ETHIOPIAN

POLICE FORCE
HOSPITAL
ICU protocol / package/ QUALITY
OFFICE
April .2025
On those ICU protocol package the following protocols are
included

1. ICU Nursing Care Protocol

2. ICU Vital Sign Monitoring Protocol

3. Fluid Balance Monitoring Protocol

4. Enteral Nutrition Protocol
5. G.I. Prophylaxis Protocol
6. DVT Prophylaxis Protocol
7. ICU Medication Administration Protocol
8. ICU Admission Protocol

9. ICU Discharge Protocol

1
1. ICU Nursing Care Protocol
1. Purpose

To provide high-quality, patient-centred care for critically ill patients in the ICU, ensuring safety,
optimal outcomes, and adherence to best practices.

2. Scope

This protocol applies to:

 All ICU patients: Those requiring intensive monitoring, life-support, or specialized care.
 Nursing staff: Registered nurses, nurse practitioners, and other allied nursing staff working in
the ICU.

3. Team Composition

 ICU Nurse Manager: Oversees nursing staff and ensures adherence to protocols.
 ICU Nurses: Direct care providers who perform daily assessments, administer treatments,
monitor patient status, and communicate with the healthcare team.
 Multidisciplinary Team: Includes intensivists, respiratory therapists, physiotherapists,
dietitians, and other specialists involved in patient care.

4. General ICU Nursing Responsibilities

 Patient Assessment: Perform regular, systematic assessments, including vital signs,

neurological status, cardiovascular and respiratory functions, and other ICU-specific
parameters.
 Monitoring: Continuous monitoring of heart rate, blood pressure, oxygenation (SpO2),
temperature, and other life-support indicators using ICU monitoring equipment.
 Communication: Maintain clear communication with the multidisciplinary team, the
patient’s family, and the patient (if appropriate).
 Documentation: Accurate and timely documentation of assessments, interventions,
medication administration, and patient responses.

5. Specific Nursing Interventions and Care Protocols

a. Respiratory Care

2
  Ventilator Management: Monitor mechanical ventilation parameters (e.g., tidal volume,
respiratory rate, oxygenation levels) and troubleshoot alarms.
 Airway Management: Ensure proper positioning for airway clearance (e.g., head-of-bed
elevation), suctioning as needed, and management of tracheostomy tubes.
 Oxygen Therapy: Administer oxygen as prescribed and monitor effectiveness via pulse
oximetry and blood gas analysis.

b. Cardiovascular Care

 Hemodynamic Monitoring: Continuous monitoring of blood pressure, central venous

pressure (CVP), and other critical parameters.
 Medications: Administer vasoactive drugs (e.g., vasopressors, inotropes) as prescribed,
monitoring for efficacy and side effects.
 Fluid Management: Assess fluid balance, manage intravenous (IV) fluids, electrolytes, and
ensure appropriate adjustments based on patient’s condition.

c. Neurological Care

 Glasgow Coma Scale (GCS): Perform regular neurological assessments using the GCS or
other tools to assess consciousness and neurological function.
 Sedation and Analgesia: Administer sedation and pain management according to protocols,
including monitoring sedation depth and pain scales.
 Seizure Monitoring: Observe for signs of seizures, and administer anticonvulsants if needed.

d. Renal Care

 Urine Output Monitoring: Measure and document urine output regularly, monitor for signs
of oliguria or anuria, and adjust fluid management accordingly.
 Dialysis Support: Assist with dialysis initiation, monitoring, and maintenance if the patient
requires renal replacement therapy.

e. Infection Control

 Aseptic Technique: Strict adherence to aseptic technique during invasive procedures (e.g.,
central line insertion, catheter management).
 Antibiotic Stewardship: Administer prescribed antibiotics and follow protocols for culture
and sensitivity tests, ensuring the correct drug, dose, and duration.
 Infection Surveillance: Regular surveillance for signs of hospital-acquired infections (e.g.,
ventilator-associated pneumonia, catheter-associated urinary tract infections).

3
f. Nutrition and Hydration

 Enteral Feeding: Administer enteral nutrition via feeding tube as ordered, ensuring patient
tolerance, and monitoring for complications such as aspiration.
 Parenteral Nutrition: For patients unable to tolerate enteral nutrition, manage intravenous
nutritional support according to institutional guidelines.
 Fluid Balance: Track fluid intake and output closely, monitoring for signs of fluid overload
or dehydration.

g. Mobility and Positioning

 Patient Repositioning: Reposition patients regularly (at least every 2 hours) to prevent
pressure ulcers, improve circulation, and optimize respiratory function.
 Early Mobilization: Engage in safe early mobilization practices (e.g., passive range of
motion, sitting up in bed) to promote recovery and reduce complications like deep vein
thrombosis.

h. Family Communication and Support

 Regular Updates: Provide regular updates to the patient’s family, ensuring they are involved
in care decisions and understand the patient’s condition.
 Emotional Support: Offer psychological support to families, addressing concerns and
offering counselling resources when appropriate.

