Organisational issues Flashcards
Early recognition and review
rapid response team
standardised approach to detection of deteriorating patients
NEWS2
critical care outreach
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
levels of care
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
GPICS
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
key standards around admission
– 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
MDT
daily input from nursing, micro, pharmacy, physiotherapy
regular input from dietetics, SALT, psychology
standards around discharge
- follow up programme
- OP appt 2-3 months post hospital discharge
- discharge in hours
- standardised handover
- structured rehab programme
When are scoring systems used in critical care
- 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.
types of scoring systems
illness severity scoring systems
diseased specific scoring systems
Illness severity scoring systems
- 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
disease specific scoring systems
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
Disease specific illness severity score
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
limitations of scoring systems
data accuracy e.g. subjective components
applicability to cohort
changing predictive ability e.g. withdrawal on patient with 95% mortality = 100% mortality
evaluation of scoring systems
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.
ideal scoring system
- valid to your population
- simple
- discriminates (survivors from non survivors)
- calibrated (degree of accuracy)
qSOFA
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
scores in relation to admission to crucial care
- 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
monitoring service quality
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
Other measurements of service quality
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
What are the hazards of patient transport
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
classification of transfers
by location - primary, secondary, tertiary
indication - clinical, non-clinical, repatriation
urgency - time critical, urgent, routine
mode of transport - foot, road, air
how do you carry out a transfer
clear decision making and communication. checklists
1. decision making
2. personell
3. equipment
4. patient
decision making related to transfer
- patient stable?
- urgency identified
- indication identified
- benefit outweighs risk
- patient and relative informed
- received hospital airway and consultant accepting
Personnel
- doctor - trained in transfer with appropriate skills
- nurse / ode - traipsed in transfer and familiar with equipment
- paramedic crew
- specialist e.g. perfusionist
equipment
checklist!
- trolley
- ventilator
- oxygen
- suction
- monitoring
- infusion pumps
- airway equipment
- drugs
- documentation / notes
- mobile phone
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
handover of transferred patient
multilevel
- consultant - consultant icu
- consultant - consultant parent team
- tranferring - receiving team medical and surgical
other important aspects of transfer
- clear documentation
- checklists
- documentation including observations during handover
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
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
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)
Critical incident
an active error with significant consequences
patient safety incident is potential or actual harm due to any healthcare event
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
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.
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
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
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
fire safety
3 critical care incidents in last decade
high degree of morbidity, loss of life, staff affects
greater fire risk in critical care
oxygen - high concentrations
heat - dependence on electrical equipment, electrosurgery
fuel - emollients, bedding, bin, alcohol
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
facilitation of emergency evacuation
- policy
- vacation cards
- evacuation aids
- smoke hoods
- power supply
- training
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
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
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
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
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)
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
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
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
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
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
improving light and temperature
dimmable, flexible light sources
natural light where possible
improving isolation
pen, paper, voice, speaking valves
hearing aids / glasses
sensory orientation - clock, calendar, bulletin board, television
visitation
normal routine
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)
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
utilities per bed space
4 O2
3 air
3 suction
16-20 power outlets
bedside light
4 data outlets
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
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
family support zone
separate family area
bed and shower if possible
tea coffee water toilets
separate entrance
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
