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Organisational issues Flashcards

1
Q

Early recognition and review

A

rapid response team
standardised approach to detection of deteriorating patients
NEWS2

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2
Q

critical care outreach

A

MDT organisational approach to ensure safe, equitable, quality care for acutely unwell and recovering patients irrespective of location NICE/NCEPOD recommendations
- patient track and trigger
- rapid response
- education training support
- safety and governance
- audit
- rehabilitation
- enhancing service delivery

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3
Q

levels of care

A

0 = normal ward care in acute hospital
1 = increased observation or intervention. basic support of single organ system. needs met with additional advice / support from critical care. rehab needs not met on standard ward
2 = increased observation, intervention. advanced organ support of 1 system, monitoring and support of 2. level 1 + enhanced nursing needs
3 = advanced respiratory support, advanced support of 2 or more organs

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4
Q

GPICS

A

Medical
- daytime consultant : patient 1:8 - 1:12
- resident:patient > 1:8
- all resident rota should have basic airway skills
- 24/7 access to doctor / ACCP with advanced airway skills
Nursing
- level 3 = 1:1
- level 2 = 1:2
- supernumerary senior nurse (1 per 10 beds)
- < 20% temporary staff per shift

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5
Q

key standards around admission

A

– decision to admit discussed with consultant
- once decision to admit, admission within 4hrs
- clear TEP
- consultant in person review within 12hrs, or sooner
- non-clincal transfer minimised

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6
Q

MDT

A

daily input from nursing, micro, pharmacy, physiotherapy
regular input from dietetics, SALT, psychology

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7
Q

standards around discharge

A
  • follow up programme
  • OP appt 2-3 months post hospital discharge
  • discharge in hours
  • standardised handover
  • structured rehab programme
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8
Q

When are scoring systems used in critical care

A
  • illness severity scores e.g. SOFA
  • Outcome prediction models e.g. APACHE II
  • Decision support tools e.g. NEWS

physiological scoring systems assess and monitor outcomes and treatments for service evaluation and research. ISS is anatomical not physiological.

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9
Q

types of scoring systems

A

illness severity scoring systems
diseased specific scoring systems

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10
Q

Illness severity scoring systems

A
  • APACHE II = acute physiology and chronic health evaluation. worse score first 24hrs. max score 71. Age, acute physiology (vitals, biochemical), chronic disease (cirrhosis, NYHA4, resp, dialysis, immune). AUROC 0.85. 25 = 50% mortality
  • SAPS (simplified acute pjusology) AUROC 0.86. similar to apache
  • SOFA - sequential organ failure assessment. repetitive every 48hrs. each organ system 0 - 4 (max 24)
  • POSSUM - surgical patients
  • TISS - therapeutic intervention score - assessment of nursing workload. worse scores correlate with worse outcomes
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11
Q

disease specific scoring systems

A

CAP - CURB65 - risk of death at 30 days increased
UGI bleeding - rockall - risk of rebleeding. GBS - likelihood of endoscopy.
Pancreatitis - Glasgow score 3 = severe acute. ransom
liver - MELD, child Pugh, kings criteria
PE - wells score
GRACE score - mortality in ACS
AF - CHA2DS2VASC - risk of stroke

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12
Q

Disease specific illness severity score

A

MELD - predicts 3 month mortality in patient with cirrhosis. help to guide transplant. 4 values
- bilirubin
- creatinine
- sodium
- INR
6 - 40 % mortality
predict short term mortality in patients with cirrhosis and variceal bleeding, acute alcoholic hepatitis, surgery

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13
Q

limitations of scoring systems

A

data accuracy e.g. subjective components
applicability to cohort
changing predictive ability e.g. withdrawal on patient with 95% mortality = 100% mortality

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14
Q

evaluation of scoring systems

A

discrimination - how well score discriminates between those who will die and those who will survive. AUROC observed vs predicted mortality. reaonsable > 0.7 excellent > 0.9. eg apache II 0.85. coin toss 0.5
calibration = how close predicted values are to observed values
validity = how well it reflects reality. internal and external. sofa outside icu but poor validity within.

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15
Q

ideal scoring system

A
  • valid to your population
  • simple
  • discriminates (survivors from non survivors)
  • calibrated (degree of accuracy)
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16
Q

qSOFA

A

screening for risk of death from infection outside icu
2/3 of BP < 100 GCS < 15 RR > 22
better than sofa, sirs in this context
not used to diagnose sepsis

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17
Q

scores in relation to admission to crucial care

A
  • caution in interpretation
  • not designed to support decisions regarding admission
  • likely inaccurate when used on individual level
  • individualised decision making
  • no clear mortality cut off
  • probabilities for whole populations - provide additional information to a patient centred decision making process
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18
Q

monitoring service quality

A

standardised mortality ratio
observed / predicted number of deaths
predicted based on apache
SMR > 1 worse than predicted
limitations
- coding / data quality
- does not reflect icu care alone (pre-icu care)
- excludes readmissions, transfers
- only measures in hospital deaths

