ICU NURSE PRIVILEGES

The critical care setting is one of the most complex environments

in a healthcare facility. Critical care units must manage the
intersecting challenges of maintaining a high-tech environment
and ensuring staff competency in operating the equipment,
providing high-quality care to the facility's sickest patients, and
tending to the needs of staff members working in a very stressful
environment. While other hospital units may need to manage one
or two challenges at a time, critical care settings must manage
them all simultaneously while remaining focused on the delivery of
safe patient care.
Several important factors play a role in fostering patient safety in
the intensive care unit (ICU) environment and are discussed in this
article. These strategies include the following:

 Having a culture that supports and promotes safety

activities
Operating an ICU structure in which the care of ICU
pariensts is directed and managed by
intensivevists___ physicians with specialized training
in critical care medicine
Ensuring that the work environment can support the
ability of caregivers to interact productively, make
vital decisions and perform medical interventions
and operate medical equipment safely.

COMPLICATIONS IN CRITICAL
CARE

Before building initiatives to enhance safety, healthcare managers

must understand the extent of patient injuries and events in ICUs.
Critically ill patients are at high risk for complications due to the
severity of their medical conditions, the complex and invasive
nature of critical care treatments and procedures, and the use of
drugs and technology that carry risks as well as benefits.
In addition to complications of care, adverse events and errors
many of which are serious are major risks in ICUs. The 2005
Critical Care Safety Study, published in the August 2005 issue
ofCritical Care Medicine,found that adverse events in ICUs occur
at a rate of 81 per 1,000 patient-days and that serious errors occur
at a rate of 150 per 1,000 patient-days, supporting the findings of
an earlier study indicating that nearly all ICU patients suffer
potentially harmful events.

 Nearly half (45%) of the adverse events in the Critical Care Safety
Study were deemed preventable. Common ICU errors are
treatment and procedure errors especially errors in ordering or
carrying out medication orders; errors in reporting or
communicating clinical information; and failures to take
precautions or follow protocols.

GETTING STARTED

Any ICU patient safety improvement process must start by engaging leadership.
Although the data on ICU adverse events and complications is compelling, risk
managers, patient safety officers, and critical care clinicians should work together
to make a business case to executives for patient safety investments.
Once leadership support is obtained, implementing ICU safety becomes a team
effort, supported at all levels. There must be a clearly articulated plan for
improvement developed with input and involvement from frontline staff that is
understood by all managers, clinicians, and staff members. Identifying a specific
group of individuals responsible for initiating, coordinating, monitoring, and
communicating ICU safety improvements is a primary step in the process.
Whether the group is an existing patient safety committee, a newly formed ICU
task force, or some other combination of individuals depends on the facility's
structure, knowledge base, and resources. The group can expect to be involved in
education and training, communication, and baseline data gathering, which should
include a safety assessment of the critical care units in the hospital.

CRITICAL-CARE SAFETY ASSESSMENT

Patient safety experts note that improvement initiatives are more successful in
environments in which a culture of safety exists. A culture of safety flourishes in
an ICU environment in which clinicians and frontline staff feel they are part of a
team and understand how to exchange patient information and other information
in a meaningful and respectful way. Absent a culture of safety, individuals
expected to implement ICU safety initiatives do not know how best to work
together or how to communicate most effectively. Therefore, before other patient
safety practices are introduced, the healthcare facility must cultivate a culture of
safety in its critical care units.
A starting point for improving safety culture in the ICU is to conduct an
assessment of the current culture (or climate) in the critical care unit or units to
determine whether and how it affects patient care. A survey of the safety culture
should measure aspects of the units that affect patient safety as well as attitudes
of clinicians and staff members. Such aspects include perceptions of leadership's
commitment to patient safety, the degree to which teamwork and open
communication prevail, and attitudes about nonpunitive response to error.

ICU STRUCTURE AND STAFFING

A facility's approach to providing safe critical-care services will
depend largely on the way the ICUs are organized, staffed, and
designed. Work environment also affects the ability of ICU staff to
deliver quality care.
Generally, there are three organizational models for ICUs:
theopen modelallows many different members of the medical
staff to manage patients in the ICU; theclosed modelis limited
to ICU-certified physicians managing the care of all patients; and
thehybrid model,which combines aspects of open and closed
models by staffing the ICU with an attending physician and/or
team to work in tandem with primary physicians.

