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

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

face

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?

 

All About That Base? Why Nursing Needs More Than Evidence

Evidence-based nursing. This is the focus of most of the modern nursing discourse (including this blog! Controversy ahead…). In all of nursing’s domains of practice, evidence-base is a hot topic, showing that we are up-to-date, safe, and professional.

There’s just one problem. Being ‘evidence-based’ does not mean nursing is any of these things.

Our profession has doubled down on evidence-based framing in recent years, in alignment with medical professionals. This is nothing new; nursing pioneers have long aligned nursing with aspects of the natural sciences and medical sciences in order to give nursing credibility[i]. I get the sense that nursing’s drive towards evidence is to appear credible alongside medicine, as much as it is to actually improve patient care.

rct

There are several reasons why evidence is not enough to form the basis of nursing knowledge:

  1. Evidence is not automatically right or good.

One only needs to say “Wakefield” and we know that scientific evidence can be flawed[ii]. While this is an extreme example, there are many published studies that are not rigorous or are clouded by conflicts of interest. Just because something has been studied or published does not make it accurate, safe, or useful.

  1. The knowledge to practice gap is slow.

Estimates vary, but we know it can be 10-17 years for knowledge to be translated into practice. Even then, it is extremely difficult to change nursing (or medical) practice, and have these changes last. And waiting 2 decades for changes in practice won’t serve our patients in the meantime.

  1. Standardization is not a good idea.

We know that evidence does not necessarily serve all people or populations. For example, when a study shows that an intubation technique works well in one setting, it does not mean it is safe for all settings. The idea that, if we standardize our care, we will improve patient safety, is fundamentally flawed[iii].

  1. In many cases, evidence does not exist.

How should nurses practice in the context of Zika virus? We are still learning this. There are patients with Zika who need care in the meantime, and we can’t wait until we have an answer to nurse them.

  1. Evidence is not ethically neutral.

Evidence is influenced by politics and economics, from start to finish. There are important issues which have not been researched because there isn’t funding available, or other issues are more politically attractive. Even when evidence is available, it can be difficult to fund or adopt; safe staffing ratios are a prime example. Greatest need does not always drive research priorities or implementation.

ebn

So what are nurses to do?

I advocate a return to a comprehensive understanding of what makes up nursing knowledge. Carper wrote this paper in 1978[iv], and it’s still relevant and useful today.

Carper outlined that nursing has 4 kinds of knowledge:

  1. Art
  2. Science
  3. Ethics
  4. Experience

If we return to seeing nursing practice as a comprehensive body of knowledge, we can outline nursing work as being multidimensional. Evidence-based nursing has us leaning so heavily on science, that we lose the other factors in our conversations about nursing.

When we are supporting people with mental illness, we know that if we provide community supports, medication, and cognitive-behavioral therapies, we will have better outcomes than if we provide medication alone. This same logic can apply to how we use Carper’s types of knowledge.

We can form the basis of our practice with the art of nursing. We can say, no matter who I meet today, I will promote their dignity, or I will be caring, or whatever works in your practice. When we have a specific problem, such as acute kidney injury, we can use our scientific knowledge and our experience to provide expert care. We can advocate for vulnerable people because this is part of the ethics of nursing. These types of knowledge work together, and give us comprehensive nursing practice.

I think most nurses already integrate different types of knowledge in their practice. What we can change is how we talk about it. We can talk about how we apply different types of knowledge in our work. If we explain nursing knowledge in these domains, it may support nursing students to develop their practice. It may also be easier to talk about challenges, such as ethical dilemmas, when we move away from an overemphasis on evidence.

I believe in the vital role of evidence in nursing practice, as I am a nurse researcher, working to build our professional knowledge base. But I also see that we need more, and we can steer our professional conversation back to the multi-faceted knowledge that really makes up our base.


References

[i] Wuest, J. (1994). Professionalism and the evolution of nursing as a discipline: A feminist perspective. Journal of Professional Nursing10(6), 357-367.

[ii] Godlee, F., Smith, J., & Marcovitch, H. (2011). Wakefield’s article linking MMR vaccine and autism was fraudulent. BMJ342, c7452.

[iii] Learn more: http://resiliencecentre.org.uk/fact-sheets/safety-i-and-safety-ii/ Full disclosure- I am a member of the Centre for Applied Resilience in Healthcare.

[iv] Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in nursing science1(1), 13-24.

 

Clinical Trials Worth Knowing – CRICU Sepsis Nursing Workshop

This post is a collation of references and resource material from my second presentation in the inaugural Caboolture Redcliffe ICU Sepsis Workshop for nurses. The objective of this session was to work through critical appraisal of 5 prominent critical care trials with particular significance to our practice context. The completely unambiguous overtone of this session was to practise critical appraisal and engage with the literature that informs the medical decisions in our ICU.


Following a brief introduction and overview of the constructs of evidence based practice and grading of evidence, I lead the group through a structured critical appraisal of the SPLIT Trial (Young et al 2015). We used the Critical Appraisal Skills Programme (CASP) Randomised Contol Trial (RCT) Appraisal Tool to dissect the study. Following this, the participants were broken into four small groups and each given a prominent sepsis trial to appraise and feedback to the whole group in 30 minutes time.

The trials were purposely selected for discussion as they all hold specific relevance to practice in our ICU. These trials also share one commonality – they were all ‘negative’ or no difference trials. One key aspect discussed was the importance of no difference trials. During the group feedback particular focus was drawn to identifying the Population, Intervention, Comparison and Outcome (PICO), whether the study was believable (internal validity and biological plausibility), and whether it should change practice or confirmed our current practice.

About 20 minutes into the appraisal activity the groups were provided with the Bottom Line review for their relevant study to aid in synthesising final feedback and as an example of an excellent critical appraisal. The Bottom Line is an excellent critical appraisal and literature resource for Intensive Care. Founded by members of the Wessex Intensive Care Society and now with international authorship, this is one of my absolute go-to resources to help filter and process the swathe of ICU trials.

Primary Literature

Secondary Appraisal

HEAT Trial – Acetaminophen for Fever in Critically Ill Patients with Suspected Infection (Young et al 2015) Bottom Line on HEAT – Steve Mathieu
ARISE Trial Goal-Directed Resuscitation for Patients with Early Septic Shock (Delaney et al 2014) Bottom Line on ARISE – Steve Mathieu
CORTICUS Trial – Hydrocortisone Therapy for Patients with Septic Shock (Sprung et al 2008) Bottom Line on CORTICUS – Duncan Chambler
BLISS Trial – Beta-Lactam Infusion in Severe Sepsis (BLISS): a prospective, two-centre, open-labelled randomised controlled trial of continuous versus intermittent beta-lactam infusion in critically ill patients with severe sepsis (Abdul-Aziz et al 2016) Bottom Line on BLISS – Adrian Wong
SPLIT Trial – Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit (Young et al 2015) Bottom Line on SPLIT – Adrian Wong

Anthony Crocco from Sketchy EBM – How to read (most) research papers


Detecting Sepsis in 2016 – CRICU Sepsis Nursing Workshop

This post is a collation of references and resource material from my first presentation in the inaugural Caboolture Redcliffe ICU Sepsis Workshop for nurses.

The objective of this talk was to provide an update on triage and screening for sepsis, the current International standards and how this filters into ongoing refinement of diagnosis and treatment in our ICU.


JAMA Network Consensus Definitions for Sepsis and Septic Shock


Primary Literature:

Secondary Sources:

Extra Reading: