Caring for the critically ill cardiothoracic patient requires a multidisciplinary approach with nursing roles being pivotal. Nursing the critically ill cardiothoracic patient requires advanced skills and competence as well as in-depth knowledge of nursing practice, anatomy, physiology and pathophysiology, technology and pharmacology used in critical care. Integral to the nurses’ role is supporting patients and their families during and after critical illness.
Critical care areas are constantly adapting to the needs of the patient and now often extend beyond the physical unit itself. The concept of ‘critical care without walls’ is well established and ensures continuity of the patient pathway before, during and after the ICU admission. Many units now further defragment the care of the critically ill patient through advanced nurse practice, developing the role of the healthcare support worker, establishing new ways of working and offering nurse led services.
Most critical care area nursing teams include a dedicated education team, their role being primarily to ensure access to all nurses to appropriate education and to support the senior nursing team in sharing best practice.
Critical care is a complex specialty with the new nurse having to acquire many skills and competencies. The education team provides both a framework and support to meet these needs. Technology within critical care is constantly evolving and the education team has a vital role in ensuring all new equipment is introduced with a robust training programme to ensure patient safety.
It is important that all nurses are provided with the opportunity to develop throughout their careers. The education team is able to ensure all staff have access to appropriate educational opportunities.
Integral to the care of the patient is the bedside nurse. Their roles vary in different cardiac intensive care units and countries, but they are the person who has the most contact with the critically ill patient. The roles of the bedside nurse are summarised in Table 53.1. In critical care this is a registered practitioner who enhances the delivery of comprehensive patient centred care, for acutely ill patients, often on a 1:1 basis. Structured handover at the start of each shift ensures accurate transfer of clinical information ensuring continuity of safe care.
The primary role of the bedside nurse is continuous vigilance of the patient’s vital signs, recognising and assessing changes and responding immediately. This response includes communicating with the nurse in charge and the rest of the multidisciplinary team (MDT) where appropriate.
Many patients are invasively monitored. Setting up, calibration and appropriate alarm limits to ensure accuracy and safety of monitoring is the responsibility of the nurse. The critically ill cardiothoracic patient may also require advanced support ranging from continuous renal replacement therapy (CRRT) and intra-aortic balloon pump (IABP) to ventricular assist devices (VAD) or extracorporeal membrane oxygenation (ECMO). Monitoring of the patient on these devices is the responsibility of the bedside nurse. In addition to basic nurse education, critical care nurses have specialised training. This training includes setting up and ongoing management of monitoring equipment and advanced mechanical support to ensure patient safety.
Assessing the needs and delivering basic nursing care remains an essential component of the bedside nurse role. This includes communication with and support of both the patient and their family. Although the primary focus is the allocated patient, the nurse is part of a team delivering care and responding to the changing demands of the unit. This includes responding to unexpected events to allowing rapid turnover of patients when necessary, whilst ensuring patient care is never compromised.
The role of the bedside nurse may vary between units but regardless of differing degrees of autonomy, central to the bedside nurse role is the ability to rapidly respond to potentially life threatening conditions.
Health Care Support Worker/Assistant Practitioners
The value of the health care support worker role within cardiothoracic critical care is well recognised. They are not registered, and when delivering patient care always work under supervision of the registered nurse. The role is evolving and expanding with foundation degree pathways providing training in skills essential to delivering care and basic assessment.
In addition to direct patient care they perform a variety of tasks essential to the smooth running of any unit. These include checking emergency equipment, ordering supplies and cleaning and tidying the clinical area.
Advanced nurse specialist/practitioner;
One or more of these roles may be filled by one individual, for example the shift leader may also be an advanced nurse specialist or nurse consultant.
Nurse Manager/Lead Nurse/Matron
The critical care manager carries responsibility for service delivery, budgetary management, recruitment and retention. Although all units vary they are usually supported by senior clinical nurses or matrons.
The nurse manager’s role is multifaceted covering management of staff, including appraisal and performance management, handling complaints and investigating untoward incidents, and ensuring any lessons learnt are shared with the entire team. They provide leadership, ensuring that the nursing service is continually evolving to provide the highest standards of patient care. This is achieved through working with the MDT supporting, developing and implementing policies. A strong commitment to education and training, and involvement in research and audit projects is also essential.
The nursing team in the clinical area is led by a senior nurse or in larger units a team of senior nurses. The role of the senior nurse in the clinical area is to maintain an overview of all patients. At the onset of each shift, the senior nurse allocates nurses to patients, ensuring the most appropriate, safe and effective use of available skills. Consideration is also given to providing opportunities for nurses to develop skills with adequate support. The senior nurse remains visible and available to the MDT, patients and relatives throughout the shift. The senior nurse is involved in all MDT rounds.
