Levels of

ICU
 Ain-Shams University Critical
Care and emergency Nursing
Department – Master Degree (3rd)

Levels of ICU
Under superviosn of
Content:
Objectives
Introduction
ICU Design
ICU Patient Room
ICU Supportive Services
ICU Patient
ICU Team
ICU levels
Level (0)
Level (1)
Level (2)
Level (3)
References
Objectives:

Describe ICU design.

Identify ICU team with their unique role in critical p
Define critical illness.
Mention critical care patients whom in need for ICU
Compare between different levels of care.
 Introduction
The ICU, or Intensive Care Unit, provides specialized care for
patients who are critically ill or require close monitoring and
support. The level of care in the ICU is characterized by the
intensity and complexity of medical interventions and monitoring
provided to patients. There are different levels of care within the
ICU, depending on the severity of the patient's condition and the
resources available in the specific healthcare facility.

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ICU Design
 ICU Design
The intensive care unit (ICU) design process is complex and time
consuming, and needs to balance innovation with practicality, space
availability, physical limitations and cost. The ICU design process
begins with a shared critical care medicine (CCM) and hospital
vision for a new ICU. The new ICU reflects the desired appearance
and feel of the new ICU, and addresses the goals for patient care,
workflow, technology, and the environment.

Two core principles should be considered: First, an ICU is an

autonomous mini-hospital, whose design and functionality must be
synchronized with the hospital. Secondly, the ICU design process is
must balance innovation with practicality, space limitations,
healing, and cost restraints.

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 ICU Design
Number of beds: The number of beds in an ICU typically ranges
from 8 to 24. The exact number of beds needed will depend on the
size of the hospital, the patient population, and the level of care
required.
Size of rooms: Each patient room in an ICU should be large enough
to accommodate all of the necessary equipment and to allow staff to
move around easily. The recommended minimum size of an ICU
room is 125 square feet.
Staffing: ICUs are staffed by a team of highly skilled healthcare
professionals, including nurses, physicians, respiratory therapists,
and pharmacists. The ideal nurse-to-patient ratio in an ICU is 1:1 or
1:2.

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 ICU Design
Equipment: ICUs are equipped with a wide range of life-saving
equipment, including ventilators, monitors, and infusion pumps.
The cost of ICU equipment can range from $500,000 to $1 million.

Infection control: ICUs are designed to prevent the spread of

infection. This is done through a variety of measures, including the
use of negative-pressure rooms, hand hygiene protocols, and visitor
restrictions.
In addition to these key numbers, there are many other factors to
consider when designing an ICU. These factors include the layout
of the unit, the type of equipment used, the staffing levels, and the
patient population. By carefully considering all of these factors,
hospitals can create ICUs that provide the best possible care to
critically ill patients.

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 ICU Patient Room
The Patient Room and Supportive Services

The ICU patient room :

The ICU patient room is at the core of the ICU patient, visitor, and
staff experience. Each room should function semi-autonomously, be
designed similarly, accommodate one patient only to maintain
infection control and privacy, and provide a healing environment.
ICU rooms have zones (patient, caregiver, and visitor) that are
differentiated by room layout; however, the zones must be
operationally flexible. The patient’s bed should be the room’s focal
point.

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 ICU Patient Room
Room environment: The emotional welfare of ICU patients,
staff, and visitors is greatly impacted upon by the room’s
environment. Thus, a healing milieu that controls sound, light,
temperature, time, artwork and entertainment, and provides
visiting areas and privacy should be developed. Physical noise
barriers artwork (displayed on the walls, curtains, and ceiling
tiles, or electronically), televisions, thermostat, and clock.
Comfortable chairs, Wi-Fi, and electrical and USB outlets
should also be available. The patient room should include a
long-term visiting area if space permits.

Room supplies and waste management: Supplies should

be stored in secured and non-secured drawers, cabinets, and/or
mobile carts or nurse servers ICU rooms should have their own
bathrooms with automated bedpan macerators or closed
bedpan cleaners.

Room entry : The ICU room may open directly to or be set

back from the hallway. ICU doors may be controlled manually
or electronically. The area outside the patient room should
include a decentralized staff workstation, computer, sink,
storage space, hangers, and a manual or electronic
identification or message board.
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 ICU Supportive Services
Supportive Services:

Centralized work areas: Centralized work areas provide important

functions, including greeting desks, and quiet work and conferencing
areas. Limited central bed visibility is supplemented with bed-based
webcams
Corridors and central-based storage for medical devices and
carts: CU corridors establish physical and emotional ICU
cohesiveness through their lighting, artwork, sound control, and
finishings. Local device and cart cubicles near the patient rooms
minimize retrieval times. Hallway closets provide access to non-
bedside ICU equipment and supplies. Preferably, ICU patients and
supplies should enter the ICU via hallways that bypass the waiting
room and visitor entranceways.
Floorings and furnishing: Floors should be comfortable to walk on,
non-slip, easy to clean, durable, and impermeable. Walls should be
impact-resistant and hallway walls should have fixed protective
barriers.

