Critical Care Areas

Critical Care Unit (CCU) Requirements (NABH 5th Ed.)

Chapter AAC - Assessment of Patients

1. Registration, Admission, Transfer & Referral (AAC 2a, AAC 2b, AAC 2c, AAC 2d, AAC 2e, AAC 3b, AAC 3c, AAC 3d, AAC 12f):

   • CCUs must follow written guidance for admitting and transferring patients. (AAC 2a)

   • Every patient admitted to CCU must receive a Unique Hospital Identification Number (UHID). (AAC 2b)

   • Patients are accepted into CCU only if the hospital can provide the required level of care. (AAC 2c)

   • Written guidance must address managing patients during non-availability of CCU beds (e.g., managing a queue, communicating with alternate facilities). (AAC 2d)

   • Access to CCU must be prioritized based on clinical need. (AAC 2e)

   • Transferring patients out of CCU or referring them to another facility must be done safely with appropriate staff, equipment, and documentation of the reason and a summary of condition/treatment. (AAC 3b, AAC 3c, AAC 3d, AAC 12f)

   • Referrals to CCU from other departments must follow written guidance, specifying urgency. (AAC 12f)

2. Initial Assessment (AAC 4a, AAC 4b, AAC 4c):

   • Initial assessment for patients admitted to CCU must use a standardized format, including history, examination, vital signs, drug allergies, and provisional diagnosis. (AAC 4a)

   • Assessment must be performed by qualified personnel defined by the hospital. (AAC 4b)

   • The initial assessment in CCU must be performed within a defined time frame based on patient needs (e.g., rapid assessment upon arrival). (AAC 4c)

3. Reassessment (AAC 5a, AAC 5c, AAC 5d):

   • Patients in CCU must be reassessed at appropriate, frequent intervals to determine response to treatment and plan further care or discharge. (AAC 5a, AAC 5c interpretation explicitly mentions ICU needing more frequent reassessment).

   • The care plan for CCU patients must be dynamically monitored and modified during reassessment based on the patient's condition, documented in medical records (progress notes, orders, charts). (AAC 5c)

   • Staff involved in direct clinical care in CCU must document reassessments accurately, including vitals, systemic findings, and medication orders. Vague terms are not acceptable. (AAC 5d)

4. Continuum of Care - Responsibility & Coordination (AAC 12a, AAC 12b, AAC 12c, AAC 12d, AAC 12e, AAC 12h):

   • A qualified individual (primary physician) must be identified as responsible for the patient's care in CCU. (AAC 12a)

   • Patient care must be coordinated among all CCU care providers. (AAC 12b)

   • Effective communication of patient requirements must occur among CCU care providers. (AAC 12b)

   • Information about patient care and response to treatment must be shared among medical, nursing, and other providers in CCU (e.g., via case sheets, team meetings, rounds). (AAC 12c)

   • Standardized hand-over communication must be implemented during staffing shifts in CCU and during transfers. (AAC 12d)

   • Patient transfers within the hospital (e.g., to/from CCU) must be done safely with documented handover/takeover. (AAC 12e)

   • A mechanism must monitor whether adequate clinical intervention has occurred in response to critical value alerts for CCU patients; evidence of intervention must be documented. (AAC 12h)

5. Discharge Process (AAC 13a, AAC 13b, AAC 13c, AAC 13d, AAC 13e):

   • Discharge (e.g., transfer to ward or home) must be planned in consultation with the patient/family. (AAC 13a)

   • The process must be coordinated among involved departments/agencies. (AAC 13b)

   • Written guidance governs discharge against medical advice (LAMA). (AAC 13c)

   • A discharge summary is given to all patients leaving CCU (including LAMA) and a copy retained. (AAC 13d)

   • The hospital adheres to planned discharge timelines and processes from CCU. (AAC 13e)

Chapter COP - Care of Patients

1. Care in ICU/HDU (COP 9a, COP 9b, COP 9c, COP 9d, COP 9e, COP 9f, COP 9g):

   • Care of patients in Intensive Care and High Dependency Units must be provided based on written guidance (SOPs addressing all relevant objective elements). (COP 9a)

   • Defined admission and discharge criteria for ICU/HDU must be implemented (including managing "against medical advice" discharge). (COP 9b)

   • Adequate staff and equipment must be available in ICU/HDU, including all life-saving equipment handled by trained staff. (COP 9c)

   • The organisation endeavors to upgrade physical infrastructure in ICU/HDU to meet national/international guidelines (commensurate with scope/complexity). (COP 9d)

   • Defined procedures for managing bed shortages in ICU must be followed. (COP 9e)

