A CCrISP APPROACH TO THE DETERIORATING PATIENT

Mary Langcake FRACSDirector of TraumaSt George Hospital

CCrISP

• Care of the Critically Ill Surgical Patient• Developed in UK after Hillsborough Soccer

disaster• RACS administers under MOU

WHY

• We perform complex procedures on older sicker patients

• JMO’s need to deal with sick and often unfamiliar patients

WHAT

• Teaches:

“Prompt, simple actions save lives AND prevent complications”

WHOFACULTY• Multidisciplinary – surgeons, intensivists,

emergency physicians, anaesthetists• Must undertake CCrISP Instructors Course or

similar – Educator and fellow Instructors teach • Performance assessed by candidates and feedback

given to facilitate ongoing development as an educator with support from Committee as required

• Nurse co-ordinator – ED or ICU trained• Nurse observers – assist with scenarios,

proselytise about CCrISP

WHO

CANDIDATES• Pre 2008 - surgical trainees – 90% • From 2008 – surgical trainees - 20%

– Australia, New Zealand, Fiji, PNG

HOW?• Lectures• Demonstrations• Small group tutorials• MCQs• Role-playing with moulaged patients• All candidates assigned a mentor - guidance/feedback• Summative assessment

Objectives

Recognise the patient who needs simultaneous assessment and resuscitation

Employ a system of assessment – to prioritise and to prevent omissions

Be able to institute both immediate life‐saving measures and definitive  management for the critically ill patient

Formulate daily management plans for surgical patients

Patients to be consideredRoutine pre‐operative patients

Risk factors – identify and control or improve

Emergency AdmissionsSevere acute problemsCo‐morbidity

Ward/HDU patientsSudden deteriorationFailing to progress/‘not right’At risk from surgery or disease processes

Immediate ManagementA B C D E

Full Patient AssessmentChart Review

History and Systematic ExamAvailable results

Decide and Plan

Stable Patient Unstable/Unsure

DailyManagement PlanDiagnosis RequiredSpecific Investigations

Definitive TreatmentMedicalSurgical

Radiological

Immediate management

Diagnose, Prioritise and TREATimmediate threats to life

AirwayBreathingCirculationDisability/Dysfunction of CNSExposure

End of Immediate ManagementImmediate steps undertaken to 

preserve life

Ongoing monitoring established 

Stable/improving vital signs?

Called for help

Moved to theatre or HDU/ICU

Not the end , just the beginning!

Now ..find the real source of the problem!

If at any time the patient’s condition deteriorates

You must go back to the start and

Re-assess ABCDE

Immediate ManagementA B C D E

Full Patient AssessmentChart Review

History and Systematic ExamAvailable results

Decide and Plan

Stable Patient Unstable/Unsure

Daily Management PlanDiagnosis RequiredSpecific Investigations

Definitive TreatmentMedicalSurgical

Radiological

CommunicationEnsure the  patient is well‐informedCase note entry

Inform othersRecord plan against which you can check progressHelps you organise your thoughtsPre‐weekend summaries are very helpful

Nursing staffParameters, plan

Senior and other colleaguesRelatives

SUMMARYUnderstand need for simultaneous assessment and resuscitation

System of assessment reduces serious omissions

Institute a plan for definitive treatment 

Reach a diagnosis to account for deterioration

Safe and selective investigations 

Frequent clinical re‐assessment 

Inform and involve your seniors appropriately

Consider level of care necessary at each stage

SUMMARY

CURRICULUM REVIEW

• CCrISP Committee in final stages of review with plans to pilot the Australasian 3rd

edition early 2010• Aims to keep the Course relevant and fresh