Hospital seeking for accreditation

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Hospital Data Sheet

Intensive Care Committee





1.      GENERAL


           1.1     To be suitable for approval an intensive care unit must:


                  1.1.1      be fully established and operational;


                  1.1.2      have a wide spectrum of experience with an acceptable case load;


                  1.13       be part of a hospital with a comprehensive range of medical and surgical specialties;


                  1.1.4      have access to a wide spectrum of investigative facilities;


                  1.1.5      have exposure to a wide range of procedures;


                  1.1.6      have an adequate number of specialised medical, nursing and ancillary staff;


                  1.1.7      have available, at all times, clinical supervision by appropriately    qualified senior medical staff;


                  1.1.8      have suitable facilities for the role of the unit, and for the staff who work in it;


                  1.1.9      have a programme of education, review and research, which must include a formal teaching programme readily available to trainees,


                1.1.10 have defined admission, management, discharge and referral policies;

         1.2     The hospital must be prepared for the College, at intervals determined by the College, to carry out visits to the unit to assess its suitability for training. Information about caseload, staffing patterns and the rosters will be required.


         1.3     The training appointment must be entirely in intensive care, and include provision for the trainee to take part in out-of-hours unit rosters.


         1.4     When appointments to the senior staff are made, the advice of a properly constituted committee capable of evaluating the qualifications of the applicants must be sought.


         1.5     Supervisors of Training are nominated by the hospital and appointed by the College


         1.6     The College expects that trainees be involved in quality improvement activities.


         1.7     The hospital must agree to notify the College, through its Supervisor of Training, of any changes that might affect training. Changes such as a reduction in the workload or a reduction in the number of senior staff working in the unit are regarded as important.


         1.8     Intensive Care Units will be accredited for suitability for duration of ICU training. All future posts in the unit will be considered training posts. C24 indicates suitability for 24 months core ICU training and C12 indicates suitability for 12 months core ICU training.


         1.9     Applications for any change in the training status shall be sent to the College, but before granting approval the College may need to re-inspect the unit.



2.      CRITERIA


         The period of training in a unit which is approved may be determined by:

         2.1    Sufficient clinical workload and case-mix of patients to maintain a high level of clinical expertise and to provide adequate clinical exposure and education of trainees. There should normally be more than 40% of patients mechanically ventilated.


2.2   The range of therapeutic, diagnostic and investigative procedures available in the hospital;


2.3   Research activities in the unit;


2.4   Adequate nursing ratios and expertise protect trainee work duties and training time. There should normally be at least 1 nurse to 1 ventilated or similarly critically ill patient. (ie. 5.6 nurses to 1 ICU bed ratio) For more complicated cases additional nursing manpower may be required. The majority of nursing staff (normally more than 75%) should hold post registration qualifications in intensive care.


2.5   Adequate ward clerical support should be available and the Director should have secretarial support.;


2.6   Training programmes for staff must be established,


2.7   Continuing education activities must be established.


2.8 For 24 months accreditation (C24) unit caseload should exceed 750 patients/year.


2.9  For 12 months accreditation (C12) unit caseload should exceed 400 patients/year.


2.10 The unit director must be a specialist with a recognized qualification in intensive care and should normally be working fulltime in the ICU.


2.11 The supervisor of training must be a specialist with a HKCA(IC) fellowship and should normally be working fulltime in the ICU.


2.12 For 24 months (C24) accreditation, the unit must have a minimum of 3 intensive care or critical care specialist trainers. At least 2 must be fellows of the HKCA (IC).


2.13 For 12 months (C12) accreditation, the minimum requirement is 1 HKCA (IC) specialist trainer.


2.14 An intensive care specialist trainer of another intensive care or critical care college may be recognized as a trainer subject to review by the board of intensive care.


2.15 An intensive care specialist must be rostered to supervise the unit and contactable at all times. When providing supervision the specialist must be rostered only for intensive care duties.


2.16 At least one medical officer must be on duty solely for the unit, and must be present in the unit at all times, except for emergency resuscitations.


2.17  Trainees should be supervised by an on site intensive care specialist     trainer a minimum of 40% of working time.


2.18  Trainees should be rostered a minimum of 2 hours protected study time per week.


2.19  There should be evidence that the unit has a continuous quality improvement programme. SMR (standardized mortality ratio) should be reviewed regularly.


2.20  There should be an active teaching programme for medical staff, to which daily review of patients in the unit shall make a significant contribution.


2.21  The College expects there will be adequate office space for both the senior and the junior staff. Neither can be expected to carry out their roles properly without it.




         3.1   The Patient Care Area


         3.1.1 The number of beds available should be appropriate to the size and function of the hospital.


         3.1.2 The area for each bed should be sufficient to allow easy access to the patient and to allow the deployment of equipment needed to manage the patient appropriately. There should normally be 20m2 per patient bed.


         3.1.3 Services to the bed must be conveniently placed and in sufficient number     to cope with the peak demand. There should normally be 16 power points, 3 oxygen, 2 air and 2 suction outlets per patient bed.


         3.1.4 The design should take into account the serious risk of cross infection. There should be easy access to hand washing from each bed station and it should be easy to isolate individual patients. Air exchange should normally be more than 12 per hour in isolation rooms and 6 per hour in other areas of the ICU.


         3.2    Equipment


         3.2.1Equipment available in the unit must be appropriate to the work done in the unit and to the work load, judged by contemporary standards.


         3.2.2 There must be a regular equipment safety checking system in force.


         3.2.3 The beds must be of suitable design.


         3.3    Support Areas


         3.3.1 Adequate storage space is essential.


         3.3.2 There should be a clear separation of clean and dirty working areas.


3.3.3   A ward administration area is required that must readily accommodate the staff who must work there.


3.3.4   Offices must be provided for each of the full time senior medical staff working in the unit.


3.3.5   There must be suitably quiet area for the trainees to study when they have the opportunity.


3.3.6   The unit should have ready access to a teaching area with the appropriate facilities. An appropriate range of manuals, textbooks, journals and access to the internet and online journals should be available 24 hours a day.


3.3.7   A relatives' waiting area must be available, with a separate private area for  distressed relatives.