Random stuff Flashcards
Causes of hepatosplenomegaly and massive splenomegaly
Kala-Azar (visceral leischmaniasis) Malaria Myelofibrosis Sarcoidosis Amyloidosis Chronic myeloid leukaemia (CML) Lymphoma Chronic liver disease
Risks for pressure ulcers
Duration of surgery Faecal incontinence and/or diarrhoea Low albumin concentrations Disturbed sensory perception Obesity Moisture of the skin Impaired circulation Use of inotropic drugs Diabetes mellitus Too unstable to turn, or other reason for decreased mobility, High APACHE II score. Waterlow’s score, Braden’s score or other valid scores
Why may RA patient have DI in ICU
Poor neck extension due to C-spine arthritis
Risk of spinal cord injury due to atltantoaxial subluxation
Poor mouth opening due to TMJ arthritis
Poor vocal cord opening due to laryngeal arthritis or crico-arytenitis
Poor respiratory reserve due to pulmonary fibrosis
Difficulty assessing all of these issues in the context of an ICU intubation - you are not seeing this person in the pre-admission clinic; likely they are trying to die in some sort of advanced life support scenario.
how may rheumatoid arthritis influence intensive care management
Related to the RA itself
RA can be a multisystem disease.
Respiratory – pulmonary fibrosis, pleural effusion, reduced chest wall compliance.
Cardiac – increased risk of IHD, pericardial disease, valvular insufficiency, cardiac failure.
Renal – insufficiency directly related to the RA is rare, although does occur (GN, IN, amyloid).
Haematological – e.g. anaemia (chronic disease), thrombocytopenia (Felty’s).
Amyloidosis – cardiac, renal, hepatic.
Skin / pressure sores.
Difficult venous / arterial access – limb deformity.
Analgesia requirement.
Secondary amyloidosis affecting liver spleen and kidneys.
Decisions re-extubation if difficult intubation.
Post-extubation – difficulties with chest physiotherapy, mobilisation.
Psychosocial aspects of patient with chronic illness.
Related to the treatment for RA
Immunosuppression – infectious complications.
Other cytopaenias – anaemia, thrombocytopenia.
Need for adequate steroid replacement if long-term use.
Pulmonary – e.g. ILD from MTX, gold.
Renal – more likely related to medications that RA itself – e.g. NSAIDS, cyclosporine, penicillamine, gold.
Hepatic – e.g. MTX, Azathioprine.
Upper GI bleeding – NSAID, SSZ use.
Myopathy, skin breakdown, hyperglycaemia – steroids.
Drug interactions.
Potentially life threatening causes of delirium
Hypoxia Hypoglycaemia Intra-cerebral haemorrhage Meningitis/Encephalitis Poisoning Wernicke’s Encephalopathy Infection: local (wound, anastomotic leaks etc.), UTI, lung etc. Withdrawal from drugs Hypertensive encephalopathy Metabolic derangements – sodium, renal, liver.
Pulmonary changes in rheumatoid arthritis
Pleurisy/pleural effusion Pneumothorax Rheumatoid nodulosis Interstitial pulmonary fibrosis Caplan's syndrome is the combination of rheumatoid nodules and pneumoconiosis Bronchiectasis Pulmonary vasculitis Methotrexate-induced interstitial pulmonary fibrosis
Role of physiotherapist
Overall - respiratory, neurological, cardiovascular, MSSK roles
Respiratory optimisation; aid in clearning of secretions and maintaining or recruiting lung volumes
- manual hyperinflation, suction, inspiratory muscle training, positioning, percussion/vibration
Musculoskeletal optimisation
- Mobilisation, joint-protective positioning, tone-improving positioning
Orthopedic
- Management of immobilisation devices, application and removal of plaster casts, fitting of collars, braces and slings
Rehabilitation
- Exercise and education to improve function following a period of critical illness
Ultrasound signs of PTx
Loss of comet tails and “marching ants” appearance
Ribs and pleura move together
“Lung point” – motionless horizontal lines are replaced by normal lung appearance moving from non-dependent to dependent region and also seen with inspiration and the probe held stationary.
