Introduction to intensive care

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CHAPTER 2 INTRODUCTION TO INTENSIVE CARE

Introduction 18
The multidisciplinary team 18
Daily routine 19
Infection control 19
Assessing a patient 22
Formulating an action plan 25
Medical records 26
Confidentiality 27
Talking to relatives 28
Consent to treatment in ICU 29

INTRODUCTION

Setting foot in an intensive care unit for the first time can be a daunting experience. Many patients are very sick with complex, multi-system problems. Some will die. There may be large arrays of unfamiliar monitoring and therapeutic equipment at the bedside. The following pages are intended to help you survive and keep out of trouble during your first few days on the ICU. Remember, if in doubt ask someone.

THE MULTIDISCIPLINARY TEAM

The care of patients in intensive care is increasingly complex, which precludes all care being provided by a single individual or team. The critically ill patient is cared for in an area where they receive optimum care and input from a number of different specialties. A major role for junior and senior medical staff in intensive care is the coordination of all aspects of patient care, and in particular the maintenance of good lines of communication between the different teams involved. Many nursing, paramedical and technical staff are involved in the care of patients in intensive care. It is important to remember that all these people have skills and experience that you do not. Do not be afraid to ask for advice. If you treat them as colleagues you will get more from them, and remember that the unit is likely to run best when everyone supports each other.

Nursing staff

Many nursing staff in the ICU are very experienced and very knowledgeable. You should see them as allies. Listen to and carefully consider their advice. Remember also that nurses have their own job to do, which is demanding and time consuming. They are not there to run about after you, therefore if you can get something you need, get it and clear up your own mess after you!

Physiotherapists

Physiotherapists provide therapy for clearance of chest secretions. They have an important role in helping to maintain joint and limb function in bed-bound patients, and in mobilizing patients during their recovery. Physiotherapists are also key members of most outreach teams (see below). They can often provide help with the respiratory care and management of patients on general wards who are struggling to maintain adequate respiratory function, and who might otherwise require admission to a critical care unit. Their advice on when to intervene, when to temporize and when it is safe to do nothing is invaluable.

Pharmacists

The nature of intensive care is such that patients will often be on many medications. There is therefore great potential for drug interactions and incompatibility of infusions. In addition, many drug doses need to be modified in the presence of critical illness, either because of potential adverse effects in the critically ill (pharmacodynamic effect), or because their absorption, distribution and elimination may be abnormal (pharmacokinetic effect). These changes are likely to be particularly marked in patients with hepatic or renal failure, and may be difficult to predict. The pharmacist will generally review prescriptions, and is a ready source of advice on all therapeutic matters.

Dieticians

All patients who stay more than a very short time in ICU require some form of nutrition. While basic nutritional support can be provided by standard regimens, many hospitals now have nutrition teams including dieticians, who will tailor regimens to each patient’s particular requirements.

Technicians

A large number of technical staff are involved in supporting the ICU. These include laboratory technicians, renal technicians who manage haemodialysis machines, and equipment service engineers. Cultivate a good relationship with all these people. They can be an invaluable source of help.

DAILY ROUTINE

The daily routine on the ICU will vary from unit to unit. There are typically one or two main business ward rounds during the day, which members of the multidisciplinary team may attend. You may well be expected to see and assess patients prior to the ward round and then to present your findings and action plan on the round. There may also be additional ward rounds during the day as other clinicians and/or results become available (e.g. microbiology).

INFECTION CONTROL

Patients receiving intensive care are, to a greater or lesser extent, immunocompromised and are at greatly increased risk of hospital-acquired (nosocomial) infection. This may result directly from the underlying disease process, as a non-specific response to critical illness, or as a side-effect of a treatment. In addition, multiple vascular catheters and invasive tubes that penetrate mucosal surfaces effectively bypass host defence barriers, and increase the risk of systemic infection. While early appropriate antibiotic therapy is one of the key factors in improving the outcome from sepsis, prolonged use of broad spectrum antibiotics encourages development of resistant pathogens and overgrowth of other organisms.

