D R . A S H F A Q A H M E D B H U T T OM B B S , M B A , M A S , D C P S , M R C G P , ( P H D )

HOSPITAL MANAGEMENTSESSION V- CSSD, OT, ICU

THURSDAY, FEBRUARY 16, 2012

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CSSDCENTRAL STERILE SUPPLY DEPARTMENT

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THE CENTRAL STERILIZATION & SUPPLY DEPARTMENT (CSSD)

• Mission of CSSD (customer oriented)• Timely delivery of sterile goods• Quality (according to European Standards – EN)• Efficiency (line process)

• Activities of the CSSD (Spaulding)• Cleaning• Disinfection of semi- / non critical items (mucosa – non

intact skin contact) • Sterilization of critical items (high risk for infection)• Supply of sterile materials

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AIMS

• To provide sterilized material from a central department where sterilizing process is carried out under properly controlled conditions

• To alleviate the burden of work of the nursing personnel, there by enabling them to devote more of their time to patient care .

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THE CENTRAL STERILIZATION & SUPPLY DEPARTMENT (CSSD)

• Building Blocks• Well trained employees

• Information System

• Planning system: information available OR CSSD

• Tracing: set level / instrument level

• Standardization

• Processes: SOP

• Equipment and Instruments

• Infrastructure

• (External) Validation

• “Just in time” delivery – pull from the OR

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DECONTAMINATION LIFE CYCLE

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FLOW PROCESS : CSSD

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MAIN RESULTS OF THE ANALYSIS

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DEFINITION OF CSSD

Service, with in the hospital, catering for the sterile supplies to all departments , both to specialized units as well as general wards and OPDs.

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HISTORY

• 1928 – American College Of Surgeons – CSSD.• 1942 – World War II .Cairo, British SDS Unit

.• 1955 – Cambridge Military Hospital –

Regular CSSD in UK.• 1965 – First CSSD in India – Safadarajan

Hospital

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ADVANTAGES

1. Bacteriological safe sterilization.2. Less expensive.3. Elimination of unsound practices & establishment

of standard procedures.4. Assurance of adequate supply of sterile products

immediately and constantly available for sometime as well as emergency use.

5. Conservation of trained staff.6. Better quality control7. Better good of material flow8. Prolonged life by proper care of equipment

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ITEMS COMMONLY HANDLED BY CSSD STORES

1. Syringes2. Procedure Sets3. Lumbar puncture ; sternal puncture ;

venesection ; paracentesis ; aspiration ; catheterization ; tracheotomy ; suturing ; dressing ; biopsy ; incision & drainage ; aortography ; cardiac resuscitation ; etc

4. Needles5. Gloves

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ITEMS COMMONLY HANDLED BY CSSD STORES-CONT.

6. I.V. Fluids.7. Treatment Trays.8. O.T Instruments.9. O.T. Linen10. Infusion Fluids for Renal Dialysis.11. At times LINEN. (other than O.T)

NB: Diet , drugs , bedpans & urinals are not included by convention .

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PLANNING A CSSD DEPT

1. Physical Planning.2. Functional Planning.3. Personnel Planning.4. Equipment Planning.5. Financial Planning.6. Quality Control.7. Preventive Maintenance.

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PHYSICAL PLNG

1. Location & Grouping .2. Lay Out & Space Reqts.3. Fixturtes & Furniture .

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ADM & STORAGE (UNSTERILE) AREA

21² MSCALES FOR HOSPITALS > 700 BEDS

RECEPTION,CLEANING,CHECKING,ASSEMBLY & PACKING AREA

35² M

AUTOCLAVING AREA 28 ² M

STERILE STORAGE & ISSUE AREA 28 ² M

TOTAL 1,320 ² ft

AREA REQUIREMENT

RULE OF THE THUMB-ROUGHLY – 10 SQFT / BED

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EQUIPMENT'S IN CSSD

1. Jet water cleaning gadgets.2. Ultrasonic Washers3. Glove sharpener4. Needle sharpener.5. Gas, Chemical or steam autoclaves.6. Testing apparatus for efficiency of

sterilization

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OTHERS

1. Maintenance & Repair Equipment2. Adequate number of cabins & Furniture3. Telephone or intercom.4. Adequate no of syringes & procedure

sets.

