Kha PDF

Intensive Care Unit (I.C.
U)
Document No: Date of Issue : ---------------
Version/Issue No: 01 Effective Date: -------------------
Edition : 01 Document Pages: Page 2 of 39

Intensive Care Unit (I.C.U)
1. About the Department:

Scope of services
Timings
Types of patients served
2. Organogram
3. Quality Policy
4. Quality Objectives
5. Patient Registration and Admission

S.No Activity Responsibility Record
1. Advice for Hospitalization
- Patient is advised for hospitalization by the treating doctor. Treating Doctor / OP Case Paper /
- The advice is written in OP case paper for patients from OPD Casualty Medical Casualty Case paper
and written in Casualty case paper for patients from Emergency Officer
Department. For planned admissions also the advice for
hospitalization is written by the treating doctor on OP Case
Paper.
2. Patient Registration & Admission
- Inpatient registration shall be done at registration counter during Treating Doctor /
OPD hours and at emergency department during non OPD hrs. Casualty Medical
- All emergency patients shall be registered at emergency Officer
department at any time.
3. Registration at Registration Counter:
- On producing the OP case paper with written advice for Treating Doctor / OP case paper,
hospitalization, registration clerk enters the patient detail at Casualty Medical Admission register
Admission Register and prepares IP case paper for the patient. Officer
A unique identification number shall be provided to the patients.
- The Admission register shall be handed over to emergency
department after OPD hours for undertaking registration.
4. Registration at Emergency Department:
- Casualty medical officer advices admission to patient who Treating Doctor / Casualty case paper,
require inpatient admission on Casualty case paper and the IP Casualty Medical Admission register ,
case paper shall be prepared. The patient details shall be Officer IP case paper
entered in Admission register.
- Every patient who is admitted shall be provided with a unique
identification number.
- For Medico Legal Case cases, a stamp of ‘Medico Legal Case’
is put in red ink on IP case paper.
5. Criteria for admission to I.C.U
Reference standard - ME G4.2

6. In case of non-availability of beds

1. ICU shall try to keep 10% of its beds vacant at all times to meet any Ward- Incharge Nil
unexpected emergency situations.
2. ICU beds shall be used only for patients who require Intensive care. Ward- Incharge Nil
Admission to ICU shall be guided by admission criteria as given in
document ‘admission and discharge criteria’. Patient shall be
discharged from ICU as soon as discharged criteria are fulfilled.
3. All efforts shall be made to accommodate patient coming for Management , Nil
admission as far as possible. Ward-Incharge
4. The hospital doctors shall try to discharge the recovered patients in Doctors Nil
time to manage the beds for new admission.
5. In case of non-availability of bed, based on the criticality of individual Ward Incharge, Nil
care, alternative arrangements shall be made like putting extra beds nursing staff
or placing patient in a different ward until beds are available.
7. Patient receiving and initial assessment

1. Patient receiving in ICU

Ward/casualty nurse shall always accompany the ward boy /aaya during Nursing staff of Nil
patient transfer to I.C.U. ward & I.C.U
I.C.U Nursing staff shall receive the patient and IP case paper at the
nursing station.
1. Collect information about the patient. I.C.U nursing staff Patient case
a. Diagnosis and treatment and Incharge paper and
b. Respiratory status, doctor Admission slip
c. Cardiovascular status,
d. Intravenous lines,
e. intra arterial lines,
f. infusions in progress
g. Any special requirements.
2. If life threatening complications exist treat immediately. I.C.U nursing staff
3. If no immediate life threatening complications seen, continue with and Incharge
admission procedure. doctor
4. Transfer the patient from trolley to bed taking care of all IV lines drainage I.C.U nursing staff
tubes and airway.
Any special treatment instruction or information provided by the I.C.U nursing staff Patient case
ward/casualty Nursing staff shall be noted down for reference. sheet
2. Initial assessment and continuity of care
2.a. Initial assessment
Every patient being admitted to I.C.U shall undergo an established initial Nursing staff Initial
clinical assessment on the basis of prescribed format. The assessment assessment
shall include generic and individualized elements specific to patient age, form
diagnosis, condition and disease process.
Check all equipment is available and functioning, appropriately. Nursing staff Nil
5. On receiving the patient the nurses shall make a Quick Initial Nursing staff Initial
6. Assessment of the general condition of the patient assessment
a. Airway, form
b. Breathing,
c. Circulation,
d. Level of consciousness.
Initial assessment will be documented preferably within 1 hour Nursing staff Initial
assessment
form
2.b. Continuity of care
7. Connect patient to cardiac monitor. Nursing staff Nil
8. Establish appropriate oxygen therapy- continuation of therapy already in Nursing staff Nil
progress of initiation of preferred method of oxygen delivery- mechanical
ventilation, face mask, nasal canula-piece.
9. Connect transducer to any monitoring line-Arterial line central line etc. Nursing staff Nil
10. Record baseline observations on flow chart. Nursing staff Patient case
sheet
Commence I V infusion as ordered and medication. Nursing staff Nil
Check and send requisite investigations priority-wise e.g. Blood grouping, Nursing staff Patient case
sheet,
blood sugar level, ABG, electrolytes will have greater priority in selected
Investigation
situations. requisition form
Assist Doctors in necessary procedures Intubation / Cannulation / Nursing staff Nil
Catheterization etc.
Check case file, in case of MLC hand over clothes/belongings and gastric Nursing staff Patient case
sample to the police & ensure completion of MLC formalities. sheet
Inform the respective treating consultant as soon as possible for Nursing staff Nil
undertaking further treatment course.
Indent requisite medications and diet and ensure timely diagnostic tests Nursing staff Medication order
sheet , nursing
are conducted as per course of treatment
notes , diet
register,
Investigation
requisition form
8. Patient Re-assessment
1. All patients shall be reassessed throughout their stay in the Incharge medical Treatment notes
I.C.U. Re-assessment shall be done by the Incharge medical officer, Treating
officer and treating doctor at least once a day. The frequency doctor
can be augmented based on the clinical condition.
2. The following parameters shall be reassessed in routine for all Nursing staff Nursing note, Patient vital
the patients by the Nursing staff . sheet
- Temperature, Pulse and Respiration
- Blood pressure
- Any other parameter specific to the specialty and as
advised by consultant in charge
3. To ensure regular monitoring, the nurse to patient ratio shall be Nurse –Incharge Nil
maintained as 1:1 for patient on ventilator and 1: 2 for other I.C.U
patients in the I.C.U.
4. The treating doctor shall regularly check and scrutinize the Treating doctor Patient case sheet
notes made on the patient case sheet to ensure that all the
relevant information about the sign and symptoms, daily
progress or detoriation, operation notes, anaesthesia notes and
notes of investigations like X-ray and laboratory tests are
entered on the case papers and evaluate the patient’s condition
accordingly.
5. Patient Vitals are monitored and recorded periodically. Critical Nursing staff TPR chart, IO chart,
patients are monitored continually. Nursing notes shall be treatment chart, nursing
adequately written. TPR chart, IO chart, any other vitals notes etc
required shall be monitored.
6. The re-assessment done shall faithfully reflect the patient’s Treating doctor Patient case sheet
clinical condition, response to treatment and inputs to plan
further line of treatment or discharge.
7. All clinical re-assessments shall be recorded and signed with Nursing staff, Patient case sheet
name, date and time in the medical record by the staff making doctor
entry
Reference standard – ME G4.2,
9. Transfer or Referral of Patients