In most intensive care units, there is a nominated microbiologist who is familiar with the local microbiological flora and resistance patterns of the unit, and who performs a daily round on the ICU to advise on results and antibiotic therapy. This may occur as part of the main multidisciplinary ward round, or form a separate ‘mini round’. It is vital to maintain a close and cooperative relationship with your microbiologist to help you to treat patients with sepsis in an early and effective manner, while at the same time reducing the chances of antibiotic resistant strains of organisms developing.

While patients are most at risk from their own microbiological flora, particularly those organisms associated with the gastrointestinal tract, they are also at risk from organisms transferred from other patients (cross-infection). You must therefore be scrupulous about following infection control procedures.

Dress code

White coats, jackets and neck ties can easily become contaminated and carry microbiological flora from one patient to the next, and should not be worn. (Visiting staff should leave white coats and jackets outside the clinical area.) If you are going to stay on the ICU all day, it is a good idea to wear surgical blues to prevent problems with contamination of clothes. Most units now have a ‘bare below the elbow policy’, which includes removing wrist watches and jewellery. These simple measures help promote effective hand hygiene and may help reduce cross-infection.

Hand hygiene

Effective hand hygiene is the single most effective way to reduce the risk of cross-infection. Therefore, before you go near any patient in the ICU, you should:

image Ensure your hands and finger nails are socially clean. If not, wash them thoroughly with soap and water.
image Decontaminate hands with an alcohol disinfectant rub before and after every contact with a patient or their environment. In practical terms, this means before and after contact with the patient, equipment, monitoring systems around the bed space, plus the patient’s notes and charts.
image Follow local policies on the wearing of disposable plastic aprons and non-sterile gloves.

image Alcohol disinfectant rub is as effective as hand washing at reducing bacterial contamination of the hands. It is not, however, effective against some spore forming organisms such as Clostridium difficile, so hand washing with soap and water may still be required where these types of infection are a possibility.

Moving between patients

Following contact with a patient, remove your plastic apron and gloves, and either wash or decontaminate your hands with alcohol disinfectant rub before leaving the bed space. Do not share equipment between patients in the ICU. For example, stethoscopes are generally provided at each bed space. You should not use your own, which might be a vehicle for cross-infection.

Barrier nursing

Some patients may be isolated because they have a serious infection or are colonized with an antibiotic-resistant organism that might be transmitted to other patients, or even on occasions to members of staff. These patients will be barrier nursed. The basic principles are:

image Do not enter the room unnecessarily.
image Wear an apron.
image Wash your hands and put on gloves.

Other precautions such as the use of visors, masks and gowns will depend on the particular nature of the problem. Instructions for entering the room are generally displayed on the door, and the nurses will help.

image Remove protective aprons, etc. before you leave the room.
image Wash your hands before you leave the room and use alcohol rub once outside the room.

Reverse barrier nursing

Some patients are at particular risk from infection because they are immunocompromised as a result of drug therapy, radiotherapy or immune disease, including HIV infection. These patients are often barrier nursed in a side room to help protect them. The precautions are generally similar to the above. Ask nursing staff for advice if unsure.

ASSESSING A PATIENT

Each patient in the ICU needs to be seen and assessed at least twice a day. Many conventional aspects of history taking and examination are either inappropriate or impracticable. This can seem daunting to the new trainee, particularly given the large amount of information available from charts, monitors and equipment at the patient’s bedside. It is best to develop a system for assimilating key information efficiently, so that you can assess the patient and work out a plan.

History

Make sure you know the patient history in detail. Although the history may often not be available from the patient, there is generally a lot of information available from the notes, from other doctors, nurses or the referring hospital. If in doubt, telephone the referring team and request old notes and records. Take time to speak to family and friends to identify pre-existing health issues and physiological reserve, and try to ascertain the patient’s attitudes to resuscitation and life support. It may be helpful to telephone the patient’s usual doctor (GP, long-term consultant, doctors in another hospital where appropriate) for additional details of the history.

Intensive care units are often staffed using a ‘shift pattern’, and it is relatively easy for misinformation and myth to be perpetuated from one hand over to the next. If the clinical course does not fit well with the supposed diagnosis, question your assumptions and be prepared to go back to the original notes, and check your facts!