 An overwhelming majority of ICUs in the United States use the

"open" model of care, although the disadvantage of this model is
the variety of medical staff members who attend to patients.
Recent studies (Chang et al., 2005; Pronovost, et al., 2003; Rainey
& Combs, 2003) suggest that the ideal organizational structure for
the ICU is a closed unit staffed by dedicated intensivist physicians.
These studies have demonstrated that hospitals with intensivists
in their ICUs have lower hospital and ICU mortality rates, lower ICU
and hospital lengths of stay, and are more effective and efficient in
providing care. Similarly, the hybrid model ensures the presence of
a critical-care-trained physician in the ICU who can make rounds
and provide consultation regarding the care of critically ill patients,
lending a higher level of expertise to the provision of critical care
services. As more evidence supports the importance of other
models to improved patient outcomes, reliance on the open model
is slowly waning.

 As with all medical providers, appropriate credentialing mechanisms should be in

place for clinicians who manage patients in the ICU. The granting of clinical
privileges based on education and level of skill is an issue of paramount
importance to patient safety in the critical care setting. The Society of Critical Care
Medicine (SCCM), representing healthcare professionals in critical care medicine,
sets forth guidelines for granting privileges for the performance of high-risk, highvolume procedures such as central-venous catheterization, pulmonary artery
catheterization, airway intubation, mechanical ventilation, and cardioversion and
defibrillation. Also, SCCM recommends that non-ICU-certified physicians who care
for critically ill patients take continuing education courses in managing critically ill
or injured patients and handling sudden deterioration in patient condition.
New physicians and residents should be directly supervised when first performing
invasive or other high-risk procedures. Equally important, especially in teaching
facilities, is ensuring that ICU nurses and staff have ready access to information on
which providers can perform which procedures under what degree of supervision.

WORK ENVIRONMENT
Staffing an adequate number of critical-care-educated nurses is essential
for the delivery of high-quality ICU care. Researchers have begun to
demonstrate the key role of critical care nurses in intercepting medical
errors in the ICU before they reach the patient. Appropriate nurse staffing
levels are important to a safe work environment, which in turn is important
to patient care and safety.
Within the environment of the ICU, high workload and fatigue have been
identified as major negative contributors to patient safety. Critical care
units and medical teaching programs, as well as their respective
institutions, should earnestly consider establishing for physicians, nurses,
and other staff members work hours, work shifts, and on-call duties that
are most conducive to a safe work environment.
Additional measures can be used by facilities striving to enhance the ICU
work environment as a strategy to promote patient safety:

 Develop a code conduct that defines and allows zero tolerance for
abusive behavior and outlines a prcess for managing disruptive
behaviors
Provide safety science education, include a focus on teamwork and
effective communication for the ICU.

TECHNOLOGY GROUND RULES

Critical care devices and technology ranging from ventilators and physiologic
monitor systems to respirators and infusion pumps are vital for the care and
treatment of patients in the ICU. However, when devices do not undergo a rigorous
evaluation for appropriateness during selection and acquisition, or when they are used
improperly, they can contribute to patient harm.
The standardization of equipment and technology is an important strategy in humanfactors design and in the reduction of human errors. Standardization reduces reliance
on memory and helps individuals use devices and technology safely and efficiently.
Therefore, ICU systems and technology should be standardized whenever possible.
ICU equipment, technology, and systems should also be assessed from a patient safety
perspective before acquisition and implementation. Such an assessment includes an
evaluation of required user skills, engineering concerns (including problems or recall
history), infection control issues, environmental considerations, and credentialing and
privileging requirements. Furthermore, new technology and equipment should be pilottested before being put into use, and there should be systems in place to anticipate
new types of errors and enact measures to prevent such errors.