NUMBER OF SETS/SYRINGES

A - 1½ Daily requirement in use at wards / Departments

B - 1 Daily requirement in sterile state at CSSD, ready for issue

C - 1 Daily requirement being processed at CSSD

D – 1to 1½ Daily requirement held in reserve – dome in CSSD, some in medical stores

Total: 4.5 to 5 times of the daily requirement

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TYPES OF STERILIZATION TECHNIQUES

1. Dry Heat2. Steam High Pressure-Autoclaves operated by

Gas, K.oil or Electricity ( Flash, Pulse)3. Ethylene Oxide Sterilization.4. Chemical Sterilization.5. Radiation Sterilization.6. Infra Red Radiation – Syringes7. Ultra Violet Radiation – Decontamination of Air8. Ionizing Radiation / Gamma Radiation

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CHEMICAL• CIDEX • A Glutaraldehyde derivative is most effective as it destroys

spores too.

• ETHYLENE OXIDE (ETO) • Quite effective against spores too.• Useful for delicate instruments and item which can’t be

immersed in liquids• - Low Boiling Point (10 degree C)• - Prolonged Aeration• - Highly Expensive / Explosive / Toxic

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STERILISATION

• It is a process of freeing an article

from all living organisms including bacteria ,fungal spores and viruses.

• A material is pronounced sterile if it

achieves 99.99% kill of bacterial spores.

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STEAM STERILATION

- Water Saturated Wet vapor Dry saturated Vapor Super Heated Vapor / Steam

- Steam with <0.95 Dryness Factor is not useful for

Sterilization.

- Superheated Steam acts like Dry Hot Air only . ( Strength Of Steam is its Latent Heat)

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OPERATION OF POROUS LOAD STERILIZERS

The operating cycle of a porous load sterilizer normally has five stages.

a. Air removal b. Steam admission c. Holding time d. Dryinge. Air admission

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ADVANTAGES OF STEAM STERILISATION

1. Rapid heating & penetration of loads.2. Destruction of all forms of microbial life3. No residual toxicity. 4. No damage to supplies being sterilised.5. Easy Quality Control6. Economical & Reliable7. This method is unsuitable for heat

sensitive and non- permeable material

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MODE OF ACTION.

Dry Heat Oxidation Steam Denaturation = Coagulation of

ProteinsSterilization Time (Holding Time + Safety Time)

Pressure (PSI)

Temperature ( C° )

2' + 1′ = 3' 8' + 2' = 10'12' + 3' = 15'

30 20 15

134 126 121

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TYPES OF AUTO CLAVING MACHINES

1. Downward Displacement2. Vacuum Assisted.3. Pulsed Steam Dilution

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TESTS FOR EFFICENCY OF STERILISATION

1. Specially treated paper strip.

2. Pressure sensitive tape to be fixed to the

final fold

3. Brown indicator tubes - (very expensive)

4. Biological. Green strip containing bacteria

(Color must change to black)

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TESTS FOR EFFICENCY OF STERILISATION

5. Cellophane wrapped tablet containing6. Lactose - 75%7. Starch - 24%8. Magnesium Trisilicate – 1% (Tablet turns

brown during autoclaving)9. Microbiological examination of finished

products.10. Thermo - couples .

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RADIATION STERILISATION

1. Dose - 2.5 Mega Rhontgen; Source – Cobalt-60 /Caesium – 137/ Electron Beam (generated by linear accelerator)

2. Reliable, can penetrate all types of packing. Large & diverse shaped articles can be sterilised. No residual radio activity at 2.5 mega rhontgens.

3. Glass becomes dark, cotton looses tensile property, food gets undesirable flavor. Not practicable in hospitals

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STAFFING :CSSD

CENTRALISED SUPPLY (RULE OF THUMB 2 PER 100 BEDS)

SUPERVISORS (sister/male ward masters)

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STAFF NURSES 5

TECHNICIANS (ORA) 6

ATTENDANTS 24

SWEEPER 4

CLERK 1

Total 44

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DISTRIBUTION SYSTEMS :

1. Regular issue of one day’s requirement.

2. Clean for dirty exchange.

3. Milk round system (topping up

predetermined stock level)

4. As on required basis. (Grocery system)

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OPERATION OF DRY-HEAT STERILIZERS

A dry-heat sterilizer will typically have the following operating cycle.A. Heating-up. Hot air is heated electrically and circulated

through the chamber. B. The plateau period starts when the chamber temperature,

recorded by a sensor located in the part of the chamber known to be the slowest to heat up, reaches the sterilization temperature.

