• Users Online: 693
  • Print this page
  • Email this page


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 4  |  Page : 109-115

Structure and organization of intensive care units in a tertiary care hospital of north India: A comparative study against national and international guidelines


1 Departments of Hospital Administration, AIl India Institute of Medical Sciences, New Delhi, India
2 Department of Paediatric Surgery, AIl India Institute of Medical Sciences, New Delhi, India
3 Department of Paediatric Medicine, AIl India Institute of Medical Sciences, New Delhi, India

Date of Submission16-Aug-2019
Date of Decision06-Oct-2019
Date of Acceptance16-Oct-2019
Date of Web Publication18-Dec-2019

Correspondence Address:
Vijaydeep Siddharth
Room. No. 11, Department of Hospital Administration, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_16_18

Rights and Permissions
  Abstract 


Introduction: Organization of intensive care units (ICUs) have a bearing on the quality of care rendered and outcome of care. Hence, this study was conducted with the aim to examine various ICUs for compliance against the different structural and organizational parameters prescribed by the standard national and international guidelines. Methodology: A descriptive and observational study was conducted from June 2011 to September 2012 in neonatal surgery ICU (NSICU), pediatric ICU, and medicine ICU (MICU) at a tertiary care teaching hospital of Northern India. Structural and organizational aspects of each ICU were studied against the Indian and international guidelines prescribed by concerned scientific organizations/bodies. These guidelines were selected in consultation with the domain experts. All parameters were assigned equal weightage, and scoring was done by assigning a score of 0, 5, and 10 to noncompliance, partial compliance, and compliance, respectively. Data were collected through direct observations, perusing hospital records, and unstructured interview of key informants. Results: NSICU assessment against the two international guidelines revealed the adherence of 42.52% and 37.80% toward different structural and organizational parameters. Similarly, low compliance to organizational and structural parameters were observed in pediatric (national –52.38% and international –49.39%) and MICUs (national –50.52% and international –39.01%). All the three ICUs under study have been created by carving out space from their respective inpatient admission area owing to patient care requirements, hence, does not score well against the structural/spatial parameters. Conclusion: Overall, low compliance of all three ICUs was observed when compared against the prescribed guidelines for organizational and structural parameters.

Keywords: Intensive care units, medicine intensive care unit, neonatal surgery intensive care unit, organization, pediatric intensive care unit


How to cite this article:
Siddharth V, Gupta SK, Satpathy S, Agarwala S, Lodha R. Structure and organization of intensive care units in a tertiary care hospital of north India: A comparative study against national and international guidelines. Saudi Crit Care J 2019;3:109-15

How to cite this URL:
Siddharth V, Gupta SK, Satpathy S, Agarwala S, Lodha R. Structure and organization of intensive care units in a tertiary care hospital of north India: A comparative study against national and international guidelines. Saudi Crit Care J [serial online] 2019 [cited 2022 Aug 9];3:109-15. Available from: https://www.sccj-sa.org/text.asp?2019/3/4/109/273451




  Introduction Top


Recent years have witnessed quantum leaps in the way, critical care is delivered with more capacity, new ways of working, and service improvements.[1] Furthermore, there has been an incredible increase in the knowledge, technology, and skills required to treat critically ill patients, leading to the development of intensive care units (ICUs).[2] ICUs are an important and an integral component of the health-care delivery system.[3] With the evolution of technology and discovery of drugs, healthcare has become intricate and expensive. Governments and health-care providers around the world are devoting a large proportion of their budget for initiating and maintaining quality initiatives in healthcare.[4] Critical care outcomes are constantly improving notwithstanding the variations in the deployment of processes, resources, drugs, consumables, and techniques in different ICUs.[5] In most developing countries, intensive care medicine or critical care services are poorly developed, or at most, still in infancy stage.[6] In addition, delivery of intensive care has multifaceted challenges such as infrastructure, shortage of professional and technical workforce, technology, supplies, and day-to-day operating cost.

