Emergency And Critical Care Unit Management

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Emergency And Critical Care Unit Management
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• Intensive care is a young speciality. The first
  purpose-built intensive care unit (ICU) in the UK
  opened in 1964
• ICUs offer potentially life-saving intervention
  during acute physiological crises, with emphasis
  on medical need and availability of technology
• ICU nurses should develop therapeutic and
  humanistic environments which help the patient as
  a whole person towards their recovery

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The patient

• Patients are admitted to intensive care because a
  physiological crisis threatens one or more Body
  systems, and their life. Care therefore needs to
  focus primarily on supporting failed systems.
• Extrinsic needs for
• dignity
• privacy
• psychological support
• spiritual support
• nurses are with the patient throughout their
  hospital stay. A fundamental role of nurses is
  therefore to be with and be for the patient, as a
  whole person

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their relatives

• Relatives, including friends and significant
  others, are an important part of each person's
  life, giving patients courage to struggle for
  survival
• In contrast of the often high-tech focus of
  staff, families of intensive care patients often
  focus on fundamental aspects of physiological
  needs, such as shaving , pain relief and
  communication
• Rather than ruminate by bedsides, afraid to touch
  their loved ones incase they interfere with some
  machine
• relatives should be offered opportunities to be
  actively involved in care without being made to
  feel guilty or becoming physically exhausted.
  Letting relatives participate in care can help
  them psychologically

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• Physiological crises of patients often create
  psychological crises for their relatives.
  Holistic patient care should include caring for
  their families and other significant people in
  their life
• Relatives may be angry. They are usually angry at
  the disease, but it is difficult to take anger
  out on a disease. Instead, anger, complaints or
  passive withdrawal may be directed at those
  nearby, who are usually nurses .
• Relatives often experience unnecessary suffering.
  They may blame themselves, however illogically,
  for their loved one's illness

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• Feeling guilty and distressed, they neglecting
  their own physical needs, such as rest and food.
• Facilities for relatives should include a
  waiting room near the unit, some where to stay
  overnight and facilities to make refreshments
• Relatives need information, both to cope with
  their own psychological crisis and to make
  decisions. They often have a psychological need
  for hope, but with one quarter of patients dying
  on the unit, and additional post discharge
  mortality and morbidity, there may be little hope
  to offer

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• If death seems likely, relatives need to know so
  they can start grieving
• Families may experience information overload, at
  a time they are least able to cope with it
• Communication by staff is often ineffective.
  Printed information can provide useful reminders
  but should not be a substitute for discussion
  relatives need human support and contact.
• Information given should be consistent and should
  be recorded in multidisciplinary notes

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• nurses should be sensitive to both their own and
  relatives' non-verbal cues, such as posture,
  eye-contact and tone of voice
• Of all staff, nurses are best placed to meet
  relatives' needs, yet the needs are not always
  met

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the nurse

• Nurses monitor and assess patients, but they also
  provide care. Assessment is fundamental to
  providing care, but sometimes a excess of
  paperwork prevents care.
• Nurses should collaborate with doctors (and other
  members of the healthcare team). Traditional
  nurse to patient ratios of 11 for UK ICUs are
  higher than in most other countries, but UK ICU
  patients are also sicker .
• The Department of Health (2000) recommends the
  flexible use of beds for level 2 and level 3
  patients. Widely accepted nurse-patient ratios
  for high dependency are 12, which identifies
  should be the maximum number of patients per
  nurse.

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• Psychological stress caused or accentuated by
  intensive care
• dehumanizing nursing can become when machines,
  rather than people, become the focus of
  attention.
• A pragmatic solution to both economic and
  recruitment limitations has been to develop
  support worker roles. Most units employing
  support workers have found they provide valuable
  contributions to teamwork, provided skill mix of
  nurses is not reduced inappropriately

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Stress

• Patients, their relatives and nurses all suffer
  stress.
• Stress is both a psychological and physiological
  phenomenon. Psychology and physiology interact.
• Critically ill patients suffer physiological
  stress from their illness, and psychological
  stress from negative emotions such as fear

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Breaking bad news

• ICU staff often have to break the bad news to
  relatives and friends. Changes may be rapid and
  unpredictable, but if patients are dying their
  family need to be aware of the future grief to
  begin grieving

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management

• Many principles of industrial management or
  managing other healthcare areas are applicable to
  the ICU.
• Vaughan and Pilmoor (1989) suggest that
  management is getting the work done through
  people. A good shift leader is a good team
  leader, enabling other people to do their work.