Patient’s chart

Looking at the patient’s chart next is an extension of the history. It can be scanned for general trends in the patient’s condition since arrival in intensive care, or examined more closely to give a guide to progress over the preceding 24-h. Important things to note from the chart are shown below.

image Respiratory:

type and mode of ventilation, level of respiratory support

progress made in weaning

blood gases.

image Cardiovascular:

haemodynamic stability

trends in pulse, blood pressure, CVP, stroke volume, cardiac output, inotrope requirements

evidence of adequate organ perfusion (e.g. conscious level, renal output, lactate).

image Gastrointestinal:

nasogastric losses / bowel function / evidence of gastrointestinal bleeding

tolerance of enteral feed (or parenteral nutrition)

surgical drain losses.

image Renal:

fluid intake

volume and quality of urine

overall fluid balance

plasma and urinary electrolytes.

image CNS:

consciousness level

seizure activity

sedation and analgesic requirement.

image Evidence of infection:

temperature / white cell count / C reactive protein (CRP).

Examining the patient

Once you have put together the information available from the history and the patient’s chart, you should examine the patient carefully. Remember hand hygiene and infection control issues. (See Hand hygiene, p. 20.)

image Before examining a patient, you should introduce yourself and explain what you are going to do, even if the patient appears unconscious. Remember that hearing may be the last sense to be lost under anaesthesia or sedation.

Examine the patient systematically, assimilating the information available from the monitoring into your examination findings as you go. A typical approach might be as follows:

image Respiratory system:

trachea central, air entry bilateral and equal, breath sounds, added sounds

check position and adequacy of chest drains, endotracheal tubes, etc.

check type and adequacy of ventilation and ventilator settings

look at the chest X-ray as an extension of the physical examination in ICU patients

it is often helpful to consider blood gases at this stage as well.

image Cardiovascular system:

pulse, blood pressure, JVP, heart sounds, CVP, stroke volume, cardiac output

evidence of adequate perfusion

cold and ‘shut down’ or warm and well perfused

core–peripheral temperature gradient

peripheral oedema

venous / arterial catheter sites–evidence of infection.

image Abdomen:

soft or tender, distended

bowel sounds present

bowels open regularly / diarrhoea / melaena

enteral or parenteral feeding.

image Renal:

urine output

fluid balance

oedema fluid.

image CNS:

level of consciousness

dose and duration of sedative / analgesic drugs; consider stopping to allow assessment of neurological status

evidence of focal neurology / seizures / weakness

does the patient make purposeful movements to verbal command or painful stimulus?

for painful stimulus, press on nail bed or supraorbital ridge (other sites cause bruising)

intracranial pressure and cerebral perfusion pressure.

image Limbs:

adequate perfusion (especially after injury)

presence of peripheral pulses

adequate capillary refill

evidence of swelling, tenderness, DVT or compartment syndrome.

image Skin / wounds:

surgical wounds, and trauma sites, inspection for adequate healing

evidence of infection or discharge

surgical drains, volume and nature of drainage

pressure areas intact.

image Do not just pull dressings down to ‘peek underneath’. Ask the nurse about the state of the wound and if necessary arrange to inspect it formally, either the next time the dressings are changed or earlier if necessary. If appropriate, make sure the surgical team has reviewed the wounds.

Special investigations

When you have examined the patient, you should go back to the patient’s charts and records and check on anything that you have missed. Also review the patient’s important haematology, biochemical and microbiology investigations and other investigations, including CXRs and other radiological investigations.

Prescription charts

Review the patient’s drug, fluid and nutrition prescription chart. Particularly check that any routine stress ulcer prophylaxis and DVT prophylaxis is appropriately prescribed. Are current prescriptions appropriate to the patient’s needs? In particular, are antibiotics still needed? Do any prescribed drugs require plasma level monitoring? Are any of the prescribed drugs likely to interact?

Finally, make sure that you have spoken to nursing staff and other people involved in the care of the patient. Ask for their assessment of problems and priorities, which may be different from your own.