Structural component of ICU includes the physical aspects, biomedical equipment (beds, monitors, ventilators, and other devices), and organization of the multidisciplinary team. Organization includes both quantity and quality of staffing, and the leadership role adapted by the ICU medical team regarding clinical decisions (for instance, open versus closed units).[4] An effective organization helps to optimize the quality of care rendered and includes the presence of an appointed qualified medical and nursing director with the full-time availability of intensive care physicians (also during evenings, nights, and weekends).[7]

There is now an increasing body of literature supporting the superiority of closed ICU system over ICUs organized as open system.[8],[9],[10] An effective, quality service can only be delivered by an appropriately skilled workforce. A well-trained intensive care staff with full responsibility for patient care has important implications on ICU performance.[11],[12] The ICU should provide facilities for at least cardiac monitoring and invasive hemodynamic monitoring, temporary cardiac pacing, ventilatory support, and pump-controlled administration of infusions. Facilities for blood gas analysis, hemoglobin, and electrolytes should be provided within the ICU or in the immediate vicinity.[13] Currently, the ICUs in the study setting are being carved out of existing patient care areas to cater to increased patient care load, which might lead to inadequate organization of ICUs and may not be an ideal thing to do. This study attempts to explore the same against various national and international guidelines available for organizing the ICUs. There have been very few studies on structural and organizational parameters of ICU in the Indian context, and hence, this study was aimed to examine these parameters.


  Methodology Top


An observational and descriptive study was carried out in neonatal surgical ICU (NSICU), pediatric ICU (PICU), and medicine ICU (MICU) of a tertiary care teaching hospital located in North India. The tertiary care hospital where this study was conducted is having ≥1000 beds and is one of the apex public sector teaching health-care institute in the country. The study was commenced after obtaining clearance from the Institute Ethics Committee and was carried out from October 2011 to July 2012. The study was conducted as a thesis research work for MD in hospital administration and observations in all the ICUs were made by a single observer (MD hospital administration) having requisite knowledge. ICUs were evaluated against the existing national and international guidelines laid down by the scientific bodies/institutions. These guidelines were selected in consultation with the domain experts. [Table 1] (due to the nonavailability of Indian guidelines available for NSICU, it was compared against two international standards for neonatal ICUs). These guidelines focus on various domains such as location of the ICU; access, traffic, work pattern, and security; clinical areas; infant care space, and fittings; handwashing station; air borne infection isolation room; general support space; staff facilities; family support space; environmental design; support space; and education and research facilities. These guidelines also covered some of the aspects related to the health-care delivery processes in the ICU.
Table 1: Guidelines adopted for evaluating the structure and organization of intensive care units

Click here to view


These guidelines also covered some of the aspects related to the health-care delivery processes in the ICU. To quantitatively evaluate the compliance of the ICU organization and structure against the prescribed guidelines, all parameters were equal weightage. Further, noncompliance, partial compliance, and compliance to the different parameters were assigned a score of 0, 5, and 10, respectively. Subsequently, the final score was reached in percentage adherence of ICU against a given guidelines. Data were collected through direct observations and by studying pertinent hospital records. Informal unstructured interactions were also held with the key informants, that is, doctors, nursing staff, infection control unit, engineering staff, and other hospital staff to gain an insight into different organizational and structural aspects.


  Results Top


Neonatal surgical intensive care unit

NSICU is cohoused with pediatric surgery ward and is managed by the department of pediatric surgery. Pediatric surgery works as a single team under the head of department. It has the capacity to admit ten neonates (bassinets with infant warmers and incubator) requiring surgical intervention. In 2010–2011, the total number of inpatient admissions in pediatric surgery ward was 1219, and in NSICU was 205. Total area of NSICU is 95.35 m2 (1026.34 sqft), with only 65.85 m2 (708.8 sqft) comprising patient care area.