A. In the first part of this period, the equilibration time, all parts of the load attain the sterilization temperature.

B. The moment when the temperature in all parts of the load finally attains the sterilization temperature marks the end of the equilibration time and the start of the holding time.

C. Cooling. The load is cooled by circulating cold, filtered air through the chamber or through a jacket.

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SERVICE OBJECTIVES

• Decontaminate to a level compatible with the intended use of the product.

• Minimize adventitious contamination through control of the environment, personnel and materials.

• Produce items that are fit for their intended purpose within the specified life-time.

• Within the constraints of the service, provide products in a timely manner.

• Ensure the location and facilities provide a high quality and cost-effective service.

• Provide adequate labelling and instructions for safe use. • Ensure the process is validated, controlled and monitored.• Hold appropriate documentation/records to demonstrate

compliance.

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CSSD IS DIVIDE INTO 5 MAIN AREAS

• Decontamination• Assembly and processing• Sterilization• Sterile storage and • Distribution

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CSSD FUNCTIONING

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CSSD layout: single-door sterilizer configuration and flow chart

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CSSD layout: double-door sterilizer configuration and flow chart

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INDIVIDUAL SPACES WITHIN AN SSD

• Entrance areas• Contaminated returns lobby• Contaminated returns holding

area• Wash room: gowning room/area• Wash room• Wash room: domestic services

room• IAP gowning room• Inspection, assembly and

packing (IAP) room• IAP domestic services room• Materials store• Materials transfer room• Packed product transfer facility

• Sterilizer loading area• Sterilizer plant room• Unloading/cooling area• Processed products store• Despatch area• Manager’s office• Deputy manager’s office• Office(s): general• Staff room• Training room• Staff changing/WC/shower room• General areas: domestic services

room• General waste disposal/laundry

returns• Test equipment and data room.

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OPERATION THEATERS

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GENERAL PLANNING PRINCIPLES-OTS

1.The internal layout based on the traffic flow within the departmentA. A single corridor to carry patients, staff, clean and used

equipment (suitably bagged) to and from the operating theatres and out through a separate theatre exit. OR

B. Clean and dirty streams of traffic can be segregated. 2.Rooms arranged in continuous progression from the entrance

through zones of increasing sterility. 3.Staff within the department should be able to move from one

clean area to another without passing through unprotected or unclean areas.

4.Patients, staff and services should enter through the same control point.

5.Air for air-conditioning should move from cleanest to less clean areas.

6.The operating theatre should be at positive pressure in relation to adjacent rooms.

7.Reduced air movement – to reduce airborne infections

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CONSIDERATIONS AT THE INITIAL PLANNING STAGE

• Consider modular construction methods.

• Infection control teams should be consulted from the outset of any new-build or renovation project and should remain integral planning team members throughout.

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CONSIDERATIONS AT THE INITIAL PLANNING STAGE

Bench-top sterilizers in theatres are replaced by central sterile service department (CSSD).

Operating departments should ensure that they have adequate stocks of surgical instruments to overcome issues associated with dropped instruments.

Some surgical operations necessitate exposing patients in ways that they find distressing and embarrassing. Protecting their dignity is therefore a critical function.

A number of measures can be taken to minimise the invasion of privacy including the design and fitting of the building. 46

CONSIDERATIONS AT THE INITIAL PLANNING STAGE

• An increasing number of patients undergo surgery without a general anaesthetic, remaining conscious throughout the entire procedure, and hence remain aware of their surroundings even in the operating theatre.

• Designers should aim to create an environment that is conducive to making patients feel at ease and giving them confidence, thus aiding the healing process. At the same time it should facilitate efficient working, and contribute to staff morale.

