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MANAGING A UNIT
Planning, managing and
equipping an intensive care unit
within a veterinary facility
Caroline Smith, Holly Witchell
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. Patient demands
require staff with special expertise and facilities for the support of vital
functions. Careful thought is essential when creating an ICU facility, as each
hospital will have its own individual needs and expectations for what should
be offered. This article gives an overview of the main points to consider
when planning, managing and equipping an ICU.
Planning and management
Location
Layout of the intensive care unit (ICU) should
allow rapid access to and from the reception
area and consulting rooms for incoming
emergency patients, the surgical theatres
and the imaging department. This facilitates
the rapid movement of patients between
these areas for investigations and treatment
as necessary. An easily accessible, secure
outdoor space for walking canine patients is
useful and consideration for disinfection of this
area essential.
Size
The size of the ICU is dependent upon
the caseload and the type of cases seen
by the hospital. Typically, ICUs in large
multidisciplinary hospitals treating dogs
and cats can accommodate between 20
and 30 patients. The split between dog- and
cat-housing facilities will be dictated by the
caseload; however, in most instances, two
thirds of the kennel space will accommodate
canine patients of various sizes and one third
will be allocated to feline patients. Ideally,
feline kennels should be within their own space,
with noise-restricting windows and doors to
minimise the stress associated with being in
close proximity to dogs (Fig 1).
The ICU should be equipped with two or
more patient examination and procedure
tables. Dog hooks on the walls are a useful
addition for patient restraint.
Caroline Smith, Holly Witchell,
School of Veterinary Sciences, University of
Bristol, Langford House, Langford, Bristol
BS40 5DU, UK
e-mail: [email protected]
2
Depending upon the hospital caseload, a
high-dependency unit may be included in the
design. This area is dedicated to the care of the
most critical patients, such as those requiring
one-to-one intensive nursing, mechanical
ventilation or dialysis. A raised bed, incubator
or cot allows easy access to the patient from
all sides. This area requires a dedicated oxygen
source and the ability to provide advanced
monitoring (Fig 2). A wall-mounted or mobile
suction unit is essential for clearing patient
airways. Placement should allow use of the
suction unit in both the high dependency unit and
crash areas where it is most likely to be required
An area for performing cardiopulmonary
cerebral resuscitation with a hydraulic table
and ‘crash trolley’ supplies is essential in
a busy ICU. This area must have an oxygen
supply and monitoring equipment, including
an electrocardiograph and capnograph placed
locally. Typical contents of an ICU crash trolley
are listed in Table 1. After every use, the
contents of the trolley will need restocking.
Additionally, date checking of the contents can
be assigned to one of the ICU staff members
to be performed on a weekly basis. After every
breach, it is useful to seal the crash trolley or
box with dated tape or ties as confirmation that
restocking and checking has been completed.
Staffing
ICUs can be run on an open or closed basis.
Both offer advantages and disadvantages.
Open ICUs allow clinicians from any part of
the hospital to place patients within the ICU
and continue managing the patient’s care
as their own. Patients in a closed ICU have
their care directed by an ICU-based clinician
typically with specialist training in emergency
and critical care, with ongoing input from the
clinician or service through which the patient
was originally admitted to the hospital. In most
instances, some middle ground can be reached
whereby ICU-based staff manage both their
own patients and provide support and advice for
patients under the direct care of other services.
Successful ICU patient management relies
heavily upon a collaborative team approach and
open, clear communication between all staff.
Case rounds form an important part of this
communication and should be undertaken at the
beginning and end of each working day. This is
an opportunity for case discussion and planning
with input from all members of the team; its
importance cannot be emphasised enough.
The nursing team is essential to the smooth
running and success of the unit. ICU nurses have
a huge responsibility in caring for the sickest
patients, so developing a well-motivated and
Fig 1: Dedicated feline
kennelling area, with noiserestricting doors and windows
to minimise the stress for
hospitalised cats
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Fig 3: A central nurses’ station
facilitates efficiency and
communication while allowing
ongoing patient monitoring
hugely advantageous to the smooth running of
the ICU.
Fig 2: High dependency area, allowing easy
patient access and advanced monitoring and
interventions. This area is used for the most
critical patients requiring direct continuous
observation
efficient team with a strong desire to provide
the highest level of care is paramount. Nurses
with a special interest, or further qualification,
in emergency and critical care make a valuable
addition in this regard. Encouragement and
support in pursuing further education and
qualifications within the field of emergency and
critical care fosters a forward-thinking and
passionate team.
