BACCN 2013 Event Guide & Abstract Book by Benchmark Communications

The Costs of Caring

Resilience and Sustainability in Critical Care

27 Annual BACCN Conference

www.baccnconference.org.uk

15th â&#x20AC;&#x201C; 17th September 2013 Southport Theatre & Convention Centre, Southport

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WELCOME! To the 27th Annual BACCN Conference 2013 I’m delighted to welcome you all to the British Association of Critical Care Nurses 27th Annual conference here in the seaside town of Southport. The title for this year’s conference is ‘The Cost of Caring: Resilience and Sustainability in Critical Care’. Caring is central to everything we do not only in our professional lives but in our personal lives too; it’s what drives us each day and what encourages us to develop, grow and achieve more. This year’s conference offers us the opportunity to consider the wider issues and think about the effects they have on our work place, our home life and the lives of those around us. There is great value in considering broader topics rather than just technical and non-technical. As we continue to work in a challenging environment we must preserve compassion and we must care stronger, harder and more deeply than ever before, not only for our patients and their families but for each other: our colleagues, our leaders and our followers. To be successful in our roles we must develop a rich set of skills that will sustain us as nurses and health professionals. This year’s conference is a step towards that model of 360 caring and I hope that you can make every opportunity to embrace all that’s available to you as you take time out from work to recharge your knowledge, skills and networking batteries. Our programme over the next two days offers you the opportunity to do just that with keynote, concurrent and ViPER sessions covering effective care, emotional impact, austerity, caring for the elderly and critical care for children. We also have a host of workshops which will demonstrate real life situations in effective hands on sessions as well as our Simulation Lab which, following the popularity of last year, will once again be bringing you interactive scenarios for you to immerse yourself in and learn from. Our exhibition is packed to the rafters this year and offers a fantastic display of products, innovative ideas and research to browse through and enjoy during the breaks. Make sure you find time to care for yourself this conference by visiting our chill out zone for some well earned self indulgence. The social programme for this year commences on Sunday evening with cheese and wine tasting and a chance to capture yourself in a whole new light with our caricaturist. On Monday evening we’ll be getting groovy on the dance floor with our ‘Swinging 60’s’ themed gala dinner. Attendees can enjoy a drinks reception, three course meal and re-live the frenzy of Beatlemania with our live band ‘The White Ties’. On behalf of the National Board and the BACCN we welcome you to Southport for what we hope will be an informative, inspiring and fun experience which you can share with colleagues and peers on your return to the workplace.

Contents BACCN

Sponsors & Exhibitors

The BACCN 5

Sponsors 29

Corporate Partners 5

Exhibition Floorplan 30

Endorsements 5

Exhibitors List 31

Acknowledgements 5

Exhibitor Editorials 32-36

General Information

Abstracts

Conference Information 6

Workshops 40-42

Social Programme 7

Concurrents 44-64

About Southport 7

ViPERS 66-71

Posters 74-89

Conference Highlights Simulation Lab 10

Note Paper 90-91

Chill Out Zone 10 Pre-Conference Masterclass 11 Instructions to speakers 11

Conference Programme Monday - Day One

14-17

Tuesday - Day Two

18-21

Poster Walkround Schedule

22-23

Keynote Speakers 24-28

The British Association of Critical Care Nurses The British Association of Critical Care Nurses (BACCN) is one of the leading organisations in critical care nursing. BACCN was established in 1985 and has grown and developed through the hard work and dedication of its members, regional committees and National Board. The 14 regions span Great Britain and Northern Ireland, providing one of the largest and most influential professional organisations within critical care. If you are not already a member and would like to join BACCN, please visit the BACCN stand in the exhibition room.

Why become a

Corporate Partner with BACCN? With 15 regions spanning the UK and over 3000 members, the BACCN is one of the largest and most influential professional organisations within critical care. Annual national and regular international conferences, regional study days and events, an interactive website as well as its own journal ‘Nursing in Critical Care’ has set BACCN apart as one of the most progressive critical care organisations of its time. A member of the European Federation of Critical Care Nursing Association, and the World Federation of Nurses, the BACCN is also working to build links with other critical care colleagues across Europe and the rest of world. To continue to lead the way in critical care nursing, the BACCN wishes to encourage the partnership between medical supply and service companies with the aim of working towards the objectives of BACCN; to advance the art and science of critical care nursing through mutual support, education, research and multi-disciplinary collaboration. With additional resources and funding, renewed emphasis has been placed on the BACCN corporate partnership scheme. The premise that a range of companies in the marketplace with different levels of motivation and funds would need to be catered for, has led to the new tailor-made packages. It is hoped that the increased range of options and benefits means that there will be a scheme for everyone wishing to participate.

BACCN Endorsement Our emphasis on education and best practice is focal and remains at the forefront of our aims and objectives. Because of our high profile, we are keen to engage with companies seeking endorsement for educational or promotional products that meet a high quality standard. BACCN Endorsement will provide your company with creditable support from the largest critical care nursing organisation in the UK. Should you wish to discuss this opportunity further or perhaps you have another idea that is mutually beneficial, please visit the BACCN stand or email: baccn@baccn.org

Acknowledgments The BACCN would like to say a

big thank you to:

• Our conference speakers for helping us deliver such a high standard programme • The staff at the Southport Theatre and Convention Centre and the Ramada Plaza • The BACCN National board members for their continued help, support and input • To all the sponsors and exhibitors for their participation and efforts in making this conference a success

For further information please visit the registration desk.

General Information Conference Sessions

Security

Conference sessions will be held between the main conference venue – The Southport Theatre & Convention Centre (STCC) and the Ramada Hotel which is directly linked to the conference centre. All opening remarks, keynotes and plenary sessions will take place in the Theatre auditorium in the STCC. All streamed sessions will take place in the:

Your conference badge will be handed to you at registration. Please wear this at all times; it is your pass to gain access to the conference sessions.

Theatre Auditorium – STCC

There are male and female toilets located on each floor of the STCC and throughout the Ramada Hotel. There is also a cloakroom to leave luggage and coats; however, if possible, we strongly recommend that you leave your luggage at your hotel as space at the venue is strictly limited. We cannot be held responsible for loss or damage to anything you leave in the cloakroom. Please ensure items are clearly marked with your name.

Lakeside Suite – STCC Marine Suite – Ramada Hotel Hesketh Suite – Ramada Hotel Executive Lounge - Ramada Hotel Board Room – Ramada Hotel Please allow plenty of time to move between sessions to avoid disappointment. Please check the conference programme on pages 14-21 for all room allocations and session times.

Registration Desk The registration desk will be located in the main foyer and will be staffed at all times. The desk will be open throughout the conference; however the main registration times are 08.00-09.00 on Monday and 08.30-09.15 on Tuesday. Please ensure you register in plenty of time before the conference sessions begin. Please direct all enquiries to the conference registration desk or conference staff.

Messages Messages for fellow delegates can be left at the registration desk. If you need to be contacted, messages can be taken via the conference office. Conference Office tel: +44 (0)191 241 4523 fax: +44 (0)191 245 3802 email: info@baccnconference.org.uk We will endeavour to get the message to you as soon as possible.

Toilet & Cloakroom Facilities

Parking A pay and display car park is located next to the STCC.

Taxis If you require a taxi, the following companies have been recommended: Radio Yellow Top Cabs: 01704 531 000 Kwik Cars: 01704 547 000

Exhibition, Posters and Chill Out Zone The Exhibition features over 40 companies and will be held in the Waterfront Suite at the STCC. All catering will be served within the exhibition. The Poster Displays will be located in the foyer outside the Waterfront Suite. The Chill Out Zone is located in the Floral Hall.

Lunch & Refreshments Tea and coffee will be served during all conference breaks. A buffet lunch will be served throughout the Exhibition area. Please ensure you have informed the conference staff if you have any special dietary requirements and make yourself known to the venue staff at lunchtimes.

Social Programme We welcome and encourage all delegates to take part in our Conference Social Programme. If you are registered for the full conference you can attend all social events free of charge. If you are a day delegate and wish to purchase tickets, please visit the registration desk.

Welcome Reception - Sunday 15th September The welcome reception will provide an informal introduction to the conference and offer you the perfect environment to meet your fellow delegates. Enjoy a glass of wine and sample some local cheeses while making the most of our early registration, allowing you extra time in bed on Monday morning!

Gala Dinner - Monday 16th September Held in the beautiful Floral Hall in the Southport Theatre and Convention Centre, the gala dinner is a great excuse to get your glad rags on and dance into the small hours! This year’s theme is the ‘swinging sixties’ so get ready to get groovy on the dance floor with our live band The White Ties and use our 60’s themed table props to create some fantastic photos!

SOUTHPORT Southport lies on the coast just 20 miles north of Liverpool and is a traditional Victorian seaside town – but with a contemporary twist. It combines beautiful beaches, family attractions and the UK’s oldest iron pier with fantastic shopping, a superb choice of restaurants, world-class golf and a choice of accommodation from 4-star hotels to boutique guesthouses. Add to this a vibrant events programme, great nightlife and you’ll never be short of something to do. For those looking for a more relaxed break Southport has over 20 miles of unspoilt coastline and the largest area of undeveloped sand dunes in the UK. With extensive pine woods, miles of coastal walks and several impressive parks & gardens it’s the perfect place to unwind and recharge your batteries. Southport is also a great base for exploring the north west of England, whether it’s a day in nearby Liverpool or discovering the beauty of the Wirral or Lancashire countryside.

BACCN 2013 Conference Office c/o Benchmark Conferences & Events 14 Blandford Square, Newcastle upon Tyne, NE1 4HZ Tel: +44 (0)191 241 4523 Fax: +44 (0)191 245 3802 Email: info@baccnconference.org.uk Website: www.baccnconference.org.uk

Prizes Thank you to Wiley-Blackwell and SP Services for their prize donations

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Conference Highlights Adult and Child Simulation Lab sessions Our Simulation lab is the ideal environment to take part in our adult and paediatric scenarios and gain hands on skills whilst under the supervision of our experts who will complete a full de-brief offering discussion and feedback after the session. Numbers to these sessions are limited so make sure you sign up early at the information desk.

Child 1) Neurosurgical scenario Designed for all delegates working in A&E or adult critical care who may be involved in the stabilisation and transfer of a child with a neurosurgical condition.

Child 2) Collapsed neonate scenario Suitable for all delegates working in A&E or adult critical care who may be involved in the assessment and stabilisation of a critically ill neonate awaiting the arrival of a dedicated paediatric transfer team.

Adult 1) Management of newly admitted, critically ill patient scenario This scenario is designed for delegates working in adult critical care, HDU or A&E environments, who might be involved in the assessment and stabilisation of a critically ill adult patient.

Adult 2) Progressive physiological deterioration of a post-operative adult critical care patient scenario This scenario is suitable for delegates working in adult critical care, who may be involved in the assessment and treatment of critically ill level three patients following surgery. THINK THESE SESSIONS AREN’T FOR YOU because you’re not child trained or working in PICU? Or you have years of experience in your unit already? Remember – there are differences in the critically ill adult and child, yet there are some commonalities. There are also contextual variances when working in a different situation or team, and so your skills will transfer to the situations our experts have devised and you may be at a transferring centre ... Please sign up for your preferred session at the registration desk. Please note places are strictly limited to 15 per session, and bookings are taken on a first come, first serve basis.

Thank you to our Simulation Lab suppliers :

Chill Out Zone We are delighted to bring back our conference ‘Chill Out Zone’ offering you a range of products and treatments to help build your own ‘resilience and sustainability’ right here at conference. With relaxation treatments, health advice and a touch of retail therapy it’s the perfect place to rejuvenate after a walk around our exhibition hall. The Chill Out Zone is located in the Floral Hall in the conference centre and will be open during all breaks and lunches.

“In it to Win It” – Final Session Delegates attending the final session of the conference wil be entered into a free prize draw for a place at the BACCN2014 conference!

Pre-conference Masterclass Sunday 15th This year’s pre-conference Masterclass focuses on ‘How to maintain continuous renal replacement therapy in ICU’ and is led by Annette Richardson, Nurse Consultant Critical Care and Jayne Whatmore, Sister ICCU from Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust. Our experts will provide delegates with an interactive opportunity to hear and discuss problems associated with CRRT, including reviewing Acute Kidney Injury (AKI) through examining the causes of AKI and highlighting the indications for commencing continuous renal replacement therapy (CRRT). Practical hands on experience at resolving alarms and troubleshooting will also be made available to attendees and the session will also be looking into the prevention, detection and treatment of CRRT complications with an aim of helping to improve quality and safety in critical care.

Masterclass Programme Times

Agenda Programme

13:30

Registration

14:00

Welcome from Chair Vanessa Gibson, Northumbria University

14:30

How to maintain continuous renal replacement therapy in ICU Annette Richardson & Jayne Whatmore, Newcastle upon Tyne Hospitals NHS Foundation Trust

16:30

Q&A and closing remarks from the Chair

This Masterclass session is sponsored by Baxter Healthcare Ltd and will take place in the Marine Suite at the Ramada Hotel.

SPONSORED BY: BARD LIMITED

W09: Sedation and the Mechanically Ventilated Patient: When is Enough Enough and How Do You Know? Marcia Bixby (Consultant, USA)

C45: Fire in the Intensive Care Unit Marghanita Jenkins (Royal United Hospital Bath NHS Trust)

POSTER WALK ROUND 8 (15:55 - 16:10)

Poster Walk Schedule Monday 16th September 2013 Poster Walk 1:

10:55 - 11:10 (3 papers)

P01: Staff perceptions of implementing a computerised decision support system to manage glycaemic control in the critically ill; Helen Beard West Suffolk Hospital Foundation Trust P02: Optimising the Quality of Care Provided to Long Term Intensive Care Patients – a New Role; Sara Collingridge, Peter Doyle, Lisa Hollins, Ruth Tollyfield, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust P03: Bereavement Care in the Critical Care Oncology Setting; the Promotion, Planning, and Organisation of a Memorial Service; Rachael Crayton, Katy Andrews, Critical Care Unit, The Christie NHS Foundation Trust

Poster Walk 2: 12:25 - 12:45 (4 papers) P04:

Role And Place Of Qualified Physicians Experienced In“Emergency Medicine” In Bulgaria For Rendering CPR; Assistant Professor Diana Dimitrova, Medical University of Sofia

P05:

Preparedness of Emergency Care Center in Bulgaria For Rendering CPR During Emergency and Disaster Situations; Assistant Professor Diana Dimitrova, Medical University of Sofia

P06:

Reducing Re-Admissions of Cardiothoracic Transplantation Patients to Intensive Care Through Use of a Criteria Linked Assessment Tool; Helen Doyle, Alison Thompson, Peter Doyle, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust

P07:

Schwartz Rounds: Improving patients’ experience and quality in a Cardiothoracic Critical Care Unit; Allan Seraj, Peter Doyle, Geraldine McVeigh Harefield Hospital,Royal Brompton and Harefield NHS Foundation Trust

Poster Walk 3: 12:45 - 13:05 (4 papers) P08 :

Length of Stay and Age as Determinants of Death in Intensive Care: a Retrospective Population Cohort Study; Judy Dyos, Dr Anne-Sophie Darlington, Southampton University Hospital Foundation Trust, Professor Maureen Coombs, Victoria University NZ

P09 :

Meeting Stakeholders Expectations With Current Resources; Nicky Edmondson, Melanie Woolfall,Heather Bendall, Martin Hope, Royal Lancaster Infirmary

P10 :

Changing the Culture – Preceptorship in Cardiac Surgical Intensive Care; Caroline Ennis, Lisa Scullion, Catherine Ravel, Ursula Burns, Belfast Health And Social Care Trust

P11 :

Introduction of Cam-ICU Tool On The Critical Care Unit; Yvonne Helm, Mary Cavill, Sarah Holden, Royal Blackburn Hospital - ELHT

Poster Walk 4: 15:40 - 15:55 (3 papers) P12 :

Acute Kidney Injury in the Cardiac Surgery Population; Rebekah Thomson, St Georges Hospital

P13 : Reducing Catheter Errors and Related Infection Through Improved Arterial Line Dressing, Management and Monitoring Procedure; Patricia Hogg, Barbara Jameson, Dr Dominic Errington, Joanna McBride, County Durham & Darlington NHS Foundation Trust P14 :

Staff Opinion of Delirium in our Critical Care Unit; Tessa Horton, Laura Eldridge, Clare Finn, King’s College Hospital

Tuesday 17th September 2013 Poster Walk 5: 11:00 - 11:25 (5 papers) P15 :

Life At Home After Intensive Care: The Family Caregiver Experience; Sarah Holling, Cathy Derham, University of Surrey

P16 :

Novel Intensive Care Unit (ICU) Outreach Service: Malaysian ICU Nurse Perspectives; Dr Salizar Mohamed Ludin, Noorazizah Mohd Ali, Norasimah Razak, International Islamic University Malaysia

P17 :

An Audit of the Use of Bowel Management Systems and the Development of an Assessment Tool to Assist Prevention of Moisture and Pressure Damage in the critically Ill; Joanna Peart, Gemma Wightman, Newcastle Hospitals NHS Trust

P18 :

Facilitating Student Learning: Creative Approaches to Critical Care Placements; Gail Quigley, Brian McFetridge, Martha McColgan, Gerry McMenamin, Western Health and Social Care Trust Stephanie Dunleavy, University of Ulster

P19 :

Competencies For Securing the Anchor Fast Device; Tina Stubbs, Homerton University Hospital NHS Foundation Trust

Poster Walk 6: 12:40 - 13:00 (4 papers) P20 : Speech and Language Therapy in Critical Care : Benefits and Boundaries; Janet Thomas, Jessica Bell, West Suffolk NHS Foundation Trust P21 :

A Safety Conventional Arterial System - Simulation Pilot Study; Emily Hodges, Dr Damian Laba, Dr Robin Heij, Dr Peter Young, The Queen Elizabeth Hospital NHS Foundation Trust

P22 :

A Multi-Faceted Approach to Introducing an Innovative New Process For Recognition and Response to Deterioration in Acutely Ill Adult In-Patients; Debbie Van Der Velden, Liz Staveacre, North West London Hospitals NHS Trust

P23 :

Is Anchor Fast Oral Endotracheal Tube Fastener Cost Effective? Samantha Westbrook, Frimley Park Hospital NHS Foundation Trust

Poster Walk 7: 13:00 - 13:25 (5 papers) P24:

Nurses role in immediate care of patients undergoing liver transplantation; Anan Purushothaman, Jayanthi Shamalee Patabendige, Kings College Hospital NHS Foundation Trust

P25 : Procedural Sedation : Best Practice in any Clinical Arena; Marcia Bixby, Consultant USA P26:

End Tidal CO2 ( ETCO2 ) Monitoring: Is it Just Another Number? Marcia Bixby, Consultant USA

P27 :

Glycaemic control in the Intensive Care: Tight, loose and automated; Deborah Ebsworth, S.P Booth, K.Sim, McIndoe Burns Centre, Queen Victoria Hospital

P28 :

Implementation of Citrate Anticoagultion Throughout Critical Care at Leeds Teaching Hospital Trust; Charlotte Trumper, Leeds Teaching Hospitals NHS Trust

Poster Walk 8: 15:55 - 16:10 (3 papers) P29 :

The Quality Improvement of Palliative Care in the Intensive Care Unit; Ariesta Milanti Endang, Pauliina Mansikkamaki, University of Indonesia

P30 :

Effect of Fecal Management System (FMS) on Critically Ill Patients in Hong Kong; Grace Lau, Nora Kwok, Lan Lau, Sze Wah Ng, Chun Fai Wong, Paul Wong, Yuen Fan Tam, Lin Mui Fung, Pamela Youde, Nethersole Eastern Hospital, Hong Kong

P31:

The ICU Nurse Coordinator Role in a Multi- Disciplinary Team Caring for Patients Treated With Ventricular Assist Device (VAD); Miriam Abuhazira

Keynote Speakers S01:

The Cost of Caring: Building Emotional Resilience

S02:

The Importance & Impact of Laughter

Julie Scholes

Lisa Sturge

Director of Postgraduate Studies in the Brighton Doctoral College, and Professor of Nursing

Director, Laughterlines Coaching

Biography

Julie’s clinical background is in critical care nursing. Since 1987 she has been in nurse education and since 1993 her primary role has been in research. Julie’s research interests include the acquisition of competence, facilitating expertise for new roles in practice and patient involvement in innovation. She has undertaken research for a large range of clients from national and international public sector funders to private investors.

Lisa Sturge is the Director of Laughterlines Coaching which is based in Bosham, near Chichester in West Sussex. Lisa works with a range of organisations and businesses across the UK in order to promote laughter and well-being both in the work place and in everyday life.

Julie’s recent research has explored decision making under stressful situations in the simulation environment. She is author of ‘Expertise in critical care practice’, editorin-chief of Open Nursing Journal, Co-editor of Nursing in Critical Care and Chair of the Faculty Ethics and Governance Committee.

Abstract This paper will examine the risks and rewards of caring amidst the competing demands of contemporary health care practice. Resilient strategies are important to help defend against burn out and stress that can ultimately lead to depleted caring. However, resilience is an overused and contested term. It originates within the school of positive psychology and self-help. Failure to act resiliently can lead to negative labelling (that in past years was called: ‘acopia’) with the locus of control for resilience residing with the individual leaving organisations free to assuage their responsibility for the well being of staff. This paper will examine these issues, offering a critical review of the contemporary literature and recent case studies to illustrate the multi factorial conditions and contexts that create the emotional cost of caring. The paper will also argue, that although high quality care comes at an emotional cost, it is also the reward that keeps critical care nurses, nursing.

Lisa started her career in the educational field, initially teaching pupils in mainstream schools. She then became a special needs co-ordinator, managing specific programmes to support children with a range of special educational needs, as well as their parents and families. Lisa then re-trained as a personal development coach, laughter yoga teacher and laughter facilitator. Now a master NLP practitioner (INLPTA), Lisa uses a mixture of coaching and NLP (neuro-linguistic programming) to enhance her laughter workshops and training. Lisa set up the Chichester Laughter Club in 2008 and her work has been featured in a range of media, including TV and radio shows. The aim of Laughterlines Coaching is to teach the benefits of regular laughter to as many people as possible firsthand, helping them to discover new and creative ways of increasing the amount of joy, relaxation and playfulness in everyday life.

Abstract The physical and mental benefits of laughter are now well documented. Laughing helps to strengthen our immune system, improve our circulation and promotes better sleep. Laughing also encourages creativity and playfulness, improving levels of emotional intelligence, strengthening communication and increasing confidence. Yet on average, research shows that adults are only laughing about 15 times a day, compared to children, who can giggle and laugh around 200 times a day! So why aren’t adults letting go and enjoying a good belly laugh more often? We will be looking at how laughter can positively affect us in our relationships and in our work and we will be looking at ways in which we can access more playfulness and laughter every day.

This interactive talk will include:-

values.

• The benefits of laughter on the mind and the body

There is mixed evidence about whether or not age affects physical function, and so prognosis. So should older people be admitted to critical care? Should admission be selective? Do older patients need specialist support, and if so is that support available? With increasing focus on long-term outcomes of and rehabilitation from critical illness (NICE, 2009), are older people at greater risk of cognitive decline and dementia following ICU admission (Ehlenbach et al, 2010)? How well have we been prepared to care for this group of patients? Is our ICU ageist? Care of the older person on ICU too often raises more questions than answers.

• Interactive laughter exercises • The origins and principles of Laughter Yoga • Everyday strategies for laughter • For more information please go to www.laughterlinescoaching.co.uk

S03:

A Caring Age? Older People and Critical Care

This session will explore whether or not we care appropriately for this potentially vulnerable majority of our patients, how prepared our speciality is to meet these challenging demands, and whether we need to consider age-specific aspects in our practice.

Philip Woodrow Practice Development Nurse, Critical Care, East Kent Hospitals Univeristy NHS Trust

Biography Philip Woodrow is a Practice Development Nurse for Critical Care at East Kent Hospitals NHS Trust. Since qualifying in 1986, Philip has worked mainly in Intensive Care and education. His current role primarily involves facilitating various acute care courses for registered staff. Publications include three books: Ageing: Issues for Physical, Psychological & Social Health (Whurr/Mosby 2002), High Dependency Nursing Care: observation, intervention and support (Routledge, 2nd edition 2009) and Intensive Care Nursing: a framework for practice (Routledge, 3rd edition 2011).

Abstract Most patients in most critical care units are old (>65 years of age) (Pisani, 2009), and the numbers of older patients admitted to critical care is increasing (Ridley, 2005; Roch et al, 2011). Healthcare provided to older people has often been found to be suboptimal (NCEPOD, 2010; Parliamentary and Health Service Ombudsman, 2011). So is care of older people in critical care a cause for concern? The above reports generally portray critical care favourably when compared with other clinical areas. However, we should be cautious about being complacent. Admission of older people to ICU can provoke passionate debates, which we, as nurses, are likely to hear and face. We therefore need to proactively consider the issues; this conference provides a valuable context in which to explore our own concerns and

S04:

Is it all Rubbish? Sustainability, Climate Change & the Implications for Critical Care Prof Janet Richardson Professor of Health Service Research, (Honorary Consultant in Public Health - NHS Plymouth) Faculty of Health, Education & Society Plymouth University

Biography Janet is a nurse with clinical experience in cancer and supportive care. Following a psychology degree she began to research patients’ views of healthcare, and health service effectiveness. Much of this work focused on engaging staff and users in the development, commissioning and evaluation of services using participatory approaches. She teaches research methods and evidence-based practice. Her current research engages healthcare providers in finding solutions to the challenges that climate change and resource depletion could have on health and healthcare delivery.

