Hal 1-50
Hal 1-50
Hal 1-50
L
CARE NURSING
www.ketabpezeshki.com
ACCCNS CRITICA
L
CARE NURSIN
G
SECOND EDITION
Doug Elliott
Leanne Aitken
Wendy Chaboyer
www.ketabpezeshki.com
Mosby
is an imprint of Elsevier
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
Title: ACCCNs critical care nursing / [editors] Doug Elliott, Leanne Aitken and Wendy
Chaboyer.
Edition: 2nd ed.
ISBN: 9780729540681 (pbk.)
Notes: Includes index.
Subjects: Intensive care nursingAustralia.
Other Authors/Contributors: Elliott, Doug. Aitken, Leanne. Chaboyer, Wendy.
Australian College of Critical Care Nurses.
Dewey Number: 616.028
Publisher: Libby Houston
Developmental Editor: Elizabeth Coady
Publishing Services Manager: Helena Klijn
Editorial Coordinator: Geraldine Minto
Edited by Melissa Read
Proofread by Tim Learner
Indexed by Cynthia Swanson
Cover design by Lamond Art & Design
Typeset by Toppan Best-set Premedia Limited
Printed by China Translating & Printing Services Ltd.
www.ketabpezeshki.com
Contents
9
10
Foreword
vi
215
Preface
vii
11
(ACCCN)
ix
Contributors
xi
Reviewers
xiii
Acknowledgements
xiv
Detailed Contents
xv
Abbreviations
xviii
Section 1
Scope of Critical Care
1
17
38
57
78
103
105
Psychological Care
133
156
251
Malcolm Dennis, David Glanville
562
291
325
22
352
23
381
24
414
25
445
26
479
27
Appendices
506
Glossary
Picture Credits
Christopher Gordon
Management of Shock
654
679
710
746
Alterations
20
Resuscitation
623
Trauma Management
17
581
Emergency Presentations
David Johnson, Mark Wilson
579
Index
539
763
783
790
793
www.ketabpezeshki.com
Foreword
practice tips.
ACCCNs Critical Care Nursing is a beneficial resource
for
As a specialty area of nursing practice, critical care n
ursing
ting. In
riencing
pies
urses
at the
heir
care
http://www.wfccn.org
vi
www.ketabpezeshki.com
Preface
environment, while still allowing the universal
core elements that represent critical care practice int
ernationally.
This second edition of ACCCNs Critical Care N
ursing has
Critical care as a clinical specialty is over half a
century
nd expertise
duca-
s and clini-
ade.
in showcas-
knowl-
ralia, New
and
d contribu-
n are
ces and to
hest
geographic
en for their
ses
trong profes-
Our
sional reputations.
t from
e by prac-
uced
earchers and
critical care
form
e students
ew
this book
ions
posed by critical care nurses as they practise in the l
ocal
beyond the
learning needs of these students. The aim
of the book
his
standing of the complex world of critical care nu sections: the scope of critical care nursing, core comrsing.
We therefore encourage our readers to continue of critical care nursing. Inclusion of new chapters and
to also
to guide their clinical practice. A range of websit reviewers as well as on evolving and emerging practic
e links
es
in critical care.
Section 1 introduces a broad range of professional issues
related to practice that are relevant across critical car
e.
Initial chapters provide contemporary information on
the scope of practice, systems and resources, quality and
safety, recovery and rehabilitation, and ethical issues.
Content presented in the second section is relevant to the
majority of critical care nurses, with a focus on concepts
that underpin practice such as essential physical, psychological, social and cultural care. Remaining chapters in
this section present a systems approach in supporting
physiological function for a critically ill individual. This
edition now has multiple linked chapters for some of the
major physiological systems 4 chapters for cardiovas
cular, 3 for respiratory, and 2 for neurological. Chapters
on support of renal function, gastrointestinal, liver and
nutritional alterations, management of shock, and multiorgan dysfunction complete this section.
The third section presents specific clinical condition
s
such as emergency presentations, trauma, resuscitation
,
paediatric considerations, pregnancy and post-partum
considerations, and organ donation, by building on the
principles outlined in Section 2. This section enables
readers to explore some of the more complex or unique
aspects of specialty critical care nursing practice.
Chapters have been organised in a consistent format t
o
ease identification of relevant material. Where appropri-
es
es,
vii
www.ketabpezeshki.com
viii
P R E FA C E
a critique of a research publication that explores a rel The delivery of effective, high-quality critical care nursing
ated
topic, and learning activities to assist both the reader We trust that this book will be a valuable resource in
and
Doug Elliott
Leanne Aitken
Wendy Chaboyer
www.ketabpezeshki.com
al representation.
Editorial Board,
ver
e Australian Critical
sation
mber-
onal
corpo-
and
are encouraged to participate in the activities
of the
College; to receive the College journal and Critical Ti
mes
relating to critical
care nursing. These include:
Resuscitation
Advisory
Panel:
consists
of
eight
In addi
l care
tion to
branc
committees. The panel has also developed p h educ
ational
and sy
CCCN
on a number of national health workforce and nurs
ing
nually
siums,
conduc
ts thre
nal con
s each
ACCCN
te of
uing E
n (ICE)
conjun
with o
dical c
Advisory
olleagu
m
The A
ustralia
New Z
Intensi
ve Car
ety
S), the
/ACCC
al Scie
ntific M
eeting
on Intensive Care and the Australian and New Zealand
Paediatric & Neonatal Intensive Care Conference.
ACCCN has a representative on the Australian Resuscitation Council (ARC), and has representation at a federal
government advisory level through the Nursing and Midwifery Stakeholder Reference Group (NMSRG) chaired by
the Chief Nurse of Australia, and is also a member of the
Coalition of National Nursing Organisations (CoNNO).
The founding Chairperson of the World Federation of
Critical Care Nurses (WFCCN) continues to represent
ACCCN on the WFCCN Council, and the College also
has representatives on the World Federation of Paediatric
Intensive and Critical Care Societies, and is a member of
the Intensive Care Foundation.
More information can be found on the ACCCN website:
www.acccn.com.au
ix
www.ketabpezeshki.com
of
e of
es on
the health-related quality of life (HRQOL) and illn
ess
experiences of individuals with critical and ac
ute illnesses, and the use of technologies to improve
patient
outcomes. Doug has received research funding from
the
NHMRC and the Australian Commission on Safety
and
Quality in Health Care, as well as competitive fu
nding
from other national organisations, health service and
belief that improvement in practice and resultant pat range of clinical practice issues within critical care and
ient
trauma.
