically ill patients. When resources are limited, hospitals have the responsibility to assure transfer of the critically ill patient to an appropriate facility. In 1988, the Society of Critical Care Medicine (SCCM) published "Recommendations for services and personnel for the delivery of care in a critical care setting" (1). Several years later, "Guidelines for the categorization of services for the critically ill patient" were developed by the SCCM to accommodate regional differences in resources (2). This present document attempts to combine these previous guidelines to address the delivery of quality care for critically ill patients in hospitals with comprehensive resources as well as in hospitals with limited resources. The views reflected in this publication are based upon an updated literature review and a consensus opinion of experts in the field of critical care medicine. These experts include physicians, nurses, pharmacists and pharmacologists, and respiratory therapists. These current recommendations apply to hospitals with primarily adult critical care facilities. Hospitals caring for critically ill children should comply with separate guidelines outlining service and personnel requirements published by the Society of Critical Care Medicine in collaboration with the American Academy of Pediatrics (3). The care of critically ill pediatric patients as well as the care of patients with other highly specialized problems such as peripartum emergencies, spinal cord injuries, and burns should be addressed in each hospital in the form of specific policies relating to in-hospital care or transportation to appropriate facilities. FINITIN F LVLS F CAR efinition of levels of care from comprehensive to limited is necessary to assure the most efficient use of resources within a geographic region. ach hospital should define its goals with respect to the extent of critical care services to be delivered. These goals should reflect the hospital s overall mission and should be considerate of regional needs for critical care services. These guidelines propose two levels of care:
1. Level I units care for the complicated, critically ill patients requiring the continuous availability of sophisticated equipment, specialized nurses, and physicians with critical care training. These units are subdivided into Level 1A (academic) and Level 1C (comprehensive) units. Although all Level I units provide comprehensive critical care, Level 1A units will have an additional academic mission. Accordingly, Level I academic units require the additional commitment of the clinical staff to education and research in the field of critical care medicine. 2. Level II units have limited resources to provide critical care to the communities they serve. While these units may be able to deliver a high quality of care to patients with single-organ failure, transfer agreements must be arranged for patients whose problems are complex or highly specialized. Standards described for Level II hospitals in these guidelines represent minimal standards required to provide quality care to critically ill patients. Cooperation between hospitals and professionals within a given region is essential to assure that an appropriate number of Level I and II units are designated. A duplication of services may lead to under-utilization of resources, under-development of skills by clinical personnel, and may be costly. A detailed discussion of the importance of regionalization of critical care services has been addressed by the American College of Critical Care Medicine (4). State and federal governments should be encouraged to enforce the appropriate distribution of critical care services within a region and to participate in the development of referral and transfer policies. Standards for interfacility transfers with reference to federal and local law have been delineated in a collaborative publication by the Society of Critical Care Medicine and by the American Association of Critical Care Nurses (5). The following tables summarize recommendations for services and personnel for Level I and Level II units:
FINITIN F HSPITAL RSURCS = ssential = esirable = ptional I. Medical Staff rganization A. A distinct medical staff critical care organizational entity (department, division, section or service) exists. 1. Privileges (both cognitive and procedural) for members of the critical care team are approved by the medical staff credentials committee based on previous training and experience as defined by the medical staff. 2. A section of the medical staff bylaws delineates the regulations governing the implementation of these conditions. 3. Budgetary activities relating to unit function, quality assurance, and utilization review are conducted as joint medical/nursing/administrative endeavors. 4. A critical care representative serves on the medical staff xecutive Committee. B. The team is organized and led by an intensivist with time, expertise in and significant commitment to the care of the critically ill patient within the hospital. C. Patient management is directed by an attending level physician who: 1. Is privileged by the medical staff to have clinical management responsibility for critically ill patients (6). 2. Is board certified in Critical Care Medicine or has equivalent qualifications. 3. Sees the patient as often as required by acuity but at least twice daily. 4. Is either the patient s attending physician or a consultant who provides direct management of critically ill patients.. Medical Staff members should participate on the institution s Bioethical Committee. II. Unit rganization A. A physician Unit irector is required - In general, the director should meet the guidelines for the definition of an intensivist as published by the Society of Critical Care Medicine (7). B. Specific requirements for the Unit irector include: 1. Training, interest, and time availability to give clinical, administrative and educational direction to the ICU 2. Board certification in Critical Care Medicine
