2 CHAPTER 1 Critical care organization Critical Care Unit layout The Critical Care Unit should be easily accessible by departments from which patients are admitted and close to departments which share engi- neering servic es. In a new hospital, all critical care facilities should ideally be proximal to operating theaters, emergency department, laboratories, and imaging suites. It is desirable that critically ill patients are separated from those in the recovery phase or needing coronary care where a quieter environ- ment is needed. Providing intensive care and high dependency care in the same Critical Care Unit allows \202 exibility of staf \201 ng, although the differing requirements of these patients may limit such \202 exibil ity. Size of unit Requirements depend on the activity of the hospital with additional beds requi red for regional specialties such as cardiothoracic surgery or neurosurgery. Very small (<6 beds) or very large (>14 beds) units may be dif \201 cult to manage, although larger unit s may be divided operationally and allow better concentration of resources. Patient areas \200 Patient areas must provide unobstructed passage around the bed with a \202 oor space of 2 6m2 per bed and bed centers of at least 4.6m. Curtains or screens are required for privacy. Floors and ceilings must be constructed to support heavy equipment (some may weigh >1000kg ). Doors must allow for passage of bulky equipment as well as wide beds. A wash hand basin with elbow-operated or proximity-operated mixer taps, soap, and antiseptic dispensers shoul d be close to every bedspace. The speci \201 cation should include 50% of beds as isolatio n cubicles. Air pressure control in cubicles should ensure effective patient isolation. Ser vices must include adequate electricity supply (at least 28 sockets per bed) with an uninte rruptable power supply for essential equipment. Oxygen (4), medical air (2), and high (2) a nd low (2) pressure suction outlets must be available for every bed. The bed areas should h ave natural daylight and patients and staff should ideally have an outside view. Communicat ions systems include an adequate number of telephones, intercom systems to allow bed-to-bed communication, and a system to control entry to the department. Computer networks should e nable communication with central hospital administration, laboratory and radiology systems, and the internet. \200 Other areas required Other areas include adequate storage space, separate clean-treatment a nd dirty utility/sluice areas, of \201 ces, laboratory, seminar room, cleaners \200\231 ro om, staff rest room, staff change and locker room, toilets and shower facilities, relatives \200\231 area including a quiet area for grieving family, and an interview room. CRITICAL CARE UNIT LAYOUT 3 See also: Infection control \200\224general principles, p544. 4 CHAPTER 1 Critical care organization Critical Care Unit staf \201 ng (medical) Critical care has evolved from its early success in simple mechanical ventilation of the lungs of polio victims to the present day where pa tients usually have, or are at risk of developing, failure or dysfunction of one or more or gan systems requiring mechanical and pharmacological support and monitoring. The unit shoul d have dedicated consultant sessions allo- cated for direct patient care with additional se ssions for management, teaching, and audit activities. These sessions should be divided bet ween several critical care-trained specialists who should be supported by trainee doctors p roviding round-the-clock cover on a rota which provides adequate rest. Required skills of critical care medical staff Management Senior medical staff, assisted by senior nursing and drugstore colleagues, command the primary responsibility for the struct ural and \201 nancial management of the unit. It is through their actions that treatment of the critically ill is initiated and perpetuated; they are ultimately responsible for the activity of the unit and patient outcome. Decision-making In the Critical Care Unit, most decisions are made by team consensus. Clini cal decisions fall under three categories: (i) decisions relating to common or routine prob lems for which a unit policy exists; (ii) decisions relating to uncommon problems requiring discussion with all currently involved staff, and (iii) decisions of an urgent nature take n by critical care staff without delay. Practical skills Expertise in the management of complex equipment, monitoring proce- dures and performance of invasive procedures are required. Clinical experience Medical staff require experience in the recognition, prevention and man agement of critical illness, infection control, anesthesia, analgesia, and organ support. Technical knowledge The critical care specialist has an important role in the choice of equ ipment used in the unit. Advice should be sought