1. Transfer of Patients (Diagnostic unit/OT)
Patients scheduled to go for diagnostic tests/surgery shall be Nursing staff , Nil
transferred safely to the required service area by the ward boy/aaya ward boy/aaya
on a stretcher or wheelchair. A Nursing staff shall always
accompany the patient during such occasions
Details of hospital transfer shall be entered in ‘Transfer In & Out’ Nursing staff , Transfer In- Out
Register. technician register
2. Referral of Patients
If patient requires diagnostic tests or further care that cannot be Doctor, Referral slip
provided at the hospital then the patient shall be referred to the Nursing staff
nearby referral centre.
Whenever needed ambulance shall be provided by the hospital for Nursing staff , Nil
quick transportation of patients. ambulance
driver
An advance telephonic communication with the referral centre shall Casualty List of contact details of
be done to ensure the required service is available and intimate the Medical Officer, ambulance
staff of the higher centre about the referral. Nursing staff
The Nursing staff shall document the referral details and coordinate Casualty Refer In-Out register
for the referral process. Medical Officer,
Nursing staff
Patient along with the referral slip and case sheet shall be referred Casualty Referral slip
to the higher centre. Medical Officer,
Nursing staff
The nursing staff shall also contact the referral centre and follow up Casualty Refer In-Out register
about the condition of the patient post referral. Medical Officer,
Nursing staff
Reference standard – ME G4.2
10. Requisition for diagnostics, collection & transfer of samples and

receiving of reports
1. Treating doctor shall prescribe the investigations in the requisition Doctor Investigation requisition
form/doctor’s note and counter sign the same with name, date and form/doctor’s note
time.
2. For laboratory test, the sample shall be collected by Nursing staff Nursing staff Sample dispatch register
following aseptic procedure. The sample shall be transported to
the lab by the ward boy/aaya by the use of transportation boxes.
The samples shall be labelled with the patient name, ID and test
name.
3. For emergency test requisitions the labels shall be marked with Nursing staff Sample dispatch register
EM. and lab staff shall be intimated over the phone too.
4. After all tests are done, reports shall be received from the Nursing staff Test Report
concerned diagnostic area as per the turnaround time for test.
5. The reports received should be discussed with the doctor during Nursing staff Test Report
his/her rounds. In case of any critical results the doctor shall be
immediately intimated through phone or by a messenger
11. Nursing care

