Critical Care Manual of Clinical Procedures and Competencies

Jane Mallett, John Albarran, Annette Richardson

• Publisher: Wiley-Blackwell
• Year: 2013
• ISBN:
  9781118496138
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

This manual is aimed at all healthcare practitioners, from novice to expert, who care for the critically ill patient, recognising that different disciplines contribute to the provision of effective care and that essential knowledge and skills are shared by all practitioners. It provides evidence-based guidelines on core critical care procedures and includes a comprehensive competency framework and specific competencies to enable practitioners to assess their abilities and expertise. Each chapter provides a comprehensive overview, beginning with basic principles and progressing to more complex ideas, to support practitioners to develop their knowledge, skills and competencies in critical care.

Chapter 1

Scope and delivery of evidence-based care

John W. Albarran¹ and Annette Richardson²

¹University of the West of England, Bristol, UK

²Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK

Importance of critical care

Healthcare around the world, to a greater or lesser degree, encompasses the treatment and care of people with a wide range of conditions. Some will be critically ill and clinical decisions and interventions will have immediate and fundamental impact on whether they live and/or their degree of recovery. It is, therefore, imperative that treatment and care of critically ill patients is the best that can be provided. Excellence, however, requires appropriate interventions with a strong evidence base and practitioners¹ who are com­petent to deliver treatment and care. The aim of Critical Care Manual of Clinical Procedures and Competencies is to support optimum treatment and care for patients who are critically ill by detailing the latest research and rationales for evidence-based procedures and competencies in each specific area. As such, the manual is ideally placed to be used as a reference and resource for advancing critical care practice and education.

Background and classification of critically ill patients

Critical care² has developed considerably over many years, with a number a key policies and initiatives emphasizing and escalating the pace of change. A significant transformation took place following the publication of the critical care modernisation policy document entitled ‘Comprehensive Critical Care’ (DH 2000a). This strategy document led to a restructure of the organization of critical care services by advocating that provision of care should extend beyond the walls of intensive care units and be comprehensive in meeting patients’ needs. It highlighted the provision of care within a continuum of primary, secondary and tertiary care, with the greater part of services in the secondary care setting. It set out the vision for how critical care should be delivered, replacing the division of intensive care beds and high dependency beds with a classification system focused on levels of care (Table 1.1). ‘Critical care’ is a global definition, and is used as an umbrella term for intensive and high dependency care and includes the care of critically ill patients on the ward (DH 2000a: 7).

Table 1.1 Classification of critically ill patients

(DH 2000a, © Crown copyright 2011)

Classification	Definition
Level 0	Patients whose needs can be met through routine ward care in an acute hospital
Level 1	Patients at risk of their condition deteriorating, or recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice and support from a critical care team
Level 2	Patients requiring more detailed observation or intervention, including support for a single failing organ system or postoperative care, and those ‘stepping down’ from higher levels of care
Level 3	Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure

The classification system provides a blueprint for delivering critical care services along a continuum which spans from managing the healthcare needs of patients with multi-organ failure patient (level 3) to those at risk of their condition deteriorating (level 1). Individuals whose needs can be met on general hospital wards without support from the critical care outreach teams are not considered critically ill (level 0).

The organization of care for different categories of patient varies according to patient requirements and also how this is accommodated by the local service. At present, patients with level 3 needs are generally cared for in a clinical area that is designated primarily for this category of patient and is often referred to as an intensive care unit. This is because this group need high levels of monitoring, intervention and organ support that requires specialist expertise and equipment. Sometimes the level 3 care facility is also a ‘specialty only’ unit (such as patients with neurological problems or burns).

Patients with level 2 and 1 needs are cared for in a variety of settings. These include a designated level 2 and/or 1 unit (which may or may not include specialist-only beds); specific area/beds within a level 3 facility (which may or may not include specialist-only beds); and specific area/beds within a level 0 care facility (which may or may not include specialist-only beds). Patients requiring level 2 and 1 care on a level 0 care facility are often there on a temporary basis with the support of the multidisciplinary critical care outreach team.

While the levels of critical care (1 to 3) are clearly defined (DH 2000a) and therefore allow for a joint understanding of the needs of patients and the required level of care, a variety of service organizations’ designations and terms have been used to describe critical care facilities; these include intensive care unit (ITU or ICU), critical care unit (CCU), high dependency unit (HDU), special care unit (SCU) and post-anaesthetic care unit (PACU). It is important, therefore, that the patient’s needs and the care facility are clearly and accurately identified and that all involved in service planning and provision and delivery of care have a shared understanding in order to effectively and efficiently meet the patient’s requirements. For the purposes of this manual the term ‘critical care’ follows that of more recent documentation and developments and refers to patients requiring care at levels 1 to 3.

It is worth noting that as well as the varying levels of critical care requirement and the locations where this care can be delivered, the characteristics of the patient population are important in determining the level of care required. The considerable heterogeneity of the patients is a challenge, as differences in age and sex; type, trajectory and duration of disease; co-morbidities and complications all cause difficulties in defining a patient requiring critical care (Vincent and Singer 2010).