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 ICU Supportive Services
The waiting room: A waiting room with soft-lighting, warm colours,
artworks, Wi-Fi, power and USB outlets, televisions, vending
machines, bathrooms, lockers and coat hangers, and long-term
sleeping arrangements, if possible, should be located adjacent to the
ICU. Seating arrangements should be configured as small groups of
chairs separated by privacy dividers. Consultation rooms and a social
worker’s office should support family meetings.
Staff lounge: The staff lounge should have a pleasant ambiance with
comfortable seating, artwork, ICU communications, televisions,
computers, and a food area and refrigerator. There should also be
private changing areas, scrub dispensers, lockers, bathrooms, nap
alcoves, and storage areas (for coats and footwear).

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 ICU Supportive Services
Staff lounge: The staff lounge should have a pleasant ambiance with
comfortable seating, artwork, ICU communications, televisions,
computers, and a food area and refrigerator. There should also be
private changing areas, scrub dispensers, lockers, bathrooms, nap
alcoves, and storage areas (for coats and footwear).
Staff communications: Telephones, overhead speakers,
nurse-call (intercom) systems, and bidirectional transmitters
should be integrated into the ICU. Nurse-call systems are
capable of point-to-point and global communications and can
be integrated into real time locating systems (RTLS). Similarly,
staff assigned bi-directional transmitters can handle point-to-
point and global ICU and hospital communications, and convey
voice, telephone, pagers, alarms, and e-mail using wireless and
cellular networks.
Pharmacy: A fully equipped satellite ICU pharmacy is
necessary if the hospital has a decentralized medication system.
In contrast, less support is required if the hospital pharmacy
system is centralized. Medications may also be stored in
secured cabinets at the ICU bedside.
 ICU Supportive Services
Free-standing: laboratory devices may be positioned in a
defined centralized areas, depend on the ICU workflow, testing
needs, space available, and resources.
ICU logistics: Bulk supplies are usually stored in supply
rooms in stationary or track based shelving, closed supply
cabinets, or rolling exchange carts.
Infection control: Infection prevention requires good design
and a ‘culture’ of infection prevention. As hand-washing and
surface disinfection are the corner stones of infection control,
ICUs should have multiple sinks, cleansing fluid dispensers,
and easy to clean surfaces. However, design teams are now
supplementing these with automated hand-washing
surveillance, surface hygiene monitoring systems, copper or
silver antibacterial surface coatings, impermeable, washable,
and antimicrobials-coated keyboards and mice, and
environmental decontamination (hydrogen peroxide or
ultraviolet light) systems.
 ICU Supportive Services
Conference facilities, on-call suites, and offices: On-call
suites, conference facilities, and respiratory therapy offices
should be located within or near the ICU.
Signage: The signage process is facilitated by virtual ICU walk-
throughs to simulate patient, staff, and visitor traffic patterns,
and maximize hallway efficiencies.
Security: Electronic locks with card access should be used to
protect and monitor entry to all sensitive ICU areas.
Additionally, the ICU should be monitored with video cameras
and locally-based webcams.
Advanced informatics: Advanced ICU informatics systems
seek to electronically integrate the ICU patient with all aspects
of care (devices, data, supplies, caregivers, medical and
administrative applications), and the electronic medical record
(EMR). These systems should also help utilize the data and
monitor the ICU environment.

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 ICU Patients
ICU Patients
ICU patients are critically ill patients who require intensive care.
They may have a variety of conditions, including:
•Heart problems: Heart attacks, strokes, and other cardiovascular
diseases
•Respiratory problems: Pneumonia, acute respiratory distress
syndrome (ARDS), and other lung diseases
•Trauma: Injuries from car accidents, falls, and other incidents
•Burns: Severe burns that require extensive treatment
•Sepsis: A life-threatening infection that can cause multiple organ
failure.
ICU patients are typically very sick and require around-the-clock
care. They may be on life support, such as a ventilator, and they
may be receiving a variety of medications. ICU patients are also at
high risk of infection, so they are carefully monitored to prevent
the spread of disease.
 ICU Team
Staffing in the intensive care units
Working with critically ill patients commonly require collaboration
with a multidisciplinary team of health care professionals. The
goal of team is to provide effective and comprehensive biological,
psychological, social, and spiritual dimensions of a person care.