1. Correct Identification of patient
The correct identification of the patient shall be ensured at all Nursing staff Nil
point of care and especially before initiating any invasive
procedure.
Patient id band/ Pt id no, verbal confirmation and Bed no, any two Nursing staff Patient case sheet
of the identification marks shall be followed to correctly identify
the patient.
2. Timely and accurate nursing care
Treatment charts shall be maintained and updated. Drugs given Nursing staff Patient case sheet
shall be documented in case sheet. The drug dosage given
should Co-relate it with drugs, time and doses prescribed.
3. Ensuring accuracy of verbal/telephonic orders
Verbal or telephone orders shall be accepted only on emergency Nursing verbal order register,
when it is impossible or impractical for the physician to write staff , doctor patient case sheet
them.
Abbreviations should not be used when an order is given or Nursing verbal order register
received. staff , doctor
Read back the order to the physician including the patient’s Nursing verbal order register
name, treatment order/drug name and spelling of the drug to staff
avoid an error due to sound alike drugs, Dosage, pronouncing it
in single digits (e.g. 15 mg should be read as one five), route,
frequency (e.g. three times daily, not TID).
Document the order immediately including the date, time, and Nursing verbal order register
physician’s name. Receiver’s name and signature. staff
Ensure the order is countersigned by the same doctor within 24 Nursing verbal order register,
hours of communication of the verbal order. staff , doctor patient case sheet
4. Nursing Hand-over
The nursing staff shall follow handing over formalities after every Nursing staff Nursing hand-over
shift. A Nursing hand-over register shall be maintained for the register
same.
During change of each shift, patient handover shall be given; A Nursing staff Nursing hand-over
practice of giving bedside patient handover shall be carried out. register
All details of patient condition, treatment given and care to be Nursing staff Nursing hand-over
given next shall be explained to the next nursing staff on-duty. register
All details explained shall be documented in the nursing hand- Nursing staff Nursing hand-over
over register and signature of the nursing staff giving and taking register
handover shall be documented in the register.
12. Care of vulnerable and High risk patients

1. Vulnerable patients shall be identified and measures taken to Nursing staff & Nil
protect them from any harm I.C.U –Incharge
2. Unconscious and comatose patient, stuprose patient, patient Nursing staff & Nil
with suppressed immune system cord are some of the I.C.U –Incharge
vulnerable patients
3. High risk patients shall be identified and treatment given on Nursing staff & Nil
priority. Certain type of high risk cases are patients with I.C.U –Incharge
myocardial problems, respiratory failure, wound infection or
sepsis etc.
4. All aseptic measures like universal precautions and standard Nursing staff & Nil
I.C.U –Incharge
treatment guidelines shall be followed in the care of High risk
patients
5. Regular periodic monitoring of the vulnerable patients shall be Nursing staff & Patient case sheet
I.C.U –Incharge
carried out to ensure their safety
Reference Standard: ME G4.2
13. Safe Drug Administration

1. Following parameters shall be verified before administration of drugs by Nursing staff Drug chart,
the person administering the drug Nursing notes
 Written medication order (For verbal order refer the document ‘written
orders for medications’
 General appearance (physical incompatibility) of the medicine for
administration (for e.g. melting, clumping etc.)
 Patient identification
 Dosage of medication
 Route of administration
 Time of administration
2. All the medications administered in In-patients shall be documented in Nursing staff Drug chart,
drug order sheet and nurses chart Nursing notes
3. In case of any adverse reactions, the treating doctor shall be notified as Nursing staff Drug chart,
soon as possible and details of the event shall be documented in the Nursing notes
incident reporting form
4. Any high risk medication shall be administered by/under the supervision Nursing staff Drug chart,
of a senior Nursing staff only Nursing notes
5. Close monitoring of the patient after the drug administration shall be Nursing staff Drug chart,
carried out Nursing notes

14. Blood Transfusion

6. There must be doctor’s order for blood transfusion specifying: Treating doctor Patient case sheet
- Type of component
- No. of units to be administered
- Rate of administration
- Medications if any
- Special procedures if any
7. The Nursing staff shall identify the purpose of blood transfusion Nursing staff Blood transfusion
and send a filled up blood transfusion requisition form to the requisition form
blood bank for receiving the requested blood/blood component.
8. On receiving the blood, the Nursing staff shall re-check of the Nursing staff Nil
blood group and expiry date on the bag.
9. Blood should be allowed to stand at room temperature for 30-45 Nursing staff Nil
minutes before its administration. Except platelets which is to be
transfused immediately.
10. Prepare all bedside articles and prepare patient for blood Nursing staff Blood transfusion
transfusion Explain the patient & relatives about the procedure consent form
and take consent of the patient on the blood transfusion consent
form.
11. Nursing staff shall verify the patient’s name, IP No. on the sticker Nursing staff Patient case sheet
(attached on the blood bag) & form received from the Blood Bank
in the patient’s presence, at the bedside, prior to transfusing.
12. Physical preparation of patient Nursing staff Nil
- Check IV Cannula for blockage or any complication
- Check vital signs
- Check site of B.T
- Use of 18 or 20 gauge Intra cath for infusion is
recommended
13. After transfusion the patient must be closely observed and Nursing staff Vital monitoring chart
assessed for:
- Vital signs
- Rate of flow
- Signs of circulatory overload
- Urinary output
- Needle site for signs of infiltration, haematoma &
dislodgement of needle etc.
- Any possible transfusion reaction / complication including
fever, chills, back pain, dyspnoea, hypotension,
hemoglobinuria, bleeding.
- Patency of infusion set.
Keep the patient warm & comfortable with a blanket
14. In the event of a suspected transfusion reaction, follow the Nursing staff Transfusion reaction
following steps: form/ Incident reporting
- STOP the transfusion immediately form
- INFORM the doctor immediately
- Recheck all blood labels and patient identification
- Draw blood sample in a separate tube from other limb.
- Record the reactions in nursing sheet with time.
- Submit all documents with blood specimen, blood bag &
transfusion set to Blood Storage centre.
15. On completion of B.T., consult doctor for further treatment. Nursing staff Nil
16. Nursing staff to record the following in the Nursing note: Nursing staff Nursing note
- Time of start and completion of B.T.
- Volume of blood administered
- The group & type of blood administered
- Rate of flow
- Any reactions observed
- Any medications administered
17. SAFETY MEASURES Nursing staff Nil
- Follow strict aseptic technique throughout the procedure.
- Appropriate filter has to be used for transfusion.
- Care is to be taken to prevent introduction of air in the
apparatus.
- No Medications shall be administered simultaneously with
blood or blood components via the same IV line.