from non-medical colleagues. Pharmacological knowledge Drug therapy regimens are clearly open to the problems of drug in ter- actions, while pharmacokinetics are often severely altered by the effects of major org an system dysfunction, particularly involving the liver and kidneys. Adverse reactions are common. Teaching and training The modern critical care specialist has acquired skills that cannot b e gained outside the Critical Care Unit. Therefore, it is necessary to impart this knowledg e to doctors training in the specialty. CRITICAL CARE UNIT STAFFING (MEDICAL) 5 6 CHAPTER 1 Critical care organization Critical Care Unit staf \201 ng (nursing) Critically ill patients require close nursing su pervision. Many will require high-intensity nursing throughout a 24h period while others ar e of a lower dependency and can share nurses. In addition to the bedside nurses, the depart ment needs additional staff to manage the day-to-day running of the unit, to assist in lift ing and handLing of patients, to relieve bedside nurses for rest periods, and to collect dr ugs and equipment. These additional nurses (or nurse assistants) can be termed the \200 \230 \201 xed nursing establish- ment \200\231 and the nature of their duties is such that they will usually include the higher grade nurses. The bedside nurses are a \200\230varia ble establishment \200\231 and their numbers are dependent on activity such that more patie nts require higher numbers. Most departments \201 x part of their variable establishment by assuming an average activity. Fixed establishment Providing one nurse per shift requires a rota of 5.5 nurses. In additio n, staff handover, annual leave, study leave, and sickness are usually calculated at 22% su ch that one additional nurse is required. Thus, the provision of one nurse in charge of eac h shift and one nurse to support the bedside nurses requires 11 nurses in those two roles a lone. In larger units, there may be a need for additional nurses supporting the nurse in ch arge. Variable establishment The same principles apply for the provision of bedside nurses. Thus, to provide 1:1 nursing for a bed requires 5.5 nurses and to provide 1:2 nursing requires 2 .75 nurses. The total number required depends on the occupancy and the nurse-to-patient rat io for each occupied bed. One of the dif \201 culties in staf \201 ng a Critical Care Uni t relates to the variable dependency and occupancy. An average dependency weighted occupanc y (average occupancy x average nurse-to-patient ratio) should be used to set the establishm ent of bedside nurses with additional nurses being drafted in from a bank or agency to cove r peak demands. Skill mix Nursing skill mix is the subject of much controversy as the need for economy is b alanced against the need for quality. As stated above, the \201 xed nursing will usually be of higher grade since the role incorporates the administration of the unit and superviso ry nursing. The bedside nurses will be made up of those who have received post-quali \201 cation training in critical care and those who have not. The ratio of trained to untrained critical care nurses should be of the order of 3:1 to facilitate in-service teaching. CRITICAL CARE UNIT STAFFING (NURSING) 7 8 CHAPTER 1 Critical care organization Outreach support Critical care outreach aims to augment the effectiveness of Critical Care Units by utilizing their expertise at all stages in the evolution of critical illness. Outr each teams typically support patient care outside the Critical Care Unit to prevent admissi on or readmission. However, the outreach team will also expedite timely admission to a Crit ical Care Unit for those that need it. Outreach teams work in collaboration with staff in g eneral ward areas and should be utilized following the identi \201 cation of a dete- riora tion in the patient \200\231s condition to provide advice, support, education, and a link t o the critical care facility. Many outreach teams in the UK are developed around critical c are nurses, but they also depend on support from critical care medical staff and other m em bers of the multidiscipli- nary critical care team such as physiotherapists. In other count ries such as Australia, the model of a medical emergency team, staffed by intensivists or t rainees, is more commonplace. The outreach team should support and facilitate the ability of ward staff to: \200 Identify patients who are at risk of developing life-threatening acute illness. Patients su ffering cardiorespiratory arrest in hospital usually show gradual deterioration over severa l hours (especially in conscious level and respiratory rate) rather than an abrupt collapse . Initiate immediate resuscitation. Make appropriate referral, documentation, and communica tion. Provide psychological support and physiological surveillance to patients after discha rge from