Overview of critical care

Why Critical Care?
An Overview
Raj Kumar Mehta, MSN (Critical Care),Raj Kumar Mehta, MSN (Critical Care),
AIIMS, New DelhiAIIMS, New Delhi

HISTORY OF CRITICAL CARE
 Critical care evolved from an historical
recognition that the needs of patients with
acute, life-threatening illness or injury could
be better treated if they were grouped into
specific areas of the hospital.
 Nurses have long recognized that very sick
patients receive more attention if they are
located near the nursing station.

 Following the Crimean
War (1854-1856),
Florence Nightingale
described the
advantages of
specialized areas for
the recovery of
postoperative patients
History of Critical Care…

 Intensive care began
in the United States
in 1920’s, when Dr.
W.E. Dandy
established the first
3-bed neurosurgical
ICU at Johns Hopkins
Hospital in Baltimore.

 In 1927, the first premature infant care center
was established in Chicago
 During World War II, “shock wards” were
created to resuscitate wounded soldiers

 As a result of the nursing
shortage that followed
World War II,
postoperative patients
were grouped in “recovery
rooms” to ensure attentive
care
 The benefits recognized led
to establishment of
recovery rooms in nearly
every U.S. hospital by 1960

 In 1947-1948, the
polio epidemic raged
through Europe and
the United States,
resulting in a
breakthrough in the
treatment of patients
dying from
respiratory
paralysis.

 In Denmark, manual ventilation was
accomplished through a tube placed in
the trachea of polio patients.
 Patients with respiratory paralysis and/or
suffering from acute circulatory failure
required intensive nursing care.

 With the efficacy
of centralized
care of the
critically ill
proven,
respiratory ICU’s
were developed
in many hospitals

 During the 1950s, the development of
mechanical ventilation led to the organization
of respiratory intensive care units (ICUs) in
many European and American hospitals.
 The care and monitoring of mechanically
ventilated patients proved to be more efficient
when patients were grouped in a single
location.

 General ICUs for very sick patients, including
postoperative patients, were developed for
the similar reasons.
 In 1958, approximately 25 percent of
community hospitals with more than 300
beds reported having an ICU.
 By the late 1960s, most United States
hospitals had at least one ICU.

 During the 1960’s “critical care” developed as
a specialty in response to:
 Improved patient outcome with ICU care
 Advancements in postoperative resuscitation and
monitoring
 Surgeon’s willingness to perform more ambitious
surgical procedures
 By 1970, most U.S. hospitals had at least one
ICU

 In 1970, 29 physicians with a major interest in
the care of the critically ill and injured met in
Los Angeles, California to discuss the
formation of an organization committed to
meeting the needs of critical care patients:
the Society of Critical Care Medicine
(SCCM).

 In 1986, the American Board of Medical
Specialties approved a certification of
special competence in critical care for
the four primary boards: anesthesiology,
internal medicine, pediatrics, and
surgery.

 Between 1990 and the present, critical
care significantly reduced in-hospital
time as well as costs incurred by
patients with diseases such as
cerebrovascular insufficiency and lung
tumors.

 The development of new and
complicated surgical procedures, such
as transplantation of the liver, lung,
small intestine, and pancreas, created a
new and important role for critical care
following transplantation.

 Widespread utilization of non-invasive
patient monitoring has further reduced
the cost and medical/nursing
complications associated with care of
critically ill and injured patients.

 Widespread utilization of pharmacologic
therapy for critical care patients with specific
organ system failure reduced time spent in
both critical care units and in the health care
facility.
 In 1997, more than 5,000 ICUs were
operational in intensive care units across the
United States.

