Critical Care Outreach

1. Critical Care Outreach Critical Care Outreach Team Leeds Teaching Hospitals Trust

2. Learning Outcomes • Understand Critical Care Outreach • Understand NEWS and its use • Be able to assess a patient using ABCDE approach

3. Critical Care Without Walls • Review of Critical Care Services by Department of Health in 2000 • Bringing critical care expertise to patients in ward environments • Prevent acute deterioration and provide timely transfer to critical care environments • Supporting patient rehabilitation following discharge from critical care • Education of hospital staff involved in patient care

4. Critical Care Outreach Team • Senior nursing staff with extensive critical care experience • Nurse led service with dedicated ICU Consultant available for Outreach Team

5. Outreach Service Availability at LTHT • 08:00 - 20:00 at SJUH • 08:00 - 18:00 at LGI • Overnight outreach cover is provided by ICU team.....currently • Contactable by bleep or ask for outreach office at LGI and SJUH

6. Outreach in practice Assessment and review of patient using: • ABCDE assessment of patient • History and clerking notes • NEWS recording • Fluid balance • Blood results, radiological reports eg CXR, ECHO • Level of care required and ceilings of care

7. Right Patient - Right Bed • Level 0 - Ward based care IVI and b.d obs • Level 1 - Patients needing additional clinical input e.g. continuous oxygen, chest drains, 4 hourly observations, GCS 4 hourly • Level 2 - Patient requiring single organ support eg more than 50% O2, CPAP or BIPAP, vasoactive drug infusions, hourly observations for potential deterioration • Level 3 - Advanced respiratory support or more than one organ failure

8. National Early Warning System • Track and Trigger system of recording physiological parameters to detect changes in patient’s condition • Score aggregate has a graded response to alert senior clinical input and increase frequency of observations • Measures six physiological parameters but unusual stand alone changes should also trigger a response eg reduction in AVPU

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12. ABCDE - a reminder • Airway - Patency, O2 (15 litres NRB) • Breathing - Examine, O2 saturations, RR, Auscultate , ABG, CXR • Circulation - Examine, Pulse, BP, CRT, IV access, Bloods, Fluids • Disability - AVPU, Pupils, BM, GCS • Exposure - Temp, Rash, Abdomen, Bleeding, Legs, drug charts, history, all results

13. Patient Scenario Jane is a 55 year old lady who has had a temperature following her laparoscopic cholestectomy two days ago She has been on ward post - operatively feeling unwell. You are asked to see her as her NEWS is high and your senior is in theatre…

14. Assessment • A – patent • B – RR 28, SaO2 88%, increased work of breathing, coughing++ • C – HR 136bpm, BP81/46 CRT 4 secs, T 39.4 • D – Alert but drowsy • E – Feels thirsty, not on any medicines. Bowel sounds present – bowels opened yesterday, wound sites dry. Calves SNT • A – Oxygen 15l NRB • B – Auscultate then consider ABG and CXR and sputum sample for m,c&s • C – IV access, bloods, fluid challenge, 12 lead ECG, - is she passing urine? • D – GCS, pupils and glucose • E – NEWS = 11 Review notes/Op notes/ Drug Chart? Blood results, BUFALO, fluid balance chart started ?catheterise

15. What needs to be done? • ABCDE approach • What investigations are you going to do and in what order! • What would you like the nursing staff to do? • Who needs to know about this lady?

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17. NEWS > 5….Does your patient have: Systemic Inflammatory Response Syndrome 2 or more signs of inflammation: • T >38 or <36 • HR >90 • WCC>12 or <4 • RR>20 • Altered conscious level • BM >7.7 (if not diabetic) If patient is neutropenic then just 1 of the above Sepsis? SIRS AND clinical evidence of infection Red Flag Sepsis SBP <90mmHg despite fluid challenge Lactate >2mmol/l Heart Rate >130/min Respiratory Rate >25/min Oxygen Saturations <91% Responds to Voice/Pain or Unresponsive Purpuric rash

18. BUFALO in Sepsis

19. New plans for the patient? • Outreach referral + senior review • Review NEWS, blood results, CXR, ABG • Urinary catheter • Further fluid resuscitation - how much? • Has she had his antibiotics yet? • What level of care do they need?

20. The End Result • This patient responded well to IV fluids and antibiotics her NEWS reduced to 4. • She stayed on the ward with outreach support. • She was discharged home with oral antibiotics after 4 days.

21. Summary • Use the assessment checklists and skills you have been provided with • Get support from your seniors and outreach sooner rather than later • Document, document, document

22. References • Standardising the Assessment of Acute Illness Severity in the NHS:‘Recommendations for a NHS Early Warning Score (NEWS)’. A report from the Royal College of Physicians: July 2012 • National Patient Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospitalised patients London • Department of Health (2000) Comprehensive Critical Care: A Review of Adult Critical Care Services London, Department of Health http://www.doh.gov.uk/pdfs/criticalcare.pdf