INTRODUCTION
The health care industry all over the world has been undergoing great
changes over the past two decades and the Philippines has been part of
these transformational events having great impact on the quality of nursing
practice. There are new expectations in the way nurses and the nursing
practices are to be delivered particularly now that there are many
challenges that besiege the present time as a consequence of the
complexities of globalization. In the Philippines, the Professional Regulation
Commission Board of Nursing (PRC-BON) is committed to provide needdriven, effective and efficient specialty nursing care services of high
standard and at international level within the obtainable resources. To
respond to this mission and commitment, a PRC-BON Working Group in
Developing the Nursing Specialty Framework was formed sometime in 1996
to take on the task of setting the process-based framework and guidelines
for specialty nursing services. Working Group members comprise clinical
nurse practitioners, nurse educators and nurse managers.

 However, the expanding healthcare and nursing knowledge

together with new and evolving healthcare sites, structures, and
technologies all have contributed to the need and desire for
specialty nursing organizations like the Critical Care Nurses
Association of the Philippines, Inc. (CCNAPI) to revisit the existing
statement of its Standards of Nursing Practice in order to provide
clear and updated statements regarding the scopes of practice
and standards of critical care nursing. This will ensure continued
understanding and acknowledgment of nursings varied specialty
professional contributions in todays healthcare environment.
Critical care nursing is that specialty within nursing that deals
specifically with human responses to life-threatening problems2 .
These problems deal dynamically with human responses to actual
or potential life-threatening illnesses.

 The framework of critical care nursing is a complex, challenging

area of nursing practice which utilizes the nursing process
applying assessment, diagnosis, outcome identification, planning,
implementation, and evaluation. The critical care nursing practice
is based on a scientific body of knowledge and incorporates the
professional competencies specific to critical care nursing practice
and is focused on restorative, curative, rehabilitative,
maintainable, or palliative care, based on identified patient
need3 . It upholds multi and interdisciplinary disciplinary
collaboration in initiating interventions to restore stability, prevent
complications, achieve and maintain optimal patient responses.
The critical care nursing profession requires a clear description of
the attributes, guidelines and nursing practice standards in guiding
the critical care nursing practice to fulfill this purpose

 The critical care nursing competencies statements developed in

2005 are aligned with the PRC-BON statement of the 11 Core
Competencies for Entry Level for Safe and Quality Nursing Care.
The CCNAPI Core Competencies of a Critical Care Nurse are stated
according to the levels of expected behavior defining the actual
knowledge, skills and abilities in the practice of critical care by a
nursing professional. These statements cover expected behavior of
a Nurse Clinician I, Nurse Clinician II and Nurse Specialist that will
serve as the basis for assessing competence in critical care
practice. In the CCNAPI Standards of Practice, there is no
statement that covers the goals, scope of practice and procedural
standards in the care of the critically ill. Hence, these are
important aspects that should be covered in this working paper

 The focus of care for the critically ill patient is holistic. However, to
organize statement in this paper physiological focus will be categorized
under bodily functional systems such as pulmonary system,
cardiovascular system, renal system, neurological system and other
system. The specific objectives of developing this paper are:
1.1 To identify Critical Care Nursing Service characteristics and
contributions of nurses to patient care in the specialty.
1.2 To develop specific competencies required for the delivery of
nursing care in the critical care.
1.3 To provide a framework for evaluation of nursing practice within
the specialty of critical care.
1.4 To provide a basis for the assessment of staff development needs
in the critical care nursing
. 1.5 To guide the development of collaborative relationship with other
members of the health care team.

 This process-based framework not only describes the critical care nursing services in
Philippines, but also assists critical care nurses to have a better understanding of
what is expected of them from the organization and the public perspectives.
PHILOSOPHY OF CRITICAL CARE NURSING
Critical care nursing reflects a holistic approach in caring of patients. It places great
emphasis on caring the bio-psycho-social-spiritual nature of human beings and their
responses to illnesses rather than the disease process. It helps to maintain the
individual patients identity and dignity. The caring focus includes preventive care,
risk factor modification and education to decrease future patient admission to acute
care facilities. The Critical Care Nurses of the Philippines, Inc. (CCNAPI) believes that
as an organization of critical care nurses, it is conscious of its responsibility for the
promotion of mans health and welfare for national development, and has the desire
to give support for professional and personal growth and development. CCNAPI has
organized itself into a national association committed to the ideals of service to the
people, equality, justice and social progress.