Abstract The future impacts of climate change are well documented, with forecasts made of increasing health problems caused by heatwaves, storms, floods, fires, droughts and infectious diseases. The potential of areas becoming uninhabitable and associated geopolitical problems could lead to increasingly mobile populations; this is likely to result in changes in patterns of disease, and other health problems associated with displaced

Keynote Speakers communities, such as malnutrition. Much of this will lead to a higher demand on public health and emergency services. Locally, in the UK we have seen the significant impacts on communities of more frequent floods, and this can lead to increased demand on emergency services, mental health problems and depression. So it is evident that climate change will provide significant challenges for future healthcare. Much of the focus on sustainability and the NHS to date has been on estates and waste management, and efforts to reduce carbon emission. However climate change is not the only pressing issues of future healthcare. The planet has limited natural resources and their availability can be compromised by geopolitical issues and long supply chain. Plastic products used widely in the NHS are oil-based and vulnerable to price fluctuations, and lithium used in batteries used to power cardiac pacemakers is classed as a scare resource. This poses challenges for critical care where difficult decisions about resource management may need to be made in the future. So what we can do? Using examples from research conducted by our Sustainability, Society and Health Research Group, this talk will focus on areas where mitigation and adaptation can be integrated into health service delivery, and will consider the implications for critical care. The presentation will also illustrate how sustainability can be integrated into the curriculum to ensure that we are developing health professionals who will be able to deal with the very real challenges they will face in the future.

with amusing stories of everyday life. It’s tangible and sustainable for individuals and teams to choose new ways of being and creating change. Jenny is a certified professional coach, a master trainer for the temperament typing model True Colors® and has a 101 certificate in transactional analysis and is also a mindulfness practitioner. Jenny’s sessions are always lively, thought provoking and innovative. She has an amazing ability to quickly engage with others and create a trusting environment which enables others to shine. Her engaging and interactive sessions help illustrate the importance of understanding your own core values and needs and developing an awareness and appreciation of others. For the past 3 years Jenny has been working with the NHS. Jenny co- designed and delivered ‘The Difference is You’ programme For Guys and St Thomas. Almost 2,000 staff across the organisation have participated in the programme and it is now a mandatory part of their CIPD programme. When time allows, Jenny enjoys contributing to publications and journals and recent articles include ‘Creating a Positive workplace Culture’ in Nursing Management.

Abstract How well do you know yourself? How well do you know the people you work with?

S05: It’s All About You! Jenny Sergeant Personal & Professional Development, True Colours UK LLP

Biography Jenny Sergeant is a managing partner at True Colors® UK and has her own development consultancy. Jenny spent the first 20 years of her career in the retail industry, having held senior executive positions with companies such as TK Maxx. She is highly regarded and well known for her ability to develop high performing teams. Jenny’s real passion has always been in developing people. She has spent the last 10 years working with a variety of organisations to improve their performance through the development of emotional intelligence and resilience. Jenny has the ability to translate complex psychological models into useful tools and combines this

How can you improve the relationships with others and build your resilience? From this plenary session you will not only discover the answers to the questions above but take away some valuable insights that will support your personal journey. The impact of stress on our psychological and physical wellbeing is well documented. You may carry on working but the impact of stress can affect your focus, attention to detail and your relationships with others. Research in 2010 indicated that 37% of NHS staff reported that either their physical health or emotional wellbeing had been effected from undertaking their daily activities. There’s lots of different training available but how do we start to create our own ‘toolkit’ for handling day to day pressures and build our resilience. Just as our core muscles play a vital role in good posture, balance and physical injury prevention, so our emotional core plays a similar role in our mental wellbeing. At the heart of our emotional core are our values and needs. Values are those things which are most important to us, for example being dependable or being competent. Needs are those things we must have in place in order to honour our values, for example being organised and having time to think. When our core is not strong because our values and/or our needs are not

being met, we move from being committed to becoming disengaged. Our emotions become negative and we move from being content to becoming distressed. The impact of this can be felt not only by the individual but by all of our relationships and in the case of nurses, the patients. When you know what your core values are and feel good about them, you can perform at your highest potential in every area of your life. Share this with others to gain mutual understanding and compassion and a common wellbeing. True Colors(R) has been used successfully across the world for over 30 years. Based on time tested psychological theories as used by Myers-Briggs. True Colors® provides easy to use tools that help you help yourself. You can use True Colors® to improve communication skills, build self-esteem and to enhance the smooth functioning of your team.

S06:

Skin care- addressing the challenges to preventing pressure ulcers in critical care

Andrea Berry Lead Nurse, Greater Manchester Critical Care Network

Andrea Baldwin Lancashire & S Cumbria Critical Care Network

Biography - Andrea Berry

Wales and Northern Ireland (CC3N).

Biography – Andrea Baldwin Andrea qualified as a nurse in 1984 and commenced work with Lancashire & South Cumbria Critical Care Network in 2004 with a responsibility for improving quality nursing care; having previous experience as a Senior Nurse and as a Practice Development Nurse in Intensive Care. Through collaborative work she has produced national Standards and Competencies for critical care education. As Network Director she is committed in her work to ensure critical care patients receive the best care and outcomes from the service. Andrea is currently the Co-Chair of the National Critical Care Networks of England, NI & Wales group.

Abstract The nature of critical illness means patients are often at ‘higher risk’ of developing pressure ulcers. The reasons for the increased risk are many and often complex. The national drivers to improve care are clear and abundant 1,2,3. This presentation will consider issues that healthcare professionals should be aware of pertaining to the surveillance and prevention of pressure ulcers in critical care patients. It will discuss international and national guidance and how that fits within the critical care environment in driving the quality agenda. Links will be made between the Cost of Caring and what that actually means to organisations and individuals in respect of pressure ulcers through QIPP, CQUINS and the Safety Thermometer4. Finally we refer to a Critical Care Skin Bundle developed by the North West Critical Care Networks and provide data to demonstrate where change has been effective. References

Andrea trained at Victoria Hospital Blackpool, qualifying in 1983, on completion she commenced her ICU career.

[1] NICE The prevention and treatment of pressure ulcers. 2005

In 1991 Andrea was appointed Senior Sister for the ICU at the Royal Albert Edward Infirmary, Wigan. Over the following 17 years she proceeded to take on the roles of Practice Development Facilitator, Clinical Nurse Manager, Matron and Associate General Manager for Critical Care, Anaesthetic & Pain Services.

[2] DH Essence of Care 2010 – Benchmark for Prevention and Management of Pressure Ulcers. 2010

In 2007 Andrea was appointed Lead Nurse for the Greater Manchester Critical Care Network, her role being to drive service improvement. She currently chairs the Critical Care National Network Nurse Lead Forum for England,

[3] Tissue Viability Society. Achieving Consensus in Pressure Ulcer Reporting. 2012 [4] DH Delivering the NHS Safety Thermometer CQUIN 2012/13. A Preliminary Guide to Measuring ‘Harm Free’ Care

S07:

Two Hot and Topical Critical Care Nursing Issues for Debate Annette Richardson Nurse Consultant Critical Care, Newcastle upon Tyne Hospitals NHS Foundation Trust

Fiona Lynch Nurse Consultant, Evelina London Children’s Hospital, St Thomas’ Hospital

Abstract • What is the impact of the Francis inquiry for critical care nursing? • Caring for the critically ill child in your adult unit: the highs, lows and the anxieties? Recent public and professional spotlights on the role of the critical care nurse have driven a close examination and raised questions about the impact on quality delivered to the critically ill patients and their families. The impacts of the Francis inquiry and caring for the critically ill child in an adult ICU are the two current topics to be covered in this debate. The debate will allow for difficult issues to be raised and opinions to be expressed. It will provide an opportunity to challenge the important issues, think, share and influence, from your point of view, future critical care nursing policies.

Sponsors Baxter Healthcare Ltd Masterclass Sponsor - Stand 48 We are proud to launch the next software update to the Aquarius machine – which encompasses new features regarding Total Fluid Loss (TFL) Management and display of realtime delivered dose. To learn more about this next stage in Aquarius development, please visit the Baxter stand. Baxter Healthcare have entered into a definitive asset purchase agreement with NIKKISO Co., Ltd, a dialysis and kidney care pioneer based in Japan, regarding Baxter’s current CRRT business and products. This is a natural transition based on Baxter’s existing relationship with NIKKISO around the manufacture of the Aquarius machine. With its nearly 50-year legacy in dialysis and kidney care technologies, coupled with its expertise and experience with Baxter products, we are confident that NIKKISO will continue to deliver high quality service and CRRT products for the NHS. Baxter and Nikkiso are committed to the ongoing success of the CRRT business and to ensuring support and business continuity during the integration period. Customers, new and old, can expect continued high levels of service, support and quality. This includes: 24 hour pager support, technical and customer service support and all educational services. Please visit us in the exhibition area to find out more.

Fresenius Medical Care Workshop Sponsor - Stand 20 Fresenius Medical Care is the world’s leading company in the field of dialysis, combining expertise in the development and production of technologically-advanced products with comprehensive care for patients. We offer products and services to optimise the therapy outcome, in-line with the specific needs of the individual patient and therapy approach. We are also market leaders in the provision of partnership dialysis unit programmes with nearly 60 clinics in the UK. Our programmes include: Haemodialysis/Haemodiafiltration; Continuous Renal Replacement therapy (CRRT); Pharmaceuticals (Nephropharm); Renal Clinics; Peritoneal dialysis; Home Haemodialysis; Water treatment; Dialysis software.

Bard Ltd Workshop Sponsor - Stand 43 Visit our stand to witness the demonstration of the Arctic Sun® 5000 Temperature Management System that helps clinicians to effectively manage patient temperature in a non-invasive manner. The Arctic Sun® 5000 Temperature Management System is a surface cooling system that nurses can initiate in minutes via a programmable automated treatment. Also, on the stand is the Bard® Dignishield® Stool Management System which is designed with a unique self-closing mechanism that reduces exposure to harmful microorganisms during bag changes and reducing cleanup. ArcticSun, Bard and Dignishield are registered trademarks of C.R. Bard Inc., or an affiliate

Hollister Ltd Conference Bag Sponsor - Stand 8 & 12 Hollister Critical Care offers you a complete portfolio of products to manage most patients’ faecal management issues. ActiFlo and InstaFlo are both Indwelling Bowel Catheter systems. Faecal Collectors are designed to contain liquid stools. Anchor Fast Oral Endotracheal Tube Fastener is the secure and easy to use alternative to tape.

Exhibitor Floorplan

CAFE

38 CAFE

40 42

3 8

Entrance

CAFE

46 47

Don’t forget to look for your exhibitor ‘theatre card’ in your delegate pack. Visit each exhibitor stand to complete your card and be entered into a prize draw!

Stand Allocation Stand No.

Exhibitor Name

Stand No.

Exhibitor Name

Starkstrom

Alpha Solway Ltd

Fraser Health

SP Services

B. Braun Medical Ltd

Code Blue Nurses

The Intensive Care Society

Distinctive Medical

Charter Kontron Ltd

Intersurgical

8 & 12

Hollister Ltd

Fukuda Denshi UK

Draeger Medical UK Ltd

Gambro

Guy’s and St Thomas’ Critical Care

Medstrom

Secco FMS

Trudell Medical International

Athrodax Healthcare Internatial Ltd

Medtronic UK Ltd

Ethicon Biopatch

Amputees in Action

Healthcare 21 UK Ltd

ASPiH

Central Medical Supplies Ltd

Edwards Lifesciences UK & Ireland

Thornbury Nursing

HCA Hospitals

ConvaTec

KwickScreen

Hamilton Medical UK

Fresenius Medical Care

Bard Ltd

Your World Healthcare

Educationl Management Solutions

Orion UK

Queen Alexandra’s Royal Army Nursing Corps

Kapitex Healthcare Ltd

BACCN

24 & 25

LINET UK

Baxter Healthcare Ltd

Henleys Medical Supplies Ltd

Fannin (UK) Ltd

Exhibitor Editorials Alpha Solway Ltd – Stand 28 Alpha Solway Limited is a leading independent manufacturer and supplier of specialist chemical protective clothing and respiratory products. Committed to offering innovative PPE solutions, we have an extensive range of products to solve many issues within the workplace. Our products are available throughout the UK, Europe and the Rest of the World.

B. Braun Medical Ltd – Stand 5 As a member of one of the world´s leading healthcare companies our ability to develop innovative products, services and systems, in partnership with the NHS, reflects on our global commitment and promise of Sharing Expertise. B. Braun offers an outstanding range of products and services from surgical instruments and implants to IV infusion systems and safety devices, all supported by comprehensive education and training programmes.

Amputees in Action - Stand 15 Amputees in Action is a unique agency, working independently to provide the UK’s largest directory of trained professional amputee actors for film, screen, emergency and military services training simulations. Our personnel use their personal trauma experiences to enable graphic realism, and along with our team of special effects artists, enhance the appearance of limb-loss scenarios. www.amputeesinaction.co.uk

ASPiH – Stand 16 Formed in 2009 through the merger of the National Association of Medical Simulators (NAMS) and the Clinical Skills Network (CSN) the overarching goal of ASPiH will be to enable wider sharing of knowledge, expertise, and educational innovation related to simulated practice across the healthcare professions.

Athrodax Healthcare International Ltd – Stand 36 Athrodax Healthcare, in association with quality medical devices company ‘Dale Medical Products’, looks forward to presenting a range of specialty patient-care products along with the ‘Spiro’ speaking valve from Fogless International and other niche products.

BACCN - Stand 47 The British Association of Critical Care Nurses - BACCN - is one of the leading organisations in critical care nursing. BACCN was established in 1985 and has grown and developed through the hard work and dedication of its members, regional committees and national board. The 14 BACCN regions span Great Britain and Northern Ireland, providing one of the largest and most influential professional organisations within critical care.

Central Medical Supplies Ltd – Stand 39 CMS has a 22 year heritage in specialist patient care. When it’s time to cool, Cincinnati Sub-Zero offers the most effective solution with Blanketroll III and the Kool-Kit. This temperature management system provides an effective alternative to traditional patient cooling techniques. The revolutionary system combines the SMART technology of the Blanketroll III with the body surface area coverage of the Kool-Kit for a non-invasive whole-body temperature management solution. Tel 01538 399541 www.centralmedical.co.uk

Charter Kontron Ltd – Stand 7 Charter Kontron is a provider of a comprehensive range of innovative medical devices and solutions. These include Thermoregulation systems, Patient Monitoring, Clinical Information and Cardiology related products covering haemodynamic, electrophysiology and telemetry.

Code Blue Nurses - Stand 30 Code Blue Nurses London is a specialist agency catering for the highest qualified Critical Care Nurses. We have experienced Critical Care Nurses on the team, who understand what nursing is like on a daily basis in London. We have NHS hospitals and a great selection of London’s finest Private Hospitals to choose your shifts from and naturally…great rates.

ConvaTec – Stand 41 For over 30 years ConvaTec Wound Therapeutics has consistently provided new and innovative products in an ever-changing healthcare environment. From the beginning, our dressings have been

defined by their excellent quality and are painstakingly designed to meet the needs of patients and the healthcare professionals who care for them.

Distinctive Medical – Stand 31 Distinctive Medical specialise in Carts & Trolleys, supplying the UK best selling Resuscitation, Paediatric and Critical Care Trolleys, backed up by a catalogue of over 6,000 products. We aim to find the solution to all of your problems. Come down to our stand for more information.

Draeger Medical UK Ltd – Stand 9

Ethicon Biopatch – Stand 37 BIOPATCH® is the only antimicrobial dressing to be supported by an evidence base of 14 Randomised Controlled Trials for the prevention of CRBSIs, seeing a decrease in the risk of these infections by up to 69%.

Fannin (UK) Ltd – Stand 27 Fannin, established in 1829 and part of the DCC group, offers an extensive range of cost-effective Airway Management, Invasive Monitoring, Venous Access, Fluid Delivery and Ventilation products, with clinical-based evidence. We aim to deliver the highest standards of service and clinical support to our customers.

Dräger is an international leader in the fields of anesthesia, respiratory care, warming therapy and patient monitoring and IT.

Please contact us on +44 (0) 800 212 827 or enquiries@ fannin.eu

“Technology for Life” is our guiding principle. Wherever they are deployed – Dräger products protect, support and save lives.

Fraser Health Stand 2

Dräger Medical UK employs over 150 people, of which two thirds are in the field supporting our customers every day.

Edwards Lifesciences UK & Ireland – Stand 17 Since the first successful heart valve replacement with the Starr-Edwards™ Silastic Ball Valve more than 50 years ago, Edwards Lifesciences has been dedicated to providing innovative solutions for people fighting advanced cardiovascular disease, the world’s leading cause of death and disability. Edwards Lifesciences is the global leader in the science of heart valves and hemodynamic monitoring. Driven by a passion to help patients, the company partners with clinicians to develop innovative technologies in the areas of structural heart disease and critical care monitoring that enable them to save and enhance lives. Please visit our website at www.edwards.com

Education Management Solutions – Stand 44 Leading clinical simulation centers use Education Management Solutions (EMS) to manage their training process. EMS’ simulation management technology, Orion, which includes skills assessment, center management, and audio/video technology records training sessions and assessment tools to ensure improved diagnostic, communication, and patient management skills. Visit booth # 44 and website http://www.EMS-works.com

Fraser Health serves 1.6 million people in 20 diverse communities from urban to rural in the Metro Vancouver area in British Columbia, Canada. With a billion dollars of hospital infrastructure projects planned, there are unprecedented opportunities for Nursing and Health Science professionals with the opening of the Surrey Memorial Hospital Critical Care Tower in 2014.

Fukuda Denshi UK - Stand 33 Fukuda Denshi UK provide the latest technology in patient monitoring and Metavision Clinical information systems. We are now proud to present the Metavision ICNARC module – to find out more, come and join us for a coffee on stand 33. There’s a chance to win a coffee machine for your department.

Gambro – Stand 10 Gambro is a global medical technology company and a leader in developing, manufacturing and supplying products and therapies for Kidney and Liver dialysis. Gambro’s Prismaflex system has been specifically designed to meet the demands placed on blood purification therapies in intensive care units. The Prismaflex delivers a full choice of therapies, which can be adapted to individual patient needs, including Flexitrate, Gambro’s full citrate-calcium management module.

Guy’s and St Thomas’ Critical Care - Stand 34 Located in the heart of London, Guy’s and St Thomas’ Critical Care department is one of the largest in the UK, with more than 70 beds. Due to an exciting expansion of specialist Critical Care Services (ECMO, e-ICU) we are recruiting additional band 5 & 6 nurses to join our team.

Hamilton Medical UK – Stand 42 HAMILTON MEDICAL are global leaders in the manufacturing and supply of Critical care ventilators for the: ICU, Transport, MRI and Non Invasive environments. Renowned for our innovation in automated ventilation therapy, HAMILTON MEDICAL are proud to present the latest in ICU ventilation technology ‘Intellivent- ASV’ on our HAMILTON S1 ventilator.

HCA Hospitals – Stand 18 London’s largest private hospital group, HCA operates 6 world-class hospitals, including The Harley Street Clinic, The Lister Hospital, London Bridge Hospital, The Portland Hospital, The Princess Grace Hospital and The Wellington Hospital. We also run HCA Laboratories and are growing via our expanding joint ventures divisions, including partnering with the NHS. We invest in Centres of Excellence for acute areas of medicine such as cardiology, oncology and neurosciences. We buy the very latest equipment, drugs and therapies and spend tens of millions of pounds on our operating theatres and intensive care facilities keeping our facilities modern, technologically up-to-date.

Healthcare 21 UK Ltd – Stand 38 Established in 2003, Healthcare 21 is one of the largest privately owned healthcare companies and is a leading provider to healthcare institutions with an expert team and an in-depth knowledge of the healthcare market. We strive to assist clinicians, in achieving optimal clinical outcomes and enhancing the quality of patient care. We are launching a new 72 hour closed suction at BACCN 2013, please come and see us.

Henleys Medical Supplies Ltd – Stand 26 Visit us on Stand 26 for your copy of our NEW 2013/14 catalogue which features SpO2 Sensors and Accessories, ECG Cables

and Electrodes, Blood Pressure Cuffs, Invasive Pressure Transducers and Cables, Temperature Sensors, Respiratory Therapy Products, Medilabel Colour-Coded Drug Labels, Patient Positioning Products and much, much more!

The Intensive Care Society – Stand 6 The Intensive Care Society is the UK representative body for intensive care professionals, patients and relatives. We are dedicated to the delivery of the highest quality of critical care to patients in the UK and support and education to our members. The ICS supports research into intensive care medicine through the Intensive Care Foundation. The Foundation coordinates research that critically evaluates existing and new treatments used in intensive care units with a particular focus on important but unanswered questions in intensive care.

Intersurgical – Stand 32 For over thirty years Intersurgical has been supplying a wide range of quality respiratory products to hospitals all over the world. We have always believed that the best way to maintain the highest standards in design, manufacture, quality and customer care is to have complete control of these aspects of our business. This integrated in-house philosophy means we can continue to provide products that consistently meet the demands of changing clinical practice, and user requirements. We are committed to providing the most comprehensive range of respiratory products offering quality, innovation and choice. Web: http://www.intersurgical.co.uk Contact: info@intersurgical.com Address: Crane House, Molly Millars Lane, Wokingham, Berkshire, RG41 2RZ T: +44 (0) 118 9656 300 F: +44 (0) 118 9656 356

Kapitex Healthcare Ltd – Stand 23 Kapitex, specialists in Tracheostomy Care and Airway Management, offer a comprehensive product range: The Tracoe Experc Percutaneous Kit, with 3 alternative Tracheostomy tubes - the Tracoetwist, TracoeVario, and the new longer length Tracoetwist Plus; The Passy Muir Valve for ventilator use and an extensive range of Tracheostomy accessories. Tel: 01937 580211 Email: sales@kapitex.com

KwickScreen - Stand 19 KwickScreen is an innovative Flexible Space Management room divider enabling the flexible transformation of open-plan spaces, whenever and wherever privacy is desired. With interchangeable printed inner screens, KwickScreen instantly adds aesthetic value to a space. Originally invented as an infection control tool, KwickScreen is now used extensively in the NHS and healthcare environments around the world.

LINET UK - Stand 24 & 25 LINET is Europe’s largest manufacturer and distributor of patient beds and pressure care equipment - Innovative brands such as Multicare, Latera and Eleganza beds. Pressure Ulcer treatment is provided by Virtuoso and Precioso including ‘Zero Pressure’. LINET UK provides: Sales & Rental, Service & Maintenance, Spare Parts, Cleaning & Decontamination.

Medstrom – Stand 11 Medstrom introduce DOLPHIN™ Therapy. The DOLPHIN™ provides a simulated fluid environment designed specifically to assist in the nursing and treatment of critically ill patients. Launched in January DOLPHIN™ Therapy has been used to assist in the treatment of patients suffering multiple trauma, de-gloving injuries, sepsis, burns, flaps and grafts; More than 20 ICU’s have already adopted Dolphin Therapy. Visit Medstrom on Stand 11.

Medtronic UK Ltd – Stand 14 Medtronic Hospital Critical Care provides Sentrino®. This is a continuous glucose management system that provides continuous glucose monitoring for patients in critical care. The novel technology uses a subcutaneous sensor to provide tracking and trending of glucose levels in critically ill patients. These levels are continuously displayed on the Sentrino® monitor.

Orion UK – Stand 22 Orion is a Finnish born innovative European R&D based company which develops, manufactures and markets pharmaceuticals, active pharmaceutical ingredients and diagnostic tests. Orion carries out extensive research with a goal of introducing new treatments into global markets. The core therapy areas in Orion’s product and research strategy are central nervous system, oncology, critical care and respiratory medicines.

Queen Alexandra’s Royal Army Nursing Corps – Stand 46 The Army Medical Services recruit Doctors, Nurses, Dentists, Vets and many other clinical roles into their Corps to take up regular and reservist roles as soldiers and officers. Based in Field Hospitals and Medical Regiments around the world – for the last 10 years we have set the benchmark for management and rehabilitation of complex trauma. We successfully continue to recruit and train people to the highest standards – we match professional development to the level set by professional bodies. For more information visit our stand or army.mod.uk/jobs or call us on 0845 600 8080

Secco FMS – Stand 35 Secco is a closed catheter system for the management and safe containment of liquid faeces. Secco combines a sophisticated set of safety features and advanced odour control benefits designed to maximise patient dignity and maintain a healthy ward environment. Secco is 30% less expensive compared to its closest equivalent product.

SP Services – Stand 29 SP Services are the premier supplier of Medical, First Aid, Paramedic and Emergency Rescue Equipment in the UK. www.spservices.co.uk If you would like information on any of SP Services products or services call their friendly SP customer services department on 01952 288 999 or visit them online, anytime at www.spservices.co.uk

Starkstrom – Stand 1 Starkstrom is a highly experienced UK manufacturer and provider of equipment used within the operating theatre, critical care and imaging environments. We supply, install, commission and maintain equipment throughout the NHS and private healthcare sectors. We provide a wide range of products for the operating theatre department, high care areas such as ITU, CCU, HDU, SCBU and PICU, and imaging suites such as MRI, CT, PET and X Ray all backed by a network of fully trained service engineers. At BACCN we will be showcasing the brand new version of our innovative Patient Equipment Transfer Trolley designed to speed up intra department patient transfers in the IICU & A & E areas.