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• Drucker (1974) identifies five roles for
  managers
• setting objectives
• organizing
• motivating and communicating
• measuring targets
• developing people

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• The shift leader should establish constructive
  working conditions at the start of each shift,
  enabling development of staffs' individual
  strengths and skills, while recognizing
  individual needs and limitations.
• Managers should individually assess and
  proactively plan and respond to needs for each
  shift, rather than seek to impose their own
  schedules on staff.

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• Managers rely on their staff to achieve the work,
  so staff are the shift leader's most important
  resource.
• Staff numbers are important. are there enough
  staff for patients already on the unit and
  expected/potential admissions?

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• abilities and qualities of staff are also
  important.
• Skill mix' is more than simply counting numbers
  of staff at each grade.
• Some staff need more support than others each
  has different experience, knowledge and skills to
  draw on

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• Specific allocation should consider
• maintaining patient safety
• optimizing patient treatment
• developing and supporting staff
• Nurses unable to safely care for a patient should
  not be allocated to their care. Each nurse is
  individually accountable for their actions, and
  should acknowledge their limitations

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• without gaining experience of nursing very sick
  patients, junior staff will be denied
  opportunities to develop their skills.
• If continually denied developmental experience,
  they may become demotivated and leave or be
  unable to care safely for sicker patients when
  more experienced staff are not available

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• two junior nurses may safely manage adjacent
  patients when both are present, but become unsafe
  if caring for two patients through covering each
  other's breaks.
• Nurse managers remain accountable for their
  actions unsafe allocation breaches

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• the shift leader also has wider moral
  responsibilities for health and safety of their
  staff and patients.
• Fire exits should remain clear and accessible at
  all times and safety and emergency equipment
  should be in complete and in working order.
• Emergency equipment varies between units, but may
  include the resuscitation trolley, emergency
  intubation trolley and (on cardiothoracic units)
  thoracotomy pack. Any environmental hazards
  should be minimized, and where possible removed.

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• The shift leader may have to assume direct
  patient care, but this causes role conflict
  between responsibility to the whole unit as shift
  leader and individual responsibility to your
  patient, and limits your availability to other
  members
• It is recommend that the shift leader should not
  provide direct patient care

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• Endacott (1999) identifies four key aspects of
  shift leadership
• presence (availability)
• information gathering (from bedside nurses)
• supportive involvement (e.g. attractive
  equipment, checking drugs, reassuring staff)
• direct involvement (taking over from bedside
  nurses when they are away or unable to cope).

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Staff morale

• Shift leaders are responsible for enabling others
  to achieve their work, so should motivate and
  communicate
• Maintaining staff and unit morale is therefore a
  management priority
• loyal staff are more likely to support shift
  leaders during crises.

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• Democratic or authoritarian leaders use their
  power and authority to achieve goals and
  objectives
• But healthcare is challenged with an philosophy
  of 'blame' culture, which should be replaced by
  one of 'safety
• A safety culture recognizes that errors will
  occur, and so an openness about reporting errors
  allows potential causes to be identified and
  rectified.

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• An alternative approach to management is
  'Transformational' leadership, which seeks to
  transform the culture of care through
• staff empowerment
• practice development
• developing other workplace characteristics

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• Shift leaders therefore need good interpersonal
  skills and respect for their staff.
• Shift leaders seeing unsatisfactory practices
  should approach staff constructively, identifying
  why staff are acting that way (rationale,
  knowledge base)

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• Breaks from work provide a psychological coping
  mechanism. European working time regulations are
  prescriptive about working time, including the
  right to breaks every four hours.
• Delayed, compromised or missed breaks often
  cause dissatisfaction
• Possible conflicts with managerial duties
  (earlier) should be considered, especially if
  relieving for breaks in inaccessible areas (e.g.
  side rooms).