 In the Critical Care Units, each patient is viewed as a unique individual with dignity
and worth. The critically ill patient should receive comfort and privacy in a highly
technological environment. In collaboration with other health care team members,
critical care nurses provide high level of patient care which includes 3 patient and
family education, health promotion and rehabilitation. To achieve this holistic care
process, participation by the patient and his/her family is always emphasized. At
the forefront of critical care science and technology, critical care nurses maintain
professional competence based on a broad base of knowledge and experience
through continuous education and evidence-based research.
With advances in sophisticated biomedical technology and knowledge, critical care
nurses are able to continuously monitor and observe patients for physiological
changes to confront problems proactively and to assist patients to achieve and
maintain an optimum level of functioning or a peaceful death. In other words, this
nursing philosophy of the CCNAPI is accomplished by looking after critically ill
patient in an environment with specially trained nurses, appropriate equipment,
adequate medical supplies and auxiliary health care personnel.

GOALS OF CRITICAL CARE NURSING

Critical or intensive care is a complex specialty developed to serve the diverse health care
need of patients (and their families) with actual or potential life threatening conditions3 . It
is therefore important that a clear statement of what critical care nursing wish to achieve
and provide should be articulated. Goals of critical care nursing include the following:
To promote optimal delivery of safe and quality care to the critically ill patients and their
families by providing highly individualized care so that the physiological dysfunction as well
as the psychological stress in the ICU are under control To care for the critically ill patients
with a holistic approach, considering the patients biological, psychological, cultural and
spiritual dimensions regardless of diagnosis or clinical setting. To use appropriate and up-todate knowledge, caring attitude and clinical skills, supported by advanced technology for
prevention, early detection and treatment of complications in order to facilitate recovery. To
provide palliative care to the critically ill patients in situations where their health status is
progressing to unavoidable death, and to help the patients and families to go through the
painful sufferings.
On the whole, critical care nursing should be patient-centered, safe, effective, and efficient.
The nursing interventions are expected to be delivered in a timely and equitable manner

SCOPE CRITICAL CARE NURSING

The scope of critical care nursing is defined by the dynamic interaction of the critically ill patient,
the critical care nurse and the critical care environment in order to bring about optimal patient
outcomes through nursing proficiency within an environment conducive to the provision of this
highly specialized care4 . 4 Constant intensive assessment, timely critical care interventions and
continuous evaluation of management through multidisciplinary efforts are required to restore
stability, prevent complications and achieve optimal health. Palliative care should be instituted to
alleviate pain and sufferings of the patient and family in situations where death is imminent.
Critical Care Nurses are registered nurses, who are trained and qualified to practice critical care
nursing. They possess the standard critical care nursing competencies in assuming specialized
and expanded roles in caring for the critically ill patients and their family. Likewise, the critical
care nurse is personally responsible and committed to continues learning and updating of
knowledge and skills. The critical care nurses carry out interventions and collaborates patient
care activities to address life-threatening situations that will meet patients biological,
psychological, cultural and spiritual needs. The critical care environment constantly supports the
interaction between the critically ill patients, their family and the critical care nurses to achieve
desired patient outcomes. It entails readily available and accessible emergency equipment,
sufficient supplies and effective supporting system to ensure quality patient care as well as staff
safety and productivity.

ROLES OF THE CRITICAL CARE

NURSES
In response to changes and expansion within and outside the healthcare
environment, critical care nurses have broadened their roles at both practice
and advanced practice levels. Competencies of critical care nurses are
honed and developed to achieve their roles as a practitioner, manager /
leader and researcher. 5.1 Practitioner Role
5.1.1 Care Provider a. Direct patient care 1. Detects and interprets indicators
that signify the varying conditions of the critically ill with the assistance of
advanced technology and knowledge. 2. Plans and initiates nursing process
to its full capacity in a need-driven and proactive manner. 3. Acts promptly
and judiciously to prevent or halt deterioration when conditions warrant. 4.
Co-ordinates with other healthcare providers in the provision of optimal care
to achieve the best possible outcomes. b. Indirect patient care Care of the
Family 1. Understands family needs and provide information to allay fears
and anxieties. 2. Assists family to cope with the life-threatening situation
and/or patients impending death.

