University of Canberra/Critical Care Nursing/Resources

General

Here are some links to resources available that give information to help families of critically ill patients.

• The Alfred ICU Visitors page and access to patient information resources

The NHS St Helens and Knowsley Hospitals have developed an Intensive Care Recovery Manual (2009) [1]. This is a terrific resource to help patients and their families as they transition from critical illness and the hard work of recovery and rehabilitation. Do you have a resource like it? Although written for a specific environment it has ideas that can be translated.

Did you know this amazing resource keeps a real time track on the global incidence of disease? Our community travels widely. We need to consider the risks, and teach prevention but also consider that our--Holly Northam (talk) 09:09, 11 August 2012 (UTC) world is 'small' when taking patient histories and performing clinical assessments.

• [2]--Holly Northam (talk) 09:08, 11 August 2012 (UTC)

Nursing Education and Philosophy

• 2005 Position Statement on Provision of Critical Care Nursing Education: Declaration of Madrid
• 2005 Declaration of Buenos Aires Critical Care Nursing Workforce
• 2009 Declaration of Vienna: Patient Rights

Cultural competence

Learning to practice with cultural competence is more than just respecting that we all come from different ancestry. The Critical Care Practice students are being provided with an opportunity to develop an 'end of life' tool kit to empower them to deliver culturally sensitive care which is appropriate for the patient, their family and situation. It is hoped this will help build resiliancy and a sense of fulfillment for the Professionals in being able to meet the needs of those involved.

Here is the presentation which provides an overview

• Cultural Sensitivity in End of Life Care (pdf slides)

The Centre for Culture and Ethnicity [3] provide useful tips and resources for organisations.

Professional Links

• AHPRA
• ACCCN
• ANZICS
• RCNA
• ACT Legislation
• ACT Health Nursing and Midwifery Scholarships
• University of Canberra
• Australian National University
• College of Intensive Care Medicine

Evidence Based Practice

• Cochrane
• JBI

• NHMRC

Scope of critical care practice

Critical care knowledge, skill and practice in Australia and New Zealand includes patient assessment, stabilisation and retrieval from remote environments to emergency departments, intensive care units, and other specialist areas (which you may like to add).

The history of critical care is relatively recent as a specialisation. The Society of Critical Care Medicine provide an overview of the history of critical care from the early days on the battle fields through to contemporary practice. http://www.sccm.org

Some useful international sites include, The Americal Association of Critical Care Nurses, [4] The British Association of Critical care Nurses, [5]

NSW Clinical Guidelines

A new clinical practice site aimed at clinicians [6]

Special Populations

Paediatrics

A paediatric simulation day provided critical care nurses with an opportunity to practice assessing and caring for a simulated deteriorating infant in a safe and supported environment. The close working relationship that exists between the interdisciplinary team as they collaborate to provide 'better' practice was exemplified in the support provided by experts in the field who included a social worker who acted as 'Mum', intensivists, emergency specialist, registrars, paediatric nurse specialist, emergency and intensive care nurse specialists and simulation support from industry.

• 
  Simulating the care of a critically ill child.

The Royal Children's Hospital Melbourne provide Clinical Guidelines for use in a range of situations. An example is the assessment and management of SVT

Pregnancy and post partum

• 
  HumanNewborn

Pregnancies and birth are normal physiological events. In most cases where woman have access to a healthy environment, nutrition and are in good health, the outcomes will be a healthy mother and healthy baby. Unfortunately on some occasions some women will experience events with may include either external trauma/ existing illness/ unrelated events that lead to complicated pregnancy, or they may experience pregancy related pathophysiological changes. The critical care nurse may be required to care for women throughout the period before and after birth in both the emergency department and intensive care environment. From time to time an emergency department or intensive care unit may even be the place that a mother may deliver her infant. Clearly collaborative care is essential throughout these occasions, and excellent multi-professional skilled care is required between the crticial care team and the obstetric team.

