The article details the newly released guidelines by India's central government for ICU admissions, outlining criteria for patient evaluation & discharge. It emphasises the need for expert consensus among critical care specialists.

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For the first time, the Central government has made available rules that hospitals may use to determine whether a patient requires treatment in an intensive care unit (ICU). The recommendations were prepared by a group consisting of twenty-four distinguished doctors who specialise in critical care medicine.

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Defining an Intensive Care Unit (ICU): What is it? Who is an Intensivist?

Intensive Care Unit (ICU)

There is no distinction between an intensive care unit, critical care, and intensive care. It is a dedicated, specialised space for interdisciplinary, targeted care of patients with organ malfunction that is either totally or partly reversible, potentially fatal.

Such therapy requires intense, ongoing monitoring and interventions by a multidisciplinary team of medical professionals, including physicians, nurses, and other support personnel, as well as the equipment and supplies required to maintain life until recovery.

Intensivist or critical care specialist

1. An expert who manages critically sick patients in an intensive care unit who has received specialised training, certification, and experience.
2. It is required that the Intensivist possess a postgraduate degree in one of the following: Internal Medicine, Anaesthesia, Pulmonary Medicine, Emergency Medicine, or General Surgery.
3. A certificate course in critical care of the ISCCM (IDCCM and IFCCM), a post-doctoral fellowship in critical care (PDCC/Fellowship) from an NMC-recognised university, or equivalent credentials from overseas such as the American Board Certification, Australian or New Zealand Fellowship (FANZCA or FFICANZCA), UK (CCT dual recognition), or equivalent from Canada b) A minimum of a year of training at a reputable intensive care unit overseas.
4. Intensivists are also recognised among a select group of ISCCM Certificate Course (CTCCM) candidates who have completed a three-year intensive care training programme after completing their M.B.B.S. Those who are certified or trained in addition need to have at least two years of ICU experience, with at least half of that time spent in the ICU.
5. If a doctor does not possess one of the aforementioned credentials or training, they should have at least three years of ICU experience—that is, at least 50% of their time spent in the ICU—after earning their M.B.B.S.

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Statements of the advisory group

The Delphi technique was used to generate unanimity in the expert consensus statements. Delphi process used Google Forms to do the polls and put together the results and Delphi comments. In Delphi polls, the steering group abstained from voting. Throughout three rounds, the remaining Experts cast anonymous votes.

When 70% or more of the experts voted for a certain alternative, the consensus was considered to have been reached.

Every response's stability was examined. The MCQ answers that produced unanimity and stability were used to write the final statements.

1. The requirement for organ support and organ failure, or the expectation of a worsening of the patient's state, should be the basis for admitting a patient to the intensive care unit.

2. Criteria for ICU Admission:

• Altered level of consciousness of recent onset
• Haemodynamic instability (e.g., clinical features of shock, arrhythmias)
• 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 illness or medical condition that may worsen in the future; Patients who have had any significant intraoperative complications (such as cardiovascular disease or respiratory instability); Patients who have had major surgery (such as thoracic, thoracoabdominal, upper abdominal, or trauma operations) that need close observation or who are at high risk of developing complications after the procedure.

3. The following critically ill patients should not be admitted to ICU:

• Patient’s or next–of–kin informed refusal to be admitted to 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 a pandemic or disaster situation where there is a resource- limitation (e.g. bed, workforce, equipment)

4. ICU discharge requirements

Regaining almost normal or baseline physiological abnormalities and a reasonable remission and stability of the acute illness that required ICU admission

1. Patient or family consents to ICU discharge for palliative care or a choice to restrict treatment.
2. Because extensive treatment doesn't seem to be beneficial (this should be a medical judgement, not requiring family consent, and ideally not based on financial restraints).

To ensure that the patient receiving treatment in a non-ICU setting receives proper care, for infection control purposes

Rationing (i.e., setting priorities when resources are few). In such a scenario, a clear, open, and acceptable written rationing policy that is fair and consistent is required.

5. The following are the minimal patient monitoring requirements while waiting for an ICU bed:

1. Continuous or intermittent blood pressure, clinical monitoring including heart rate, breathing pattern, and respiratory rate, among other things

The variables that may be measured include heart rate (continuous or intermittent), oxygen saturation (SpO2), capillary refill time, urine output (continuous or intermittent), and neurological states, such as the Glasgow Coma Scale (GCS) and the Alert Verbal Pain Unresponsive (AVPU) scale.

2. Periodic temperature recording of Blood glucose

6. Before moving a patient to the intensive care unit, the following minimum stabilisation must be achieved:

1. Providing a stable airway (tracheal intubation in cases when the patient's GCS is less than 8) and sufficient breathing and oxygenation.
2. Consistent haemodynamics, whether or not a vasoactive medication is infused.
3. Continuous management of hyper- and hypoglycemia as well as other potentially fatal electrolyte/metabolic imbalances.
4. Starting the last-resort treatment for an illness that poses a serious risk to life (such as using intravenous antibiotics for sepsis, administering antiepileptics for recurring seizures, or externally fixing a broken limb).

7. The minimal amount of observation needed to move a severely ill patient from an interfacility to a hospital or intensive care unit:

1. Continuous or intermittent blood pressure monitoring and clinical monitoring (breathing pattern, respiratory rate, pulse rate, etc.).
2. Continuous SpO2, Continuous Heart Rate, and Neurological Status (AVPU, GCS, etc.).

India has about a million intensive care unit beds, the majority of which are found in large, private hospitals. Poor individuals who are unable to pay for private hospitals must fight—sometimes unsuccessfully—to acquire an ICU bed. Prioritising ICU patients according to their conditions could be a good idea in an emergency, but generally speaking, the government should try to make sure there are enough facilities to serve everyone with critical care.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.