FINITIN F HSPITAL RSURCS = ssential = esirable = ptional 3. Time and commitment to maintain active and regular involvement in the care of patients in the unit 4. xpertise necessary to oversee the administrative aspects of unit management including formation of policies and procedures, enforcement of unit policies, and the education of unit staff 5. The ability to assure the quality, safety, and appropriateness of care in the ICU 6. Availability (either the irector or a similarly qualified surrogate) to the unit 24 hours a day, 7 days a week for both clinical and administrative matters 7. Active involvement in local and/or national critical care societies 8. Participation in continuing education programs in the field of critical care medicine 9. Hospital privileges to perform relevant invasive procedures 10. Active involvement as an advisor and participant in the organization of the care of the critically ill patient in the community as a whole 11. Participation in the education of unit staff, other physicians, house staff, and medical staff as indicated 12. Participation in scholarly activity (case reports, clinical and/or basic research) 13. Active participation in the review of the appropriate utilization of ICU resources in the hospital C. A Nurse Manager is appointed in order to provide precise lines of authority, responsibility, and accountability for the delivery of high quality patient care. Specific requirements for the Nurse Manager include: 1. An RN with a BSN or preferably a MSN degree 2. Certification in Critical Care or has equivalent graduate education 3. At least two years experience working in a critical care unit 4. Previous management experience including experience with health information systems, quality improvement/risk management activities, and health care economics
FINITIN F HSPITAL RSURCS = ssential = esirable = ptional III. 5. Preparation to participate in the on-site education of critical care unit nursing staff and physicians in training 6. Ability to foster a cooperative atmosphere with regards to the training of nurses, physicians, respiratory therapists and other personnel involved in the care of critical care unit patients 7. Regular participation in ongoing continuing nursing education 8. Ability to participate in and foster cooperation in scholarly activity in the ICU (e.g., presentations, clinical research) 9. Knowledge about current advances in the field of critical care nursing 10. Participation in strategic planning and redesign efforts Physician Availability A. A variety of studies suggest that a full-time intensivist improves patient care and efficiency as summarized in a recent review article (8). Accordingly, 24-hour in-house coverage should be provided by one or more of the following arrangements: 1. At least one physician who can manage emergencies, including airway emergencies and is certified in ACLS. This requirement may be fulfilled by senior residents, house officers, or physician extenders capable of handling emergency situations. An attending physician fully credentialled in critical care medicine must be on call and available within 30 minutes. 2. Critical care physicians appropriately credentialled to provide dedicated care to the critical care unit patients. This requirement may be fulfilled by critical care fellows. When fellows are used to fulfill this responsibility, a critical care staff physician must be on call and available within 30 minutes. B. The following physician subspecialists should be available within 30 minutes: 1. General Surgeon 2. Neurosurgeon 3. Cardiovascular Surgeon 4. bstetric - Gynecologic Surgeon 5. Urologist 6. Thoracic Surgeon
FINITIN F HSPITAL RSURCS = ssential = esirable = ptional IV. 7. Vascular Surgeon 8. Anesthesiologist 9. Cardiologist 10. Pulmonologist 11. Gastroenterologist 12. Hematologist 13. Infectious isease Specialist 14. Nephrologist 15. Neuroradiologist (with interventional capability) 16. Pathologist 17. Radiologist (with interventional capability) 18. Traumatologist (required for all designated trauma centers) 19. Neurologist 20. rthopedic Surgeon Nursing Availability (see also (9) for Trauma Center Critical Care Unit requirements): A. All patient care is carried out directly by or under supervision of a trained critical care nurse. B. All nurses working in critical care should complete a clinical/didactic critical care course prior to assuming full responsibility for patient care. C. Unit orientation is required before assuming responsibility for patient care.. Nurse to patient ratios should be based on patient acuity.. All critical care nurses must participate in continuing education. V. Respiratory Therapy Availability A. A respiratory therapist available to the unit at all times is required. Ideal levels of staffing are based on acuity, utilizing objective measures whenever possible. B. A working knowledge of the principles of management of patients with acute respiratory failure is required. C. The therapist must be familiar with mechanical ventilators and with the range of ventilatory modes.. Proficiency in the transport of critically ill patients is required. VI. Pharmacy Services Requirements (10,11) A. Unit dosing and IV admixture services B. Availability of registered pharmacists to monitor drug dosing and administration regiments, adverse reactions, drug/drug interactions, and cost containment issues C. Availability of a decentralized pharmacist with a specialized role in activities such as nutritional