outcomes is always possible. Research interests i Leanne has been active in ACCCN for more than 20 years
nclude
developing and refining interventions to improve having held positions on state and national boards, coorlong
x term recovery of critically ill and injured pat Australia in its early years, chaired the Education Advisory
ients,
www.ketabpezeshki.com
Contributors
Leanne Aitken RN, PhD, BHSc(Nurs)Hons,
Clare Fitzpatrick
GradCertMgt, GradDipScMed(ClinEpi),
ICCert, FRCNA
Nurse Researcher
BA (Hons)
Charles Hospital
Alexandra Hospital
Queensland
Brisbane, Queensland
Complex Care
JP (Qual)
Deakin University
Victoria
Queensland
Nursing, MN
MRCNA
Nurse Educator
Victoria
Victoria
Senior Lecturer
Jerusalem, Israel
CertICU, CertTeaching&Assessing
St Jude Medical
of Sydney
Practitioner)
Epworth HealthCare
of Sydney
Victoria
Richmond, Victoria
(RCCCPI)
Flinders University
Trudy D
MN, PhD
South Australia
wyer RN,
Director
Queensland
Wendy Corkill RN
ICU Cert,
BHlth, GC
BSc MNSc
ert
Northern Territory
FlexLrn,
Senior Lecturer
MClinEd,
PhD
Associate Professor
BN, MN
Care Unit
Queensland
South Australia
MAppSc(Nurs), ICCert
Professor of Nursing
Senior Lecturer,
University of Technology
University of Tasmania
Tasmania
(Crit Care), MN
GDBL, MRCNA
PhD candidate
Project Manager
in Health Care
New South Wales
xi
www.ketabpezeshki.com
xii
CONTRIBUTORS
Western Australia
Denise Harris RN, BHSc(Nurs),
Frances Lin RN, BMN, MN (Hons), Marion Mitchell RN, BN (Hon), Grad Cert
GradDipHlthAdmin& InfoSys,
PhD
MN(Res), ICCert
Lecturer & Program Convenor (Master Senior Research Fellow Critical Care
of
Critical Care
Alexandra Hospital
Queensland
Griffith University
Queensland
Project Officer
PhD candidate
rsing
University of Sydney
Lecturer
Technology, Sydney
LaTrobe University
Austin Health
Victoria
Director of Nursing
IC Cert, MRCNA
Service District
Queensland
Senior Researcher
Nurse Educator
Alfred Health
Queensland
Victoria
Transport Service
for Women
Victoria
Nurse Educator
Senior Lecturer
Nursing Research
England Health
Professor, HECVSant
Western Switzerland
Switzerland
RGN, SCM
Curtin University
Reader
University of Dundee
Queensland
United Kingdom
Assistant Professor
Senior Lecturer
University of Toronto
of Gothenburg
Sweden
Toronto
Ontario, Canada
Queensland
South Australia
St Vincents Hospital
Victoria
CCRN, CNRN
Western Australia
Leader
www.ketabpezeshki.com
Reviewers
Steven Frost RN, MPH
University of Canberra
Jon Mould PhD candidate, MSc, RGN, RSCN, RMN, Adult Cert Ed
ICCert, NeurosciCert
Senior Lecturer
Senior Lecturer
Western Australia
University of Tasmania
Tasmania
Clinical Education)
Lecturer in Nursing
School of Health
Senior Lecturer
Queensland
MPH(Candidate)
Ann Kuypers RN, Med Grad Dip(Clin Ed), Grad Cert (Periop)
Lecturer in Nursing
Lecturer Nursing
School of Health
Victoria
Lecturer
Curtin University
Western Australia
Lecturer
University of Wollongong
xiii
www.ketabpezeshki.com
Acknowledgements
and members of ACCCN, for having the belief in
us as
editors and authors to uphold the values of the Colle
A project of this nature and scope requires many tale
ge,
nted
om
Ruth
Endacott, Paul
Fulbrook,
product.
Doug Elliott
Leanne Aitken
Wendy Chaboyer
xiv
www.ketabpezeshki.com
Detailed Contents
5
78
11
Summary
12
17
Ethics in research
17
Historical influences
18
19
Budget
20
22
Equipment
22
Staff
23
Risk management
28
30
Management of pandemics
33
Summary
34
38
42
Patient safety
49
Summary
52
57
ICU-acquired weakness
58
59
Psychological recovery
61
66
68
68
Summary
72
91
Summary
96
Sedation
138
Pain
141
Sleep
145
Summary
8
103
Personal hygiene
Eye care
107
109
157
161
Religious considerations
105
Oral hygiene
156
Cultural care
Patient
170
172
Summary
9
110
173
180
180
Bowel management
115
Assessment
116
Haemodynamic monitoring
Bariatric considerations
117
Diagnostics
206
Summary
210
10
118
149
195
123
Heart failure
125
Selected cases:
Psychological Care
133
Cardiomyopathy
Anxiety
133
Hypertensive emergencies
Delirium
136
190
www.ketabpezeshki.com
215
215
227
241
242
xv
xvi
D E TA I L E D C O N T E N T S
243
Tracheal suction
387
Aortic aneurysm
244
Extubation
387
Ventricular aneurysm
245
Mechanical ventilation
388
245
Non-invasive ventilation
389
392
Summary
404
12
13
251
251
252
414
Cardiac pacing
265
414
Cardioversion
280
431
Ablation
285
Summary
440
Summary
285
291
Cardiac surgery
291
302
Heart transplantation
308
Summary
319
325
Pathophysiology
333
Assessment
335
Respiratory monitoring
338
341
Diagnostic procedures
344
Summary
347
352
Respiratory failure
353
Pneumonia
357
Respiratory pandemics
360
362
15
16
Monitoring
14
387
Infective endocarditis
Summary
11
tracheostomy
364
Pneumothorax
366
Pulmonary embolism
367
Lung transplantation
369
Summary
374
381
Airway support
383
Intubation
384
Tracheostomy
386
Pathophysiology
17
445
445
449
455
470
21
480
failure
483
Renal dialysis
488
501
506
506
Nutrition
509
Summary
20
Management of Shock
556
557
562
Pathophysiology
563
Systemic response
564
Organ dysfunction
567
Multiorgan dysfunction
569
Summary
572
579
Emergency Presentations
581
522
525
586
587
588
Respiratory presentations
589
591
526
582
Extended roles
Multiple patient triage/disaster
516
Liver transplantation
Incidence of diabetes in Australasia
554
513
Liver dysfunction
Glycaemic control in critical illness
551
Triage
508
Nutrition support
Stress-related mucosal disease
545
491
Summary
19
Cardiogenic shock
Summary
542
Neurogenic/spinal shock
479
541
Hypovolaemic shock
Anaphylaxis
472
Patient assessment
Summary
18
539
593
Acute stroke
528
539
www.ketabpezeshki.com
594
596
612
xvi
D E TA I L E D C O N T E N T S
23
24
25
Hypothermia
614
Special considerations
615
731
Summary
615
735
Trauma Management
623
Summary
623
626
Summary
649
Resuscitation
654
Pathophysiology
655
655
Management
655
670
670
Ceasing CPR
671
Tissue-only donor
Postresuscitation phase
671
Summary
Near-death experiences
671
672
Summary
672
27
746
New Zealand
746
747
Australasia
747
749
Rights
680
Comfort measures
685
686
763
765
76
768
686
Education
691
693
695
77
Staffing
696
77
Paediatric trauma
700
Summary
702
777
710
77
711
716
78
710
758
children
758
684
dysfunction
757
Developmental considerations
obstruction
755
Workforce
26
738
679
in children
729
726
GLOSSARY
78
3
PICTURE CREDITS
79
0
INDEX
793
www.ketabpezeshki.com
Abbreviations
ALT
alanine aminotransferase
AMI
AND
ANP
2-PAM
pralidoxime
ANZBA
6MWT
ANZICS
A/C
assist control
A/C MV
AACN
AATT
ABG
ACCCN
ACD
active compressiondecompression
ACE
angiotensin-converting enzyme
ACEM
ACh
acetylcholine
AChE
acetylcholinesterase
ACN
ACNP
ACS
ACS
ACT
ACTH
adrenocorticotrophic hormone
ADAPT
ADE
ADH
