CONCEPT OF CRITICAL CARE

1. CONCEPTOF CRITICAL CARE PRESENTED BY:- JASPREET KAUR SODHI MSc.FINAL YEAR

2. INTRODUCTION The intensive care unit is not merely a room or series of room filled with patients attached to interventional technology; it is the home of an organization: the intensive care team.

3. THE INTENSIVE CARE TEAM. This team – • Doctor • Nurses • Therapists • Nutritionists • Chaplains and other support staff, builds an environment for healing or dying.

4. CRITICAL CARE NURSING Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems.

5. CRITICAL CARE NURSING Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems.

6. SEVEN Cs OF CRITICAL CARE • Compassion • Communication (with patient and family). • Consideration (to patients, relatives and colleagues) and avoidance of Conflict. • Comfort: prevention of suffering • Carefulness (avoidance of injury) • Consistency • Closure (ethics and withdrawal of care).

7. CRITICAL CARE NURSE A critical care nurse is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care .

8. CRITICAL CARE UNIT • Critical care unit is a specially designed and equipped facility staffed by skilled personnel to provide effective and safe care for dependent patients with a life threatening problem.

9. THE AIM OF THE CRITICAL CARE:- is to see that one provides a care such that patient improves and survives the acute illness or tides over the acute exacerbation of the chronic illness.

10. THE EVOLUTION OF CRITICAL CARE Forty years of development in critical care and critical care nursing has given rise to a recognized speciality in nursing practice . Critical care units have evolved over the last four decades in response to medical advances .

11. HISTORICAL PRESPECTIVES • Florence nightingale recognized the need to consider the severity of illness in bed allocation of patients and placed the seriously ill patients near the nurses’ station. • 1923, John Hopkins University Hospital developed a special care unit for neurosurgical patients . • Modern medicines boomed to its higher ladder after world war 2

13. Bennett, D. et al. BMJ 1999;318:1468-1470

14. Bennett, D. et al. BMJ 1999;318:1468-1470

15. Bennett, D. et al. BMJ 1999;318:1468-1470

16. HISTORICAL PRESPECTIVES • As surgical techniques advanced it became necessary that post operative patient required careful monitoring and this came about the recovery room. • In 1950, the epidemic of poliomyelitis necessitated thousands of patients requiring respiratory assist devices and intensive nursing care. • At the same time came about newer horizons in cardiothoracic surgery, with refinements in intraoperative membrane oxygen techniques.

17. HISTORICAL PRESPECTIVES • In 1953, Manchester Memorial Hospital opened a four bedded unit at Philadelphia was started. • By 1957, there were 20 units in USA and • In 1958,the number increased to 150.

18. CONTEXTUAL FORCES • The expansion of American hospital system and hospital insurance. • Architectural, hospital changes towards private and semi private accommodations. • Reallocations for direct patient care responsibility and creations of new forms of care. • During 1970’s,the term critical care unit came into existence which covered all types of special care

19. TYPES OF ICUs There are two types of ICUs, • An open :-. In this type, physicians admit, treat and discharge and • A closed: in this type, the admission, discharge and referral policies are under the control of intensivists.

20. ICUS CAN BE CLASSIFIED AS: • Level I: This can be referred as high dependency is where close monitoring, resuscitation, and short term ventilation <24hrs has to be performed. • Level II: Can be located in general hospital, undertake more prolonged ventilation. Must have resident doctors, nurses, access to pathology, radiology, etc. • Level III: Located in a major tertiary hospital, which is a referral hospital. It should provide all aspects of intensive care required.

21. STAFFING • Large hospital requires bigger team.

22. Medical staff • Carrier intensivists are the best senior medical Staff to be appointed to the ICU. • He/she will be the director. • Less preferred are other specialists viz. From Anaesthesia, medicine and chest who have clinical Commitment elsewhere. • Junior staff are intensive care trainees and trainees on deputation from other disciplines.

23. NURSING STAFF • The major teaching tertiary care ICU will require trained nurses in critical care. • It may be ideal to have an in house training programme for critical Care nursing. • The number of nurses ideally required for such units is 1:1 ratio. • In complex situations they may require two nurses per patient. • The number of trained nurses should be also worked out by the type of ICU, the workload and work statistics and type of patient load.

24. UNIT DIRECTOR:- Specific requirements for the unit director include the following: • Training, interest, and time availability to give clinical, administrative, and educational direction to the ICU. • Board certification in critical care medicine. • Time and commitment to maintain active and regular involvement in the care of patients in the unit.

25. Availability (either the director or a similarly qualified surrogate) to the unit 24 hrs a day, 7 days a week for both clinical and administrative matters. • Active involvement in local and/or national critical care societies.

26. Participation in continuing education programs in the field of critical care medicine. • Hospital privileges to perform relevant invasive procedures. • Active involvement as an advisor and participant in organizing care of the critically ill patient in the community as a whole. • Active participation in the education of unit staff. • Active participation in the review of the appropriate use of ICU resources in the hospital.

27. NURSE MANAGER • An RN (registered nurse) with a BSN (bachelor of science in nursing) or preferably an MSN (master of science in nursing) degree • Certification in critical care or equivalent graduate education • At least 2 yrs experience working in a critical care unit • Experience with health information systems, quality improvement/risk management activities, and healthcare economics • Ability to ensure that critical care nursing practice meets appropriate standards . • Preparation to participate in the on-site education of critical care unit nursing staff

28. NURSE MANAGER • Ability to foster a cooperative atmosphere with regard to the training of nurses, physicians, pharmacists, respiratory therapists, and other personnel involved in the care of critical care unit patients • Regular participation in ongoing continuing nursing education • Knowledge about current advances in the field of critical care nursing • Participation in strategic planning and redesign efforts

29. Critical Care Unit nursing requirements:- • All patient care is carried out directly by or under supervision of a trained critical care nurse. • All nurses working in critical care should complete a clinical/didactic critical care course before assuming full responsibility for patient care. • Unit orientation is required before assuming responsibility for patient care. • Nurse-to-patient ratios should be based on patient acuity according to written hospital policies.