The critical care nurse is an extemely important provider of care and enabler in these cases. Having an understanding of what is 'normal' in changed physiological parameters that occur in pregnancy is essential in caring for these women, along with the ability to recognise the risks of critical illness and early clinical signs of deterioriation. There are a range of conditions that can lead to critical illness and a heightened risk of mortality. Preeclampsia is one of these, and closely associated is the HELLP (Hemolysis Elevated Liver enzymes and Low Platelet count) Syndrome. Helpful information resources for both Health Care providers and the community can be found at the Preeclampsia Foundation.

The US based Institute for Healthcare Improvement (IHI) have recently published (October 2012) the culmination of work produced by faculty and participants of the IHI Perinatal Improvement Community, a 'How-to Guide: Prevent Obstetrical Adverse Events'. These guidelines provide recommendations about care bundles related to a range of interventions including the use of oxytocin, vacuum extraction and foetal heart rate monitoring.

The critical care nurse has a pivotal role in guiding ensuring the care of the woman and her loved ones is optimised- the long term consequences of critical illness for this population have implications for not only physical and mental health of the mother, but the health, well-being and relationship between the baby and mother, and her partner. Providing the mother with every opportunity to establish breast feeding and bonding with her infant from birth, 'skin to skin' contact between 'mum and bub', and enabling her partner to be supported and empowered throughout this time is a major feature of ongoing care and recovery.

Sepsis

7th Sept 2012, The ACCCN advises that "The World Sepsis Declaration calls on the world to take immediate steps to reduce the global burden of sepsis securing the provision of resources and political backing for the priority actions needed to achieve them.

On September 13th the first World Sepsis Day will be launched worldwide as one of the initiatives of the World Sepsis Alliance in which ACCCN is a member, to improve both public and professional awareness of sepsis as a leading cause of death worldwide."

The official website has resources as does the Facebook page.

Kaye Rolls and ICU Connect (7th Sept 2012) highlight that Sepsis kills more people per 100,000 than stroke, MI and cancer. For the last 2 years NSW CEC has been running a 'Sepsis Kills' program aimed at implementing the Sepsis clinical pathway The sepsis pathway promotes: • Early flagging of severe infection and sepsis • Early involvement of senior clinicians in diagnosis and management of sepsis • Appropriate and timely fluid resuscitation • Prompt administration of antibiotics (within one hour) • Serum lactate monitoring • Referral of care to appropriate clinical teams including retrieval if appropriate A 2005 Victorian study, 'The microbiology and outcome of sepsis in Victoria, Australia,' by Sundararajan et al provided insights into the burden of sepsis in the Australian context and some of the possible causal organisms.

Trauma Care

NSW Health Institute of Trauma and Injury Prevention Institute, Trauma Clinical Practice Guidelines and other resources including:

• Management of hypovolaemic shock in the trauma patient • Emergency airway management in the trauma patient • Management of haemodynamically unstable patients with a pelvic fracture NSW Head injury Guidelines

Fluid replacement

• Australian blood transfusion guidelines were updated in June 2012.

Respiratory Care

Understanding and recognising 'normal' can be very challenging when completing physical assessment if the context of the patients age, gender and history are not considered. We know the anatomy and physiology of each person transforms across the 'normal' life span from the infant to the adult, through to the elderly. The implications of respiratory pathophysiology must always be interpreted in the context of age, weight and existing conditions- understanding the context of the problem guides the person's care and clinical management.

A useful overview of respiratory failure can be found in this 2012 medscape article [7]

Some sites,

• American Association for respiratory care, [8]
• ARDS Network, [9]
• Australian Lung Foundation [10]
• Lung Health Promotion Centre, the Alfred Hospital, Victoria [11]
• National Asthma Council of Australia, [12]
• Learning Radiology chest xrays, [13]
• Learning radiology [14]
• Chest x-ray atlas, [15]
• Critical Care Medicine Tutorials, [16]
• Fisher and Paykel Respiratory and Acute Care, [17]
• NHMRC Ambient air quality standards setting [18]

Cardiovascular Care

We rarely think about the possibility of arrhythmia's in paediatric presentations. Research published in the Emergency Medicine Journal (2012) examines 'Paediatric arrhythmias in the emergency department' [19]. The needs of the critically ill child are explored in more detail by clicking here.

