ED Nurses Vent and Haemodynamics Workshop

This post captures some of the resources discussed in the ED Nurses Vent and Haemodynamic Monitoring workshop at Redcliffe Hospital. These resources are high quality FOAM and can help with expanding upon the learning and piqued curiosity from the workshop. Happy self-directed learning.

Pro-tip on organising and capturing your CPD activities: Keep a portfolio. Quite simply, document your intended personal learning objective; identify a high quality resource that addresses this (article, workshop, conference); document a reflection on your achieved personal learning outcome. For a comprehensive overview of a Nursing Professional Portfolio head to this guide from the ACN. My newly discovered resource for keeping track of CPD portfolio is this great app from Ausmed Education.


Arterial lines, central lines and haemodynamic monitoring

Quick snapshot on Arterial lines – http://lifeinthefastlane.com/ccc/arterial-line/

Literally the whole chapter on Haemodynamic Monitoring, an amazing resource – http://www.derangedphysiology.com/main/core-topics-intensive-care/haemodynamic-monitoring

arterial pressure waveform

Image from Deranged Physiology


Acute Respiratory Failure

Medscape emedicine overview of Respiratory Failure – http://emedicine.medscape.com/article/167981-overview

British Thoracic Society Guidelines for a host of diseases, diagnoses and therapies in ARF – https://www.brit-thoracic.org.uk/standards-of-care/guidelines/


Non-Invasive Ventilation

NIV Clinical Practice Guidelines – http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0007/239740/ACI14_Man_NIV_1-2.pdf

Q&A format NIV for the criitcally ill patient from LITFL – http://lifeinthefastlane.com/non-invasive-ventilation/

LIFTL Critical Care Compendium NIV – http://lifeinthefastlane.com/ccc/non-invasive-ventilation-niv/

Great 5 minute overview of NIV


Rapid Sequence Induction/Intubation

RSI Checklist Podcast and host of resources – https://emcrit.org/podcasts/intubation-checklist-2-0/

The Vortex Approach : a unique and systematic approach to safe emergency airway management – http://vortexapproach.org/

Nice overview of indications for RSI

RSI Dump Sheet adapted from KI Docs


Post-Intubation Care

The go-to package for post-intubation, EMCrit – https://emcrit.org/podcasts/post-intubation-package/


Mechanical Ventilation

For those that want EVERYTHING, here is the chapter from Deranged Physiology – http://www.derangedphysiology.com/main/core-topics-intensive-care/mechanical-ventilation-0

Don’t forget the importance of alarm settings – CritIQ video

A huge suite of brilliant videos from Respiratory Review – The Principles of Mechanical Ventilation

A short lecture on basic ventilator settings using the Hamilton T1 – https://www.youtube.com/watch?v=XOt4nMrJgww

Hamilton T1 online settings simulator – https://www.hamilton-medical.com/.static/HAMILTON-T1/start.html


The Crashing Ventilated Patient

This is a brilliant lecture with some good mental models and mnemonics for assessing and treating the patient who crashes post-intubation

Take the Resilience Challenge

There are many pressures in healthcare, all of which have an impact on people who work on the front lines. Resilience Challenge, a new interactive videogame, aims to raise awareness about these pressures.

http://game.resiliencecentre.org.uk/

In the early 2000’s, Safer Healthcare Now and other initiatives were launched to improve the 10% error rate in hospitals worldwide. After over a decade of research, and billions of dollars of funding, the error rate remains unchanged. So what went wrong? There are several perspectives on why patient safety hasn’t improved. These include a) we didn’t understand safety as a culture, not just individual errors b) we need to strengthen what goes right, not just eliminate what goes wrong, and c) we need better engagement between researchers and clinicians to makes sure that researchers are asking the right questions and clinicians are implementing the results.