- If any IV fluids are to be given immediately before, during
or after transfusion always use physiologic saline to
prevent haemolysis of the blood in the tubing.
- Once the blood is exposed to the atmosphere for more
than 30 minutes, it should be discarded.
Reference Standard: ME E.13.8, ME E.13.9, 13.10
15. Nutrition in critical illness


16. Storage and retrieval of records

1. Storage of records
All medical records of the patient shall be complete & legible with Nursing staff Patient case sheet
proper name & signature of the author with date & time
The patient information shall only be shared amongst the care Nursing staff Patient case sheet
providers. While on use the files should be stored in nursing
station under the custody of I.C.U nursing staff
On patient discharge the file shall be checked for completion and Nursing staff Patient case sheet
sent to MRD for storage. Only copy of the discharge summary
shall be handed over to the patient during his discharge.
2. Retrieval of records
Access to clinical records of patient is allowed to entitled Nursing staff record requisition
personnel only on request. Whenever the clinical record of a register
follow up patient is sought after by the treating doctor, he/she
shall fill in a record requisition register at MRD for availing the
same. For retrieval of case sheet of an MLC patient, court
permission shall be soughted
17. Purchase of external services & supplies

Refer SOP in pharmacy & store manual
18. Maintenance of infrastructure of I.C.U

1. Seismic safety of infrastructure
The I.C.U shall ensure the seismic safety of the infrastructure. Non I.C.U In-charge Nil
structural components shall be properly secured.
Fixtures and furniture like cupboards, cabinets, and heavy equipments, I.C.U In-charge Nil
hanging objects shall be properly fastened and secured.
2. Safety of electrical establishment

I.C.U shall not have temporary connections and loose hanging wires I.C.U In-charge Nil
Periodical check / test of all electrical installation by electrical Engineer/ I.C.U In-charge & Maintenance
maintenance staff shall be done once a week maintenance staff checklist
ICU shall have a dedicated earthling pit system available I.C.U In-charge Nil
Wall mounted digital display shall be available in ICU to show earth to I.C.U In-charge Nil
neutral voltage
Quality output of voltage stabilizer will be displayed in each stabilizer I.C.U In-charge Nil
as per manufacturer guideline
Power boards shall be marked as per phase to which it belongs I.C.U In-charge Nil
Floors of the ICU shall be non slippery and even and daily cleaning I.C.U In-charge & Nil
done housekeeping -
Incharge
Windows/ ventilators if any shall be intact and sealed I.C.U In-charge Nil
3. Fire Safety
The I.C.U shall have a fire exit to permit safe escape to its occupant at Management Nil
time of fire
Fire exits shall be clearly visible and routes to reach exit clearly Management Nil
marked.
Smoke and heat detectors and fire extinguishers will be placed at Management & Nil
strategic locations in I.C.U for ensuring fire safety. I.C.U Incharge
19. Thermoregulation in I.C.U

20. Counseling of patient attendant

1. Since the I.C.U deals with critically ill patients, counselling of Treating doctor Nil
patient attendants is also a necessity. In most of the cases, the
family members get more scared than the patient which leads to
a lot of emotional anguish to the patient. Hence doctors can
prevent this by giving a little bit of their time in counselling the
attendants to allay their fears.
2. Doctors shall counsel the attendant on a daily basis about the Treating doctor Nil
status of the health of the patient, the treatment being given and
any associated criticalities if any are also noted to them in a very
sympathetic manner.
3. The family members shall be impressed upon with the need to Treating doctor Nil
provide emotional support to the patient. They shall also be kept
in confidence and assured that the hospital & doctors are trying
their best to treat the patient.
4. Counselling of the attendant of patient with less survival chance Treating doctor Nil
& nursing staff
shall be done in a very kind and compassionate manner and
emotional support to them shall be provided. However they
should be tried to made understand the reason for the criticality
too and how it is beyond the limit of the medical care to save
him/her.
21. Patient discharge