Some thought must be given to the number
of nurses required to staff the ICU as the level
of care needed by patients is typically much
higher than for those in wards. The nurse
to patient ratio should be no more than 1:8,
but sometimes patients will need 1:1 care.
Additionally, 24-hour staffing is considered
standard of care in most ICUs and a nurse
should be in attendance at all times.
Due to the high patient turnover and
importance of exceptional levels of cleanliness,
dedicated cleaning and patient care staff are
Table 1: Essential and desirable items
for an intensive care unit-based crash
trolley
Communication
Being a central hub for the hospital, the ICU
must be well equipped for communication. In
a large unit, a central nurses’ station with at
least one telephone point for both incoming and
outgoing calls is essential (Fig 3).
Typically, some form of alarm system is
also required to alert staff in all areas of the
hospital if there is a problem in the ICU. This
may be in the form of an overhead paging or
alarm system, or pocket-carried pagers that
can be activated from the ICU.
One or more computers both for medical
record keeping and internet access facilitates
efficient record keeping and patient care.
Record keeping
Critically ill patients typically require more
frequent
observations,
monitoring
and
interventions than stable ones. For this reason,
an ICU hospital sheet that allows at least hourly
recordings of pulse and respiratory rates,
temperature and blood pressure, with additional
space for further monitoring parameters,
fluid therapy instructions, feeding and walking
instructions, and medications is recommended.
Importantly, the hospital sheet must clearly
Storage
When planning an ICU, consideration must
be given to storage space. It is advisable to
have a small area to keep stocks of frequently
used items such as intravenous catheters,
bandaging materials, syringes, needles, and so
on. Patient files, belongings, bedding, food and
bowls may also need to be stored in a location
that can be accessed easily. Some hospitals
may wish to stock frequently used medications,
controlled drugs and fluids within the ICU or
the layout may mean storage within a separate
pharmacy is more practical.
Table 2: Laboratory equipment
considered essential and desirable
for an intensive care unit
Essential
Desirable
Laryngoscope
Intravenous catheter
supplies
Essential
Desirable
Centrifuge
Cross-matching kits
Endotracheal tubes
in small, medium
and large sizes
Drugs (may include
atropine, adrenaline and
reversal agents)
Spectrometer
Endotracheal tube
ties
Large-volume saline
flush syringes
Prothrombin time
and activated partial
thromboplastin time
analyser
Syringes and needles
Packed cell volume/
haematocrit reader
Haematology machine
Cuff-inflation syringe
Urinary catheter for
difficult intubations
Defibrillator
Microscope and
Diff-Quik
Serum biochemistry
machine
Dry swabs
Mini surgical kits for
venous cut down,
tracheostomy, entering
the chest
Blood glucose
monitor
Ambu-bag (Ambu) or
anaesthetic circuit
display the patient’s name and its owner’s contact
details, the patient’s problem list, a plan for the
day and a list of concerns or notifiers so that
nursing staff are clear as to when the primary
clinician needs to be contacted about a problem
with the patient. A large space for free text allows
observations to be recorded. Useful additions
include pain score and modified Glasgow coma
score guidelines, calculation space for resting
energy requirement, resuscitation codes and
areas for recording fluid ins and outs, blood type
and transfusion history. An example of an ICU
hospital sheet is shown in Fig 4.
Blood gas analyser
Urine dipsticks
Blood-typing kits
Fig 4: Example of an ICU hospital sheet with
space for hourly observations and drug
administration, a problem list and a notifier list
for clinician concerns
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Fig 5: Basic laboratory area within an intensive care unit
Laboratory
The ICU should be equipped with basic
laboratory facilities to allow rapid bedside
patient assessment (Fig 5). Suggested essential
equipment is given in Table 2.
The laboratory area requires numerous
power outlets and clean, clear benchtop
workspace. For infection control purposes, it
should ideally be in an area separate from the
ICU kennelling facilities.
Infection control
Infection control forms an important part in
the planning of an ICU facility, both in terms of
protecting immunocompromised patients from
being exposed to pathogens and preventing
spread from patients with infectious agents.