CURRENT STATUS
 Over 4 million patients are admitted to
the 5000+ U.S. ICU’s every year
 Average mortality rate is 10-20%
 More than 80% of all US hospitals have at
least one ICU

CURRENT STATUS…
 The cost of caring for such critically ill
patients has risen as a result of the
specialized care
 15-20% of a typical hospital’s budget
 ICU care costs represent 1% of the U.S.
gross national product

Critical care in India
 Critical care practices in India have
evolved significantly over the past
decade
 As in most other developing nations,
critical care medicine as a specialty has
developed very slowly and only recently
in India.

 The coronary care units were developed in
the early to mid-1970s.
 Perhaps the main pioneer of the field of
critical care in India was Farokh E Udwadia, a
brilliant physician with international training in
pulmonology.
Critical care in India…

 In the mid 1970s, Udwadia developed the
first respiratory care units in the country in
two hospitals in Mumbai — a community
hospital and a private one.
 The most major achievement of these units
was not only to bring down the mortality of
tetanus, but also to open the eyes of society
to the need for critical care services.

 These few enthusiastic, trained consultants
came together in 1992 to discuss critical care
on a common platform, and they formed the
national Indian Society of Critical Care
Medicine (ISCCM).

 The society had its teething troubles and has
now established itself very firmly as a
representative body of critical care
consultants in India.
 The ISCCM has over 2000 members today,
and has 16 city branches.

 Manpower development of the specialists has
been a major issue.
 Most of the current directors have been
trained abroad
 The certificate course in critical care, the first
organized training activity in critical care
medicine, was started 4 years ago by the
ISCCM and has been evolving well.

 Postdoctoral Fellowship in Critical Care
Medicine conducted by the National Board of
Examinations has recently been announced.
 The training of nurses, technicians, and
therapists has begun in some isolated foci
but has not evolved into a meaningful training
activity.

 Critical care in India is thus at the crossroads of
development.
 The beginning has been made but there is still a
long way to go.
 The field is full of a lot of dynamism, opportunity and
challenges.
 One hopes that all the efforts will lead to a humane,
scientific and meaningful service for the multitude of
critically ill patients.

History of Critical Care Nursing
 Although there have always been very ill
and severely injured patients, the concept of
critical care is relatively modern.
 As advances have been made in medicine
and technology, patient care has become
more complex.

 To provide appropriate care, nurses
needed specialized knowledge and skills,
and the care delivery mechanisms needed
to evolve to support the patients’ needs for
continuous monitoring and treatment.

 The seed of critical care was sown about 140 yrs
ago by Florence Nightingale
 The first intensive care units emerged in the
1950s to provide care to very ill patients who
needed one-to-one care from a nurse.
 From this environment the specialty of
critical care nursing emerged.

 Definition
 Critical care is the care of seriously ill
patients with life threatening illnesses or
trauma, as also of patients who have
the potential to develop life-threatening
complications from their disease.
Overview of critical care

Overview of critical care….
 Critical care should, correctly speaking, be
reserved for patients with severe but
potentially reversible problems.
 Patients with chronic terminal illnesses, with
the end close at hand, should be given every
care at home or in the ward of a hospital, but
not in critical care units.

 Intensive or critical care has blossomed into a
specialty with special training and certification
in the west, and also in many developed or
quickly developing East Asian Countries.
 The specialty is a young but growing one in
our country.

 It is important, particularly in a poor country
like ours, that the few good critical care
units we have, admit patients who truly need
appropriate care
 It is sad to see critical care units cluttered
with patients who are unquestionably better
looked after in the wards, or at home

Conditions require
Intensive/critical care
 Acute life-threatening illnesses which are
potentially reversible
 Acute illnesses with potential and likely to
occur life-threatening complications
 Monitoring of vital parameters of patients with
symptoms/signs that suggest the possibility
of an evolving life-threatening illness.