6. Infection Prevention Protocols

 Hand Hygiene: Strict adherence to hand hygiene protocols before and after patient care.
 Personal Protective Equipment (PPE): Ensure that staff and visitors wear appropriate PPE
(e.g., gloves, gowns, masks) to prevent the spread of infections.
 Environmental Cleaning: Ensure regular cleaning and disinfection of patient care areas and
equipment.

7. Documentation and Reporting

 Patient Care Records: Maintain accurate, detailed, and up-to-date records of all assessments,
interventions, and patient responses.
 Incident Reporting: Report any adverse events, near-misses, or significant changes in the
patient’s condition to the ICU management team.

4
  Shift Handover: Ensure effective communication during handover to the next shift, including
patient status, critical care interventions, and any changes.

8. Patient and Family Education

 Patient Education: Provide explanations of procedures, treatment plans, and expected

outcomes to patients (as appropriate based on their condition).
 Family Involvement: Educate family members on ICU processes, visiting hours, and how
they can contribute to the patient’s recovery (e.g., assisting with personal care).

9. Emergency Protocols

 Cardiac Arrest: Follow ACLS (Advanced Cardiovascular Life Support) protocols in the
event of a cardiac arrest, ensuring timely response and documentation.
 Rapid Response Team Activation: In case of sudden deterioration, activate the hospital’s
Rapid Response Team for immediate intervention.

10. Continuous Quality Improvement

 Audit and Monitoring: Regular audits of ICU practices to ensure compliance with this
protocol, patient outcomes, and adherence to best practices.
 Staff Training: Ongoing education and training programs to ensure that ICU nursing staff is
up-to-date with the latest evidence-based practices and technologies.

5
2. ICU Vital Sign Monitoring Protocol
1. Purpose

To ensure continuous, accurate, and timely monitoring of vital signs in ICU patients for early
detection of clinical deterioration and to guide appropriate medical interventions.

2. Scope

Applies to all healthcare providers (primarily ICU nurses) caring for critically ill patients in the ICU
setting.

3. Vital Signs to Monitor

 Heart Rate (HR)

 Respiratory Rate (RR)
 Blood Pressure (BP) – non-invasive or arterial
 Oxygen Saturation (SpO₂)
 Temperature (T)
 Central Venous Pressure (CVP) – if line is present
 Mean Arterial Pressure (MAP) – especially for patients on vasopressors
 Pain score (if patient is responsive)
 Neurological status (e.g., GCS)

4. Monitoring Frequency
Patient Condition Vital Sign Monitoring Frequency
Stable ICU patient Every hourly (or continuous where available)
Unstable/critical patient Every 15–30 minutes, or continuous if on life support
Post-operative (first 24 hrs) Every 15–30 minutes, then hourly if stable
On vasopressors/inotropes Continuous (MAP preferred), document every 15–30 mins
Post-cardiac arrest Every 5–15 minutes during stabilization phase
After a procedure/intervention Every 15 minutes for 1 hour, then resume routine

5. Equipment Used

 Cardiac monitor
 Pulse oximeter

6
  Arterial line (for invasive BP and MAP)
 Thermometer (core or surface)
 Capnography (if intubated or sedated)
 Manual equipment for verification (e.g., manual BP cuff)

6. Documentation

 All vital signs must be documented immediately after assessment in the patient’s electronic
or paper record.
 Include time, method (e.g., manual, electronic), and any interventions or abnormalities.
 Use trends/charts to track changes over time.

7. Response to Abnormal Values

Vital Sign Trigger for Immediate Action
HR < 50 or > 130 bpm Notify physician; assess rhythm and perfusion
RR < 8 or > 30/min Check airway, sedation level, oxygenation
SpO₂ < 90% Increase O₂, suction airway, call for help
BP < 90 systolic or > 180/110 Check for bleeding, shock, stroke, hypertensive crisis
Temp > 38.5°C or < 35°C Suspect infection/sepsis or hypothermia
MAP < 65 mmHg May need fluid resuscitation or vasopressors
Sudden neuro changes Assess GCS, call doctor, prepare for CT or resus

8. Quality Assurance

 Regular calibration of monitors and thermometers.

 Random audits of documentation accuracy and response time.
 Mandatory training for all new ICU staff on this protocol.

9. Infection Control

 Use disposable covers and clean devices after each use.

 Hand hygiene before and after vital sign monitoring.

10. Review and Updates

 Protocol to be reviewed annually or as new guidelines are released (e.g., by WHO, SCCM, or
institutional policies)

7
 3. Fluid Balance Monitoring Protocol
1. Purpose

To ensure accurate and consistent monitoring of fluid intake and output for critically ill and high-risk
patients, enabling timely intervention and promoting optimal fluid management.

