critical care nursing

1. CRITICAL – Criteria of
Admission & Role of Nurse
1
Prof. Dr. Ram Sharan Mehta, MSND, CON, BPKIHS

2. Objective Parameters Model for ICU admission
Vital Signs
• Pulse < 40 or > 150 beats/minute
• Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the
patient's usual pressure
• Mean arterial pressure < 60 mm Hg
• Diastolic arterial pressure > 120 mm Hg
• Respiratory rate > 35 breaths/minute
Laboratory Values (newly discovered)
• Serum sodium < 110 mEq/L or > 170 mEq/L
• Serum potassium < 2.0 mEq/L or > 7.0 mEq/L
• PaO2 < 50 mm Hg pH < 7.1 or > 7.7
• Serum glucose > 800 mg/dl
• Serum calcium > 15 mg/dl
• Toxic level of drug or other chemical substance in a
hemodynamically or neurologically compromised patient
Prof. Dr. R S Mehta, BPKIHS 2

3. • Radiography/Ultrasonography/Tomography (newly
discovered)
• Cerebral vascular hemorrhage, contusion or subarachnoid
hemorrhage with altered mental status or focal
neurological signs
• Ruptured viscera, bladder, liver, esophageal varices or
uterus with hemodynamic instability
• Dissecting aortic aneurysm
• Electrocardiogram
• Myocardial infarction with complex arrhythmias,
hemodynamic instability or congestive heart failure
• Sustained ventricular tachycardia or ventricular fibrillation
• Complete heart block with hemodynamic instability
Prof. Dr. R S Mehta, BPKIHS 3

4. • Physical Findings (acute onset)
• Unequal pupils in an unconscious patient
• Burns covering > 10% BSA
• Anuria
• Airway obstruction
• Coma
• Continuous seizures
• Cyanosis
• Cardiac tamponade
Prof. Dr. R S Mehta, BPKIHS 4

5. Prof. Dr. RS Mehta, BPKIHS 5
Role of
Nurses in
ICU

6. • ICU nurses play a vital role in the patient’s care,
including the following:
– Taking regular blood tests
– Changing the patient’s treatment in line with test
results
– Giving the patient the drugs and fluids that the doctors
have prescribed
– Recording a patient’s blood pressure, heart rate and
oxygen levels
– Clearing fluid and mucus from the patient’s chest using
a suction tube
– Turning the patient in his or her bed every few hours
to prevent sores on the skin
Prof. Dr. RS Mehta, BPKIHS 6

7. Contd…
– Cleaning the patient’s teeth and moistening
the mouth with a wet sponge
– Washing the patient in bed
– Changing the sheets
– Changing a patient’s surgical stockings, which
help circulation when he or she is inactive
(lying still) for a long time
– Putting drops in the patient’s eyes to make it
easier to blink
Prof. Dr. RS Mehta, BPKIHS 7

8. Monitoring the patients in ICU: Summary
• Decrease anxiety & fear: reassure, sedation
• Assess: all physiological parameters
• Inspect & examine pt.: LOC, secretions etc.
• Vitals : TPR BP RR HR Pao2, paco2, urine output
• Weight gain
• Capillary refill: 3-5 sec
• Phy. Exam: head to toe & systematic
• ETT, Airway, subcutaneous emphysema, chest tube,
• Skin temp, gastric distention
• All relevant Laboratory reports: ABG, BUN, LFT etc.
Prof. Dr. R S Mehta, BPKIHS 8

9. Responsibilities of critical care nurse
 Critical care nurses are responsible for making sure that
critically ill patient and members of their families receive close
attention and the best care possible.
 Foremost, the critical care nurse is a patient advocate. AACN
(American Association of Critical-Care Nurses) defines
advocacy as respecting and supporting the basic values, rights
and beliefs of the critically ill patient.
 Critical care nurses practice in settings where patients require
complex assessment, high-intensity therapies and
interventions and continuous nursing vigilance.

10. Responsibilities of critical care nurse…
 Critical care nurses rely upon a specialized body of knowledge, skills
and experience to provide care to patients and families and create
environments that are healing, humane and caring.
 Respect and support the right of the patient or the patient's
designated surrogate to autonomous informed decision making.
 Help the patient obtain necessary care.
 Respect the values, beliefs and rights of the patient.

11. Responsibilities of critical care nurse…
 Intercede for patients who cannot speak for themselves in
situations that require immediate action.
 Monitor and safeguard the quality of care the patient
receives.
 Act as a liaison between the patient, the patient's family and
other healthcare professionals.