   • Infection control practices specific to ICU/HDU must be followed. (COP 9f)

   • The organisation must implement a quality assurance programme for the ICU, using risk-adjusted standardized mortality rate, infection rates, readmission rates, and re-intubation rates as KPIs. (COP 9g)

2. Resuscitation Services (COP 5a, COP 5b):

   • Resuscitation services (Code Blue) must be available to patients in CCU at all times. (COP 5a)

   • During CPR, assigned roles and responsibilities must be complied with. (COP 5b)

   • Crash carts and necessary equipment/medications must be available. (COP 5a interpretation) Protocols should be displayed. (COP 5a interpretation)

3. Post-Event Analysis of Resuscitation (COP 5e):

   • A multidisciplinary committee must conduct post-event analysis of cardiopulmonary resuscitations occurring in CCU. Analysis should cover initiation, team arrival time, resource availability, sequence of events, outcomes, and be completed within a defined time frame. (COP 5e)

4. Nursing Care (COP 6a, COP 6b, COP 6d, COP 6e, COP 6f, COP 6g, COP 6h):

   • Nursing care must be provided in accordance with written guidance (nursing manual covering vital signs, medication administration, hygiene). (COP 6a)

   • Nursing clinical practice guidelines relevant to CCU (fall prevention, pressure ulcer prevention, DVT risk assessment/prevention) must be developed, implemented, and reviewed annually. (COP 6b)

   • Acuity-based staffing must be implemented to improve patient outcomes in CCU, linked to outcomes like pressure sores, falls, medication errors, VAP. (COP 6d)

   • Nursing care must be aligned and integrated with overall patient care, using a nursing care plan (assessment, plan, implementation, evaluation, modification). (COP 6e)

   • Care provided by nurses must be documented accurately in the patient record (nursing progress notes). (COP 6f)

   • Nurses in CCU must have appropriate and adequate equipment for safe and efficient care (sphygmomanometers, thermometers, etc., ensuring appropriate sizes). Inventory should be maintained. (COP 6g)

   • Nurses must be empowered to make patient care decisions within their defined scope of practice. (COP 6h)

5. Procedural Sedation (COP 12a, COP 12b, COP 12c, COP 12d, COP 12e, COP 12f, COP 12g, COP 12h):

   • Procedural sedation must be administered in a consistent manner following a SOP (identification of procedure, ordering mechanism, assessment, monitoring, discharge criteria). (COP 12a)

   • Informed consent must be obtained by the person administering sedation. (COP 12b)

   • Competent and trained persons (doctor or nurse under supervision of a doctor) must administer sedation. Technicians should not. (COP 12c)

   • The person monitoring sedation (trained in detecting abnormalities) must be different from the person performing the procedure. (COP 12d)

   • Intra-procedure monitoring must include heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, and level of sedation, and be documented. (COP 12e)

   • Patients must be monitored after sedation, and this must be documented. (COP 12f)

   • Criteria must be used to determine the appropriateness of discharge from the observation/recovery area (relevant if sedation recovery is a separate step). (COP 12g)

   • Equipment and workforce must be available to manage patients who go into a deeper level of sedation than intended (emergency resuscitation equipment, trained personnel). (COP 12h)

6. Blood Transfusion Safety (COP 8b, COP 8c, COP 8d):

   • Transfusion of blood/blood components in CCU must be done safely (SOP covering orders, storage, transport, verification before transfusion (patient ID, monitoring), monitoring during transfusion). (COP 8b)

   • Blood/components must be used rationally (SOP for indications, inventory, ordering schedules). (COP 8c)

   • Informed consent must be obtained for transfusion (valid for multiple transfusions within defined period, specific timeframe for transfusion-dependent patients, include risks/benefits/complications). (COP 8d)

7. Nutritional Care (COP 19a, COP 19b, COP 19c, COP 19d, COP 19e):

   • Patients admitted to CCU must be screened for nutritional risk (e.g., using NRS 2002, MNA). (COP 19a)

   • Nutritional assessment must be done for patients found at risk during screening (by dietician). (COP 19b)

   • A therapeutic diet must be planned collaboratively for CCU patients requiring it. (COP 19c)

   • Patients must receive food according to the written order (therapeutic or normal diet). (COP 19d)

   • If family provides food, they must be educated about limitations and monitored. (COP 19e)

8. End-of-Life Care (COP 20a, COP 20b, COP 20c, COP 20d, COP 20e):

   • End-of-life care in CCU must be provided in a consistent manner, respecting patient/family values, religion, and cultural preferences, and involving the patient/family. (COP 20a)

