What should be included in comprehensive Surgical Intensive Care Unit (SICU) guidelines and policies regarding roles, referral systems, and patient admission and discharge?

Comprehensive SICU Guidelines and Policies

Administrative Structure and Leadership

The SICU must be led by a full-time director whose professional activities are devoted at least 75% to intensive care, holding sole administrative and medical responsibility for the unit without top-level responsibilities in other departments. 1

Director Qualifications and Responsibilities

• The director should be a senior accredited specialist in intensive care medicine with formal education, training, and experience in critical care, typically with a prior degree in anesthesiology, internal medicine, or surgery 1
• The director coordinates all activities of the intensive care team including nurses, residents, fellows, and allied health professionals 1
• Responsibilities include defining admission and discharge criteria, establishing diagnostic and therapeutic protocols, supervising trainees, and organizing formal daily rounds 1
• The director serves as the final arbitrator between surgical demand and patient interests, supervising safety, efficacy, and workability of processes 2

Staffing Structure and Roles

Medical Staff Composition

Physician staffing should be calculated using the formula: FTE physicians per 6-8 ICU beds based on number of shifts, occupancy rate, holiday/illness coverage, and clinical/research/teaching workload. 1

• An experienced physician certified in intensive care medicine must be on duty and available upon request at short notice during off-duty hours 1
• Medical staff members take over complete medical and administrative responsibilities for admitted patients 1
• Extended work shifts negatively impact patient and staff safety and should be avoided 1

SICU Nurses

Nurses should maintain a one-to-one ratio for critically ill patients requiring comprehensive care and constant monitoring. 2

• SICU nurses are integral members of the multidisciplinary team participating in daily rounds 1
• Nurses require training in intensive care-specific competencies including advanced monitoring, resuscitation, and technical skills 1
• Efficient communication processes must be organized between medical and nursing staff 1

SICU Resident Rotators

Residents from medical and surgical specialties may work in the SICU after 2 years of training in their primary specialty, with minimum rotation duration of 6 months (optimally 1 year) for those qualifying in intensive care and 3 months (optimally 6 months) for others. 1

• Residents must work under clearly defined supervision and be involved full-time in SICU activities 1
• They assure supervised continuity and participate in duties under supervision of a qualified intensive care physician 1
• Regular staff carries final medical responsibility for all resident activities 1
• Overlapping training periods should be implemented to reinforce expertise 1
• Residents can assist with continuity during nights, weekends, and holidays provided there is 24-hour back-up from regular staff 1

SICU Fellows

Fellows in critical care medicine should have completed their primary specialty training and be engaged in advanced intensive care training with increasing autonomy under attending supervision. 1

• Fellows participate in academic pursuits including research and teaching activities 1
• They should gain adequate personal experience in management of diverse ICU patient populations 1
• Fellows contribute to quality improvement initiatives and protocol development 1

Multidisciplinary Team Members

The modern SICU team must include at minimum: intensivist, ICU nurse, pharmacist, respiratory therapist, physiotherapist, and primary team physician, with this multidisciplinary approach associated with improved patient outcomes. 2

• Additional specialists (oncologists, cardiologists, nephrologists) should be available based on clinical needs 2
• All team members participate in daily rounds for information sharing and therapy planning 1

Admission Criteria and Policies

General Admission Framework

Each SICU should establish clearly defined admission criteria based on physiologic parameters, severity of illness scores (APACHE II), and resource requirements. 1, 3, 4

• Admission decisions should consider the patient's physiologic status and need for intensive monitoring or interventions 4
• Prognostic indices and severity scores should guide admission decisions 1
• Priority should be given to patients requiring comprehensive care, constant monitoring, and possible emergency interventions 2

Specific Admission Indications

Patients meeting ICU criteria include: respiratory rate >25, oxygen saturation <90%, systolic blood pressure <90 mmHg, or signs of hypoperfusion. 5

• Patients requiring invasive or noninvasive respiratory support 1
• Patients needing central line access and hemodynamic monitoring 1
• Patients requiring renal replacement therapies when appropriately trained personnel are available 1
• Postoperative patients with life-threatening conditions or potential instability 2

Transfer Criteria to Higher Level of Care

Indications for transfer to tertiary or quaternary facilities include: intracranial pressure monitoring needs, acute hepatic failure with coma, unstable congenital heart disease, need for temporary cardiac pacing, head injury with Glasgow Coma Scale <8, multiple traumatic injuries, or heart failure requiring interventional cardiology. 1