Resilience Challenge is one way that researchers at in the Centre for Applied Resilience in Healthcare (CARe) at King’s College London are addressing these questions. We are studying how we foster organisational resilience in order to improve patient safety and support clinicians to provide high quality care. Organisational resilience is the ability of a system to adapt safely to pressures in healthcare. The Resilience Challenge videogame supports nurses, doctors, and healthcare professionals to explore this concept, and understand what it means in practice. Organisational resilience is not about individuals coping with poor working conditions; it’s about creating better environments in hospitals so that people can give great care.

The videogame is based on guiding a patient’s journey through the hospital safely. It combines comic book style visuals with accurate medical imagery to create an experience that is both familiar and imaginative. We want to engage with people from a broad range of backgrounds including healthcare students, professionals, and the public to understand the pressures healthcare providers face at work, and how organisations can support clinicians and safe decision-making. 

The Resilience Challenge is part of CARe’s wider work to inform policy about healthcare safety. The game is designed to raise awareness of the pressures on healthcare professionals and to start conversations about what can be done at an organisational level to support successful decision-making. CARe’s goal is to make healthcare systems work safely for everyone involved.

The Resilience Challenge was created through a collaboration between King’s College London’s Centre for Applied Resilience in Healthcare (CARe) and Karman Interactive, brokered and supported by the Cultural Institute at King’s.

Play the game, and please complete the survey at the end to support CARe’s research.

Learn more about our work here: http://resiliencecentre.org.uk/

 

Podcast Ep. 7 – O Captain! My Captain! – Leadership

Practice change limits the possibilities. We should aim for practice evolution.

It’s been a long time between episodes. I place all blame for this on Victoria Brazil and our Simulcast project. This return coincides with a refreshed and revised vision for Injectable Orange. Backed by a great, new editorial team, we will be tackling the issues that affect nursing. What better way to launch the professional issues series, than by interviewing SallyAnne Jones, a friend, mentor and president elect of the Australian Nursing and Midwifery Federation and the Queensland Nurses Union, leader in critical care nursing and true role model for our profession.

During the podcast Sally refers to the work of Daniel Goleman on emotional intelligence and leadership, encourages us to read and study broadly beyond the nursing literature and to make reflective practice and active pursuit that we schedule time for like any other leadership task. This is an interview that has already change my practice.

 


On to the podcast:

Fortnight of SMACC Talks: December 1st – 15th

As many of you know, there is a close relationship between the SMACC conference and Injectable Orange. Each fortnight we will be sharing a few of our favourite talks from the 2016 SMACC Dublin Conference as they are released via podcast or vodcast. Every past talk from the previous SMACC conferences are available via the SMACC website. For those of you who haven’t experienced SMACC, we hope these serve as the wardrobe door to your educational Narnia.

 
05/12/16 – Things that scare me

Speaker: Ross Fisher
Meta-description: In our professional and private lives there are things that scare us, how we manage that fear defines us.
Podcast:

Video:

THINGS THAT SCARE ME-Ross Fisher from Social Media and Critical Care on Vimeo.


06/12/16 – Where is the love in critical care?

Speaker: Liz Crowe
Meta-description: Critical Care is a place where love/passion and commitment must flourish, professional to patient, leaders to teams and colleagues, educator to trainee, skill to humanity- this is how we do it while maintaining our technical skills and our sanity.
Podcast:

Video:

WHAT’S LOVE GOT TO DO WITH IT–Liz Crowe from Social Media and Critical Care on Vimeo.


07/12/16Disaster Triage: Who gets what?
Speaker: Sara Gray
Meta-description: What happens in a mass casualty disaster when you run out of beds? Out of ventilators? Out of blood? Come discuss how (or whether) we should triage scarce resources during disasters.
Podcast:

Video:

Disaster Ethics- Who gets what- -Sara Gray from Social Media and Critical Care on Vimeo.