the Critical Care Unit. Educate and train general ward staff in the identi \201 c ation of deteriorating vital signs, the use of appropriate early warning scoring systems, a nd the institution of appropriate management. Though no study has speci \201 cally shown m ortality reduction through the use of outreach or medical emergency team, ward staff and pa tients greatly value their support. The outreach teams can prompt decisions regarding resus citation status and this has led to a reduction in inappropriate cardiac arrest calls. \200 \200 Outreach team calling criteria These are usually de \201 ned locally based on breaching li mits of vital signs. Early warning scoring systems Simple risk assessment tools are available to aid the identi \201 cation of patients at risk of deterioration. These are based on weighted scores given to routinely available vital sign data. OUTREACH SUPPORT 9 Typical outreach calling criteria \200 Respiratory rate >25 or <8/min. \200 Oxygen satu ration <90% on FIO2 >0.35. \200 Heart rate >125 or <50 beats/min. \200 Systolic blood p ressure <90 or >200mmHg, or a sustained fall of >40mmHg from the patient \200\231s normal v alue. Sustained alteration in conscious level. Patient looks unwell or you are worried abou t their condition. \200 Early warning scoring system 3 2 <40 1 41 \200\22350 0 51 \200\223100 1 101 \200\223110 2 111 \200\223129 \211 130 3 HR BP <70 71 \200\22380 81 \200\223100 101 \200\223199 >200 RR \211 8 9 \200\22314 15 \200\22320 21 \200\22329 \211 30 Temp <35.0 35.0 \200\22338.4 \211 38.5 CNS A V P U A = alert; V = responds to voice; P = responds to pain; U = unconscious. Key paper Morgan RJM, Williams F, Wright MM (1997). An early warning scoring system for det ecting devel- oping critical illness. Clin Intensive Care 8: 100. See also: Survivor follow-up, p12; Communication, p18. 10 CHAPTER 1 Critical care organization Critical Care Unit admission criteria The Critical Care Unit should be seen as the hub of c ritical care provision throughout the hospital. In the UK, critical illness is now de \201 ned according to patient dependency levels (see table opposite), ranging from those suitab le for ward care through to true intensive care requirement. Thus, admission to the Critica l Care Unit is not necessary for all of those with a critical illness, particularly where a well-functioning outreach team can support care in the general ward environment. While dep endency levels do not necessarily de \201 ne the need for admission to a Critical Care Uni t, it is generally those requiring level 2 or 3 care who are considered for admission. Admission criteria may be set on a priority basis related to patient dependency levels, the ir speci \201 c diagnosis, physiological or biochemical abnormalities, or investigational \201 ndings. Local policies for critical care admission should: Identify who has day-to-day responsibili ty to make admission decisions. Include a mechanism for reviewing dif \201 cult cases and dif \201 cult ethical decisions. Identify those who are too well or too sick to bene \201 t from critical care admission (in the context of other facilities available locally). Ide ntify priorities for admission during times of high utilization of beds, e.g. level 3 patie nts admitted as a higher priority than level 2. Identify when, who, and how to transfer pat ients to other units. Identify categories of patients who should or should not be admitted to Critical Care Units, including conditions where admission is mandatory. Identify any age criteria below which admission is precluded. Clarify the links with local incident managem ent policies, contingency plans, and triggers for the implementation of these plans. \200 \200 \200 A critical care consultant should consider the nature and severity of the patient \200\231s illness, the potential reversibility of their condition, the long- and short-term probabil ity of survival, and the wishes of the patient when deciding on Critical Care Unit admissio n. Although patients with \200\230do not attempt resuscitation \200\231 orders or terminal il lness for palliative care may \201 t the criteria for level 2 or 3 care, a clear assessme nt needs to be made on how they would bene \201 t from admission. Admission may be justi \201 ed if there is bene \201 t to the patient in terms of avoiding cardiac arrest or bett er provision of palliation. However, many such patients will clearly not bene \201 t from admission to the Critical Care Unit or from continuation of treatment once admitted. Manage ment of such patients can be dif \201 cult. Local guidance needs to ensure decisions are r eviewed regularly. Mechanisms to share decision-making between several senior members of th e team (sometimes with senior staff uninvolved with the patient \200\231s care) should be i n place given the potential of legal challenge of clinical