30. Critical Care Unit nursing requirements :- • All critical care nurses must participate in continuing education. • An appropriate number of nurses should be trained in highly specialized techniques such as renal replacement therapy, intra-aortic balloon pump monitoring, and intracranial pressure monitoring. • All nurses should be familiar with the indications for and complications of renal replacement therapy.

31. RESPIRATORY CARE PERSONNEL REQUIREMENTS • Respiratory care services should be available 24 hrs a day, 7 days a week. • An appropriate number of respiratory therapists with specialized training must be available to the unit at all times. Ideal levels of staffing should be based on acuity, using objective measures whenever possible. • Therapists must undergo orientation to the unit before providing care to ICU patients.

32. RESPIRATORY CARE PERSONNEL REQUIREMENTS • The therapist must have expertise in the use of mechanical ventilators, including the various ventilatory modes. • Proficiency in the transport of critically ill patients is required. • Respiratory therapists should participate in continuing education and quality improvement related to their unit activities.

33. Ideally, 24-hr in-house coverage should be provided by intensivists who are dedicated to the care of ICU patients and do not have conflicting responsibilities. • Ideal intensivist-to-patient ratios vary from ICU to ICU depending on the hospital’s unique patient population. Hospitals should have guidelines for these ratios based on acuity, complexity, and safety considerations. • The following physician subspecialists should be available and be able to provide bedside patient care within 30 mins:

34. PHYSICIAN SUBSPECIALISTS • General surgeon or trauma surgeon • Neurosurgeon • Cardiovascular surgeon • Obstetric-gynecologic surgeon • Urologist • Thoracic surgeon • Vascular surgeon • Anesthesiologist • Cardiologist with interventional capabilities • Pulmonologist

35. PHYSICIAN SUBSPECIALISTS • Gastroenterologist • Hematologist • Infectious disease specialist • Nephrologist • Neuroradiologist (with interventional capability) • Pathologist • Radiologist (with interventional capability) • Neurologist • Orthopedic surgeon

37. OTHER PERSONNEL: A variety of other personnel may contribute significantly to the efficient operation of the ICU. These include:- • Unit clerks • physical therapists • occupational therapists • Advanced practice nurses • Physician assistants • Dietary specialists, and • Biomedical engineers.

38. LABORATORY SERVICES • A clinical laboratory should be available on a 24-hr basis to provide basic hematologic, chemistry, blood gas, and toxicology analysis. • Laboratory tests must be obtained in a timely manner, immediately in some instances. "STAT" or "bedside" laboratories adjacent to the ICU or rapid transport systems.

39. Radiology and imaging services: • The diagnostic and therapeutic radiologic procedures should be immediately available to ICU patients, 24 hrs per day. • Portable chest radiographs affect decision making in critically ill patients.

40. ORGANIZATION OF ICU • It requires intelligent planning. • One must keep the need of the hospital and its location. • One ICU may not cater to all needs. • An institute may plan beds into multiple units under separate management by single discipline specialist viz. medical ICU, surgical ICU, CCU, burns ICU, trauma ICU, etc.

41. ORGANIZATION OF ICU • The number of ICU beds in a hospital ranges from 1 to 10 per 100 total hospital beds. • Multidisciplinary requires more beds than single speciality. ICUs with fewer than 4 beds are not cost effective and over 20 beds are unmanageable. • ICU should be sited in close proximity to relevant areas viz. operating rooms, image logy, acute wards, emergency department. • There should be sufficient number of lifts available to carry these critically ill patients to different areas.

42. ORGANIZATIONAL MODELS FOR ICUs: • the open model allows many different members of the medical staff to manage patients in the ICU. • the closed model is limited to ICU-certified physicians managing the care of all patients; and • the hybrid model, which combines aspects of open and closed models by staffing the ICU with an attending physician and/or team to work in tandem with primary physicians.

43. DEFINITION OF INTENSIVE CARE UNIT EQUIPMENTS:- • Intensive care unit (ICU) equipment includes patient monitoring, respiratory and cardiac support, pain management, emergency resuscitation devices, and other life support equipment designed to care for patients who are seriously injured, have a critical or life-threatening illness, or have undergone a major surgical procedure, thereby requiring 24-hour care and monitoring.

44. PURPOSE • An ICU may be designed and equipped to provide care to patients with a range of conditions, or it may be designed and equipped to provide specialized care to patients with specific conditions

45. DESCRIPTION • Intensive care unit equipment includes:- • patient monitoring • life support and emergency resuscitation devices • diagnostic devices

46. PATIENT MONITORING EQUIPMENTS • Acute care physiologic monitoring system • Pulse oximeter • Intracranial pressure monitor • Apnea monitor

47. Bennett, D. et al. BMJ 1999;318:1468-1470

48. LIFE SUPPORT & RESUSCITATIVE EQUIPMENTS • VENTILATOR • INFUSION PUMP • CRASH CART • INTRAAORTIC BALOON PUMP

49. Bennett, D. et al. BMJ 1999;318:1468-1470

50. DIAGNOSTIC EQUIPMENTS • MOBILE X-RAYS • PORTABLE CLINICAL LAB. DEVICES • BLOOD ANALYZER