2. Scope

This protocol applies to:

 ICU patients
 Post-operative patients
 Patients on IV fluids, diuretics, or renal replacement therapy
 Patients with fluid balance concerns (e.g., heart failure, renal failure, sepsis)

3. Monitoring Components

A. Intake

 Oral fluids
 IV fluids (including medications)
 Enteral feeds (NG, PEG)
 Blood products
 Parenteral nutrition

B. Output

 Urine
 Stool (if liquid or high volume)
 Emesis
 Drain output (e.g., chest tube, wound drain)
 Insensible losses (estimated if necessary)
 Dialysis effluent

8
4. Monitoring Requirements
Patient Condition Monitoring Frequency
Stable patient on maintenance IV Every 8 hours or per shift
ICU/critically ill patient Hourly intake and output documentation
Oliguria, anuria, or AKI Hourly urine output and strict fluid charting
On diuretics or vasopressors Hourly output; review fluid response closely
Post-operative (major surgery) Hourly for first 24–48 hours, then every 4–8 hrs
On dialysis/CRRT Hourly or per dialysis machine output

5. Daily Fluid Balance Calculation

 Formula:
Net Balance = Total Intake – Total Output
 Must be calculated and recorded at the end of each shift and summarized daily.
 Trending over 24–72 hours is required for ICU patients.

6. Equipment and Tools

 Urine meters or Foley catheter bags

 Calibrated jugs or syringes for oral intake
 Fluid balance charts or electronic medical records (EMR)
 Weighing scales for daily weight (indirect fluid balance indicator)
 Infusion pumps (for accurate IV fluid delivery)

7. Documentation

 Every entry must include:

o Time
o Type and volume of intake/output
o Route (e.g., IV, oral, drain)
o Nurse's initials
 Use a standardized fluid chart or EMR module.
 Mark cumulative totals every shift.

9
8. Clinical Triggers for Escalation
Finding Action
Urine output < 0.5 mL/kg/hr Notify physician; assess renal function, hydration
Positive balance > +1500 mL/day Risk of overload; consider diuretics or fluid limit
Negative balance > –1000 mL/day Assess dehydration; review fluid prescription
Sudden weight gain (>1 kg/day) Check for fluid overload
No output from drains Check patency or dislodgement

9. Infection Prevention

 Strict asepsis for urine/drain collection

 Change collection devices per policy
 Hand hygiene before and after contact

10. Quality Control

 Supervisors should audit fluid charts at least weekly

 Spot checks for hourly urine documentation in ICU
 Re-train staff if documentation is inaccurate or incomplete

11. Review & Update

 Protocol should be reviewed annually or after changes in:

o National/international guidelines
o Hospital policy
o Audit findings

10
 4. Enteral Nutrition Protocol
1. Purpose

To provide guidelines for the safe initiation, monitoring, and maintenance of enteral nutrition (EN) in
patients who cannot meet their nutritional needs orally but have a functioning gastrointestinal tract.

2. Scope

Applicable to:

 ICU and non-ICU adult patients requiring tube feeding

 Nurses, physicians, and dietitians responsible for nutritional care

3. Indications for Enteral Nutrition

 Inability to maintain oral intake > 5 days

 Intubated/mechanically ventilated patients
 Neurological or swallowing disorders
 Post-operative GI surgery with functioning bowel
 High nutritional risk (NRS-2002 or MUST score ≥ 3)

4. Contraindications

 Intestinal obstruction or perforation

 Severe hemodynamic instability
 High-output GI fistula not bypassed by feeding tube
 Active GI bleeding
 Intractable vomiting or ileus

5. Route of Administration
Route Indication
Nasogastric (NG) Short-term feeding (≤4–6 weeks)
Nasoduodenal/Nasojejunal Risk of aspiration or gastric intolerance
PEG/PEJ Long-term feeding (>6 weeks)

11
6. Initiation Protocol

1. Confirm Tube Placement

o X-ray confirmation required for new NG/NJ tubes
o Mark tube exit site; document insertion length
2. Start Feeding
o Begin with isotonic formula unless otherwise indicated
o Initial rate: 10–30 mL/hr, depending on tolerance and patient status
o Advance every 4–6 hours as tolerated to target rate
3. Water Flush
o Before and after each feeding or medication: 30–50 mL sterile water
o Every 4 hours for continuous feeding

7. Monitoring and Assessment

Parameter Frequency Notes
Tube placement Before each use Check external length, aspirate pH if
needed
Gastric residual volume (GRV) Every 4–6 hrs (if Hold feeding if GRV > 500 mL unless
indicated) specified
Bowel function Daily Document stool pattern, signs of ileus
Weight Twice weekly Track nutritional progress
Labs (electrolytes, glucose, urea, Every 2–3 days initially Adjust as needed
etc.)
Hydration status Daily Monitor urine output, mucous membranes

8. Complication Management
Issue Response
Diarrhea Review medications, formula rate/type, consider probiotics
Constipation Increase fluids, consider laxatives, assess mobility
Aspiration Elevate head-of-bed (30–45°), reassess route (post-pyloric)
Tube dislodgement Stop feeding, notify physician, replace tube if necessary
Blocked tube Flush with warm water/pancreatic enzyme solution

9. Medication Administration via Tube

 Use liquid formulations if possible

 Flush before and after each medication with 15–30 mL water

12
  Do not mix medications with formula
 Crush only approved medications; check compatibility

10. Documentation

 Type of formula, rate, volume administered

 Tolerance signs (e.g., nausea, vomiting, distension)
 GRV (if measured), bowel function, hydration status
 Medications and flushes given via tube
 Daily fluid balance and nutritional intake

11. Discontinuation of EN

 Transition to oral diet once:

o Swallowing is safe (assessed by SLP if needed)
o GI tract can tolerate oral intake
 Gradually wean off EN as oral intake increases
 Remove tube only with physician order

12. Infection Prevention

 Hand hygiene before handling tube/feed

 Change feeding bag and tubing every 24 hours
 Store open formula as per manufacturer’s guidelines
 Maintain clean work area

13. Staff Training & Review

 Mandatory training for all staff handling EN

 Protocol reviewed annually or after major guideline updates (e.g., ASPEN/ESPEN)

13
5. G.I. Prophylaxis Protocol
1. Purpose

To prevent stress ulcers, gastrointestinal bleeding, and complications of acid-related disorders in

critically ill or high-risk hospitalized patients.

2. Scope

This protocol applies to:

 ICU patients
 Post-operative or trauma patients
 Patients on mechanical ventilation or with high bleeding risk
 Nurses, physicians, and pharmacists involved in patient care

3. Indications for GI Prophylaxis

Initiate prophylaxis if ANY of the following major risk factors are present:

Major Risk Factors

Mechanical ventilation > 48 hours
Coagulopathy (Platelets < 50,000; INR > 1.5; aPTT > 2x normal)
History of GI ulcer or bleeding within past year
Traumatic brain/spinal cord injury
Severe burns (>35% total body surface area)

Or if ≥2 of the following minor risk factors are present:

Minor Risk Factors

Sepsis
ICU stay > 7 days
High-dose corticosteroids (>250 mg hydrocortisone/day or equivalent)
Use of NSAIDs
Acute renal or hepatic failure
Enteral feeding intolerance

14
4. Agents Used for Prophylaxis
Class Examples Notes
Proton Pump Inhibitors Pantoprazole, Omeprazole IV or oral; effective, preferred in high-risk
(PPIs) patients
H2 Receptor Antagonists Ranitidine*, Famotidine Renal dosing required; tolerance may
(H2RAs) develop
Sucralfate Used when bleeding risk Less effective; does not alter pH; not for
is low ventilated patients

*Note: Ranitidine has been withdrawn in some countries due to safety concerns. Confirm local
availability.

5. Dosing Guidelines (Adults)

Drug Route Dose
Pantoprazole IV 40 mg once daily
Omeprazole PO/NG 20–40 mg once daily
Famotidine IV/PO 20 mg every 12 hours
Sucralfate PO/NG 1 g every 6 hours

6. Administration Guidelines

 Prefer oral or enteral administration when GI tract is functional.

 For NPO or ventilated patients, use IV route.
 Do not administer sucralfate concurrently with other oral meds—may impair absorption.
 Assess renal function before using H2 blockers.

7. Monitoring
Parameter Frequency Action
GI symptoms (bleeding, Daily Report signs of GI bleeding (melena,
pain) hematemesis)
Hemoglobin/Hematocrit Every 24–48 hours Monitor for occult bleeding
Renal function (if on H2RA) Every 2–3 days Adjust dose as needed
Gastric residuals (ICU) Per enteral feeding May indicate GI intolerance
protocol

8. Discontinuation Criteria

Discontinue GI prophylaxis when:

15
  Risk factors resolve (e.g., extubated, stable labs)
 Enteral feeding is well-tolerated
 Patient is transferred out of ICU or to a general ward with no ongoing risks

9. Safety and Precautions

 Long-term PPI use is associated with:

o Clostridioides difficile infection
o Pneumonia
o Hypomagnesemia
o Bone fracture risk
 Avoid unnecessary continuation after ICU discharge

10. Documentation

 Indication for starting prophylaxis

 Drug, dose, route, and frequency
 Daily assessment of need
 Reason for discontinuation (when applicable)

11. Review and Quality Control

 Periodic audits of GI prophylaxis use (ICU and wards)

 Education for prescribers on overuse and deprescribing
 Annual review of the protocol based on current guidelines (e.g., ASHP, SCCM, local policy)

16
 6. DVT Prophylaxis Protocol
1. Purpose

To prevent the development of DVT and pulmonary embolism (PE) in hospitalized patients by early
identification of risk factors and timely initiation of prophylactic measures.

2. Scope

Applicable to:

 All adult inpatients (medical, surgical, ICU)

 Healthcare providers responsible for patient care (physicians, nurses, pharmacists)

3. Risk Assessment

Use validated tools such as:

 Padua Prediction Score (medical patients)

 Caprini Risk Assessment Model (surgical patients)
 Hospital-specific VTE risk assessment forms

High-Risk Patients Include:

 Major surgery (especially orthopedic, pelvic, abdominal)

 Prolonged immobility (>72 hours)
 Trauma or spinal cord injury
 Active cancer or chemotherapy
 Previous DVT/PE
 Sepsis, stroke, or severe infection
 Heart or respiratory failure
 Pregnancy or postpartum state
 Obesity (BMI >30)

17
4. Types of Prophylaxis

A. Pharmacologic Prophylaxis
Agent Dose Route Frequency
Enoxaparin (LMWH) 40 mg SC Once daily
Enoxaparin (renal) 30 mg SC Once daily if CrCl <30 mL/min
Heparin (UFH) 5,000 units SC Every 8–12 hours
Fondaparinux 2.5 mg SC Once daily

Adjust doses for renal function, age, and weight. Monitor platelets for HIT (heparin-induced
thrombocytopenia).

