Introduction to Critical Care Module 9 Aims of session

What is critical care nursing? Life threatening Unstable Complex Specialised nursing Intensive care Ask for types of patients who may be critically ill. Polio outbreak in Denmark in 1950’s – not enough iron lungs available. Used technique from theatre to blow air into lungs – halved death rate. Forerunner of today’s ventilators Increasing numbers of critically ill patients, often cared for in general wards. Media reports in 1990’s highlighted problems in numbers of beds available. Led to review by government.

Critical to success. The place of efficient and effective critical care services within the acute hospital. Audit Commission. 1999. London. Demand outstrips supply of critical care services. Increases in technology leads to greater demand. Variation in quality of service e.g. survival rates, treatments often due to clinical perference.

Comprehensive Critical Care Recommendations for modernising critical care. DoH 2000. Local management Levels of care Data management Follow up Outreach Early warning Staffing Critical care services integrated into hospital wide approach – not just within boundaries of icu Data management – collection of data to provide evidence of best treatments and best use of resources Staffing levels agreed. Education and training needs analysis

Supporting evidence Sub-optimal care. McQuillan et al, 1998. Predicting/preventing cardiac arrest. Schein et al, 1990. Preventable in hospital deaths Brennan et al, 1991, Leape et al, 1991. Wilson et al, 1995. Late ICU referral > worse outcome. Brennan et al, 1991, Ward admissions to ICU mortality Goldhill et al, 1999, mortality after discharge from ICU. Rowan et al, 1993.

Levels of care (Department of Health, 2000 Levels of care (Department of Health, 2000. Intensive Care Society, 2002) Level 0 Needs can be met through normal ward care. Level 1 At risk of deterioration or recently relocated from higher levels of care. Level 2 More detailed observation or intervention, including single organ failure, and those stepping down from higher levels of care. Level 3 All complex patients requiring advanced respiratory support, or support for multi organ failure. The parameter used to measure the patients acuity was the “Levels of care” introduced as a classification of critically ill patients in the Comprehensive Critical Care document (DOH, 2000), and further defined by the ICS.

Levels of care Mr A. had a hernia repair 2 days ago, awaiting discharge. Mrs. B took 20 paracetamol 24 hours ago, had gastric washout and charcoal. Awake but disinterested.

Levels of care Miss C. underwent emergency over sewing of a gastric ulcer 2 days ago. Now has a chest infection. Mrs. C collapsed in the street following a cardiac arrest today. CPR given at scene. Inotropic drugs infused

Levels of care Mr. D suffered exacerbation of chronic obstructive pulmonary disease. Ventilated and sedated. Oxygen requirement = 6 (60%0. Dr E underwent emergency abdominal surgery 24 hours ago (Aortic aneurysm rupture). In ICU. Has 4 (40%) oxygen via mask, epidural for pain relief, CVP line.

What do we do at the bedside? AWARENESS CLINICAL JUDGEMENT TREATMENT Bedside

AWARENESS Observations and vigilance Ask what observations are important? Mention behaviour and resps Bedside

Observations Respiratory rate Heart rate Blood pressure Commonest physiological abnormality of patients admitted to ICU. Goldhill et al, 1999. Preceding arrest, change in Behaviour 84% Respiratory function 53% Mental function 42% Schein et al, 1990. Mortality increases with the number of abnormal physiological values 1 4.4% 2 9.2% 3 23.4% Respiratory rate Heart rate Blood pressure Conscious level Urine output Temperature SpO2 Bedside

KNOWLEDGE Education Experience Guidelines Policies Procedures Resources MEWS Bedside

TREATMENT Simple measures A,B,C, Oxygen Fluids Getting help Bedside

Team work and communication Sharing knowledge and skills Knowing your limits Listening to others Helping each other Communicating well Good record keeping Keeping the patient and their family informed

Case study 1 42 year old man Anterior resection for Ca rectum 6 days later faecal peritonitis Laparotomy and admit to ICU overnight Transferred back to the ward at 07:00

Case study 1 Leaving ICU T 36.2, RR 16, HR 97 (SR), BP 100/62, CVP 0, NS 120, UO 80-90, NG/drains 1L (-1400) 3l O2 via NS, SaO2 99%

A. C. T! High flow oxygen Fluids Get help. Readmitted to ICU Intubated and ventilated with high dose inotropes. 3rd laparotomy and tracheostomy. Slow recovery after 14 days. Referred by pain nurse at 08:30 who called Outreach. A -  B - NS 3LO2 RR, SpO2 C - BP, HR, colour, skin temp, OU, NG loss D - irritable E - NAD

Case study 2 77 year old man admitted for AP resection. 12 days post op MEWS up to 9. Admitted to ICU 22 hours later.

Case study 2 During 22 hours 9 entries in notes 9 descriptions of deterioration 4 requests for abdo and CXR Blood transfusion More fluids Observe and review repeatedly 9 hours later, mention of ICU referral ICU involved 16 hours later (no ICU bed) Died in ICU 7 hours after admission