Do Doctors Do it Better by Webb

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Sarah Webb highlights how the upskilling of critical care nursing staff can make for more efficient and effective high acuity care teams.

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  • Good afternoon everyone. My name is Sarah Webb and I’m an Intensive Care nurse at Royal North Shore Hospital in Sydney. Currently I’m working as the Resuscitation Clinical Nurse Consultant.

    Where I work we are incredibly lucky to have such a good relationship with the doctors we work with in ICU. Not only do they encourage multidisciplinary teaching within our unit but they also really encourage the nurses to meet their full potential in all facets of nursing; clinical competence, research, leadership and management and education… which is evidenced by the fact that I have the opportunity to stand before today.


  • Now we all know that the nursing profession has come from humble beginnings. Once upon a time nurses weren’t even allowed to take a blood pressure, insert a urinary catheter, a cannula, or administer medicine.

    Similarly however, the medical profession has undergone some evolution also.

    Over time however medicine has become more complex with ever increasing medical knowledge and advances in technology requiring nurses to assume more and more responsibility to keep up with the workload and maintain patient safety.

    These days an experienced ICU nurse will know how to prime, set up, trouble shoot , monitor performance and manage every single piece of equipment in this room.
    Perhaps this is why reducing nursing ratios in ICU is associated with Increased mortality , Increased mean length of stay, Increased pulmonary and cardiac complications complications and Increased reintubation.

    The critical care nursing workforce is highly qualified with 50-75% having post graduate qualifications in Critical care and more than 80% have ALS accreditation.
  • With the education and training that critical care nurses now receive there are often situations were this is challenged.

    As a nurse working in ICU for about 2 years, when I’m finally feeling like I’m getting the hang of things when one I ask one of our doctors if they would like the ventilation parameters weaned for extubation. I asked would you rather I weaned the PEEP or pressure support first to which he replied “what’s PEEP”. I often think about because it suddenly made me realise that doctors actually are human and can you believe I might even be able to help them learn something about ICU as well.

    This story also really made me think about competence. Who is competent to prescribe the weaning program for this patient?

  • The reality and perhaps the ultimate difference between nurses and doctors is that Doctors have ultimate responsibility of patients. As nurses we like quick ward rounds, clear plans for the day, we hate fence sitting on end of life matters, and we love protocols so we draw on our knowledge of how to do these things. procedures, and guidelines. Where as for the doctors you need to weigh the risks and benefits of your decisions, consider all possibilities of outcome and to do this you draw on your extensive academic knoweldge and breadth of experience. But some of the workload in ICU is predictable and contrary to urban myth actually works best when is based on guidelines and protocols.
  • Myth Number 1, only doctors can lead resuscitation. And by leading resuscitation I mean the delivery of advanced life support algorithms and team management. There was a brilliant PK from an ICU nurse Tamara Hills that exemplifies the importance of effective non-technical skills in Crisis Resource Management. Having worked as the resscitation coordinator at our hsopital, I think experienced ICU nurses have a lot to offer in these situations.

    Not only have expereinced nurses attended training in CRM they also have a lot of experience in these situation usually, inside and outside ICU.

    They know the staff all the staff so they can delegate roles and tasks clearly rather than ‘can someone give the adrenaline”,
    They know the environmnent, not just in ICU but also in cath labs, the wards. So they’ll the nearest blood gas machine is and where the nearest thromoblysis. is kept. As we said earlier they also know how to manage the equipment, be it the balloon pump, the dialysis machine and especially the defibrillator.

    Exerienced ICU nurses are good at anticipating, we’ll often know what you need before you’ve even asked for it… I’m sure all the nurses in this audience would know exactly what this means.

    Perhaps the biggest advantage ICU nurses have in places that I’ve worked in is knowledge of the ALS algorhtyhms. In Australia Critical care nurses are assessed in Advanced Life Support every year.

    This time last year we conducted an audit that looked at als accreditation in our hospital.

  • As you can see, it demonstrated that the nurses are all accredited, barely no doctors and yet we were expecting our doctors to run every medical emergency.


    In light of this SCSSC is now providing fortnightly als courses for our doctors and even our ICU consultants have agreed that they will also attain als accreditation… which is incredibly powerful leadership for the more junior trainees.
  • In general it’s been shown that ALS nurses are on par with ALS doctors in the delivery ALS algorithms

    Experienced nurses contribute to communication, leadership and team
    work, which ultimately impact patient outcomes

  • Myth Number two. Only doctors can prescribe ventilation weaning

    Optimizing ventilation weaning is worth doing because it comprises 40 percent of the duration of mechanical ventilation and it is thought that between 20-30 percent of patients are difficult to wean. Reintubation is associated with a 7-11x increase in hospital mortality making the assessment of readiness to wean particularly important.


