Introduction

Published on 10/02/2015 by admin

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Last modified 10/02/2015

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Chapter 1. Introduction

Immediate assessment of the critically ill

ABCDE: Immediate assessment and intervention 2

Early warning: Track and Trigger systems 3

Medical emergency team calling criteria 6

Early warning score (EWS and MEWS) systems 7

This book is concerned with the recognition, assessment and management of acute medical patients during the first 24h of admission. The effectiveness of care during this time will have a major impact on both the immediate chances of survival and the long-term outlook. Delays in initiating treatment costs lives; this has long been known in acute myocardial infarction (the familiar issue of ‘door to needle’ time), but is also the case in other conditions – notably stroke and severe sepsis. The initial care of the critically ill patient has to be targeted and timely.

In order to address this issue, the organisation of the medical care of the critically ill patient has undergone a revolution in recent years. Inter-professional demarcation is being removed, with the development of multidisciplinary teams. The nurses within these teams have extended skills in the recognition and management of the acutely ill medical patient. These teams have a number of overriding principles:

1. Core competencies in the management of the critically ill

2. Immediate access to appropriately skilled team members

3. Effective prioritisation – assessing and treating the sickest patients first

4. Emphasis on the immediate identification of patients who are critically ill, who are deteriorating or who are at risk of deterioration

5. The need to initiate appropriate corrective action and to know who to call for help and with what degree of urgency

6. A reduction in duplication of work such as multiple admission clerking

This process has been facilitated by the development of Early Warning Systems based on simple nursing observations. These should identify patients who require urgent intervention and who may need prompt detailed assessment from the medical staff or, increasingly, from a Critical Care Team. Examples of such teams include Medical Emergency Teams and nurse-led Critical Care Outreach Teams.

ABCDE: Immediate Assessment and Intervention

Immediate survival depends on urgent attention to the safety of the critically ill patient – the Airway, the Breathing, the Circulation. Subsequent progress depends on a more comprehensive assessment – by measuring Disability and Exposing the patient for detailed examination. This plan of immediate action based on the mnemonic ‘ABCDE’ is a recurring theme in the book – emphasising the critical importance of urgent and effective resuscitation. Urgent initial treatment may have to proceed in the absence of a definite diagnosis. However, a detailed assessment will be necessary to make a comprehensive diagnosis and to plan subsequent management; to do this requires a history, examination and an understanding of the underlying medical conditions. Each chapter therefore emphasises both the immediate safety of the patient and the nature, mechanisms and management of the underlying disease. The challenge for the nurse is to integrate this very technically demanding work with a humane and caring approach, combining modern clinical expertise with traditional nursing skills.

The first chapter gives an overview of the initial assessment and the early management which will be necessary to ensure the patient’s immediate survival. Fig. 1.1 provides a summary of the most urgent nursing observations – matched with the corrective interventions that may be necessary – and page references to relevant sections in the book. Detailed descriptions of resuscitation in specific conditions appear in later chapters.