12. Role of Nurses in ICU
Roles of
Critical
Care
Nurse
Advocator
Educator
Collaborator
Coordinator
Manager
Nursing care
provider

13. PATIENT SAFETY AND QUALITY CARE
IN INTENSIVE CARE UNIT

14. Patient safety
S- sense the error
A- act to prevent it
F- follow safety guidelines
E- enquire into accidents/death
T- take appropriate remedial measures
Y- your responsibility

15. Why safety concerns are more in
critical care ???
 Complex environment with potential patient safety challenges
 Vulnerability of being exposed to incidents as a result of
severity in conditions
 High complexity care with involvement of multi disciplinary
teams
 Failure of team performance

16. Some Nursing Quality Indicators
 Patient fall
 Medication error
 Needle Stick injury
 Health care associated infections
 Pressure Sore
 Hypoglycemia
 Phlebitis

17. PARAMETERs THAT INDICATE
QUALITY CARE

18. 1. Mortality
Standardized mortality rate (SMR) or risk adjusted
mortality rate
 Mortality rates are not often the indicators of performance
even if those are often referred to. However, mortality rate
related to prior prediction is a sensitive indicator for
comparison.
 SMR allows comparison of actual performance of the
institution with predicted performance, based on the average
mortality as expressed by national or international data.

19. Formula:
• Risk-adjusted Mortality = (Observed Rate/Risk-adjusted
expected Rate) X100
• Observed rate = Actual death in ICU/institution.
• Risk adjusted expected rate = Predicted death rate by
predictive Model

20. 2. Morbidity
Iatrogenic Pneumothorax
 Associated mortality and morbidity, prolonged stay, cost implications.
Formula: (Number of pneumothorax / Number of cases) X 1000
Incidence of severe Acute Renal Failure in noncoronary ICU
 Renal failure increases possibility of death (60.3%) notwithstand
whether renal replacement therapy has been initiated.
 Even a modest increase in the serum creatinine level (0.3 to 0.4 mg
per deciliter increases risk of death by 70% when compared to
normal creatinine levels.
 Number developed severe renal failure/Number managed in ICU X
100

21. Decubitus (Pressure) ulcer
 Prolonged uninterrupted pressure over bony prominences
causes necrosis and ulceration.
 Stage 1 indicates superficial color change, Stage 2 represents
partial thickness skin loss, Stage 3: full thickness skin loss, and
Stage 4 denotes deep and extensive tissue damage involving
muscle, tendon or bone.
 Hip and buttock sores represent 67% of all pressure sores.
Formula: Number of pressure ulcers / Number of cases X 1000

22. 3. Operational or Process
Length of Stay (LOS)
• ICU beds are limited in any hospital. Rationalized use for
needy patients therefore is necessary.
• LOS is, therefore, used to assess quality of care and resource
utilization.
Formula: Total occupied bed days / number of patients in a
given time frame (weekly/monthly /yearly)

23. Compliance to protocol
 Selected guidelines, protocols, treatment bundles in the unit
to improve patient care, resource utilization, and reduce
iatrogenic complications.
 Compliance to protocols, guidelines and treatment bundles
are expected to improve patient care.
 Formula: Number of times followed/ number of times
expected to follow × 100

24. ICU readmission rate
• Readmission to the ICU within 24 hrs of transfer during a
single hospital stay. This is an indicator of post ICU care.
• A higher readmission rate indicates premature decision to
shift out patients.
• Formula: (Number of readmitted patients/ Total patients
managed in ICU) × 100

25. 4. Error and Patient Safety
Patients' Fall Rate
• An untoward event, which results in the patient coming to
rest unintentionally on the ground or another lower surface.
• This is a safety issue for a patient in ICU. Accidental fall could
lead to morbidity, prolonged stay and customer
dissatisfaction.
• Formula: fall rate = (no. of falls/no. of bed days) × 1000

26. Medication error
• Description Medication error could be due to wrong
prescription, dosing or communication gap (verbal or written)
• These errors may caused significant patient harm (eg. injury
requiring treatment, prolonged hospital stay, and death.)
• Medication error rate = (no. of error /no. of bed days) × 1000

27. Adverse Events/Error Rate
 Common ICU errors are related to treatment, procedure,
ordering or carrying out medication orders, reporting or
communication, and failures to take precautions or follow
protocols.
 Critically ill patients are at high risk for complications due to
the severity of medical conditions, complexity of treatment,
poly pharmacy and technology based interventions.
 Nearly all ICU patients suffer from potentially harmful events.
Nearly half (45%) of the adverse events are preventable.
 Adverse events/ error rate = (no. of error /no. of bed days) ×
1000