decisions. CRITICAL CARE UNIT ADMISSION CRITERIA 11 Critical care levels of dependency Level 0 Patients are appropriately cared for in ordinary hospital wards such as are availab le in all acute hospitals and all general departments of surgery and medicine. Patients may need administration of medication, patient- controlled analgesia, intravenous maintenance \202 uids, blood transfusion, and other simple treatments. Observations would usually be required less frequently than every four hours. Level 1 Patients are at risk of their condition deteriorating, e.g. recently relo- cated fr om higher levels of care, requiring additional monitoring or input from staff with speci \201 c expertise. In addition to level 0 requirements, patients may need administration of intravenous \202 uids at rates in excess of 3,000mL/d, and regular but infrequent trachea l suction via a tracheos- tomy. Observations would be required at least every four hours. Level 2 Patients require single-organ monitoring and support, e.g. inotropic support for th e cardiovascular system, renal replacement therapy or non-invasive ventilatory support, pat ients with major uncorrected physiological abnormalities, patients classi \201 ed as Ameri can Society of Anaesthesiologists \200\231 3 or 4 following minor or major surgery, patient s requiring preoperative optimization but not requiring post-operative ventilation. In addi tion to level 1 requirements, patients may need frequent tracheal suction via a tracheostom y tube or rapid blood transfusion (perhaps up to six units in 24h). Level 3 Patients require advanced respiratory monitoring or support, or moni- toring and su pport for two or more organ systems (or one organ system with chronic impairment of at leas t one other). 12 CHAPTER 1 Critical care organization Survivor follow-up Recovery from a critical illness continues for a prolonged period after discharge from hospital, particularly after a severe critical illness involving a long stay . Mortality after hospital discharge is up to three times higher than that of the general p opulation for two to three years after hospital discharge. Patients often experience a vari ety of physical and psycholog- ical symptoms after prolonged critical illness (see table op posite). If not recognized as a sequel to critical illness, this can lead to unnecessary tr eat- ment and investigation, contributing further to their morbidity. Many hospitals are now running critical care follow-up clinics to provide multidisciplinary support to patients after critical illness. These clinics allow patients to gain an unders tanding of their illness. There are usually gaps in the patient \200\231s recollection of e vents. They may suffer hallucinations or delu- sions, or misinterpret events they have patc hy knowledge of. This can lead to frustration and anger. Explanations to complete their kno wledge are very helpful in helping patients come to terms with what happened to them and th is is usually reassuring. Provision of information that helps the patient understand a real istic timeframe for their recovery overcomes any unrealistic expectations they may harbor. The whole family dynamic often changes as a result of a critical illness. Close family memb ers experience anxiety and depression during the critical illness. This changes to a state of overprotection after the illness which can often be frustrating for the patient. A follow-up clinic also gives an opportunity for patients and relatives to provide feedback on areas of care that could be improved to the bene \201 t of subsequent patients. SURVIVOR FOLLOW-UP 13 Typical problems post-critical care discharge Weakness Stress Weight loss Irritability Fatigue Depression Poor appetite and taste changes Anxiety Voice changes Amenorrhoea Insomnia Lack of con \201 dence Skin and nail changes Guilt Itching Poor concentration Hair loss Poor memory Painful joints Social isolation Peripheral neuropathy Sexual problems (Impotence/libido) See also: Outreach support, p8. 14 CHAPTER 1 Critical care organization Patient safety The nature of critical illness makes patients particularly vulnerable. They often cannot communicate or react normally to protect themselves. Normal defense mechanisms are breached by various tubes and catheters, increasing the risk of infection. Complex dru g treatment regimens increase the risk of adverse reactions. Immobility increases the risk of muscle wasting or thromboembolism. It can be unclear whether deterioration in a patient \200\231s condition is a result of the disease or the treatment. Protection in a complex environment The critical care team must deal with an increasing arr ay of data on multiple organ systems, support devices, monitors, treatment, and evidence on which to make decisions. Without some decision support aids, it is easy to miss some issue s, with patient harm as a possible