The senior nurse role also includes the coordination of admission, transfer and discharge of patients. Integral to the role is an awareness of infection status of all patients, with excellent infection control practice being important in preventing hospital acquired infection.
Advanced Nursing Roles
Advances, developments and challenges in modern healthcare provision result in a constantly changing clinical environment. This is especially evident in the cardiothoracic critical care area as this heavily resourced setting continues to proactively respond to deliver high quality, safe patient care. As a result there is an ever changing face to critical care nursing.
Advanced nursing roles have developed in recent years to improve patient care by ensuring immediate response and a less fragmented approach. The roles encompass many job titles, such as clinical nurse specialists, advanced nurse practitioners and nurse consultants. All of these roles enable the nurse to work with increased autonomy within specific guidelines, following appropriate training and assessment. An example of this is that in many units management of the immediate postoperative cardiac surgical patient is nurse led with advanced nurse specialists managing ventilation, haemostasis, fluid and electrolyte balance and drug prescription within defined guidelines.
The early identification of the deteriorating patient on the hospital ward is crucial in preventing admission or readmission to the critical care area. The nurse led outreach team works closely with the ward and ICU staff to ensure this happens. The outreach team is available 24 hours/day, 7 days/week.
The three essential objectives of an outreach team are as follows:
1. Prevent readmissions by recognising and treating the deteriorating patient, and if required, ensure admission to critical care happens in a timely manner.
2. Enable discharge from critical care by supporting ward staff in the monitoring and management of this group of patients.
3. Share critical care skills, including recognition of the deteriorating patient, with ward staff.
Excellent communication and teaching skills are as important to the outreach nurse as advanced clinical skills. Their role is to support and develop ward staff in identifying and managing the deteriorating patient. An effective outreach team will enjoy excellent teamwork with ward staff, thus ensuring safe and effective care post discharge from the critical care area.
Many hospitals utilise an early warning system, for example MEWs, to provide an early predictor of clinical deterioration. Such systems provide a trigger for ward staff to alert the outreach team of the deteriorating patient so ensuring early intervention and management.
It is well recognised that patients can experience long lasting side effects after recovery from critical illness. Patients and their families need to be given support in managing the psychological impact of their illness.
The support and follow-up needs of the cardiothoracic patient post ICU and hospital discharge has traditionally been met by the ‘parent’ team of cardiology, surgery or transplantation. This is now changing with many units providing follow-up immediately post ICU discharge and longer term.
The impact, not only of a critical possibly life threatening illness, but also the sensory overload in the ICU and polypharmacy, including opiates, may affect patients’ psychological recovery. Patients may also suffer from sleep deprivation and periods of delirium whilst in the ICU, both of which may impair long term psychological recovery. Symptoms reported by patients following an ICU admission include memory loss and/or memory gaps and nightmares that may continue after hospital discharge.
In addition to clinics assessing psychological recovery and offering specialist support, many cardiothoracic critical care units are introducing patient diaries. The diary is completed on behalf of the patient giving a day to day record of the admission to the ICU and is a useful tool for helping fill in memory gaps and promoting psychological recovery.
Nurses have an integral role within the multidisciplinary team in providing skilled, advanced care of the patient in cardiothoracic critical care. The recognition that care of the critically ill patient extends beyond the boundaries of the intensive care unit has led to the development of nursing roles to ensure early detection and supportive follow-up of all patients.
Communication and collaborative working are central to safe, effective patient care regardless of each unit’s nursing strategy or patient pathway.
A well-organised education team is required to ensure development and maintenance of essential skills.
The development of advanced nurse specialist roles is required to ensure patients receive care and intervention in a timely manner.
An outreach team with excellent communication skills is essential to ensure ongoing care post ICU discharge.
Follow-up of patients by ICU teams is important in long term recovery.
A cardiothoracic critical care unit is a highly complex environment requiring an interplay of multiple medical specialties and allied health professionals involved in the care of those patients recovering from the insult caused by cardiac surgery. Most of these units will treat patients suffering from any organ dysfunction that happens in addition to cardiorespiratory issues. In general, systems and processes will be similar to those used in any critical care unit.
There is very limited room for error in this highly dynamic environment. The complexity of the patients’ needs has driven the development of standardised pathways and protocols to improve outcomes and maximise efficiency. This is supported by the increasing demand by the public and regulatory authorities to provide treatment and support in an environment that operates within a structured framework.
The past 10 years has seen an explosion in the number of guidelines and protocols available to the critical care clinician to aid the management of the individual patient. This has been facilitated by how easy it is now to share electronic documents.