The team of professionals caring for patients in critical care units

can be divided into three large groups:
-Nurses, whose numbers include bedside nurses, administrative
and educator nurses, and practical nurses.
-Providers including physicians and advanced care practitioners.
-Allied health personnel, including physician assistance,
respiratory therapists, nutrition support specialists, pharmacists,
physiotherapists, and social workers.
Registered nurses
Advanced practice nurses
Patient-care technician
• Provides direct patient care to critically ill patients
• Bathes patients
• Obtains vital signs
• Assists with transportation of patients for testing
Physical therapist
• Assesses muscle groups and mobility.
• Develops specialized care plan
• Teaches gait and transfer training to patients and other health care
team
members
 ICU Team
Occupational therapist
• Assesses a patient’s activities of daily living
• Teaches the patient and his family methods for completing these
tasks and
achieving the discharge plan
Speech pathologist
• Assesses ability to swallow
• Assesses for speech and language disorders
• Teaches techniques for dealing with swallowing impairment,
• Works with health care providers to reinforce treatment
Dietitian
• Monitors a critically ill patient’s dietary intake
• Assesses the patient’s daily caloric intake and reports deviations
• Devises meal plans to meet the practitioner recommended needs
for the patient
• Recommends dietary interventions
Social services
Respiratory therapist
ICU Levels
 Level (0)
Level 0: Ward Care

• Patients whose needs can be met through normal WARD care in

an acute hospital.
• Patients who have recently been relocated from a higher level of
care, but their needs can be met on an acute ward with additional
advice and support from the critical care outreach team.
• Patients who can be managed on a ward but remain at risk of
clinical deterioration.

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 Examples on Level 0
• A patient with DKA who is on appropriate treatment and was
initially very acidotic but is gradually improving and requiring no
organ support.
• A patient who was hypotensive in the Emergency Department but
who has responded to intravenous fluids and is now
hemodynamically stable with a lower risk of deterioration, such that
they can go to a medical ward.

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 Examples on Level 0
• A patient with OSA (Obstructive sleep apnea) who has their own
CPAP machine, knows how to use it and does not have acute
respiratory failure.
• A patient recently discharged from an enhanced care unit or
critical care unit who is stable with a low risk of deterioration.

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 Level (1)
Level (1) - Enhanced Care
• Patient recently discharged from a higher level of care.
• Patient in need of additional monitoring/clinical interventions,
clinical input or advice.
• Patient requiring critical care outreach service support.

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 Examples on Level 1
• Patients requiring minimum of 4hr of GCS assessment
• Patients on established intermittent renal support.
• Patients who receiving insulin infusion of diapentes.
• Patients with a chest drain in situ.
• Post operative surgical patient who are still requiring 4hr
observation.
• Patients requiring respiratory physiotherapy to treat or prevent
respiratory failure.
 Examples on Level 1
• Parenteral nutrition.
• Boluses of intravenous fluid.
• Epidural analgesia or patients-controlled analgesia in use.
• Patient who are at risk for aspiration pneumonia
• Patient who requiring continuous oxygen therapy
• Patients with tracheostomy
• Abnormal vital sign but not requiring a higher level of critical
care.
• Risk of clinical deterioration and potential need to step up to
level 2 care.

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 Level (2)
Level 2: Intermediate ICU Care

This level of care is provided to patients who are moderately ill and
require more intensive monitoring and interventions.

• Patients in this level may need invasive procedures like central

venous catheterization or arterial line placement. They may also
require mechanical ventilation or continuous renal replacement
therapy.

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 Examples on Level 2
Patients needing pre-operative optimization :

• Cardiovascular, renal or respiratory optimization required

prior to surgery. (Invasive monitoring inserted to assist
optimization (arterial line, and CVP as a minimum).
Patients needing extended postoperative care :
• Immediate care following major elective surgery.
• Emergency surgery in unstable or high-risk patients.
• Where there is a risk of postoperative complications or a need
for enhanced interventions and monitoring.
 Examples on Level 2
Patients stepping down to Level 2 care from Level 3 :

• Requiring a minimum of hourly observations.

• At risk of deterioration and requiring level 3 care again.