antidiuretic hormone
ADL
ADP
adenosine diphosphate
AE
adverse event
AED
AHA
AHEC
AIS
AKI
ALF
ALI
ALP
alkaline phosphatase
ALS
Society
ANZOD
xviii AoCLF
AV
atrioventricular
AVDO
AVM
arteriovenous malformation
AVPU
AODR
AORTIC
APACHE
Pain/Unconscious
BBB
bloodbrain barrier
BDI
BiPAP
BiVAD
APC
activated protein C
BIS
bispectral index
APRV
BLS
aPTT
BMV
Bag/mask ventilation
ARAS
BP
blood pressure
ARC
BPS
ARDS
BSA
ARF
BSLTx
BTF
ASL
AST
ATC
ATCA
ATN
ATP
adenosine triphosphate
ATS
AV
arteriovenous
BURP
BVM
bagvalvemask
CaO
CABG
CAM-ICU
CAP
community-acquired pneumonia
www.ketabpezeshki.com
A B B R E V I AT I O N S
CPOT
xix
CAUTI
CPP
CAV
CPP
CAVH
CPR
cardiopulmonary resuscitation
CBF
CRASH
CBG
corticosteroid-binding globulin
CCF
CCU
CRF
CRH
corticotrophin-releasing hormone
combination of these
CRP
C-reactive protein
CCU
CRRT
CDSS
CSF
cerebrospinal fluid
CEO2
CESD
CFI
CFM
CHD
CHF
CI
cardiac index
CI
critical illness
CIM
CINM
CIP
CIPNP
CIS
CK
creatine kinase
CLAB
CLD
CLF
cLMA
CLRT
CMV
CMV
cytomegalovirus
CNE
CNPI
CNS
CO
carbon monoxide
CO
cardiac output
CO
carbon dioxide
COAD
COPD
CPAP
CPB
cardiopulmonary bypass
CPDU
CPG
CPM
CPOE
head injury
EC
extracorporeal circuit
CSSU
ECC
CSWS
ECG
electrocardiograph/y
CT
computerised tomography
ECMO
CTG
ED
emergency department
CVC
EDD
CVD
cardiovascular disease
EDD-f
CvO2
EDIS
CVP
CVVH
EEG
electroencephalogram
CVVHDf
EGDT
CXR
chest X-ray
EMD
electromechanical dissociation
DAI
EMS
System
DASS
EN
enteral nutrition
DAT
ENID
DCD
EPAP
DCM
dilated cardiomyopathy
ePD
DDAVP
1-deamino-8-D-arginine vasopressin
EQ-5D
Euroquol 5D
ERC
ESBL-E
extended-spectrum beta-lactamase-
(Vasopressin)
DKA
DO
diabetic ketoacidosis
oxygen delivery
producing Enterobacteriaceae
DPL
ESLD
DRG
diagnosis-related group
ESLF
DSC
ETC
DVT
ETCO2
EBI
ETIC-7
EBN
ETT
endotracheal tube
EBP
EVLW
EC
ethics committee
FAED
(o)esophagealtracheal Combitube
www.ketabpezeshki.com
xx
A B B R E V I AT I O N S
HRQOL
HRS
hepatorenal syndrome
trauma
HSV
FBC
HTLV
FDA
IABP
FES
IAC
IAP
intra-abdominal pressure
FFA
ICC
intercostal catheter
FFP
ICD
FI
fear index
ICDSC
FiO2
ICG
indocyanine green
fMRI
FRC
FTE
FAST
FEV
fortnight)
FVC
FWR
GABA
gamma-aminobutyric acid
GAS
GCS
GEDV
GGT
gamma-glutamyl transpeptidase
GI
gastrointestinal
GIT
gastrointestinal tract
GM1
monosialoganglioside
GTN
glyceryl trinitrate
3
HCO
H CO
2
sodium bicarbonate
carbonic acid
hydrogen
HADS
HAI
Hb
haemoglobin
HbF
fetal haemoglobin
HCM
hypertrophic cardiomyopathy
HDU
high-dependency unit
HE
hepatic encephalopathy
HFA
HFNC
HFOV
HH
heated humidification
HHNS
Hib
HIT
Heparin-induced thrombocytopenia
HME
heatmoisture exchanger
HPA
hypothalamicpituitaryadrenal
HRC
LDL
low-density lipoprotein
ICH
intracranial haemorrhage
LDLT
ICP
intracranial pressure
LFTs
ICT
LMA
LN
liaison nurse
LOC
level of consciousness
technologies
ICU
ICU-AW
LOC
loss of consciousness
ICU LN
LP
lumbar puncture
IDC
indwelling catheter
LVAD
I:E
inspiratory:expiratory (ratio)
LVEDV
IES
LVEF
IgE
immunoglobulin E
LVF
IHD
intermittent haemodialysis
LVP
IL
interleukin
LVSWI
ILCOR
MAP
MARS
Resuscitation
IMA
MASS
INR
MCA
IO
intraosseous
MED
IPP
MET
IPPV
MET(s)
metabolic equivalent(s)
IPT
information-processing theory
MEWS
ISS
MIDCAB
ITBV
IVC
MIDCM
IVIg
intravenous immunoglobulin
mmHg
JE
Japanese B encephalitis
MODS
LAD
MRI
LAP
MRO
bypass
minimally invasive direct cardiac massage
millimetres of mercury
multiple organ dysfunction syndrome
magnetic resonance imaging
multi-resistant organisms
www.ketabpezeshki.com
A B B R E V I AT I O N S
Paw
MRS
Pv
venous pressure
MRSA
PAC
MVC
PAF
platelet-activating factor
MVE
PALS
NAC
N-acetylcysteine
PaO2
NAS
PAOP
NASCIS
PAP
NAT
PART
patient-at-risk team
NDE
near-death experience
PAWP
NDU
PbtO2
NE
norepinephrine
NF B
NGT
nasogastric tube
NHBD
non-heart-beating donation
NHMRC
NHP
NIBP
NIRS
near-infrared spectroscopy
NIV
non-invasive ventilation
NMB
neuromuscular blocking
NMDA
N-methyl-d-aspartate
NMJ
neuromuscular junction
NO
nitrous oxide
NO2
nitric oxide
NOC
NOK
next of kin
NP
nurse practitioner
NPA
nasopharyngeal aspirate
NPP
NPY
neuropeptide Y
NSAIDs
NTS
NTT
nasotracheal tube
NYHA
O2
oxygen
ODIN
OEF
OHCA
OLTx
OSA
OTDA
PA
alveolar pressure
Pa
arterial pressure
PaCO2
PaO
xxi
PSG
polysomnography
PCI
PT
prothrombin time
PCT
PTA
posttraumatic amnesia
PCV
pressure-controlled ventilation
PTCA
PCWP
angioplasty
PD
peritoneal dialysis
PTSD
PDH
PTSS
PDR
PTT
PDSA
Pv
PDU
PvO
PE
pulmonary embolism
PVR
PEA
QI
quality improvement
PEEP
QOL
quality of life
PEFR
QOLIT
PET
QOLSP
PETCO2
QUM
pH
QWB
quality of wellbeing
PI
pulsatility index
RAAS
reninangiotensinaldosterone system
PICC
RASS
PiCCO
RAS
PICU
RBC
PN
parenteral nutrition
RCA
PND
RCA
PNS
RCSQ
Pplat
plateau pressure
REM
PPE
RICA
ROSC
RRS
RR
respiratory rate
PROWESS
PRVC
venous pressure
2
www.ketabpezeshki.com
xxii
A B B R E V I AT I O N S
STEMI
RRT
SVDK
RRT
SVG
RTS
SVR
RVF
SVT
supraventricular tachycardia
RVP
SVV
RVSWI
SaO
SpO
SvO2
SA
sinoatrial
SAC
SAED
SAFE
SAH
subarachnoid haemorrhage
SAI
SAPS
SARS
SARS-CoV
SAS
SBE
SBP
SCA
SCI
SCUF
SE
status epilepticus
SEI
SF-36
Short Form 36
SGRQ
SIADH
SICQ
SIG
SIMV
SIP
SIRS
SjvO
SLTx
SOFA
assessment
SPECT
SR
systematic review
SSG
STAI
UO
urine output
upper respiratory tract infection
SWS
URTI
TAFI
ventilation
TB
tuberculosis
V/Q
ventilation/perfusion
TBI
VT
tidal volume
ventilator-associated lung injury
TCD
transcranial Doppler
VALI
TEG
thromboelastograph
VAP
ventilator-acquired pneumonia
TIPS
VAS
VAS-A
shunt/stent
TISS
VC
vital capacity
TLC
VC
volume-controlled (ventilation)
TNF
VCv
TNS
VE
minute ventilation
TOE
transoesophageal echocardiograph/y
VF
ventricular fibrillation
tPA
VICS
tPD
VO2
oxygen consumption
TPN
VRE
vancomycin-resistant Enterococcus
TPR
VT
ventricular tachycardia
VTE
venous thromboembolism
VV
veno-venous
TSANZ
TSC
WBC
TSH
thyroid-stimulating hormone
WCC
TST
WFCCN
TT
thrombin time
WHO
TV
tidal volume
WOB
work of breathing
TVI
XeCT
UEC
www.ketabpezeshki.com
SECTION
www.ketabpezeshki.com
www.ketabpezeshki.com
Leanne Aitken
expenditure.2
Wendy Chaboyer
Doug Elliott
Learning objectives
After reading this chapter, you should be able to:
y 119,000
units (ICUs)
of
individual nurses
de. In New
r to 26 ICUs,
ed to coro-
Key words
much higher
dmissions to
clinical leadership
INTRODUCTION
conservative
estimate of cost exceeded $A2600 per da
y, with more
ces
fifth to clinical
DEVELOPMENT OF CRITICAL
CARE NURSING
Critical care as a specialty emerged in the 1950s and
1960s in Australasia, North America, Europe and South
Africa.4,8-11 During these early stages, critical care consisted
3
www.ketabpezeshki.com
e units
primarily of coronary care units for the care of cardiol
ogy
d led
ative
care.