Loss of “waves on the beach” appearance in M-mode
Daily sedation breaks
- benefits, risks and evidence
Exposure to sedating agents is undesirable, given that most agents have unpleasant side-effects
Interruptions in sedation may decrease the total dose of sedation over the course of one’s ICU stay
Proposed advantages
- More rapid weaning from ventilation
- Reduction in ICU length of stay
- Reduced need for vasopressors
- Reduced need for fluid boluses
Expected disadvantages
- Greater risk of self-extubation
- Greater psychological distress; potential for PTSD
- Increased nursing workload
- Increased patient-ventilator dyssynchrony
Cochrane verdict (2014) - meta-analysis, n=1282; no strong evidence in support of this practice. Tracheostomy may be performed less often.
Structure for retrieval question
Vehicle Equipment Monitoring Drugs Pt preparation Personel Communication (NOK and receiving hospital)
CLABSI rate
= confirmed blood stream infections / central line days x 1000
i.e. Number of confirmed blood stream infections per 1000 central line days
Acceptable is <1/1000 days
standardised mortality ratio (SMR) - calculation
observed number of deaths / expected number of deaths
therefore need to know;
- A time interval (you decide - three months, one year, etc.)
- A measurement of the observed number of deaths (ICU mortality numbers should be available widely)
- An estimate of the predicted mortality (this can be achieved using a scoring system; averaged out for the sample population)
SMR - results
An SMR of 1 means the mortality is as expected.
An SMR of < 1 is better than expected, and >1 is worse than expected.
Reasons for an elevated SMR
Apparent increase -
- scoring system data incorretly entered and underestimates mortality (eg no entry for chronic diseases, GCS just put as 15 for all)
- “Lead time bias” - treatment received prior to ICU admission may result in artifically normalised acute physiology scores
- “Healthy worker effect” - there are more well patients being admitted eg following elective surgery
Actual increase
- External to ICU;
A population with greater pre-ICU morbidity is suddenly available - eg suddenly providing ecmo
Pre-ICU care has changed its practice (for the worse)
Parameters which govern ICU admission have changed - pressure from other specialties/wards
Discharge arrangements have changed - eg no access to pall care
- Internal to ICU; actual underperfomance;
many causes - new/poorly trained staff, poor equipment
Good guidelines statement should:
Identify the organisation responsible
Define the purpose of the guideline
List individuals and groups responsible for its development
Document clearly the process of evaluation of the evidence
Provide a bibliography
Detail the assumptions
Record public policy and economic questions which were considered
Identify the need for special training required for implementation
Record how consumer concerns were taken into account
Detail methods for dissemination
Detail the timeframe for evaluation
The process of writing guidelines should include
Identify the practice
Compose the guidelines panel - form a multidiciplinary working party
Identify the question
Develop research strategies
Write the guidelines
Recursive improvement
Implementation
Audit and quality assurance
Revision
Capabilities of a level I ICU
Mechanical ventilation
Simple invasive cardiovascular monitoring
24-hour timeframe is the limit unless staffed by a FCICM
Capabilities of a level 2 ICU
Complex multi-system life support for an indefinite period
Minimum of 6 beds
At least 4 full time specialists on the roster
Capabilities of a level 3 ICU
Tertiary referral unit
Complex multi-system life support for an indefinite period
Commitment to academic education and research
At least 4 full time specialists per 12-bed “pod”
Staffing requirements in an ICU
A medical director
At least one specialist rostered
At least one other doctor rostered
Patient reviews at least daily, and ideally twice daily
1:1 nursing for ventilated patients and 1:2 for HDU-level patients (any fewer nurses, andmortality seems to increase)
There should be a nursing team leader, and nurse in charge of the unit
There should be at least one nurse educator per 50 nurses
There should be a documented educational program
Structure/practical set up consdierations for an ICU
All patients should be easily visible.