A clinical guideline is a systematically developed statement to assist practitioner and patient decisions about appropriate health care for specific circumstances. Protocols tend to be a more prescriptive set of instructions for the management of a specific condition.
The publication of Rivers’ Early Goal Directed Therapy study in 1999 popularised the development of bundles in critical care. This study showed that the use of a specific bundle of care for the management of severe sepsis in a single centre significantly improved mortality. Although the study has been subsequently exposed to significant criticism, bundles began to be developed for a wide range of situations within critical care.
A bundle is defined by the Institute for Healthcare Improvement (IHI) as a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices – generally three to five – that, when performed collectively and reliably, have been proven to improve patient outcomes.
Advantages and criticisms of care bundles are listed in Table 54.1.
|Advantages of care bundles||Criticisms of care bundles|
|Standardisation between patients||May not take into account individual patient|
|Evidence of improved patient outcomes when bundles are used||May limit individual clinician’s autonomy or independence|
|Promote efficient use of resources by utilising proven and effective interventions||An unintended side effect of standardisation may be that it discourages excellent or exceptional clinical practice|
|Can potentially limit fringe practices which may be unproven or dangerous (and frequently expensive)||May be unduly influenced by external forces such as government or industry|
|Some individual bundle elements may have limited evidence; and evidence may change with time|
|Result in additional administrative burden for staff|
Bundles have now been developed for a wide range of clinical scenarios in the critical care unit. An example of a widely adopted bundle of care is that developed for the prevention of central line associated bloodstream infections (CLABSI) promulgated by the IHI and is shown in Table 54.2. Implementation of the central line bundle in the state of Michigan, USA resulted in a 66% reduction in CLABSI over an 18 month period.
|Central Line Bundle|
|Maximal barrier precautions|
|Chlorhexidine skin antisepsis|
|Optimal catheter site selection – avoidance of using the femoral vein for central venous access in adult patients|
|Daily review of line necessity with prompt removal of unnecessary lines|
Bundles are designed to be adopted as a full package rather than being taken up as single points in a piecemeal approach. It is essential that they are regularly reviewed, as some elements of the bundle may be subject to new research findings – an example being intensive blood glucose control, which was included for a time in ICU care bundles, but has subsequently been shown to be associated with higher mortality than more liberal targets.
The care of patients in the cardiothoracic critical care unit benefits from the input of multiple medical specialists and allied health professionals. Complex patients often suffer from multiple medical comorbidities, and complications following surgery can affect almost every organ system.
There has been extensive research in the general critical care setting into the relative merits of ‘open’ versus ‘closed’ units. ‘Closed’ units have the care directed by specialists in critical care medicine who call on other teams as required. ‘Open’ units allow the primary team to admit and direct the care with (or without) support from critical care specialists. Complex patients may benefit from a shared model of care; however conflict over management strategies and goals of care can easily emerge.
A close and constructive working relationship between all teams, with clear and open communication, are essential to ensure the system works well for the patient.
Most surgical patients admitted in cardiothoracic critical care will move from a very high to a low level of dependency within a few hours. Such patients can be managed in a nurse led unit according to predefined pathways with minimal medical input. However, complex patients require input from a wider multidisciplinary team.
Clinical governance encompasses a variety of measures designed to ensure that health organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
The cardiothoracic critical care unit requires a strong focus on clinical governance, to ensure patient safety, and continuous improvement in quality of care. The key elements of clinical governance as published by the National Health Service (NHS) in England can assist in ensuring a comprehensive programme of quality improvement is in place within individual units.
One approach to developing a robust structure of clinical governance is to consider the so-called ‘pillars’ of a clinical governance as shown in Figure 54.1.
Figure 54.1 Pillars of clinical governance. Extracted from College of Intensive Care Medicine IC-8: Guidelines on Quality Improvement.
Clinical Audit involves a systematic analysis of an area of practice to improve clinical care and/or health outcomes, or to confirm that current management is consistent with the available evidence or accepted guidelines. Audit has become a core skill expected of health professionals, and can act as an important tool to drive improvements in quality of care.
The ‘audit cycle’ describes a widely accepted approach to undertaking clinical audit activities. After first identifying a topic to audit, accepted standards are clearly defined. Current practice is then measured and compared to those standards. This is then communicated to the team, a plan for change designed and implemented, and finally re-audit should take place to examine how those changes have influenced practice.
Critical care is now firmly in the era of evidence-based medicine, and there is a vast array of literature examining new concepts and re-examining established practices. Clinical effectiveness requires consideration of health economics and ensuring that best value for money is obtained.