• Complicated burns >10% total body surface area require specialized burn unit access 1

Referral System

Outreach and Communication

All SICU levels must provide feedback to referral centers after patient transfer, which is essential for quality improvement and education. 1

• Tertiary and quaternary SICUs should provide peer community outreach education including educational conferences, technical skill competencies, stabilization, and resuscitation training 1
• Community outreach should focus on technical skills for stabilization, resuscitation, and communication for triage and transport 1
• Case conferences should be organized as part of educational activities 1

Rapid Response Teams

Implementation of Rapid Response Teams (RRT) or Medical Emergency Teams (MET) as ICU outreach teams is associated with decreased cardiac arrest rates outside the ICU and reduced in-hospital mortality. 2

• RRT team composition varies by institution but should be available 24/7 2
• Ward staff must be trained to recognize deteriorating patients early for timely RRT activation 2
• Lowest frequency of calls occurs between 1:00-6:59 AM, yet mortality is highest around 7:00 AM, indicating need for enhanced ward staff alertness 2

Transport Services

Quaternary facilities or specialized SICUs must have access to a critical care transport program with a dedicated trained pediatric/surgical team and specialized equipment. 1

• When outsourcing transport, all team members must have training in emergency and critical care 1
• Management and risk estimation of transport must be coordinated by the SICU team 1

Discharge Criteria and Policies

Discharge Framework

Each SICU must have clearly defined criteria for escalation and de-escalation of resources based on the patient's physiologic status. 1

Discharge Pathways

When a patient's physiologic status improves, discharge can occur through: transfer to acute care bed within the facility, return transfer to referring facility, transfer to skilled nursing or rehabilitation facility, or discharge home. 1

Post-Discharge Requirements

After SICU discharge, the following must occur: 1

• Appropriate communication with accepting facility including oral handoff, clear written summary, and exchange of necessary health information 1
• Discharge planning and communication with family or caregivers if going home 1
• Communication with primary care physician who will assume care 1
• Communication with subspecialists and arrangement of appropriate follow-up 1
• Care coordination with outpatient services including: durable medical equipment delivery and instruction, home pharmacy and nutrition support, ongoing rehabilitation needs (occupational/physical therapy), and ancillary support as required 1

Quality Assurance and Performance Improvement

Monitoring and Metrics

All SICUs should implement prognostic indices, severity scores (APACHE II), and therapeutic intervention scores for quality monitoring. 1, 3, 6

• APACHE II scoring provides excellent classification with high sensitivity and specificity for outcome prediction 3
• Standardized mortality ratios should be calculated and monitored 6
• Re-admission rates should be tracked (target <6.5%) as re-admitted patients have significantly higher mortality 6
• Length of stay patterns should be analyzed, particularly for patients staying >2 weeks 6

Clinical Practice Guidelines Compliance

Integration of acute care nurse practitioners in a "semiclosed" SICU model significantly increases compliance with clinical practice guidelines. 7

• All staff should participate in quality improvement initiatives 1
• Care bundles should be implemented including lung protective ventilation, early enteral feeding, and daily sedation vacation 2
• Medical record keeping should follow problem-oriented or system-oriented approaches 1

Ethical and Legal Considerations

End-of-Life Care Policies

Each SICU must have clearly defined policies addressing: 1

• Care of the dying patient 1
• Do Not Resuscitate (DNR) concept and implementation 1
• Role of relatives in decision-making 1
• Patient rights including the right to refuse treatment 1
• Living wills and advance directives 1
• Ethical problems related to clinical research 1

Resource Allocation

Principles of triage and resource allocation must be established, with the intensivist serving as arbitrator between surgical demand and patient interests. 1, 2

• Budgeting and cost-containment principles should guide resource utilization 1
• Medico-legal aspects must be considered in all policies 1
• Hospital ethical guidelines related to intensive care should be established 1

Training and Education

Physician Training Requirements

Training programs must include: 1

• Admission and discharge procedures 1
• Priorities in care of critically ill or injured patients 1
• Medical record keeping in intensive care 1
• Quality management principles 1

Nursing Education

Nurses require training in: 1

• Technical skills for stabilization and resuscitation 1
• Advanced monitoring techniques 1
• Communication for triage and transport 1

Academic Pursuits

Quaternary and tertiary SICUs should participate in academic activities including research, teaching, and community education. 1