RECOGNISING WHEN TO ESCALATE Flashcards
Benefits of using iSBAR to hand over?
Structured
Easy to remember and fall back on in a crisis
Succinct
Recognised by all clinicians
It improves information transfer and pt outcomes
What does iSBAR stand for?
Introduction
Situation - “I’m calling about a pt i am concerned that…”
Background - “pt was admitted on…”
Assessment - “i think the problem is xyz and i have given…”
Recommendation - “i need you to… and is there anything i need to do in the meantime”
What are the levels of critical care?
Ward care
Level 1 - enhanced care
Level 2 - critical care
Level 3 - critical care
Which pts should be under “ward care” in terms of levels of care?
Patients whose needs can be met through normal ward care in an acute hospital.
Patients who have recently been relocated from a higher level of care, but their needs can be
met on an acute ward with additional advice and support from the critical care outreach team.
Patients who can be managed on a ward but remain at risk of clinical deterioration.
Which pts should be under “level 1- enhanced care” in terms of levels of care?
Patients requiring more detailed observations or interventions, including basic support for a single organ system and those ‘stepping down’ from higher levels of care.
● Patients requiring interventions to prevent further deterioration or rehabilitation needs which cannot be met on a normal ward.
● Patients who require on going interventions (other than routine follow up) from critical care outreach teams to intervene in deterioration or to support escalation of care.
● Patients needing a greater degree of observation and monitoring that cannot be safely provided on a ward, judged on the basis of clinical circumstances and ward resources.
● Patients who would benefit from Enhanced Perioperative Care.(3)
Which pts should be under “level 2- critical care” in terms of levels of care?
atients requiring more detailed observations or interventions, including basic support for a single organ system and those ‘stepping down’ from higher levels of care.
● Patients requiring interventions to prevent further deterioration or rehabilitation needs which cannot be met on a normal ward.
● Patients who require on going interventions (other than routine follow up) from critical care outreach teams to intervene in deterioration or to support escalation of care.
● Patients needing a greater degree of observation and monitoring that cannot be safely provided on a ward, judged on the basis of clinical circumstances and ward resources.
● Patients who would benefit from Enhanced Perioperative Care.(3)
Which pts should be under “level 3 - critical care” in terms of levels of care?
Patients needing advanced respiratory monitoring and support alone.
● Patients requiring monitoring and support for two or more organ systems at an advanced level.
● Patients with chronic impairment of one or more organ systems sufficient to restrict daily activities (co-morbidity) and who require support for an acute reversible failure of another organ system.
● Patients who experience delirium and agitation in addition to requiring level 2 care.
● Complex patients requiring support for multiple organ failures, this may not necessarily include
advanced respiratory support.
Under which level of care should this patient be:
A patient with DKA who is on appropriate treatment and was initially very acidotic but is gradually improving and requiring no organ support.
Ward level care
Under which level of care should this patient be:
A patient requiring NIV/CPAP for single organ failure.
Level 1
Under which level of care should this patient be:
A patient requiring NIV/CPAP who has borderline blood pressure and also needs vasopressor support
Level 2
Under which level of care should this patient be:
A patient requiring mechanical ventilation
Level 3
Under which level of care should this patient be:
A patient requiring NIV/CPAP who has borderline blood pressure, vasopressor support and is agitated or delirious?
Level 3
What are the human factors or non-technical skills that are important for successful rescutation of a pt?
The cognitive, social and personal resource skills that complement technical skill and contribute to safe and efficient task performance
Deficiencies in these are a cvommon cause of adverse events
What are examples of human factors for successful resuscitation?
Situational awareness
Decision making
Team working including clear roles, effective communication and leadership
Task management
Stress management
Reflection and debriefing
Distraction
Lack of resources
Fatigue
Frequency of monitoring and NEWS score?
0 - 12 hourly
1-4 - 4-6 hourly
3 in a single parameter - at least 1 hourly
5 or more - at least 1 hourly
7 or more - continuous monitoring
Who can be admitted to ICU?
It’s appropriate for pt requiring or likely to require advanced respiratory support, pts requiring support of 1 or more organ systems and pts with chronic impairment of 1 or more organ systems who also require support for an acute reversible failure of another organ
They must require higher level of monitoring organ support, reversible pathology and a physiological reserve to survive intensive and invasive treatment
What is APACHE II?
A common scoring system used in ICU
Acute Physiological And Chronic Health Evaluation
A score based on the worst physiological derangement in the first 24 hours, age and chronic health. A score >35 indicates pt is unlikely to survive
What must be monitored and why when a pt is on NIV?
Pulse and bp - can reduce cardiac output and cause haemodynamic instability
Monitor fluid balance
What are the types of NIV?
BiPAP
CPAP
High flow nasal cannula
Contraindications to NIV?
Facial burns/facial trauma
Recent upper GI surgery
Vomiting
Fixed airway obstruction
Undrained pneumothorax
Patient is unable to protect their own airway E.g. moribund with low GCS or copious secretions
Life threatening hypoxaemia
Multiple comorbidities
Confusion and agitation
Patient refusal
Bowel obstruction
Haemodynamic instability
Why is safety netting important?
Safety netting advice can protect both the patient and the doctor. It can help to ensure that a patient with unresolved or worsening symptoms knows when and how to access further advice, and is an important way of reducing clinical risk and the risk of receiving a complaint.
What is safety netting?
a term used to describe the advice we give to patients or their relatives or carers as we discharge them from the Emergency Department
This is specific guidance given to pt about their condition and how and when to seek further medical help
What is the ReSPECT process?
The ReSPECT process creates personalised recommendations for a person’s clinical care and treatment in a future emergency in which they are unable to make or express choices.
These recommendations are created through conversations between a person, their families, and their health and care professionals to understand what matters to them and what is realistic in terms of their care and treatment.
Process for reporting a medical error?
Pt should recieve an apology, be told what went wrong and what actions are being taken to prevent this from happening
Report to the Learn From Patient Safety Event service (used to be the National Reporting and Learning System)
Reflect