B. Mechanical Prophylaxis

Use when pharmacologic therapy is contraindicated:

 Graduated compression stockings (GCS)

 Intermittent pneumatic compression (IPC) devices

Initiate as early as possible and continue until patient is ambulating.

5. Contraindications to Pharmacologic Prophylaxis

 Active or high risk of bleeding

 Severe thrombocytopenia (Platelets <50,000)
 Intracranial hemorrhage or recent neurosurgery
 Uncontrolled hypertension (SBP >200 mmHg or DBP >120 mmHg)
 Coagulopathy or INR >1.5 (not due to anticoagulation)
 Recent GI bleeding (<2 weeks)

6. Timing and Duration

Patient Type Start Time Duration
General medical Within 24 hours of admission Until fully mobile or discharged
Surgical (low risk) Pre- or post-op day 1 7–10 days
Surgical (high risk/orthopedic) 6–12 hours post-op Up to 35 days post-op (e.g., THR, TKR)
ICU patients Within 24 hours Throughout ICU stay or immobility

18
7. Monitoring and Documentation

 Daily assessment for VTE risk and bleeding

 Platelet count monitoring (especially with UFH)
 Record:
o Type of prophylaxis
o Dose, route, and timing
o Patient tolerance and side effects
 Document VTE risk reassessment every 48–72 hours

8. Patient Education

 Importance of prophylaxis
 Signs and symptoms of DVT/PE (e.g., calf pain, swelling, shortness of breath)
 Mobility encouragement and leg exercises

9. Quality Assurance

 Monthly audit of VTE prophylaxis compliance

 VTE event tracking and RCA (Root Cause Analysis) for failures
 Staff education updates annually or with new guidelines

10. Review and Policy Updates

 Based on international guidelines (e.g., ACCP, NICE, ASH)

 Annual protocol review or upon new evidence

19
7. ICU Medication Administration Protocol
1. Purpose

To guide ICU healthcare professionals in the safe, timely, and precise administration of
medications, minimizing errors and ensuring optimal outcomes for critically ill patients.

2. Scope

Applies to:

 Nurses, physicians, and pharmacists in ICU settings

 Adult ICU patients (can be adapted for neonatal/pediatric ICU if needed)

3. General Principles

 Always follow the 8 Rights of medication administration:

1. Right patient
2. Right medication
3. Right dose
4. Right time
5. Right route
6. Right reason
7. Right response
8. Right documentation
 Use barcode medication administration (BCMA) and double-checks for high-alert
medications.
 Prioritize sterile technique, particularly for IV medications.

4. Common ICU Medication Routes

Route Use Special Notes
IV Push Emergencies, rapid onset needed Check compatibility, push slowly as directed
IV Infusion Continuous meds (e.g., vasopressors, Use infusion pumps with dose guard settings
insulin)
Enteral When oral route is not possible Crush only approved drugs, flush before/after
(NG/OG/PEG) administration
Subcutaneous Insulin, anticoagulants (e.g., enoxaparin) Rotate sites, monitor for hematomas

20
5. High-Alert Medications in ICU

These must be double-checked independently by 2 licensed professionals:

 Insulin (IV and SC)

 Heparin (unfractionated or LMWH)
 Potassium chloride (IV)
 Opioids (morphine, fentanyl)
 Sedatives (midazolam, propofol)
 Neuromuscular blockers (e.g., vecuronium)
 Vasopressors/inotropes (e.g., norepinephrine, dopamine)
 Anticoagulants (e.g., warfarin, DOACs)

6. Timing and Prioritization

Type Administration Timeframe
STAT/emergency Immediately (within 5–15 minutes)
Time-critical (e.g., antibiotics, insulin) ± 30 minutes of scheduled time
Routine ± 1 hour of scheduled time
PRN Based on clinical indication and frequency

7. ICU-Specific Monitoring

 Vitals: Monitor pre- and post-medication (especially with sedatives, pressors, diuretics)
 Blood glucose: For insulin and corticosteroid therapy (typically q4–6h)
 Sedation score: For sedatives (e.g., RASS, SAS)
 Pain score: For analgesics
 Lab monitoring:
o Creatinine, liver enzymes (for nephrotoxic/hepatotoxic drugs)
o INR/aPTT (for anticoagulants)
o Electrolytes (for diuretics, digoxin, etc.)

8. Documentation Requirements

 Time and dose of administration

 Route and method used (e.g., bolus, infusion)
 Patient's response or side effects
 Site of administration (for injections)
 Signature or electronic confirmation

21
Always document immediately after administration—never before.

9. Handling Errors and ADRs

 Report immediately to the ICU physician.