consequence. Decision support in its simplest form inclu des aide memoires to remind the team of what they should be doing. The Fast Hug mnemonic de scribed in the table opposite is one such tool to ensure some of the basics of critical car e are not forgotten. Other aides include communication sheets and structured record systems . One of the most common causes of treatment error relates to drug prescription and administr ation. Electronic prescribing from templates will reduce errors associated with poor handwr iting but these are not foolproof. Learning from mistakes Learning from mistakes is fundamental to the improvement of patient safety. Incident reporting systems are now widespread amongst Critical Care Units to: \200 \200 Ensure action is taken to prevent similar incidents in the future. Ful \201 ll legal dutie s to report certain kinds of accident, violent incidents, dangerous occurrences, and occupa tional ill health. Ensure accurate information is collected to identify trends and take ste ps to prevent similar incidents from re-occurring. Provide evidence in pursuance of litigat ion claims, both for and against the hospital. Record incidents of particular interest for quality assurance, including the ability to demonstrate accident reductions, as part of a r isk management strategy. It is essential that con \201 dentiality is maintained and disciplinary action avoided, ex cept where acts or omissions are malicious, criminal, or consti- tute gross or repeated mis conduct. Deliberate harm Because critically ill patients are vulnerable, the possibility of delibera te harm should be borne in mind. In order to protect patients, staff must undergo pre-emplo yment health and criminal records checks. Staff must be vigilant to ensure visitors are le ft with no opportunity to harm the patients. There must be clear record keeping and review by all members of the multidisciplinary critical care team to ensure unexpected changes in condition are recognized. Because deliberate harm is uncommon, recogni- tion requires a hig h index of suspicion. PATIENT SAFETY 15 Fast Hug Feeding Oral or enteral preferred to parenteral Analgesia The minimum amount to avoid pain Sedation The minimum amount to achieve a calm patient Thromboprohylaxis Low molecular weight heparin 30 head up if not contraindicated In patients in whom eviden ce of bene \201 t Head of bed elevated Ulcer prophylaxis Glucose control Tight glycaemic control protocol Key paper Vincent JL. Give your patient a fast hug (at least) once a day (2005). Crit Care Med 33: 1225 \200\2239. See also: Fire safety, p16; Clinical goverence, p22; Infection control \200\224general prin ciples, p544; Infection control \200\224dangerous pathogens, p548. 16 CHAPTER 1 Critical care organization Fire safety Fires affecting the Critical Care Unit are rare but are particularly dif \201 cult in that patients are not easily evacuated; yet their lives depend on services which \201 re may disrupt. Smoke, while dangerous to staff and the less sick patient who may be b reathing spontaneously, is less of a problem to those receiving mechanical ventilation sinc e their fresh gas supply is from outside the affected environment. Therefore, it follows th at in the event of \201 re, the priority is to ensure safety and means of escape for the staff \201 rst. Control of smoke Smoke and toxic gasses are a common association with \201 re and may, in themselves, be \202 ammable, particularly in association with high concen- trations of o xygen. The main techniques for control of smoke include containment (e.g. \201 re-resisti ng walls, doors, and seals) and dispersal (e.g. positive pressure air supply), the latter b eing used in patient areas. The possibility of \202 ammable or toxic fumes should be cons idered when equip- ping and furnishing the Critical Care Unit. Escape from \201 re \200 \200 Escape routes should be well marked and unobstructed. The nature of critical illness is suc h that not all patients can be evacuated. The staff should escape \201 rst by proceeding to the nearest exit away from the \201 re. Patients should be evacuated in the order of t he least sick \201 rst. Evacuation of patients should be managed by someone trained in th e use of breathing apparatus; in most cases, this will be the \201 re brigade. If patient s are to be evacuated, they should be moved to a place of safety on the same \202 oor as the Critical Care Unit. Patients should not be moved downstairs (or lifts used) unless \201 rst approved by a Fire Of \201 cer. In the majority of \201 res, containment will r educe the need for full evacuation. \200 Preventing \201 re \200 \200 Automatic smoke or heat alarms should be provided in all areas. Cooking areas and laborator y areas must be separated from patient areas by \201 re doors. Fire doors are provided to protect staff and patients, and should not