 5.1.2 Extended Roles as critical care nurses Critical care nurses

have roles beyond their professional boundary. With proper
training and established guidelines, algorithms, and protocols that
are continuously reviewed and updated, critical care nurses also
perform procedures and therapies that are otherwise done by
doctors. Such procedures and therapies are: a. Sampling and
analyzing arterial blood gases; b. Weaning patients off
ventilations; c. Adjusting intravenous analgesia / sedations; d.
Performing and interpreting ECGs; e. Titrating intravenous and
central line medicated infusion and nutrition support; and f.
Initiating defibrillation to patient with ventricular fibrillation or
lethal ventricular tachycardia. g. Removal of pacer wire, femoral
sheaths and chest tubes h. Other procedures deemed necessary
by their respective institution under a clinical protocol.

 5.1.3 Educator a. Provides health education to patient and family to promote understanding
and acceptance of the disease process and to facilitate recovery. b. Participates in the training
and coaching of novice healthcare team members to achieve cohesiveness in the delivery of
patient care. 5.1.4. Patient Advocate a. Acts in the best interest of the patient. b. Monitors and
safeguards the quality of care which the patient receives.
5.2. Management and Leadership Role The critical care nurse in her management and
leadership role will be able to render the following responsibilities: a. Perform management
and leadership skills in providing safe and quality care b. Accountability for safe critical care
nursing practice c. Delivery of effective health programs and services to critically-ill patients
in the acute setting d. Management of the critical care nursing unit or acute care setting e.
Take lead and supervision among nursing support staff f. Utilize appropriate mechanism for
collaboration, networking, linkage building and referrals. 5.3. Researcher Role The critical
care nurse in her researcher role will be able to render the following responsibilities: a.
Engage self in nursing or other health related research with or under supervision of an
experienced researcher.
b. Utilize guidelines in the evaluation of research study or report c. Apply the research process
in improving patient care infusing concepts of quality improvement and in partnership with
other team-players

 Advanced Practice Level This is the future direction in the Philippines and to be benched marked
with other countries. For now, a thorough study of Advanced Practice Nursing in critical care will
be pursued to align with the BON initiative on specialization framework. The current healthcare
environment demands intensive care nurses to have advanced knowledge and skills to provide the
highest possible level of care to the critically ill patients. 5.1.4 Expanded Roles a. Nurse
Specialist / Clinical Nurse Specialist
Typically, the education and preparation of the critical care nurse practitioner is provided by the
respective hospital or institution without advanced educational preparation beyond that of the
basic baccalaureate degree. Advanced educational preparation refers to the care nursing training
program run by the university or Institute offering Advanced Nursing Studies or other recognized
critical care program both local and overseas. A registered nurse, who is a nursing degree holder,
should have more than more than __ years of uninterrupted practice experience in the critical care
field and has attained advanced education and expertise in caring patients with critical problems
can function as a critical care nurse specialist. He /She is also eligible to be accredited by the PRCBoard of Nursing as a Clinical Nurse Specialist. The Hospital Authority supports this accreditation.
The critical care nurse specialist is responsible for building up nursing competencies in the ICU
entity. He / She contributes to continuous improvement in critical care nursing through staff and
clients education and uphold quality nursing guidelines and patient care through clinical research
and refinement of ICU standards.

 Advanced Practice Nurse Advanced Practice Nurse (APN) in the

critical care unit takes lead in developing practices to meet
changing clinical needs and to facilitate patient care processes
across professional and organizational boundaries. He /She should
have the recommended number of post registration nursing
experience, which are spent in the critical care field, exhibiting indepth professional knowledge and skills. An APN (Critical Care) is a
holder of a) clinical master degree in a clinical nursing specialty
(Medical-Surgical) such as Critical Care Nursing OR b) master
degree in nursing or related discipline / management together with
recognized critical care training qualification(s). The Advanced
Practice Nurse executes the nursing team leaders responsibilities
as designated in the position of APN (NO) or APN (Ward/Unit
Management).

