Introduction to Introduction to Critical CareCritical Care

Module 9Module 9

What is critical care What is critical care nursing?nursing?

Life threateningLife threatening UnstableUnstable ComplexComplex

Specialised nursingSpecialised nursing Intensive careIntensive care

Critical to success.Critical to success.

The place of efficient and effective critical The place of efficient and effective critical care services within the acute hospital.care services within the acute hospital.Audit Commission. 1999. London.Audit Commission. 1999. London.

Comprehensive Critical Comprehensive Critical CareCare

Recommendations for modernising Recommendations for modernising critical care. DoH 2000.critical care. DoH 2000. Local managementLocal management Levels of careLevels of care Data managementData management Follow upFollow up OutreachOutreach Early warningEarly warning StaffingStaffing

Supporting evidenceSupporting evidence Sub-optimal care.Sub-optimal care.

McQuillan et al, 1998.McQuillan et al, 1998.

Predicting/preventing cardiac arrest.Predicting/preventing cardiac arrest. Schein et al, 1990.Schein et al, 1990.

Preventable in hospital deathsPreventable in hospital deaths Brennan et al, 1991, Leape et al, 1991. Wilson et al, 1995.Brennan et al, 1991, Leape et al, 1991. Wilson et al, 1995.

Late ICU referral > worse outcome.Late ICU referral > worse outcome. Brennan et al, 1991, Brennan et al, 1991,

Ward admissions to ICU Ward admissions to ICU mortality mortality Goldhill et al, 1999, Goldhill et al, 1999,

mortality after discharge from ICU.mortality after discharge from ICU. Rowan et al, 1993.Rowan et al, 1993.

Levels of careLevels of care(Department of Health, 2000. (Department of Health, 2000. Intensive Care Society, 2002)Intensive Care Society, 2002)

Level 0Level 0Needs can be met through normal ward care. Needs can be met through normal ward care.

Level 1Level 1At risk of deterioration or recently relocated from higher levels At risk of deterioration or recently relocated from higher levels

of care.of care.

Level 2Level 2More detailed observation or intervention, including single More detailed observation or intervention, including single

organ failure, and those stepping down from higher levels of organ failure, and those stepping down from higher levels of care.care.

Level 3Level 3All complex patients requiring advanced respiratory support, or All complex patients requiring advanced respiratory support, or

support for multi organ failure.support for multi organ failure.

Levels of careLevels of care

Mr A. had a hernia repair 2 days Mr A. had a hernia repair 2 days ago, awaiting discharge.ago, awaiting discharge.

Mrs. B took 20 paracetamol 24 Mrs. B took 20 paracetamol 24 hours ago, had gastric washout and hours ago, had gastric washout and charcoal. Awake but disinterested.charcoal. Awake but disinterested.

Levels of careLevels of care Miss C. underwent emergency over Miss C. underwent emergency over

sewing of a gastric ulcer 2 days ago. sewing of a gastric ulcer 2 days ago. Now has a chest infection.Now has a chest infection.

Mrs. C collapsed in the street Mrs. C collapsed in the street following a cardiac arrest today. following a cardiac arrest today. CPR given at scene. Inotropic drugs CPR given at scene. Inotropic drugs infusedinfused

Levels of careLevels of care Mr. D suffered exacerbation of Mr. D suffered exacerbation of

chronic obstructive pulmonary chronic obstructive pulmonary disease. Ventilated and sedated. disease. Ventilated and sedated. Oxygen requirement = 6 (60%0.Oxygen requirement = 6 (60%0.

Dr E underwent emergency Dr E underwent emergency abdominal surgery 24 hours ago abdominal surgery 24 hours ago (Aortic aneurysm rupture). In ICU. (Aortic aneurysm rupture). In ICU. Has 4 (40%) oxygen via mask, Has 4 (40%) oxygen via mask, epidural for pain relief, CVP line.epidural for pain relief, CVP line.

Bedside

What do we do at the What do we do at the bedside?bedside?

