Govt issues ICU admission guidelines: The Union Health Ministry has issued latest guidelines on intensive care unit (ICU) admissions, stating hospitals cannot admit critically ill patients in the ICU in case of refusal by them and their relatives. As per the guidelines compiled by 24 experts, keeping in a patient in ICU is futile when no further treatment is possible or available in a disease or in terminally ill patients if the continuation of therapy is not going make an impact on the outcome or survival.

Govt Guidelines for ICU Admission: Full list of instructions

1) Primary Criteria:

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Criteria for admitting a patient to ICU should be based on organ failure and need for organ support or in anticipation of deterioration in the medical condition.  
 

2) ICU Admission Criteria: 

  • Altered level of consciousness of recent onset 
  • Hemodynamic instability (e.g., clinical features of shock, arrythmias) 
  • Need for respiratory support (e.g. escalating oxygen requirement, de–novo respiratory failure requiring non-invasive ventilation, invasive mechanical ventilation, etc.) 
  • Patients with severe acute (or acute–on–chronic) illness requiring intensive monitoring and/or organ support 
  • Any medical condition or disease with anticipation of deterioration 
  • Patients who have experienced any major intraoperative complication (e.g. cardiovascular or respiratory instability) 
  • Patients who have undergone major surgery, (e.g. thoracic, thoraco–abdominal, upper abdominal operations, trauma who require intensive monitoring or at a high risk of developing postoperative complications). 

3) The following Critically Ill Patients should not be admitted to ICU: 

  • Patient’s or next–of–kin informed refusal to be admitted in ICU 
  • Any disease with a treatment limitation plan 
  • Anyone with a living will or advanced directive against ICU care 
  • Terminally ill patients with a medical judgement of futility 
  • Low priority criteria in case of pandemic or disaster situation where there is resource limitation (e.g. bed, workforce, equipment). 

 

4) ICU Discharge Criteria 

  • Return of physiological aberrations to near normal or baseline status 
  • Reasonable resolution and stability of the acute illness that necessitated ICU admission 
  • Patient/family agrees for ICU discharge for a treatment-limiting decision or palliative care. 
  • Based on lack of benefit from aggressive care (should be a medical decision, not obligating family agreement and as far as possible should not be based on economic constraints).  
  • For infection control reasons with ensuring appropriate care of the given patient in a non ICU location 
  • Rationing (i.e., prioritisation in the face of a resource crunch). In this event there should be an explicit and transparent written rationing policy that should be fair, consistent and reasonable. 

5) The minimum patients monitoring required while awaiting an ICU bed include the following: 

  • Blood pressure (continuous/intermittent) 
  • Clinical monitoring (e.g., pulse rate, respiratory rate, breathing pattern, etc.) 
  • Heart rate (continuous/intermittent) 
  • Oxygen saturation - SpO2 (continuous/intermittent) 
  • Capillary refill time 
  • Urine Output (continuous/intermittent) 
  • Neurological status e.g. Glasgow Coma Scale (GCS), Alert Verbal Pain Unresponsive (AVPU) scale etc. 
  • Intermittent temperature monitoring 
  • Blood sugar 

 

6) Minimum stabilisation required before transferring a patient to ICU include the following: 

  • Ensuring a secure airway (i.e., tracheal intubation if the patient has a GCS ≤8) 
  • Ensuring adequate oxygenation and ventilation. 
  • Stable haemodynamics, either with or without vasoactive drug infusion. 
  • Ongoing correction of hyperglycemia/hypoglycemia and other life-threatening electrolyte/metabolic disturbances 
  • Initiation of definitive therapy for life-threatening condition (e.g., external fixation of a fractured limb, administration of antiepileptics for recurrent seizures, antiarrhythmic drug infusion for unstable arrhythmias etc, intravenous antibiotics for sepsis) 

7) Minimum monitoring required for transferring a critically ill patient (inter-facility transfer to hospital/ICU):

  • Blood pressure (continuous/intermittent) 
  • Clinical monitoring (pulse rate, respiratory rate, breathing pattern, etc.) 
  • Continuous Heart rate 
  • Continuous SpO2 
  • Neurological status (AVPU, GCS, etc.)