be wedged open. If a closed door would compromi se the care given to patients but is essential to separate \201 re compartments, then an electro-mechanical device should hold the door open and be disabled by the \201 re alarm. Fire extinguishers and blankets of the appropriate types should be readily available and s taff should be properly trained in their use. FIRE SAFETY 17 18 CHAPTER 1 Critical care organization Communication Good communication is essential to the smooth running of the Critical Care Un it. This includes communication between staff, patient, visiting professionals, and relativ es. Patient communication Critically ill patients may still be able to hear bedside conversatio ns despite sedation or apparent unconsciousness. All procedures should be explained to the patient in simple terms before starting, even if they appear to be unconscious. The patient who is not competent to consent to treatment may still appreciate verbal discussion or exp lanation. Multidisciplinary team communication The multidisciplinary approach to critical care involv es medical and non- medical staff in decision-making. Ward rounds are a forum for such inte rdisci- plinary communication, and the specialist leading the round should ensure all prese nt are both truly involved and understand the day \200\231s plan. The plan for the day is m ore likely to succeed if those effecting the plan are involved in setting it. All changes f rom the plan, whether due to unforeseen emergencies or failure of the patient to respond, s hould be fully discussed and documented. Communication with visiting teams The critical care staff should be responsible for the day -to-day care of critically ill patients, including coordinating the input from various non- Critical Care Unit professionals. The admitting team should be involved in major strategy decisions and should be accompanied to the bedside or relatives \200\231 area by a member o f the critical care medical staff. They should be encouraged to write a clear note of their thoughts and proposed man- agement plans in the patient records. Communication with relatives Relatives are often overwhelmed by the environment of a Critic al Care Unit, are worried about the patient, and are easily confused by the infor- mation g iven. Most communication should be face to face, avoiding lengthy discussions on the teleph one. Where several people are imparting infor- mation, differences in emphasis or content s erve to confuse. \200 \200 All communication with relatives should be fully documented. It is essential the bedside nu rse is present when relatives are spoken to since there are often questions and concerns wh ich crop up later that may be directed to that nurse. Relatives have greater contact with t he nurses and often build up a relationship with them. Where admitting teams need to commun icate with relatives about a speci \201 c aspect of the illness, the bedside nurse and, id eally, a member of the Critical Care Unit medical staff, should be present. Most interviews with relatives should be away from the bedside although it is often helpful to impart simp le information at the bedside, particularly to demonstrate particular issues. Again, it mus t be remembered that the patient may hear the conversation. While it is preferable to inter view all relatives together, this is not always practical. Information changes when deliver ed second-hand so it may be better to communicate directly with various relatives separatel y in these circumstances. COMMUNICATION 19 Key paper Pronovost P, Berenholtz S, Dorman T, et al. (2003) Improving communication in the ICU using daily goals. J Crit Care 18: 71 \200\2235. 20 CHAPTER 1 Critical care organization Medicolegal aspects The Critical Care Unit is a source of many medicolegal problems. Patien ts are often not competent to consent to treatment. They may be admitted following trauma, violence, or poisoning, all of which may involve a legal process. Admission may also follow complications of treatment or medical mishaps occurring elsewhere in the hospital. The nat ure of critical illness is such that complications are common and litigation may follow. Consent and agreement Many procedures in critical care are invasive or involve signi \201 cant risk. The patient is often not competent to consent for such treatment and, in many co untries, surrogate consent or assent cannot be legally given by the next of kin. Neverthele ss, it is, important that the risks and bene \201 ts of any major or risky procedure are e xplained to the next of kin and that this discussion is documented in the case records. For major decisions, par- ticularly those involving withdrawal or withholding of life-prolongi ng treat- ments, the patient should ideally be involved in discussions. If not feasible, re latives should be asked to give their view of what the patient