1. Introduction to Critical Care
Module 9
Aims of session

2. 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.

3. Critical to success.
The place of efficient and effective critical care services within the acute hospital. Audit Commission 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.

4. 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

5. 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, 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.

6. Levels of care (Department of Health, 2000
Levels of care (Department of Health, 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.

7. 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.

8. 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

9. 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.

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

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

12. 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% %
Respiratory rate
Heart rate
Blood pressure
Conscious level
Urine output
Temperature
SpO2
Bedside

13. KNOWLEDGE Education Experience Guidelines Policies Procedures
Resources
MEWS
Bedside

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

15. 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

16. 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

17. 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%

18. 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

19. 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.

20. 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