 Acute or immediate life threatening crises or
complications in a chronic illness, even when
the latter by itself is almost certain to cause of
death within a matter of months e.g. A pt.
with cancer at a stage when life expectancy
is 3-6 months.
Conditions require
Intensive/critical care…

 An acute complicating pneumonias in such a
pt is a life-threatening emergency which is
treatable, curable, and may well necessitate
critical care.
 Therefore, a critical care unit as already
mentioned, should not be used for terminal
cases where the end is close at hand.
Conditions require
Intensive/critical care

 The tendency to use a critical care unit
as the last halt or ‘stopping station’
before an expected departure from this
world, should be strongly restricted.
Conditions require
Intensive/critical care…

Advantages/disadvantages of
critical care unit
 The chief advantage is that it provides better
and more organized care
 The main disadvantage is of a hostile
environment contributing to anxiety,
emotional stress, loneliness, fear and a
greater risk of developing nosocomial
infections.

ICU
Intensive
Care
Unit
I See Youor

Concept Of ICU
 More care Continuous & Intensive
 Specialty Care
 Source of Areas ( Med, Sur etc )
 Open/ Closed
 Provides advanced Life support through the
application of Technology
 Initial Assessment of Airway, Breathing &
Circulation & Intervention

Design of ICU
 1 ICU bed/ 100 beds More in tert care hos
 Unit of 4 -8 beds
 Occupancy 75%
 Bed Area 200sq ft
 Central Nursing Station
 Changing rooms
 Store, office, lab, Seminar room, Waiting
room

Staffing of ICU
 Director- medical + nursing
 Physician/ consultants
 Resident Doctors
 Sister I/C
 Nursing sister (1:1)
 Physiotherapist
 Technician
 Ancillary staff

Team work
 Physician-Instructions, overall
 Nursing staff-Nursing care, Assessment
& recording, Physiological, Social,
Therapy
 Physiotherapist
 Technician

The Flow Sheet…
 Recording round the clock information of
different organ systems- computerized / Manual
 Vital signs
 Neurological Status
 Haemodynamic Parameters
 Ventilation settings
 Respiratory parameters
 Input/output
 Laboratory Data
 Medication

SYSTEM ORIENTED ROUNDS
ACCURATE TRANSMISSION OF
CLINICAL INFORMATION
COMPULSIVE
AND FOLLOW EVERY SINGLE
DETAILS
“ Head to Toe Format”

 Identification/problem list
 Major events during the last 24 hrs
 Neurological- Mental status, Complaints,
CNS/E
 Cardiovascular System
 Respiratory
 Renal/metabolic
The Flow Sheet…

 Gastrointestinal
 Infectious Diseases
 Hematological
 Psychological
 Nutrition,
 Endocrine,
 Others-Tube, Medication etc
The Flow Sheet…

ABOUT CRITICAL CARE
NURSING
 Oxford Dictionary gives the meaning of
critical as crucial; as crisis; of
emergency as requiring immediate
action; and of intensive as thorough
and constant observation.

 These are all interrelated, because
those patients who present with life
threatening conditions are in a ‘crucial’
state/situation, needing ‘immediate
action’, and requiring ‘thorough and
constant’ observation.
ABOUT CRITICAL CARE
NURSING…

Definition of Critical Care Nursing
 Critical care nursing is that specialty within
nursing that deals specifically with human
responses to life-threatening problems.
 A critical care nurse is a licensed
professional nurse who is responsible for
ensuring that acutely and critically ill patients
and their families receive optimal care.

Definition of a Critically Ill Patient
 Critically ill patients are defined as those
patients who are at high risk for actual or
potential life-threatening health problems.
 The more critically ill the patient is, the more
likely he or she is to be highly vulnerable,
unstable and complex, thereby requiring
intense and vigilant nursing care.

Number of Critical Care Nurses in
the United States
 According to “The Registered Nurse
Population” study done in March 2000 by the
Department of Health and Human Services,
there are 403,527 nurses in the U.S. who
care for critically ill patients in a hospital
setting.