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• The ICU work is unpredictable workload will
  sometimes exceed resources, so shift leaders and
  staff should identify priorities, accepting that
  some lesser priorities are not always achieved
• Ideally, staff should take breaks away from their
  workspace, but busy shifts may sometimes prevent
  this. If full breaks cannot be taken, providing
  refreshments at bedsides (this task could be
  dele- gated) may help staff function safely, and
  maintain morale

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Staffing levels

• Staff levels should be individualized to
  patient/unit needs .
• If shift leaders consider unit, patient or staff
  safety is compromised through inadequate staff
  (or any other problem they are unable to
  resolve), they should inform senior managers, who
  have (higher) responsibility for the unit.
•  

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During the shift

• Staff need to feel confidence in their
  shiftleader.
• While shift leaders usually have more experience
  and knowledge than their staff, each member of
  staff has potential to contribute knowledge,
  experience or values, and shift leaders should be
  prepared to learn from, as well as guide and
  teach, their staff.

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• Shift leaders may be pressurized to accept
  patients 'because there is an empty bed, there
  appear to be enough staff or because' patients
  need the ICU.
• the pressure cannot always be relieved by
  admission to other wards. While medical staff
  must decide whether patients require ICU
  admission, shift leaders must decide whether
  patients can be safely nursed on the unit. This
  decision includes
• imminent shifts
• dependency of patients already on the unit
• skills of staff available

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• Good shiftleaders may inspire loyalty in their
  staff, but being in charge can isolate
  shiftleaders from other support mechanisms.
• Shiftleaders also need their breaks a stressed
  shift leader is less likely to be able to support
  their staff.

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emergency
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Triage

• Triage (pronounced /'tri??/) is a process of
  prioritizing patients based on the severity of
  their condition.
• This rations patient treatment efficiently when
  resources are insufficient for all to be treated
  immediately. The term comes from the French verb
  trier, meaning to separate, sort, sift or select.

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• There are two types of triage simple and
  advanced. The outcome may result in determining
  the order and priority of emergency treatment,
  the order and priority of emergency transport, or
  the transport destination for the patient, based
  upon the special needs of the patient or the
  balancing of patient distribution in a
  mass-casualty setting.

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• Simple triage is usually used in a scene of a
  "mass-casualty incident" (MCI), in order to sort
  patients into those who need critical attention
  and immediate transport to the hospital and those
  with less serious injuries. This step can be
  started before transportation becomes available.
  The categorization of patients based on the
  severity of their injuries can be aided with the
  use of printed triage tags or colored flagging

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• Triage separates the injured into four groups
• 0 The deceased who are beyond help
• 1 The injured who can be helped by immediate
  transportation
• 2 The injured whose transport can be delayed
• 3 Those with minor injuries, who need help less
  urgently

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advanced triage

• In advanced triage, doctors may decide that some
  seriously injured people should not receive
  advanced care because they are unlikely to
  survive. Advanced care will be used on patients
  with less severe injuries.
• Because treatment is intentionally withheld from
  patients with certain injuries, advanced triage
  has ethical implications. It is used to divert
  scarce resources away from patients with little
  chance of survival in order to increase the
  chances of survival of others who are more likely
  to survive.

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The triage categories (with corresponding color
codes), in precedence, are

• Immediate The casualty requires immediate
  medical attention and will not survive if not
  seen soon. Any compromise to the casualty's
  respiration, hemorrhage control, or shock control
  could be fatal.
• Delayed The casualty requires medical attention
  within 6 hours. Injuries are potentially
  life-threatening, but can wait until the
  Immediate casualties are stabilized and
  evacuated.
• Minimal "Walking wounded," the casualty requires
  medical attention when all higher priority
  patients have been evacuated, and may not require
  stabilization or monitoring.
• Expectant The casualty is expected not to reach
  higher medical support alive without compromising
  the treatment of higher priority patients. Care
  should not be neglected, spare any remaining time
  and resources after Immediate and Delayed
  patients have been treated