FORMULATING AN ACTION PLAN

When you have finished assessing the patient, record your examination findings and any important results in the medical notes. Summarize your findings by making a brief list of the current problems, for example:

image Increased WCC and CRP. Catheter-related sepsis?
image Haemodynamically unstable. Increasing inotrope requirements. Adequately filled?
image Urine output deteriorating, rising creatinine. Needs renal referral.

Formulate an action plan

Using this approach, you can prioritize problems and formulate a plan of action. In practice, this should be done in consultation with the consultant looking after the ICU. The action plan should include the following:

image Action targeted against problems identified.
image Integrated plan for each organ system requiring support.
image Ventilation and / or weaning plan.
image Nutrition and 24-h fluid balance plans.
image Changes to drug therapy.
image Any further investigations required.

Communication

When you have finished with the patient and detailed your findings and plans in the medical notes, you should tell the nursing staff and others involved in the patient’s care what is planned. In particular:

image Leave detailed instructions and parameters for the manipulation of drugs such as inotropes, which are generally titrated to response (e.g. what is the target blood pressure? Specify systolic or mean).
image Discuss any major changes in therapy or new problems with the referring consultant team.
image Keep the relatives informed of progress.
image Ensure all staff and the relatives up to date with the overall prognosis of the patient. (See Talking to relatives, p. 28.)

MEDICAL RECORDS

The nature of intensive care is such that many different individuals are involved in the care of the patient. At the same time, the patient’s condition may change rapidly, requiring frequent changes in therapy. If everyone is to keep up with the patient’s progress, accurate, contemporaneous note-keeping is essential. It is also worth bearing in mind that medico–legal cases frequently arise where patients have suffered trauma or complications from medical and surgical treatment, and that your record-keeping might therefore be scrutinized in the future.

In many units, the patient’s charts, pathology results, X-rays and prescription charts are now kept electronically or ‘on line’. Whichever system is used, you should record:

image Daily examination and progress notes.
image Interventions and procedures.
image Complications of procedures, which must be recorded accurately and honestly. Complications do occur, and providing you have followed correct procedures, they do not imply negligence. (Failure to record them or act appropriately upon them does!)
image Results of important investigations.
image The patient’s chart is often used to record blood gases, biochemistry, haematology and microbiology results. This is a legal document and therefore the results do not need to be routinely copied into the medical notes. Important positive and negative findings, however, particularly those which carry either diagnostic or prognostic significance, or which directly affect management, should be transcribed.
image It is essential to record the content and outcome of discussion with the patient’s relatives, so that other staff do not give conflicting advice or opinions.

image All entries in the medical records must include date, time, name (printed) designation (i.e. ICU resident / specialist registrar) and signature.

Occasionally, because of the pressure of work in the ICU, it may not be possible to make full notes at the time, for example when admitting and resuscitating a very unstable patient. It is crucial, however, that notes are written at the earliest opportunity, and the fact that they have been written retrospectively should be recorded.

CONFIDENTIALITY

The patient’s medical condition and treatment are matters of confidentiality. While it is generally accepted in intensive care that relatives should be kept informed of what is going on, you must respect the patient’s wishes and confidentiality at all times. Therefore:

image Make sure you know to whom you are talking before giving out any information.
image Avoid discussing a patient’s condition on the telephone. You do not know who is on the other end of the line. The press have been known to telephone and not admit who they are. If a relative lives too far away to make it to the hospital, offer to telephone them back on a previously agreed number.
image Occasionally patients may request that information is not given to one of more of their relatives. This should be respected. If difficulties ensue, discuss with senior staff.
image Never make any comment to journalists. Refer them to your hospital press liaison officer or your consultant.
image Occasionally the police may request information about a patient or request a blood test. Remember that your first duty is to the patient, no matter what he or she is alleged to have done. If in doubt, refer them to your consultant.

