Introduction to intensive care

Published on 27/05/2015 by admin

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Last modified 27/05/2015

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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.

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