 Fill out an incident report as per facility policy.
 Manage adverse drug reactions (ADR) promptly and document clearly.
 Conduct root cause analysis if needed.

10. Medication Storage and Labeling in ICU

 Keep emergency drugs in accessible crash carts (e.g., epinephrine, atropine)

 Clearly label all syringes and infusion bags
 Store look-alike/sound-alike (LASA) drugs separately
 Use color-coded labels for high-risk drugs where applicable

11. Drug Preparation

 Reconstitute/prepare only at bedside or in designated clean areas

 Use aseptic technique at all times
 Use infusion pumps with accurate programming
 Discard unused portions as per expiration guidelines

12. Staff Training & Quality Control

 All ICU staff should be:

o ACLS-certified
o Trained on critical care medication protocols
o Competency-assessed annually
 ICU audits should include:
o Medication error tracking
o Documentation accuracy
o High-alert drug complianc

13. Special Considerations

 Renal/hepatic dose adjustments

 Drug-drug and drug-nutrition interactions
 Holding or adjusting meds in unstable hemodynamic

22
 8. ICU Admission Protocol
The ICU Admission Protocol outlines the criteria and procedures for admitting patients to the
Intensive Care Unit (ICU). This protocol is designed to ensure that patients who require intensive
monitoring and treatment are admitted to the ICU in a timely and organized manner. It also defines
the responsibilities of healthcare providers involved in the admission process.

1. Purpose

To provide clear guidelines for the appropriate selection, assessment, and admission of patients to the
ICU, ensuring that the highest standards of critical care are maintained. The protocol aims to
maximize the utilization of ICU resources while ensuring that patients who require intensive
monitoring and treatment receive the care they need.

2. Scope

This protocol applies to:

 All patients who are considered for admission to the ICU.

 The healthcare team involved in the ICU admission process, including physicians (attending,
intensivists, residents), nurses, and other clinical staff.

3. Objectives

 To establish clear admission criteria for ICU patients.

 To ensure timely and effective transfer of patients to the ICU.
 To ensure appropriate resource allocation and prioritize patients based on clinical need.
 To maintain a high standard of care for patients admitted to the ICU.

4. Admission Criteria

A. General Admission Criteria

Patients who meet any of the following conditions should be considered for ICU admission:

1. Respiratory Failure

 Acute respiratory failure (e.g., hypoxemia, hypercapnia, or the need for mechanical
ventilation).
 Severe asthma exacerbation requiring invasive ventilation or high-flow oxygen therapy.

23
  Chronic obstructive pulmonary disease (COPD) exacerbation requiring invasive
mechanical ventilation.
 Severe pneumonia or ARDS (acute respiratory distress syndrome).
 Respiratory distress due to heart failure, trauma, or drug overdose.

2. Cardiovascular Failure

 Shock (cardiogenic, septic, hypovolemic, obstructive) unresponsive to initial resuscitative

efforts.
 Severe arrhythmias requiring continuous monitoring or interventions such as defibrillation
or pacing.
 Myocardial infarction (MI) with hemodynamic instability.
 Post-cardiac surgery patients requiring intensive monitoring and care.

3. Neurological Conditions

 Acute stroke (ischemic or haemorrhagic) with significant neurologic deterioration or severe

disability.
 Traumatic brain injury (TBI) requiring invasive monitoring (ICP monitoring).
 Status epilepticus that is refractory to medical management.
 Severe head injury with GCS < 8, requiring intensive monitoring.
 Severe coma or altered mental status of unknown etiology or requiring intensive care for
airway protection.

4. Renal Failure

 Acute kidney injury (AKI) requiring dialysis or close monitoring of fluid balance.
 Chronic kidney disease (CKD) with fluid overload or in need of intensive monitoring or
dialysis.

5. Multisystem Organ Failure

 Multiple organ dysfunction syndrome (MODS) or multiorgan failure that requires intensive
monitoring and intervention.
 Severe metabolic disturbances such as acidosis, alkalosis, or electrolyte imbalances that
cannot be corrected in a general ward.

24
6. Severe Trauma

 Major trauma patients with significant blood loss, severe burns, or polytrauma requiring
continuous monitoring and life-saving interventions.
 Post-operative recovery from major surgery where intensive care is needed due to
complications (e.g., haemorrhage, respiratory failure).

7. High-Risk Pregnancy

 Obstetric emergencies such as eclampsia, severe preeclampsia, or other complications

requiring intensive care.

8. Drug Overdose/Poisoning

 Acute drug overdose (e.g., opiates, benzodiazepines, or other life-threatening substances)

requiring intensive monitoring, ventilation support, or antidote administration.

B. Specific Indications for Admission

 Severe uncontrolled pain that cannot be managed on a general ward.

 Severe infections with sepsis that requires aggressive monitoring, resuscitation, or organ
support.
 Severe hypothermia or hyperthermia requiring controlled rewarming or cooling.
 Transplant recipients who need intensive monitoring post-transplantation.