1. Discharge planning involves the following activities: Treating Doctor Patient vital sheets,
- Development of a care plan for post discharge care. investigation results,
- Arranging for the provision of services, including nurses notes etc.
patient/family education and referrals.
- The Nurse in charge as well as the Registrar is responsible
for coordinating the discharge with other team members.
2. The Discharge process shall be planned in consultation with the Treating Doctor, Patient vital sheets,
patient and/or family. Nursing staff investigation results,
nurses notes etc.
3. Discharge planning shall be initiated on the basis of assessment Treating Doctor Doctor’s notes
of patients’ condition, i.e. the patient should be matching the
discharge criteria.
Discharge criteria from I.C.U :
4. Assessment of the patient shall be made for being ‘medically Treating Doctor Patient vital sheets,
stable’ and fit for discharge. This may include assessment of investigation results,
functional, medical, medication, and nutritional needs. nurses notes etc
5. The Treating doctor shall write the discharge orders in the IP Treating Doctor Doctor’s note
case paper to initiate the necessary formalities for discharge.
6. A Discharge Summary shall be prepared and signed by the Treating Doctor/ Discharge Summary
treating doctor or Medical officer on duty (in case of non Medical officer on
availability of treating doctor) and given to the patient. duty
7. In case of Medico Legal Case, police shall be informed before the Treating doctor, patient case sheet
patient is discharged. Nursing staff
8. A copy of discharge summary shall be attached with IP case Nursing staff Patient case sheet
paper
9. Details of the discharge shall be entered in the discharge register Nursing staff Discharge register
10. The discharge summary shall contain the following information Management Discharge summary
- Details of the patient including Hospital IP Number form

- Date of admission and date of discharge
- Name of the doctor in charge of the case
- Patient history
- Reason for admission.
- Significant findings.
- Diagnosis
- Investigation results.
- Details of any procedure performed.
- Medication.
- Other treatment given.
- Course in the hospital
- Follow up
a. Advice.
b. Medication
- Instructions regarding when and how to obtain urgent care
11. During discharge, the patient shall be counselled on Medication Nursing staff Patient discharge
intake, care at home, diet intake, any medical precautions if any checklist
and identifying symptoms requiring immediate medical care.
22. Leave against Medical Advice & Absconding Patients

1. Leave Against Medical Advice
Under the scope of patient rights, no patient can be kept in Treating doctor, LAMA consent form
hospital against their will. Nursing staff
In case the patient or patient party wants to take away their Treating doctor, Nil
Nursing staff
patient against medical advice The nursing staff and the doctor
concerned should try to persuade the patient to stay and at the
same time try to find out why the patient wishes to leave, if
possible the problem should be resolved.
The treating doctor should also explain the criticality of patient Treating doctor Nil
and probable complications that may arise.
Despite this if the patient still wishes to take his / her own Nursing staff LAMA consent form
discharge, the Patient / relative shall be asked to sign the LAMA
consent form’. The same is attached to the case file.
In the event that the patient refuses to sign the form, this should Nursing staff LAMA consent form
be documented clearly in the Medical Records.
All discussions and risks explained should be recorded in the Nursing staff Patient case sheet
patient’s Medical Records.
A Discharge summary shall be prepared and handed over to the Treating doctor, Discharge summary
Nursing staff
patient. The Nursing staff shall fill the Discharge Summary and
attach it along with the IP case paper mentioning ‘LAMA’.
2. Absconding
If any patient leaves the hospital during the course of treatment Nursing Staff IP case paper
without informing the concerned staff, then the patient shall be
considered as absconded and the same shall be written on the IP
case paper.
The Nursing staff shall inform the treating doctor & RMO which Nursing Staff, IP register
shall be further informed to police. RMO
23. End of Life care

1. Core Principles for End-of-Life Care
Clinical policy of care at the end of life and the professional Doctor, Patient case sheet
practice it guides should: Nursing staff
- Respect the dignity of both patient and caregivers;
- Be sensitive to and respectful of the patient's and family's wishes;
- Use the most appropriate measures that are consistent with patient
choices
- Encompass alleviation of pain and other physical symptoms;
- Access and manage psychological, social, and spiritual/religious
problems;
- Offer continuity (the patient should be able to continue to be cared
for, if so desired, by his/her primary care and specialist providers);
- Provide access to any therapy which may realistically be expected to
improve the patient's quality of life, including alternative or non-
traditional treatments;
- Respect the right to refuse treatment
- Respect the physician's professional responsibility to discontinue
some treatments when appropriate, with consideration for both
patient and family preferences.
- Promote clinical and evidence-based research on providing care at
the end of life.
2. Identify the following:
- If the patient has any cultural or religious beliefs which necessitate Doctor, Nil
alternative procedures to nurses undertaking Last Offices. If this is Nursing staff
the case then follow the instructions for the specific religion
guidelines.
- If the body of the deceased is likely to leak after death, a body bag
will be required.
- If any special requests made before death, e.g. the keeping on of
jewellery, clothes to be worn.
- If the eyes have been donated for corneal grafting.
- If there are any radiation precautions still in force.

