MEDA WELABU PRIMARY HOSPITAL

ICU ADMISION AND DISCHARGE

PROTOCOL

2016

MEDA WELABU BIDIRE

 INTRODUCTION

ICU
An Intensive Care Unit (ICU) is a hospital facility for care of critically ill patients at a more intensive level
than is needed by other patients.
In many developed countries, it is usually staffed by specialized personnel & the unit also contains various
kinds of monitors & life support equipment that can sustain life.
The patient population in ICU may present with a large variety of pathologies but shares the potential
reversibility of one or more threatened vital functions.
Appropriate utilization of Intensive care unit (ICU) resources is an important issue in poor resource
settings like our country where there is a national struggle to contain health expenditure. Generally, ICU
uses 8% of the total hospital budget, but in countries like USA it consumes14-20% of total hospital budget.
Due to the rapid urbanization, motorization, industrialization, and rapid population growth, the Ethiopia
health sector is facing a double burden of diseases, although infectious diseases still account for the major
part of the burden. Even though the medical care facilities are progressively growing in number and in
capacity, obtaining timely and optimal emergency and critical care has been practically difficult. The
Emergency Medical Service System (EMSS) as a system, and acute care medical practices, are found in
rudimentary state. Due to this situation, patients with acute illness, mothers with complicated delivery and
victims of different accidents have been managed sub-optimally. Due to such problems, morbidity and
mortality associated with accidents, acute illnesses and a complicated delivery are high. To decrease
such mortality and morbidities the FMOH has been in the process of strengthening EMSS and acute care
units or intensive care units by providing necessary training, equipment, different operational guidelines
and protocols.
 Annex.1- ICU color coded ICU triage

1.RED 2. ORANGE 3. YELLOW 4. GREEN

CRITERIA RESUSTATION URGENT LESS URGENT NOT URGENT
(0 MINUTE) (15 MINUTE) (60 MINUTE) (180 MINUTE)

A-AIR WAY Obstructed Threatened

airway stridor airway

B-BREATHING SPO2 <80 SPO2: 80-90 SPO2: 90-94 SPO2: >95

RR>35 or <8 RR:31-35 RR: 26-30 RR: 26-30
C-CIRCULATION HR>130 HR; 121-130 HR; 111-120 HR; 50-110
BP sys <80 HR<40 HR:40 -49
BP sys: 80-89
GLAUCO COMA GCS Less than GCS: 9-13 GCS= 14 GCS= 15
SCORE or equal to 8

TEMPRATURE Tp>40 Tp: 38.1-40.0 Tp: 34.1-38.0

Tp<32 Tp: 32-34
2. Definition
An Intensive Care Unit (ICU) is a specially staffed and equipped, separate and self-contained
area of a hospital dedicated to the management and monitoring of patients with life threatening
conditions.
It provides special expertise and the facilities for the support of vital functions and uses the
skills of medical, nursing and other personnel experienced in the management of these problems.
It encompasses all areas that provide Level 2 (high dependency) and/or Level 3 (intensive care)
care as defined by the Intensive Care Society document Levels of Critical Care for Adult Patients
(2009).
Multidisciplinary rounds are a patient-centered model of care, emphasizing safety and
Efficiency that enables all members of the team caring for patients to offer individual expertise
and contribute to patient care in a concerted fashion.
3. Scope
This protocol provides guide for all health professionals who play a role in the admission and
discharge of patients from intensive care units.
4. Rationale
Admissions to critical care unit are often unplanned. Immediate access to resuscitation and
critical care is fundamental in the management of many life threatening disease conditions.
Delayed admission to intensive care is associated with a significant increase in mortality. Lack of
access to critical care management has been identified as a major contributor to post-surgical
mortality.
Any patient in hospital may become high risk for sudden deterioration However, the recognition
of acute illness may be delayed or its subsequent management may be inappropriate. This may
result in late referral and/or avoidable admissions to critical care, and may lead to prolonged
critical care stay and increased morbidity and mortality.
Patients in the ICU will be evaluated and considered for discharge based on the reversal of the
disease process or resolution of the unstable physiologic condition that prompted admission to
the unit.
Therefore, a protocol for admitting and subsequently discharging critically ill patients is
essential. In addition for continuous developments in critical care, periodic review of these
criteria is necessary.
5. Objectives
5.1 The general objectives of this protocol are: to ensure quality of care for acute critical
conditions, through appropriate, transparent and timely admission and discharge of patients to or
from critical care, and to bring accountability for the system and to facilitate the proper utilization
of limited resources.
5.2 The Specific Objectives of this Protocol are: to aid physicians and nursing staff in determining
patient appropriateness for Adult ICU admission and discharge. To decrease significant delayed
admission to intensive care. To admit patients to the intensive care units based on clinically
based criteria. To improve ICU bed utilization by addressing overflow placement of ICU patients.
to coordinate appropriate patient discharge from the ICU with relevant units.