Thornbury Nursing – Stand 40 Established in 1983, Thornbury Nursing Services is one of the UK’s leading independent nursing agencies. We provide skilled healthcare workers across the UK to an ever expanding spectrum of clients requiring the best clinical staff on a temporary basis. We have a variety of work available with extremely competitive pay rates! For further information on how you can join our team contact us today: 0845 120 5252

Trudell Medical International – Stand 13 Trudell Medical International (TMI) manufactures the AeroChamber Plus range of Valved Holding Chambers (VHCs) for use with pressurised MDIs from all leading manufacturers, and the AeroEclipse II breath actuated nebuliser. AeroChamber Plus VHCs are available in infant mask (orange), child mask (yellow), large mask (blue) and mouthpiece variants.

Your World Healthcare – Stand 21 Your World Healthcare are proud to be one of the leading healthcare recruitment agencies. We are one of the largest providers of agency, fixed term contract and permanent healthcare professionals to the NHS and private clients. Visit stand 21 to find out how we can assist you.

The multiFiltrate System

Ci-Ca® - The way to effective citrate anticoagulation

• • • •

Integrated citrate and calcium pumps Controllable anticoagulation, also for patients with high bleeding risks1 Device-assisted calcium management Active influence on the acid-base status

1. Robert Kalb. (2013). Therapeutic Apheresis & Dialysis. Regional Citrate Anticoagulation for High Volume Continuous Venovenous Hemodialysis in Surgical Patients With High Bleeding Risk. 17(2), p202-12 Date of preparation: August 2013 UK/ABT/MFT/0813/0002

Go further at the UK’s number 1 private children’s hospital

PICU vacancies at The Portland Hospital Current vacancies • Staff Nurse/Senior Staff Nurse • Sister/Charge Nurse If you’re a highly motivated PICU Sister/Charge Nurse or Nurse who can deliver exceptional levels of care alongside a commitment to enhancing your personal and professional development, The Portland Hospital would like to hear from you. We’re significantly expanding our dedicated Children’s Services department – this includes our 7-bed PICU which is growing to 10 beds this year – and we want you to be part of this development. Part of this planned growth will enhance the structure of our staff teams and provide them with more support. Alongside the growth of the PICU ward, you’ll have access to a number of different educational courses for PICU and general paediatrics. This includes facilitation of the Foundation PICU Programme or General Paediatrics Programme. We recognise that our world-class reputation is built on the skills and experience of our dedicated staff team, so we’re looking for: Nurses • excellent clinical skills • effective communication • the ability to build strong relationships with children and their families.

Sister/Charge Nurse • demonstrable success in leading and delivering practice • proven ability to analyse complex problems and implement practical solutions • the ability to think and plan strategically • the ability to build strong relationships with doctors, embassies and families. Working alongside a multi-disciplinary team of like-minded colleagues, using state-of-the-art equipment and techniques, you’ll be responsible for providing the highest standards of holistic, family-centred care. In return, we’ll make sure you have all the resources, support and opportunities you need to keep doing what you do best. The Portland Hospital has an international reputation for excellence, at the forefront of private healthcare. We offer a wide range of specialities, including areas of world-leading complex care from ENT and neurosurgery to gastro and craniofacial cases. We work with the country’s leading consultants, from London’s top teaching hospitals, using the latest technologies. All we need now is you.

For more information on these positions and other specialist paediatric nursing vacancies, and to arrange to come and look around, call Prity Chavda, Recruitment Advisor, on (0)20 7563 4289 or email her at paediatricnursing@hcahealthcare.co.uk www.theportlandhospital.com/careers/

RECRUITMENT

Abstracts

Workshop Abstracts W01 & W07: Haemodynamic

Monitoring: Applying Innovation and Evidence to Practice

Tim Collins & Rebecca Seaman, Maidstone & Tunbridge Wells NHS Trust Haemodynamic monitoring is essential for the management of critically ill patients’ within Intensive Care. There are numerous methods of assessing advanced haemodynamic monitoring in the critically ill but it is the accurate measurement, interpretation and resultant decision making of these parameters of cardiac function that ultimately enhance tissue perfusion and patient outcome (Fawcett 2006). Achieving optimal fluid volumisation in critically ill patients requires meticulous management. With under filling exposing the patient to hypovolaemia with low cardiac output states and the alternative of overfilling, exposing the patient to pulmonary oedema and acute lung injury (Bellamy 2006). This fine balance often poses a dilemma to critical care practitioners. There will be two separate interactive simulation workshops using state of the art cardiac output simulation technology and audience response keypads. The workshops will allow delegates to participate in a real time simulation involving optimising volumisation, perfusion and oxygen delivery using a case study approach. These haemodynamic workshops will practically demonstrate evidence based applications of assessing preload as well as explore parameters available from transpulmonary thermodilution to enable fluid optimisation to be effectively achieved (Marik et al 2009). The NICE (2011) evidence based approach for achieving fluid optimisation using stroke volume will be demonstrated and the benefits to patient outcomes will be examined. Workshop 1: Target driven therapy and fluid optimisation: This workshop will focus upon a postoperative target driven therapy (TDT) case study that has recently arrived on the critical care unit from theatres following major high risk surgery. Hamilton et al (2011) meta-analysis involving 29 RCT’s found that pre-emptive target driven haemodynamic intervention following high risk surgery increases patient outcomes and reduces postoperative complications and infections. The literature is conclusive that TDT reduces hospital length of stay which has patient and service improvement benefits with more availability of acute hospital beds (NICE 2011, Hamilton et 2011, Mayer et al 2010 & Pearse et al 2005). This workshop will demonstrate, using a simulation approach, how fluid optimisation and TDT can be achieved. Workshop 1: Learning Outcomes: 1. Assess, measure and manipulate cardiac preload to achieve fluid optimisation according to NICE (2011) and

other published literature 2. Understand the application and limitations of stroke volume variation (SVV) 3. Understand the evidence base behind target driven therapy & its benefits to patient and hospital outcomes. 4. Apply evidence based decision making in providing pre-emptive TDT for high risk postsurgical patients within critical care using a case study approach. Workshop 2: Haemodynamic optimisation in Sepsis and ARDS: This workshop will focus upon a postoperative patient who has been ventilated due to severe sepsis who develops acute respiratory distress syndrome (ARDS). The simulation will demonstrate how to fluid optimise a patient in sepsis and how to apply target driven vasopressors and inotropes to achieve effective cardiac output and systemic vascular resistance to encourage optimal perfusion. Application of transpulmonary thermodilution (TPTD) parameters will be examined including demonstration on how to effectively perform this procedure so that these measurements can further inform sepsis and ARDS management (Vincent 2011). The clinical application of extra vascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) will be demonstrated and how this can inform ARDS decision making (Monnet et al 2007). Workshop 2: Learning Outcomes: 1. Assess, measure and manipulate preload, cardiac output and SVR to achieve effective perfusion and oxygen delivery in sepsis/ARDS 2. Know how to effectively perform TPTD fluid bolus and its physiology 3. Understand TPTD parameters including GEDV, CFI, EVLW & PVPI and how to augment these parameters 4. Apply evidence based decision making in providing haemodynamic target driven therapy when managing an sepsis/ARDS patient References: Bellamy M (2006) Wet, dry or something else? British Journal of Anaesthesia. 6:755-757 Fawcett J (2006) Hemodynamic monitoring made easy. London. Elsevier. Hamilton et al (2011) Meta-Analysis on the Use of Preemptive Hemodynamic Intervention to Improve Postoperative Outcomes in Moderate and High-Risk Surgical Patients. Anesthesia & analgesia:112(6):1392-1402.

W02: Introduction of Citrate CRRT:

“The Trials and Tribulations”

Diane Eady, Caroline Wood, United Lincolnshire Hospitals NHS Trust

SPONSORED BY FRESENIUS MEDICAL CARE What happens when your current filter equipment comes to the end of its life? The trust goes out to tender of course! A key element of the tender criteria was the ability for any new equipment to deliver Citrate as an anticoagulation therapy. There is increasing evidence to suggest that regional citrate anticoagulation improves filter efficiency and therefore the effectiveness of continuous renal replacement therapy (CRRT). (Monchi, Berghmans et al 2004 and Kutsogiannis, Gibney et al 2005). If we consider Lewin’s Change Management model (Lewin 1947) we can clearly signpost the journey we have taken. Our stakeholders included not only the nursing and medical staff who would ultimately use the equipment but the clinical engineering team, the finance and procurement departments along with the management teams within the organisation. All had the opportunity to evaluate the options presented (Unfreezing stage – Lewin 1958). A strategy for introduction and implementation was set. We are two separate Intensive Care units within the same trust so implementation took place consecutively in order to ensure robust training and support during our most vulnerable moments. Citrate was introduced from the outset in both units however one opted to use CVVHD and the other CVVHDF. Training was provided by the company over a period of 4 weeks each and enabled a high proportion of staff to gain an insight and some ‘hands on’ experience with set up and management of the filter. ‘Super users’ also received extra information in relation to troubleshooting and manipulation of the therapies. This 4 week period was not without difficulty involving objections about the choices of equipment and therapy selected prompting a reluctance to accept these despite the vigorous evaluation process that had been undertaken at the unfreezing stage (Change stage - Lewin 1958). Four months on the transition towards the Re-Freezing stage (Lewin 1958) is well underway although not quite completed. The strongest objectors remain sceptical but are gradually becoming less resistant to the change. This evolving process has given rise to the development of guidelines, prescriptions and education packages which, along with on-going support from the company have provided a framework to support improving confidence and competence with citrate therapy within the clinical area. Early anecdotal evidence suggests improved filter life so less ‘down time’ and fewer nursing interactions with the equipment thus ‘Releasing time to care’ (National Nursing Research Unit 2010). In the future we plan to undertake audit to provide quantitative data to support the benefits of citrate therapy.

W03: Trauma Critical Care Skills Major Chris Carter, QARANC, Chair BACCN Military Region SUPPORTED BY AMPUTEES IN ACTION Background: The British Association of Critical Care Nurses (BACCN) Military Region has developed a one day trauma critical care skills workshop, in response to membership feedback, changes in military and civilian trauma practice and training in the UK. The Faculty are pleased to offer this workshop to delegates attending national conference, as the content is relevant to civilian and military nurses who nurse the critically ill trauma patient. Learning Outcomes: This aim of this workshop is to provide junior critical care nurses an introduction into the essential knowledge and skills to nurse the critically ill patient. Workshop Curriculum: The workshop uses a series of short lectures to introduce delegates to the pathophysiology of trauma, catastrophic haemorrhage and shock, chest injuries, neurological injuries, spinal injuries, abdominal injuries, pelvic and limb injuries and pain management. Then using case studies delegates discuss the nursing management of patients and undertake a series of practical trauma skills relevant to critical care nursing. Conclusion: This workshop has predominately been delivered within the military nursing environment, therefore we look forward to sharing our experiences with other critical care nurses who are involved in nursing the critically ill trauma patient, in order to share and develop professional practice.

W04: Writing for Publication Julie Scholes, Director of Postgraduate Studies in the Brighton Doctoral College, and Professor of Nursing This workshop will offer a practical guide through the stages of writing a paper for publication. This will include considering the topic for publication, focussing the content of the paper and honing the argument of your paper. The discussion will include an exploration of the top tips to getting your paper published and will also identify the common mistakes that cause papers to be rejected. The workshop will also outline the ethical principles underpinning publication. The workshop is to be facilitated by experienced authors, reviewers and the editor of two nursing journals.

W05: Catastrophic Haemorrhage Major Chris Carter, QARANC, Chair BACCN Military Region Background: Catastrophic haemorrhage is the leading cause of military battlefield deaths and the second leading cause of death in civilian patients after trauma. In order to save life, treatments must begin at the point of injury and continue through the entire casualty pathway. The treatment of catastrophic haemorrhage has been the subject of research which has resulted in a greater understanding of clot formation, novel hybrid resuscitation, massive transfusion and other treatments such as Damage Control Surgery which have been introduced into Military and Civilian practice. Aim: The aim of this interactive workshop is to explore the treatment of catastrophic haemorrhage from the point of injury to definitive care in the intensive care unit. This session will include a review of clot formation, novel hybrid resuscitation, massive transfusion and other treatment options available to deal with catastrophic haemorrhage. Conclusion: Although focusing on the military patient, this workshop will be relevant to both military and civilian critical care nurses as it will provide an introduction the current research relating to the treatment catastrophic haemorrhage following trauma. References: Kirkman E, Watts S, Copper G. (2011) Blast injury research models. Philos Trans R Soc Lond B Biol Sci. 366:144-159 Brohi K, Cohen MJ, Ganter MT, Matthay MA Mackersie RC, Pittet JF. (2007) Acute traumatic coagulopathy: initiated by hypooerfusion: modulated through the protein C pathway? Ann Surg. 245:812-818 Fuller G. Bouamra O. Woodford M. Jenks T. Stanworth S. Allard S. Coats T. Brohi K. Lecky F. (2012). Recent massive blood transfusion practice in England and Wales: view from a trauma registry. Emergency Medical Journal. 29: 118-123. Hodgetts TJ. Mahoney PF. Kirkman E. (2007). Clinical developments: damage control resuscitation. Journal of the Royal Army Medical Corps. 153; 4: 299-300. Rossaint R. Bouillon B. Cerny V et al. (2010). Management of bleeding following major trauma: an updated European guideline. Critical Care. 14: 1-29.

W06: DIY Happiness Jenny Sergeant, True Colours UK LLP A pilot programme by Kings Health partnership and GSTT has clearly shown that employees are motivated by the need to make a difference but morale and resilience is undermined by their values not being met. Both options will be fully supported by research and practical evidence and all participants will get something to takeaway. DIY happiness

Main group session- Happier@work based on the DIY happiness programme developed by SLAMâ&#x20AC;&#x2122;s mental Health promotion team. Their research has clearly demonstrated that these elements are fundamental to both creating healthier workplaces, teams and individuals. Based on 6 key elements of mental health the audience creates tips to share for each element which promotes discussion and interaction.

W08: Therapeutic Temperature

management

Helen Jones, Neuro ICU SPONSORED BY BARD LIMITED Content: - Practical aspects of Cooling - Reasons for cooling - What are the ideal characteristics of a temperature control device? - Importance of monitoring - Rewarming phase - An audit of two topical therapeutic hypothermic cooling systems commercially available and which one was preferred by the Neuro ICU and why

W09: Sedation and the Mechanically Ventilated Patient: When is Enough Enough and How Do You Know? Marcia Bixby; Consultant, USA Managing sedation for patients who are mechanicall ventilated is not an easy skill to learn. The current standards that utilize lower doses of sedationmedications to allow for daily neurological assessment of patients as well as reduce incidents of VAP can also lead to patient safety issues. Knowledge of how sedation medications work and the evidence based standards that guide how we titrate those medications is key to safe sedation in this populations. This presentation will include appropriate patients for sedation titration and use of sedation and pain assessment scales to ensure adequate comfort and anxiety levels. Strategies to decrease sedation infusions to prevent accumulation of medications that lead to prolonged sedation will be included. OBJECTIVES At the completion of this session the learner will be able to: 1. Identify appropiate patients for sedation titration during mechanical ventilation 2. Be familiar with assessment scales to manage sedation and pain 3. Recognize the importance of sedation titration to prevent accumulation of medications.

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Concurrent Abstracts C01: Being There: Dealing with a

Serious Untoward Incident within Critical Care Neil Boyland, Royal United Hospital Bath NHS Trust PURPOSE Dealing with any Serious Untoward Incident is challenging and demanding for all staff concerned. The purpose of this presentation will discuss a ‘Staff Story’ within Critical Care following a Serious Untoward Incident, where a patient came to harm. The author will discuss the process, components and challenges that were presented in such a case and how the author addressed the dynmanics within their team in such a way to be able to move the Critical Care department forward. PRESENTATION DESIGN Due to the seriousness of this incident the impact on the medical and nursing staff were significant and the impact and ongoing support lasted over 18 months.The cost of caring and emotional resilience towards staff were in its self multifaceted in acheiving the best outcome for staff concerned. The presentation will cover working alongside internal and external agencies, legal representation with external law teams and the preparation for Coroners Inquest.The author will also discuss the impact of family members in relation to the incident. CONCLUSION Meeting the emotional demands for staff following this Serious Incident were not expected or predicted by the author. The complexities and stressors were unique and required professional input for some staff groups. The approach of openess, professional integrity and true team work has been overwhelming, and has helped to move the Critical Care Unit to where it is today. The power and the ability to return to the teams original purpose is a true example of how resillience has been tested and how strong team dynamics and leadership can overcome such incidents to once again gain normality. References: Bassett S (2012) Accountability in the NHS. Nursing Management. NursingStandard. ol 19 No 8 pp 24-26 Breen J (2012) Patients Death Highlighted Value of Practical Emotional Support.Nursing Standard. Vol 27 No14 pp 27 Cox C (2010) Legal Responsibility and Accountability. Nursing Management Vol 17No 3 Levy S (2012) Information Systems That Support effective clinical decisionmaking.Nursing Management; Vol 19 No 7 pp 20-22 National Institute for Clinical Excellence (NICE) (2005) Post Traumatice StressDisorder.Nazarko L (2002) A Catastrophe waiting to happen. Nursing Management. Vol 9 Number 3. Nursing Standard (2013) First Encounter with the Death of a patient leaves lasting effects. Vol 27 No 15-17 pp16 Royal College of Nursing (2005) Working with Care:

improving Working Relationships in Health Care. London: RCNStordeur S. D.’Hoore W and vandenburghe C (2001) Leadership,organisational stress and emotional exhaustion amoung hospital nursing staff. Journal of Advanced Nursing. Vol 35 533-542

C02: Work, Rest and Play! Julie Platten, North of England Critical Care Network , Jenny Ritzema, Gateshead Health NHS Trust Over the last 10 years there have been major national changes in the delivery of critical care services (DOH 2000, 2001, 2005); this has led to a dramatic modernisation of critical care services in the QEH. Due to the changes, our ITU and HDU merged and became the Critical Care Department (CCD) this increased our bed capacity and nursing establishment but as result diluted the skill mix within the unit. During this period of change there were many staff absences and stress was identified as an underlying factor (either personal or work related). The purpose of Stressbusters group was to identify and evaluate what support measures were already in place for the multi disciplinary team in the workplace, and agree what other methods may be required as we continue to move forward with the modernisation of critical care services. Stressbusters was led by a Band 7 open to all staff to improve cohesive working, with support from senior managers which was very important.Through Stressbusters we have managed to make some positive changes within the critical care department, for example introduction of day light bulbs in badlylit areas using risk assessments to provide the needed evidence. The group also organises a range of activities including white water rafting, paint balling,and murder mystery nights with the aim of improving team work.In the future we are looking to rename Stressbusters, to encompass all members of the MDT who work within CCD. The rebranding will include a name change to‘Team CC’, Stressbusters was nurse lead, Team CC will be open to all members of the unit. We will continue to organize activities and improve working practices through improved teamwork and communication.

C03: Arterial Line Safety - Learning

from a Serious Untoward Incident on the Intensive Care Unit

Marghanita Jenkins, Royal United Hospital Bath NHS Trust In 2008, the National Patient Safety Agency (NPSA), produced a Rapid Response Alert (NPSA, 2008) highlighting problems with infusions and sampling errors from arterial lines causing potential harm to

patients. Another alert was issued by the Medicines and Healthcare products Regulatory Agency (MHRA), regarding glucose being incorrectly used as arterial line flush, resulting in high, incorrect blood sugar readings and subsequent infusion of insulin, causing ‘potentially fatal hypoglycaemia’ (MHRA, 2012). In February 2011, a patient on the Intensive care Unit (ICU) at the Royal United Hospital, Bath, (RUH) was affected by one such incident, causing catastrophic harm. The ensuing internal and external investigations, leading to a seven-day coroner’s inquest, were extremely difficult for all involved. Nevertheless, the wish to ensure such an incident “never” happens again in our unit, has driven us to reflect on both local and national guidelines for arterial lines. The Serious Untoward Incident (SUI) investigation highlighted to us the need for a change in our practice and led us to develop a ten-point action plan. However, the desire by staff to show the coroner and particularly the patient’s family, that we had learned from what had happened, led us to explore practice further and produce an even more comprehensive action plan. Part of that plan is to share, on a national level, what we have learned through our experience. This includes disseminating the changes in practice we have made regarding arterial lines in Bath and sharing the result of a national survey around care of arterial lines - completed by the Consultant team involved in the SUI at the RUH. The process of investigating and responding to the SUI has been incredibly complex and prolonged. We hope, by sharing our experiences to help prevent further such episodes from happening again to another patient, family and ICU. There are lessons to be learnt but standards and recommendations in arterial line safety need to be examined in detail on a national level to prevent such incidents reoccurring. References 1. National Patient safety Agency (2008) New guidance issued following problems with infusions and sampling from arterial lines. 2. Medicines and Healthcare products Regulation Agency (2012) Drug safety update July 2012, vol.5 issue 12;A2.

C04:

Living with a Long Term Tracheostomy - a patient’s perspective

Anne-Marie Carter, Linda Kent, Mrs Linda Chu, Miss Kim Williamson, Mrs Frances Clark, Mr Marcus Peck, Suman Shresthra Frimley Park NHS Trust We would like to introduce you to Danny, a 53 year old gentleman who was repatriated to our DGH for rehabilitation following Campylobacter infection and Guillian-Barre Miller Fisher syndrome. He had spent three weeks on a neuro-intensive care unit, during which time a tracheostomy was performed for persistent bulbar weakness and vocal cord palsy. After a complex time with

us involving several tracheostomy changes and one failed decannulation, Danny faced the reality of a long term tracheostomy. He was previously fit and well and now was confronted with significant physical, emotional and psychological changes in his life. This ultimately had an impact not only on Danny but also on his young family.The outreach team visited Danny daily to support him which included teaching him to manage his tracheostomy. Danny was now attempting to adapt to an altered body image with a total change in his daily life, which was a daunting prospect for both him and his family. However in time, through ongoing psychological support and education, we were able to help him through this process. Danny’s case brought up a whole new scope of practice that led us to review our tracheostomy policy. This made us aware of the very limited support and resources available to tracheostomy patients in the community. For Danny and his wife, to be discharged home with very little assistance, was a frightening prospect. We have found that the most useful interventions in helping patients come to terms with critical illness is hearing another patient’s story. This presentation tells the story of how the outreach team managed and supported this patient.

C05: The Development of a Trauma Critical Care Skills Workshop

Major Chris Carter, QARANC, Chair BACCN Military Region Within the last ten years significant changes within military and civilian trauma care has advanced critical care nursing practice and the patient pathway. In response to membership feedback the British Association of Critical Care Nurses (BACCN) Military Region developed a one day trauma critical care skills workshop.The aim of the BACCN Military Region Trauma Critical Care Skills Workshop is to provide nurses who have limited experience of nursing trauma patients a foundation in essential knowledge and skills. This workshop is aimed at both the military and or UK clinical environments. AIM This presentation will outline current literature relating to trauma care and training, the development of the workshop, course development and delegate feedback. RESULTS Over the past 18 months workshops have been delivered in a variety of clinical units around the UK and feedback from instructors and delegates has been positive. CONCLUSION Since commencing this project the interest in this workshop has continued to grow. This has assisted with the Military Region contributing to the professional development of future generations of critical care nurses

who may be required to deal with the trauma patient in critical care.

C06: Training for Trauma: Educational Initiatives for Improving Trauma Care in Critical Care - Reviewing the Past, Realising the Future

Dean Whiting, University Of Bedfordshire The aim of this session is to determine whether there is a need for specialist education in trauma critical care within the general critical care environment. Between the ages of 1 and 40-years, trauma is the most significant cause of death and disability worldwide and causes a great burden upon society (WHO,2004). In 2007 the NCEPOD reported that 60% of severely injured patients were likely to receive sub-optimal trauma care in UK hospitals. A host of reviews such as the ‘Major Trauma Care in England’ report (NAO, 2010) and legislative changes ensued and specialist regional trauma networks have been introduced to provide a focused and streamlined care-pathway, similar to those used within the military trauma system (Hodgetts et al, 2007). Critical care services play a large part within these networks and trauma accounts for approximately 10% of all critical care admissions (ICNARC, 2012), yet there are no formal specialist education programmes for critical care nurses. Examination of the latest research, national guidelines and analysis of current opinion identifies that critical care nursing has fallen behind in terms of trauma care compared to other professional groups. At best, education ofcritical care nurses is reliant upon general and prehospital based shortcourses to fill the gap, however these do not explore fully the specifics of nursing a trauma patient within the critical care environment.The critical care nurse remains at the forefront of patient care and this is no different when faced with the management of the critically ill trauma patient. It is believed that the management of these patients should be afforded appropriate education, tailored to managing trauma patients in general critical care units. References Hodgetts, T., Davies, S., Russell, R., & McLeod, J. (2007). Benchmarking the UKmilitary deployed trauma system. Journal of the Royal Army Medical Corps.153(4), 237-238. Intensive Care National Audit & Research Centre. (2012). Major TraumaAdmissions. London, ICNARC National Audit Office. (2010). Major Trauma Care in England. London, The Stationary Office.World Health Organisation. (2004). Injuries and Violence: TheFacts. http://www.who.int/violence_injury_prevention/key_facts/ VIP_key_facts.pdf

C07: Education for Nurses from around

the World: Erasmus Mundus Joint Master Veronica Braganza, Alejandra Guerrero, Dr Mosteiro, University of Oviedo, Spain

INTRODUCTION Nursing is an art, science and a universal language in the act of caring. However, to uphold this profession it is important that nurses receive advanced education with a skills perspective focused on clinical reasoning, clinical judgment, communication skills, innovation and process excellence. For most developing countries this is merely impossiblethe Erasmus Mundus Master in Emergency and Critical care Nursing (EMMECC NURSING) however provides this excellence in not only theoretical knowledge but clinical practice as well. OBJECTIVE To describe the EMMECC Nursing program and its benefits to the development of expertise in nursing. DESCRIPTION The Erasmus Mundus Master in Emergency and Critical Care Nursing is the first international joint degree in advanced nursing available in Europe. It offers a highly specialized education in nursing, with an advanced perspective. EMMECC NURSING is promoted by a consortium coordinated by the University of Oviedo (Spain) and counting with the partnership of the Metropolia University of Applied Sciences of Helsinki (Finland), the University of Algarveand the Polytechnic Institute of Santarém (Portugal).The EMMECC NURSING Master prepares clinical nurses to provide advanced nursing care within acute care services. It ensures student preparedness, evidence-based training and clinical handson experience; all academic and experiential training modules are specifically designed to fulfill the needs of intensive care and emergency units. The duration of this master is 18 months (90 ECTS). An integral characteristic of this master is that it provides scholarships in the aim of giving International and European students an opportunity to achieve their dream of advanced nursing education. COMMENTARIES Nowadays, Emergency and Critical Care Units play an increasingly important role in our Hospitals. Therefore, educational programmes like the EMMECC NURSING will produce highly competitive nurses who will provide high added value, safe and effective care with holistic dimensions in favor of our patients and their needs

C08: iMobile: Delivering Critical Care

to the Wards

Sophie Hadfield, Kings College Hospital NHS Trust BACKGROUND Critical care treatment is a limited resource. Research demonstrates that current facilities will fail to match future demands, due to an aging population and an increase in co-morbidities (Rhodes et al 2012). In 2012, the general intensive care unit (ICU) at Kings College Hospital (KCH) had 2047 admissions,an increase of 16% since 2011. To deal with this increased demand, a new 65 bed ICU is planned for 2016. Interim solutions to address these capacity issues include the development of a mobile critical care team -‘iMobile’ - who will deliver

critical care therapy to selected patients on the wards. PROPOSAL Mobile is a novel concept that aims to provide early goal directed therapy to patients at risk of deteriorating. iMobile will be a multi-disciplinary team operating 24/7 and the service is expected to ‘go live’ in August 2013. Suitability for iMobile treatment will be based on set criteria with a four-hour review period in which to assess response to treatment. Examples of interventions will include non-invasive respiratory support and flow monitoring for fluid optimisation. ICU nurses will be present on the wards to facilitate treatment with the support of ICU registrars and/or consultants. DISCUSSION There will be many challenges in implementing this service. Providing critical care treatment in the ward environment will require strong leadership, good collaboration and robust guidelines to ensure that quality of care and patient safety are improved and not compromised. Collaborative working with the wardstaff is key. Responses from a scoping exercise are positive; general feedback from ward nurses indicate acceptance, support and desire for this unique opportunity to develop skills and knowledge in managing deteriorating patients through first hand experience. References Rhodes A et al (2012) The variability of critical care bed numbers in Europe;Intensive Care Medicine 38:1647–1653

C09: The Septic Patient and Fluid Resuscitation Nicola Mcann, Royal Victoria Infirmary AIM The aim of this case study is for the author to explore and share an aspect of care of an elderly critically ill patient. A case study will be discussed with the focus on fluid resuscitation. BACKGROUND During the past decade, the number of patients admitted to the intensive care unit (ICU), aged 80 years and older, has increased (Nguyen et al, 2011). There is a reluctance amongst many physicians to admit the oldest, fearing a ‘squandering’ of resources, the admission could be more deleterious than healing and that the patient and/ or the family may not even want the admission (Nguyenet al, 2011). Older people are more prone to infection and a resultant sepsis due to the effects of aging and comorbidities (Destarac and Ely, 2002). Older persons tend to be treated less aggressively, however, quality of life, comorbidities and patient preference should all be considered when determining the aggressiveness of care (Destarac and Ely, 2002). Worldwide, sepsis is a major killer, and in the UK sepsis kills more people than lung, bowel and breast cancer put together (Robson and Daniels, 2008). To the National Health Service (NHS), the costs are significant (Robson and Daniels, 2008). The sepsis cascade is a complex process, which involves the culmination of interactions between the hosts immune, inflammatory and

coagulation responses and the infecting microorganism (Russell, 2006). Severe sepsis and septic shock are associated with multi organ dysfunction and ultimately death (Russell, 2006).The Sepsis Six care bundle, within The Surviving Sepsis Campaign (2013),recommends the timely administration of fluid therapy, in the hope of reversing tissue hypoxia and organ failure, as one of the major forms of treatment. Aggressive fluid resuscitation within the first few hours could considerably reduce mortality (Rivers et al, 2001). However, the effects of fluid resuscitation within sepsis care, remains poorly evaluated (Ospina-Tascon,2010). The colloid vs crystalloid debate remains a bone of contention between scholars. CONCLUSION With an ever-aging population, increasing numbers of older people will be admitted to ICU’s with sepsis related illnesses. Treatment should be prescribed on an individual patient-centred basis and should not be rationed by age.

C10:

Critical Care Survivors: Emotional Consequence of Admission

Cheryl Phillips, University of South Wales Amanda Hale, Tracey Rich, Critical Care Unit, Royal Gwent Hospital Aneurin Bevan Health Board Introduction: The psychosocial implications related to critical care survival and the experiences of patients in the post -discharge phase of the journey is an emerging field of research. There are current concerns that critical care services need to develop to integrate patient support mechanisms beyond discharge from hospital, such as physical and psychological follow up and support (NICE, 2009, Jones et al., 2010). This has led some healthcare professionals to introduce patient diaries to enable the patient to read about key things that happened during their admission to help them make sense of events that occurred while they were unconscious and vulnerable (Bergbom et al., 1999, Egerod et al., 2007). Learning outcome: To share emotional experiences of critical care survivors with those who may care for them Presentation outline Diary team drivers: Amanda Hale & Tracey Rich Research perspective: Cheryl Phillips Patient perspective: short film (using StoryWorks to produce this) Study Design & Methodology This study is longitudinal and uses Grounded Theory. Participants are being interviewed at 2, 6 & 12 months post discharge from hospital. Summary This PhD study is still in progress and the presentation will focus on the emotional impact of the critical illness journey that is present in the data collected so far, rather than on the study findings and conclusions which are still in progress.

The Plutchik wheel of emotion will probably be used as a framework for the presentation. Participants’ recovery seems in part to rely on them making sense of what has happened to them whilst in critical care. They describe it as a life changing event that gives them a different perspective on life. References: Bergbom I., Svensson C., Berggren E. & Kamsula M. (1999) Patients’ and relatives’ opinions and feelings about diaries kept by nurses in an intensive care unit: pilot study. Intensive Critical Care Nursing. 15(4)185-191. Egerod I., Schwartz-Nielsen K.H., Hansen G.M. & Lærkner E. (2007) The extent and application of patient diaries in Danish ICUs in 2006. Nursing in Critical Care. 12(3)159167. National Institute for Health & Clinical Excellence (2009) Clinical Guideline 83: Rehabilitation after critical illness. London. Plutchik wheel of emotion http://en.wikipedia.org/wiki/ File:Plutchik-wheel.svg. Accessed 20/03/2013 Jones C., Bäckman C., Capuzzo M., Egerod I., Flaatten H., Granja C., Rylander C. & Griffiths R.D. (2010) Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomized, controlled trial. Critical Care.14(5):1-10 at http://ccforum.com/ content/14/5/R168 Accessed 10/06/11

C11:

Back to Life, Back to Reality

Susie Lawley, Gateshead Health NHS Trust In light of the 2009 NICE guidelines on Rehabilitation after Critical Illness, a service was set up by Aileen Rooney at the QE Gateshead to address the holistic needs of patients following critical illness. After 72 hours of ventilation contact is established with the rehab team (Nurse Practitioner, two specially trained healthcare assistants and a physiotherapist), a photo diary is commenced and a comprehensive rehabilitation pathway document is initiated. The aim of this service was to meet the guidelines of CG83 and address the problems cited by previous patients. One of the major problems cited by patients was the feeling of abandonment on discharge to a home ward for which continued contact with the rehab team from Critical Care until after discharge from hospital is a great antidote. Patients receive intensive rehabilitation from the healthcare assistants from the time they are fit enough in Critical Care to the point of discharge from hospital.This rehabilitation includes promotion of independence with hygiene and dressing, trips outside of the clinical setting, promotion of a personally tailored exercise program and continued emotional support. The Rehabilitation pathway is co-ordinated by the Nurse Practitioner and supported by a Critical Care Physiotherapist who also jointly holds the follow up clinic. Preliminary service audit show that since the service was established there was a reduction in length of stay post critical care of 50%, increased quality of life indicators, 75% reduction in read mission to critical care, 54% increase in patients who have no problems walking about, 12% increase in patients who have no problems sleeping and a 19% reduction in patients who

experience extreme pain. Due to the success of the service it has grown from just one Nurse Practitioner to the large team it is now and there may be scope for further expansion. National Institute for Health and Clinical Excellence (NICE). Rehabilitationafter critical illness.NHS National Institute for Health and ClinicalExcellence. 2009.ICUsteps. Intensive care: a guide for patients and relatives. ICUsteps; theintensive care patient support charity Web site. http://www.icusteps.com/guide.Accessed March 2013

C12: Development of a Rapid Inter-

professional Ultrasound Assessment of Critically Ill Patients in a Large Central London Intensive Care Unit

Sarah Casboult, Dr Philip Hopkins, Dr Agnieszka Skorko, Karina Heelas, King’s College Hospital NHS Trust INTRODUCTION Ultrasonography (US), a safe and non-invasive diagnostic imaging technique is now used extensively in the critical care setting. International competencies have been agreed to support the use of US by non-radiologists in shock assessment; the primary trauma survey; and placement of lines and drains (1,2).However, despite an increasing role for nursing staff in the use of complex near patient devices; this has not included involvement in assessment and treatment of critically-ill patients with US. Here we describe the development and testing of a nurse-led inter-professional US imaging schedule in the 32-bedded general ICU. METHOD Baseline survey, peer-review, round-table discussion and inter-professional interviews were conducted with imaging and critical care staff to document baseline perceptions and attitudes towards the development of a nurse-led inter-professional ultrasound assessment protocol for critically-ill patients.This baseline analysis was also used to generate consensus for the required number and format of essential ultrasound windows that could be beneficially and safely utilised by the whole inter-professional ICU team. RESULTS Key outcomes were the need to develop a common inter-professional language; clearly identify anatomical targets for imaging and provide a list of achievable binary questions. 91% of nurses wanted to learn basic ultrasound techniques,while 65% felt it would change the medical management of patients. Nurses and doctors achieved level-1 competency for all 10 windows after an equivalent number of supervised and solo (reviewed) examinations. CONCLUSION We have developed a 10-window inter-professional ultrasound survey for use in the assessment and care of critically-ill patients. Critical care nurses were able to acquire the necessary competencies at a similar pace to

physician colleagues. A randomised controlled trial is now planned to test whether the inter-professional ultrasound survey produces benefits such as enhanced detection of complications of critical illness; reduced reliance on ionizing radiation and better inter-professional working.

• Review of culture and statistics to improve knowledge and standards and reduce HCAIs within critical care

References Neri L et al. 2007. Toward an ultrasound curriculum for critical caremedicine. Crit Care Med 35: S290-304. Volpicelli G et al. 2012. International evidence-based recommendations forpoint-of-care lung ultrasound.

• Network regionally and nationally

Intensive Care Med 38: 577-91.

C13:

Critical Care Infection Prevention and Control Nurse (CCIPCN) – Establishing a Role

Eunice Strahan, RICU, Belfast Health and Social Care Trust BACKGROUND The Regional Intensive Care Unit (RICU) is a regional referral critical care unit in Northern Ireland with 17 level 3 and 8 level 2 beds.Due to the high incidence of infection, high bed occupancy and large number of critical care staff the need for a dedicated, specialised critical care infection prevention and control nurse (CCIPCN) for RICU was identified. AIMS/OBJECTIVES The overall aim of the post is to contribute to a reduction in health care associated infections (HCAIs) in critical care. Primary drivers are: • Develop a culture that focuses on infection prevention and control (IP&C) • Prevent transmission of microorganisms and ensure best practice • Motivated and knowledgeable staff •Audit/research intervention The post commenced in May 2012 and is being funded for two years from a charitable source. A values clarification exercise was carried out and the role of CCIPCN described (Manley, 2003). Multidisciplinary IP&C champions have been identified and an educational IP&C video is being compiled to complement existing staff training. Leadership, teamwork, communication, education, staff willingness to maintain standards and improve practice, role models, audit and research are key aspects in developing a culture that focuses on IP&C. RESULTS A driver diagram is being used as a measurement framework for tracking progress towards the goal (NHS, 2013). A database for positive isolates has also been compiled allowing measurement and comparison of statistics. DISCUSSION Implications for the future include: • Multidisciplinary infection prevention and control champions

• CCIPCN role- influence IP&C practice throughout adult critical care

• CCIPCN – approval of permanent post Key Words: infection, specialised, culture, change REFERENCES Manley K (2003) Values Clarification: A tool for developing a common vision and strategic direction London: Royal College of Nursing National Health Service (2013) Quality and Service Improvement Tools Online at:http://www.institute.nhs.uk/ quality and service improvement tools/quality andservice improvement tools/driver diagrams.html [Accessed on: 23 April 2013]

C14: Views of Doctors and Nurses

about Transferring Critically Ill Patients Home to Die: Results of a National Survey

Dr Ann-Sophie Darlington, Dr Tracy LongSutehall University of Southampton Prof Alison Richardson, University Hospital Southampton NHS Foundation Trust Prof Maureen Coombs, Victoria University and Capital And Coast District Health Board Wellington BACKGROUND Health policy has focused on enabling increased choice for patients to die in their preferred place of care. However, it is not clear if, or how, this might apply to those dying in critical care. The aim of this study was to determine experiences of, and views towards, transferring critical care patients home to die by conducting a national survey of nursing and medical staff in critical care units. METHODS An online survey, containing 17 statements, was developed informed by the literature and six focus groups with critical care and community health care staff and patient representatives. The lead consultant and lead nurse of 409 critical care units in the UK were invited, by e-mail, to take part. RESULTS 180 respondents completed the online survey (24% response rate). Experience with transferring home to die was reported by 36%. The majority agreed that transferring home to die is a good idea in principle (88%) and that transfer is important in terms of preferred place of death (81%). 36% agreed that it would be unethical to prolong a patient’s life to facilitate a transfer and 13% agreed that a transfer was not worth the risk of dying in the ambulance. Statistically significant differences for some views

were found for physicians and nurses. Nurses reported higher average scores (on 1-5 Likert scale) on several statements, for instance stating that it is satisfying to transfer a patient home to die (t=-2.39; p=0.018), feeling able to organise a transfer (t=-2.15,p=0.033), and indicating that transfer is a feasible option in critical care (t=-3.93, p=0.00). CONCLUSION Statistically significant differences between doctors and nurses were found for some views. However, all respondents’ views were generally positive, but with some expressing reservations in terms of ethical concerns and the risk of dying on the route home. Funding: Marie Curie Cancer Care UK

C15: Patients Supporting Patients, Post ITU Support Without Walls

Gemma Bayley, Sharon Hoskins, East Sussex NHS Trust SUMMARY • Patients and relatives have started a Community Outreach service having identified a gap in follow up services • Ex-patients and relatives will support anyone on the unit, wards and at home • An empathic service to offer real support to patients and relatives who have endured a life threatening experience in the ITU • A group of pro active volunteers have raised funds and professionally set up this service, helping each other with essentially post traumatic stress, of which a gap counselling or follow up services can’t. AIM • To highlight the need for counselling support for recovering patients wherever housed. The unique resource we have that is untapped. • How to set up a community outreach group. • Impressing for change to follow up services to a timelier manner and making courtesy home calls. • Linking with GP’s and community services to refer patients to group. Only another patient can understand the trauma of an ITU experience and the feeling that it leaves. Disengagement from family and the community, anxiety,depression, lasting disabilities, insomnia, and inability to work are common but unique problems within this patient group. Recovery from critical illness doesn’t end on discharge from hospital, let alone when a patient leaves the intensive care. Once discharged to a general ward or home the patients are isolated from others like them and are often unaware that the distressing and bizarre experiences they’ve endured are actually normal for someone who’s been through a period of critical illness. Meeting others that have been through a similar

experience and are at different stages in their recovery can help reassure patients that there is light at the end of the tunnel and dispel much of their worry.

C16: Family Presence during CPR in

Adult Critical Care Settings: Hearing the Voice of Family Members

Dr Ahmad Saifan, Applied Science Private University This study explores family members’ attitudes towards family witnessing CPR in adult critical care settings. Leininger’s cultural care theory was used as a theoretical framework for this study. The study was conducted in six hospitals in two major Jordanian cities. A purposive sample of 5 family members, who had experience of having a resuscitated relative, was recruited over a period of six months. An individual semi-structured interview was utilised as the main data collection method in this study. The study findings revealed three main categories: the role of family members during CPR, family needs, and barriers to allowing FWR. Family need for information and proximity were their main needs during CPR. Uniquely, this study shows that FWR gives family members the opportunity to practice their religious and cultural beliefs. All interviewed family members wanted the option to stay beside their loved one during CPR. Distinctively, most of the family members want this option for some religious and cultural reasons such as praying and supplicating to support their loved one. All family members expressedseveral needs at the time of CPR. The need for information about the patient’s condition was the most important need. Updating family members about the patient’ scondition would reduce their tension and improve their acceptance for the end result of CPR.The study recommends that family members of resuscitated patients should be treated properly by good communication and involving them in the treatment process. The implications concentrate on producing specific guidelines forallowing FWR in the Jordanian context. REFERENCES Weslien M, Nilstun T, Lundqvist A and Fridlund B.(2005). ‘When the unrealbecomes real: family members’ experiences of cardiac arrest.’ Nursing in Critical Care 10(1): 15-22. Fulbrook P, Albarran J and Latour J.(2005). ‘A European survey of critical care nurses’ attitudes and experiences of having family members present during cardiopulmonary resuscitation.’ International Journal of Nursing Studies 42(5):557-568.

C17: A Realistic Evaluation of Early Warning Systems and Acute Care Training in Northern Ireland: Findings and Recommendations

Jennifer McGaughey, Dr Bronagh Blackwood, Dr Peter O’Halloran, Prof S Porter, Queen’s University of Belfast PURPOSE The purpose of this concurrent session is to present the main findings and recommendations from a five year study evaluating the implementation of Early Warning Systems (EWS) and the Acute Life-threatening Events: Recognition and Treatment (ALERT) course in Northern Ireland. AIM The presentation will provide delegates with an understanding of those factors that enable and constrain successful implementation of EWS and ALERT in practice in order to provide animpetus for change. METHODS The research design was a multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory [1]. The stages included identifying the programme theories underpinning EWS and ALERT, generating hypotheses, gathering empirical evidence and refining the programme theories. This approach used a variety of mixed methods including individual and focus group interviews, observation and documentary analysis of EWS compliance data and ALERT training records. A within and across case comparison facilitated the development of mid-range theories from the research evidence. RESULTS The official RRS theories developed from the realist synthesis were critically evaluated and compared with the study findings to develop a mid-range theory to explain what works, for whom in what circumstances. The findings of what works suggests that clinical experience, established working relationships, flexible implementation of protocols, ongoing experiential learning, empowerment and pre-emptive management are key to the success of EWS and ALERT implementation. Each concept is presented as ‘context, mechanism and outcome configurations’ to provide an understanding of how the context impacts on individual reasoning or behaviour to produce certain outcomes. CONCLUSION These findings highlight the combination of factors that can improve the implementation and sustainability of EWS and ALERT and in light of this evidence several recommendations are made to provide policymakers with guidance and direction for future policy development. REFERENCES 1. Pawson R and Tilley N. (1997) Realistic Evaluation. Sage Publications; London

C18: Training Intensive Care Nurses

Improves Knowledge and Confidence in Dealing with Airway Emergencies

Jennifer Ricketts, Dr Caroline Wilson, Dr Matthew Size, Buckinghamshire Healthcare

NHS Trust, Stoke Mandeville Hospital BACKGROUND The fourth national audit project (NAP4) investigated hospital major airway events. It demonstrated that almost a fifth of major airway events occurred in the Intensive Care Unit (ICU) with a consequent higher morbidity and mortality compared with events elsewhere. Quality of care improvements identified include the immediate availability of a standardised difficult airway trolley, the widespread use of capnography and its correct interpretation, and improved knowledge and skills of staff in recognising and dealing with airway emergencies[1]. Following the introduction of a standardised airway trolley an education course was designed and implemented to teach these skills to ICU nurses. METHODS The course consisted of simulated ICU airway emergencies, airway equipment stations, lectures on the DAS guidelines and a human factors workshop. All ICU nurses were invited to attend and completed a pre and post course evaluation questionnaire. Six key areas of airway knowledge were assessed along with the nurses’ confidence in applying this knowledge to clinical practice. These areas included interpretation of capnography, recognition of a displaced endotracheal tube and performance of cricoid pressure. Analysis was performed on the data sets using the Wilcoxon signed-rank test and statistical significance was taken as p<0.05. RESULTS All entrants completed the course and evaluation forms from all course attendees were completed. Eight forms were excluded, as they were incomplete, leaving 54 forms to be analysed. Knowledge scores before the course had a median value of10 (interquartile range [8-11]) out of a maximum of 18 points. The post-course questionnaires found significantly improved knowledge scores with a median value of 15 (interquartile range [13-17], p<0.0001). Confidence scores, from a maximum of 24 points, were found to significantly improve following the course, with pre and post course median values of 11.5 (interquartile range [10-15])and 20 (interquartile range [17.75-22], p<0.0001) respectively. DISCUSSION The findings of the NAP4 study highlight the need for dedicated airway training for ICU staff. Airway knowledge and confidence scores in applying the knowledge to clinical practice were low amongst ICU nurses prior to attending the course. Significant improvements were seen in both areas as a direct result of the course, highlighting the effectiveness of dedicated skills training. Ongoing audit and analysis of future airway events will determine if the improvement in skills and knowledge translates into improved clinical outcomes. REFERENCES Cook T, Woodall N, Harper J, Benger J. Major complications of airwaymanagement in the UK: results of the Fourth National Audit Project of the RoyalCollege of Anaesthetists and the Difficult Airway Society. Part 2: intensivecare and emergency departments. British Journal of Anaesthesia 2011; 106:632-642.

C19: A Reduction in Accidental Device Removal Through the Implementation of a Delirium Assessment Tool in the ICU Patient Population

Emma Johnson, Dr Justin Roberts, Dr Jay Naisbitt, Dr Hugo Buckley, Salford Royal NHS Trust PROJECT AIM To have 95% of patients receiving delirium assessments once every 24 hours, thus a reduction in device removal by 50% by November 2012. INTRODUCTION Delirium has been shown as a predictor of death, increased cost, and longer duration of stay in ventilated patients (1) affecting over 50% of patients within intensive care units, however it still remains unrecognised in 66 to 84%of cases(2). Accidental medical device removal (AMDR) is an independent cause of iatrogenic patient harm and has a strong correlation with delirium(3). The unplanned removal of a medical device such as an endotracheal tube can pose an immediateand life threatening risk to a patient. METHOD All methodology used came from an in house quality improvement initiative using strategies from the Institute for Healthcare Improvement(4). An education package was compiled and test of change began. At the same time data was collected on the number of devices in place on patients and AMDR was collected for the preceding 24hrs. As education awareness increased a dramatic decrease in AMDR was seen and plotted on monthly run charts. RESULTS Over a six month period of the project and following significant tests of change a staggering decrease in AMDR was noted which correlated most significantly with the education of nursing and medical staff around delirium and the implementation of a daily assessment for all appropriate ICU patients. The project aims were met, and these results have been sustained today and AMDR is now recognised as a rare event within critical care at SRFT.

BACKGROUND An organ or tissue transplant has been proven to be an effective life enhancing treatment for end-stage organ or tissue failure (NICE 2011). The Department of Health (DH) in 2008 recommended that all health care professionals who had potential involvement in donor patients should receive regular education and training. This study provides an original contribution to knowledge as no research has been undertaken since to evaluate whether these recommendations have been implemented and whether any relationship exists between education and its influence towards health care professionals perceived attitude, confidence,knowledge and decision making within three different health professions working within critical care areas within the NHS. METHOD This mixed methods study utilised a self-completion questionnaire distributed to doctors, nurses and operating department practitioners (ODPs) n=3000 workingin Intensive Care, Emergency Departments and Operating Theatres within 18 hospitals and focus group interviews involving 8 nurses from 3 hospitals within England. The questionnaire response rate was 1180. THE RESULTS The results revealed that only 23.7% of the sample were given pre-registration donation education and only 56.2% stated they received education as part of post-registration CPD. Data established knowledge deficits relating to contraindications for solid organ and tissue donation, ability to discuss brainstem death to relatives and differences in clinical management between circulatory and non-circulatory donation approaches. Results found a direct relationship that CPD education improves attitude and participation in donation care amongst health professionals. Data established that there was no bias towards attitude or education provision if the participant worked within a transplant centre versus a nontransplant centre. The study found that there was a direct relationship between experience and the more senior the practitioner the more knowledge and confidence they had towards donation. Doctors consistently demonstrated more knowledge and perceived confidence relating to donation issues compared to nurses. CONCLUSION

REFERENCES 1. Pandharipande P, Lorazepam is an independent risk factor for transitioningto delirium in intensive care unit patients January 20062. http://www.mc.vanderbilt.edu/icudelirium/ overview.html August 20123. 2. Mion L, Minnock A, Anne F. Patient initiated device removal in intensivecare units: a national prevalence study. Critical Care Medicine. December 2007.Issue 12; 2714-27204. http:// www.ihi.org/knowledge/Pages/Measures/default.aspx August 2012

This study provides a contemporary assessment of HCPs attitude, knowledge and education provision relating to donation.

C20: Organ & Tissue Donation: An

donation

REFERENCES Department of Health (2008) Organs for Transplants: A report from the organdonation task force, London: DH.National Institute for Healthcare & Clinical Excellence (NICE) (2011) Organdonation for transplantation: Improving donor identification and consent ratesfor deceased organ

Evaluation of Health Care Professionals Knowledge, Training and Attitude

C21:

Tim Collins, Maidstone & Tunbridge Wells NHS Trust

Samantha Harris-Fox, University Hospitals of Leicester NHS Trust

Life after ECMO

BACKGROUND Recommendations from ‘Critical to Success’ (Audit Commission, 1999) and ‘Comprehensive Critical Care’ (Department of Health, 2000) advocate the use of intensive care unit (ICU) follow-up services to provide support for patients and relatives following critical illness and subsequent discharge from hospital. Follow up is also viewed as a means of ensuring service evaluation. The purpose of this presentation is to describe the multidisciplinary follow-up service we have developed to support patients and their families after receiving ECMO at Glenfield General Hospital, Leicester. It is also to present some of the data collected from the follow-up clinics. ECMO patient and their families are invited to return to Glenfield six months following discharge from hospital to attend the follow-up clinic. The clinic involves a chest xray, lung function tests, visit of the unit and where appropriate the opportunity to see ECMO. A multidisciplinary approach is adopted and time is spent with the patient and their family talking about their time in ICU and experiences post discharge from hospital. The (HADS), PTSS 14 and EQ5D questionnaires are used to help evaluate patients psychological problems. Between April 2010 and April 2013, 60 patients attended the follow-up clinic. Data from these clinics show ECMO patients suffer from a range of physical and psychological problems which, if not addressed, have implications for patients and families. Long-term problems may impose a continuing financial burden not only on primary and secondary health services but also on society as 70% of patients had not returned to work at 6 months post ICU.It is essential that ICU’s offering ECMO to adult patients must also provide a follow-up service for patients and their families. However such a service has financial implications and to be highly effective, funding needs to be in place to fully support follow-up services. REFERENCES AUDIT COMMISSION. (1999). Critical to Success. The Place of Efficient andEffective Critical Care Services within the Acute Hospital. London: Departmentof Health. DEPARTMENT OF HEALTH. (2000). Comprehensive Critical Care. A Review of AdultCritical Care Services. London: Department of Health.

C22: Vital Signs Monitoring - Research into Practice and the Failure to Rescue

Janka Webb, Sandwell and West Birmingham NHS Trust

recording, evaluating and reporting of vital signs in acute ward areas in order to establish if there is a link between current practice and the continued failure to recognise and respond to early changes in these parameters and prevent the deterioration of patients (NCEPOD, 2005, 2007, & 2012; NPSA, 2007. and NCEPOD,2012. METHOD A mixed methodology using a grounded theory approach was used to undertake 32 hours of observations on practice and 15 semi-structured interviews in order to develop an in depth description of current practice in the context of the acute ward environment. RESULTS The findings of the research demonstrate significant differences in the espoused values of staff and actual clinical practice. Almost without exception, vital sign observations are undertaken by unqualified staff, clinical assessment and clinical decision making is being defaulted to Student Nurses, skills and competencies of staff are poor and diminishing year on year and there is significant discrepancy between what is monitored and what is documented.These findings provide new evidence about why there is still a persistent failure in our hospitals to recognise and respond to changes in patient observations in a timely manner. RECOMMENDATIONS Vital signs observations must routinely be carried out by trained staff or delegated with clear supervision and reporting processes on all observations. All staff need to complete competency assessments on vital signs observations and use of EWS. Wearing of fob watches must be compulsory.Further research is needed in this area. REFERENCES NCEPOD (May, 2005) An acute problem? A report of the National ConfidentialEnquiry into Patient Outcome and Death. NCEPODNCEPOD (2011) Perioperative care “ Knowing the risk”. A report of the National Confidential Enquiry into Patient Outcome and Death. NCEPODNCEPOD (2012) Time to Intervene? A report of the National Confidential Enquiry into Patient Outcome and Death. NCEPODNICE (2007) Acutely ill patients in hospital: Recognition of and Response to acute illness in adults in hospital. National Institute for Health and Clinical Excellence (NICE guideline no 50). NPSA (2007) Safer Care for the Acutely Ill Patient: Learning from SeriousIncidents. 5th Report from the Patient Safety Observatory. National Patient Safety Agency

PURPOSE The measurement and recordings of a patient’s vital signs is carried out routinely on adult patients admitted to hospital at least every 12 hours (NICE,2007). Accurate measuring and recording of these vital signs is essential for providing a baseline for monitoring improvement or deterioration of a patient’s condition. This qualitative research project aimed to describe the measuring,

C23: The Value of Critical Care Outreach: A Matter of Outcomes

Sally Wood, John Burke, Leon Smith, Andrew Hermon, Tamas Szakmany, Royal Glamorgan Hospital, Cwm Taff Health Board, South Wales

BACKGROUND Outreach services are the cornerstone of delivering high quality care to the acutely unwell patients on the ward. However, the success of critical care outreach (CCOR) has been controversial in the literature (Hutchings et al, 2009). This may be explained by the difficulty in defining a positive outcome since this may not only involve measurement of improved physiological variables and reduction in cardiac arrest rates, but also consideration of whether admission to critical care is mandated and ‘do not attempt resuscitation’ (DNAR) decisions. OBJECTIVE In this service evaluation we investigated if this wider meaning of a positive outcome for an acutely unwell patient can be used to define the ‘success’ of the CCOR service. METHODS Prospective audit in the a 500 bedded DGH with a 10 bedded ITU/HDU and CCOR service implemented in June 2010. We used a replicable, structured and systematic data collection tool alongside retrospective evaluation of mortality/length of stay data for 695 new patient referrals to CCOR over a 24months period. Positive Outcomes defined as: • MEWS score decreased after interventions • MEWS score below 4 • Patient admitted to ITU/HDU • Resuscitation status reviewed resulting in DNAR order Negative Outcomes defined as: • MEWS increased following CCOR interventions • Patient suffered an unexpected cardiac arrest after CCOR visit RESULTS • 98% of patients had a ‘Positive Outcome’ • 72% MEWS score decreased or remained below 4 • 15% of patients admitted to ITU • In 11% of patients treatment limitations were put in place. • We only found in 2% of patients that the MEWS score increased • None of the patients suffered unexpected cardiac arrest whilst in outreach care.

modernisation of adult critical care services in England: time series and cost effectiveness analysis’ BMJ; 339: b4353.Published online 2009 November 11. doi: 10.1136/ bmj.b4353

C24: Utilisation of Organ Donation

Funds to Promote Donation Within Critical Care and Emergency Medicine

Katie Fox, Julie Pascoe, University Hospital North Staffs and NHS Blood and Transplant This paper will provide a framework for the utilisation of donor reimbursement monies provided by NHS Blood and Transplant (NHSBT), in order to promote organ donation at the University Hospital of North Staffordshire (UHNS). NHSBT, as part of the taskforce recommendations (DoH 2008) reimburse the trust £2086 for each organ donation. This money is provided if consent is gained from the donor family regardless of donation proceeding or not. NHSBT (2009) provide advice for donation committee chairs on finances; suggesting the money be used to support future donation activity, with donation committees being involved in the management of monies. At UHNS the aim from the commencement of reimbursement was ensuring use for the correct purpose. Firstly this involved identifying a finance manager to oversee the fund. Due to the complexity of finances this is vital. The second aim was to identify necessary expenditure to go along with the guidance from NHSBT in supporting future donation activity. At UHNS this meant providing nursing care for the donor, education for the staff and ensuring equipment is available which will benefit and support donation. Thirdly a robust spending plan was produced which demonstrated why this money was vital to the future of organ donation at UHNS. These three factors have ensured greater prominence for donation, within critical care and the trust as a whole. Financial constraints in austere times within hospitals coupled with lack of knowledge by donation committees may mean reimbursement monies are swallowed up elsewhere. This should be guarded against by using the UHNS strategy outlined; finance manager, spending plan, judicious use of monies. This has resulted in the increasingly higher profile role of organ donation at UHNS, significantly contributing to the rise in donation by 240% over 5 years at HNS. REFERENCES Department of Health (2008) Organs for Transplants: A report from the Organ Donation Taskforce. London, Department of Health. NHS Blood and Transplant Donation Committee: Information for Donation Committee

CONCLUSION

Chairs. Bristol, NHS Blood and Transplant.

These results clearly indicate that when a clinically more appropriate, wider definition of positive patient outcome is applied, the benefits of CCOR are demonstrable.

C25: The Use of Music to Aid

REFERENCES Hutchings A., Durand M.A., Grieve R., Harrison D., Rowan K., Green, J., CairnsJ., Black N. (2009) ‘Evaluation of

Prevention of ICU Psychosis in Mechanically Ventilated Patients

Ben McIntyre, Isle of Wight NHS Trust

AIM The aim of this study was to examine the potential for using music as a non-invasive, non-pharmaceutical aid to prevent ICU Psychosis (IP). SUMMARY This study begins by identifying common factors that are believed to cause IP. It examines several studies where music has been employed to alleviate the causative factors. However, no studies have extrapolated all the data to focus on IP but this study has, theorising that by using music, IP could be reduced. The study explores how music could be applied, when it could be used and what music would be appropriate. It also examines the benefits of music on reduced costs and impact on organisations. METHOD A literature search was carried out and seven studies (see below) were identified as of sufficient relevance. A critiquing tool was developed to address quantitative and qualitative data. The reason for this amalgamation is because the subject required a qualitative aspect due to the psychological perspective of the topic but also including quantitative to utilise a more scientific methodology. This critiquing tool examined the studies for validity and empirical rigorousness. Once validated, the studies were used to evolve a discussion on the use of music to alleviate the causative factors. This discussion demonstrated that music could reduce many of these factors including anxiety, pain, orientation, etc. Then examination of the use of music occurred including a delivery system, the timing, the kind of music and the costs involved as well as any potential side effects of music usage. CONCLUSION The conclusions suggest that music could alleviate IP. It is a non-invasive and simple adjunct to care in a highly technical environment. It can reduce the causative factors of IP and therefore is suggestive that it can reduce IP. REFERENCES Almerud,S. & Petersson,K. (2003) Music Therapy- a complementary treatment for mechanically ventilated intensive care patients, Intensive and Critical Care Nursing, 19, pp21-30 Granberg, A., Bergbom Engberg, I. & Lundberg,D. (1998) Patients’ experience of being critically ill or severely injured and cared for in an intensive care unit in relation to the ICU syndrome, Intensive and Critical Care Nursing, 14,pp294-307 McCaffrey, R. & Locsin, R. (2004) The effect of music listening on acute confusion and delirium in elders undergoing elective hip and knee surgery, Journal of Clinical Nursing, 13 (6b), pp91-96 Papathanassoglou,E.D.E. & Patiraki, E.I. (2003) Transformations of self: a phenomenological investigation into the lived experience of survivors of critical illness, Nursing in Critical Care, 8(1), pp13-21 Tsuchiya,M., Asada,A., Ryo,K., Noda,K., Hashino,T.,

Sato,Y., Sato,E.F. & Inoue,M. (2003) Relaxing intraoperative natural sound blunts haemodynamic change at the emergence from propofol general anaesthesia and increases the acceptability of anaesthesia to the patient, Acta Anaesthesiologica Scandinavica, 47, pp939-943 Voss,J.A., Good,M., Yates,B., Baun,M.M., Thompson,A., Hertzog,M. (2004) Sedative music reduces anxiety and pain during chair rest after open-heart surgery,Pain, 112, pp197-203 Wong,H.L.C., Lopez-Nahas,V. & Molassiotis,A. (2001) Effects of music therapy on anxiety in ventilatordependent patients, Heart & Lung, 30(5), pp376-387

C26:

Targeting Delirium; Then and Now

Rebecca Seaman, Ciaran Hart, Hayleigh Watson, Jeanette Partlett, Maidstone & Tunbridge Wells NHS Trust Delirium has been a recognised psychological condition following a period ofcritical illness for a significant amount of time. There is a wealth of definitions of describing delirium. One such definition states: ‘Delirium is an acute confusional state characterised by fluctuating mentalstatus, inattention, and either disorganized thinking or altered level ofconsciousness’ (Page, 2008). There are also a number of research articles supporting the devastating effects of the condition which reduces patient’s morbidity and mortality (NICE, 2010). A multidisciplinary group of staff at Maidstone ITU wanted to address the delirium care for our patients, following a conference in 2011. The group felt delirium was not often discussed, assessed or specifically treated routinely. We also successfully applied for a £8000 award to buy equipment to support the change in practice. The aim of this award is to adopt a successful innovation of best practice into the area of care that we work in. This helped us focus on managing the project and implementing the change. This presentation will demonstrate how the group facilitated a major change in practice which involved multi-professional team working in order to challenge existing practice. This involved implementing a number of practice development strategies in order to achieve the group’s common goal in enhancing delirium care within the unit. The aims of the presentation are to: • Discuss how the project was supported with an award from the SHA South of England ‘Innovation Adoption Challenge’ • Present the teaching packages used to assist the implementation of CAM-ICU andthe Delirium Care Bundle • Explain the educational support which was used to establish the change in practice • Share our current plans to support the needs of longterm patients with our early mobilisation and weaning guidelines • Discuss the results of a Documentation Audit which was

done before the change and 1 year on REFERENCES National Institute for Health and Clinical Excellence (2010) Delirium: diagnosis, prevention and management. London: National Institute for Health andClinical Excellence

or imagined. The patients viewed the experience as unpleasant but reported no serious detrimental impact six weeks following discharge. It had happened but they were able to move on with their lives. Patients highlighted the role of staff, relatives and the ICU environment as important influences in theirexperience of delirium and staff should be mindful of these factors.

Page V. (2008). Sedation and Delirium Assessment in the ICU. Care Crit Ill;24:153-158.

REFERENCES

C27: Gone But Not Forgotten: The

Barr, J., et al (2013) Critical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. 41(1) 278-280

Psychological Impact of Delirium Following Elective Cardiac Surgery

Michelle Scallon, Queen’s University Belfast Lisa Scullion, Belfast Health And Social Care Trust INTRODUCTION Post operative delirium is a distressing and serious complication following cardiac surgery which is associated with increased morbidity, mortality, development of cognitive impairment and PTSD (Barr et al, 2013). Whilst much has been written on the prevention and management of delirium in ICU, there is limited research on the personal impact of delirium from the patients’ perspective. INTENDED LEARNING OUTCOMES • Raise awareness of delirium • Understand delirium from the patient’s perspective • Educate staff on how to provide better care for patients with delirium AIM The aim of this study was to gain insight into the patient’s lived experience of delirium following elective cardiac surgery. METHOD The study used interpretative phenomenology to explore the impact of delirium from the patient’s perspective. Ten patients participated in semi- structured interviews which were held immediately after their six week outpatient review appointment. Patients were asked about their memories of the ICU environment, staff, equipment and procedures. They were also asked to describe their experience of delirium and to reflect on its subsequent impact on their lives. The interviews were tape recorded, transcribed and thematically analysed. FINDINGS AND IMPLICATIONS Five themes emerged from the data: the ICU environment; memories and perceptions of delirium; feelings and sources of comfort; effects of delirium and coping styles. Patients described an eclectic range of emotions and experiences during their ICU admission. They shared vivid memories of confusing and disturbing events but could not always determine whether these were factual

C28: The Role of Assistant

Practitioners in the Critical Care Unit at Royal Devon and Exeter Foundation Trust Mary Prodigalidad, Alan Rolfe, Royal Devon And Exeter Foundation Trust A case presentation for the fundamental role of Assistant Practitioners in the Critical Care Unit in Royal Devon and Exeter Foundation Trust Background and aim Four Health Care Assistants extended their role and completed an 18 month competency based programme of supervised training to specifically meet the needs of the critical ill patients as Assistant Practitioners. The programme took place in the Critical Care Unit of Royal Devon and Exeter Foundation Trust. This case report aims to provide recognition and understanding of the limited role as an Assistant Practitioner in the Critical Care Setting. Description The Assistant Practitioners were assigned to provide complex care for a long term ventilated Guillan-Barre Syndrome patient. They worked with Registered Nurses and were involved in the multi-disciplinary meetings with the patient’s ongoing care and preparation for discharge. Some of their responsibilities included unsupervised provision of basic hygiene care, respiratory care such as tracheal suctioning and stoma care with the incorporation of Ventilator Care Bundles. The Assistant Practitioners played a pivotal role in the psychological care of the patient, including trips off the unit. Result The patient was discharged from the Intensive Care Unit directly to a specialised Nursing Care Home with a ventilator after 345 days of staying in the Intensive Care Unit. The patient was cared for by the four Assistant Practitioners for a total of 206 days based on the data collected using the Care View System. The patient never developed a ventilator assisted Pneumonia although developed a urinary tract infection on one occasion. No pressure sores or weight loss has been reported. Conclusion The Assistant Practitioners are highly skilled carers and

have become an integral part of the unit. They have proven to impart excellent quality care in the Critical Care Unit within the limitations of their roles. Their years of experience, knowledge and skills have complemented the role of the Registered Nurses and became one of the sources of information.

C29: Decreasing Avoidable Pressure Damage in ICU

Paul Caddell, Belfast Trust Purpose Aim to reduce avoidable pressure damage by 50% Pressure ulcers create psychological and physical problems for patients, carers and their families. They are associated with an increased incidence of infection and increased risk of death in older people(1) Pressure ulcers are a key clinical indicator of the standard and effectiveness of care(2); the American Nurses Association has described them as a nursing sensitive patient outcome. Noradrenaline infusions, APACHE II scores greater than 13, Anaema, prolonged stay and faecal incontinence have been identified as additional risk factors in critical care. In this study 10% of patients developed pressure damage despite interventions aimed at preventing them(3). Method Utilise the IHI “Model for Improvement” to reduce avoidable pressure damage by 50% Collect data use for improvement - to see what we are good at and where to focus. Make changes that will result in improvement and use data to know if we are achieving our aim. We have established an interest group – Pressure Ulcer Group (PUG) with clearly defined roles and responsibilities. We have developed a structured and systematic approach to improvement based around the Trust “Skin bundle” documentation. Summary What are the findings so far: Having a shared improvement goal has promoted teamwork Team work is an essential component of an effective culture We have identified Key areas for development and processes that can be linked to increased pressure damage risk References 1 National Institute of Clinical Excellence “Pathway for pressure ulcer management”. 2 Elliott, R et Al Quality Improvement Programme to Reduce the Prevelance of Pressure Ulcers in an Intensive Care Unit. Am J Crit Care 2008;17(4):328-334. 3 Theaker C, Mannan M, Ives N. Risk factors for pressure

sore development in the critically ill. Anaesthesia 2000; 55(3): 221-224

C30 : Pressure Ulcer Prevention Standards and Measurement of Prevalence Using the Safety Thermometer: a Critical Care Network Project Joanna McBride, Julie Platten, Annette Richardson, North of England Critical Care Network Pressure ulcers are an underrated and extremely painful event harming the critically ill. Pressure ulcers can increase morbidity and mortality, reduce quality of life and constitute a significant financial burden to the NHS (Reddy et al, 2006). A ‘Pressure Ulcer Prevention and Treatment Group’ with nursing representation from critical care units was established andsupported by the North of England Critical Care Network (NoECCN) to tackle this patient safety problem. Initially a benchmarking exercise was undertaken to review current practices including, assessment of pressure ulcer risk, pressure relieving equipment and successful pressure ulcer prevention strategies. A series of prevalence audits were performed to measure and compare the level of harm within the region. This was progressed by utilising the NHS Safety Thermometer data collated on a monthly basis. Data was presented back to the Network Group to assist with unit comparisons and measurement of improvement over time. The mean baseline prevalence rate was established at 9% (range 33%-0%) across the Network. 83% of those reported were categorised as 1 or 2 category. The Network group developed a series of pressure ulcer prevention standards plus identified a set of risk factors specific to critically ill patients. The pressure ulcer standards were categorised into four key elementsknown as a ‘SKIN’ bundle.The ‘SKIN’ bundle represented the following; Surface, Keep moving, Incontinence and Nutrition; this was then launched in February 2013 (NoECCN, 2013). The Pressure Ulcer Prevention and Treatment Group continues to collaborate by sharing information to enable learning, to reduce pressure ulcers and improve the quality of care to critically ill patients.

C31: The Valuable Role of Critical Care Networks in Assuring Quality Care

Joanna McBride, Julie Platten, Lesley Durham, Dr Andrew Kilner, Dr Isabel Gonzalez, North of England Critical Care Network Within the current NHS, driving quality improvement and outcome measurement through a positive cultural change in behaviour is paramount. Within the UK, Critical Care

Networks can facilitate and enable this process within the critical care environment. For the last six years the North of England Critical Care Network has been performing ‘critical care unit appraisals’ (peer reviews) and recently, have developed a network wide ‘unit level dashboard’. The ‘unit appraisal’ is designed to act as a quality assurance marker for critical care across the network and to provide support for critical care services to achieve their aspirations. These are undertaken by a senior clinical team from the network. They follow a structured format that reviews unit data and addresses a number of issues including clinical care, organisational factors and staffing considerations. The format includes self-assessment of the ‘No ECCN Standards for Critical Care Services’, ICNARC report, semi-structured interviews and 360 degree feedback from key practitioners from critical care and within the trust. A report is then produced and key recommendations made. The unit level dashboard aims to provide clinicians with relevant and timely information to benchmark, maintain and improve quality patient care. A multi-professional group from the region developed the dashboard. Categories with field definitions assigned included; occupancy, discharge out of hours, delayed discharges and staff sickness. Data was submitted from all critical care units on a monthly basis. An annual report shows a comprehensive picture from the region. Both of these initiatives have been received well across the network. They have enabled units to be assured of the quality of the services they deliver, monitor trends, celebrate their successes and engage with Trust senior managers to focus on areas for improvement. The contribution of a proactive facilitative critical care network supports the

• Planning and preparedness Engagement and planning by nursing staff for such a move is vital while also maintaining current critical care provision. Nursing staff were represented on procurement groups for equipment which they would be using. As well as familiarisation training to the new hospital site and unit, considerable time was required in training for new equipment. • The actual move Processes were required to safely transfer patients while staffing both units until the existing hospital closed. Going live on day one with new monitoring,infusion pumps and a Clinical Information System were challenges staff faced. • Settling into a new unit and hospital The physical layout of the new unit differed greatly with increased single rooms and cubicles requiring a review of work flows and processes. CONCLUSION Within current financial climates, new units and hospitals are and will be relatively unique. Therefore, it is important that experiences are shared with others embarking on this journey ensuring their planning and preparedness and that the resources of staff, space, equipment and time are utilised effectively.

C33: Small Evaluation Study of

Anchorfast Endotracheal Tube Holders

process of service improvement and quality assurance.

Linda Winrow; The Walton Centre NHS Trust

C32: Moving Out, Moving In and

AIM To determine if the Anchorfast Endotracheal Tube (ETT) Holder would be a cost effective alternative to the currently used Velcro ETT tapes.

Moving On: The Experience of Moving into a New Hospital and New Critical Care Unit

Brian McFetridge, Francis Smith, South West Acute Hospital, Western Health and Social Care Trust. AIM To share experiences of planning, moving and settling into a new hospital and new critical care unit. DISCUSSION On the 21st June 2012, the Erne Hospital closed its doors for the last time and the new South West Acute Hospital, Northern Ireland opened. Our reflection on this experience focuses on the key role nursing plays in the planning, preparation and physical move to a new hospital and critical care unit. Moving into a new critical care unit within a new hospital poses many benefits to patients and staff, but also challenges. In the current climate of austerity, the importance of nursing engagement is vital for staff to be well prepared, and for equipment and processes to be productive and effective. This presentation reflects three key stages:

BACKGROUND Endotracheal intubation is a fundamental aspect of airway management in critical care but can contribute to the development of lip and mouth pressure sores for patients (Black et al. 2010). In addition, oral endotracheal intubation may limit access to perform oral hygiene, which has been shown to influence rates of ventilator acquired pneumonia (Institute for HealthcareImprovement, 2011). Anchorfast ETT holder appeared to be a possible solution to these problems, although the cost per unit seemed prohibitive. It was therefore decided to trial the Anchorfast ET tube holder and compare it against the currently used Velcro ET tube tapes. Our concerns being one of cost, tissue damage and slippage leading to the displacement of the ET tube. METHOD A Baseline evaluation of currently used ETT tapes by nursing staff was undertaken followed by a similar evaluation of the Anchorfast ETT holder. Particular focus being on the frequency of change of both holders and evidence of tissue damage with Anchorfast. RESULTS The Anchorfast ETT holder provided a cost improvement

of £3.01 per patient/perday and there was no evidence of tissue damage in that patient group.

beyond simple concerns of discharge planning in the Critivcal Care Unit.

REFERENCES Black, M.J., et al (2010) Medical device related pressure ulcers in hospitalised patients.International Wound Journal, Vol. 7, no. 5Institute for Healthcare Improvement (2011) How-to Guide: PreventVentilator-Associated Pneumonia. http://www.ihi.org/knowledge/Pages/Tools/

Keyword: Critically ill patients, Intensive Care Units (ICU), Transition,Transitional care

HowtoGuidePreventVAP.aspx (Accessed22/04/2013)

C34:

Malaysian ICU Nurses Constructive Response to Critical Ill Patients Transition / Experience: A Qualitative Analysis

Dr Salizar Mohamed Ludin, International Islamic University Malaysia Professor Paul Arbon, Dr Steve Parker, Flinders University BACKGROUND Providing support for critically ill patients throughout their transition(s) while in the Intensive Care Unit and following any transfers, is an important element of the nursing process during hospitalisation for critical illness. Because nurses are the primary caregivers in critical care contexts, responding to patients’ transition experience is important and can facilitate better nursing care. To date, apart from the associated discussion of discharge planning issues, little is known about nurses’ response to critically ill patients and their families’ experience while in health transition. AIM This study aimed to explore ICU nurses’ awareness on their response to critically ill patients’ transition and their families’ transition experience. METHODOLOGY An interpretive descriptive research approach was used to explore nurses’ awareness of patients’ and families’ transition experiences, followed by an interpretation of the findings from an ethnographic stance. In this study, focus group (n=25), and in-depth individual interviews (n=10) were conducted sequentially in four Malaysian tertiary hospitals in 2008. The data was then subjected to qualitative thematic analysis. RESULTS Themes emerging from the results included: possessing faith and hope, being compassionate and caring, having patience, contentment, supportive, alert, knowledgeable and skillfull, and informative. These were then interpreted as utilising the therapeutic use of self, providing education and adopting family centred care. CONCLUSION The findings demonstrate the breadth of nurses’ response to patients’ and families’ experiences and the journey of care. ICU nurses need to be resilient by showing their constructive response to patient and family experiences. The major implication of this study is that the critically ill patients’ transition experience is complex and extends

C35:

The Impact of a Nurse Inserting PICCs in Critical Care

Helen Beard, West Suffolk Hospital Trust BACKGROUND In 2010, it was proposed that a Nurse, practicing within a 9 bedded Critical Care Unit, should train to insert peripherally inserted central catheters (PICCs), in order to reduce the number of patients who are discharged to the wards with a central venous catheter (CVC) in situ. Part of the rationale for this proposal was based on the ‘Matching Michigan’ project, with the specific objective of minimising the number of patients discharged to general wards with quadruple lumen CVCs and, in turn to reduce the risk of catheter related bloodstream infections (Gunst et al, 2011, Pronovost et al, 2006). METHOD Performed as an evaluative study, a retrospective review of all patients admitted to Critical Care was conducted over two ten month periods (cohorts) to compare the number of patients who were discharged from Critical Care to general wards with a CVC and the number of PICC lines inserted within Critical Care prior to, and following the introduction of the nurse performing the procedure. Data was also collected to establish dwell times of the vascular access devices and incidence of catheter related bloodstream infections/ complications. FINDINGS The results of the study indicated that the introduction of a nurse supported PICC insertion service within Critical Care increased the number of PICC insertions, but there was no reduction in the number of patients discharged to the wards with a CVC. However, the findings also indicated that there was minimal risk of infection to those patients who were discharged with a CVC. REFERENCES Gunst, M., et al. (2011). ‘Peripherally inserted central venous catheters may lower the incidence of catheter related bloodstream infections in surgical intensive care units’, Surgical Infection, 12 (2), pp.279-282. Pronovost, P.J., Needham, D., Berenholtz, S. Sinopoli, D. (2006) ‘An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU’,New England Journal of Medicine; 335 (26), pp. 2725-2732.

C36: Septic Patient? Think BUFALO Lorna Johnson, Dawn Stevenson, Leeds Teaching Hospitals NHS Trust INTRODUCTION A Trust wide education and awareness campaign was developed within a large multi-centred teaching hospital

to improve the recognition, treatment and outcome for septic patients. METHODOLOGY An audit tool was designed that the Critical Care Outreach Team completed on septic patient referrals for three months prior to the implementation of the campaign. This included observing the time frame for each of the sepsis six interventions to establish whether they were achieved within 24 hours or at all. Patient outcome data was also collected demonstrating increased mortality for this group of patients and poor compliance and sepsis awareness across the organisation. Intervention A poster was designed on the recognition of SIRS, sepsis, severe sepsis and the immediate treatment of sepsis. An acronym was designed to make the sepsis 6 easier to remember and to promote timely intervention: Blood cultures + septic screen, Urine output - monitor hourly Fluid resuscitation, Antibiotics, IV Lactate measurement, Oxygen. To correct, hypoxia Blood culture packs were introduced with the ‘BUFALO’ acronym printed on the front of the packs alongside a checklist sticker for attaching to the patients notes. Business Cards were distributed from a ‘BUFALO’ educational awareness stand that was showcased at the Nursing and Midwifery Conference in Leeds. Education was delivered through Patient Care and Safety days, ILS updates for health, RRAPID (Recognising and Responding to Acute Patient Illness and Deterioration) study days held by the Critical Care Outreach Team and via clinical educators throughout the trust.

16) who commenced the protocol within 3 hrs normalised their ph on average in 18.54hrs and Ketones in 20.7 hrs. Patients (n=9) who were started on the protocol at more than 3hrs normalised their pH at 16.23 hrs and Ketones at 31.8hrs. Use of a protocol was only one factor in patient management,early review by a diabetic specialist was also an important element. The time at which a diabetologist reviewed patients (n=27) ranged between 1hr and 84hrs (mean average 24.3hrs), and this was examined against patient length of stay. The time of review of a patient to their discharge excluding patients with secondary complications and prolonged length of stay due to social circumstances (n=23 ) resulted in a patient discharge range of 3-98hrs (mean 32 .5hrs, median 24.5hrs, mode 7hrs) after review. The main component provided by the diabetologist was enabling the transition of the patient from acute diabetic crisis management to long term management. In conclusion protocol driven care for DKA patients is essential but it is the education to enable patients to manage their diabetes that makes the difference. REFERENCES Hex N, Bartlett C, Wright D, Taylor M and Varley D.(2012). Estimating thecurrent and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. DiabeticMedicine. Jul 29 (7) p855-62

RESULTS

Narendran P and Gough S C (2009) Type 1 diabetes: the theme for this edition. British Journal of Diabetes &

Early indications showed that a change in culture has been noted and that sepsis is being recognised earlier with timelier intervention. There has been a reduction in the transfer of patients to critical care, increased compliance with the sepsis 6 and an improved patient safety culture

Vascular Disease 9: 246

across the organisation.

C37: Diabetic Keto Acidosis Improved Treatment Shorter Length of Stay

Iain Wheatley, Phillippa Dibley, Bukola Olyanju, Lani Santos, Bagnos Cudiamat, Emilie Cudiamat, Valarie Duckhouse, Stacey Starr, Emma Bingham, Frimley Park Hospital NHS FT Patients with type 1 diabetes take 830,000 sickness days per year costing around £94 million, and those admitted to hospital with diabetic keto-acidosis (DKA) cost the NHS almost £16 million in 2010 -2011 (Hex et al, 2012). In patients under the age of 30 with type 1 diabetes DKA and hypoglycaemia are the most common causes of death (Narendran and Gough, 2009). Effective management of DKA is imperative to improve patient outcome and reduce hospital length of stay. This retrospective audit of the notes of 31 patients, admitted over a 12 month period with DKA, identified key elements that reduce length of stay. The use of a standardised protocol within 3 hrs of patient admission resulted in an average length of stay of 61hrs. Patients (n=

C38: Intentional Rounding in the ICU Taking a C.A.R.E(ing) approach

Ian Naldrett, Royal Brompton and Harefield NHS Trust In January 2011 the prime minister called for changes in the way nurses deliver care. One of his recommendations was the introduction of hourly nursing rounds on Acute wards, the likes of which have been used extensively in the US. However, there is limited data and research on its use in the UK (National nursing research unit 2012) and there appears to be no research on its use in the intensive care unit. It is also not surprising that with the extending of traditional nursing roles in the ICU it has become ever more important to ensure patients receive safe evidence based essential nursing care. Especially when we know as a profession that some of these core activities such as Oral hygiene and Progressive early mobility decrease morbitity and mortality in post critical care. (Vollman 2013) To address this issue in a 20 bedded Cardiothoracic ICU, which is also a regional ECMO referral centre, we have developed a prompting system which includes 4 domains known as the C.A.R.E system: • Clean – Interventional hygiene • Ask – Pain, sedation and Delirium,

• Re-positioning – Pressure area care and rehabilitation • Safety Evaluation – Environment and safety assessment In this presentation I intend to examine the value of a prompting system in the ICU over the barriers a checklist may have on the outcome of improved fundamental nursing care and patient comfort. This approach to service improvement is especially appealing in austerity times as it can be implemented at minimal cost to the service, whilst addressing current changes in political healthcare policy, with the intention of making a real difference to the quality of care patients receive. REFERENCES Vollman K. (2013) ‘Understanding Critically ill patients response tomobilisation’, Critical care nursing quarterly, Vol 36. No 1. pp 17-27. National Nursing Research unit.(2012) Policy +, Intentional rounding; What’s the evidence. Issue 35 April 2012. London. Author.

C39:

The Journey, the Challenges and the Benefits of Implementing the Productive Ward Scheme Within Critical Care

Hayleigh Watson, Maidstone And Tunbridge Wells NHS Trust The Productive Ward scheme was introduced within the acute NHS hospital setting with the aim to release time to care (NHS Institute for Innovation and Improvement 2008). Initially aimed at general wards, it focuses on challenging generally accepted practices and procedures to reevaluate efficiency in order to make everyday practice more efficient, cost effective and to allow nurses more time with their patients (NHS Institute for Innovation and Improvement 2008). The process was implemented within the Intensive Care Unit at Maidstone Hospital in early 2011 and our early work established that on an average day a nurse only spent 55% of their time on direct patient contact.This result was lower than expected and gave us the motivation to push start the project which has, after the initial stages, shown improvement in efficiency in several daily tasks. Examples of these include reducing the step count taken to administer an IV medication from 69 to 33, and in setting up haemofiltration from 207 to 110. This was following the reorganisation of the unit and by challenging previous practices which then led to an increase in time available for direct patient contact. It is this successful change that we wish to share with fellow critical care practitioners, along with the challenges and developments that were encountered in applying this ward based process to a critical care environment. This presentation will aim to explore the background of the scheme, the implementation of the process, and the issues we faced along the way; in the initial change process and in sustaining the project. Through explaining the Productive Ward techniques the presentation will explore the benefits

to patient care and staffworking practices and relate this to contemporary literature (Wilson 2009). REFERENCES NHS Institution for Innovation and Improvement. (2008). Releasing Time To Care.University of Warwick, Coventry. NHS Institution for Innovation and Improvement (2008) Ward Leaders Guide. University of Warwick, Coventry. Wilson, G (2009) Implementation of releasing time to care “ the productive ward”. Journal of Nursing Management. 17:5 pp 647-654.

C40: Developing Cultural Change

in VAP Prevention and Increased Compliance with a Novel Ventilation Care Bundle

Simon Gray & Angela Neumann, Jay Naisbitt Salford Royal NHS Trust Ventilation-Associated Pneumonia (VAP) is a potentially preventable cause of mortality and prolonged length of stay and is associated with increased cost (1). Our high neuroscience case mix and perceived high incidence of VAP had given false credence to a culture of inevitable VAP development. A quality improvement program on VAP prevention was initiated to break this cultural barrier and improve compliance with an adapted DoH VAP bundle (2) consisting of eight care elements. An audit demonstrated a baseline of 100% compliance with the Institute for Healthcare Improvement ventilation care bundle. A sensitive working operational definition for VAP was identified utilising the Singh modification of the Clinical Pulmonary Infection Score(3) in conjunction with an established Non-directed Bronchial Lavage surveillance program. Multiple Plan-Do-Study-Act cycles of intervention involving the introduction of new equipment, comprehensive education and training program’s were undertaken. Continuous data collection demonstrated marked variance around an improved baseline of compliance. Innovative forcing functions and utilising an electronic prescribing system have resulted in a reduction of variance with increased overall compliance sustained for the last six months. This sustainability allows for the development and introduction of novel interventions to further reduce VAP incidence. Implementation of the care bundle has resulted in a cultural shift where VAP is now seen as a preventable Healthcare Associated Infection.

REFERENCES 1. Augustyn, B. 2007. Ventilation-Associated Pneumonia: Risk Factors &Prevention. Critical Care Nurse. 24 (4), pp 34-39.2. 2. Department of Health. 2011. High Impact Intervention: Care bundle to reduceventilation-associated pneumonia. Department of Health, London. Available athttp:// webarchive.nationalarchives.gov.uk/20120118164404/ hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Ventilator-

Associated-Pneumonia-FINAL.pdf3. 3. Singh N, Rogers P, Atwood CW, Wagener MM, Yu VL. 2000. Short- course empiricantibiotic therapy for patients with pulmonary infiltrates in the intensive careunit: a proposed solution for indiscriminate antibiotic prescription. AmericanJournal of Respiratory Critical Care Medicine. 162 (2 Part 1), pp 505–511.

C41: Working with Industry to Improve Clinical Practice

Andrea Baldwin, Lancashire & S Cumbria Critical Care Network Whether we like it or not the NHS continues, as ever, on its quest to evolve into a successful business and that despite its ever present principle of placing patients at the centre of all it does, there is an unprecedented need for healthcare professionals to deliver services that are base on quality, safety and productivity. Within the changing NHS landscape the national drivers are evident for NHS organizations to increasingly collaborate with external experts to enable them to meet their challenges, and that joint working with partners who can supplement their own skills and resources can provide benefits that may not necessarily be achievable by healthcare professionals in practice alone. In order to work towards this concept a group of health care professionals were invited to work with Hollister Ltd and form a Clinical Advisory Group (CAG), to identify the issues and challenges in critical care practice. The group was established with representation from critical care units and Clinical Networks from across England and Wales. Key to the success of this group was its size and working relationship, the ability to obtain current views from within their sphere of influence, and as members, the ability to champion best practice is essential.The group has worked with Hollister specifically to identify causes and incidence of patient harm in relation to endotracheal tube use, and have developed guidance for best practice for endotracheal tube fixation. Improving quality, patient safety and clinical practice are key goals for those working in critical care. The ability to work with industry and utilize their expertise is seen as a valuable method of achieving change for the benefits of the service and ultimately the patients for which we care. REFERENCES Department of Health (2010) Equity and Excellence: Liberating the NHS. TheStationery Office Limited, ID P0023774842. Department of Health (2010) Moving Beyond Sponsorship: interactive toolkitfor joint working between the NHS and the pharmaceutical industry. DH, London. Department of Health (2011) The Operating Framework for the NHS in England2012/13. Ousey K and Bielby A. (2011) Quality joint working with industry: the need to move beyond sponsorship. Wounds UK, 7 (1). pp. 155-156. ISSN 1746-68145.

Glover (2009) Viewpoints: Quality compliance and partnership: a new dawn.Wounds UK 5(4): 160–616. http:// www.hollister.com/uk/tube

C42: Endotracheal Tube Securement Leanne Kellegher, The Walton Centre NHS Foundation Trust Aim and background Securing an endotracheal tube on a patient can often be detrimental to the patient and traumatising to the patient’s family. Limited evidence is available to determine the most effective method of ETT fixation (Black, M.J et al, 2010). Design and methods A patient case study was conducted to determine the effectiveness of the Anchor Fast Oral Endotracheal Tube Fastener. Results The Anchor Fast was applied early on day one, remained insitu until day 5 when it was renewed. On day 7 Anchor Fast was clean and intact, however removed for tracheostomy insertion. The patient’s facial skin, lips & tongue were in perfect condition & 100% clear of any skin damage that can be caused by securing an endotracheal tube. The patient’s wife who has medical background in specialising in trauma wounds and was anxious with the possible damage that she had seen when securing ETT’s. Conclusions Staff securing the Anchor Fast Endotracheal Tube holder reported that it was easier to apply than other securing tools that they had previously used. In this case Anchor Fast was effective in the prevention of skin damage. References Black, M.J, Cuddigan, J.E, Walko, M.L, Didier, A.L, Lander, M.J, Kelpe, M.R (2010) Medical device related pressure ulcers in hospitalised patients. International Wound Journal, Vol. 7, no. 5.

C43: How a Multidisciplinary

Rehabilitation Class Can Enhance Recovery from Critical Illness

Caroline Wilson, Lucy Mummery, East Kent Hospitals The purpose of this presentation is to discuss the implementation of a multidisciplinary rehabilitation class for critical care survivors and how recovery of patients has been enhanced. Despite widespread recognition that many patients experience persistent psychological and physical problems following critical illness, there is little consensus on the most beneficial method of rehabilitation. The idea of a rehabilitation class, run jointly by critical care nursing and physiotherapy staff, was progressed from idea to reality over a period of many months. Funding to set up and run the class for an initial 12 months was secured

via an innovative Trust run scheme called After Dragons Den. Patients who have experienced a stay in critical care of greater than three days are visited on the ward prior to leaving hospital. The purpose of the visit is to identify unresolved concerns prior to discharge to continue the process of understanding the patient’s critical care experience and to discuss the rehabilitation class and its potential benefits.

patients involved are small, so an individual nurse / doctor will not gain much “hands on” experience so the sharing of experiences is beneficial if not essential. The Queen Elizabeth Hospital has valuable experiences of these discharges which have been instrumental in developing our guidelines that we can share.

Following discharge home patients are invited to attend for a comprehensive physical assessment and a subsequent six week class of exercise and discussion in the physiotherapy gym.The discussion can take place individually but tends to take place as a group,with patients talking together and gaining insight both from each other and the rehabilitation class staff.

DOH End of life Care Strategy: Promoting high quality care for adults at the endof their life. 2008. NHS London. ICUsteps. Intensive care: a guide for patients and relatives. ICUsteps; theintensive care patient support charity Web site. http://www.icusteps.com/guide. Accessed March 2013

The benefits have been beyond expectation. All patients have improved physically, demonstrated by improvement in function tests and in the achievement of personal goals. Various individual problems have been identified and resolved including pain management, over granulation of tracheostomy sites and sorting outpatient appointments that had failed to be booked. But perhaps the most consistent improvement has been in patient confidence and in their comprehension and acceptance of all that has happened to them.The Hospital Anxiety and Depression Score (HADS) is used to screen for psychological problems prior to discharge home and at the end of the rehabilitation programme. Similarly, the Six Minute Walk Test is used to assist assessment of physical function and all patients are asked to set a personal goal and achievement of this is assessed on completion of the programme. Results have been beyond expectation.

C44:

Going Home - Final Journey

Joanne Wilkinson, Gateshead Health NHS Trust Approximately 460,000 people will die annually each year in England. The majority of patients in the UK, and internationally, state they wish to die at home, however locally in the North East only 21% will die at home. It is common that across Britain that one fifth of the patients admitted to Critical Care will not survive because the treatment is futile or the patient wishes to stop / withdraw treatment. The minority of patients will be awake and able to express their preferred place to die and if they express a preference to die at home then this option should be seriously considered. At the Queen Elizabeth Hospital, Gateshead we have developed a guideline, specifically for critical care patients, to assist staff in deciding if such a transfer home can be achieved and provides a checklist to facilitate the actual discharge.The checklist ensures no step in the organisational process is missed. A major time pressure is expected in such situation as the patient is expected to die in the next 24-48 hrs. Therefore the process needs to be streamlined and efficient ensuring that all involved are fully aware of what dying at home will entail. Involving external agencies to ensure adequate support is in place for both the patients and their relatives.

REFERENCES

C45: Fire in the Intensive Care Unit Marghanita Jenkins, Royal United Hospital Bath NHS Trust On the 22nd November 2011, on the Intensive Care Unit (ICU) at the Royal United Hospital (RUH), Bath, during a routine transfer of a patient to another hospital, the CD-size oxygen cylinder used to provide the patient with oxygen exploded when turned on Kelly et al (2013). This resulted in a fire spreading rapidly to the surrounding area including the bed linen, curtains and mattress. The patient involved was removed from her bed to safety, the rest of the patients were evacuated incredibly quickly as the unit was plunged into darkness due to a thick, acrid, black smoke. Two doctors put out the fire. The patient involved was transferred to a regional burns unit, with burns to her legs, two members of staff were kept in for observation with smoke inhalation. All staff from the ICU were seen by a clinical psychologist, before being allowed home. Such an incident has obviously left staff involved traumatized. Out of that trauma comes a strong desire to re-examine and learn. While we wait the results and recommendations following investigation by the Health and Safety Executive (HSE) we have made changes within our unit. This includes the way in which we use and store oxygen, the ICU fire evacuation policy which has been re-written and tested while fire training for all ICU staff has been improved. The issues raised following the events of that night extend to all ICU’s. For example The Department of Health recommends staff should leave a fire to those experienced in fire fighting and using fire extinguishers (Fire Safety, 2005) – had two doctors not put out our fire so quickly, it would have spread rapidly to the surgical block above. As a result of our experience and investigations we have realised the greater implications of fire leading us to call for national recommendations to promote fire safety on the ICU. These need to be shared for others to re-evaluate and change practice. References Kelly F.E., Hardy R., Hall EA. Fire on intensive care unit caused by an oxygen cylinder. Anaesthesia 2013;68, 102104. The Regulatory Reform (Fire Safety) Order 2005.

Based upon our experience to date, the numbers of

C46:

Organ Procurement in a BrainDead Child – What is the nursing role?

Veronica Braganza, Corsino Rey Galan, University of Oviedo, Spain Objective To describe a case of child abuse that has caused brain death, making him a candidate for organ donation. To discuss the role PICU nurses have in these cases. Case study A 54-day-old infant was transferred to the PICU of a public tertiary care hospital in Spain, due to severe intracranial lesions. The parents reported that the child had hypo-activity, without any history of trauma or shaking. On assessment the child had a Glasgow coma score of 3/15, anisocoria with mydriatic right pupil and generalized hypertonia. He was immediately intubated and mechanically ventilated. On examination he had various degrees of injuries to his nasal outer wing, mandibles, mastoid, neck and parieto-occipital region. Interventions were initiated to control intracranial hypertension, but the patient progressed to brain death. The probable cause of the child’s extensive injuries was child abuse. The abuse was reported, and the surrogate consent taken for organ donation. However, from the time of identification until successful transplantation the nursing role is extremely vital. Commentaries Brain death is very uncommon in young children; therefore there is a shortage of organ donation from children of this age. Brain death cases in children are due to hypoxic encephalopathy, thus organs can be transplanted successfully. Almost 30% cases of brain death are unfortunately traumatic brain injuries attributed to child abuse and motor vechicle accidents. Therefore, as nurses we must be knowledgeable and skilled; providing specialized nursing care which may include maintenance of cardiovascular and ventilatory support and thermoregulation and monitoring of specific clinical data in the brain dead child. We must focus on the nursing process at all times, including the different tests necessary for the diagnosis of brain death- aiding in the medical and legal management of these potential donors.

Even in the acute deterioration the impact of a specialised paediatric retrieval service taking a child to a PICU , where the child and family are not known well, does not necessarily represent the child’s best interests. In some circumstances the local hospital may be the most appropriate place for children with complex issues to be managed through the final stages of life.

Sim Lab: Mock Dock: Using Simulation to Embed Learning Nicola Morton, University of Hull Over the last year compensation claims have cost my Trust over £1.1 million. Work into mortality rates suggest that poor documentation and inadequate communication leads to errors and inefficiencies which contribute to 8% of deaths. The literature on adverse errors suggest sub-optimal communication and teamwork contribute to patients’ errors and impact substantially on patient safety and the efficient use of resources. Within our Trust, issues have arisen surrounding decision making and their impact on patient safety and mortality. These were accompanied by concerns regarding the standard of documentation. It was felt that we needed to reinforce a culture of best practice with every member of staff taking responsibility and accountability for their actions. Mock Dock training is essentially simulation training centred around a coroners court room scenario. A critical incident from clinical practice was used to form the basis of the scenario and the key players were role-played by a combination of nurses, doctors, a genuine coroner and a genuine prosecuting barrister. The simulation aspect is reinforced with lectures and discussion about human factors and patient safety, decision making, roles and responsibilities, communication and the importance of documentation. The aims of the training are to: 1) Develop an awareness of the roles. responsibilities and accountability we all have in relation to patient safety 2) Reinforce the necessity for accurate documentation 3) Explore clinical decisions and how they can negatively impact upon the patient.

C47: Where Should this Child Die,

4) Understand the role we all have in decreasing patient mortality through safe and effective clinical care.

Matthew Norridge, Florence Nightingale School of Nursing and Midwifery

The training event is so popular that it is to be replicated at the Trusts’ “Best Practice Awards” day, forms the basis of our regional BACCN regional study event and will be repeated within the Trust twice a year. I am also incorporating it into my Degree programme teaching.

Regional PICU or Local General Hospital?

Most children with complex needs die in a tertiary PICU rather than in the local hospital that has looked after them all of their lives. As more children survive infancy with congenital birth defects and other complex conditions the number of children who die in early childhood within our communities is increasing. Greater awareness of the need for structured paediatric palliative care and an understanding of illness trajectories is necessary for health care professionals to consider ‘where’ is the most appropriate place for these children to die.

References Hall P (2005) Interprofessional teamwork : Professional cultures as barriers Journal of Interprofessional Care Supplement 1 pg 188-196 Zwarenstein M, Reeves S (2002) Working together but apart : Barriers and routes to nurse-physician collaboration Journal on Quality Improvement 28 pg 242247

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ViPER Abstracts V01: Improving Patient Outcome and

Experience in the Intensive Care Unit (ICU) Through Introduction of the ICU Rehabilitation Round

Elaine Manderson, Evelyn Corner, Chelsea and Westminster Hospital NHS Trust BACKGROUND The implications of critical illness can be catastrophic: muscle wasting, disability, stress, anxiety and depression are common sequalae. Hence, optimisation of recovery as well as survival is increasingly pertinent in ICU. This led to the introduction of the NICE (CG83) guidelines for Rehabilitation after Critical Illness (2009), which recommends regular physical and psychological assessment and implementation of patient agreed goals. AIM To implement NICE CG83 through the introduction of an ‘ICU rehabilitation round’ and a self-help manual. This project addresses the trust values of excellence, respect and kindness. METHOD This was a nursing and physiotherapy initiative. The proposal was presented to the wider multi-disciplinary team, and staff completed a questionnaire to establish current understanding of ICU rehabilitation. For the rehabilitation rounds, we compiled a checklist to address every aspect of the patients care needs. This includes: ventilation weaning; physical function; nutrition; cognition; communication; and self-care. The round consists routinely of: the clinical nurse specialist; bedside nurse, senior physiotherapist; and junior doctor. The dietician, pharmacist and senior medical staff also attend as required. The round began in November 2012. It is held every Monday at 2.30pm at the patients bedside. Inclusion is based on perceived clinical. A self-help manual called ‘on the road to recovery’ was also developed. This guides patients’ through the difficult transitions from ICU to home. It contains information on diet, appearance, exercise, mobility, pain control, sexual function, sleep, mood, memory and speech. RESULTS 11 patients have been included in the rehabilitation round. Their average length of stay is 29.6 days. The introduction of the round has resulted in: 1. Increased completion of patient agreed goals; 2. A more holistic approach to ICU recovery; 3. Earlier instigation of communication strategies; 4. Greater consideration of the need for pastoral care.

The self-help manual is currently undergoing stakeholder review and will be implemented in the coming months. Outcomes: Staff feedback has been positive. The staff questionnaire will be repeated to see if the rehabilitation round has influenced staff opinion of rehabilitation in ICU. A patient survey will also be distributed to examine the impact of these initiatives on patient experience. REFERENCES National Institute for Health and Clinical Excellence (NICE). (2009) Rehabilitation After Critical Illness Great Britain. Great Britain. Available at: www.nice.org.uk.

V02: Out of Hospital Cardiac Arrest - Outcomes and Issues Following ITU Admission as a Result of Out of Hospital Cardiac Arrest Matthew Moore St Georges Healthcare NHS Trust The intent of this paper is to present an overview of some of the issues surrounding adults admitted to a Cardiothoracic Critical Care unit following Out of Hospital Cardiac arrest (of suspected cardiac aetiology) and with a GCS less than 8. It will include In ITU and post ITU outcome data and concludes with anextracxt of interviews with a patient (survivor) and his wife. The intitial presentation is an audit of all admissions during a one year period, the subsequent component is a brief case review from the patients perspective. Between Feb 2013-2013, 91 adults were admitted to a Cardiothoracic Critical Care Unit in a large London Teaching Hospital. 39 patients died during ITU admission, leaving 52 patients surviving to ITU discharge. Of the 52 ITU survivors 43 left hospital, 39 of whom were discharged to their own homes. The remaining four were discharged to either long term or intermediary care facilities. Average length of ITU stay was 6.8 days (range 0-62 days), and ward stay 18.3days. Patients waiting longer or intermediate care stayed longer (10, 65, 66, and109 days respectively). Discharge home assumed ‘good’ neurological recovery, although questions may be raised regarding the means of quantifying this statement. Memory impairment,character changes, subsequent health (issues some requiring hospital readmission) are frequently problematic. A patient, ‘Terry’ will be presented who has been through this journey. His thoughts, feelings and experiences (and those of his wife) will be presented to support this ‘case presentation’.

V03: Let’s Go Round Again! Quality

Improvement in Critical Care Thorough Intentional Rounding Peter Doyle, Ruth Tollyfield, Allan Seraj, Felicia Cox, Harefield Hospital, Royal Brompton and Harefield NHS Trust SETTING Harefield Hospital is a 150 bed cardiothoracic hospital with transplantation, artificial heart, ECMO and PCI services. Our critical care department consists of 23 level 3, and 10 level 2 beds. INTRODUCTION Intentional rounds were recognised by the Royal College of Physicians and Royal College of Nursing (2012) as structured processes of regular checks at set intervals. Our team decided to adapt this initiative to the intensive care setting to address clinical challenges and provide guidance for shift leaders. METHODS Our intentional rounds, performed twice daily, included pressure area care andrenal replacement therapy (RRT) rates: 1. Pressure area care: this involved checking whether key elements of pressure sore prevention had been performed including completion of Waterlow scoring, frequency of repositioning, use of lateral positioning and of pressure relieving pads. 2. RRT rates: this element was identified after we established that our haemofiltration fluid use per hour was double that seen in ICU in our sister hospital. This pattern continued even after adopting similar therapy guidelines. The shift leader checks whether therapy rates had been adjusted in line with latest biochemical results. RESULTS 1. Pressure ulcer incidence: in the 4 months since the initiative began pressure ulcer incidence averaged 2.25 per month compared with 7.8 per month prior to the commencement of intentional rounding. 2. RRT rates: Since this was added to our intentional round the averageml/kg/hour over 24 hours has dropped to 31.5 from the previous average of 35.7. This would equate to a saving of £40K over 12 months. CONCLUSION We believe that use of a rounding tool to ensure focus on key areas can ensure that guidelines are followed, and outcomes positively affected.

REFERENCES Ward rounds in medicine. Principals for best practice. Royal College ofPhysicians and Royal College of Nursing, October 2012.

V04:

Implementing a Computerised Decision Support System to Improve the Adherence of Blood Glucose Control in the Critically Ill Helen Beard West Suffolk Hospital Trust Following the publication of the landmark study by Van den Berge et al (2001), which demonstrated a reduction in mortality in Level 3 cardiac surgical patients who underwent intensive insulin therapy to maintain tight blood glucose control, there has been huge interest in the concept of intensive insulin therapy within the field of Critical Care medicine. Since 2007, the Critical Care Unit at the West Suffolk Hospital have been using a dynamic blood glucose control algorithm modified from the Bath Protocol (Preston et al 2006) to manage hyperglycaemia in critically ill patients, however, a review of the use of this algorithm, indicated that there was variability in adherence in following the algorithm, leading to fluctuations in blood glucose and evidence of hypoglycaemia. In 2013, twelve years on from Van den Berge’s initial study and many subsequent studies, the debate continues regarding the efficacy of intensive insulin therapy. Paddle et al (2011) indicates that the attention is now focused on the safe delivery of insulin and reducing the risk of swings in blood glucose control. BBraun, an infusion device manufacturer, have devised a computerised decision support system which aims to reduce variability in blood glucose control by prompting timely blood glucose sampling and adjusting insulin therapy, taking into account actual nutrition regimes. In order to eliminate the variability of adherence with the dynamic protocol, this system has subsequently been adopted and implemented in the Critical Care Unit at the West SuffolkHospital. This ViPER presentation intends to demonstrate how the system was introduced and implemented to the unit, discuss the impact it has had and provide an evaluation of its effectiveness compared to using a dynamic system of blood glucose control. REFERENCES Griesdale E, et al (2009) Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. New England Journal Medicine; 360: 1283-97 Paddle J, Eve R, Sharpe K (2011) Changing practice with changing research: results of two UK national surveys

of intensive insulin therapy in intensivecare patients. Anaesthesia; 66:92-96 Preston S, Laver S, Turner D (2006) Introducing intensive insulin therapy: the nursing perspective. Nursing in Critical Care; Volume 11, Issue 2, pages 75–79 Van den Berghe, et al (2001) Intensive Insulin Therapy in Critically Ill Patients New England Journal Medicine; 345:1359-1367

V05: Health Care Assistants: Valuable

Critical Care Team Members

Catherine Dunston, Sarah McHenry, BFW Teaching Hospitals NHS Trust Providing adequate and safe staffing numbers within a Critical Care environment can be challenging. Within Lancashire and South Cumbria Network we know that units’ non-professional healthcare workers, such as Health Care Assistants (HCA’s), tend to be less skilled than in other areas of acute care, and their role is predominantly that of assisting registered nurses. Literature demonstrates that non registered nurses play an important role and add value to the care of patients in the critical care environment, and their roles are increasing in complexity (1, 2). With this in mind and in order to ensure there is a workforce that can support delivery of a quality critical care service, Blackpool Teaching Hospitals NHS Trust made a decision to develop HCAs so they could contribute towards effective delivery of patient care. Following the creation on a robust competency-based training programme, HCA’s progress to a point where they are capable to independently care for level 2 patients, with registered nurses retaining overall accountability. Their role, as an example, includes caring for patients with tracheostomies (non-ventilated), performing suctioning, providing basic wound and care activities, mobilisation, ECG recording, documenting physiological observations and providing nutritional support.The development of the critical care HCA role requires recognition of their value as a team member, time and investment for education and training, including mentoring, assessing and ongoing support.The overall benefits we have seen are: • A Critical care team with an increased range of skills to enable safe effective staffing of the service • Increased clinical capability to support the registered nursing workforce • Increased HCA motivation and morale • Increased HCA retention rates • Maintenance of 1:1 patient to carer ratios, for level 2 patients REFERENCES BACCN (2010). Standards for Nurse Staffing in Critical Care. BACCN2. Johnson, M., Ormandy, P., Long, A., Hulme, C. (2004)

The role andaccountability of senior health care support workers in intensive care units.Intensive and Critical Care Nursing. 20. 132-134

V06:

Compliance with Fluid Balance Monitoring Sue Snelson Northern Lincolnshire and Goole NHS Foundation Trust It is clearly evidenced that early recognition of the deteriorating patient and timely interventions improves mortality and reduces length of hospital stay (Hogan 2012). NPSA (2008) highlighted that failure to measure basic vital signs and poor fluid balance monitoring to identify deterioration and timely intervention are a key cause of mortality in acutely ill patients. In November 2008 NEWS was introduced within our Trust to promote early recognition of the deteriorating patient. However compliance with fluid balance monitoring was highlighted as an ongoing concern. Local mortality dashboard figures suggest that inadequate fluid balance monitoring contributes to 5.1% of in-hospital deaths. The Department of Health (DOH 2008) highlighted that the ability to accurately monitor fluid balance is a key clinical competence.Therefore it was decided to undertake a pilot project following a snapshot audit of compliance with the Trust fluid balance guideline on one ward. This identified only 20% compliance and a programme of interventions over a four week period was commenced. This included brief teaching sessions in the ward staffroom capturing as many staff as possible and the use of a 2 sided laminated “how to guide” in the front of all patients bedside observation folders. Re-audits confirmed that compliance with accurate fluid balance monitoring had improved to 80%. As a result we were asked to roll this out to all acute wards across three sites within the Trust which has subsequently been completed. This poster will outline the issues raised surrounding noncompliance and how these can be addressed in order to improve patient safety thus reducing mortality and length of hospital stay. REFERENCES Department of Health (2008) Competencies for recognising and Responding toAcutely Ill Patients in Hospital DOH London Hogan H, et al (2012) Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. BMJ Quality and Safety Online First 10.1136/bmjqs-2012-001159 http://qualitysafety.bmj.com National Patient Safety Agency (2008) The How to Guide for Reducing Harm from Deterioration available from http://www.patientsafetyfirst.nhs.uk

V07: Safety Bung Poses Increased

Infection Risk to Patients Through Colonisation at Venous Access Ports Emily Hodges, James Richardson, Graham Rogerson, Peter Young, The Queen Elizabeth Hospital NHS Trust There is a current move to introduce needle free bungs (Smartsite Needle Free Valve) to the end of all venous connectors throughout our trust in an effort to help prevent sharps injury. However, we hypothesized that logically these may present an increased infective risk to patients by acting as a bug trap. The valve end may be capped off but is frequently left exposed as per its design. In either situation we felt that it does not provide a barrier to infection and may allow bacteria to sit in the valve chamber which in fact would also reduce the effectiveness of cleaning. We designed a controlled trial looking at the transmission of pathogenic bacteria through a standard three way tap (BD connector) versus the new needle-free connector. This involved introducing a contaminated syringe tip to both groups. Both connectors were then cleaned in the recommended way with chlorhexidine and alcohol before a sterile sample of saline was pushed through the apparatus and collected at the patient end. This was then incubated in growth media and plated. In the needle free group 19/20 samples were heavily contaminated and one was negative. In the three way tap group six were positive for growth and fourteen were negative. Using a Fisher’s Exact test these results were highly significant (p<<0.01).We believe this has serious safety implications with the original set-up providing greatly reduced infective risk to patients. We are also looking at improvements in the rate of transfer in this existing three way tap group.

V08: The Unusual Patient Case Mix of a

New VA ECMO Service

Joanne Noble, Lisa Morgan, Elton Gelandt, King’s College Hospital NHS Trust INTRODUCTION King’s College NHS Foundation Trust (King’s) is one of four major trauma centres in London. The hospital not only provides a comprehensive clinical emergency service, but is also a tertiary referral centre for specialist care including primary angioplasty for myocardial infarction (PAMI), cardiothoracic surgery, neurosurgery, hepatobilary and haemato-oncology. To complement the existing cardiac and trauma services at the Trust, a VA ECMO facility was introduced in February 2012. This would allow the hospital to provide emergency treatment of potentially reversible cardiogenic shock unresponsive to conventional therapy. There have been a total of 7 patients who have undergone ECMO therapy since the service was established, all of which have been considered unusual cases.

METHODS Interest was shown by an initial team of 8 senior nurses (Band 6 & 7s), 3 perfusionists, 3 technicians and 4 consultants. All staff undertook training, as per the Extracorporeal Life Support Organisation Guidelines (2010). Patient referral and decision for ECMO therapy was made jointly by the managing intensivist, on-call ECMO consultant, and referring cardiologist/cardiac surgeon or admitting consultant, and the local veno-veno. RESULTS There have been 4 VA ECMO and 3 veno-veno (VV) ECMO cases. The VA ECMO clinical conditions were: 1) Post cardiac arrest with severe septicshock 2) Right heart failure and distributive shock 3) Acute myocarditis 4) Hypothermic cardiac arrest. The provision of VV ECMO was in patients who could not be considered for treatment at a nearby commissioned respiratory ECMO centre, due to specialist needs: 1) Respiratory failure in hepatopulmonary syndrome 2) Pulomonaryhaemorrhage 3) Potential bridge to transplantation in cystic fibrosis. CONCLUSION The provision of VA ECMO at King’s is still in its early stages. However, the wide range of specialist clinical services offered at the Trust have exposed the ECMO team to a number of unique and complex cases during its initial phase. REFERENCES Extracorporeal Life Support Organisation Guidelines for ECMO Centres, Version1.7, ELSO, February 2010

V09: The Inter-Professional Understanding and Utilisation of Berlin ARDS Definitions and Oxygenation Index in a Central London Intensive Care Unit (ICU) Fiona Wade-Smith, Phil Hopkins, Catherine Bell, Angela Feehan, Kim Peters. Kings College Hospital NHS Trust INTRODUCTION Adult respiratory distress syndrome (ARDS) is a major cause of oxygenation failure in patients admitted to ICU and can be a cause and consequence of critical illness. However, ARDS is a highly dynamic condition and early categorisation of severity and prediction of outcome have proved difficult(1,2). Here, we describe the epidemiology of early oxygenation failure in 3130 ventilated patients to a London ICU, as well as exploring current nurse and clinician understanding.

METHOD Institutional ethical approval and statistical support was obtained. The clinical information system (Medtrack) was utilised to obtain APACHE II data for all ventilated admissions over a 21 month period. These values were then used to calculate the PaO2/FiO2 (PFR) in all patients. We applied this to the PFR component of the Berlin ARDS definition and examined the associated patient outcome (3). Data were extracted and analysed with Sigmaplot 11.0 (SystatSoftware Inc). Finally we surveyed the interprofessional use and understandingof the Berlin Criteria for ARDS and Oxygenation Index using Surveymonkey. Result table 1 shows the distribution of the Berlin ARDS PFR ranges and associated outcomes. Our inter-professional survey showed the dynamic nature of ARDS was poorly understood in relation to Oxygenation Index and that the Berlin definitions were not being applied. Only 3.6% of nurses surveyed were able to use the Berlin Criteria definitions to categorise a patient’s lung injury, without looking up the criteria. CONCLUSION The lung injured population within our ICU can be usefully described through early application of the PFR category of the Berlin ARDS definition. However, the interprofessional understanding and use of these descriptions of oxygenation failure were limited. After a period of multi-disciplinary teaching a secondary survey will be distributed to establish whether the understanding of the Berlin Criteria and Oxygenation Index has improved. REFERENCES (1)Doyle RL et al. 1995. Identification of patients with acute lung injury:predictors of mortality. Am J. Respir Crit Care Med. 152:1818–1824. (2) Monchi M et al. 1998. Early predictive factors of survival in the acuterespiratory distress syndrome. A multivariate analysis. Am J Respir Crit CareMed 158:107681. (3) ARDS Definition Task Force. 2012. Acute respiratory distress syndrome: the Berlin Definition. JAMA 307: 252633.Table 1 has been sent to info@baccnconference.org.uk as arranged with the conference organisers.

V10:

Ventilator Associated Pneumonia - Improving Practice Katherine Gray, Sarah Jarvis, Jamie Bomford, Nandita Divekar, Medway NHS Trust AIM Improving Practice – by exploring the compliance of the ventilator care bundle, and addressing the ‘hunch’ that our mouth care standards were not as good as we would wish them to be. We aimed to improve practice by auditing, especially mouth care and head up. METHOD

For six months very visible bedside auditing was carried out at the daily ward round to measure compliance with the Ventilator Care bundle, the audit was started at the same time we introduced a new mouth care complete solution kit. The mouth care product was used for the first 3 months of the audit, and then we reverted to our traditional practice for the second 3 months. We did not have proper data supporting our compliance with the VAP bundle, particularly mouth care. This was then followed up by a simple staff satisfaction survey. Defining VAP was a starting point, we adapted the CDC (2012) definition. RESULTS Auditing improved practice, especially head up. Sedation hold was the most contentious factor as we use short acting sedation. We included sub-glotticaspiration, this was the least compliant factor, but improved due to simple logistical reasons. Mouth care, with the bespoke mouth care product was excellent, much better than when reverting to traditional practices. We have found that we cannot keep mouths as clean without the mouthcare product, and use more anti-fungal treatment, we need to consider whether we purchase this or another product, cost is the complicating factor, this will be outlined. In the first 3 months we had no VAP, in the second 3 months we had 1 VAP. Staff experience of the product was surveyed, this was excellent. Audit improved our practice. REFERENCES Magill S, Fridkin S, (2012) Improving Surveillance Definitions for Ventilator Associateded Pneumonia in an Era of Public Reporting and Performance Management CLINICAL INFECTIONS DISEASES, Vol 54, Issue 3 Center for Diseases Control Prevention CDC (2012) Ventilator AssociatedPneumonia www.cdc.gov/hai/vap/vap

V11:

Emergency Resternotomy in the Resuscitation of a Patient Post-cardiac Surgery - the Expanding Role of the Nurse Lorraine Bell, Janet Mills, Belfast Health And Social Care Trust INTRODUCTION Managing cardiac arrest following heart surgery varies from thatof standard resuscitation. Patients who have arrested due to a tamponade or haemorrhage will require the chest to be re-opened. Between 20 to 50% of cardiac patients who have had a cardiac arrest will require emergency resternotomy. Delays waiting for theatre staff and senior surgeons may reduce the patient’s survival rate. Rapid resuscitation is essential to preserve life. AIM • To educate nursing staff to execute a well managed

reopening of a patient’s chest following an arrest postcardiac surgery.

V12: Child Bereavement Support Project

• To promote an innovative Cardiac Advanced Life Support (CALS) protocol as an integrated part of clinical practice.

Lucy Mires, Anita Bowman, Medway NHS Trust

METHOD

PRESENTATION OUTCOMES

Following training in the CALS protocols a multidisciplinary team evolved to cascade training to all staff. Cardiac Surgery Intensive Care (CSICU) nursing staff are taught new innovative skills that empower them to manage the arrest in an efficient, calm, controlled manner to assist in the resternotomy of patients’ post-cardiac arrest. To facilitate this a streamlined emergency kit comprising of five pieces of equipment is used; compared to a standard theatre set of thirty pieces or more.

The aim of this presentation is to think about children visiting a relative in a Critical Care setting and how it can be improved.

RESULTS To date 81% of nursing staff have attended a CALS study day, with yearly updates. This is a multidiscipline approach where all new F2 doctors and anaesthetists who have their placement within CSICU are trained with CALS as part of their induction. DISCUSSION Studies have shown that if patients’ are reopened within five to ten minutes, the patients survival rate increases (Nolan and Basket, 2005; Dunning etal 2005). Training nursing staff in well-managed arrest situations, comprising of new skills, contributes to the rapid resuscitation that is required. This programme has forged firm partnerships with multipractitioners and junior/senior staff within the unit thus concreting the dynamics within the team. REFERENCES Chaudhry, S. (2005) Running a cardiac surgery advanced life support course. British Medical Journal Careers. Pages 200- 201. Dunning, J., Nandi, J., Ariffin, S., Jerstice, J., Danitsch, D. and Levine, A.(2006) The Cardiac Surgery Advanced Life Support Course (CALS): Delivering Significant Improvements in Emergency Cardiothoracic Care. The Society of Thoracic Surgeons. Elsivier Incorporate Dunning, J., Levine, A., Strang, T. And Gofton, K. (2010) The Cardiac Surgery Advanced Life Support Course. Course Manual. Dunning, J., Fabbri, A., Kolh, P., Levine, A., Lockowandt, U., Mackay, J.,Pavie, A., Strang, T., Versteegh, M. and Nashef j, S. (2009) Guideline for resuscitation in cardiac arrest after cardiac surgery. European Journal of Cardio-

BACKGROUND Assisting children and their families through bereavement in an acute setting is difficult for all of those involved. Mortality rates of ICU patients can be 17% (ICNARC 2010). In an ICU nurse’s role our focus then turns to caring for the dying patient, and their family. When children are involved anywhere in the grieving process, it can become more stressful for families and nursing staff. AIM Within Critical Care environments there may be hours and days, rather than weeks and months to prepare families for death. Families have said that what they need most at this time is “information” (The Child Bereavement Charity 2011). We wanted to give grieving families with children as much practical help as possible around death. THE PROJECT The Project was established to enable nurses to practically support families with children. A working group was established to develop the Project. Examples of the project include: • Workbooks to encourage children to positively talk about their relative, to express their understanding about what is happening, how they feel and how they may be able to help • Matching friendship bracelets are given to children and their relative in ICU • A reference list of books and DVD’s for children of a bereaved patient is given to parents • Memory boxes can be started CONCLUSION This project was set up to aid nursing staff, parents and guardians with practical ideas and resources to guide them through the early part of grief. We believe that the project has gone some way to providing that service and preparing children. REFERENCES

thoracic Surgery Pages 1 – 24.