At least 20m2 per patient, or 25m2 per single room
At least one isolation room per every 6 patient beds
At least one wash basin for every 2 patient cubicles
At least 16 powerpoints per bed space
Windows are “desirable”.
There should be several dedicated areas: A staff working area and adequate storage space A pharmacy preparation room An equipment storage room A dirty utility A staff room offices seminar room A family room for relatives A cleaner's room A blood gas machine Library facilities
Approach to a fire
Remove the staff and patients from immediate danger.
Alert the switch board and fire department
Contain the fire by closing doors and windows
Extinguish the fire if it is practical and safe to do so.
And after that, you evacuate the remaining patients.Reverse triage is applied at this stage.
Follow orders from the fire warden
Risk factors for medication error:
Illness severity Extremes of age Unexpected admission Sedation Prolonged hospital stay Doses of drugs which require dosage calculations High staff stress, poor nurse-to-patient ratios Multiple simultaneous care providers
Prevention of medication error
Standardise the medications
Medication reconciliation (reconciling the list of ICU medications with the normal list of medications which the patient takes at home)
Computerise dose calculation and infusion devices
Adequate staffing
Checklist for drug administration
Avoid excessive working hours
Pharmacist participation in ICU care
The ideal scoring system would have the following characteristics:
- Scores calculated on the basis of easily/routinely recordable variables
- Well calibrated
- A high level of discrimination
- Applicable to all patient populations in ICU
- Can be used in different countries
- The ability to predict mortality,functional status or quality of life after ICU discharge
APACHE (Acute Physiology and Chronic Health Evaluation)
Includes the three factors that influence outcome in critical illness-
pre-existing disease, patient reserve and severity of
acute illness
Calculted using; Physiological variables, chronic health conditions and emergency /elective admissions and post- operative/non- operative admissions
Based on the most abnormal measurements in the first 24 hours of ICU stay
Can be used to calculate standardised mortality ratios for a population
A score of 25 represents a predicted mortality of 50% and a score of over 35 represents a predicted mortality of 80%.
SOFA (Sequential Organ Failure Assessment)
Degree of organ dysfunction related to acute illness
Defined score ( 1-4) for each of six organ systems- respiratory, CVS, CNS, Renal, coagulation and liver
Daily scoring of individual and composite scores possible during course of ICU stay
Can follow an individuals trend overtime
How to promote handwashing
System change
- Regular workplace survey to assess unmet goals
0 Ensure that products for hand hygiene are available at the point of care.
- Improve tolerability of hand hygiene products
- Improve ward infrastructure to improve access to handwashing facilities
Training and education
- Health-care workers should check each others’ compliance
- Regular education meetings
- Engage external educators
- Engage internal educations who can act as role models
- Focus on the doctors, who are generally the worst offenders
Reminders in the workplace
- Posters
- Promotions and rewards
- Schedule presentations
- Frequent educational sessions
Evalation and feedback
- Regular monitoring of compliance
- System of observers with centralised reporting
- Rewards and demerits for compliance (or its lack)
- Audit of changes in incidence of health care associated infections
- Establish a system for continuous recording and reporting hand hygiene product consumption
How are scoring systems useful
They (try to) predict outcome and length of stay
They can be used to compare predicted and observed outcome
They stratify patients for clinical trials, according to disease severity
They assess ICU performance
They allow resources to be allocated to ICUs according to the illness severity of their patients
They allow a comparison of ICUs
APACHE
APACHE stands for Acute Physiology, Age and Chronic Health Evaluation (I-IV).
APACHE II is the most commonly used one 12 variables are measured Scores range from 0 to 71 The risk of hospital death is computed by combining APACHE II score with Knaus' weighted coefficient for different types of disease entities. A score of 25 represents a predicted mortality of 50% and a score of over 35 represents a predicted mortality of 80%. Derived from histrical data set
SOFA
SOFA stands for Sequential Organ Failure Assessment .