would want in this situation although their views should not necessarily dictate decisions, responsibility for which li es with medical staff. Research presents consent problems in the critically ill and requires close ethical committee supervision. Note-keeping It is impossible to record everything that happens in critical care in the pat ients \200\231 notes. The 24h observation chart provides the most detailed record of what h as happened but summary notes are essential. Such notes must be factual without unsubstanti ated opinions about the patient or about previous treatment. All entries must be timed and signed. Records of ward rounds must include the name of the consultant leading the round. T hese notes may be used later in legal proceedings; they may be used against you but, if wel l kept, will usually form the best defense. Errors and mishaps In the event of an error or mishap, the episode should be clearly docu- mented after witnessed explanation to the patient and/or relatives. An apology is not an ad mission of liability but is usually much appreciated, as is explanation in an open and tran sparent manner. Dealing with the police Most police enquiries relate to patients who are admitted after sus picious circumstances. While there is a duty to maintain patient con \201 dentiality, it m ay be in the patient \200\231s interests to impart information about them. This may be with the consent of the patient or the next of kin. Written state- ments or verbal information may be requested. Any information given should be strictly factual, avoiding opinion. Dealing with the Coroner The Coroner must be informed of any death where a death certi \201 cate cannot be issued. Death certi \201 cates can be issued where the death is due to a natural cause and the patient has been seen professionally by the doctor within 14 days prior to death. The table opposite documents the conditions requiring the Coroner to be inf ormed. Where there is any doubt, the Coroner should be consulted. MEDICOLEGAL ASPECTS 21 Deaths which must be noti \201 ed to HM Coroner in the UK No doctor attending within prior 14 days Death without recovery from anesthesia Suicide Sudden or unexplained death Medical mishap Industrial accident or disease or related to employment Violence, accident, or misadventure Suspicious circumstances Alcoholism Poisoning Death in custody or shortly after detention 22 CHAPTER 1 Critical care organization Clinical governance Clinical governance is a framework through which health care organizati ons are accountable for continuously improving the quality of their services and safeguardi ng high standards of care by creating an environment in which excellence in clinical care w ill \202 ourish. For critical care, clinical gov- ernance requires the culture, systems, and support mechanisms to achieve good clinical performance and ensure quality improvement is embedded into the unit \200\231s routine. This includes action to ensure risks are manag ed, adverse effects are rapidly detected, openly investigated, and lessons learned, that go od practice is rapidly disseminated and that systems are in place to ensure continuous impr ovements in clinical care. There must be systems to ensure all clinicians have the right ed ucation, training, skills, and competencies to deliver the care needed by patients. There m ust also be systems in place to recognize and act on poor performance. The Critical Care Unit interfaces with most of the rest of the hospital and its clinical go vernance arrangements must contribute to patient care throughout the hospital. Some aspects of critical illness are managed outside the Critical Care Unit, yet the critical care team retains responsi- bility for ensuring quality and safety of this care. Essential components of clinical governance Clear management arrangements Everyone must kno w who they are accountable to, the limits of their decision-making, and who must be informe d in the decision-making process. Quality improvement Through the process of clinical audit, the standard of practice is moni tored and changes effected to improve quality. Clinical effectiveness Evidence-based practice is essential where sound evidence exists to support clinical decisions. Protocols and guidelines standardize practice. Risk assessment and management A register of clinical risks should be kept, to which new ri sks are appended as they are assessed. An action plan should be developed for managing each risk and its implementation monitored. Staff and organizational development Including continued professional education, clinical s upervision, and pro- fessional regulation. Patient input Complaints monitoring should be used to learn lessons and improve practice wi thin Intensive Care Unit (ICU). Patients \200\231 and relatives \200\231 sugges- tions and surveys can be used to adapt quality initiatives to the needs of patients. CLINICAL GOVERNANCE 23 See also: Audit, p24. 