Critical Care Outreach Critical Care Outreach Team Leeds Teaching Hospitals Trust

Learning Outcomes Understand Critical Care Outreach Understand NEWS and its use Be able to assess a patient using ABCDE approach

Critical Care Without Walls Review of Critical Care Services by Department of Health in 2000 Bringing critical care expertise to patients in ward environments Prevent acute deterioration and provide timely transfer to critical care environments Supporting patient rehabilitation following discharge from critical care Education of hospital staff involved in patient care

Critical Care Outreach Team Senior nursing staff with extensive critical care experience Nurse led service with dedicated ICU Consultant available for Outreach Team

Outreach Service Availability at LTHT 08:00 - 20:00 at SJUH 08:00 - 18:00 at LGI Overnight outreach cover is provided by ICU team.....currently Contactable by bleep or ask for outreach office at LGI and SJUH

Outreach in practice Assessment and review of patient using: ABCDE assessment of patient History and clerking notes NEWS recording Fluid balance Blood results, radiological reports eg CXR, ECHO Level of care required and ceilings of care

Right Patient - Right Bed Level 0 - Ward based care IVI and b.d obs Level 1 - Patients needing additional clinical input e.g. continuous oxygen, chest drains, 4 hourly observations, GCS 4 hourly Level 2 - Patient requiring single organ support eg more than 50% O2, CPAP or BIPAP, vasoactive drug infusions, hourly observations for potential deterioration Level 3 - Advanced respiratory support or more than one organ failure The 4th years need explanation about different ICU categories, they do not already know this

National Early Warning System Track and Trigger system of recording physiological parameters to detect changes in patient’s condition Score aggregate has a graded response to alert senior clinical input and increase frequency of observations Measures six physiological parameters but unusual stand alone changes should also trigger a response eg reduction in AVPU

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Need to highlight Outreach contact details, actions required for different track and trigger systems.

ABCDE - a reminder Airway - Patency, O2 (15 litres NRB) Breathing - Examine, O2 saturations, RR, Auscultate , ABG, CXR Circulation - Examine, Pulse, BP, CRT, IV access, Bloods, Fluids Disability - AVPU, Pupils, BM, GCS Exposure - Temp, Rash, Abdomen, Bleeding, Legs, drug charts, history, all results

Patient Scenario Jane is a 55 year old lady who has had a temperature following her laparoscopic cholestectomy two days ago She has been on ward post - operatively feeling unwell. You are asked to see her as her NEWS is high and your senior is in theatre…

Assessment A – patent B – RR 28, SaO2 88%, increased work of breathing, coughing++ C – HR 136bpm, BP81/46 CRT 4 secs, T 39.4 D – Alert but drowsy E – Feels thirsty, not on any medicines. Bowel sounds present – bowels opened yesterday, wound sites dry. Calves SNT A – Oxygen 15l NRB B – Auscultate then consider ABG and CXR and sputum sample for m,c&s C – IV access, bloods, fluid challenge, 12 lead ECG, - is she passing urine? D – GCS, pupils and glucose E – NEWS = 11 Review notes/Op notes/ Drug Chart? Blood results, BUFALO, fluid balance chart started ?catheterise

What needs to be done? ABCDE approach What investigations are you going to do and in what order! What would you like the nursing staff to do? Who needs to know about this lady?

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NEWS > 5….Does your patient have: Systemic Inflammatory Response Syndrome 2 or more signs of inflammation: T >38 or <36 HR >90 WCC>12 or <4 RR>20 Altered conscious level BM >7.7 (if not diabetic) If patient is neutropenic then just 1 of the above Sepsis? SIRS AND clinical evidence of infection Red Flag Sepsis SBP <90mmHg despite fluid challenge Lactate >2mmol/l Heart Rate >130/min Respiratory Rate >25/min Oxygen Saturations <91% Responds to Voice/Pain or Unresponsive Purpuric rash

BUFALO in Sepsis

New plans for the patient? Outreach referral + senior review Review NEWS, blood results, CXR, ABG Urinary catheter Further fluid resuscitation - how much? Has she had his antibiotics yet? What level of care do they need?

The End Result This patient responded well to IV fluids and antibiotics her NEWS reduced to 4. She stayed on the ward with outreach support. She was discharged home with oral antibiotics after 4 days.

Summary Use the assessment checklists and skills you have been provided with Get support from your seniors and outreach sooner rather than later Document, document, document

References Standardising the Assessment of Acute Illness Severity in the NHS:‘Recommendations for a NHS Early Warning Score (NEWS)’. A report from the Royal College of Physicians: July 2012 National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients London Department of Health (2000) Comprehensive Critical Care: A Review of Adult Critical Care Services London, Department of Health http://www.doh.gov.uk/pdfs/criticalcare.pdf