Patients receiving single organ support :

• (exceptions: Basic Respiratory and Basic Cardiovascular
Support occurring simultaneously without any other organ
support should be considered as Level 2 and Advanced
Respiratory Support alone is Level 3)
 Examples on Level 2
Patients receiving Basic Respiratory Support:
Indicated by one or more of the following:

• Mask / hood CPAP or mask / hood Bilevel positive airway pressure

• (noninvasive ventilation)
• Patients who are Intubated to protect the airway but needing no
ventilatory support
• CPAP via a tracheostomy
• More than 50% oxygen delivered by face mask.
• Close observation due to the potential for acute deterioration to the
point of needing advanced respiratory support.
• Physiotherapy or suction to clear secretions at least two hourly,
whether via tracheostomy, mini tracheostomy, or in the absence of
an artificial airway.
• Patients who are recently (within 24 hours) extubated after a
period (greater than 24 hours) of mechanical ventilation via an
endotracheal tube.
 Examples on Level 2
Patients receiving Basic Cardiovascular Support
• Use of a CVP line for monitoring of CVP and to deliver titrated
fluids to treat hypovolemia.
• Use of an arterial line for monitoring the arterial pressure and/or
sampling of arterial blood.
• Single intravenous vasoactive drug used to support or control
arterial pressure, cardiac output or organ perfusion.
• Single/multiple intravenous rhythm controlling drug(s) to support
or control cardiac arrhythmias
 Examples on Level 2
Patients receiving Basic Respiratory Support..

• Close observation due to the potential for acute deterioration to

the point of needing advanced respiratory support.
• Physiotherapy or suction to clear secretions at least two hourly,
whether via tracheostomy, Mini tracheostomy.
• Patients who are recently (within 24 hours) extubated after a
period (greater than 24 hours) of mechanical ventilation via an
endotracheal tube
 Examples on Level 2
Patients receiving Advanced Cardiovascular Support:
• Multiple intravenous vasoactive and/or rhythm controlling drugs
(e.g. inotropes, amiodarone, nitrates).
• Continuous observation of cardiac output.
• Intra-aortic balloon pumping and other assist devices.
• Insertion of a temporary cardiac pacemaker
 Examples on Level 2
Patients receiving Renal Support:
• Acute renal replacement therapy (e.g.haemodialysis,
hemofiltration etc.) or provision of renal replacement therapy to a
chronic renal failure patient who is requiring other acute organ
support in a critical care bed
Patients receiving Neurological Support:
• Central nervous system depression
• Invasive neurological monitoring or treatment
• Continuous intravenous medication to control seizures
• Therapeutic hypothermia using cooling protocols or devices
Patients receiving Dermatological Support :
• Patients with major skin rashes, exfoliation or burns. (e.g. greater
than 30% body surface area affected).
 Level (3)
Level 3: Critical Care

This level of care requires advanced respiratory support alone or

monitoring and support for two or more organ systems. This level
includes all complex PATIENTS requiring support for multi-organ
failure.).
• Patients requiring monitoring and support for two or more organ
systems at an advanced level.
• Patients with chronic impairment of one or more organ systems
sufficient to restrict daily activities (co-morbidity) and who require
support for an acute reversible failure of another organ system.

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 Examples on Level 3
Patients receiving Advanced Respiratory Support alone

Indicated by one of the following:

• Invasive mechanical ventilatory support applied via a trans-laryngeal
tracheal tube or applied via a tracheostomy.
• Bi-level positive airway pressure (BIPAP) applied via a trans-
laryngeal tracheal tube or applied via a tracheostomy
• CPAP via a trans-laryngeal tracheal tube.
• Extracorporeal respiratory support.

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 Examples on Level 3
Patients receiving a minimum of 2 organs supported

Examples:
• Basic Respiratory and Neurological support.
• Basic Respiratory and Hepatic Support.
• Basic Respiratory and Renal support.
• Basic Cardiovascular and Hepatic support.
• Basic Cardiovascular and Renal support.
• Advanced Cardiovascular and Renal support.
• Advanced Cardiovascular and Hepatic support.
• Advanced Cardiovascular and Neurological support

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References:
1. Atiyah, R. H., Saleh, N. D., & Jaber, M. I. (2023). Fundamentals of the
Intensive Care Unit" ICU". European Journal of Science, Innovation and
Technology, 3(3), 415-421.
2. https://www.datadictionary.nhs.uk/attributes/critical_care_level.html#:~:te
xt=Level%203%20(PATIENTS%20requiring%20advanced,for%20multi%
2Dorgan%20failure.)

3. ICU Fundamentals: Basic of Intensive Care. (2019). Egyptian Ministry of

Health and Population. Retrieved November 11, 2023, from
https://www.mohp.gov.eg/theducation/SecondGroup/Critical_care_and_e
mergency/Term1/ICU_Fundamentals/ICU_Fundamentals.pdf

4. Intensive Care 2020 and Beyond: Levels of Adult Critical Care Second
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5. Leach, R. M. (2023). Critical care medicine at a glance. John Wiley &

Sons.
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Prepared By:
1- Gerges Nady Gerges
2- Ahmed Mohamed Abdelaziz
3- Nouhem Refaat Faragallah
4- Dina El-sayed
5- Naira Ali