TALKING TO RELATIVES

The relatives of critically ill patients may well ask to speak to a doctor about the patient’s condition, or you may ask to speak to them. Discussions with relatives should generally take place in a quiet room away from the patient’s bedside, unless the patient is awake enough to take an active part in such communications.

image Do not talk ‘over’ the patient, who may be aware of the surroundings and able to hear, but unable to communicate back. (Hearing is said to be the last sensory modality to be lost with sedative drugs.)
image Do not talk standing in the corridor; use a side room away from other families.
image Avoid talking to very large groups of relatives. Speak to key members of the family and encourage them to explain things to other relatives.
image It is always advisable to take a nurse with you so that he or she knows what has been said. The relatives will probably only retain a fraction of what has been said to them, and the nurse can reinforce what you have said later. The nurse will also offer comfort and moral support to the patient’s family.
image Adjust the explanation of events to the level of understanding of the relatives, and avoid medical jargon and abbreviations.
image Be honest and not overly optimistic about the ability of intensive care to turn around desperate situations. There are inherent uncertainties about the outcome of any particular disease, and it is best to be cautious rather than attempting to quote probabilities of survival. It is often useful to explain that intensive care offers a level of support that ‘buys time’ for the patient’s body to recover, but may do little to ‘cure’ the patient. Rather, recovery depends largely on the physiological and immunological reserve of the patient.
image Do not criticize other medical or nursing colleagues’ management of the patient. Remember that hindsight is a wonderful thing. Difficult questions or decisions should be referred to senior colleagues or the referring teams.
image Do not let family members push you into making statements that are not true. This is particularly important concerning prognosis. Don’t agree with statements like ‘He is going to be all right isn’t he, Doctor’ if it is not true.
image Record in the medical notes what has been said to the family. This ensures continuity and prevents misunderstandings.
image Accept that relatives will not always absorb bad news the first time they hear it. Time and repeated explanations may be required. Bear in mind that relatives may also be selective about which particular items of your information they choose to retain. Complex psychological issues come into play here, and it is important not to be judgemental. Remember also that different cultural groups respond in different ways to bad news (see Breaking bad news, p. 434).

CONSENT TO TREATMENT IN ICU

Consent is a difficult area in the ICU. Patients have often had no opportunity to discuss intensive care treatment prior to admission. They are admitted on the presumption that they would wish to undergo life-sustaining treatments, if given the choice. The validity of obtaining consent from third parties (e.g. spouses, partners, other relatives, etc.) is questionable in this context. Nevertheless, it is often still considered normal practice to do so. In England and Wales, this position has recently been formalized in the Mental Capacity Act 2005 (Explanatory Notes to Mental Capacity Act 2005 Chapter 9, accessed Feb 2009 http://www.opsi.gov.uk/acts/acts2005/en/ukpgaen_20050009_en_1).

When is consent required?

Patients in the ICU will have repeated interventions performed, for example, tracheal suction, arterial and venous line insertion, and passage of tubes into various orifices. Most units would not seek specific consent for these procedures, but you should always explain to the patient, and the relatives if present, what you are going to do. For more significant invasive procedures like returning to theatre for re-laparotomy, tracheostomy, or insertion of intracranial pressure monitoring, it is usual to seek formal consent whenever possible. If the patient is obtunded but potentially able to understand the treatment being proposed, it may be appropriate to seek consent directly from the patient. If you are in any doubt, seek senior help.

Many patients requiring intensive care are unfit to give consent, that is to say, they ‘lack capacity’ as defined by the Mental Capacity Act 2005. Patients without capacity have the right for major decisions concerning their well-being (and this is includes significant medical interventions) to be referred to an ‘advocate’. In most cases, the next of kin will act as the advocate, even where this relationship is somewhat remote.

You should inform them of the nature of the proposed procedure, the anticipated benefits and likely risks. Where alternatives are available, these should also be discussed. Most hospital consent forms have a section for third party assent, and it is usual practice to obtain it. If the relatives are not present, then it is courteous and avoids conflict to obtain assent over the telephone. Such discussions should always be documented in the notes. If nothing else, this ensures relatives are kept informed and provides an opportunity for an update on the patient’s condition. Relatives do not respond well to news of the death of a patient in the operating theatre when they did not know that an operation was planned!

Where there is no clear next of kin, or where there is conflict between the perceived best interests of the patient and the wishes of the next of kin, UK law provides for an ‘independent mental capacity advocate’ (IMCA) to become involved. These are potentially complex and sensitive situations, which should be referred to your consultant who in turn may refer the matter on to the hospital medical director or other senior manager. If there is continued dispute, application may have to be made to the courts for a ruling as to the patient’s best interest.