    Training
    While ventilation management in general is a key component of ICU medical training, this is also true for nursing training. In fact, within the first three months of working in ICU, a nurse must be able to demonstrate minimum safe practice in caring for a ventilated patient. In post graduate clinical competency, you must be able to demonstrate an advanced level of assessment in respiratory function, intubation, ventilation efficacy, trouble shooting the ventilator, weaning and tracheostomy management.

    Continuity
    One of the difficulties with usual non-protocolised led weaning is the fact that these patients are often in ICU for protracted periods of time but the medical teams will rotate weekly which usually means they need to play catch up to learn where the patient is up, what has been working and what hasn’t worked. The advantage of protocols or case managed is that it enables continuity of care throughout their ICU stay and avoids frequent changes to the weaning plan.


    ICU discharge
    This is especially the case in an ICU sans frontiers model. The corporate or hospital knowledge that experienced nurse brings to case management is a great advantage because they know the the staff, the skill mix and complexities of the ward environments enabling better communication and follow up on ICU discharge.

  • In general the evidence for ventilation weaning supports case management typically advanced practice nurses or multidisciplinary teams, and weaning protocols consistently produce faster ventilator discontinuation times when compared to “usual care”

    And so again, it’s not about being a doctor or not, it’s about having appropriate training, and a service that promotes continuity and consistency.



  • And finally myth number 3, only doctors can insert central lines.

    Due to the technical complexity and potential procedural risk of complications CVC insertion has traditionally been the domain of medical staff usually in ICU or anaesthesia, often supported by interventional radiology.

    However, the use of CVCs and pICCs has increased in recent years due to their aplication in many acute and chronic care settings. This significantly increases in the workload doctors who have other competing clinical responsibilities within their specialty. For these reasons, some hospitals have adopted advanced practice nurse-led models of care which have the advantage of competent and experienced clinicans providing a standardised technique for insertion management and follow up, as well as consistency in the training of other health care professionals.


  • It is already known that the central line insertion complications are reduced when performed by experienced clinicians rather than novices.


    Recently it has also been shown that insertion outcomes from nurse led CVC placement are similar to that of medical practitioner placements and that they can actually improve infection complication sthrough good insertion technique, diligent surveillance and staff education.

    Again it’s not about being a doctor or not, it’s about appropriate training and having a service that promotes consistency in insertion, education and follow up.

  • Despite the relatively slow uptake of critical care nurse practiioners in Australia this maybe about to change in the future.
    With the aging population, advances in technology and a pattern of increasing work for intensivists outside the ICU environment, for example, in ICU outreach and medical emergency teams we may be facing more evolutionary expansion to the nursing role.




  • Well, they certainly do a bloody good job, but I’d like to think it works better when we work together.
  • What I’m talking about today, will hopefully reinforce this principle I hope to show that expereinced and appropriately training ICU nurses can safely increase their scope of practice within ICU. To illustrate this point I will briefly discuss the evolution of nursing and medicine, reflect on the training and education of ICU nurses, assess three facets of ICU care where nurses may just be able to do it better!
  • Do Doctors Do it Better by Webb