12/12/16 – The Immediate Responder and the Disaster Gap.
Speaker: Christina H. Hernon, M.D., FACEP
Abstract: After a major formative experience at a life-threatening mass casualty incident (MCI), emergency physician Christina Hernon felt incredibly unprepared despite over 2 decades of training in emergency and first response. Despite every first aid, first responder, and emergency course teaching students to ask, “Is the scene safe?” and instructing them not to enter an unsafe scene, all of this training is completely inadequate for those present the very moment an incident occurs, who are then amidst and surrounded by an unsecured and potentially unsafe scene. Afterwards, she had an acute stress reaction exactly like after rough calls in prehospital Emergency Medical Services, yet was offered none of the typical supports offered to first responder agencies or hospital personnel. Feeling somehow betrayed, but unsure what to be mad at, she tried to understand why she felt so unprepared and overlooked. In deconstructing and reflecting on the experience, she self-identified neither as bystander nor first responder, but as an on scene, immediately responding, victimized rescuer. Realizing that she didn’t fit into any already existing category, she uncovered a new group of rescuers and an undefined time period that we need to give attention to. The Disaster Gap is the time between the moment an incident occurs, through the first call for help, and until the first of the clearheaded First Responders arrives. In this definable time gap, the only available rescuers are people who are on scene when the event happens, who may be traumatized by their experience themselves, and who, regardless of tools or training, take immediate action to help another person or make the situation better. These Immediate Responders are present at virtually every scene and have been for all of time, yet we know very little about them, their actions, their safety, their impact, and their recovery. By trying to understand the Disaster Gap and Immediate Responders, we can improve training, preparedness, resilience, and recovery.
Podcast:

Video:

The Impromptu Immediate Responder- Christina Hernon from Social Media and Critical Care on Vimeo.


Don’t forget to subscribe to the SMACC Podcast – via iTunes or your preferred podcast app. Also remember there is a third and final small release of tickets for DASsmacc Berlin on the 1st Feb 2017.

How we do pain assessment: Critical-Care Pain Observation Tool

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What is the Critical-Care Pain Observation Tool (CPOT)?

The CPOT is a behavioural assement pain scale. The CPOT includes evaluation of four different behaviours (facial expressions, body movements, muscle tension, and compliance with the ventilator for mechanically ventilated patients or vocalisation for non-intubated patients) rated on a scale of zero to two with a total score ranging from 0 to 8. The CPOT is feasible, easy to complete, and simple to understand. The full itemised CPOT, descriptions of behaviours and directives for use are available here.

When should we use CPOT?

The gold standard for the evaluation of pain is still patient self-report. When this is not possible, due to sedation, intubation/mechanical ventilation or delirium, the CPOT should be used. In my unit we have chosen CPOT due to a clinical governance group consensus that the supporting literature for ICU behavioural pain scales demonstrates that CPOT has been validated in patient groups that are most similar to our ICU case-mix.

Why do we need another assessment tool?

The addition of a pain assessment tool specifically validated in both mechanically ventilated and delirious ICU patients, allows us to deliver more objectively targeted pain relief and achieve a greater balance between sedation and analgesia. It also allows us to more reproducibly assess the efficacy of our pain relief interventions, both pharmacological and non-pharmacological. Currently available options for pain assessment of the non-speaking or delirious patient are highly subjective and therefore difficult to reproduce from one clinician to the next. It is difficult to determine whether this predisposes patients to excessive or inadequate analgesia.

In combination with our use of the Richmond Agitation-Sedation Scale (RASS) to set targets for sedation choice, CAM-ICU Delirium assessment to screen for the presence of delirium, and the careful selection of sedative and analgesic agents (see ICUdelirium.org protocol for example), we are aiming to reduce the rate of ICU associated delirium and potentially reduce the number of days patients require mechanical ventilation. These practices align with the recommendations made in the Society for Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit.

How can you quickly and easily calculate the CPOT?

In my ICU we have a CPOT calculation and assessment guide in our clinical information system. There is also a great website that provides a huge number of medical scoring calculators, MDCalc. They also have a free App. The MDCalc CPOT calculator is available here.

Watch the video below for an overview and examples of the CPOT assessment

Where can I find more resources for best practice in ICU sedation, pain and delirium management?