6 organ systems are scored according to their function
The degree of organ support is taken into account
Used to analyse secondary endpoints in clinical trials
There is a defined score of 1-4 for each organ system, which is collected daily. This not a predictive model- there are no mortality algorithms here. A higher SOFA score can be said to relate to increased mortality, but there is no mathematical model to help us figure out exactly how the total score relates to survival.
Components of an ICU quality assurance program
- ICU Morbidity and Mortality data collection and review
- Incident Monitoring data collection and review
- Hospital Outcome data collection and review
- Staff working hours, retention, continuing education
- Occupational safety record
- Appointment of a Quality Assurance Coordinator
What data should be regularly collected
Morbidity and mortality data collection
Incident monitoring
Patient and family satisfaction surveys
Staff satisfaction surveys
Feedback from external non-ICU services and prehospital staff
CVS changes in old age
A decrease in elasticity and an increase in stiffness of the arterial system. Thus:
- Increased afterload on the left ventricle
- left ventricular hypertrophy
- Increase in systolic blood pressurey,
- Changes in the left ventricular wall that prolong relaxation of the left ventricle in diastole; thus diastolic dysfunction and the propensity towards pulmonary oedema
- Aortic valve calcification
Dropout of atrial pacemaker cells resulting in a decrease in intrinsic heart rate.
With fibrosis of the cardiac skeleton there is calcification at the base of the aortic valve and damage to the His bundle as it perforates the right fibrous trigone.
Decreased responsiveness to β-adrenergic receptor stimulation
Decreased reactivity to baroreceptors and chemoreceptors,
Increase in the levels of circulating catecholamines.
Resp changes in old age
Decrease in exchange surface area (“senile emphysema”):
- Dilatation of alveoli
- Enlargement of airspaces
- loss of supporting tissue for peripheral airways
- Carbon monoxide transfer decreases with age, reflecting mainly a loss of surface area.
Decreased static elastic recoil of the lung, thus
- Increased residual volume
- Increased functional residual capacity.
Decreased expiratory flow rates (especially small airways)
The ventilation/perfusion ratio heterogeneity increases, with low V/Q zones appearing as a result of premature closing of dependent airways.
Decreased compliance of the chest wall, thus increased work of breathing
Decreased respiratory muscle strength (though this depends on the heart, and on nutrition)
Decreased sensitivity of respiratory centres to hypoxia and hypercapnia
PK changes in old age
Reduction in first-pass metabolism, thus increased oral bioavailability of a few drugs.
Body fat increases, body water decreases; thus:
- Hydrophilic drugs have a smaller volume of distribution
- lipophilic drugs have an increased volume of distribution and a longer half-life
Drugs with a high hepatic extraction ratio decrease in systemic clearance
Activities of cytochrome P450 enzymes are preserved in normal ageing
Renal clearance may be decreased due to age-related changes in renal function
Problems on home d/c after a long ICU stay
Tracheostomy:
- Tracheal stenosis
- Tethering of skin
Mobility:
- Muscle wasting, neuromyopathy
- Slow recovery of normal function (up to 1 year)
Skin
- Hair loss
- Nail ridging
- MRSA colonisation
- Facial scraring due to pressure areas from NGT and ETT
Sexual dysfunction - a 39% incidence
Psychological problems
- PTSD, in about 15% (27.5% for ARDS survivors)
Miscellaneous
- loss of taste
- loss of appetite
- ocular trauma
- scarring near region of tape fixing for ETT
- Decreased visual acuity in patients who are profoundly hypotensive.
Unnecessary medication – Frequently medication commenced in ICU is commenced post discharge.
Tools that are available to assess the functional status of a patent following hospital discharge after a prolonged period of stay in the Intensive Care Unit.