Admission
General principle of ICU admission
• ICU beds are very few in number in any country. However, the number of patients who compete
for ICU admission & care is very high. For this reason, admission of patients to the ICU must be
based on a guideline.

Admission Policy
Admission of a patient to the ICU must be decided by ICU
Director/Consultant in Charge/Physician in charge on duty. If the case is difficult to make a
decision by Physician in Charge,
ICU director will decide the admission. If a decision is made to admit a patient to the ICU, the
nurses must be informed beforehand to get prepared. Before accepting referral for admission to
ICU from other hospital, there should be early communication and once decision is made, the
liaison office should be informed for facilitation to transfer. If many patients are competing for
admission to the ICU, the following five questions must always be addressed so that one may
make an appropriate decision.
Factors that must be considered in the assessment of a possible admission to the ICU:
1. Primary diagnosis & the other active medical problems
2. Prognosis of the underlying condition/ is recovery still possible?
3. Age, life expectancy & expected quality of life post discharge
4. Wishes of the patient &/ or relatives
5. Availability of the required treatment, technology & professional
Admission Criteria
The ICU admission decision may be based on two models utilizing prioritizing and diagnosis.
These admission criteria are meant to guide the physician and do not replace the physician’s
judgment.
Prioritization Model for ICU Admission
This system dense those that will beneath most from the ICU (Priority 1) to those that will not
beneath at all (Priority 4) from ICU admission.
Priority 1 – Unstable
Requires intensive treatment and monitoring that cannot be provided outside of the Critical care
unit. E.g. Respiratory support, continuous vasoactive drug infusions, etc. Admission should take
place as soon as possible.
Priority 2 – High risk of sudden deterioration.
Requires invasive monitoring and may potentially need immediate intervention. E.g. a patient with
chronic co-morbid conditions who develops acute severe medical or surgical illness.
Priority 3 – Reduced likelihood for recovery due to underlying illness. May receive intensive
treatment to relieve acute illness but limits on therapeutic intervention may be set, such as no
intubation or cardiopulmonary resuscitation.
Priority 4 – Little or no anticipated beneath (too well to beneath) from critical care or patients
with terminal and irreversible illness (too sick to beneath from ICU care) facing imminent death.
Required care and monitoring can be administered in a ward setting. Admission of this type of
patient to the ICU is generally not considered appropriate.
Diagnosis Model for ICU Admission
This model uses specific conditions or diseases to determine appropriateness of ICU admission.
Patients with the following conditions are candidates for admission to the ICU. The following
conditions include, but are not limited to:
Respiratory
1. Acute respiratory failure requiring ventilator support e.g. ARDS
2. Acute pulmonary embolism with hemodynamic instability
3. Massive hemoptysis
4. Pneumothorax (with hemodynamic instability)
Cardiovascular
1. Shock states
2. Life-threatening dysrhythmias
3. Dissecting aortic aneurysms
4. Hypertensive emergencies
5. Acute Coronary Syndrome (Unstable angina, NSTEMI, STEMI)
6. Acute pulmonary edema
7. Acute congestive heart failure with respiratory failure and/or requiring hemodynamic support
8. Post cardiac arrest
9. Cardiac tamponed or constriction with hemodynamic instability
10. Complete heart block