    1. 1. Do Doctors do it BEST?
    2. 2. Nursing Medicine Emotional Corporate Procedural Skills Academic Emotional Corporate Procedural Skills Academic
    3. 3. #1 Only doctors can lead resuscitation
    4. 4. 2013 ICU Nurses Emergency Nurses Medical Staff Medical Emergency Responders 92% 97% 2% 5%
    5. 5. #1 Source Purporse Setting Design Findings Gilligan et al. (2005) Do nurses with ALS training provide good team leadership in cardiac arrests? Five UK EDs Prospective quasi-experimental 57 participants in simulated scenarios Nurse’s time to defibrillate were equal to those doctors with ALS training. Recommendation that experienced nurses assume the ALS leader role where a senior doctor is not available. Lin et al. (2009) Is a senior nurse more skillful at resuscitation? 1200 bed metropolitan medical centre, Taiwan Cross-sectional observational study 55 head nurses Age, work experience related to skills in assisting with CPR. Kirk (2006) Review of the Rapid Response Team 10 acute care hospitals U.S. Literature review 13 papers Nursing leadership ensures clear definition of roles and responsibilities. Makinen et al. (2007) Assess resuscitation skills to facilitate an educational program. 2 University Hospitals Sweden and Finland Observational, convenience sample of 150 nurses Nurses trained in resuscitation leadership had superior non-technical skills. Clements & Curtis (2012) Assess the impact of nursing roles in trauma and in hospital resuscitation Australia Literature review 18 papers Nurses involved in trauma and other resuscitations contribute to effective communication, leadership and team work, which ultimately impact patient outcomes.
    6. 6. #2 Only doctors can prescribe ventilation weaning
    7. 7. Authors Method Purpose Setting Findings Garrubba et Literature MDT vs standard care for 3 papers al, 2009 Review tracheostomy weaning UK, Australia Reductions in time to decannulation, length of stay and adverse events. Blackwood et al, 2012 Literature Review Effects of protocol ventilation weaning 11 trials (1971 pts) America, Europe, Australia Reduced ventilation time, weaning time and ICU LOS Ely, 1996 RCT Nurse led protocol vs physician judgment 300 Reduced ICU LOC Kollef, 1997 RCT Nurse led protocol vs physician judgment 357 Safe, reduced ventilation time Krishnan, 2004 Quasi-RCT Nurse let protocol vs physician judgment 299 No difference Marelich, 2000 RCT Nurse led protocol vs physician judgment and standardised approach 335 Reduced duration of mechanical ventilation, reduced VAP #2
    8. 8. O #3 Only doctors can insert central lines
    9. 9. Source Purporse Setting Design Findings Alexandrou Literature Review UK Integrative Literature et al (2009) Review 10 studies No difference in rates of adverse event between a specialist nurse and a medical officer. Yacopetti et al (2010) Compare outcomes of insertions performed by a CNC or anaesthetic doctor 368 CVC insertions Prospective audit No difference in rates of insertion complications. CRBSI rate was higher in the doctor group Alexandrou et al (2011) Patients outcomes or catheter placement services 760 CVC insertions Descriptive statistical for comparison rates and proportions Nurses who are formally trained and credentialed to insert CVCs can improve organizational efficiencies. Alexandrou et al (2014) To report characteristics and outcomes from an advanced practice nurse led CVC service 4 560 CVC insertions Single centre observational study Low complication rates #3
    10. 10. Looking Forward
    11. 11. Do Doctors Do It Best? Teach Empower Ask Mentor
    12. 12. • Churchman JJ, Doherty C (2010) Nurses’ views on challenging doctors’ practice in an acute hospital. Nursing Standard. 24, 40, 42-47. Date of acceptance: March 5 2010. Outline • Clements, A., & Curtis, K. (2012). What is the impact of nursing roles in hospital patient resuscitation? Australasian Emergency Nursing Journal. • Eastwick-Field, P. (1996). Introducing nurse-initiated management of cardiac arrest. Nursing standard (Royal College of Nursing (Great Britain): 1987), 10(26), 46. • Foot, C., Host, D., Campher, D., Tomczak, L., Ziegenfuss, M., Cohen, J., & Nunnink, L. (2008). Moulage in high-fidelity simulation-A chest wall burn escharotomy model for visual realism and as an educational tool. Simulation in Healthcare, 3(3), 1-5. • Gill, F. J., Leslie, G. D., Grech, C., & Latour, J. M. (2012). A review of critical care nursing staffing, education and practice standards. Australian critical care. • Gilligan, P., Bhatarcharjee, C., Knight, G., Smith, M., Hegarty, D., Shenton, A., . . . Bradley, P. (2005). To lead or not to lead? Prospective controlled study of emergency nurses’ provision of advanced life support team leadership. Emergency Medicine Journal, 22(9), 628-632. • Numata, Y., Schulzer, M., Van DerWal, R., Globerman, J., Semeniuk, P., Balka, E., & FitzGerald, J. M. (2006). Nurse staffing levels and hospital mortality in critical care settings: literature review and meta‐analysis. Journal of advanced nursing, 55(4), 435-448. • RPN, R., & Alberto, L. (2006). Consensus Forum: worldwide guidelines on the critical care nursing workforce and education standards. Crit Care Clin, 22, 393-406. • Stein L (1967) The doctor-nurse game. Archives of General Psychiatry. 16, 6, 699-703. References

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