care of
lity
today.
a high demand for education specific to critic
al care
Development
of critical care nursing was characteris
ation
ed by
the development of technology such as mech
a number
anical of features,4 including:
s the
he
between nursing and medical clinicians
are
now considered essential elements of critical care.12
As the practice of critical care nursing evolved, s
o did
the associated areas of critical care nursing educ
and specialty professional organisations such a
Australian College of Critical Care Nurses (ACCCN). T
combination of adequate nurse staffing, observati
on of
and practice
nurses
to practise in critical care areas.13 Formal educati
on
ked
12
The role of
nuing
ade-
flective
critical care nursing. The knowledge, skills and atthe advent of specialist critical care units. Initially, this
titude
necessary for quality critical care nursing practic the work setting, with nurses and medical officers learne have
level
(for
example,
Kings
College,
24
Employment in critical
22,25
www.ketabpezeshki.com
beginner
competent
specialist
expert
Induction/
Practice
orientation
to critical
Training
care
nursing
education
Postgraduate
initial competencies
Education
Graduate
Certificate
FIGURE 1.1 Critical care nursing practice: training and education continuum.
des
g education
pen-
unit level.30
s are dis-
cal care
oli-
s and
ual
eir annual
r part-
include ele-
kforce
fessional
ori-
of compe-
urses
ds.31,32
tween
kills, classified
and
erpersonal.
nuum
training and
easing
ompetence is
equally
knowledge,
demon-
performing that skill within the clinical environme research is therefore required to refine the structure of a
nt is
deemed competent. As noted above, a set of compet Other competency domains and assessment tools have
ency
statements for specialist critical care practice co ferently, the American Association of Critical-Care Nurses
mprises
20 competency standards grouped into six do for the Acute and Critical Care Clinical Nurse Specialist,36
mains:
tation and evaluation) and eight standards of professional performance (quality of care, individual practice
evaluation, education, collegiality, ethics, collaboration,
research and resource utilisation) (see Online resources).
organisations
representing
critical
care
www.ketabpezeshki.com
nurses
ber
, and
en-
roles
ns a
include:
ing rights and the prevailing medical views, and the level
below).
Processes for authorisation to practise as a nurse practi- ment are the most well-established in the critical care
tioner (NP) have been introduced by professional regi
consultant
45-47
trauma,
49
emergency
50
(Chapter 22), critical care ou practice and forms part of the clinical reasoning process.
t-
Clinical reasoning is
52-54
(Chapter 2)
vel-
of
rofes-
cribed
with
CONSULTANT
ought
ritical
milar
racic,
in the
ating
ents
e and
ent
involves
clinical practice, education, quality improvemen
t and
research activities.55 Within these work portfolios, lea
dership and the development and dissemination of know
ledge45,46 within a multidisciplinary team are integr
al to
effective practice.47 Practice includes rolemodelling of
expected behaviours, policy and clinical guideline de
actual or potential patient problems, and to make clinical decisions to assist in problem resolution and to achieve positive
patient outcomes.58
THEORETICAL PERSPECTIVES ON
DECISION MAKING
categories:
1. analytical or rationalist
2. intuitive or humanistic.
www.ketabpezeshki.com
63
tio-
and can be
aviours
uitive knowl-
he
nical deci-
or-
ng therefore
ysis
theory (DAT).60
tuition, the
sists
s use intu-
the
That is,
n authors64
eory
amine criti-
emory
g it as a way
olver
ence when
term
memory. Additionally, IPT claims that there are limits
to
us of many
ny
omplex deci-
g how
are, it is an
cuses
ing.61 The
and
ocused on
ing-
10 studies (11
us on
s decision
the
outcome.61
Australia,
aches
g Australia.
eno-
ches such
aloud. Two
studies reported the types and frequency of deci Other studies indicated that experienced and inexperisions
made during the time period and identified that critic and that role models or mentors are important in assistal
61,68
evaluation,
61
68
studies highlighted the importance of enabling ex In summary, clinical decision making is a component of
pert
nurses to provide a narrative account of their pr cal care nursing practice. It involves gathering and analysactice.
LEADERSHIP IN CRITICAL
CARE NURSING
Effective leadership within critical care nursing is essen
tial at several organisational levels, including the unit and
hospital levels, as well as within the specialty on a broader
professional scale. The leadership required at any give
n
time and in any specific setting is a reflection of the surrounding environment. Regardless of the setting, effective
leadership involves having and communicating a clear
vision, motivating a team to achieve a common goal,
making
care team.
conference
76
www.ketabpezeshki.com
presentations,
representation
TABLE 1.1 Australian and international critical care nurses decision-making research
Author [Country]
Bucknall, 200061
[Australia]
200168 [Australia]
Sample
18 CC nurses (range of
Data collection
Observation (2-hour periods)
Findings
Three types of decision:
evaluation (51%)
communication (30%)
intervention (19%)
course)
12 CC nurses with 2 years
CC experience from 3
intervention (40%)
units
groups
communication (26%)
years CC experience
and follow-up
interview
Thinking
aloud (2-hour
periods)
Hypotheses
as a framework for decision
assessmentdeveloped
(19%)
[Australia]
CC nurses from 2
semi-structured interview
organisation (13%)
Clinical
processes
education
(2%)
Observation followed by
metropolitan hospitals;
18 inexperienced
surgery were:
(3 years) and 20
experienced CC nurses
settling in procedures
(3 years).
collegial assistance.
Same as above
Observation in 2 phases:
as above] [Australia]
unstructured, narrative
nursing colleagues.
structured observation
checklist. Followed up by
interview.
suggestive of complications.
Adherence to evidence-based practice also
influenced quality of decision making.
7 CC nurses with a CC
qualification, 5 years
CC experience, and
interviews
included:
working 2 days/week
patients condition
response to therapy
implications of treatment
pathophysiology
options in treatment.
In-depth, semi-structured
Thompson, 2008
67
and Australian
registered nurses
working in surgical,
clinical experience.
interviews
[various countries]
www.ketabpezeshki.com
Sample
Data collection
Findings
Hoffman, 200971
[Australia]
8 CC
4 expert
nurses: 4 novice and
Thinking
period of
aloud
care);
(during
interview
2-hour
[Iran]
14 CC nurses from 4
interviews
3 themes
were involved
in reasoning
strategies:
Expert nurses
were more
proactive in
collecting
relevant cues to anticipate problems and make
decisions.
Ramezani-Badr, 2009
In-depth, semi-structured
104
[Various countries]
hospitals, currently
intuition
with 3 years CC
hypothesis testing.
andCanadian
holding
245experience
Dutch, UK,
at least a bachelor of
make decisions:
nursing.
patients risk-benefits
Thompson, 2009
Judgement classification
66
and Australian
registered
dichotomous
Description
of anurses
clinical situation forratings
whichorthe
clinician has to generateintervene.
questions and develop hypotheses; with
testing74
working in surgical,
ratings on 3 nursing
action74
Clinicians are asked to reflect on their actions after a particular event. Reflection focuses on clinical judgments made,
Description
Iterative hypothesis
additional questioning the clinician will develop further hypotheses. Three phases:
1. asking questions to gather data about a patient
2. justifying the data sought
3. interpreting the data to describe the influence of new information on decisions.
Interactive model
74
Schema (mental structures) used to teach new knowledge by building on previous learning. Three components:
1. advanced organisers blueprint that previews the material to be learned and connects it to previous materials
2. progressive differentiation a general concept presented first is broken down into smaller ideas
3. integrative reconciliation similarities and differences and relationships between concepts explored.
Case study75
Description of a clinical situation with a number of cues, followed by a series of questions. Three types:
1. stable presents information, then asks clinicians about it
2. dynamic presents information, asks the clinicians about it, presents more information, asks more questions
3. dynamic with expert feedback combines the dynamic method with immediate expert feedback.
