The Supreme Court has approved a set of uniform guidelines for intensive care units, proposing that stable patients who do not require further organ support or physiological monitoring be discharged from the hospital or transferred to hospital wards.
The guidelines were part of a report, drafted by a three-member committee and examined by medical experts, and approved by the court on April 20 as “practical, enforceable and necessary as minimum ICU standards.” A bench of Justices Ehsanuddin Amanullah and R Mahadevan directed the states and union territories to formulate an action plan outlining five core areas of the document and a methodology for implementation by May 18.
The document highlighted the trauma experienced by patients’ relatives, who often lack knowledge about ICU care and rely solely on doctors’ advice to prolong stay, as a main reason for the new proposals.
The document, titled ‘Guidelines for the organization and delivery of intensive care services’, reads: ‘Upon clinical stability, when there is no need for further organ support and/or close physiological monitoring, patients should be transferred to lower levels of care such as a ward, high dependency unit or discharged, as deemed appropriate by the treating physician.’
“It is important to emphasize that clinical judgment must be used to determine the most appropriate level of care for a critically ill patient,” the court-appointed committee comprising All India Institute of Medical Sciences (AIIMS) doctor Nitish Naik, Additional Solicitor General (ASG) Aishwarya Bhatti, and advocate Karan Bhariuk, who acted as amicus curiae, explained.
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Several eminent medical professionals examined the guidelines, including Naresh Trehan of Medanta, Harsh Mahajan of Mahajan Imaging and Laboratories, Shiv Sareen of the Institute of Liver and Biliary Sciences (ILBS), Devi Prasad Shetty of Narayana Health, Pankaj Chaturvedi and Shail Pushp Bhosale of Tata Memorial Centre, and Soumitra Rawat of Sir Ganga Ram Hospital. They attended the court hearing on Monday and were asked to appear at the next hearing.
DK Gupta, Chairman, Felix Hospital, Noida, welcomed the proposals. “At present, hospitals do not have uniform guidelines for ICU but they have uniform operating protocols. It is a welcome step if the Supreme Court comes up with such a guideline,” he said.
Regarding discharge of patients, Gupta said: “A longer stay in the ICU exposes patients to hospital-acquired infections, and it is recommended that patients be shifted to the ICU or ward if their condition is stable. We do not encourage discharge of patients from the ICU. Instead, if they are shifted to the ICU, it helps prevent readmission to the ICU.”
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He said a long ICU stay could lead to “ICU psychosis”, affecting the patient mentally, and that family support on a regular ward helped early recovery.
The report established common minimum standards for intensive care units. It suggested a ratio of one nurse for every two or three patients in the ICU, and around-the-clock monitoring by a specialist with a postgraduate degree recognized by the National Medical Council (NMC). The Guidelines specify these requirements but leave oversight of implementation to the states and union territories.
Identifying nursing care as a key component, the report said that a basic ICU must maintain a nurse-to-patient ratio of one to two or one to three, depending on the severity of the medical condition. In a Level 3 ICU, reserved for critically ill patients who require multi-organ support, this ratio can be one to one, as patients are unstable or on ventilators.
The size and strength of an ICU bed can vary based on the total number of hospital beds and the type of services provided, such as surgical, medical, trauma, or emergency services, as well as the number of operating rooms. To enhance operational efficiency, the guidelines suggested that a basic-level ICU should contain six to eight beds, and those requiring critical care should be extended to 12 beds. The document also emphasized round-the-clock monitoring by resident doctors who work in shifts.
The guidelines detail infrastructure requirements to enhance physiological monitoring and support of organs. These facilities include bedside facilities, emergency and non-emergency equipment such as wheelchairs, patient carts, transport ventilators, and portable oxygen cylinders. They also cover imaging and laboratory services, infection control, fire safety, allied healthcare staff, documentation and periodic audits.
The authority directed all state health secretaries and additional secretaries to hold a meeting with relevant experts. They are to develop an action plan to implement the draft guidelines, prioritizing five issues as essential and mandatory.
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Once this is finalized, the action plans need to be shared with the Union Health Minister, who will hold a meeting with his counterparts in states and Union Territories to finalize a jointly agreed draft. This will be presented to the court in the next session.
The court order stems from a 2024 petition arising out of a medical negligence case in the National Consumer Forum. Asit Baran Mondal had filed the case seeking compensation for his wife’s death in a Kolkata hospital in 2013, citing alleged medical negligence.
During these proceedings, the Center informed the court about the model guidelines for ICU and Critical Care Unit (CCU) prepared by the Union Health Ministry in 2023. They cannot be implemented unless states adopt similar measures, as health is a state subject under the Constitution.