It is an “open-model ICU” which lacks designated, dedicated full-time faculty/director. Patients are admitted by Senior Resident (MCh-Pediatric surgery), in consultation with the faculty on call, and they provide round the clock cover to NSICU patients. Each day, one faculty member is responsible for administrative and clinical responsibilities of the NSICU. One assistant nursing superintendent (ANS) is dedicated for nursing administration and supervises 20 staff nurses (Grade I and Grade II), who are responsible for nursing care of admitted neonates. One operation theater assistant (OTA) is available only during the day time for the management of intensive care equipment. One hospital attendant and sanitary attendant are posted in each shift for housekeeping services. NSICU has got state of the art ventilators, sophisticated multiparameter monitors, cots incubators, and incubator for intrahospital transport. Hospital supplied drugs/consumables are made available to all the admitted neonates; however, all the required drugs/consumables are provided free of cost to all the Below Poverty Line/needy patients as per the hospital policy. Overall, NSICU compliance against recommendations of the seventh consensus conference on newborn ICU design, 2007 was observed to be only 42.52%, whereas overall compliance against design guidelines for neonatal units for Australia and New Zealand was found to be only 37.80% [Table 2].
Table 2: Compliance of neonatal surgical intensive care unit against recommendations of the seventh consensus conference on newborn intensive care unit design, 2007 Clearwater Beach, Florida and Design guidelines for neonatal units for Australia and New Zealand

Click here to view


Pediatric medicine intensive care unit

Pediatric MICU is located within the pediatric medicine ward. It is a distinct patient care facility in addition to the neonatal ICUs and NSICU located within the same hospital. Total patient care area including nursing station is 95.04 m2 (1023.00 sqft), that is, 11.88 m2 (127.87 sqft)/bed. It has a capacity of accommodating only eight patients (five beds and three bassinets). It is a closed type of ICU headed by faculty, department of pediatric medicine, who is an intensivist but also has other assigned responsibilities of the department. Clinical and administrative rounds are taken by the head, PICU. Patients are admitted by the senior resident on duty in consultation with the head, PICU. Senior residents, pediatric medicine, are available round the clock.

There are two sister-in-charges dedicated for PICU, available during the morning shift and 23 nursing staffs (Grade I and II nursing sisters) are posted in PICU, for nursing care of the patients. One OTA is available only during the morning and evening shift for managing intensive care equipment. One respiratory therapist is posted in PICU and is available during the morning shift on working days. One hospital attendant and sanitary attendant are posted in each shift for housekeeping services. On analysis, it was found that PICU is complying with guidelines prescribed by Indian Society of Critical Care Medicine only in little more than half (52.38%) of the total parameters; however, when compared against the guidelines given by pediatric section of Society of Critical Care Medicine, USA, compliance was found to be slightly under 50% [Table 3].
Table 3: Compliance of organizational and structural aspects of pediatric intensive care unit against guidelines prescribed by the Indian Society of Critical Care Medicine and Society of Critical Care Medicine

Click here to view


Medicine intensive care unit

MICU is an eight-bedded patient care facility cohoused within the general medicine ward. Total patient care area in MICU is approximately 112 m2 (1205 sqft), which includes patient care area, nursing station, circulation area, drug preparation area, small store cum changing area, and large equipment storage area as well. Other ancillary areas such as sluice room and staff accommodation are common for both MICU and medicine ward. Each ICU bed is state of the art, sophisticated with bed head panel having manifold points, and electrical points. Each bed is equipped with multiparameter monitor capable of measuring four pressures simultaneously and high-end sophisticated ventilator.

It is an open model ICU under the administrative control of head, department of general medicine. There is no designated and dedicated full-time faculty/head assigned for MICU. Senior resident, general medicine, on duty admits the patients in consultation with respective in charges for different MICU beds. Each physician is responsible for taking clinical rounds and deciding treatment for the patients admitted under them. MICU is manned round the clock by senior resident with requisite training and experience in general medicine. They have no other assigned responsibilities of the department. MD (Medicine) residents are also posted in MICU and works under the close supervision of faculty and senior resident.

One ANS has been entrusted with the responsibilities of managing MICU along with medicine and hematology ward. One sister in charge is solely dedicated for MICU and has a team of 22 nursing staffs (Grade I and II nursing sister) posted round the clock in shift duties. Only one respiratory therapist who administers physiotherapy and respiratory therapy to admitted patient is available during the morning shift on working days. There is only one OTA, who is available during the morning shift for managing intensive care equipment. One hospital attendant and sanitary attendant are posted in each shift for housekeeping services.