 Outcomes Manager Outcome management has been introduced into the healthcare
system to ensure achievement of quality and cost-effectiveness in the delivery of
patient care. Some critical care units have adopted clinical pathways (e.g., Critical
Pathways, Protocols, Algorithms and Orders) in the management of specific diseases
such as Acute Myocardial Infarction and Cardio-thoracic Surgeries. Qualified nurse
experts are involved in the development and implementation of patient outcomes
management.
5.2 Challenges that critical nurses will face: The challenging needs from the critical
care nursing service and its environments demand the nurses: 5.2.1 To develop,
foster and maintain a level of knowledge about the norms, values, beliefs, patterns
of ill health and care needs of the people; 5.2.2 To analyze and evaluate specialist
skills and criticize their evolving roles; 5.2.3 To review current studies and researches
and to examine contextual issues thus enabling evaluation and synthesis of new
knowledge, traditional techniques, religious and cultural influences to be applied in
nursing practice, particularly, evidence-based nursing practice; and 5.2.4 To exercise
professional judgments expected of them in the critical care clinical setting.

 TRAINING OF NURSES FOR CRITICAL CARE SERVICES The institution / hospital should
provide training opportunities to ensure staff competencies. This will enable the nurses
working in the critical care units to cope with the complexities and demands of the
changing needs of the critically ill patients. The following training activities should be
supported in order to maintain a high standard of care: 6.1 Orientation program /
Preceptorship and mentoring program New recruits to the critical care shall attend an
orientation program and be given the opportunities to work under supervision.
Experienced staff in the unit should be readily available for consultation.
6.2 In-service training program a. Unit / hospital based training courses / workshop /
seminar at hospital level b. On-the-job training and bedside supervision 6.3 Critical
Care Nursing Program (Post-Graduate specialty program) a. Post-graduate Course in
Critical Care Nursing / Cardiac Special Care Nursing / Cardiac Intensive Care Nursing
shall be reviewed, evaluated and endorsed to PRC-BON by the CRITICAL CARE NURSES
ASSOCIATION OF THE PHILIPPINES, INC for accreditation i. Advanced Critical Care
Nursing (ACCN) Provider Course b. It is recommended that the WFCCN policy statement
of education shall be used as a framework for designing a critical care program. (Please
see declaration of Madrid, 2005)

 6.4 Continuing Nursing Education a. CCNAPI recommends that all practicing CCN shall ensure
that they continuously update their knowledge, skills and behavior through active
participation in related critical care nursing education. This shall include but not limited to
the following adult and pediatric concepts on: a. Advanced Cardiac Life Support b. Basic
Critical Care Course (BCCC) c. Cardiac Assessment d. Neurological Assessment e. Respiratory
Assessment f. Continuous Renal Replacement Therapy g. Advanced Pharmacology h.
Advanced Intravenous Therapy i. Others as may be deemed necessary to enhance critical
care practice
7. LEVELS & CATEGORIES OF CRITICAL CARE PROVISIONS WITHIN PHILIPPINES With respect
to the physical set-up and supporting facilities of critical care units in the Philippines, the
Department of Health (DOH) Standards requires the critical care units / intensive care unit to
be a self-contained area, with the provisions for resources that will support critical care
practice. Currently, the DOH is reviewing these standards to come-up with updated
requirement. Sometime in 2003, the Philippine Society of Critical Care Medicine (PSCCM),
Society of Pediatric Critical Care Medicine (SPCCM) and the CCNAPI stratified into different
levels and categories the care provisions in critical care practice to make it similar to its
counterparts overseas with the goal of having effective utilization and organization of
resources. Hence, as a guide, CCNAPI will incorporate these standards into this guideline

 7.1 Levels of Care provision The role of a particular critical care unit will
vary, depending on staffing, facilities and support services as well as the
type and number of patients it has to manage. Taking into account the
guidelines of the Society of Critical Care Medicine, the critical care service
provision in Philippines can be classified into 3 levels: Level 1 Should be
capable of providing immediate resuscitation for the critically ill and short
term cardio-respiratory support because the patients are at risk of
deterioration; Has a major role in monitoring and preventing complications
in at risk medical and surgical patients; Must be capable of providing
mechanical ventilation and simple invasive cardiovascular monitoring; Has
a formal organization of medical staff and at least one registered medical
officer available to the unit at all times; 9 A certain number of nurses
including the nurse in-charge of the unit should possess post-registration
qualification in critical care or in the related clinical specialties; and Has a
nurse: patient ratio of 1:1 for all critically ill patients.