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19
Q

Other measurements of service quality

A

measurement of structure, process or outcome
can be described as minimum standard or quality indicator
structure
- min standard - 2x consultant ward round, infection surveillance, participation in national audit, nurse:patient ratio
- quality indicator- nurse staffing and skill, pharmacist presence
process
- min standard - night time discharges, bundles
- quality indicators - delirium screening, rehab assessment, EOLC
outcome
- min standard - SMR, early discharge, m+m
- quality indicators - patient surveys

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20
Q

What are the hazards of patient transport

A

patient
- dislodgement of tubes, lines
- deterioration en route
- loss of temp control
- drugs - run out, need for emergency
- equipment - o2, ventilator malfunction
- lack of back up / support
- loss of information during handover
staff
- motion sickness
- physical injuries
- disruption of shift work
organisational
- staffing ratios / on call cover

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21
Q

classification of transfers

A

by location - primary, secondary, tertiary
indication - clinical, non-clinical, repatriation
urgency - time critical, urgent, routine
mode of transport - foot, road, air

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22
Q

how do you carry out a transfer

A

clear decision making and communication. checklists
1. decision making
2. personell
3. equipment
4. patient

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23
Q

decision making related to transfer

A
  • patient stable?
  • urgency identified
  • indication identified
  • benefit outweighs risk
  • patient and relative informed
  • received hospital airway and consultant accepting
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24
Q