The College of Intensive Care Medicine in Australia and New Zealand recommends examining three broad types of outcome measures as listed in Table 54.3.
|1. Structural measures|
|2. Process measures|
|3. Outcome measures|
Critical care units should participate in programmes that measure the effectiveness of the care they provide. A number of professional societies in intensive care around the world run audit and quality assurance programmes whereby individual units submit patient outcome data which are then analysed and compared to similar units. A number of outcome measures are able to be calculated, including the standardised mortality ratio (SMR), which compares actual mortality rates to those predicted by tools such as the APACHE-III (Acute Physiology and Chronic Health Evaluation III), and exponentially weighted moving average (EWMA) charts which may allow early identification of developing trends. These outcome measures will usually have a process for identifying poorly performing ‘outlier’ units, allowing investigation of cause and provision of support to improve quality of care.
An effective risk management system requires both proactive and reactive elements. Staff should be encouraged to identify and report risk (both clinical and non-clinical), and the department needs to have tools to manage and minimise this risk. Critical care remains a human endeavour and so errors will always be expected to occur – an effective risk management system understands this, but strives to prevent and minimise any harm that occurs as the result. When errors do occur, reporting needs to be strongly encouraged so that learning can take place, and systems examined to try and prevent similar events occurring in the future. Staff need to feel reassured that in reporting actual or potential (‘near-miss’) incidents, they will be supported – a ‘no-blame’ culture is essential for staff to feel safe to report. Equally, investigation of events should be undertaken in a structured, fair and open manner by trained staff. The aim of an accident investigation is not to assign blame, but to determine what can be done to prevent the event occurring again in the future. Regular mortality and morbidity review meetings are another important component of a system wide risk management programme. These meetings should ideally be multidisciplinary, including trainee involvement, and involve a thorough review and discussion of patient complications, adverse events and deaths. Action points should be minuted and progressed.
Risk management can frequently be seen as only examining negative events, but learning from good performance is equally important. Identifying and publicising examples of excellent practice can help to drive positive culture change as much as learning from negative events.
Learning from instances of both good and bad practice requires a culture of openness where these events can be discussed in a constructive and meaningful way.
Increasingly, the health system is moving to a culture of open public reporting of serious adverse events, as well as reporting outcomes and quality measures. Cardiothoracic surgery was one of the pioneering specialties in this field and has well-developed systems in place for public reporting of surgical outcomes.
‘Dashboarding’ is another developing area where key quality measures are made available in real time in an easy to follow graphical format. This can allow all members of the team to see the unit’s achievements over a range of key performance indicators – the information can be made public, for example via a website.
Medical research is essential for the ongoing advancement of the specialty. This includes research into basic science, new innovations or technology, and re-examining traditional ideas and thinking (or medical dogma).
Research can drive improvements in quality and safety, such as the development of care bundles mentioned previously in this chapter. Medical research has traditionally been driven by individual researchers, but over the last 20 years a number of collaborative groups have formed with the aim of producing high quality multicentre clinical trials in critical care medicine. These include the Canadian Critical Care Trials Group, the Australia & New Zealand Intensive Care Society Clinical Trials Group and the UK Intensive Care Society, as well as many others.
Developing a safe and effective culture within cardiothoracic critical care requires multidisciplinary involvement in patient care, and the use of validated protocols and bundles of care, especially in the management of high risk conditions or technical procedures. The seven pillars of clinical governance provide an excellent structure for considering the essential elements of care, processes and quality within the ICU. Although often seen as ‘background functions’, these elements are essential to providing the highest quality of care to the individual patient.
Cardiothoracic critical care is a highly complex environment requiring input from multiple health professionals.
Standardised pathways and protocols have been developed to improve outcomes and maximise efficiency.
Cardiothoracic critical care requires a strong focus on clinical governance to ensure patient safety and quality improvement.
Risk must be actively managed and organisations should develop a culture which encourages the team to report when things have gone wrong.
Learning from incidents should be incorporated into practice and clinical outcomes made available to the public so as to drive improvements in performance.
Critical care is a highly data intensive environment. It has been estimated that over the course of a 24 hour period nearly 1500 data items may be documented on a typical critical care patient and this volume of data is growing all the time. Historically, a subset of these data would have been transcribed into a paper-based record, which was not always legible, could sometimes go missing and was difficult to analyse. Under these circumstances the emergence of clinical information systems (CIS), computer-based systems that collect, store, manipulate and display clinical data, has been widely identified as offering significant benefits to healthcare delivery in critical care. While there is evidence that CIS can contribute to improvements in patient care, they also pose new challenges. A balanced appreciation of their capabilities and their effects on clinical work practices is therefore necessary.