QALY(Quality Adjusted Life Years - the only objective tool) HAD (Hospital Anxiety and Depression) PQOL (Percieved Quality of Life) EuroQol SF 36 (36 item short-form survey)
Some units do discharge clinics
Proposed advantages of daily sedation breaks
More rapid weaning from ventilation Reduction in ICU length of stay Reduced need for vasopressors Reduced need for fluid boluses Allow to assess neurological status
Expected disadvantages of daily sedation breaks
Greater risk of self-extubation and removal of other devices
Greater psychological distress; potential for PTSD
- potential for pain, esp in burns/trauma etc
Increased nursing workload
Increased patient-ventilator dyssynchrony
Risk of MRI in critically ill
Risks from the magnet
- Ferromagnetic material movement
- Malfunction of pacemakers
- Projectile trauma from nearby objects
- Cardiac damage from PA catheters
- Pulse oximeters and ECG dots can overheat and cause burns.
Risks from contrast
- Gadolinium is usually quite safe, but it may cause exacerbation of nephrogenic systemic fibrosis.
- Anaphylactic reactions are possible.
Risks from the isolated room
- Airway disconnection alarms might go unheard
- Long ventilator tubing creates excessive amounts of dead space
- Extra dead space makes is difficult to trigger.
- MRI-compatible anaesthetic machines are available, but they are expensive (~ $80,000) and frequently the ventilators on them are somewhat unsophisticated.
- Long infusion tubing results in a delay of medication administration
- Some drugs may require pumps, and cannot be given; pumps may require ridiculously long tubing and additional batteries to function
- The MRI chamber is usually cold, and hypothermia can develop
- Monitoring equipment is of poor quality
Risks from being critically ill
- Thermoregulation is impaired, and hypothermia is more likely to develop
- Judgement is impaired, and patient movement delays the process
- Resuscitation equipment cannot be taken into the room.
- If cardiac arrest occurs, it can take some time to dismount the MRI couch
Effect of genetics on ICU course (!)
Risk of developing MODS from acute pancreatitis is influenced by TNF-α gene variants
Risks of developing ARDS in community acquired pneumonia is related to genes encoding proteins A and D of pulmonary surfactant
Susceptibility to sepsis (and to death from sepsis) seems to be related to a whole host of genetic variations,
Delirium in critical illness is associated with a apolipoprotein E4 polymorphism
Outcome in brain injury seems to be worse for people featuring the apolipoprotein E-ε4 genotype
In addition, the following comorbidities feature significantly in ICU outcomes, and have a known genetic basis;
- NIDDM
- IHD
- Emphysema (α-1 antitrypsin deficiency)
- Cerebrovascular disease
Various genetic disorders and sporadic mutations / chromosomal abnormalities eg Down syndrome, Prader-Willi (OSA and obesity hypoventilation syndrome.)
Toxic epidermal necrolysis
History of exposure to a new drug -> 1-3 weeks of waiting
Fever and flu-like symptoms for 1-3 days before skin eruption
Skin eruption: poorly defined macules with purpuric centres, Then, blisters and epidermal detachment
Symmetrical, primarily over face and upper trunk
Complications similar to burns
Mucosal involvement in 90%
BOOP and respiratory mucosal sloughing can also occur
Liver failure, ARDS
Drugs which are known to cause TEN:
phenytoin NSAIDs Penicillins Quinolones Carbamazepine Valproate Allopurinol Fluconazole Sulfonamides Barbiturates
Rationale of daily clinical exam
History and physical examination is the mainstay of diagnosis in non-ICU environments
ICU patients are frequently unable to offer a history
Physical examination may be able to reveal new pathology, which would otherwise have not been
suspected from routine bloods and radiography.
Clinical features are more reliable than other methods in the diagnosis of certain conditions (eg. delirium, weakness, etc)
Advantages of daily clinical exam
Cheap
Non-invasive (mostly)
Sequential
May detect deterioration early
Better than imaging for neurological assessment
Assesses function as well as structure
Many ICU devices enhance physical examination technique (eg. CVP waveform supercedes the examination of the JVP)
Disadvantages of daily clinical exam
Poor sensitivity and specificity
New pathology may be missed
Interpreter-dependent
Poor reproduceability of findings
Many barriers to traditional techniques in the ICU (eg. the patient is uncooperative, dressings and lines obscure physical signs)
“Features of an Ideal Transport Ventilator”.
