Expert Insights: Ministry of Health's ICU Guidelines 2023 - ICU admission criteria and intensivist

Whom to admit in the ICU (intensive care unit) and whom to discharge from the ICU? Who is eligible to be an intensivist? Ministry of Health and Family Welfare, India has recently released these guidelines in which experts across the country, as well as from Dubai and Canada provide logical and practical points on these and many more relevant issues.

TheExpert consensus statementshave been made using the Delphi methodology to generate
consensus. The Steering Group for Delphi process was SNM, RKM & PN who conducted the Delphi
surveys using Google forms, prepared the Delphi statements & the reports. The Steering Group
did not vote in Delphi surveys. The rest of the Experts voted anonymously over three rounds.
Consensus was defined as achieved for an option when voted by 70% or more of the Experts.
Stability was checked for all responses. The final statements were drafted from the MCQ responses that achieved consensus and stability

1. Criteria for admitting a patient to ICU should be based on organ failure & 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 (eg., 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 & 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 & 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 a nd 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.)