When MICU was evaluated against the organization and design parameters prescribed by the Indian Society of Critical Care Medicine and European Society of Intensive Care Medicine, compliance was observed to be 50.52% and 39%, respectively [Table 4].
Table 4: Compliance of medicine intensive care unit with guidelines prescribed by the Indian Society of Critical Care Medicine and European Society of Critical Care Medicine

Click here to view


Multidisciplinary professional needs of all the above-mentioned ICUs are met through other specialty/super specialty departments/centers located within the institute. Following table describes the salient features of all three ICUs [Table 5].
Table 5: Brief details about neonatal surgical intensive care unit, pediatric intensive care unit, and medicine intensive care unit

Click here to view



  Discussion Top


The ICUs can be organized at three levels, that is, Level 1 (Small district hospital, small private nursing homes, and rural centers), Level 2 (larger general hospitals), and Level 3 (tertiary level hospitals).[18] All the ICUs under this study are level 3 ICUs. Level 3 ICUs are headed by intensivist, are closed units, have the facility for imaging, laboratory and diagnostic investigations, facility for dialysis, protocols for infection control, and participation in research.[18] In this study, low compliance has been observed with regard to parameters prescribed by various national and international guidelines on design and organization of ICUs. All the ICUs under study were retrofitted into the existing health-care facility, that is, respective wards were not planned at the time of estabishing the health-care facility, which is the primary reason for low compliance observed against the guidelines. These ICUs have been established over a period of time with the felt need for provisioning of these services. It is also pertinent to mention that these guidelines are quite recent, and the ICUs under study were established long back, and hence, the comparison may not be fully justified but it could help in improving the ICUs, wherever feasible.

In the hospital, where this study has been carried out, there are approximately 250 ICU beds of different clinical specialties in physically distinct ICU. It has been reported that the number of ICUs increases with the increase in size of the hospital. Furthermore, the number of mixed surgical/medical and coronary care/medical units decreased, and specialized units becomes prevalent. The isolation facility in ICU is important from infection control point of view; however, in our study, none of the ICUs had got facility for isolating patients. However, in a Croatian study, it was found that possibility of isolating patients existed only in 73 ICUs (62.4%).[20]

In this study, it has been observed that ICUs are being managed by the clinical specialists from respective specialties who also have other assigned patient care responsibilities. Intensivists are available in the hospital but they are not being mandatorily involved in the care of patients admitted in ICUs of respective specialties. There are no full-time dedicated heads for managing ICUs. Only PICU is a closed ICU, whereas the rest is open units. While there are designated nursing in charge for all the three ICUs but do not have adequate number of nursing staff to maintain the nurse: patient ratio as per prescribed standards. A study done in US showed that full-time ICU medical directors were present in 80% of the hospitals. In 64% of the units, the medical director or designee was involved in the care of >90% of the patients. A consistent charge nurse was available in 90.6% of the units.[21] ICU chiefs of staff were mostly anesthesiologists (48 or 41%), usually working in surgical units; followed by internists (39 or 33.3%), predominating in medical, coronary care, mixed coronary care/medical, and respiratory units; neurologists (10 or 8.5%); pediatricians (9 or 7.7%), predominantly in pediatric and neonatal units; and psychiatrists (6 or 5.1%). Similarly, in another study, a permanently employed ICU specialist was in charge of admission in 91 ICUs (77.8%), and of discharge in 113 (96.6%) ICUs.[20]

A study on the group of 500 hospitals with fewer than 300 beds in the United States showed that intensive care specialists were present in only 57% of them.[22] One of the conclusions of EURICUS I study that include 89 ICUs in the European Community was that “medical skills might become relatively more important than organizational criteria when the patient is sicker.”[23] In PICUs of United States, pediatric intensivist was present in 94% of the PICUs although they were less common in the smallest (1–6 beds) units (82%), in comparison with PICUs with seven beds (P < 0.01). The supply of pediatric intensivists and nurses increased with increasing numbers of PICU beds. Head nurses were employed in 114 (97.4%) ICUs, and only three (2.6%) units were headed by a nurse from another ward.[20]