AWARENESS

CLINICAL JUDGEMENT

TREATMENT

Bedside

Observations Observations and and vigilancevigilance

AAWARENESSWARENESS

Bedside

ObservationsObservationsRespiratory rateRespiratory rate Commonest physiological Commonest physiological

abnormality of patients admitted to abnormality of patients admitted to ICU. ICU. Goldhill et al, 1999.Goldhill et al, 1999.

Preceding arrest, change inPreceding arrest, change in BehaviourBehaviour 84% 84% Respiratory function 53%Respiratory function 53% Mental function 42% Mental function 42%

Schein et al, 1990.Schein et al, 1990.

Mortality increases with the number Mortality increases with the number of abnormal physiological valuesof abnormal physiological values 11 4.4%4.4% 22 9.2%9.2% 3 3 23.4%23.4%

Respiratory rateRespiratory rate Heart rateHeart rate Blood pressureBlood pressure Conscious levelConscious level Urine outputUrine output

TemperatureTemperature SpOSpO22

Bedside

•Education •Experience•Guidelines•Policies•Procedures•Resources•MEWS

KKNOWLEDGENOWLEDGE

Bedside

Simple measuresSimple measures A,B,C,A,B,C, OxygenOxygen FluidsFluids Getting helpGetting help

TTREATMENTREATMENT

Team work and Team work and communicationcommunication

Sharing knowledge Sharing knowledge and skillsand skills

Knowing your limitsKnowing your limits Listening to othersListening to others Helping each otherHelping each other

Communicating Communicating wellwell

Good record Good record keepingkeeping

Keeping the Keeping the patient and their patient and their family informedfamily informed

Case study 1Case study 1

42 year old man42 year old man Anterior resection for Ca rectumAnterior resection for Ca rectum 6 days later faecal peritonitis6 days later faecal peritonitis Laparotomy and admit to ICU Laparotomy and admit to ICU

overnightovernight Transferred back to the ward at Transferred back to the ward at

07:0007:00

Case study 1Case study 1

Leaving ICULeaving ICU T 36.2, RR 16, HR 97 (SR), BP T 36.2, RR 16, HR 97 (SR), BP

100/62, CVP 0, 100/62, CVP 0, NS 120, UO 80-90, NG/drains 1L (-NS 120, UO 80-90, NG/drains 1L (-

1400)1400) 3l O2 via NS, SaO2 99% 3l O2 via NS, SaO2 99%

A. C. T!A. C. T!

Referred by pain nurse Referred by pain nurse at 08:30 who called at 08:30 who called Outreach.Outreach.

A - A - B - NS 3LOB - NS 3LO22 RR RR, ,

SpO2SpO2 C - BPC - BP, HR, HR, colour, , colour,

skin temp, OU, NG lossskin temp, OU, NG loss D - irritableD - irritable E - NAD E - NAD

High flow oxygenHigh flow oxygen FluidsFluids Get help.Get help.

Readmitted to ICU Readmitted to ICU Intubated and ventilated Intubated and ventilated with high dose with high dose inotropes. 3rd inotropes. 3rd laparotomy and laparotomy and tracheostomy.tracheostomy.

Slow recovery after 14 Slow recovery after 14 days.days.

Case study 2Case study 2

77 year old man admitted for AP 77 year old man admitted for AP resection.resection.

12 days post op12 days post op MEWS up to 9.MEWS up to 9. Admitted to ICU 22 hours later. Admitted to ICU 22 hours later.

Case study 2 Case study 2

During 22 hoursDuring 22 hours 9 entries in notes9 entries in notes 9 descriptions of deterioration9 descriptions of deterioration 4 requests for abdo and CXR4 requests for abdo and CXR Blood transfusionBlood transfusion More fluidsMore fluids Observe and review repeatedlyObserve and review repeatedly 9 hours later, mention of ICU referral9 hours later, mention of ICU referral ICU involved 16 hours later (no ICU bed)ICU involved 16 hours later (no ICU bed) Died in ICU 7 hours after admissionDied in ICU 7 hours after admission