Physical preparation of dead body
- Eyes should be closed immediately as in sleep. If relatives have Nursing staff Nil
consented to.
- Body to be straightened with arms laid at the sides.
- Mouth should be closed immediately.
- Remove all support equipments
- Give thorough sponging to the patient.
- To change patient clothes.
- Keep the head & chin in position.
- Bandages may be used if necessary.
- Plug nose and ears with cotton plug.
- Cover the patient with new white bed sheet.
- Attach an identity card to the dead body having name & IP No
Procedural steps post death
- Allow the relatives to be with the body for a while. Arrange to meet Nursing staff Patient case sheet
the religious rites if possible.
- Nursing staff to follow the routine discharge procedure as per
Discharge policy.
- Primary Nurse to arrange for Mortuary / Dead body van if required.
- If the deceased is to be viewed by relatives on the ward ensure
there is no blood or body Wrap the patient carefully in a sheet and
fasten with tape. Fluid leakage about the face.
24. Equipment Management

Calibration of Equipments
1. All the measuring equipments/ instrument shall be Ward - Incharge Nil
calibrated.
2. An ISO certified calibration agency shall be identified to Ward - Incharge Nil
calibrate the equipments/instruments.
3. Calibration labels/stickers shall be placed on the Ward - Incharge Equipment register
equipment denoting the date of calibration and indicating
the status of calibration/ verification when recalibration is
due.
4. All calibration certificates shall be maintained by the Ward - Incharge Calibration certificate
Incharge or centrally stored by the Store-Incharge of the
hospital.
5. The ward shall maintain an equipment register to Ward - Incharge Equipment register
document details of equipment and calibration status.
6. It shall be the duty of the Incharge to ensure updation of Ward - Incharge Equipment register
calibration for all equipments as per their schedule.
General Maintenance
7. Up to date manufacturer’s instructions for operation and Ward - Incharge Manufacturer’s instruction
maintenance of equipments shall be kept in the
department so that the same can be readily available to
staff when required.
8. Defective/Out of order equipments shall be labelled and Ward - Incharge
stored appropriately away from traffic area, until it has
been repaired
9. Daily dusting/ dry wiping of equipments shall be done by Ward - Incharge Nil
housekeeping staff. The laboratory technician shall do a
daily check on the functioning of equipments every
morning before commencement of testing procedure.
10. An equipment register shall be maintained to document Ward - Incharge Equipment register
details of equipment - name, hospital code, and date of

installation, name of manufacturer, maintained in A
house/maintained by external agency or manufacturer,
Warranty Period, under AMC/CMC.
Preventive and Breakdown Maintenance
Preventive Maintenance
11. All equipments shall be covered under AMC/CMC Ward- Incharge Equipment register
including Preventive maintenance.
12. The lab-Incharge shall maintain an updated record on Ward- Incharge Equipment register
AMC & Preventive maintenance in equipment register this
should include details like :
o Frequency of Preventive Maintenance/Calibration
- As per manufacturer guidelines
- Presently being followed
o Preventive Maintenance/Calibration Done On
o Preventive Maintenance/Calibration Due On
o Expenditure with cost and details
o Remarks with Functional Status
13. Preventive maintenance shall be carried out as per Ward- Incharge Equipment register
Maintenance Schedule for each individual equipment
based on manufacturer’s recommendations.
14. The following shall be checked during a preventive Ward -Incharge Equipment Service Report
maintenance-
 Physical condition of the equipment/ facility
 lubrication, calibration, cleaning or replacing parts that
are expected to wear or which have a finite life
 Maintenance report verification
Maintenance / Service report shall be obtained from
service agency and after verification marked as O.K. /Not
O.K.
Breakdown Maintenance
15. Faulty or defective equipment shall not be used regardless Ward -Incharge Equipment register
of how minor is the problem and must be reported in the
first instance to the in-house maintenance engineer
/outside agency hired for maintenance as soon as

possible and seen that the problem is attended to as soon
as possible.
16. A label of “out of order” shall be attached to the equipment Ward -Incharge Nil
and information regarding breakdown shall be passed to
all staff including any shift changes.
17. On restoration of the equipment, the Equipment Ward -Incharge Nil
Breakdown Record should be updated. This indicates that
the breakdown/maintenance is performed of the
equipment.
The “out of order” sticker shall be removed after the
restoration of the equipment.
18. All the breakdowns occurring in the department should be Ward -Incharge Equipment register
maintained in the equipment register and include the
following
 Breakdown Date and Time
 Breakdown Details (Technical fault or other reasons)
 Date and Time of Rectification
 Total Time Taken (Rectification Time – Breakdown
Time)
 Rectification Details with expenditure including cost (if
any)
 Remarks with functional status
 Reasons for delay if any
25. Storage and Inventory management of drugs and consumables

Inventory Management
1. All drugs and consumables to be used shall be stored under the Ward-Incharge, Stock register
supervision of ward Incharge in cupboards at ward store Nursing staff
room/nursing station.
2. The stock stored shall be kept in original packages/labelled containers Ward-Incharge, Stock register
on labelled racks. Nursing staff
3. Stock level shall be daily checked and updated in a stock register. The Ward-Incharge, Stock register
expiry date for each batch of drugs shall also be mentioned in the Nursing staff
register.
4. A system of timely forecasting and indenting of drugs and Ward-Incharge Stock register
consumables shall be practiced .The ward Incharge shall ensure there
is a buffer stock available for emergency use before putting an indent
for new stock.
5. A crash cart for storage of emergency drugs equipment and Ward-Incharge, Crash cart checklist
consumables shall be maintained and a crash cart checklist shall be Nursing staff
used for daily (in very shift) stock checking and updation of the same.
Storage of drugs and consumables for daily use
6. All drugs and consumables required for daily use shall be kept neatly Nursing staff Nil
arranged in a medicine trolley.
7. The all drug and consumable containers shall be labelled. Nursing staff Nil
8. A medicine trolley register shall be maintained to record details of Nursing staff Medicine trolley
usage. register
9. Oxygen cylinder if kept in the ward shall be placed vertically chained Nursing staff Oxygen cylinder
onto the oxygen cylinder stand. A daily checking form shall be used on checking checklist
the cylinder.
Storage of Narcotic & Psychotropic Drugs
10. Narcotic & Psychotropic drugs shall be kept locked under the custody Ward-Incharge Narcotic &
of the Incharge. A register shall be maintained for the same for daily Psychotropic drug
stock updation. register
26. Infection control practices