28. Needle Stick Injury Rate
 A penetrating stab wound from a needle (or other sharp
objects) that may or may not be associated with exposure to
blood or other body fluids
 Needle stick injuries can cause transmission of blood borne
pathogens. Needle stick injury can occur due to faulty
handling of needle, syringe with needle, suture needle,
recapping of needle, and faulty disposal. Annual incidence
ranges from 600,000 to 800,000 at global level.
 Formula: Incidence per 10,000 venipunctures

29. Reintubation Rate
 Reintubation within 48 hours of extubation
 Accidental extubation and subsequent reintubation can lead
to prolonged stay, longer ventilation and higher nosocomial
pneumonia and mortality.
 (Number reintubated/ Number extubated) × 100

30. 5. Infection Control
Ventilator Associated Pneumonia (VAP)
• Ventilator associated pneumonia increases morbidity and
mortality.
• It has cost implications as it increases days of ventilation.
Reduction in the incidence rate is desirable in ventilated
patients.
• Formula: No of patient with VAP/No. of days mechanically
ventilated with ET tube x 1000days

31. Blood Stream Infection Due to Central Line
• Blood stream infection rates = number of central line related
BSI per 1000 central line-days
• Bloodstream infection (BSI) had emerged as a major killer.
• No.of central line-associated BSI/Number of central line-
days×1000

32. Urinary Catheter Related Infection
• Prevalence wise, urinary tract infection is most common. It
increases morbidity (if not mortality), cost and stay.
Formula for calculation: Number of UTI/Number of catheter
daysx1000

33. 6. Human Resource
 Satisfaction level of the staff working in the hospital/unit
 Satisfied work force gives better output.
 Retention rate remains high
Formula: On a 1 to 5 point scale where 1 represents lowest
satisfaction and 5 indicates highest possible satisfaction

34. 7. Customer Focus
 Perception of patients and their relatives about the care
received is an important determinant for forming public
opinion.
 If care perceived is not good, it causes customer (patient,
relatives) dissatisfaction.
 Patient's and family's satisfaction level should never be
ignored and regular attempts to assess the gap between
actual level of care (based on the survey by healthcare
provider and other quality parameters discussed above) and
perceived level of care (customer dependent), should be
made.
Formula: On a 1 to 5 point scale where 1 represents lowest
satisfaction and 5 indicates highest possible satisfaction

35. Patient Satisfaction
• Reflects performance of the hospital as perceived by patients
satisfaction is directly related to financial return to the
hospital and also reveals institutions credibility in the
population it functions. It also gives opportunity for
improvement.

36. Tools to Deliver Quality Care
 Evidence based medicine and nursing: Measures to improve
quality of healthcare delivery and patient safety must
be based on evidence.
 Protocols, checklists, bundles and guidelines:
Delivery of healthcare is a science in three domains: the first
is to understand disease biology/ dynamics; the second is to
find effective interventions; the third is to find strategies to
deliver the most appropriate intervention effectively by
incorporating relevant research findings into daily practice.

37. Clinical Management Bundles:
 There are more opportunities for clinicians to modify their
care in an effort to improve patient outcome as more high-
level evidence in critical care medicine becomes increasingly
available.
 A “bundle” is a group of interventions related to a disease
process that, when executed together, result in better
outcomes than when implemented individually.

38. Basic Bundle for all ICU patients: A
checklist
FAST HUG
 Feed, Analgesia, Sedation, Throboprophylaxis, Head of bed
elevation, Ulcer prophylaxis, Glucose Control

39. The ‘Antibiotic Care Bundle’
 Clinical criteria for initiation of antimicrobial therapy
 Actively get specimens for microbiology
 Initial empiric antibiotic choice based on local policy
 Remove infected source: foreign body, drain collections
 Modify when microbiology results are available
 Daily review of antibiotic choice and continuation
 Regular expert input

40. 5. Ventilator Care Bundle
General:
a. DVT prophylaxis:
• Unfractionated heparin 5000 units every eight hourly or
twice daily
• GI stress ulcer prophylaxis: H2 blocker as prophylaxis
• Eye and Skin Care
b. Skin prep
• 2% chlorhexidine is better than 10% povidone; chlorhexidine
povidone and chlorhexodine sequential cleaning is even
better as skin preparation for central line insertion.