   • A multi-professional approach must be used for end-of-life care (involving doctors, nurses, psychologists, etc.). (COP 20b)

   • End-of-life care must be in consonance with legal requirements (e.g., DNR/DNI decisions must follow statutory laws and hospital guidelines). (COP 20c)

   • End-of-life care must address the unique needs of such patients and families (e.g., addressing religious/socio-cultural beliefs). (COP 20d)

   • Symptomatic treatment, particularly pain alleviation, must be provided effectively. (COP 20e)

9. Care for Vulnerable Patients (COP 16a, COP 16b, COP 16c, COP 16d, COP 16e, COP 16f):

   • The organisation must identify and manage vulnerable patients in CCU (all CCU patients are inherently vulnerable; specific groups like elderly, children, sedated, comatose). (COP 16a)

   • Responsibility for identification, risk management, and monitoring (at least twice daily) must be defined. Informed consent process for these patients should be addressed. (COP 16a interpretation)

   • Care must be organized and delivered according to written guidance for vulnerable patients. (COP 16a interpretation)

   • A safe and secure environment must be provided (fall prevention, grab bars etc.). (COP 16b)

   • Patients at risk of fall must be identified using a validated tool and managed according to written guidance. (COP 16c)

   • Patients at risk of developing/worsening pressure ulcers must be identified using a validated tool (Braden scale) and managed according to written guidance. Staging systems should be used. (COP 16d)

   • Patients at risk of deep vein thrombosis (DVT) must be identified using a validated tool and managed according to written guidance. (COP 16e)

   • Patients who need restraints must be identified and managed according to a written guidance (SOP for appropriate use and control). (COP 16f)

10. Pain Management (COP 17a, COP 17b, COP 17c, COP 17d):

    • Patients in CCU experiencing pain must be effectively managed. (COP 17a)

    • Patients admitted to CCU must be screened for pain (considered as 5th vital sign, yes/no question in initial assessment). (COP 17b)

    • Patients with pain must undergo detailed and periodic reassessment (intensity using validated scale, character, frequency, location, duration, radiation). (COP 17c)

    • Pain alleviation measures or medications must be initiated and titrated according to the patient's need and response (includes medical, surgical, anaesthetic techniques). (COP 17d)

Chapter MOM - Management of Medication

1. Medication Storage (MOM 3a, MOM 3b, MOM 3c, MOM 3d, MOM 3e, MOM 3f, MOM 3g):

   • Medications in CCU medication rooms must be stored in a clean, safe, and secure environment with limited access. Temperature monitoring must be done daily. (MOM 3a) Beyond expiry drugs stored separately. (MOM 3a interpretation)

   • Sound inventory control practices must guide storage. (MOM 3b)

   • A defined list of high-risk medications must exist. (MOM 3c)

   • High-risk medications must be stored in predetermined areas where clinically necessary, such as CCU, with safeguards to prevent inadvertent administration. (MOM 3d)

   • High-risk medications, including look-alike/sound-alike (LASA) meds and different concentrations, must be stored physically apart in CCU. (MOM 3e)

   • A list of emergency medications (on crash carts) must be defined and stored uniformly in CCU, with defined contents and no other drugs. (MOM 3f)

   • Emergency medications in CCU must be available all the time and replenished promptly when used (at least daily inventory check). (MOM 3g)

2. Medication Prescription (MOM 4a, MOM 4b, MOM 4c, MOM 4d, MOM 4e):

   • Medication prescription in CCU must follow good practices/rational guidelines; clinicians trained. (MOM 4a)

   • Prescriptions must adhere to minimum requirements (patient name/UHID, generic name, strength, dosage, instructions, duration, quantity, prescriber details). Avoid error-prone abbreviations, write in capitals, initial corrections. (MOM 4b)

   • Drug allergies/ADRs must be ascertained and documented prominently before prescribing. (MOM 4c)

   • Mechanism to assist clinicians in CCU with appropriate prescribing (e.g., drug reference to check interactions, duplication, dose adjustments). (MOM 4d)

   • Implementation of verbal orders in CCU must follow safe practices (SOP, define who/when , authentication, approved list, repeat back/read back, countersigned within 24 hrs). (MOM 4e)

3. Medication Reconciliation (MOM 4h):

   • Reconciliation of medications must occur at transition points involving CCU (admission, transfer to/from, discharge) and be documented. Prescribed meds checked for accuracy. (MOM 4h)

4. Medication Administration (MOM 7a, MOM 7b, MOM 7c, MOM 7d, MOM 7h):

   • Medications must be administered in CCU by those permitted by law (registered nurse/doctor). (MOM 7a)