1. Restricted entry
- Taking into consideration infection control measures and prevention Ward –Incharge, Nil
of overcrowding only one attendant at a time shall be allowed to nursing staff
meet the patient.
- Visitors shall be allowed entry only during visiting hours as per the
visiting policy
- Keeping in purview the infection control practices the attendant shall
have to change into sterile gowns, mask & slippers before entering
into the patient zone
- Hand washing shall be advocated before and after visiting the ICU
for the visitors.
2. Linen Management
For linen management refer SOP Auxiliary services Linen & Laundry Nursing staff SOP Auxiliary
6.3.1,6.3.2,6.3.3 services
3. Hand Hygiene
- Availability of wash basin with running water, soap, clean All ICU staff Hand hygiene
towel/tissue paper/hand dryer shall be ensured at the casualty monitoring
- Poster depicting steps of hand washing shall be displayed near all checklist
wash basins.
- All staff involved in patient care shall be trained on hand hygiene
practices.
- The Infection control nurse shall monitor for adherence to hand
hygiene practices.
Perform aseptic hand wash or alcohol base handrub:
a. Before entering the ICU
b. Before performing any invasive procedure including peripheral
cannula insertion and removal.
c. Before use of multidose vials
d. Before administration of IV fluids or medications/drugs.
Perform routine hand wash:
a. After touching environmental surface.
b. Whenever soiled
4. Barrier Nursing Practices

- The department shall define list of infectious diseases requiring Nursing staff Nil
special precaution and barrier nursing.
- Staff shall be trained for barrier nursing practices.
- Nursing Staff shall be trained on barrier nursing practices.
- Patients shall be assessed individually to determine any infection
that would require additional isolation precautions.
- Personal Protective Equipment shall be available to all the staff in
the ICU for the appropriate use.
5. Use of PPE
The staff should always adhere to the use of PPE like surgical gloves, Nursing staff Nil
uniform. In case of barrier nursing masks and aprons shall be used.
Gloving : Select gloves according to need
a) Sterile: For procedures using aseptic technique such as insertion of
central venous catheter and handling respiratory secretions of any
patients.
b) Non sterile: For procedures such as emptying urinary drainage
bags, insertion of peripheral IV catheters, contact with contaminated
surfaces or equipments.
6. General cleaning
- Wet mop floor using detergent and standard Housekeeping Nil
disinfectant/0.5%chlorine solution. staff
- Clean all furniture and lights using warm water, detergent and
disinfectant/0.5% chlorine solution every morning.
- Clean the toilets and corridor daily with detergent water and
disinfectant.
- Prepare cleaning solutions daily or as needed, and replace with
fresh solution frequently
Terminal cleaning
- Use vacuum cleaner to clean the AC Vent and ducts if available,
once in a month.
- Wet-dust horizontal surfaces by moistening a cloth with a small
amount of a recommended hospital detergent/disinfectant.
- Avoid dusting methods that disperse dust (e.g., feather-dusting).

- Close the doors of immunocompromised patients’ rooms when
vacuuming, waxing, or buffing corridor floors to minimize exposure
to airborne dust.
7. Waste Management
The following colour - coding system shall be used in waste Housekeeping Nil
management segregation. staff
Blue Bag:
 Syringes
 Tubings
 Saline bottles
Puncture Proof containers: White
 Broken glass articles
 Medicine vials
 Needles (to be disposed only after burning)
 Scalpels
 Metal articles, like forceps to be disposed.
Yellow Bag:
 Blood stained bandages, gauze, cotton, tissues, and gloves
 Infectious wastes
 Human organs
Black Bag:
 Paper
 Plastic & other general waste
8. Microbiological surveillance
As an infection control measure to check the sterility of the environment Infection control Culture
and surfaces in I.C.U, swabs shall be collected from patient care
nurse/ I.C.U sensitivity report
surfaces, utilities,floor,instruments & A.C vent to be sent for
microbiological culture surveillance . Incharge
9. Water testing
Once in a month overhead water tank cleaning and water testing shall Infection control Water testing
be done to check sterility of water. nurse/ I.C.U report
Incharge
10. IV care practice