The varying patient characteristics and the complexity of caring for the critically ill has resulted in the require­ment for teams of multidisciplinary specialist critical care practitioners to deliver the care, including: doctors, nurses, advanced critical care practitioners, physiotherapists, dieticians and healthcare assistants engaged in patient care. Although at times specific individuals within the team are involved in the delivery of particular aspects of the care, the overall delivery of critical care is highly reliant on teamwork and the ability of a number of varied types of practitioner to deliver the care over time. Therefore throughout this manual the term critical care practitioner (or practitioner) will be used to represent the various specialist critical care roles.

National guidance

Over the past few years NHS strategies have focused on improving quality, patient care safety, patient outcomes and cost effectiveness of treatment and care (DH 2007a, 2009, 2010a; Richardson 2011). To achieve this, the critical care modernisation strategy recommended that guidelines, standards and protocols for critical care be developed by multiprofessional staff (DH 2000a)³ (see also Table 1.2). In 1999, the National Institute for Clinical Excellence was introduced to act as a politically independent body aimed at improving the quality of care by setting national standards, developing evidence-based guidelines for a variety of conditions and issuing guidance on patient safety (Sibson 2011). It was high-profile examples (such as the Bristol Royal Inquiry [BRI 2001] into children’s heart surgery) that have in part served to precipitate key developments and changes in how healthcare professionals’ competence is monitored (Sibson 2011). In an attempt to regain public confidence and control the spiralling economy, the NHS engaged in implementing a series of wide-reaching measures. These were devised to reduce risks by ensuring that clinical interventions were informed by an evidence base, regular auditing of practice, and by the maintenance of staff performance and competency. Alongside these NHS initiatives were the rising public expectations for more explicit justification and rationale for interventions used in patient care and for increased engagement with service users in the evaluation of healthcare services (Williams 2006; NICE 2007, 2009).

Table 1.2 Differences between protocols, procedures and guidelines

Protocols	Procedures	Guidelines
A protocol should be developed by a multidisciplinary team with the aim of providing a complete account of the steps required to deliver care or treatment to a patient Typically they are either developed locally to implement national standards (such as National Service frameworks or guidelines produced by NICE; see below) or to establish care provision drawing from the best available evidence in the absence of nationally agreed benchmarks (Institute for Innovation and Improvement 2011)	Procedures are operational elements that arise from local protocols. They are applicable to individual patients with each detailing the order of activities to be performed It is not uncommon for these to be developed prior to writing a protocol and they should also be underpinned by the best evidence	Clinical guidelines are systematically developed statements that seek to support healthcare professionals and patients’ decision making under specific circumstances (Thomas and Hotchkiss 2002) Guidelines can cover conditions (asthma), symptoms (chest pain), clinical procedures (endotracheal suctioning) and responses (resuscitation of unresponsive and unconscious people). Again, guidelines are intended to reduce variations in practice, to optimize care and treatment, and provide the means of increasing the accountability of healthcare professionals. The effectiveness of guidelines is based on a systematic appraisal of research and meeting a series of key criteria that include reliability and validity of data, cost-effectiveness and clinical applicability (Thomas and Hotchkiss 2002). The development of clinical guidelines is a labour-intensive process that demands skill in critical appraisal, time to systematically evaluate the quality of research, consultation with experts, and therefore may take two years to complete (Snowball 1999)

In summary, the policies and changes to the NHS and critical care have collectively spearheaded improvements in the delivery and management of critical care services, resulting in grea...

Table of contents

• Cover
• Title page
• Copyright page
• List of contributors
• Foreword
• Foreword
• Preface
• List of abbreviations
• Chapter 1: Scope and delivery of evidence-based care
• Chapter 2: Competency-based practice
• Chapter 3: Recognizing and managing the critically ill and ‘at risk’ patient on a ward
• Chapter 4: Admitting a critically ill patient
• Chapter 5: Assessment, monitoring and interventions for the respiratory system
• Chapter 6: Monitoring of the cardiovascular system: insertion and assessment
• Chapter 7: Titration of inotropes and vasopressors
• Chapter 8: Assessment and support of hydration and nutrition status and care
• Chapter 9: Continuous renal replacement therapies: assessment, monitoring and care
• Chapter 10: Assessment and monitoring of analgesia, sedation, delirium and neuromuscular blockade levels and care
• Chapter 11: Assessment and monitoring of neurological status
• Chapter 12: Assessment and care of tissue viability, and mouth and eye hygiene needs
• Chapter 13: Assessment of sleep and sleep promotion
• Chapter 14: Physical mobility and exercise interventions for critically ill patients
• Chapter 15: Transfer of the critically ill patient
• Chapter 16: Rehabilitation from critical illness
• Chapter 17: Withdrawal of treatment and end of life care for the critically ill patient
• Chapter 18: Cardiopulmonary resuscitation
• Index