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NATURAL LIGHTING

Natural light is of particular importance to the wellbeing of patients and staff. All surgical facilities, where possible, should have natural daylight directly from windows, or by means of borrowed light from windows across corridors. Lack of natural light is one of the most common complaints made by staff about their working environment.

Where natural light is not available through conventional means, consideration should be given to using recently-developed technology, which allows natural light to be ducted to internal rooms even in multi-storey buildings.

Where possible, the following areas within the department should have natural light: operating theatres; recovery unit; staff rest room.

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CAPACITY PLANNING- LATER

• A separate sheet is provided to you to presents a method of determining the number of operating theatres that will be needed for a new, or for a reconstructed, operating department for in-patients. The method also provides an estimate of unused capacity.

• In the calculations, using the model of eight theatres, it is assumed that at least one theatre will be reserved for emergencies.

• One session (half a day) per theatre each week should be reserved for planned preventive maintenance and cleaning. 49

OT ZONING

Outermost protective zone:Generally at level of hospital cleanliness

Patient waiting, OT reception, Staff change rooms and toilets, Trolley-bay, Patient traffic area, Cafeteria. Positive air-pressure relative to rest of hosp.

maintained.

Clean zone: Higher Positive air-pressure level than outer zone.

Aseptic or sterile zone: Higher Positive air-pressure relative to other areas so as to exclude entry of air from any other areas. Communicate with dirty corridor or disposal area through inter-lock hatch system.

Disposal zone: less air press than sterile zone. Instruments temporary stored/collected before being sent for sterilization.

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SITING CONSIDERATIONS

• Ideally, all the operating theatres in the hospital should be in one location with one recovery unit. This helps with flexibility of operation, efficiency of staffing, clinical governance and safe management of emergencies.

• Operating theatre departments that admit patients for emergency surgery should have the following services on the hospital site as a minimum standard• emergency care (A&E department);• 24-hour access to imaging, including scanning;• critical care;• laboratory services (pathology);• in-patient acute services; and• orthopaedic/trauma services. 51

SITING CONSIDERATIONS

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ANAESTHETIC ROOMS

• In the UK it is common practice for each operating theatre to have its own anaesthetic room. • It is common practice in the US, in some

European countries and Pakistan to exclude the traditional anaesthetic room from the operating department layout. Patients are prepared for their operation in the operating theatre. This has been taken up in the UK by a small number of trusts.

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PREPARATION ROOMS

• One preparation room for each theatre• Where the laying-up of trolleys is undertaken

under the protection of the ultra-clean ventilation canopy it is imperative that the ultra-clean ventilation system is operating at full duty• Under no circumstances should two or more

operating theatres share a single preparation room, due to the potential risk of cross-infection via the ventilation airflows.

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RECOVERY UNITS OR PACU (POST ANAESTHETIC CARE UNIT)

• Most patients are transferred from the operating theatre to the recovery unit.

• This will affect the size of each space, as it should be large enough to accommodate an adult bed with additional space for the monitoring equipment and to ensure immediate access for staff in case of emergency

• Provision is required for quiet dark spaces (using adjustable lighting levels) in which patients can recover from specific anaesthetics

• The need to segregate male from female patients should also be considered. 55

ACCOMMODATION IN AN EIGHT ROOM THEATER

• Integral • communications base;• eight operating theatres• eight anaesthetic rooms;• patient support facilities (admissions lounge with

changing facilities, waiting area, interview room);• recovery unit with 16 bed spaces (with associated

ancillary accommodation);• staff support facilities (porters’ base, changing facilities,

rest rooms, reporting room);• storage areas (equipment, bulk store);• disposal areas (dirty utility, disposal hold, housekeeping

room).

• Integral or co-located• education and training facilities;• anaesthetic department;• administrative offices.

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FUNCTIONAL RELATIONSHIPS

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TRAFFIC FLOW IN OPERATING DEPARTMENT

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A LAPORSCOPY SETUP IN OT

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SCRUB SINK WITH NON-TOUCH TAPS

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RECOVERY AREA

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THEATRE CONTROL PANEL

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MEDICAL GAS AND EQUIPMENT

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• 12 socket-outlets and connection to the UPS/IPS systems

• PAS theatre record system networked to hospital mainframe;

• 1 oxygen outlet;• 1 nitrous oxide outlet;• 1 medical air outlet;• 1 surgical air outlet;• 2 medical vacuum points;• anaesthetic gas

scavenging points.