   • Prepared medication in CCU must be labelled before preparing a second drug. (MOM 7b)

   • The patient must be identified using two identifiers (UHID/Name) before administration. (MOM 7c)

   • Medication must be verified from the order and physically inspected (appearance, expiry date) before administration. Strength, route, timing must be verified. (MOM 7d)

   • Explicitly for high-risk medications, verification by at least 2 staff (nurse-nurse or nurse-doctor) is required and documented. Nurses must be knowledgeable and empowered to highlight errors. (MOM 7d interpretation)

   • Measures must be implemented to avoid catheter and tubing misconnections during administration (using design features, tracing lines, verifying attachments). (MOM 7h)

5. Medication Monitoring & Errors (MOM 8a, MOM 8b, MOM 8c):

   • Patients must be monitored after medication administration in CCU (for beneficial/adverse effects, e.g., via lab results). (MOM 8a)

   • Medications must be changed where appropriate based on monitoring (clinical response, ADRs). (MOM 8b)

   • The organisation must capture near miss, medication error, and adverse drug reaction events occurring in CCU (define terms, SOP for identifying, documenting, reporting, analysing, acting). (MOM 8c)

6. Special Categories of Medications (MOM 9a, MOM 9b, MOM 9c, MOM 9d):

   • Narcotic drugs and psychotropic substances must be used safely in CCU (SOP, follow relevant acts). (MOM 9a)

   • These medications must be prescribed by appropriate caregivers (narcotics by designated doctor). (MOM 9b)

   • These medications must be stored securely in CCU (narcotics in a double lock cabinet), separately from other meds. (MOM 9c)

   • Proper record must be kept of usage, administration, and disposal. (MOM 9d)

Chapter PRE - Patient and Family Rights

1. Informed Consent (PRE 2g, PRE 4a, PRE 4b, PRE 4c, PRE 4d, PRE 4e):

   • Informed consent must be obtained by the treating doctor or a member of the treating team before blood transfusion, anaesthesia, surgery, research protocols, and any other invasive/high-risk procedures/treatment performed in CCU (e.g., intubation, line insertion). (PRE 2g)

   • The process must follow written guidance and statutory norms (list of procedures requiring consent, witness signature, handling repeated procedures/changes). (PRE 4a, PRE 4b)

   • Consent must include info on procedure, risks, benefits, alternatives, and who will perform it, in understandable language. (PRE 4c)

   • Organisation must define who can give consent when patient is incapable (statutory norms, next of kin, emergencies). (PRE 4d)

   • Consent must be taken by the person performing the procedure. (PRE 4e)

2. Patient Education (PRE 5f):

   • Patient and/or family in CCU should be educated on various pain management techniques when appropriate, respecting their beliefs. (PRE 5f)

3. Enhanced Communication (PRE 8b, PRE 8c, PRE 8d):

   • Special situations requiring enhanced communication with patients and families in CCU must be identified (e.g., breaking bad news, handling adverse events, discussing prognosis). (PRE 8b)

   • Enhanced communication must be done effectively. (PRE 8c)

   • Unacceptable communication must not occur. (PRE 8d)

4. Multi-disciplinary Counselling (PRE 3g):

   • Patient and/or family in CCU must be provided multi-disciplinary counselling when appropriate (identifying situations, team involves doctors from different specialties, nurses, physiotherapists, etc.). (PRE 3g)

Chapter HIC - Hospital Infection Control

1. Hand Hygiene (HIC 2d, HIC 3b):

   • Adequate and appropriate facilities for hand hygiene must be accessible to healthcare providers in all patient-care areas in CCU. (HIC 2d)

   • Adherence to hand-hygiene guidelines (WHO) is mandatory; instructions displayed. (HIC 3b)

2. Standard and Transmission-Based Precautions (HIC 3a, HIC 3c):

   • Adherence to standard precautions at all times in CCU is mandatory. (HIC 3a)

   • Adherence to transmission-based precautions in CCU is mandatory (appropriate PPE usage in identified situations). (HIC 3c)

3. Safe Injection Practices (HIC 3d):

   • Adherence to safe injection and infusion practices in CCU is mandatory (one needle, one syringe, one time). (HIC 3d)

4. Engineering Controls (HIC 4a):

   • Appropriate engineering controls must be in place in CCU to prevent infections (e.g., optimum spacing between beds (1-2m), air quality, water supply monitoring and maintenance). (HIC 4a)

5. Housekeeping (HIC 4c):

   • Adherence to housekeeping procedures in CCU (cleaning frequency, disinfectants, terminal cleaning, blood/body fluid clean up, isolation rooms). (HIC 4c)