24 CHAPTER 1 Critical care organization Audit Audit has become an essential part of medical practice. The main purpose is to improv e quality of care. In the Critical Care Unit, this should involve all members of the multid isciplinary team. Change in practice in one dis- cipline will inevitably have a knock-on ef fect in others. Audit may involve a review of activity, performance against pre-determined indicators or cost-effectiveness. Audit may focus on speci \201 c topics or may encompass the performance of several Critical Care Units. A successful audit requires commitment from senior staff to ensure practice is de \201 ned, data are collected, and change is effecte d where necessary. Where change is sug- gested by audit, a further review is required to en sure that such change has occurred. Data collection Ideally, a basic dataset should be common to all Critical Care Units nation ally to allow meaningful comparisons to be made. This requires a dataset detailed enough to answer questions posed, but not so detailed that collection becomes unsustainable. Resourc es must be provided in terms of computer databases and staff to collect and analyze data. T his is a skilled task that should not be delegated to junior team members. The data collect or should be familiar with the fundamentals of critical care medicine, and be provided with regular summary reviews to ensure enthusiasm continues and quality control is maintained. Methods of data entry should consider the time involved and that most of those collecting d ata are not keyboard experts. Typographical mistakes destroy the value of collected data so error trapping and data validation must form part of the housekeeping in any database used . Some audit topics require data collection outside the basic dataset. Collecting appropria te data requires clarity in setting the question to be answered and care in choosing data i tems that will truly answer the question. Audit meetings Regular audit meetings should follow a pre-de \201 ned timetable. This help s to ensure maximum staff attendance and also sets target dates for data collection and ana lysis. Audit meetings should be chaired and have de \201 ned aims. Discussion of the topic being audited must lead to recommended changes in practice and these must be followed thro ugh after the meeting. It is clear that all staff cannot attend all meetings. Dissemination of infor- mation prior to implementing proposed changes is necessary to stand some chance of carrying them through. AUDIT 25 See also: Clinical governance, p22. 26 CHAPTER 1 Critical care organization Critical care scoring systems Various critical care scoring systems have evolved to provide : \200 \200 \200 An index of disease severity, e.g. APACHE, SAPS. An index of workload and consumption of re sources, e.g. TISS. A means of comparison for: \200 \200 \200 auditing performance \200\224either in the same unit or between units. research, e.g. evalu ating new products or treatment regimens. patient management objectives, e.g. sedation, pre ssure area care. The Glasgow coma scale apart, no scoring system is practiced universally. APACHE is the predominant severity score used in the USA and UK while SAPS is more popular in mainland Europe. Inter-user interpretation of the same scoring system can be highly vari able. TISS (Therapeutic intervention scoring system) \200 A score is given to procedures and techniques performed on an individual patient (e.g. use and number of vasoactive drug infusions, renal replacement therapy, administering enteral n utrition). Some units use TISS to cost individual patients by attaching a monetary value to each TISS point scored. It can be used as an index of workload activity. A discharge TISS score can be used to estimate the amount of nursing interventions required for a patient in step-down facilities or in the general ward. TISS does not accurately measure nursing work load activity as it fails to cater for tasks and duties such as coping with the irritable o r confused patient, dealing with grieving relatives, etc. \200 SoPRA (System of patient-related activities) The SoPRA score is intended to indicate the sc ope of care (medical, nursing, and other) provided to critically ill patients to assess the intensity of the impact that each patient makes on the daily workload of the Critical Care Unit. Glasgow coma scale First described in 1974, it utilizes eye opening, best motor response, a nd best verbal response to categorize neurological status (see table oppo- site). It is the only system used universally in Critical Care Units though limitations exist in mechanical ly ventilated, sedated patients. It can be used for prognostication and is often used for t herapeutic decision-making, e.g. elective ventilation in patients presenting with a GCS <8.