Reflection on
feelings surrounding the actions and the actions themselves. Reflection on action can be undertaken as an individual
or group activity and is often facilitated by an expert.
Thinking aloud
74
A clinical situation is provided and the clinician is asked to think aloud, or verbalise his/her decisions. Thinking aloud is
generally facilitated by an expert and can be undertaken individually or in groups.
highly organised international specialty in the course Leadership styles vary and are influenced by the mission
of
ues
have
mitment of many critical care leaders throughout using theoretical underpinnings such as transactional
the
world.
www.ketabpezeshki.com
10
indivi
empower staff
to
act
independently and
change
processes and stable contexts
80-85
xpericritical
care personnel are aware of, and willi
ng toenced when a particularly visionary leader leaves
personnel in other areas of the hospital or outside
the . The
challenges often associated with the departure of a l
eader
patients
receive
optimal quality
of car are generally redu
from
a healthcare
organisation
e.
ced in
interdependently
gardless
rsing
and
with
CLINICAL LEADERSHIP
eam
char-
g the
Lead-
they are
the
general characteristics listed above, but has the
85
Members of teams
added
with
ed by
g the
urs
ated
nical
ome
as
developing
new
skills
related
to
their
www.ketabpezeshki.com
11
n numbers
ni-
cal leaders.
89,92
DEVELOPING A BODY OF
KNOWLEDGE
, quantitative
research involves the measurement (in numer
ic form) of
variables and the use of statistics to
test hypotheses.
er-
en reported in
ithin
nificant find-
d over
esearch, the
es
(ICN)
96
sing
knowledge that is being continually expanded and re
fined
by research. Importantly, the ICN acknowledge
s that
mechanisms are needed to support, review and disse
minate research.
RESEARCH
As noted above, research is fundamental in the devel
opment of nursing knowledge and practice. Researc
h is a
systematic inquiry using structured methods to u
nderstand an issue, solve a problem or refine existing kno
wledge. Qualitative research involves in-depth examina
tion
of a phenomenon of interest, typically using intervie
ws,
observation or document analysis to build knowle
dge
and enable depth of understanding. Qualitativ
e data
analysis is in narrative (text) form and involves some
form
of content or thematic analysis, with findings ge
nerally
T), is used
QUAL QUANT: both approaches are given e
to test the effect of a new nursing interventio
qual
n on patient
QUAL quant:
qualitative methods are the domin
ant
outcomes. In essence, clinical trials involve:
QUAL quant: the qualitative study is given priori
ty
the
intervention
or
alternative
treatment
treatment.
ss
nd
based
Description
Identify a clinical
A comprehensive literature review is vital to ensure that the issue or problem has not yet been solved and that the
proposed research will fill a gap in knowledge.
Write a research
considerations and the required resources (i.e. budget) for the research are identified.
Secure resources.
Resources such as funding for supplies and research staff, institutional support and access to experienced
researchers are needed to ensure a study can be completed.
Obtain
ethics
problem
or approvals.
issue.
Approval
of the proposed
researchaudits
by a human
ethics
committee
is required
before the study can
Clinical experience
and practice
are tworesearch
ways that
clinical
issues (HREC)
or problems
are identified.
commence.
Adequate time for recruitment of participants and data collection are crucial to ensure that accurate data are
question.
Disseminate the
proposal.
obtained.
A concise question includes both the phenomenon of interest and the patient population.
Clear
the proposed
design and
sample and
a plan continue
for data collection
and analysis. Ethical
and description
are vital to of
ensure
that both research
nursing practice
and nursing
knowledge
to be developed.
research findings.
www.ketabpezeshki.com
Conference presentations and journal publications are two common ways that research findings are disseminated
12
Research program
issues
& training
Technology
Practice
Patient
development
outcomes
Practice
based practice
Health status/
Evidence-
Patient/family
HRQOL
Policy
Education
assessment
systems
Clinical
information
Competencies
issues
Commonwealth &
evaluation
Product
Credentialling
Impact of
state policies
evaluation
experiences
Ethical &
international factors
Resource
Economic
Impact of
utilisation
evaluation
technology on
Program
legal issues
patient care
FIGURE 1.2 Example of critical care nursing research program.
ta-
d in
o-
s.
fessorial level,
99
and
urses
multi-
e, the
ical
etitive
ng geo-
grant
s to
The
ally
rawn
able
Care
litate
ine
i-
me.
sts
in
can be
s great
value in receiving a critical review of proposed r
esearch
before the study is undertaken, as assessors co research utilisation approaches, with a description of
mments
Over the years, various groups have identified pr this text contains a research critique to assist nurses in
iorities
for critical care research. A review of this literature id determine whether research evidence should change
enti-
practice.
SUMMARY
les,
While not all nurses are expected to conduct researc for studying and practising nursing in a range of critical
h, it
is a professional responsibility to use research in and ever-expanding scope of practice. The previous focus
practice.
101
on of
ONLINE RESOURCES
American Association of Critical-Care Nurses, www.aacn.org
Annual Scientific Meeting on Intensive Care, www.intensivecareasm.com.au
Australian College of Critical Care Nurses, www.acccn.com.au
Australia and New Zealand Intensive Care Society, www.anzics.com.au
British Association of Critical Care Nurses, www.baccn.org.uk
College of Intensive Care Medicine, www.cicm.org.au
Intensive Care Foundation (Australia and New Zealand),
www.intensivecareappeal.com
Kings College, London, www.kcl.ac.uk/schools/nursing
World Federation of Critical Care Nurses, http://en.wfccn.org
www.ketabpezeshki.com
13
Research vignette
Aitken L, Marshall AP, Elliott R, McKinley S. Critical care nurses deci-
Critique
The study aim was to identify the concepts and attributes used
by
Abstract
Aims
cesses that nurses use when assessing and managing sedation for
n-
Background
care areas; poster reminders; and audit and feedback. The aims
of the study were easy to identify and clearly stated, but the incl
u-
Design
rt
Observational study.
Methods
Nurses providing sedation management for a critically ill patient
were observed and asked to think aloud during two separate occasions for two hours of care. Follow-up interviews were conducted
to collect data from five expert critical care nurses pre- and postimplementation of a sedation guideline. Data from all sources were
integrated, with data analysis identifying the type and number of
attributes and concepts used to form decisions.
Results
Attributes and concepts most frequently used related to sedation
and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes
related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes
related to assessment (pre, 58%; post, 65%), physiology (pre, 10%;
post, 9%) and treatment (pre, 31%; post, 26%) aspects of care.
Conclusions
Decision making in this setting is highly complex, incorporating a
wide range of attributes that concentrate primarily on assessment
aspects of care.
Relevance to clinical practice
Clinical guidelines should provide support for strategies known to
positively influence practice. Further, the education of nurses to
use such guidelines optimally must take into account the highly
complex iterative process and wide range of data sources used to
make decisions.
concept.
expertby their peers and superiors. It was not clear, however, how
the data of the two pilot nurses was actually incorporated into the
findings. That is, as their data was only pre-protocol, the reported
clarify the activities that were observed. Two observers were used
to collect the data. The qualitative nature of the study and the data
in this study. The method used for analysing data that is, having
the observers analyse the data they collected, and the investigator
interview data but do not elaborate how this was done, possibly
collected the data for that particular nurse. As part of this analysis,
They note, however, that that they were able to identify relation-
The sample size five nurses observed twice each (i.e. before and
to have critical care qualifications and more than five years experi-
tional evidence about the concepts and attributes that critical care
www.ketabpezeshki.com
14
Learning activities
1. Consider the leaders to whom you are exposed in your
1. Drennan K, Hicks P, Hart GK. Intensive care resources and activity: Aus
tralia &
develop them.
2. Mentors are generally individuals who have excelled in
Australian intensive care unit. Anaesth Intensive Care 2005; 33(4): 477
82.
3. Hilberman M. The evolution of intensive care units. Crit Care Med 197
5;
3(4): 15965.