All the ICUs in our study have got sophisticated/high-end technical, that is, equipment for mechanical ventilation, multi-parameter monitors capable of monitoring four pressures simultaneously, incubators are available for preterm infants, bassinets with overhead infant warmer, electrically operated ICU beds, syringe pumps, pulse oximeters, portable radiograph, ultrasound imaging, and blood gas analyzers. None of the ICUs have got dedicated portable echocardiograph, continuous renal replacement therapy. Except for NSICU, none of the other units have got their own dedicated bronchoscope. In a study, only 75.2% (88) ICUs had equipment for mechanical ventilation. As many as 77.8% (91) ICUs had portable pulse oximetry monitoring system, only 28 (23.9%) ICUs had their own bronchoscopy equipment and personnel trained to perform the procedure. Ultrasound equipment was available in 48 (41%) ICUs, and only 28 (23.9%) ICUs had their own blood-gas analyzers. Twenty-two (18.8%) ICUs had the equipment for acute hemodialysis, and only 18 of them, or 15.4% of all ICUs, had equipment for acute continuous venovenous hemodialysis or hemodiafiltration. Most ICUs lacked expensive technical equipment (mechanical ventilators, sophisticated monitors, ultrasound set, or bronchoscope set). Unfortunately, there was also a lack of essential equipment for everyday routine work, such as infusion pumps, perfusors, enteral nutrition pumps, and computers for medical and administrative work. Almost, half of the ICUs did not have a computer.[20]

In a study done in US, nearly 100% of PICUs reported a capacity for mechanical ventilation and invasive monitoring of arterial blood pressure, intracranial pressure, and central venous pressure. Less than 80% of all PICUs had facilities for renal replacement or nitric oxide therapy. Hemodialysis, hemofiltration, and nitric oxide therapy could be performed in fewer settings (71%, 57%, and 79% of the PICUs, respectively).[24]

Although this study has been done in only three ICUs of a single institute, due to which the results may not be representative for other health-care settings, hence the results need to be carefully interpreted before drawing any conclusion. However, it has brought out the key structural and organizational concerns, when it comes to delivering the intensive care. Structural and organizational parameters can significantly affect the quality of care being rendered in a health-care facility, and same is true for an ICU. There is a need to conduct similar large scale and may be more exhaustive studies to draw some representative and valid interpretations, the findings of which can be utilized for strengthening the critical care delivered in ICUs.


  Conclusion Top


This study has brought out the need for strengthening the structural and organizational framework of the ICUs, as none of the ICUs under the study has shown encouraging results when compared against the available national and international guidelines. Meticulous planning is must before establishing a new ICU, and it becomes all the more important if an ICU space has to be created by retrofitting in an existing health-care facility.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Emergency, DH. Quality Critical Care – Beyond 'Comprehensive Critical Care'. A report by the critical care stakeholder forum London 2005.  Back to cited text no. 1
    
2.
Divatia J, Baronia A, Bhagwati A, Chawla R, Iyer S, Jani C, et al. Critical care delivery in intensive care units in India: Defining the functions, roles and responsibilities of a consultant intensivist. Indian J Crit Care Med 2006;10:53-63. Available from: http://isccm.org/PDFfiles/ISCCM Intensivist guidelines.pdf. [Last accessed on 2012 Aug 03].  Back to cited text no. 2
    
3.
Garland A. Improving the ICU: Part 2. Chest 2005;127:2165-79.  Back to cited text no. 3
    
4.
Barbieri C, Carson SS, Amaral AC. Year in review 2007: Critical care – Intensive care unit management. Crit Care 2008;12:229.  Back to cited text no. 4
    
5.
Ray B, Samaddar D, Todi D. Quality Indicators for ICU. Mumbai, India; 2009. Available from: http://isccm.org/PDFfiles/Section5.pdf. [Last accessed on 2012 Aug 04].  Back to cited text no. 5
    
6.
Okafor UV. Challenges in critical care services in Sub-Saharan Africa: Perspectives from Nigeria. Indian J Crit Care Med 2009;13:25-7.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Thijs LG. Continuous quality improvement in the ICU: General guidelines. Task force European society of intensive care medicine. Intensive Care Med 1997;23:125-7.  Back to cited text no. 7
    