11. Need for continuous invasive monitoring of cardiovascular system (arterial pressure, central
venous pressure, cardiac output)
Infectious diseases
1. Complicated falciparum malaria
2. Relapsing fever with severe complication
3. Severe tetanus
4. Severe sepsis with multi-organ failure.
Neurological
1. Severe head trauma
2. Status epilepticus
3. Meningitis with altered mental status or respiratory compromise
4. Acutely altered sensorium with the potential for airway compromise
5. Progressive neuromuscular dysfunction requiring respiratory support and / or cardiovascular
monitoring (myasthenia gravis, Guillain-Barre syndrome)
6. Acute spinal cord compression or impending compression;
7. Acute subarachnoid hemorrhage
8. Acute stroke with raised ICP
9. Coma: metabolic, toxic, or anoxic
Hematology
1. Severe coagulopathy and/ or bleeding diathesis
2. Severe anemia resulting in hemodynamic and/or respiratory compromise
3. Tumors or masses compressing or threatening to compress vital vessels, organs, or airway
4. Disseminated Intravascular Coagulation (DIC)
Endocrine
1. Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status
2. Severe metabolic acidotic states
3. Thyroid storm or myxedema coma with hemodynamic instability
4. Hyperosmolar state with coma and/or hemodynamic instability
5. Adrenal crises with hemodynamic instability
6. Pituitary apoplexy with neurohemodynamic instability
7. Other severe electrolyte abnormalities, such as:
- Hypo or hyperkalemia with dysrhythmias or muscular weakness
- Severe hypo or hypernatremia with seizures, altered mental status
- Severe hypercalcemia with altered mental status, requiring hemodynamic monitoring.
Gastrointestinal
1. Life threatening gastrointestinal bleeding
2. Acute hepatic failure leading to coma, hemodynamic instability
3. Severe acute pancreatitis
4. after emergency/Elective procedure,
Endoscopy/Colonoscopy/ERCP patient arrest
Renal
1. Acute renal failure
2. Requirement for acute renal replacement therapies in an unstable patient
3. Acute rhabdomyolysis with renal insufficiency
Acute poisoning
(With altered mental status, systemic complications or/&deranged vital signs)
1. Insecticide poisoning e.g. organophosphate poisoning
2. Snake bite poisoning (if ant venom is available)
3. Carbon monoxide poisoning
4. Drug overdose (e.g. phenobarbitone poisoning, antidepressant poisoning etc.)
Surgical
1. High risk patients in the pre-operative period
2. Post-operative patients requiring continuous hemodynamic monitoring/ ventilator support,
usually following:
O Vascular surgery
O Thoracic surgery
O Airway surgery
O Craniofacial surgery
O Major orthopedic and spine surgery
O General Surgery with major blood loss/ fluid shift
O Neurosurgical procedures
3. Post organ transplant
8.6.11 Multisystem and Other
Patients with life-threatening or unstable multisystem disease;
Conditions include, but are not limited to:
1. Toxic ingestions and drug overdose with potential acute decomposition of major organ
systems;
2. Multiple organ dysfunction syndromes;
3. Suspected or documented malignant hyperthermia;
4. Electrical or other household or environmental (e.g., lightning) injuries;

1. DISCHARGE PROTOCOL

a) All discharges must be approved by the ICU consultant/ICU responsible physician.

b) A discharge summary must be completed in the case notes prior to discharge.
c) At discharge from ICU the patient (must) be immediately accepted by the ward treating team.
d) Primary/parent teams must be informed of all patient discharges and any potential or
continuing problems
e) If appropriate, limitation/non-escalation of treatment must be clearly documented and
discussed with the parent/ primary team prior to discharge.