4. Wiles V, Daffurn K. Theres a bird in my hand and a bear by the bed I
must be
making skills. Approach a mentor in your clinical environment and ask him/her to provide feedback over a period of
months on any changes observed in your clinical decision-
making skills.
4. Consider the role that you have within critical care and
pub_constitution.php.
6. American Association of Critical-Care Nurses. Critical care nursing fact
sheet.
Aliso Viejo CA: American Association of Critical Care Nurses; 2008. [Cit
ed
FURTHER READING
Andrew S, Halcomb EJ. Mixed methods research for nursing and the health scie
nces.
Oxford: Wiley-Blackwell; 2009.
Thompson C, Dowding D. Essential decision making and clinical judgment for
nurses.
Edinburgh: Churchill Livingstone; 2010.
REFERENCES
education/doc1290_en.htm.
11. Grenvik A, Pinsky MR. Evolution of the intensive care unit as a clinical center
and critical care medicine as a discipline. Crit Care Clinics 2009; 25(1):
23950.
review of the literature. Intensive Crit Care Nurs 2005; 21(5): 26875.
26. Hardcastle JE. Back to the bedside: graduate level education in critical care.
Nurse Educ Pract 2008; 8(1): 4653.
12. Fairman J, Lynaugh JE. Critical care nursing: a history. Philadelphia: University
of Pennsylvania Press; 1998.
14. Australian College of Critical Care Nurses. Competency standards for specialist
critical care nurses, 2nd edn. Melbourne: Australian College of Critical Care
Nurses; 2002.
15. Aari R-L, Tarja S, Leino-Kilpi H. Competence in intensive and critical care
nursing: a literature review. Intensive Crit Care Nurs 2008; 24: 7889.
16. Bench S, Crowe D, Day T et al. Developing a competency framework for
critical care to match patient need. Intensive Crit Care Nurs 2003; 19:
13642.
30. Nalle MA, Brown ML, Herrin DM. The Nursing Continuing Education Consortium: a collaborative model for education and practice. Nurs Admin Q
2001; 26(1): 6066.
31. Nursing and Midwifery Board of Australia. Australian Health Practitioner
Regulation Agency; 2011. [Cited January 2011] Available from: http://www.
17. Coghlan J. Critical care nursing in Australia. Intensive Care Nurs 1986; 2(1):
37.
nursingmidwiferyboard.gov.au.
32. Nursing Council of New Zealand. Welcome to the Nursing Council of New
18. Armstrong DJ, Adam J. The impact of a postgraduate critical care course on
nursing practice. Nurse Education in Practice 2002; 2(3): 16975.
19. Badir A. A review of international critical care education requirements and
Zealand. Nursing Council of New Zealand; 2008. [Cited January 2011]. Available from: http://www.nursingcouncil.org.nz/index.cfm/1,25,html/Home.
33. Cowan DT, Norman I, Coopamah VP. Competence in nursing practice: a
comparisons with Turkey. Connect: The World of Critical Care Nursing 2004;
3(2): 4851.
25: 35562.
20. Baktoft B, Drigo E, Hohl ML et al. A survey of critical care nursing education
in Europe. Connect: The World of Critical Care Nursing 2003; 2(3): 857.
21. Chaboyer W, Dunn SV, Aitken L et al. Critical care education: an examination
of students perspectives. Nurse Educ Today 2001; 21: 52633.
22. Aitken L, Currey J, Marshall A et al. The diversity of critical care nursing
education in Australian universities. Australian Crit Care 2006; 19(2):
4652.
34. Boyle M, Butcher R, Kenney C. Study to validate the outcome goal, competencies and educational objectives for use in intensive care orientation programs. Aust Crit Care 1998; 11: 204.
35. Fisher MJ, Marshall AP, Kendrick TS. Competency standards for critical care
nurses: do they measure up? Aust J Adv Nurs 2005; 22(4): 329.
36. American Association of Critical-Care Nurses. Scope of practice and standards
of professional performance for the acute and critical care clinical nurse specialist.
www.ketabpezeshki.com
15
a new model of
critical care nursing organisations and their activities. Int Nurs Rev 2001;
48:
20817.
39. World Federation of Critical Care Nurses (WFCCN). [Cited January 2011].
Available from: http://en.wfccn.org.
edge, skills, and meanings in nursing practice. Am J Crit Care 2004; 13(5)
:
42630.
n nurse service
human simulation in critical care. AACN Clinical Issues 2005; 16: 89104.
42. Angus DC, Carlet J. Surviving intensive care: a report from the 2002 Brus
sels
Roundtable. Intensive Care Med 2003; 29(3): 36877.
43. Bailly N, Perrier M, Bougle M et al. The relationship between palliative an
44. Ball C. Defining the nursing contribution in critical care. Intensive Crit Ca
re
13343.
55. Elliott D, Giles B, deLeon T et al. Development and impleme
ntation of an
45. Ball C, Cox CL. Restoring patients to health: outcomes and indicators of
advanced nursing practice in adult critical care, Part One. Int J Nurs Prac
t
practitioners. J
46. Ball C, Cox CL. The core components of legitimate influence and the con
di-
nurse practi-
al
information
51724.
58. Fonteyn ME, Ritter BJ. Clinical reasoning in nursing. In: Higg
s J, Jones MA,
48. Lloyd Jones M. Role development and effective practice in specialist and
advanced practice roles in acute hospital settings: systematic review an
44.
49. Martin KD. Trauma advanced practice nurses: implementing the rol
e. J
ffs: Prentice-
Hall; 1972.
60. Kassirer JP, Moskowitz AJ, Lau J et al. Decision analysis: a progress report
.
67. Thompson C, Dalgleish L, Bucknall T et al. The effects of time pressure and
Ann Intern Med 1987; 106(2): 27591.
61. Bucknall TK. Critical care nurses decision-making activities in the natur
al
70. Currey J, Botti M. The influence of patient complexity and nurses experience
ce:
ing
nurses cue collection during clinical decision-making: verbal protocol analyCompany; 2009. p. 13769.
64. Currey J, Botti M. Naturalistic decision making: a model to overcome met 72. Hough M. Learning, decisions and transformation in critical care nursing
ho-
11.
education. In: Higgs J, Jones MA, Loftus S et al, eds. Clinical reasoning in
nti-
3):
p. 40530.
75. Rivett DA, Jones MA. Using case reports to teach clinical reasoning. In: Higgs
1328.
66. Thompson C, Bucknall T, Estabrookes CA et al. Nurses critical event risk
assessments: a judgement analysis. J Clin Nurs 2009; 18(4): 60112.
J, Jones M, Loftus S et al, eds. Clinical reasoning in the health professions, 3rd
edn. Philadelphia: Butterworth-Heinemann; 2008. p. 47784.
76. Davidson PM, Elliott D, Daly J. Clinical leadership in contemporary clinical
practice: implications for nursing in Australia. J Nurs Manag 2006; 14:
18087.
77. Shirey MR. Authentic leaders creating healthy work environments for nursing
practice. Am J Crit Care 2006; 15(3): 25668.
78. Shirey MR, Fisher ML. Leadership agenda for change toward healthy work
environments in acute and critical care. Crit Care Nurse 2008; 28(5): 66.
79. Crofts L. A leadership programme for critical care. Intensive Crit Care Nurs
2006; 22(4): 2207.
80. Cook MJ. The renaissance of clinical leadership. Int Nurs Rev 2001;
48(1):3846.
81. De Geest S, Claessens P, Longerich H et al. Transformational leadership:
worthwhile the investment! Eur J Cardiovasc Nurs 2003; 2(1): 35.
82. Manojlovich M. The effect of nursing leadership on hospital nurses professional practice behaviors. J Nurs Adm 2005; 35(78): 36674.
83. Murphy L. Transformational leadership: a cascading chain reaction. J Nurs
Manag 2005; 13(2): 12836.
84. Ohman KA. Nurse manager leadership. J Nurs Adm 1999; 29(12): 16, 21.
85. Ohman KA. The transformational leadership of critical care nurse-managers.
Dimens Crit Care Nurs 2000; 19(1): 4654.
86. Tregunno D, Jeffs L, Hall LM et al. On the ball: leadership for patient safety
and learning in critical care. J Nurs Admin 2009; 39(78): 3349.