5. ICU Admission Procedure

A. Initial Assessment and Referral

 Referring Physician's Role: The referring physician (e.g., emergency department physician,
surgical team, or primary care physician) should conduct a thorough initial assessment and
determine the patient's need for intensive care.
 Clinical Evaluation: The referring physician must evaluate and document:
o The patient's vital signs and clinical condition.
o The severity of the illness or injury.
o The need for specialized monitoring and treatment that cannot be provided outside
the ICU.

25
B. Decision for ICU Admission

 Intensivist/Consultant Role: An intensivist or senior physician should review the patient's

condition and decide if ICU admission is necessary based on the following:
o The presence of criteria for critical illness.
o The availability of ICU resources (e.g., bed availability, equipment).
o Prioritization of ICU admissions based on the severity of the patient's condition.

C. ICU Bed Allocation

 Assessment of ICU Capacity: Bed availability should be assessed in real-time. If the ICU is
at full capacity, critically ill patients should be prioritized, and elective admissions may be
deferred.
 Coordination with ICU Team: If the patient meets the criteria for ICU admission, the
nursing and ICU care team must be notified immediately for bed preparation.

D. Transfer and Documentation

 Transfer from the Emergency Department or Ward: The patient should be transferred to
the ICU with appropriate monitoring and documentation, including:
o A comprehensive patient history (including pre-existing conditions).
o Initial management (e.g., medications, ventilator settings).
o Diagnostic results (e.g., lab results, imaging studies).
o Intensive care needs and the rationale for ICU admission.
 Patient Monitoring and Preparation: Upon transfer, ensure that the ICU team sets up
monitoring equipment (ECG, pulse oximetry, blood pressure cuff, etc.) and prepares the
patient’s bed space for care.

6. ICU Admission Documentation

 Admission Note: The intensivist or attending physician should document an admission note
that includes:
o Admission diagnosis.
o Clinical condition at the time of admission.
o Treatment plan including any immediate interventions required.
o Monitoring needs (e.g., mechanical ventilation, continuous blood pressure
monitoring, etc.).
o Resuscitation status (e.g., full code, do-not-resuscitate (DNR)).

26
 o Consultations with other specialists, if needed.
 ICU Care Plan: Outline the immediate management goals, including stabilization,
monitoring, and targeted interventions based on the patient’s condition.

7. Family Notification and Communication

 Family Briefing: Notify the family regarding the patient's condition and the need for ICU
admission. Offer a family meeting to discuss the patient’s prognosis, expected course of
treatment, and involvement in decision-making.
 ICU Visitation Policy: Explain the visitation policy for ICU, ensuring that family members
understand visiting hours, the need for hygiene protocols, and the importance of infection
control.

8. Discharge Criteria from ICU

 Stabilization: The patient should be stable enough to be transferred to a less intensive unit
(e.g., a step-down unit or general ward) once:
o Vital signs have stabilized.
o Organ support (e.g., mechanical ventilation, dialysis) is no longer needed.
o The patient’s condition has improved sufficiently to transition to lower-level care.
 Multidisciplinary Assessment: The ICU team (including physicians, nurses, and specialists)
should assess whether the patient is ready for discharge from the ICU based on recovery
status, prognosis, and ongoing care needs.

9. Conclusion

This ICU Admission Protocol ensures that patients who require intensive monitoring and care are
admitted in an organized and efficient manner. By adhering to these guidelines, ICU resources can be
utilized effectively while ensuring optimal care and safety for critically ill patients.

27
9. ICU Discharge Protocol

The ICU Discharge Protocol outlines the guidelines and procedures for safely transferring patients
from the Intensive Care Unit (ICU) to a lower level of care, such as a step-down unit, general ward, or
home. This protocol ensures that the patient is stable, ready for less intensive monitoring, and that all
necessary discharge planning and documentation are completed.

1. Purpose

To ensure that patients who are discharged from the ICU are stable, appropriately monitored, and
provided with a safe transition to a lower level of care or home. The protocol outlines the criteria,
process, and responsibilities involved in the ICU discharge.

2. Scope

This protocol applies to:

 All ICU patients who are being transferred out of the ICU.
 The healthcare team involved in the discharge process, including physicians (intensivists,
attending, residents), nurses, and allied health professionals.

3. Objectives

 To establish clear criteria for patient discharge from the ICU.

 To ensure safe and appropriate transition from the ICU to the general ward or home.
 To ensure proper documentation, patient education, and follow-up care.
 To provide clear instructions for ongoing care after ICU discharge.

4. Discharge Criteria

A. Clinical Stability

Patients must meet the following clinical stability criteria before discharge from the ICU:

1. Cardiovascular Stability:
o Stable heart rate and blood pressure without the need for vasopressors or intensive
inotropic support.
o No requirement for invasive monitoring (e.g., arterial lines, central venous pressure
monitoring).