41. c. Maintain internal environment:
• Hb ≥ 7g%;
• Electrolytes
• Glycemic control
d. Support of failing organ systems as appropriate: inotropes,
dialysis
e. Infection control
• Hand Hygiene
• Use 60 – 90% alcohol or 0.5-1.0% chlorhexidine
• Oral Hygiene – chlorhexidine 2% or povidone 10% at least
thrice a day

42.  Ventilator Circuits – change if visibly contaminated
 Suction - no difference between closed and open
 Body Position – 30° – 45° Head of Bed up

43. Bundle for prevention of Ventilator Associated
Pneumonia is known as WHAP
 Early Weaning
 Hand Hygiene
 Aspiration Precautions
 Prevention of contamination

44. Extra Miles Stones for Patient Safety
CPRS (Computerized patient record system)

45. BCMA(Bar Coded Medicine
Administration)

46. Patient ID Band

47. Vulnerable Patient Categorization and Special
Identification
Special color coding on the door

48. Improved Safety of High-Alert Medications
Ensure correct identification, storage,dispensing and
administration of “High Alert Medications”.

49. Improved Hand Hygiene Compliance to prevent
HAI

50. Reduced Risk of Patient Harm
Resulting from Fall
 Accurate initial and reassessment using proper tool
 Adequate safety measures (side rails, call bells)

51. Surgical Safety Checklist
Surgical Safety Checklist

52. SCORE USED IN ICU

53. RASS (Richmond Agitation Sedation Scale)
SCORE
Score Description Definition
+ 4 Combative Overtly combative, violent, immediate danger to
staff
+ 3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive
+ 2 Agitated Frequent non-purposeful movement, fights
ventilator
+ 1 Restless Anxious but movements not aggressive vigorous
0 Alert and Calm
- 1 Drowsy Not fully alert, but has sustained awakening (eye-
opening/eye contact) to voice (>10 seconds)
Verbal
stimulation
- 2 Light sedation Briefly awakens with eye contact to voice (< 10 sec)
- 3 Moderate sedation Movement or eye opening to voice (but no eye
contact)
- 4 Deep sedation No response to voice, but movement or eye opening
to physical stimulation
Physical
stimulation
- 5 Unarousable No response to voice or physical stimulation

54. SAPS II (Simplified Acute Physiology
Score)
• SAPS II (Simplified Acute Physiology Score) is a severity of
disease classification system in patients admitted to ICU for
aged 15 or more.
• After 24 hours of admission to the ICU, the measurement has
been completed and resulted in an integer point score
between 0 and 163 and a predicted mortality between 0%
and 100%.
• The point score is calculated from 12 routine physiological
measurements during the first 24 hours, information about
previous health status and some information obtained at
admission.

55. • One study reported
[Le Gall JR et al. A new simplified acute physiology score (SAPS II) based on a European / North American multicenter study. JAMA.
1993;270:2957-63]
Mortality SAPS II Score
10% 29 Points
25% 40 Points
50% 52 Points
75% 64 Points
90% 77 Points

57. APACHE
(Acute Physiology And Chronic Health
Evaluation) Score

58. Apache II Score
Approximate Mortality Interpretation
Score Non op Post op
0-4 4% 1%
5-9 8% 3%
10-14 15% 7%
15-19 24% 12%
20-24 40% 30%
25-29 55% 35%
30-34 73%
35-100 85% 88%

59. What is Clinical
Documentation?
Clinical documentation in a patient's
record includes any and all
documentation that relates to the care of
the patient during the patient's stay or
encounter.
59
Prof. Dr. RS Mehta, BPKIHS

60. In the inpatient setting, some of the important
pieces of the patent’s clinical documentation
include:
• Patient History & Physical examination
• Progress Notes
• Orders
• Procedure Reports
• Anesthesia Reports
• Pathology Reports
• Radiology/Nuclear Medicine Reports
• Cardiology Reports
• Consultation Reports
• Notes Provided by Nursing Staff
• Discharge Summary
60
Prof. Dr. RS Mehta, BPKIHS

61. Why is Clinical
Documentation Important
• Patient Care & Quality
• Legal Protection
• Operations and Management
• Strategic and Financial Planning
• Research
• Reimbursement & Revenue
61
Prof. Dr. RS Mehta, BPKIHS

62. The move toward Electronic Medical Records (EMRs)
and
Critical Care Information Systems (CCIS)
62
Prof. Dr. RS Mehta, BPKIHS

63. SEVEN Cs OF CRITICAL CARE
• Compassion (empathy, concern)
• Communication (with patient and family).
• Consideration (to patients, relatives and
colleagues) and avoidance of Conflict.
• Comfort: prevention of suffering
• Carefulness (avoidance of injury)
• Consistency
• Closure (ethics and withdrawal of care).
63
Prof. Dr. RS Mehta, BPKIHS

64. Thank you
64
Prof. Dr. RS Mehta, BPKIHS