Where Critical Care Nurses Work ?
 According to “The Registered Nurse
Population” study, 59% of all nurses work in
the hospital setting, and critical care nurses
work wherever critically ill patients are found –
intensive care units, pediatric ICUs, neonatal
ICUs, cardiac care units, cardiac catheter labs,
telemetry units, progressive care units,
emergency departments and recovery rooms.

Where Critical Care Nurses Work?
 Increasingly, critical care nurses work in
home healthcare, managed care
organizations, nursing schools,
outpatient surgery centers and clinics.

What Critical Care Nurses Do?
 Critical care nurses practice in settings
where patients require complex
assessment, high-intensity therapies
and interventions, and continuous
nursing vigilance.

What Critical Care Nurses Do?...
 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.
 Foremost, the critical care nurse is a patient
advocate

The Roles of Critical Care Nurses
 Critical care nurses work in a wide variety of
settings, filling many roles.
 They are bedside clinicians, nurse educators,
nurse researchers, nurse managers, clinical
nurse specialists and nurse practitioners.

 With the onset of managed care and the
resulting migration of patients to alternative
settings, critical care nurses are caring for
patients who are more ill than ever before.
 Managed care has also fueled a growing
demand for advanced practice nurses in the
acute care setting.
The Roles of Critical Care Nurses…

 Advanced practice nurses are those who
have received advanced education at the
master’s or doctoral level.
 In the critical care setting, they are most
frequently clinical nurse specialists (CNS) or
acute care nurse practitioners (ACNP).

 A CNS is an expert clinician in a particular
specialty - critical care in this case.
 The CNS is responsible for the identification,
intervention and management of clinical
problems to improve care for patients and
families.

 They provide direct patient care, including
assessing, diagnosing, planning and
prescribing pharmacological and non-
pharmacological treatment of health
problems.

 ACNPs in the critical care setting focus on
making clinical decisions related to complex
patient care problems.
 Their activities include risk appraisal,
interpretation of diagnostic tests and
providing treatment, which may include
prescribing medication.

Critical Care Nurse Certification
 Although certification is not mandatory for practice in
a specialty like critical care in everywhere, many
nurses choose to become certified.
 Certified critical care nurses (CCRN) must have
been in critical care practice for a minimum of two
years to be eligible for the examination.

Nursing Shortage More Pronounced
for Critical Care Nurses
 The growing nursing shortage is especially acute in
the specialty areas of nursing.
 e.g. adult critical care units, pediatric and neonatal
ICUs and emergency departments.
 Hospitals are offering critical care nurses ever more
attractive incentives, including sign-on bonuses,
relocation bonuses, reimbursement for continuing
education and certification, and other attractive
benefits.

Future of Critical Care Nursing
 Rapid advances in healthcare and technology
have contributed to keeping more people out of
the hospital.
 However, patients in critical care units are more
ill than ever before.
 Many patients who would have been cared for in
a critical care unit five years ago are now being
cared for on medical floors or at home.

 Many patients in today’s critical care units
would not have survived in the past.
 It has been proposed that the hospitals of the
future will be large critical care units, and other
types of care will be provided in alternative
locations or at home.
Future of Critical Care Nursing

 Critical care nurses will need to keep pace
with the latest information and develop
skills to manage new treatment methods
and technologies.
 As issues relating to patient care become
increasingly complex and new technologies
and treatments are introduced, critical care
nurses will need to become ever more
knowledgeable.
Future of Critical Care Nursing…

Seven Cs of Critical Care
 Compassion
 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).

CONCLUSIONS
 An organized, intensivist-led patient care
model
 Improves patient care
 Decreases resource utilization
 Results in fewer complications
 Decreases mortality
 Lowers total hospital costs
 Improves and continually updates non-intensivist
physician/nurses critical care knowledge

Overview of critical care

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (7)

Similaire à Overview of critical care

Similaire à Overview of critical care (20)

Plus de Raj Mehta

Plus de Raj Mehta (6)

Dernier

Dernier (20)

Overview of critical care