• Learning radiology offer some great resources on cardiac lectures and xray assessment[20]

• Student nurse connections have this terrific collection of cardiovascular nursing resources [21]

One of the most important aspects of performing ECG's in the first instance is safe care of the patient throughout the procedure and correct placement of the leads before and during the assessment. It is really important to have good contact between the patients skin and 'dot's that connect the leads. It is also extrememly important to perform serial ECG's using the original 'dot' placement so that any ECG changes can be detected. The time, date and patients name must always be documented when performing the ECG along with any relevant clinical information.

The ECG Library provides an overview of recordings and examples of the impact of pathophysiolocial changes upon the conduction through the heart. The USC ECG Learning Center provides lots of opportunites to practice reading ECG's. ECG quizes and teaching materials can be found at the ECG Learning Center and at ECG Quiz. Another useful rhythm identification resource.

The Heart Rhythm Society provides a range of resources on arrhythmia and cardiac devices along with other useful information. An extraordinary use of social media- a generous 56 year old patient allowed for the real time video and tweeting of his cardiothoracic surgery.These images provide a useful insight into the standard routine of the surgical process.

CTS Net, the cardiothoracic Surgeons site, provides some information that helps in understanding the current practices. These wikiversity images and links provide a much better insight into the practice of cardiothoracics surgery.

Integumentary Failure

Our skin is our largest organ and makes up roughly 7% of total body weight [22], and when it fails the consequences can be catastrophic.

Wound Care

• The Australian Wound Management Association [23]
• European Pressure Ulcer Advisory Panel [24]
• Healthinsite Wound Care [25]
• 2010 Article on 'Abdominal Wound Dehiscence in Adults: Development and Validation of a Risk Model' [26]

Burns Care

Caring for burns requires expertice. The Royal Childrens Hospital Melbourne have Clinical Practice Guidelines [27] and parent information sheets.

The NSW Agency for Clinical Innovation 2011 Guidelines are extremely helpful [28]

The Cochrane Library Evidence Resources for Burns [29]

Psychological Care: In hospital

The skills required to provide competent psychological care for patients (and their loved ones) who face the experience of critical illness, are increasingly being recognised as essential to long term recovery. An increased recognition of the potential for harm that arises when patients experience anxiety, pain, delirium, over-sedation and sleep deprivation, has led to a number of interventions to improve long-term patient outcomes. These include the introduction and validation of assessment tools, efforts to improve communication and include family presence, and judicious use of pharmacotherapy.

Delirium

ICU Delirium and cognitive impairment study group [30]

Sleep

Australasian Sleep Association [31]

Psychological Care: Pre-hospital, Remote locations and Emergency

A range of mental health issues can lead to life threatening conditions. In the same way that early detection of the deteriorating patient can lead to early intervention and patient rescue, skilled assessment in the pre-hospital environment or emergency department may provide opportunites for specialist care to protect the patient from further harm. The loved ones of the critically ill patient are also at risk of developing stress related illness, holistic care should encompass strategies to support the family.

Mental Health First Aid 'is the help provided to a person developing a mental health problem or in a mental health crisis'. This program is highly recommended [32]

Disaster Management

• Cochrane resources for earthquakes [33]

Transitioning to end of life care

Can we can improve the the end of life experience for dying patients and their families? It is not uncommon for patients to die in the Emergency Department. On some occasions this is unavoidable; however, on many occasions the best interests of the patients are not being met, and the quality of the experience is diminished. This article raises some important points about managing the patient journey. Is it time to rethink our policies and the way we manage our resources?

• [34]

How do we define a good death? How does the expertise of skilled palliative care align with our practice in caring for critically ill people both in the critical care environment of intensive care, the emergency department or when being transfered from their homes to hospital? A just published care bundle 'Improving palliative care: the care and communication bundle' is a useful guide to improve the experience for all involved in caring for patients at end of life in the intensive care environment.