 Level 2 Should be capable of providing a high standard of general criitcal care for
patients who are stepping down from higher levels of care or requiring single organ
support/support post-operatively; Capable of providing sustainable support for
mechanical ventilation, renal replacement therapy, invasive hemodynamic monitoring
and equipment for critically ill patients of various specialties such as medicine,
surgery, trauma, neurosurgery, vascular surgery; Has a designated medical director
with appropriate intensive care qualification and a duty specialist available
exclusively to the unit at all times; The nurse in-charge and a significant number of
nursing staff in the unit have critical care certification; and A nurse: patient ratio is
1:1 for all critically ill patients. Level 3 Is a tertiary referral unit, capable of managing
all aspects of critical care medicine (This does not only include the management of
patients requiring advanced respiratory support but also patients with multi-organ
failure); Has a medical director with specialist critical / intensive care qualification and
a duty specialist available exclusively to the unit and medical staff with an
appropriate level of experience present in the unit at all times; A nurse in-charge and
the majority of nursing staff have intensive care certification; and A nurse: patient
ratio is at least 1:1 for all patients at all times.

 7.2 Categories of Critical Care Unit The Critical Care Unit can be categorized according to patients
age group or medical specialties. a. Age group i. Neonatal ii. Pediatric iii. Adult b. Specialty In the
existing environment, majority of the Critical Care Units in the Philippines provide service for patients
of various specialties. They are labeled as General ICUs. In certain hospitals, the critical care unit /
service is dedicated to the following specific groups: i. Medical ii. Surgical iii. Cardio-thoracic iv.
Cardiac v. Respiratory vi. Neurosurgical 10 vii. Trauma
7.3 System operation of Critical Care Units The operation of critical care units can be classified into
Open System and Closed System. a. Open System The admitting and other attending doctors dictate
management, change management or perform procedures without consultation or communication
with a Critical Care Specialist. A Critical Care Specialist may be available for advice or be consulted to
provide interventional skills (optional). No one designated person assumes the gatekeeper role. b.
Closed System Management is coordinated by a qualified Critical Care Specialist. The critical /
intensive care specialist has clinical and administrative responsibility. There is a multi-disciplinary
team of specially trained critical care staff. The intensivist is the final common pathway for all
medical decision-making including the decision to admit or discharge. Irrespective of the ICU
System Operation, i.e. open system or closed system, or a mixture of the two, there should be a
designated group of registered nurses under a unique management to provide highly specialized care
to the critically ill patients. The nurse in-charge and the majority of nursing staff in each unit should
have the relevant qualification in the specialty of the respective Unit.

 7.4 Critical Care Nursing Workforce The CCNAPI will adopt the
Position Statement of the World Federation of Critical Care Nurses
on the Provisions of Critical Care Nursing Workforce also called the
Declaration of Buenos Aires ratified in the full council meeting last
August 27, 2011 at the Sheraton Hotel, Buenos Aires, Argentina.
The declaration presents guidelines universally accepted by
critical care professionals, which may be adapted to meet the
critical care nursing workforce and system requirements of a
particular country or jurisdiction. The declaration states the
specific central principles governing the provision and provides for
specific recommended critical care nursing workforce requirement.
The complete declaration is attached as Annex to this guideline.

 8. COMPETENCIES FOR CRITICAL CARE NURSES The competence of critical

care nurses together with established nursing standards and the identified
core competencies for registered nurses will result to excellence in critical
care nursing practice. This three pronged holistic framework ensures
quality performance through an adherence to nursing standards, the
application of competencies, and the integration of appropriate nursing
model/s into the care delivery process. To achieve safe and quality clientcentered care, nurses working in the critical care units are envisioned to
adopt not only the stated core competencies of registered nurses but also
the specific competencies stipulated in the following eleven major key
responsibility areas: 8.1 Safe and Quality Nursing Care 8.2 Management of
Resources 8.3 Legal Responsibilities 11 8.4 Ethico-Moral Responsibilities
8.5 Collaboration and Teamwork 8.6 Personal and Professional
Development 8.7 Communication 8.8 Health Education 8.9 Quality
Improvement 8.10 Research 8.11 Record Management