• anaesthetic machine located on anaesthetic medical supply unit only;

• flat-screen monitor and recording system for patient records;

• 2 infusion pumps;• 3 syringe pumps;• blood warmer;• feeding pump

CEILING MOUNTED PENDANTS

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MEDICAL GAS OUTLETS

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DOORS WITHIN THE OPERATING SUITE

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Doors through which beds or trolleys will pass should be wide enough to allow easy passage with attachments, including sterile drapes. It should bepossible for them to stand in the open position. All doors should be fitted with vision panels capable of being obscured, and have laser-proof blinds. All doorsshould close quietly

EXIT BAY

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STAFF ACCOMMODATION

• Theatre staff work in stressful situations every day. The provision of well-designed facilities will be a morale boaster.

• There are five main categories of staff facilities, all of which should be designated clearly as non-clinical areas:• rest facilities;• changing rooms and associated facilities;• office accommodation;• facilities for education and training;• storage.

• Areas 1 and 2 should be located within the operating department. 68

STORAGE ROOM FOR SUPPLIES AND EQUIPMENT

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CEILING

• A minimum clear height of 3000 mm between the finished floor level and ceiling is required to allow unrestricted adjustment of the operating luminaire and other ceiling-mounted equipment.

• The building structure should be capable of supporting the loads generated when the ceiling mounted medical supply unit is installed.

• Modular ceilings are not acceptable in the operating theatre. The ceiling in the operating theatre should also be able to withstand an occasional wash and have a completely sealed finish to maintain microbiological standards.

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FLOOR

• Carpets are not acceptable anywhere in an operating department. Floors should be able to withstand harsh treatment, including:• the rolling loads of heavy mobile equipment;• frequent spillages with subsequent “mopping-up”; and• regular hard cleaning.

• Flooring should also have the following• characteristics:• hygienic finishes;• slip-resistant;• continuous;• smooth;• impervious;• sealed joints;• easily cleanable;• wear-resistant

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VENTILATION STRATEGY

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The ventilation system in the operating theatre suite has four main functions:

• dilution of bacterial contamination;• control of air movement within the theatre suite such that the transfer of airborne bacteria from less clean to cleaner areas is minimized;• control of space temperature and humidity;• to assist in the removal and dilution of waste anaesthetic gases.

Room Pressure To

Preparation room Positive Theater

Theater Positive All other rooms excluding preparation room

Anesthetist room Positive Corridor

Disposal Negative Corridor

Corridors Neutral

AIR HANDLING UNIT

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OT LAYOUT

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INTENSIVE CARE UNIT(ICU)

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ICU INTRODUCTION

• The intensive care unit is for critically ill patients who need constant medical attention and highly specialized equipment, to control bleeding, to support breathing, to control toxaemia and to prevent shock. They come either from the recovery room of the operating theatre, from wards or from the admitting Section of the hospital.

• This unit requires many engineering services, in the form of controlled environment, medical gases, compressed air and power sources. As these requirements are very similar to those in the operating department, it is advisable to locate the intensive care unit adjacent to the recovery room of, the operating department. If engineering provisions are to be centralized for economy, the recovery room and the intensive care unit should be on either side of the support area.

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SHOULD EVERY HOSPITAL HAVE ICU?

• The number of beds in ICU should correspond to approximately 1-2% of the total beds in the hospital. In small hospital of 50-100 beds, this would mean only one or two beds.

• This number would not warrant the provision of an intensive care unit. Such a unit should contain no fewer than six beds in order to justify the highly sophisticated equipment and highly specialized manpower involved.

If so what alternatives to considered?• A patient who requires long-term intensive care should be referred

to a higher-level hospital.• Intensive care beds can be provided within the recovery room of

the operating department.• Patients who are highly dependent on nursing can be given beds

or rooms very close to the nurses' station in the ward, sustained with a portable oxygen tank and monitoring equipment.

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DEPARTMENTAL RELATIONSHIPS

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FUNCTIONAL RELATIONSHIPS

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ENTRANCE

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BED SPACE LAY OUT PLAN

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THANK YOU