6. Biomedical Waste (BMW) (HIC 4d):

   • BMW generated in CCU must be handled appropriately and safely (segregation, collection, storage). (HIC 4d)

7. HAI Prevention (HIC 5a, HIC 5b, HIC 5c, HIC 5d):

   • Action must be taken to prevent Catheter-Associated Urinary Tract Infections (CAUTI) in CCU (implement care bundles). (HIC 5a)

   • Action must be taken to prevent Ventilator-Associated Pneumonia (VAP) / Ventilator Associated Complication (VAC) in CCU (implement care bundles). (HIC 5b)

   • Action must be taken to prevent Catheter Linked Bloodstream Infections (CLABSI) in CCU (implement care bundles). (HIC 5c)

   • Action must be taken to prevent Surgical Site Infections (SSI) for relevant patients in CCU (implement care bundles). (HIC 5d)

8. Instrument Reprocessing (HIC 7a, HIC 7b, HIC 7c):

   • Adequate space and appropriate facilities must be provided for instrument reprocessing serving CCU. (HIC 7a)

   • Cleaning, packing, disinfection, sterilization, storing, and issue of items must be done as per written guidance, with clear expiry dating based on packaging/mode. (HIC 7b)

   • Reprocessing of single-use instruments used in CCU must be done as per written guidance, defining reuses and monitoring. (HIC 7c)

Chapter FMS - Facility Management & Safety

1. Medical Gases (FMS 6a, FMS 6b, FMS 6c, FMS 6d):

   • Written guidance must govern procurement, handling, storage, distribution, usage, and replenishment of medical gases in CCU. Uniform color coding and signage required, adhering to statutory requirements. (FMS 6a)

   • Medical gases in CCU must be handled, stored, distributed, and used safely (standardized color coding, air purity checks in CCU terminals). (FMS 6b)

   • Procedures must address safety issues at all levels (storage, supply lines, end-user areas), including alarm units, valve boxes, and 24x7 monitoring of plant alarms. (FMS 6c)

   • Alternate sources for medical gases, vacuum, and compressed air must be provided for CCU in case of failure. (FMS 6d)

2. Fire and Non-Fire Emergencies (FMS 7a, FMS 7b):

   • The organisation must have plans and provisions for early detection, abatement, and containment of fire and non-fire emergencies in CCU (fire plan, personnel, safety measures, training, mock drills, records, emergency illumination). (FMS 7a)

   • A documented and displayed exit plan must be available in CCU areas. (FMS 7b)

3. Utilities (FMS 2d, FMS 2e):

   • Adequate potable water and electricity must be available round the clock in CCU, with alternate sources as backup. Water quality must be monitored (biochemical, microbiological, endotoxin levels for RO water). (FMS 2d, FMS 2e)

4. Security (FMS 3b):

   • Operational planning must identify CCU as an area needing extra security and describe access for staff, patients, and visitors (mechanism to identify, defined access categories, CCTV). (FMS 3b)

5. Hazardous Materials (FMS 3e, FMS 3f):

   • Hazardous materials used in CCU (e.g., chemicals, lab samples) must be identified and used safely. A plan for managing spills must be implemented, and staff trained. (FMS 3e, FMS 3f)

6. Equipment Management (FMS 4b, FMS 5b):

   • Medical and non-medical equipment used in CCU must be inventoried and proper logs maintained (unique ID, classification by risk for medical equipment, quality/test/installation certificates). (FMS 4b, FMS 5b)

   • Equipment must be periodically inspected and calibrated for proper functioning. (FMS 4d, FMS 5d)

Chapter HRM - Human Resource Management

1. Staff Immunisation & Post-Exposure Prophylaxis (HIC 8b, HIC 8e):

   • An immunisation policy must be implemented for CCU staff (e.g., Hepatitis B). (HIC 8b)

   • Appropriate post-exposure prophylaxis must be provided and documented for CCU staff who sustain workplace-related injuries/exposures (e.g., needle stick). (HIC 8e)

Chapter IMS - Information Management System

1. Medical Record (IMS 3c, IMS 3d, IMS 4b):

   • The medical record for CCU patients must provide a complete, up-to-date, and chronological account of patient care, with sheets filed sequentially and entries chronologically. (IMS 3c)

   • Authorised staff must make entries in the medical record, following SOP on who can enter and content. (IMS 3d)

   • The medical record must contain details of all assessments, re-assessments, and consultations (medical, nursing, rehabilitation, etc.) performed in CCU. (IMS 4b)