COMMON PROBLEMS RELATING TO CONSENT

Jehovah’s Witnesses

Jehovah’s Witnesses have religious objections to receiving transfusions of blood or blood products. Where these views are declared, it is usual practice to discuss with the patient what therapy they will and will not accept, and then to obtain a written disclaimer. The patient is then managed in the appropriate way, but without the use of blood products. The situation in intensive care is difficult if the patient is unable to express his or her view at the time; if there is sufficient evidence of the patient’s religious beliefs, these should be respected. Further advice can be obtained from Jehovah’s Witness liaison committees. These are formed by the Jehovah’s Witness churches on a regional basis, and are extremely approachable and helpful groups. Your hospital chaplaincy should have contact details.

The situation with children is different. The child should be brought under the protection of the courts to decide whether a blood transfusion should be given.

See Blood transfusion, p. 250, and Management of Jehovah’s Witnesses, p. 254.

Advance directives

An increasing number of people are writing so-called advance directives to outline what treatment they would or would not wish to receive in the future, should they be unfit to make this decision at the time. The best known scenarios for such directives come from patients who have progressive neuro-muscular disease or early onset of progressive dementia. Such directives may take the form of a request not to be admitted to intensive care for assisted ventilation in the case of severe pneumonia. In general terms, where these decisions are properly documented then they should be respected.

image At the current time in the UK, while it is accepted that patients have a right to decline treatment, they do not necessarily have a right to demand treatment. There is no onus on medical or nursing staff to provide treatment that they otherwise believe to be unnecessary or indeed harmful just because patients and their families demand it.

Organ donor register

Registry with the national organ donor register and the possession of a signed organ donor card is a form of advanced directive allowing people to outline their wishes regarding potential organ donation after their death. Recent legislation has emphasized the need to follow the patient’s wishes in respect to potential organ donation where this has been properly documented, regardless of the views of the next of kin (see Brainstem death and organ donation, p. 437).

HIV testing

The ethical guidelines on HIV testing are clear. Patients should not be tested for HIV infection without informed consent, which is taken to include adequate counselling both before the test and after a positive test result. The situation in intensive care is therefore difficult, as it is unlikely that informed consent can be obtained. The decision whether or not to perform an HIV test depends therefore on the precise clinical situation.

In most cases, knowledge of the patient’s HIV status does not alter the management of an acute critical illness, and therefore an HIV test should not be performed until the patient is over the acute illness and able to give informed consent.

There are situations, however, where knowledge of the test result may alter immediate clinical management. For example, in the context of a central nervous system infection or cerebral abscess of unknown aetiology, knowledge of the patient’s immune status leads to consideration of a very different range of pathogens and may avoid the need for invasive brain biopsy. In such circumstances it may be reasonable to perform an HIV test without consent, but this can only be justified if there is likely to be direct and immediate benefit to the patient.

The social stigma surrounding HIV infection is reducing, and the benefits of long-term prophylaxis for patients, their families and partners have become well established. As the risk–benefit ratio of testing changes, it is likely that the ethical position will also change, opening the way for a more liberal stance in relation to testing in the future. At the present time, however, HIV testing remains a contentious area. Discuss matters with your consultant and, if necessary, involve the specialists in HIV or GU medicine.

image You should not perform an HIV test for the benefit of staff who consider that they may be at risk from blood contamination. Universal precautions should be adopted for all patients, to avoid occupational risk when dealing with patients’ body fluids. If you receive a needle-stick injury or are contaminated with infected blood, you should follow your local occupational health guidelines. An assessment of the risk of HIV exposure will be made and, if appropriate, post-exposure prophylaxis prescribed. Post-exposure prophylaxis is time critical, and is most effective when started within 4 h of possible exposure. (See Universal precautions, p. 19.)

Consent for post-mortem examination

Issues relating to consent for post-mortem examination and the retention of tissue from deceased patients have generated significant attention lately. These are addressed in Chapter 16. (See Consent for post-mortem examination, p. 435.)

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