• The Australian and New Zealand Intensive Care Society and College of Intensive Care Medicine of Australia and New Zealand have a Statement on Withholding and Withdrawing Treatment which you may find helpful [35]

• A Canadian Virtual Hospice offers on-line resources that may help you when thinking about innovative care strategies. It is designed for most importantly those who are requiring hospice care and their families, but also an excellent range of resources for Professionals. [36]

• Palliative Care Australia [37]

Resources to help people autonomously define what interventions they would like to sustain their life and to give guidance to healthcare providers can be found in 'A National Framework for Advance care Directives' [38]

Organ and tissue donation

End of life care should always include opportunites for compassionate and respectful discussion about the dying persons wishes regarding organ donation. This is an area of practice that requires excellence in communication skills, and accuracy in the information. I am including helpful resources here.

• Dr Deb Verran, specialist transplant surgeon and social media expert, 'Scoop it' site[39]

• For many people with chronic disease and organ failure, transplantation is the only hope. In this clip, a young man with heart and lung failure from pulmonary hypertension, tells it the way he's experiencing it. [40] As health care professionals, and knowledge experts we have a powerful responsibility to strongly advocate for improvements in organ donation rates, and to provide information support and empowerment to those considering the decision to donate. Tianna Formosa, a 16 year old with the congenital heart defect Eisenmenger Syndrome, discusses her experience of critical illness and the challenges and benefits experienced in receiving her heart lung transplantation.

• What is the difference between organ and tissue donation? The Conversation ran this explainer about tissue donation, [41]

Many Australians hope to help others when they die by donating their organs and tissues. They are encouraged to tell their families, but they can also give their approval to donate organs and tissues of their choice by registeriing on Australia's national organ donor register [42], a secure data based which may be accessed by specially approved health professionals (usually organ donor coordinator nurses) at the time of death.

Australian organ donation rates remain low at 15.1 donors per million population (dpmp) in 2012 (adjusted to new census data), when benchmarked against international 'best practice' of Spain with 33- 35 dpmp [43]. The Australian and New Zealand Organ Donor Registry (ANZOD)[44] provides a month by month update on the numbers of organ donors, organs donated and transplanted. The number of patients on the waiting list can also be found on this site.

• The NHMRC provide recommendations for both health professionals and the public about considering organ and tissue donation [45]

The 'ANZICS Statement on Death and Organ Donation' and the 'ANZICS Statement on withdrawing and withholding treatment' provide guidance to the critical care community from the perspective of the Intensivist. [46] The National Protocol for Donation After Cardiac Death guideline which was developed for Australian practice and informs the policies implemented in hospitals around Australia [47]

• Donatelife has responsibility for managing and supporting organ and tissue donation in Australia [48]

ATCA is the Australasian Transplant Coordinators Association and they are the professional group representing donor coordinators. The ATCA guidelines [49] are used in conjunction with the Transplantation Society of Australia and New Zealand (TSANZ) organ allocation protocols [50] to guide the processes of organ donation and transplantation.

The process of organ donation surgery requires the expert skills of the anaesthetist. Because the patient has died, it is not possible to donate for transplantation unless the intensive care unit use their skills and expertise to try to maintain the function of the organs. This is extremely difficult and requires specialist skills and care. After the family has had the opportunity to complete their farewells to their loved one, and when the transplant team has arrived and are ready in the operating theatre, the deceased patients care and efforts to preserve the organ function become the responsibility of the anaesthetist and the anaesthetic nurse. Dr Russell, an anaesthetist in the US provides an excellent overview of the pathophysiology that affects the organs of brain dead patients who have circulation and ventilation maintained before organ donation. He also provides evidence based recommendations about the care that can help preserve organ function. The term 'harvest' is a term that has been associated with organ donation, but is not encouraged in Australian practice. This is in deference to the expressed wishes of donor families.

'Hot' topics, news and blogs in critical and emergency care

• 'Life in the fast lane', a commentary and resource blog [51]
• 'ICU Connect', it started in NSW and now has an international following [52]
• Canberra's living legend, Ian Miller's 'Impacted Nurse' [53]
• Case Reports in Anaesthesia has some terrific resources including 'Pain Powerpoint, Anatomy and Physiology of pain,' ventilation and other insights [54]