28
 o Normal ECG findings or stable arrhythmias with adequate perfusion.
2. Respiratory Stability:
o Respiratory rate, oxygen saturation, and ventilation parameters should be within
normal limits for the patient's condition.
o The patient should be able to breathe independently without mechanical ventilation or
with minimal support.
o Spontaneous breathing with appropriate oxygenation and ventilation (FiO2 < 0.4 or
room air with adequate oxygen saturation).
o If on mechanical ventilation, the patient should have undergone a successful
spontaneous breathing trial (SBT).
3. Neurological Stability:
o Awake and alert, or neurologically stable, with the ability to maintain an adequate
airway.
o No signs of intracranial hypertension, seizures, or acute neurological deterioration.
o Glasgow Coma Scale (GCS) ≥ 13 or improvement in baseline neurological status.
4. Renal Function:
o Stable renal function with no need for continuous renal replacement therapy (CRRT)
or dialysis.
o Adequate urine output (if not on dialysis).
5. Metabolic Stability:
o Stable electrolytes, glucose levels, and metabolic status, with no ongoing major
imbalances.
o Nutrition support (oral, enteral, or parenteral) has been tolerated, and the patient is
maintaining an adequate nutritional intake.
6. Infection Control:
o No ongoing signs of active infection that require ICU-level interventions or isolation.
o All infection control measures are either complete or manageable outside of the ICU.

B. Multidisciplinary Review

 Intensivist Review: The intensivist or attending physician should review the patient’s overall
progress and confirm that all criteria for discharge from the ICU are met.
 Nursing and Allied Health Review: The nursing team and allied health staff (e.g.,
respiratory therapists, physical therapists) should assess the patient's functional recovery,
ensuring the patient is stable enough to transition to a general ward or home.

29
5. ICU Discharge Process

A. Final Assessment

Before discharge, the following should be assessed and confirmed:

 Clinical status: Ensure the patient is clinically stable and meets discharge criteria.
 Airway management: Confirm that the patient is able to maintain a clear airway
independently.
 Oxygenation and ventilation: Ensure that oxygenation is adequate, and the patient is
breathing independently, if applicable.
 Pain management: Ensure that the patient’s pain is well-controlled and does not require
intensive pain management that necessitates ICU-level care.
 Organ function: Confirm that organ systems are functioning well without the need for
intensive monitoring or support.

B. Preparation for Transfer

 Notify receiving unit: The receiving healthcare team (e.g., general ward, step-down unit)
should be informed of the patient's transfer, and appropriate handover documentation should
be provided.
 Complete documentation: Ensure the discharge note includes all relevant details, such as:
o Diagnosis and treatment received during ICU stay.
o Any ongoing medical needs (e.g., medications, rehabilitation).
o Follow-up care and recommended discharge instructions.
 Communication with the family: Family members should be informed about the patient’s
condition, the transfer process, and any changes in care.
 Patient education: Provide the patient and family with clear instructions for care after
transfer, including:
o Medication schedules and any changes in prescriptions.
o Signs and symptoms that require urgent medical attention.
o Follow-up appointments and post-ICU care.

C. Discharge Documentation

 ICU Discharge Summary: This should include:

o Reason for ICU admission.
o Course of treatment (including interventions, medications, and responses to
treatment).

30
 o Summary of the patient’s current condition.
o Any ongoing medical needs (e.g., therapy, medications).
o Follow-up instructions and plans.
 Transfer orders: Detailed transfer orders should be completed, ensuring all necessary patient
information is handed over to the next healthcare team.

6. Post-ICU Care and Follow-Up

A. Follow-Up Care

 Post-ICU follow-up: Arrange for follow-up visits with appropriate specialists (e.g.,
cardiology, pulmonology, nephrology, physical therapy) based on the patient's condition.
 Long-term monitoring: Some ICU patients may require prolonged monitoring,
rehabilitation, or other specialized care after discharge. This should be planned in advance.

B. Supportive Services

 Rehabilitation services: If necessary, arrange for physical, occupational, or respiratory

therapy to aid in the patient's recovery.
 Home care: For patients discharged to home with ongoing needs (e.g., oxygen therapy,
wound care), arrange for home healthcare services.
 Family support: Ensure that the family is equipped with the knowledge and resources for
ongoing care and support after discharge.

7. ICU Discharge Communication and Handover

 Handover to the receiving unit: The ICU team should provide a comprehensive handover to
the receiving ward or healthcare provider, detailing the patient’s condition, care requirements,
and any specific needs (e.g., medications, monitoring).
 Family communication: Ensure clear communication with the family about the next steps in
the patient's care and any instructions they need to follow at home or on the ward.

8. Special Considerations

 Critical or complex cases: For patients with complex needs or high risks of deterioration,
consider transferring to a high-dependency or intermediate care unit before discharge to a
general ward.

31
  End-of-life care: For patients with poor prognosis and limited recovery potential, ensure that
end-of-life discussions and palliative care plans are in place, including communication with
family members and provision of comfort care.

9. Conclusion

The ICU Discharge Protocol ensures that patients are carefully evaluated for clinical stability before
transfer, receive appropriate follow-up care, and are provided with comprehensive discharge
instructions. By adhering to this protocol, healthcare providers can ensure a smooth and safe transition
from the ICU to a lower level of care or home, optimizing patient outcomes and promoting recovery.

32