a) Clean injection ports with 70% alcohol before accessing the system Nursing staff
.
b) Cap all stopcocks when not in use
c) Use aseptic techniques for insertion of central venous catheters.
d) Don’t routinely replace peripheral arterial catheters, central venous
catheters, haemodialysis catheter or pulmonary artery catheter.
11. Catheter care
A. Barrier Precautions During Catheter Insertion and Care Nursing staff Nil
i. Wear clean gloves when inserting a peripheral venous or
arterial catheter
ii. Wear maximum barrier protection, including sterile gowns,
gloves, mask, and cap and use a large sterile drape when
inserting a central line (arterial or venous).
B. Selection of Catheter Insertion Site
i. Weigh the risk and benefits of placing a device at a
recommended site to reduce infectious complications against
the risk of mechanical complications (e.g. pneumothorax,
subclavian artery puncture, air embolism, catheter
misplacement).
ii. Do not routinely use cut-down procedures as a method to
insert catheters.
C. Cutaneous Antisepsis
i. Although the surface area for prepping is dependent on the
size of the extremity, in adult patients, an area 2 to 4 inches
in diameter is generally accepted for central lines.
ii. Cleanse the skin with chlorhexidene or povidone iodine
swab.70% alcohol may be used to prep for peripheral
catheters.
iii. Do not palpate the insertion site after the skin has been
cleansed with the antiseptic.
iv. Do not routinely apply topical antimicrobial ointment to the
insertion site.
D. Catheter site dressing
i. Use either sterile gauze or semipermable transparent dressing
to cover the catheter site.
ii. The first change of the dressing shall take place after 24hr. The
second change shall take place after 48 hrs after the first
change. Afterwards, change catheter site dressings every 72
hours routinely or before or when they become damp, soiled or
loose.
iii. Replace catheter site dressing when the device is removed or
replaced Change dressings more frequently in diaphoretic

patients.
iv. Avoid touch contamination of the catheter insertion when
replacing the dressings.
E. Replacement of Catheter
i. In adults replace short peripheral venous catheters and rotate
peripheral venous sites every 48-72 hours to minimize the risk of
phlebitis. Remove and replace when signs and symptoms of
infections are present, i.e. warmth, tenderness, erythema or
tenderness at the insertion site.
ii. Leave peripheral venous catheters in place in children until IV
therapy is completed unless complications (e.g. phlebitis,
infiltration) occur.
iii. Replace peripheral intravenous locks every 96 hours.
iv. The frequency of replacement of peripherally inserted central
venous catheters and totally implantable devices are a physician
decision.
12. Quality assurance

1. Department Incharge shall be vigilant about the key characteristics. Incharge Nil
Based on the observation, every month Department-Incharge shall
record his / her remark against the key characteristics as to whether
the key characteristics meet the acceptance norms or not. Specific
comments for the key characteristics may also be written.
2. All reports shall be verified and signed by the radiologist/sonologist Incharge Reports
and then dispatched.
3. These quality indicators shall be maintained by the technicians and Incharge Indicator register
reviewed by the Incharge:
- Downtime critical equipments
- Transfer Rate
- Readmission rate
- Average length of stay
- No of adverse events per thousand patients
- Culture Surveillance sterility rate
- Re-intubation rate
- LAMA rate
- Average length of stay
- Risk Adjusted Mortality Rate/Standard Mortality Rate
- No of Pressure Ulcer developed per thousand cases
- Adverse events are identified
- Infection rate (UTI, VAP)
4. Internal Audits Auditor & Auditee Internal Audit
o Audits shall be conducted as per pre scheduled audit plan and report
organized and carried out by designated internal auditors.
CAPA report
o While planning Audit it should be ensured that the internal
auditors do not audit their own activities.
o A Quality management system procedure for Internal Audit
shall include the following
 Selection of Internal Auditors.
 Criteria for Internal Auditors.

 Audit Planning and methodologies.
 Audit recording, non-conformance and summary report
preparation.
o Where audit findings indicate deficiencies or the opportunity for
improvement corrective or preventive action is promptly taken,
this is documented and carried out within an agreed upon time.
Note: Refer Internal Audit procedure in Lab Manual for details

Annexure: Clinical protcols
- Step down of patient

- Pain management
- Sedation
- Starting central lines
- Early eternal nutrition
- Care of unconscious paraplegic patients
- Management of anaphylactic shock
- Non invasive ventilation in case of respiratory failure
- Intubation
- Extubation
- Tracheotomy
- Care and Monitoring of patient on ventilator

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Intensive Care Unit (I.C.

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1. About the Department:

Types of patients served

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5. Patient Registration and Admission

Reference standard - ME G4.2

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6. In case of non-availability of beds

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7. Patient receiving and initial assessment

1. Patient receiving in ICU

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9. Transfer or Referral of Patients

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10. Requisition for diagnostics, collection & transfer of samples and

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11. Nursing care

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12. Care of vulnerable and High risk patients

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13. Safe Drug Administration

Reference standard - ME G4.2

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14. Blood Transfusion

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blood or blood components via the same IV line.

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15. Nutrition in critical illness

Reference Standard: ME G4.2

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16. Storage and retrieval of records

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17. Purchase of external services & supplies

18. Maintenance of infrastructure of I.C.U

2. Safety of electrical establishment

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19. Thermoregulation in I.C.U

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20. Counseling of patient attendant

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21. Patient discharge

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- Details of the patient including Hospital IP Number form

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22. Leave against Medical Advice & Absconding Patients

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23. End of Life care

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- If there are any radiation precautions still in force.

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24. Equipment Management

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details of equipment - name, hospital code, and date of

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/outside agency hired for maintenance as soon as

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25. Storage and Inventory management of drugs and consumables