Infection control involves minimising the ‘traffic’
of both people and animals through the ICU
facility and includes rules about ICU attire.
Adoption of a ‘bare below the elbows’ rule
has reduced infection transmission in human
hospitals and is thought to offer the same benefits
in veterinary practice. Similarly, jewellery and
nail varnish should be discouraged. Gloves and
plastic aprons should be readily available for
patient examination (Fig 6).
Multiple sink units with hand soap and paper
towels should be located around the ICU and
sanitising hand gel stations should be placed
prominently, particularly near the entrance
and exit doors (Fig 7).
Occasionally,
significantly
immuno­
compromised patients or infectious patients
will require ICU care. Barrier-nursing
techniques, with the creation of a temporary
isolation area within the ICU ward, is effective.
Clear floor marking can be laid out, with
gloves and aprons stationed at the periphery.
Equipment required by that patient for its
care should remain within the barrier mark.
This may include monitoring equipment,
medications, hospital records, food, bowls and
bedding materials. Similarly, dirty bedding and
waste must be cleanly bagged before exiting
the barrier mark.
Fig 6: Gloves and aprons should be
available around the room, with easy
access
maintenance of a clean environment. Highcontact areas, such as phones, keyboards, desk
surfaces and door handles, should be cleaned
with disinfectant F10 wipes (F10 Products)
every few hours. Daily cleaning should consist
of wiping down all surfaces and monitoring
equipment, vacuuming and mopping the floors
with disinfectant solution. Kennels should be
cleaned as needed when dirtied by the occupant
and completely disinfected between patients.
Deep cleaning should take place on a monthly
basis – this includes walls, fridges, cupboards
and shelves.
Microfibre cloths have been shown to clean
surfaces more effectively than plain cloths
(Moore and Griffith 2006). Using detergent
before disinfectant also increases the removal
of organic matter and bacteria.
A daily, weekly and monthly cleaning
schedule ensures that no job gets missed.
suction and scavenging. Suspended ceiling
columns could also be considered, as these
can add accessibility to specific areas for triage
or high-dependence cases.
Oxygen
Several kennels should be equipped with
oxygen outlet ports nearby. This allows oxygen
delivery to the patient within that kennel either
by creating an oxygen kennel or providing nasal
cannulae or prongs. There should be about two
oxygen kennels for every 10 kennels, dependant
upon the size of the ICU and caseload. If oxygen
is administered via nasal prongs or catheters,
humidifiers should be placed between the
oxygen and the patient. These usually come
with the purchase of the oxygen kennel and can
also be purchased individually.
Standard operating procedures
Surgical air
Standard operating procedures (SOPs) are
essential to the smooth running of the ICU,
as they ensure that common procedures
are performed in the same way every time.
SOPs can be applied to both clinical and nonclinical tasks. Each hospital will have differing
needs for SOPs and they can be created for
cleaning protocols, controlled drug handling,
‘infection control procedures, peripheral or
central catheter placement, blood collection or
transfusion administration, the management of
certain diseases such as diabetic ketoacidosis
or seizures, and so on.
The SOPs should be kept in a centralised
location in electronic or paper form and clearly
labelled.
Surgical air is necessary for patients that are
on long-term oxygen therapy, for example,
patients that are being ventilated.
Equipment
When considering an ICU, thought must be
given to both the necessity and proximity
of the relevant equipment in context of the
number and types of patients that will be
cared for.
Cleaning
Medical gas supply
There should be minimal equipment and
storage on the work surfaces to facilitate
There should be medical gas supply built into
the ICU to supply piped oxygen, surgical air,
4
Fig 7: Sinks should be kept clean and
clear, and there should be access to
both hand wash and sanitising spray
or gel. Paper towels prevent crosscontamination from hand drying
Suction
Suction equipment is important in an ICU
and is useful for cleaning endotracheal and
tracheostomy tubes, clearing airways in
patients that have regurgitated acutely and
aiding oral hygiene in ventilated patients.
Scavenging
Scavenging is necessary for any gaseous
anaesthesia within the ICU.
Electrical supply
Electrical sockets should be abundant within
the ICU. There must be two sockets to every
kennel and also at certain points around
the room. Ceiling columns with integrated
electrical sockets are useful in providing
centralised access points.