FINITIN F HSPITAL RSURCS = ssential = esirable = ptional support formulations, cardiorespiratory resuscitation efforts, and clinical research projects VII. ther Personnel A variety of other personnel may contribute significantly to the efficient operation of the ICU. These include unit clerks, physical therapists, occupational therapists, advanced practice nurses, physician assistants, pastoral care specialists, social workers, dietary specialists, and biomedical engineers. VIII. Laboratory Services (12,13) A. A clinical laboratory should be available on a 24 hour basis to provide basic hematological, chemistry, and blood gas analysis. B. "STAT" or "bedside" laboratories adjacent to the ICU or rapid transport systems (e.g., pneumatic tubes) provide an optimum and cost effective setting for obtaining selected laboratory tests in a timely manner. IX. Services Provided in Unit An ICU has the capability of providing basic monitoring and patient support. In order to do so the ICU is prepared to provide: A. Continuous monitoring of the electrocardiogram (with high/low alarms) to all patients B. Continuous arterial pressure monitoring (invasive and non-invasive) C. Central venous pressure monitoring. quipment to maintain the airway, including laryngoscopes and endotracheal tubes. quipment to ventilate, including ambu bags, ventilators, oxygen, and compressed air F. mergency resuscitative equipment G. quipment to support hemodynamics, including infusion pumps, blood warmer, pressure bags, blood filters H. Transport policies which address transport monitors, transport ventilators, and resuscitative equipment (see (5) for a detailed description) I. Beds with removable headboard and adjustable position J. Adequate lighting for bedside procedures K. Suction L. Hypo-hyperthermia blankets M. Scales N. Temporary pacemakers. Temperature monitoring devices P. Pulmonary artery pressure monitoring Q. Cardiac output monitoring R. Inspired 2 monitoring capability for all ventilators
FINITIN F HSPITAL RSURCS = ssential = esirable = ptional S. Hemodialysis T. Peritoneal dialysis U. Capnography V. Transutaneous 2 monitoring or pulse oximetry for all patients receiving supplemental oxygen W. In-house availability of a CT scanner, cardiac catheterization lab, echocardiography, nuclear medicine testing and venous oppler techniques. If not available in-house, transfer agreements should exist with institutions which have this capability X. Fiberoptic and rigid bronchoscopy Y. Fluoroscopy capability in unit or readily available in radiology Z. Intracranial pressure monitoring
RFRNCS 1. Task Force on Guidelines, Society of Critical Care Medicine: Recommendations for services and personnel for delivery of care in a critical care setting. Crit Care Med 1988; 12: 809-811 2. Task Force on Guidelines, Society of Critical Care Medicine: Guidelines for categorization of services for the critically ill patient. Crit Care Med 1991; 19:279-285 3. American Academy of Pediatrics and the Guidelines/Practice Parameters Committee of the American College of Critical Care Medicine, Society of Critical Care Medicine.: Guidelines and levels of care for pediatric intensive care units. Crit Care Med 1993; 21:1077-1086 4. Regionalization of Critical Care Medicine: Task force report of the American College of Critical Care Medicine, SCCM. Crit Care Med 1994; 22:1306-1313 5. Guidelines Committee of the American College of Critical Care Medicine; Society of Critical Care Medicine and American Association of Critical-Care Nurses Transfer Guidelines Task Force: Guidelines for the transfer of critically ill patients. Crit Care Med 1993; 21: 931-937 6. Guidelines Committee, Society of Critical Care Medicine. Guidelines for granting privileges for the performance of procedures in critically ill patients. Crit Care Med 1993; 21:292-293 7. Guidelines Committee, Society of Critical Care Medicine: Guidelines for the definition of an intensivist and the practice of critical care medicine. Crit Care Med 1992; 20:540-542 8. Carlson RW, Weiland, Srivathsan K. oes a full-time 24-hour intensivist improve patient care and efficiency? Crit Care Clin, 1996; 12:525-551 9. Carl L. Nursing criteria for trauma center site review. J merg Nurs 1983; 9:74-77 10. asta JF, Jacobi, J, Armstrong K. Role of the pharmacist in caring for the critically ill patient. In: The Pharmacologic Approach to the Critically Ill Patient. Third dition. Chernow B (d). Baltimore, Williams & Wilkins, 1994, pp 156-166 11. Chuang LC, Suttan J, Henderson JP. Impact of the clinical pharmacist on cost saving and cost avoidance in drug therapy in an intensive care unit. Hosp Pharm 1994; 29:215-221 12. Weil MH, Michaels S, Puri V, Carson RW. The stat laboratory. Am J Clin Path 1981; 76:34-42 13. Salem M, Chernow B, Burke R, et al. Beside diagnostic testing: Its accuracy, rapidity, and utility in blood conservation. JAMA 1991; 2226:382-89
These guidelines have been developed by a Task Force of the American College of Critical Care Medicine of the Society of Critical Care Medicine, and thereafter reviewed by the Society's Council. The guidelines combine two previously published guidelines ("Recommendations for Services and Personnel for elivery of Care in a Critical Care Setting," Crit Care Med 1988 Aug; 16(8): 809-811 and "Guidelines for Categorization of Services for the Critically Ill Patient," Crit Care Med 1991 Feb; 19(2): 279-285) and will be published in Critical Care Medicine. These guidelines reflect the official opinion of the Society of Critical Care Medicine and should not be construed to reflect the views of the specialty boards or any other professional medical organization. The Writing Panel who participated in the preparation of this document includes: Marilyn T. Haupt, M, FCCM (principal author); Carolyn. Bekes, M, FCCM; Robert W. Bayly, M, FCCM; Richard J. Brilli, M, FCCM; Linda C. Carl, RN; Michael N. iringer, M, FCCM; ennis M. Greenbaum, M, FCCM; Judith Jacobi, Pharm, FCCM; Michael S. Jastremski, M, FCCM; Stanley A. Nasraway, M, FCCM; iana L. Nikas, RN, MN, FCCM; W. ric Scott, M, FCCM; Antoinette Spevetz, M; James R. Stone, M, FCCM; Jonathan Warren, M, FCCM; and Suzanne K. Wedel, M, FCCM. Approved by the Council of the Society of Critical Care Medicine in February 1998. To be revised in 2002.