Personnel

A
  • doctor - trained in transfer with appropriate skills
  • nurse / ode - traipsed in transfer and familiar with equipment
  • paramedic crew
  • specialist e.g. perfusionist
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25
equipment
checklist! - trolley - ventilator - oxygen - suction - monitoring - infusion pumps - airway equipment - drugs - documentation / notes - mobile phone
26
Patient
- appropriate resuscitation and stabilisation - risk assess likelihood of deterioration A: securely tied, documented B: established on transportventilator, ABG C: need for vasoactive, fluid, appropriate IV access D: sedation, GCS, BM, indication for intubation E: infusions attached, alarms, 5 point harness, warming
27
handover of transferred patient
multilevel - consultant - consultant icu - consultant - consultant parent team - tranferring - receiving team medical and surgical
28
other important aspects of transfer
- clear documentation - checklists - documentation including observations during handover
29
transfer risk assessment
low risk - own airway NEWS 1-4, FiO2 < 0.4, no vasoactive support, GCS 14 - nurse led medium risk - NEWS 5-6, own airway, FiO2 < 0.6, low dose pressor, GCS 9-13. nurse, doctor, ideal critical care high risk - intubated, FiO2 > 0.6, CVS unstable > 0.2mcg/kg/min. critical care doctor and nurse
30
ambulance codes
IFT 1 - ARP1 - 7 mins. facility unable to provide immediate resuscitation IFT 2 - ARP2 - 18 mins - time critical life limb sight threatening IFT 3 - nil set response time. don't need immediate time critical intervention IFT 4 - nil of the above
31
Error
Act that can lead to undesirable outcome preventable adverse effect of care - latent - lies dormant before situation arises when it is identified - active - action directly causes error in real time Unsafe acts - unintended - slip, lapse - intended - mistake (rule/knowledge based)
32
Critical incident
an active error with significant consequences patient safety incident is potential or actual harm due to any healthcare event
33
incidents in critical care
patient - complex, lots of interventions, mistakes more costly due to reduced reserve, impaired defences, multiple medical devices/pharmaceuticals staff - shift working patterns, cognitive overload environment - complex, diverse potential problems, high acuity. high turnover, highly distracting
34
Never Event
Specific type of critical incident - can result in severe harm or death - known source of risk - has existing guidance and safety recommendations - preventable - easily identified and defined In critical care - feeding down misplaced NG tube, transfusion of ABO-incompatible blood products, unintentional connection of patients to air instead of O2 - medications - mis selection of strong potassium solution, wrong route of medication administration, insulin overdose.
35
Steps following critical incident
- maintain patient safety - any medical interventions required immediately e.g. stopping blood transfusion, administering glucose - escalate to consultant and nurse in charge - submit incident report - document in notesro - duty of candour - explore root cause - support staff
36
root cause analysis
detailed, structured exploration of factors leading to a patient safety incident, in order to identify potential learning points - gather and map iformation - identify care and service delivery problems - analysis - generate recommendations - implement solutions classify incidents into low/no/moderate/severe/death/public interests fishbone model to identify contributing factors - individual, training, equipment, working conditions, communication, team, organisational
37
Reducing errors
latent - automated systems, standardisation of equipment active - checklists, double checks, briefing, guidelines, handovers, sim training NatSSIPS - national safety standards for invasive procedures LocSSIPS - local safety standards for invasive procedures
38
fire safety
3 critical care incidents in last decade high degree of morbidity, loss of life, staff affects
39
greater fire risk in critical care
oxygen - high concentrations heat - dependence on electrical equipment, electrosurgery fuel - emollients, bedding, bin, alcohol
40
reducing risk of fire
pipeline oxygen - knowledge of how to switch off safe use off oxygen cylinders - upright storage, appropriate flow rate, turn off, store away from combustibles avoid o2 enrichment - min FiO2 necessary, 10 air changes per hour fire training - mandatory unit design - clinical / non-clinical, compliance with regulations
41
facilitation of emergency evacuation
- policy - vacation cards - evacuation aids - smoke hoods - power supply - training
42
how might an icu be evacuated
- risk of personal harm balanced against duty of care - staff prioritised first - may require cessation of support e.g. ecmo, RRT immediate - raise alarm - escalate to seniors - use fire extinguishers - transport o2 cylinders - turn off pipeline oxygen next step - prep patients for transfer - evacuate to safe area - horizontal - internal major incident policy evacuation triage - patients closest to fire - least unwell - most unwell - side rooms
43
critical care demand
high cost low volume specialty finite resources and increasing demand - aging population with multiple chronic conditions - increasing number and complexity of surgery - new therapies - rising public expectations - cost effectiveness greatest for the sickest patients - value for money - best health outcome relative to cost. health economics - maximise value from a given set of resources. measurement includes ICNARC
44
rationing
allocation of healthcare resources in the face of limited availability, necessarily meaning beneficial interventions are withheld from some individuals. 3 levels - macro - state or national government - determining overall health budgets - meso - regionally or locally e.g. CCG - countable to Secretary of State for health via NHSE - micro - individual clinicians and patients
45
NHSE strategic aims for critical care
- prevent avoidable morbidity and mortality as a result of patients requiring critical care not accessing it - avoid triage by resource as opposed to triage by outcome - access to care based on anticipated cacpity to benefit - equity of access
46
efficiency in health economics
allocative - ensuring value derived from serve outweighs cost (budget, case selection) technical - maximising outcomes available given level of resource (governance, QI)
47
health economic evaluation
- cost benefit analysis - total cost vs benefits (monetary value assigned to outcomes) - cost minimisation analysis - effects of interventions therapeutically identical, identify lowest cost option - cost-effectiveness analysis - outcome measure of incremental cost-effectiveness - compare interventions with the same outcome measure
48
QALY
composite measure of state of health of aperson in which benefits, in terms of length of life, are adjusted to reflect quality of life. 1 year of life at perfect health = 1.0 QALY short form 36, EQ5D
49
research challenges in critical care
as short term mortality has improved, research aimed at longer term morality, morbidity, HRQOL and socio0economic impact - harder to measure heterogeneity of population diversity f presentations outcomes also dependent on care in other areas predicting patient outcome based on population scores
50
Environmental hazards on ICU
Noise - should be less than 40db, frequently exceed 90db - psychological and physiological stressor - vary patient to patinet - affect sleep light and temperature - no lateral light - disruption of sleep-wake cycle - low temp inhibits sleep, patient variation restricted mobility and isolation - limitation in movement, eating, communication add to stress
51
Improving ICU environment - minimising noise
behaviour - avoiding unnecessary chat equipment - minimise alarm volumes, telephones icu design - high sound absorption, surrounding nursing station with clear glass single rooms ear plugs, music, noise cancelling devices
52
improving light and temperature
dimmable, flexible light sources natural light where possible
53
improving isolation
pen, paper, voice, speaking valves hearing aids / glasses sensory orientation - clock, calendar, bulletin board, television visitation normal routine
54
Design of ICU
goal to create healing environment - improvement in physical and psychological state of patients, staff, visitors optimum design - reduces medical errors, improve outcomes, reduce LOS, increase social support allow rapid access to relevant acute areas round the clock communication centrally located lifts and doors, wide corridors no through traffic areas for public reception, patient management, non-clinical areas (3x area devoted to clinical)
55
patient care zone
ideally - patient zone, family zone, caregiver minimum floor space of 20m2, single rooms larger ratio of single:multiple beds depend on ICU, but more recommended (infection control) isolation rooms some negative pressure adequate lighting patients visible at all times natural light reduce sound transmission - sound absorbing, acoustic baffling safe air quality - filtration, negative pressure, 15 air changes per hour air conditioning and heating for comfort clock and calendar access to outdoor area medical utility - floor column - space for monitoring, equipment, belongings signage
56
utilities per bed space
4 O2 3 air 3 suction 16-20 power outlets bedside light 4 data outlets
57
clinical support zone
decentralisation - most care at bedsides central station - adequate space for staff, centralised clinical management, interaction, socialisation monitor, pharamcy, drug prep sterile and non-sterile item dedicated radiology display
58
unit support zone
storage areas - 10m2 per bed separate access for delivers close to patient area clean dry utility rooms facilities for point of care testing pneumatic tibe to transfer spcimens offices - reception, medical, nursing on call rooms staff lounge wash rooms seminar room
59
family support zone
separate family area bed and shower if possible tea coffee water toilets separate entrance
60
operational policies
clear defined for admission discharge, management Ines of responsibilities infection control, isolation, transport, end of life, sedation etc non clinical activities QI - structure, processes, outcomes education research

FFICM (14 decks)

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