Lighting
It is important to be able to control the
lighting within the ICU and ideally it should
be dimmable. This allows provision of a lowstimulus environment for sound- and light-
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Fig 9: Kennels should be
easy to access and clean,
and allow direct patient
observation from most
aspects of the room
Fig 8: Intensive care units can benefit from a centrally located
ceiling column with both gas and electrical outlets. Spotlights
are helpful for performing tasks in low light conditions.
Walk-in kennels (shown in the background) are useful for
large or recumbent patients
sensitive patients and patient rest periods,
during which patient checks should be kept
to a minimum. Spotlights located above
examination tables provide a focused light
source for intravenous catheter placement,
and so on (Fig 8).
Kennels
Kennels should be easy to clean and maintain,
and numbered and correlated to a numbered
drawer for in-patient medications and a
numbered file for in-patient records. Steel
kennels are ideal for small to medium patients
and walk-in kennels with non-slip flooring are
suitable for large or recumbent patients.
Each kennel should be furnished with a
clipboard to which the daily hospital sheet can
be attached (Fig 9).
Other equipment
The caseload and kennel space will dictate how
much other equipment is required. Items of
equipment that are considered essential and
desirable for the smooth running of the ICU are
listed in Table 3.
does not have to be within the ICU but the
ease of access in a crisis can be lifesaving. A
dedicated fridge and freezer with the ability to
monitor maximum and minimum temperatures
Table 3: Items of equipment
considered essential and desirable for
the provision of intensive patient care
Essential
Desirable
Intravenous fluid pumps
Capnograph
Syringe drivers
Chest drainage unit
(eg, Thora-Seal,
Medtronic Minimally
Invasive Therapies)
Oscillometric blood
pressure device
Electrocardiograph
Doppler blood pressure
device
Heat mats
Blood pressure cuffs in
multiple sizes
Temperature
management system
(eg, Bair Hugger, 3M)
Pulse oximeter
Incubator
Multiparameter
monitors
Blood products
Generally, a hospital large enough to require an
ICU will be treating patients that may require
blood products. Storage of these products
Pressure bag
Mobile ultrasound
are required for appropriate blood product
storage. A logbook of products received and
recipients forms part of the medical record and
allows auditing of blood product administration
within the hospital.
The administration of blood products
necessitates blood typing; therefore, bloodtyping kits should be added to the ICU
inventory. Benchtop cross-matching kits
are also available and useful for out of hours
cross-matching when required for blood
administration and when external laboratories
are closed.
Summary
Planning and equipping an ICU is a multifaceted
and challenging task. Each hospital will have its
own individual needs and expectations for what
the ICU should offer and these will influence
the design, layout and management. There
are plenty of resources online and numerous
publications within the human field that can
guide the planning of a new facility. Above all,
the success of the ICU rests upon the ability of
the team to work and communicate together to
achieve the highest level of patient care.
Reference
MOORE, G. & GRIFFITH, C. (2006) A laboratory
evaluation of the decontamination properties of
microfibre cloths. Journal of Hospital Infection 64,
379-385
doi: 10.1136/inp.i5579
Caroline Smith graduated from the Royal Veterinary College (RVC). After a short period in general
practice she decided to pursue a career in emergency and critical care. She undertook an internship in
a large referral hospital in Rochester, USA, and stayed on as an emergency veterinarian. After returning
to the UK, she worked for an out-of-hour’s provider before embarking upon a residency in emergency
and critical care back at the RVC. She spent two years in private referral clinics before moving to
Langford Veterinary Services to help develop and expand the critical care service already offered.
She particularly enjoys management of emergency trauma cases, sepsis control and fluid therapy.
Holly Witchell qualified as a veterinary nurse in 2008. She worked in small animal practice for four
years followed by two years in a mixed practice veterinary hospital. She joined Langford Veterinary
Referral Services in March 2011, where she began her role as a night nurse and went on to work in the
ICU. She gained the certificate in emergency and critical care in 2013 and became head ICU nurse in
2014. She gained the AVECCT Veterinary Technician Specialist (Emergency and Critical Care) in 2015.
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Planning, managing and equipping an
intensive care unit within a veterinary facility
Caroline Smith and Holly Witchell
In Practice 2016 38: 2-5
doi: 10.1136/inp.i5579
Updated information and services can be found at:
http://inpractice.bmj.com/content/38/Suppl_4/2
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