87. Dierckx de Casterl B, Willemse A, Verschueren M et al. Impact of clinical
leadership development on the clinical leader, nursing team and care-giving
process: a case study. J Nurs Manag 2008; 16(6): 75363.
32636.
81.
89. Taylor CA, Taylor JC, Stoller JK. The influence of mentorship and role modeling on developing physician-leaders: views of aspiring and established physician-leaders. J Gen Intern Med 2009; 24(10): 113034.
90. Williams AK, Parker VT, Milson-Hawke S et al. Preparing clinical nurse
leaders in a regional Australian teaching hospital. J Continuing Educ Nurs
2009; 40(12): 5717.
www.ketabpezeshki.com
16
98. Elliott D. Making research connections to improve clinical practice [edit 102. Aitken LM, Marshall AP, Elliott R et al. Critical care nurses decision making:
o-
99. Dunn S, Yates P. The roles of Australian chairs in clinical nursing. J Adv
Nurs
18(1): 3645.
103. Hough MC. Learning, decisions and transformation in critical care nursing
practice. Nurs Ethics 2008; 15(3): 32231.
104. Ramezani-Badr F, Nasrabadi AN, Yekta ZP et al. Strategies and criteria for
100. Marshall AP. Research priorities for Australian critical care nurses: Do w
www.ketabpezeshki.com
Denise Harris
INTRODUCTION Ged Williams
Learning objectives
workforce
Key words
resource management
critical care
business case
staf
competence
credentialling
UTILISATION OF RESOURCES
governance
skill mix
budget
risk management
pandemic
patient dependency
www.ketabpezeshki.com
18
all
he rule
its high-
hing
par-
to the
within a
to
care
many
fficient
h.
seen
clini-
giti-
take a
HISTORICAL INFLUENCES
hat
ealth
ered
in a given situation).
ervices.3
gests
arger
for
ract
sit
well with pragmatic managers and policy makers.
2
An
1970s
saw the development of the first critical care uni
ts in
ng
e-
aved
hed a
eart
economies
of scale
by cohorting
patie
disease
prevention
campaign
lends acritically
greater ill
benefit
nts
to adevelopment of expertise in doctors and nurs
es who
greater
number in the population than does one
itals
ab-
re
the
tween
not
limited to:
specialise in the care and treatment of critical the severe end of the disease spectrum. For instance, the
ly ill
patients
critically ill patient outcomes are better if patients same diagnosis, but treated only in a medical ward. Each
are
cared for in a specifically equipped and staffed crit unique approach to funding ICU services in its jurisdicical
care unit.4
pied.
13
www.ketabpezeshki.com
19
make
Funding based on achieving positive patient outc
omes
all-in/over-
nits
approach
s who
were most likely to achieve positive outcomes in ter
all teams
to of treatment and the inherent
The benefit
d access to
approach
Evaluate the
benefit and cost
education,
training
andof the
peer support ca
ms of
n also create
vel-
am. Further-
h out-
empathetic
ing
unique to
e or
If such units
ers. In
ering levels of
or
e expected in
ts for
al funding
be
more common, whereas in the public hospitals of mo
st
Western countries an educated guess/risk is often ap
plied
to the decision as to whether a patient should enter t
he
critical care unit or not.
It is vital to note the very important role played by ru
ECONOMIC CONSIDERATIONS
AND PRINCIPLES
One early comprehensive study of costs f
ound that 8%
Valueof patients
ral
med 50% of
care
ile 41% of
the
nd consumed
diffi-
ralian studies
es of
increasingly
umbers,
ity of acute
re-
utcome has
l care service
may still be cost-effective
despite
the
changes in
case-mix.15,16
Approach
Benefitrisk
Description
tients
on,
monetary costs.
Benefitcost
fifth
upport
Implicit approach
authors
provide scenarios as examples of poor economic deci suggested that if all healthcare provided were appropriate,
sion
making in critical care and argue for less extrem appropriate can be subjective, although not always. The
e vari-
ances in the types of patient ICUs choose to treat in o approaches that can be used to assess appropriateness of
rder
18,19
have
the
medical
practitioner
must
contemplat
e
benefitrisk and benefitcost considerations but should
also involve the patient/family in the contemplation and
ultimate decision. What is best for the patient is not just
the opinion of the treating doctor and needs to
be
considered in much broader terms, such as the patients
previous expressed wishes and the familys opinion as
de-facto patient representatives. The quality of the
decision and the quality of the expected outcome require
many competing considerations.
The quality agenda in healthcare has argued for bes
t
practice and best outcomes in the provision of healt
h
services, although it may be more pragmatic to consider
value when discussing what is and what is not an appropriate decision in critical care. The following equation
expresses the concept value simply:
Quality
Cost
Benefit Sustainability
Price Suffering
have used the resources but for the current occupants, and
and
non-monetary
(suffering).
Non-monetary
costs
www.ketabpezeshki.com
20
uisite
Ethico-economic analyses of services like critical care
and
key
re the
ng,
portant
by
-legal
or
services budget.
and
TYPES OF BUDGET
and
nager
critical
thin
care resources.
BUDGET
rvice
the
ons
en-
anager
ely.
e with
ini-
staff
h as to
flux of
their
ess-
an-
Personnel Budget
the
are
er-
xpen-
wants,
uire-
to
of x
eci-
ressed
will it
quiva-
siness
quates
day off every 4 weeks, or 19 12-hour shif attributed to work done during the after-business-hours
ts in a
6-week period.
other paid time away from the actual job that staff are
productive
employed to do.
hours. Productive hours are those utilised to prov Personnel budgets tend to be fixed costs, in that the
ide
direct work. A manager will determine the minimum expected or forecast demand. Prudent managers tend to
or
optimum number of nurses to be rostered per shift a use casual staff to flex-up the available FTE staff estand
then calculate the nursing hours per day, multipl tributing a small but variable component to the personnel
ied by
budget.22
Operational Budget
All other non-personnel costs (except major capital
equipment) tend to be allocated to the operational
budget. This includes fixed costs such as minor equipment, maintenance contracts, utility costs (e.g. electricity), and variable costs that fluctuate with patient type
and number (e.g. pharmaceuticals, meals, consumable
supplies such as gloves and dressings, laundry).
Compared with personnel costs, operational costs in critical care tend to be relatively small, but they can be
managed and rationed with the help of good information
and cooperation. For example, there is a range of dressing
materials available on the market, and a simple dressing
that requires less expensive materials should always be
used unless a more expensive product is indicated and a
protocol exists to inform staff of this clinical need.
Fixed costs can also be turned into variable costs and
hence encourage efficient usage. For example, pressurereduction mattresses, traditionally purchased as a fixed
asset with variable (and unpredictable) repair and maintenance costs, can now be leased on a per-day or per-week
basis, with no need for storage, cleaning or maintenance
costs. Further, critical care managers can work with other
hospital managers to create purchasing power by cooperating to standardise the range of products used to obtain
a better price for a product that will benefit all users.
Capital Budget
Capital budget items are generally expensive and/or large
fixed assets that are considered long-term investments,
such as building extensions, renovations and large equipment purchases. Capital budget items tend to be considered as assets that are depreciated over time. Most
hospitals consider these items as a global asset that is,
unit or department.
required
describing
the
item,
its
expected
www.ketabpezeshki.com
21
BUDGET PROCESS
variable)
dget
own measur-
ing,
e.g. patient
urs, includ-
cannot be
ty and
al manag-
he pre-
e managers
k on
d reports to
hospital
hey should
atient
dget target.
to
verrun are
evel-
the financial
with
s out. Every
esen-
explanation.
the
ity influ-
ucted,
casual staff
tion
be insidious
nts, although
enditure
time man-
ntify
boost their
uld
income surreptitiously.22
and
year-to-date expenditures for personnel
(productive and
budget is
actively to engage staff in the process
of managing
been developed and how their performance a an esprit de corps and improvements from the whole
gainst
A BUSINESS CASE
improvement. Seeking ideas from staff on how to im to justify the resources and capital expenditure to gain
prove
Example
Why?
What?
What if?
background material?
Where?