Small, light, robust and cheap
Independent of an external power wource
Easy to use and clean
Economical with gas consumption
Suitable for patients of all sizes, from neonates to huge adults
Totally variable FiO2
Able to deliver a variety of modes of ventilation
Able to ventilate with variable I:E ratios
Integrated monitoring and alarm functions
Alarms should be visual and auditory
Altitude compensated ventilation
felty syndrome
rheumatoid arthritis, splenomegaly and neutropenia.
cachexia
Loss of body weight (or failure to gain weight in children).
Loss of muscle tissue with or without the loss of fat tissue.
May or may not be associated with decreased nutrient intake (may occur in the presence of nutritional plenty)
When associated with decreased nutrient intake, it is not associated with an adaptive decrease in protein catabolism.
frailty
a multidimensional syndrome characterised by loss of physiologic and cognitive reserves in vulnerability that predisposes to the accumulation of deficits and adverse outcomes from acute stressors
Is dynamic and potentially reversible
diagnostic tools of frailty
frailty phenotype
frailty index
Comprehensive geriatric assessment (CGA) is considered the gold standard (but very complex multdiciplinary review)
Edmonton Frail Scale
frailty phenotype
a distinct clinical syndrome meeting three or more of five phenotypic criteria
- Decreased grip strength
- Self-reported exhaustion
- Unintentional weight loss of more than 4.5 kg over the past year
- Slow walking speed
- Low physical activity
frailty index
a detailed 70-item inventory of clinical deficits, often used in research
Core values of the college
integrity collaboration compassion accountability respect
Roles of the intensive care specialist
medical expert communicator and collaborator leader health advocate scholar teacher researcher
CATEGORIES OF TELEMEDICINE IN INTENSIVE CARE MEDICINE
Provision of Intensive Care Specialist support to an intensive care unit staffed by non CICM
Fellows
.
Provision of Intensive Care Specialist support to remote centres for management of acutely
critically ill patients awaiting retrieval to an intensive care unit.
Provision of Intensive Care Specialist support out of hours where 24/7 specialist cover
cannot be provided on site.
HDU staffing must include:
A medical director who is a Fellow of the College of Intensive Care Medicine (FCICM).
In addition to the attending intensive care specialist, at least one registered medical practitioner
with an appropriate level of experience immediately available at all times.
A nurse in charge of the HDU who has a post registration qualification in intensive care.
Structure of an HDU
should be minimum 4 beds
should be geographically linked to ICU which is level 2 or 3
typical HDU will require at least two oxygen, one air and two suction outlets, and at least
twelve power points for each bed space
can share other facilities (offices, seminar room etc) with ICU
equipment and monitoring minimums are also discussed in the prof document
Air transport exposes patients and crew to particular risks including:
Reduced oxygen partial pressure.
The need for pressurisation to sea level when clinically indicated.
Risk of rapid depressurisation.
Expansion of air filled cavities both within the patient and the equipment, such as endotracheal tube cuff, middle ear, air-filled spaces under airtight dressings etc.
Limb swelling beneath plaster casts.
- 3.6 Worsening of air embolism or decompression sickness.
- 3.7 Danger from agitated patients.
- 3.8 Limited space, lighting and facilities for interventions.
- 3.9 Noise.
- 3.10 Extremes of temperature.
- 3.11 Extremes of humidity.
- 3.12 Acceleration, deceleration and turbulence.
- 3.13 Vibration.
- 3.14 Electromagnetic interference between avionics and monitoring devices.
- 3.15 Danger from loose, mobile equipment.
- 3.16 Motion induced illness.
Clinical Quality Improvement definition
an interdisciplinary process designed to
raise the standards of the delivery of preventive, diagnostic, therapeutic and rehabilitative
measures, in order to maintain, restore and improve health outcomes of individuals and
populations
Aim is to ensure that high standards of clinical
practice are maintained by individuals, units, and hospitals or institutions through regular
assessments using quality indicators
Quality indicators should look at
Structure - measures whether the ICU functions according to its operational guidelines and
conforms to the policies of the College of Intensive Care Medicine.
Process - measures the way care is delivered (or not delivered) to patients and families.
Outcome - measures the results achieved.
Steps in a Quality Improvement project
Planning - includes identification of the
indicator to be improved, and development of a method to improve it. It also involves determination of the data to be collected, and the methods employed to collect and analyse data.
Implementation,
Evaluation - determination of whether the indicator is changing as a result of the behaviour change
Ensuring Sustainability - modification of behaviour to sustain the improvement, with a focus on clinical leadership
Activities that assess structure might include
audit of the number of suction outlets available to each
bed or perhaps an audit of staff qualifications.
Activities that assess the process of patient care include
clinical audit (morbidity and mortality meetings, delayed transfer out of ICU etc), compliance with protocols, guidelines and checklists, and critical incident reporting.
Includes assessing - Rate of DVT prophylaxis Rate of stress ulcer prophylaxis Early enteral feeding Delayed discharge from ICU Appropriate transfusion threshold Blood glucose control Hand washing Time to administration of antibiotics Low tidal volume ventilation in ALI/ ARDS End of Life Management
Activities that assess outcomes are
calculating risk-adjusted mortality using a scoring system (such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) and calculation of SMR),
measurement of rates of adverse events such as central venous catheter associated blood stream
infection rate or serious adverse drug event rate and surveys (e.g. patient or relative satisfaction).
Categories of supervision
Category 1. A supervisor working directly with one trainee in a clinical situation involving the
assessment and/or management of a patient, or in a non-clinical situation as
outlined above.
Category 2. A supervisor in the same department/unit as a trainee, and available for immediate
assistance and consultation.
Category 3. A supervisor present elsewhere in the hospital, but immediately available for
consultation and assistance.
Category 4. A supervisor not in the hospital, but readily contactable and, if necessary, available
within reasonable travelling time, who is specifically rostered for the period in
question.
MINIMUM STANDARDS FOR INTENSIVE CARE UNIT BASED RAPID RESPONSE SYSTEMS 2017 policy
What is RRS ICU
a hospital wide structure
provides a safety net for patients who have become crtically ill and who have a mismatch between clinical need and available resources
ICU lead the RRS
RRS ICU main components
Defined process for patient identification
System for triggering a team response
Quality assurance program
Administrative limb (usually overseen in ICU)
Staffing of RRS ICU
Medical - should not impair care of ICU patients
- if >2000 calls/year - dedicated reg
- ability to respond in <10mins
- trainees should have <25% time RRT
- other medical staff should include member of treating team
Nursing - ICU staff dedicated to team
Educational requirements of RRS team
knowledge
technical and non technical skills
leadership skills
Operations requirements of RRS
Need a clinical lead
must ensure national criteria are met for all systems
Equipment requirements ofr RRS
will vary
should be portable
must have systems in place to ensure maintenance
Overall requirements of RRS ICU
staffing
educations
operations
equipment
Components of non technical skills
task management
team working
situational awareness
decision making
Capacity
The patient is able to understand their medical condition, treatment options, and risks
and benefits of treatment options to make an informed decision. They must also be
able to communicate their decision in some way. Some conditions may impair capacity,
for example mental illness, dementia, acquired brain injury or intellectual disability.
Sometimes a qualified person may be required to make a capacity assessment.
If there is impaired capacity consent must be obtained through the following (in order):
a valid advance health directive
a guardian appointed by the Queensland Civil and Administrative Tribunal
a health attorney under an advance health directive or enduring power of attorney
a statutory health attorney(s) - may be a spouse,
your carer, but not a paid carer (although your carer may receive a carer’s pension), a close adult friend or relative who is not a paid carer, or the Public Guardian if there is no one else.
the Public Guardian.