2. Transfer/Discharge Criteria:
Transfer/discharge will be based on the following criteria:
1. Stable hemodynamic parameters;
2. Stable respiratory status (patient intubated with stable VS, AND arterial blood gases if
available) and airway patency;
3. Minimal oxygen requirements that do not exceed patient care unit guidelines;
4. Intravenous inotropic support, vasodilators, and anti-arrhythmic drugs are no longer required or,
when applicable, low doses of these medications can be administered safely in otherwise stable
patients in a designated patient care unit;
5. Cardiac dysrhythmias are controlled;
6. Intracranial pressure monitoring equipment has been removed;
7. Neurologic stability with control of seizures;
8. Removal of all hemodynamic monitoring catheters;
9. Chronically mechanically ventilated patients whose critical illness has been reversed or
resolved and who are otherwise stable may be discharged to a designated patient care unit that
routinely manages chronically ventilated patients, when applicable, or to home;
10. Routine peritoneal or hemodialysis with resolution of critical illness not exceeding general
patient care unit guidelines;
11. Patients with mature artificial airways (tracheostomies) who no longer require excessive
suctioning;
12. Patient is vegetative or neurological recovery is not expected soon, but maintains his/her
airway
13. The health care team and the patient's family, after careful assessment, determine that there
is no beneath in keeping the patient in the ICU or that the course of treatment is medically futile.
 ICU Setting
ICU should be organized in health institutions based on their capacity, human resources, facility
and equipment as FMHACA standards;
1. ICU should be organized in a health institution that could provide the necessary services and it
should be located so it is easily accessible to all departments and laboratory, with adequate
spaces, and outlet.
2. Health institution/hospitals that provide general service may have one or more ICU with
different levels of care depending on the facilities, at least one of which must be a common ICU.
Specialized hospitals on the other hand can have specialized ICU, human resources and
equipment’s available at the institution.
3. The ICU system may be open or closed depending on institutional capacity and preference.
4. The ICUs may be common or specialized, depending on institutional need and capacity.
Common ICUs are recommended for most of the general hospitals.
5. A physician director must be appointed, who can give clinical, administrative and educational
direction to the ICU. The physician director could be an intensivist, pulmonary critical care
specialist, anesthesiologist, emergency medicine specialist or a physician trained in providing
critical care. The director should assume responsibility for ensuring quality, safety, and
appropriateness of care in the ICU. The ultimate authority for admission, discharge and triage
rests with the ICU director or delegated consultant in charge.
6. There should be a multi professional ICU team/ committee.
The team should meet on a regular basis to identify and solve problems through quality assurance
and continuous quality improvement activities. The team shall comprise representative from the
departments, ICU director, head nurse, pharmacist, dietitian, CEO, and hospital director. The
committee will be chaired by hospital director and the ICU director will be the secretary.
7. ICU should be staffed with appropriately trained and skilled staff and might include intensivists,
pulmonary critical care specialists, emergency specialists, trained physicians and nurses,
physiotherapists and clinical pharmacists.
8. A national ICU training curriculum for physicians and nurses should be developed and delivered
intensively.
9. ICU should have a regular performance review.
A. the performance evaluation and review should include its admission, and discharge guidelines.
It should be done by a multi professional ICU committee.
B. A database to track admissions, outcomes and other variables should be established.
C. A mechanism to review requested admissions that were denied should be in place to assure
the appropriateness of both guidelines and decision making process.
Level OF CARE III (LOC-III): Located in a major tertiary hospital
It should provide all aspects of intensive care required. All complex procedures should be undertaken.
Specialist intensivist or physician anesthesiologist, Pulmonary & critical care specialist, nurses,
therapists, support of complex investigations and specialists from other disciplines Should be
available at all times. Minimum requirement:
• Human resources
Anesthesiologist, intensivists, pulmonary critical care, emergency medicine specialist, trained
physician and nurses plus physiotherapist, clinical pharmacist, nutritionist, Nurse: patient ratio
should be 1:1
• Medical equipment:
All of LOC 1 and 2 plus special care ECMO (optional), renal replacement therapy, bronchoscope,
esophageal tubes (Minnesota and Black More tubes), intracranial monitors, CVP catheter, arterial
lines, feeding tubes.
 References

Federal Democratic Republic of Ethiopia

Ministry of Health
ICU Admission, Transfer & Discharge Protocol
QI UNIT HEAD