How?
www.ketabpezeshki.com
22
onal
policies of each individual facility. In smaller facili
BOX 2.1
ties,
Title
Purpose
ded in
Background
Key issues
coro-
Costbenefit analysis
Recommendations
use
Risk assessment
of available resources.26
ORGANISATIONAL DESIGN
The functional organisational and unit designs ar
e govIn summary, the business case is an important tool t
hat
the
n to
in
ocu-
ld
cost-
ude
solution.
tients
ensuites, patients bathroom, linen storage, dis
posal
hat
he
perating
be well
ents
designed.26
es
onsid-
peutic
ost
resources required.
26
edi-
elines
care to
d be
ospital,
visual
ort
sin
services.
27
tent
ded
ach
bed space should have piped medical gases (oxygen
and
Monitoring
and
Therapeutic
Ventilators (invasive and
arterial
intracranial pressure
PiCCO
pulmonary artery
non-invasive)
Infusion pumps
Syringe drivers
CVVHDF
EDD-f
Resuscitators
Temporary pacemaker
Defibrillator
Suctioning apparatus
EQUIPMENT
Since the advent of critical care units, healthcare delivery
has become increasingly dependent on medical technology to deliver that care. Equipment can be categorised
into several funding groups: capital expenditure (generally in excess of $10,000), equipment expenditure (all
equipment less than $10,000), and the disposable products and devices required to support the use of equipment. This section examines how to evaluate, procure and
maintain that equipment.
PURCHASING
The procurement of any equipment or medical device
tee exists to support this process, but if this is not the case
www.ketabpezeshki.com
23
Performance
Quality
Use
Costbenefit analysis
purpose
Cleaning
ease of
gy approved
by the hospital or state government. The
advantages of
leasing equipment include the capital expendi
ture being
defrayed over the life of the lease (usuall
y 36 months),
with ongoing servicing and product upgrad
include disposables
Regulatory
control
es built into
the lease agreement and price structure. Any
central sterilising
unit (CSSU)
Adaptability
to future supply
technological
advancements
Service
agreements
infection
control
Training requirements
Australian Standards
ase or lease,
g expendi-
ent is closely
being
ew equip-
di-
owever, can
erile
y biomedical
ol,
of equipment
similar
pital equip-
been
n of
the physi-
he
ortant part
evices
nce may be
lish its
viability, thus avoiding any unnecessary expendit
ure in
time and money.28
ence patient outcomes both directly, through the initiaprovided in-house by individual facility biomedical
influence them.
STAFFING ROLES
ed
budget process.
practice
coordinator/clinical
nurse
STAFF
www.ketabpezeshki.com
24
such
to provide resources, education and leadership.30
Regis-
by the
with
b-
qualifications
and
lso
urse
ncies
riti-
of
rtifi-
cates.
31
census
based
fica-
aduate
ital-
ed on
pro-
(see
patients
have
s has
tical
here
also
orsed
part-
New
tive/
EENs
edi-
there
STAFFING LEVELS
A,
f nurses
untries
actors,
ical or
ar-
mi-
this
chapter. Once the base staffing numbers per shif helpful for new units to contact a unit of similar size and
t have
NURSE-TO-PATIENT RATIOS
late the number of full-time equivalents that are requ Nurse-to-patient ratios refer to the number of nursing
ired
to implement the roster. In Australia, one FTE is equal of needs. With approximately 30% of Australian and New
to
intensive
coronary
care
and
high-dependency
care,
34
note
that
nurse-to-patient
ratios
are
provided
years of patient throughput and patient acuity asshould depend on patient acuity, local knowledge and
sist in
expertise.
the determination of future requirements. It is Within the intensive care environment in Australia and
often
of
the
New
Zealand
Nursing
Organisation
PATIENT DEPENDENCY
Patient dependency refers to an approach to quantify the
38
For
bed-day costs.
www.ketabpezeshki.com
TABLE 2.4 Documents that guide the nurse-to-patient ratios in critical care
Document
Recommendations
All intensive care patients must have a registered nurse (division 1) allocated exclusively to their care.
High-dependency or step-down patients (in intensive care) who require a nurse-to-patient ratio of
30
35
1:2 should have a registered nurse (division 1) allocated exclusively to their care.
Enrolled nurses (division 2) and unlicensed assistive personnel may be allocated roles to assist the
registered nurse, but any activities that involve direct contact with the patient must always be
The critically ill and/or ventilated patient will require a minimum 1 :1 nurse-to-patient ratio.
At times, patients in the critical care unit may have higher or lower nursing acuity; the critical care
nurse in charge of the shift determines any variation from the 1 :1 ratio, taking into account context,
Critically ill patients (clinically determined) require one registered nurse at all times.
High-dependency patients (clinically determined) in a critical care unit require no less than one
Workforce
36
A minimum of 1 :1 nursing is required for ventilated and other similarly critically ill patients, and
nursing staff must be available to greater than 1 :1 ratio for patients requiring complex management
(e.g. ventricular assist device).
CICM: Recommendations on
The majority of nursing staff should have a post-registration qualification in intensive care or in the
specialty of the unit.
All nursing staff in the unit responsible for direct patient care should be registered nurses.
All nursing staff in the HDU responsible for direct patient care should be registered nurses, and the
Medicine
37
majority of all senior nurses should have a post-registration qualification in intensive care or
determined)
(clinically determined)
Require apresent.
standard nurse-to-patient ratio of at least 1 :2
ACCCN Australian College of Critical Care Nurses; NZNO New Zealand Nurses Organisation; WFCCN World Federation of Critical Care Nurses; CICM College of
leader)
There must be a designated critical-care-qualified senior nurse per shift who is supernumerary and whose
Description
These are nurses in addition to the bedside nurses, clinical coordinator, unit manager, educators and
non-nursing support staff. They provide Assistance, Coordination, Contingency, Education, Supervision
and Support.
5. Nursing manager
At least one designated nursing manager (NUM/CNC/NPC/CNM or equivalent) who is formally recognised as
the unit nurse leader is required per ICU.
At least one designated CNE should be available in each unit. The recommended ratio is one FTE CNE for
every 50 nurses on the ICU roster.
Provide global critical care resources, education and leadership to specific units, to hospital and area-wide
services, and to the tertiary education sector.
The ACCCN recommends an optimum specialty qualified critical care nurse proportion of 75%.
9. Resources
These are allocated to support nursing time and costs associated with quality assurance activities, nursing
and multidisciplinary research, and conference attendance.
ICUs are provided with adequate administrative staff, ward assistants, manual handling assistance/
equipment, cleaning and other support staff to ensure that such tasks are not the responsibility of nursing
personnel.
ACCCN Australian College of Critical Care Nurses; CNC clinical nurse consultant; CNE clinical nurse educator; CNM clinical nurse manager; FTE full-time
equivalent; NPC nurse practice coordinator; NUM nursing unit manager.
www.ketabpezeshki.com
26
ion
vel,
S)
plexity
systems.Althoughthesescoringsystemshavevalueinde
ter-
psycho-
38
Strict adherence to
the
are not
good predictors of nursing dependency or workload.38
h-
) was
ICU
ablish
re than
utilisa-
cedure/
may
mise
dary to
, the
onfu-
ss, the
38
A patient c
ensus
nce its
sing
mul-
, nor
nd
tiv-
of the
s.
the
tion
may
sify
ents
d to
not
of
pe-
ified
e not
coring
New
es, such
rkload
this chapter.)
While not strictly workload tools, various early w qualified critical care nurse to unqualified critical care
arning
scoring systems are increasingly being used to f New Zealand, approximately 50% of the nurses employed
acilitate
Debate
continues
in
an
attempt
to
determine
the
early warning systems generally take the format of a optimum skill mix required to provide safe, effective
stan-
dardised observation chart with an in-built track this debate has been undertaken in the general ward
and
trigger process.3941
SKILL MIX
Skill mix refers to the ratio of caregivers with va been discussed as one potential solution to the current
rying
levels of skill, training and experience in a clinic ling the use of EENs in the critical care environment have
al unit.
In critical care, skill mix also refers to the proportion Published research on skill mix has examined the substiof
34
www.ketabpezeshki.com