8.
Topeli A, Laghi F, Tobin MJ. Effect of closed unit policy and appointing an intensivist in a developing country. Crit Care Med 2005;33:299-306.  Back to cited text no. 8
    
9.
Carson SS, Stocking C, Podsadecki T, Christenson J, Pohlman A, MacRae S, et al. Effects of organizational change in the medical intensive care unit of a teaching hospital: A comparison of 'open' and 'closed' formats. JAMA 1996;276:322-8.  Back to cited text no. 9
    
10.
Ghorra S, Reinert SE, Cioffi W, Buczko G, Simms HH. Analysis of the effect of conversion from open to closed surgical intensive care unit. Ann Surg 1999;229:163-71.  Back to cited text no. 10
    
11.
Reynolds HN, Haupt MT, Thill-Baharozian MC, Carlson RW. Impact of critical care physician staffing on patients with septic shock in a university hospital medical intensive care unit. JAMA 1988;260:3446-50.  Back to cited text no. 11
    
12.
Brown JJ, Sullivan G. Effect on ICU mortality of a full-time critical care specialist. Chest 1989;96:127-9.  Back to cited text no. 12
    
13.
Vincent J, Artigas A. Guidelines for the utilisation of intensive care units. Intensive Care 1994;20:163-4. Available from: http://isccm.org/PDFfiles/Section5.pdfw. [Last accessed on 2012 Aug 12].  Back to cited text no. 13
    
14.
Browne J, Cicco R, Erickson D, Graven SN, Gregroy S, Harrrell JW. Recommended Standards for Newborn ICU Design. Report of the Seventh Consensus Conference on Newborn ICU Design. Clearwater Beach, Florida; 2007. p. 1-40.  Back to cited text no. 14
    
15.
Design Guidelines for Neonatal Units for Australia and New Zealand; 2004.  Back to cited text no. 15
    
16.
Indian Society of Critical Care Medicine (Paediatric Section) and Indian Academy of Paediatrics (Intensive care Chapter). Consensus Guidelines for Pediatric Intensive Care Units in India. Indian Society of Critical Care Medicine (Paediatric Section) and Indian Academy of Paediatrics; 2002. Available from: http://indianpediatrics.net/jan2002/jan-43-50.htm. [Last accessed on 2012 Jan].  Back to cited text no. 16
    
17.
Rosenberg DI, Moss MM, American Academy of Pediatrics Section on Critical Care, American Academy of Pediatrics Committee on Hospital Care. Guidelines and levels of care for pediatric intensive care units. Pediatrics 2004;114:1114-25.  Back to cited text no. 17
    
18.
Guidelines Committee ISCCM. Intensive Care Unit Planning and Designing in India Guidelines 2010. Guidelines Committee ISCCM; 2010. Available from: http://www.isccm.org/PDFfiles/Section1.pdf. [Last accessed on 2012 Jun 18].  Back to cited text no. 18
    
19.
Ferdinande P. Recommendations on minimal requirements for intensive care departments. Members of the task force of the european society of intensive care medicine. Intensive Care Med 1997;23:226-32.  Back to cited text no. 19
    
20.
Degoricija V, Sefer S, Kujundzić-Tiljak M, Gjurasin M. Intensive care units in Croatia: 2001 survey. Croat Med J 2002;43:713-21.  Back to cited text no. 20
    
21.
Brilli RJ, Spevetz A, Branson RD, Campbell GM, Cohen H, Dasta JF, et al. Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Crit Care Med 2001;29:2007-19.  Back to cited text no. 21
    
22.
Powner DJ. Credentialing for critical care in small hospitals. Crit Care Med 2001;29:1630-2.  Back to cited text no. 22
    
23.
Vincent JL, Fink MP, Suter PM, Sibbald WJ, editors. Intensive Care Medicine In 10 Years. Verlag Berlin Heidelberg: Springer; 2006.  Back to cited text no. 23
    
24.
Odetola FO, Clark SJ, Freed GL, Bratton SL, Davis MM. A national survey of pediatric critical care resources in the United States. Pediatrics 2005;115:e382-6.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Methodology
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed4224    
    Printed183    
    Emailed0    
    PDF Downloaded372    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]