Nolan, J. and Basket, P. (2005) European Resuscitation Council Guidelines for Resucitation 2005. Resuscitation 2005, pages 67 (supplement 1), S1-S190. Lemmer, J. and Vlahakes, G. (2010) Handbook of Patient Care in Cardiac Surgery.7th edition. London, Lippincott

ICNARC (2010) Intensive Care National Audit and Research Centre. CMP Case Mix Summary Statistics. www.icnarc.org/documents/summary The Child Bereavement Charity (2011) www. childbereavement.org.uk

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Poster Abstracts P01: Staff Perceptions of Implementing

a Computerised Decision Support System to Manage Glycaemic Control in the Critically Ill

Helen Beard, West Suffolk Hospital Foundation Trust Following the publication of the landmark study by Van den Berge et al (2001), which demonstrated a reduction in mortality in Level 3 cardiac surgical patients who underwent intensive insulin therapy to maintain tight blood glucose control, there has been huge interest in the concept of intensive insulin therapy within the field of Critical Care medicine. In 2013, the Critical Care Unit of the West Suffolk Hospital implemented the BBraun Space Glucose Control system, a computerised decision support system which reduces variability in blood glucose control by prompting timely blood glucose sampling and adjusting insulin therapy automatically, replacing a system of dynamic blood glucose control. This poster presentation intends to highlight the staff perceptions of this change in practice, evaluate the impact on the nursing workload and demonstrate how the staff had to adapt to develop confidence and trust that the computerised decision support system was safe and effective in it’s delivery of intensive insulin therapy. REFERENCES Preston S, Laver S, Turner D (2006) Introducing intensive insulin therapy: the nursing perspective. Nursing in Critical Care; Volume 11, Issue 2, pages 75–79 Van den Berghe, G., Wouters P, Weekers F, Verwaest P, Bruyninckx F, Schetz M, Vlasselaers M, Ferdinande P, Lauwers P, Bouillon R (2001) Intensive Insulin Therapy in Critically Ill Patients. New England Journal Medicine; 345:1359-1367

P02: Optimising the Quality of Care

Provided to Long Term Intensive Care Patients – a New Role

Sara Collingridge, Peter Doyle, Lisa Hollins, Ruth Tollyfield, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust INTRODUCTION Harefield Hospital is a 150 bed cardiothoracic centre with transplantation and artificial heart programmes. Our 33 bed critical care unit consists of a 23 level 3 Intensive Therapy Unit (ITU) beds, and a 10 bed High Dependency Unit. In the 2012/13 fiscal year the department admitted 1489 level 3 patients eachyear. Of those patients 647 were

discharged within 48 hours, however 132 remained on ITU for over 2 weeks. In March 2011, in order to optimise the care and management of these longer term patients, a multidisciplinary team (MDT) nurse role was introduced. METHODS One day per week an experienced ITU nurse is allocated the supernumery role of MDT nurse. This role involved a full nursing review of patients that had spent more than 2 weeks in a level 3 bed. Other key responsibilities include updating patients’ next of kin, chairing the MDT meeting, and documenting action points. In order to generate qualitative feedback about the role we sent questionnaires to 83 staff from a variety of disciplines, all of whom contribute to the management of long term ITU patients. RESULTS Returned questionnaires demonstrate that respondents are unanimously in favour of the role and felt that it had a positive impact. There were however some misconceptions about the scope of the role, including from within the nursing team. Suggestions for future development of the role were sought and will be used to guide the evolution of this development. CONCLUSION We believe that this role has the potential to enhance basic nursing care, and facilitates a multidisciplinary approach to the care of long term critically ill patients. In addition to the feedback from MDT colleagues we plan to seek feedback from service users on how the care of long term patients can be more positively influenced by this role.

P03: Bereavement Care in the Critical

Care Oncology Setting; the Promotion, Planning, and Organisation of a Memorial Service

Rachael Crayton, Katy Andrews, Critical Care Unit, The Christie NHS Foundation Trust The Intensive Care Society (1998) has recommended that bereaved relatives should be followed up. The Christie is a specialist oncology hospital and the Critical Care Unit cares for patients with a cancer diagnosis, requiring Level 2 and 3 care. A patient death in this setting can be traumatic and sudden for the surviving family members. This can result in complex grief, post traumatic stress disorders (PTSD) and bereavement related depression (Wright et al, 2010),(Gries et al, 2010). AIMS & OBJECTIVES • Overview of the issues surrounding bereavement • Background to the development of a memorial service

• Sharing of information on how to set up a memorial service • Presentation of the feasibility enquiry and questionnaire METHOD The authors joined the CCU team with prior positive experiences of ICU bereavement follow up in the form of an annual memorial event. Similar to Platt (2004) the service had been well received. On CCU there is currently nobereavement follow up and with the added stress of a cancer journey we were concerned that our relatives are at a high risk of PTSD. Feasibility enquiries were carried out and 30 anonymous questionnaires were distributed to staff to gather their thoughts. RESULTS Results from questionnaires and feasibility enquiries were positive and clearly showed that the team believed that there was a benefit to implementing this new service. It was important for the Memorial service to be a team approach. Relatives and family members were identified and invitations to the service sent out. The service will be evaluated by relatives and staff using a comments boxafter the event has taken place.We care for the relatives with a great deal of compassion which shape theirmemories of the bereavement. This puts us in a great position to aid the start of a healthy bereavement process, which may help to reduce the incidence of “survivor morbidity” (ICS, 1998).

P04: Role And Place Of Qualified

• Documentary method RESULTS The data analysis emphasized the importance, role and place of the physician specialist in EM to providing CPR. It also identified strengths and weaknesses in the specialty of EM. CONCLUSION Globally, there has been growth in the number of emergencies including DAC and the need to rendering EMC, including CPR by trained personnel. In Bulgaria, the requirements for the medical staff in providing CPR qualified in terms of urgency. There is a significant number of people in need of providing EMC and CPR in terms of a shortage of trained health personnel including doctors with specialty EM.The country has introduced a concept for the future development of the specialty EM. It provides for strict regulation of the legislation, the adoption of standards and protocols for a job in EM in providing CPR and pre-hospital care in terms of urgency and BAC. In Bulgaria a project for the preparation of paramedics with various degrees of mastery of basic skills in CPR has been started. Key words: emergency medical care, emergency medical care centres, disastersituations, Republic of Bulgaria, prehospital health care

P05: Preparedness of Emergency

Care Centre in Bulgaria For Rendering CPR During Emergency and Disaster Situations

Physicians Experienced In“Emergency Medicine” In Bulgaria For Rendering CPR

Assistant Professor Diana Dimitrova, Medical University of Sofia

Assistant Professor Diana Dimitrova , Medical University of Sofia

BACKGROUND

BACKGROUND The specialty ‘Emergency Medicine’ (EM) in Bulgaria is included in the regulatory standards for postgraduate training for masters in medicine. The specialty of EM is a recognized therapeutic program in Bulgaria and the European Union. In 2012, a modern equipped Department of EM was established for the training of physicians in the specialty of EM. This specialization provides highly qualified doctors for rendering CPR. The physician specialist in EM in the country is a key component of the health system in providing CPR events in times of emergency, and mass gatherings such as disasters, accidents and catastrophes. METHODS • Research and analysis of scientific literature data • SWOT analysis

The emergency medical care (EMC) in the Republic of Bulgaria is a part of the healthcare system to provide specific medical activities including CPR. Bulgaria has a long tradition in organizing medical care in emergency situations and in reacting to natural disaters, accidents and calamities (DAC). The conditions in the country changed a lot during the 1996-2012 period and the EMC system confronts new challenges. A new national system for urgent calls is put in place as well as EMC centres. Professionals are trained for rendering CPR. These measures improved the coordination and harmonized the provision of EMC and CPR in emergency situations and in DAC. METHODS • Research and analysis of scientific literature data • SWOT analysis

• Documentary method • An analysis of the current state of EMC centers in providing CPR according to the provision of materials, technical, scientific, methodological and human resources and funds. RESULTS The analysis of the readiness and the current state of the EMC system in Bulgaria for rendering CPR shows the need to update and improve the structure and organization of the EMC centres. The results emphasized the insufficientness of trained staff and specialists at EMCC in providing CPR including in response to BAC. It highlights the strengths and weaknesses of the system of EMCC in providing CPR. CONCLUSION There is an increasing number of disasters worlwide which serves to underline the importance of EMC and CPR at EMCC. More and more people need EMC including CPR when there is insufficient optimized willingness of EMCC in the country. This highlights the pronounced shortage of health personnel in EMC centres in thecountry. The concept for the future development of the system of EMCC is introduced. Bulgaria are preparing regulations, standards and protocols for the operation ofthe EMCC in providing EMC including CPR and during DAC. Key words: CPR, Emergency Medical Care, Emergency Medical Care Centres, DisasterSituations, Republic of Bulgaria

P06: Reducing Re-Admissions of

Cardiothoracic Transplantation Patients to Intensive Care Through Use of a Criteria Linked Assessment Tool

Helen Doyle, Alison Thompson, Peter Doyle, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust INTRODUCTION Harefield hospital is a 150 bedded cardiothoracic centre with transplant and artificial heart programmes. The transplant unit has 34 beds including 8 high dependency beds where patients undergo interventions such as BIPAP, CPAP, IABP, inotropes, haemofiltration, and ventricular assist device support. In order to clarify admission criteria and minimise risk of inappropriatead missions from the Intensive Therapy Unit (ITU), admission guidelines were formulated along with a supplementary checklist. METHODS Nursing and medical staff from the Transplant Unit and ITU were consulted prior to guideline production and criteria were agreed. In addition to the guidelines the supplementary checklist was produced to simplify assessment of patients and support audit processes. IMPACT ANALYSIS

Questionnaires were sent to ten band 6 and 7 nurses in order to attain qualitative feedback. Readmission data was also analysed pre and post implementation to ascertain the impact on the number of readmissions to ITU within 48 hours of discharge. RESULTS 10 staff returned the questionnaire, all of whom described the guidelines and checklist as either ‘useful’ or ‘very useful’. Comments included the following: ‘I feel less stressed now about assessing potential ITU discharges’ and ‘more confident in my assessment ability’. Activity data showed that the readmission rates to ITU within 48 hours of discharge had decreased from 6.3% in the year prior to implementation to 2.3% the following year. DISCUSSION We believe that clear, agreed guidelines and a supplementary checklist reduces the risk of inappropriate ITU discharges and therefore the risk of readmission to a level 3 area. Measures such as this can also have a positive impact on staff who have described how the tool contributed to increased confidence when assessing potential admissions from ITU.

P07: Schwartz Rounds: Improving

Patients’ Experience and Quality in a Cardiothoracic Critical Care Unit

Allan Seraj, Peter Doyle, Geraldine McVeigh Harefield Hospital,Royal Brompton and Harefield NHS Foundation Trust All staff in Critical Care want to provide kind and compassionate care that they would want for themselves or their own families. It is challenging, for all sorts of reasons (including individuals’ reasons and the nature of team and hospital cultures), to do this consistently.There is a clear relationship between the well-being of staff and patients’ well-being. Individuals suffering from burnout may find it more difficult to feel compassion. Staff with higher levels of empathy are less likely to suffer from burnout. The problem that lack of compassion creates for patients is obvious.There is also a cost for staff, who cut themselves off from the feelings that cause empathy and compassion to flow- especially important as higher empathy is related to lower stress. Schwartz Rounds provides a forum for staff across the hospital to come together once a month (or every other month) and explore together the emotional labour associated with caring for patients. How does Schwartz Rounds work?With the help of a facilitator, the discussion is focused on a particular case that is introduced by a mixed panel of staff, led by a doctor, who were involved in the patient’s care. The panel gives a brief summary of the patient’s case story and panellists take it in turns to describe their involvement in the case and, in particular, how it made them feel and what sort of challenges it may have raised for them. The discussion then opens up: participants ask questions, share experiences and reflect on the challenges of care. The Rounds are designed to be a safe and confidential environment: patient names are changed to protect

confidentiality and all participants are asked to agree that no names or information shared by colleagues are mentioned outside the one-hour Round. METHOD The Critical Care multidisciplinary team members participated in three Schwartz Rounds and qualitatively some of the comments from participants were analysed: ‘A cathartic event…’ General Manager ‘A great opportunity to explore care delivery in a nonthreatening environment’ Nurse ‘Excellent open (honest) discussion - Great attendance!’ Consultant ‘Excellent length of time to discuss. Very clear summaries from each panel member.’ Physiotherapist

Shaller D (2007). Patient-Centered Care: What does it take? The Commonwealth Fund. The Boorman Review [Department of Health (2009). NHS Health and Well-being Review: Interim Report Department of Health (2009) NHS Health and Well-being: Final Report. Thomas MR et al. (2007) How do distress and wellbeing relate to medical studentempathy? A multi-center study. J Gen Intern Med. 2007; 22:177-183.www. theschwartzcenter.org

P08: Length of Stay and Age as

Determinants of Death in Intensive Care: a Retrospective Population Cohort Study

‘People were cared for by staff that were supported to deliver care and treatment safely and to an appropriate standard. The provider was meeting this standard’ CQC (2012)

Judy Dyos, Dr Anne-Sophie Darlington, Southampton University Hospital Foundation Trust Professor Maureen Coombs, Victoria University NZ

The main themes that have emerged from participating in Schwartz Rounds include:

INTRODUCTION

1. Pathway for social strengthening amongst members of the interprofessional team 2. Driver for clinical change and improvement of quality 3. Opportunity for learning amongst the teams DISCUSSION The Trust has been rated highly for the support given to care providers whilst carrying out their work. Hospitals that are rated highly for patient-centred care have certain characteristics in common, one of which is ‘care for the caregivers through a supportive work environment that treats them with the same dignity and respect that they are expected to show patients and families’. Schwartz Rounds have provided this forum where members of the Critical Care multidisciplinary team can find support for their emotional labour of caring for patients and translate this support into improving the quality of care delivery. We are committed to using this forum in our continued efforts toimprove our patients’ experience. REFERENCES Firth-Cozens J and Cornwell J (2009). Enabling Compassionate Care in AcuteHospital Settings. London: The King’s Fund Goodrich J and Cornwell J (2008). Seeing the Person in the Patient: The Point of Care review paper. London: The King’s Fund Latif E, Peisah C, Wilhelm K (2008). ‘Empathy and doctor health: a study of the relationship between empathy, burnout and psychological distress in doctors’. Doctors’ Health Matters Maben J (2008). ‘The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study’. Nursing Inquiry, 14(2).

Early recognition of patients who are unlikely to survive allows healthcare staff to offer realistic information to families about likely patient outcomes and leads to appropriate utilisation of limited intensive resource. The aim of this study was to explore whether risk factors from bedside clinical data could be identified and used to develop a high risk of dying prediction model. METHOD This retrospective, population cohort study examined demographic and clinical data of all critical care patients who died in a single site over a three year period. This site is a large University based hospital in England with three adult intensive care (general, cardiac, neurological) and three high dependency units (surgical, cardiac and respiratory). Routinely collected admission, patient outcome, and clinical interventions data was extracted, collated and analysed. Univariate logistic regression analyses were conducted to investigate the predictive level of the basic and advanced organ (from CriticalCare Minimum Dataset) , length of stay and age. FINDINGS Data from 11454 patients was analysed. Of this group 596 (5.2%)patients died. Separate univariate logistic regression analyses showed that all variables were significant determinants of death. Patients who were older were more likely to die, and an increase in length of stay was also related to death. Most organ support variables had a positive relationship with the outcome variable, in that the need for support predicted death. CONCLUSION There is still no predictive tool that is easily utilised at the bedside by doctors and nurses. Whilst prognostication

remains a matter of clinical judgment, length of stay and age does have predictive value. Early identification of patients at high risk of dying remains important as uptake of such resource intensive services increases the fiscal burden on healthcare and generates complicated health care challenges to patients, family members and healthcare teams.

P09: Meeting Stakeholders

Expectations With Current Resources

Nicky Edmondson, Melanie Woolfall,Heather Bendall, Martin Hope, Royal Lancaster Infirmary The NHS has previously struggled in its attempts to keep up with the rise in public expectations, the ageing population and the “changing burden of disease”(Ham et al, 2012). Expectations in relation to quality have risen, whilst The Health and Social Care Act (2012) has led to a radical reform of NHS services. However, the Act focuses on how services are organised rather than how care is delivered. If we are to meet the rising and changing demands whilst remaining competitive, we will need to identify models of working that are fit for thefuture (Ham et al, 2012). Traditionally care delivery for patients (in ICU) was perceived as being effective on the basis that they had survived their stay in Critical Care.However, as medicine has advanced and public expectation has risen, there has been a shift towards optimising holistic recovery, encompassing a patients’recovery post discharge to the ward. These external drivers are influencing and shaping the ways we work: • We must be responsive to changes –to provide both a quality and sustainable service in the future. • National recommendations and guidance need to be implemented without additional funding. • Difficulties for staff to meet these requirements within existing workingpatterns We have therefore looked at how we currently work and have begun to: • Alter the structure of the handover • Develop the CSW role • Identify hours from varying roles to support patients following criticalillness This service improvement will help address the pressures that the currentdrivers are placing on critical care as it is today.

Care Trust All nursing practitioners in the clinical field are expected to deliver high quality nursing care and best practice. It has been well documented that new staff nurses require support during the transition period from student nurse to registered nurse. Whilst there is an evolving support system for mentors of student nurses there is less emphasis on the support required for preceptors of registered nurses. The aim of this paper is to discuss the progressive steps taken to implement a change in culture around preceptorship and mentorship. This change took place within the Cardiac Surgical Intensive Care Unit (CSICU ) inthe Belfast Trust (BHSCT). In a planned expansion of staff levels, 20 new members of nursing staff were employed over a 2yr period. It was recognised at that time that experienced nursing staff in CSICU were starting to experience ‘preceptor fatigue’. The need for a change in culture was highlighted by the preceptors in the unit. In order to implement this change we listened to the concerns expressed by the nursing staff who were preceptors at that time and we empowered them to become part of the solution to the problem. A team approach was adopted to drive this initiative forward. This led to the formation of a Core Lead Preceptor/ Mentor Team which consits of a dedicated group of 8 staff members of staff (Band 5,6 and 7) who focus on the way forward for preceptoring/mentoring in CSICU. Introduction of this model has resulted in a positive change in culture, improved staff morale, increased staff retention,larger pool of preceptors/mentors in the unit and ultimately there is now a greater number of nurses expressing interest in preceptoring and mentoring as a result of the support that has been put in place.

P11: Introduction of Cam-ICU Tool On The Critical Care Unit

Yvonne Helm, Mary Cavill, Sarah Holden, Royal Blackburn Hospital - ELHT AIMS • Early identification of delirium and treatment initiationReduce prevalence of delirium in ICU patients • Introduce use of CAM-ICU as twice-daily assessment tool in ICU CURRENT POSITION • Two-hourly RASS score Sedation Vacation Barriers • Lack of understanding of delirium • Limited knowledge of associated poor outcomes • Increased workload

P10: Changing the Culture –

Preceptorship in Cardiac Surgical Intensive Care

Caroline Ennis, Lisa Scullion, Catherine Ravel, Ursula Burns, Belfast Health And Social

• Perceptions that tool will not improve outcome (Boot 2011, Porter & McLure 2013) CASE FOR CHANGE • Very few institutes perform delirium screening systematically - reason unclear

• Improve patient safety/outcome • Reduce extended lengths of stay(Girard, Pandharipande & Ely 2008) DESCRIPTION OF PLAN • Discussed at MDT meeting for unit • Education/training in regards to the subject and CAMICU tool • Check box incorporated into daily nursing booklet • CAM-ICU flowchart attached to all chart tables/ laminated cards in drawers(Morandi 2011, Truman 2003) OPTIONS • Continue current practice • Implement new screening tool • Benefit Appraisal • Increase patient safety • Improve patient outcome • Reduce length of stay (Conner & English 2011) • Financial Appraisal. Delirium has been found to be an independent predictor of: • Increased morbidity/mortality • Increased length of stay • Long term cognitive impairment(Porter & McLure 2013, Boot 2011) Thus early identification could reduce delirium associated hospital costs. One study identified that patients with delirium spent a median 10 days longer in hospital than those without (Conner & English 2011). RISK MANAGEMENT Ensure appropriate education and training is carried out incorporating: • Types of delirium • Sedation scoring - appropriate levels • CAM-ICU tool • Link nurses to act as a reference point and promote implementation which has been shown to enhance uptake of assessment in clinical practice (Truman 2003,Boot 2011, Porter & McLure 2013) RECOMMENDATIONS Critical care nurses are in a unique position to improve patients’ quality of care and outcomes by early recognition and management of delirium. The aim is: • Reduce incidence of over/under sedation • Utilise CAM-ICU twice daily and document findings • Improve patient safety/outcome

• Reduce patient morbidity/mortality and patient length of stay

P12: Acute Kidney Injury in the Cardiac Surgery Population

Rebekah Thomson, St Georges Hospital In 2009 NCEPOD published a paper describing the effects of acute kidney injury (AKI) within the NHS and reported that 30% of cases could be avoidable. AKI impacts on overall patient mortality and quality of life. It is estimated that the costs attributable to this condition are between £434M and £620M per annum,following this report, the NCEPOD (2009) made recommendations on identifying patients at risk and implementing strategies to reduce the incidence of AKI. These strategies were targeted at the high-risk non-cardiac surgery population. The incidence of AKI amongst cardiac surgery is a recognised common complication, the literature reports 24% of patients develop AKI (Karkouti 2009) and patient mortality increases by a 7.9 fold (95% CI 6-10) in this group (Chertow 1998). In cardiac surgery the mechanism for AKI differs and has many influencing factors including patient age, existing co-morbidities, the use of cardiopulmonary bypass, transfusion of red blood cells and potential hypo-perfusion.Strategies for reducing AKI have been adopted including off-pump surgery and the use of pharmacological agents, including diuretics, dopamine, N-acetylcysteine and Atrial Natriuretic Peptide. None have shown any improvement in outcome or long term survival and most have been acknowledged to result in deleterious effects (Rosner 2006). Early recognition and implementing strategies to target modifiable risk factors is key in reducing the incidence of AKI.The NCEPOD (2009) advised the use of optimisation to improve patient mortality and morbidity and Brienza (2009) acknowledges optimisation to have an impact on renal function. A recent meta-analysis by Aya et al (2013) suggests optimisation has a positive impact following cardiac surgery, although these studies did not measure renal function specifically. A preliminary study within our unit focusing on stroke volume maximisation post-operatively showed promising results in the reduction of AKI, which are to be confirmed in a randomised control trial. REFERENCES Aya HD. Ceconni M. Hamilton M. Rhodes A (2013) Goaldirected therapy in cardiac surgery: a systematic review and meta-analysis. Br J Anaesth Apr;110(4):510-7 Brienza, N. Giglio, MT. Marucci, M (2010) Preventing acute kidney injury after non cardiac surgery. Curr Opin Cit Care. Aug; 16(4): 353-8 Chertow GM. Levy EM. Hammermeister KE. Grover F. Daley J (1998) Independent association between acute renal failure and mortality following cardiac surgery. Am J Med Apr; 104(4):343-8. Karkouti K. Wijeysundera DM. Yau TM. Callum JL. Cheng DC. Crowther M. Dupuis JY.Fremes SE. Kent B.

Laflamme C. Lamy A. Legare JF. Mazer CD. McClusky SA. RubensFD. Sawchuk C. Beattie WS (2009). Acute Kidney Injury After cardiac Surgery.Focus on Modifiable Risk Factors. Circulation; 119:495-502 National Confidence Enquiry into Patient Outcome and Death (NCEPOD) (2009) Acute Kidney Injury: Adding insult to injury. Rosner M. Okusa M (2006) Acute Kidney Injury Associated with Cardiac Surgery.Clin J Am Soc Nephrol 1:19-32

P13 : Reducing Catheter Errors and

Related Infection Through Improved Arterial Line Dressing, Management and Monitoring Procedure Patricia Hogg, Barbara Jameson, Dr Dominic Errington, Joanna McBride, County Durham & Darlington NHS Foundation Trust The arterial catheter is widely used in intensive care units to allow close and accurate monitoring of the blood pressure of patients, and to allow blood samples to be taken without the need for needles. Any complications to this critically ill patient population can be detrimental. An NPSA (2008) report identified 84 instances of harm caused by misidentification of arterial lines, 2 proving to be fatal and 76 instances of errors in sampling. A telephone audit was carried out to assess the scale of the problem and to ascertain common practices. This showed clearly that the dressing in use at that time did not address the issues raised in the NPSA report.There is a wide range of evidence available and anecdotal reports from colleagues regarding the risks and issues associated with the use of arterial lines. These include, poor identification of the line, risk of infection, particularly at the insertion site, as the arterial line is not always visible or easy to examine. The work we performed addressed the following key areas: • Development of an arterial cannula dressing with clear labelling in red, larger skin contact area using a strong adhesive to reduce accidental dislodgement and a clear window over the insertion point to reduce the identification ofpossible infection • Arterial catheter care bundle documentation record in response to the introduction of high impact interventions to monitor the insertion, removal and management of the cannula • Design of a flush bag label where two staff members date, sign and check each bag • Arterial insertion pack. The new arterial line system and dressing is in use within our trust. Using these simple steps has improved patient safety and reduced the risk associated with the management of arterial lines.

P14: Staff Opinion of Delirium in our Critical Care Unit

Tessa Horton, Laura Eldridge, Clare Finn, King’s College Hospital BACKGROUND Delirium is a common issue in all ICUs and commonly underestimated (Spronk etal, 2009). It is often defined as a form of agitation, especially in patients who have been sedated or affected by other contributing factors. Currently our unit is exploring the uses of a delirium assessment tool. Most Healthcare professionals consider delirium in an ICU to be a common and serious problem although few actually monitor it, and most admit it to be underdiagnosed (Ely et al, 2004). A recent research study published which showed that a large proportion of patients discharged from ICU suffered from poor mental health and PTSD following experiencing delirium when in ICU (Wade et al, 2012). AIM To ascertain staff opinions whether a delirium assessment tool would be useful to improve practice in a busy Critical Care Unit. METHOD An online questionnaire was sent out to all grades of doctors and nurses on the unit. The survey was anonymous and questions were closed for ease of response. We asked about prevalence, and management of delirium on the unit, as well as whether we should implement a tool with training. The time frame was 2.5 weeks with a reminder before closing. Results were correlated into graphs and tables online for analysis RESULTS We only had a 27% return rate, but a good cross-section of staff. The results showed an overwhelming response to implement a tool for assessment and staff training on recognition and management of delirium. RECOMMENDATIONS Our recommendations are to offer all members of MDT enhanced training on recognition and management of delirium as well as implementing a tool. We suggest using CAM-ICU as this is recommended by NICE (2010), and creating an inter-professional super user group for frontline support.

P15: Life At Home After Intensive Care: The Family Caregiver Experience

Sarah Holling, Cathy Derham, University of Surrey PURPOSE A literature review examining the carer experience of

supporting a patient after discharge from intensive care. BACKGROUND It is part of a nurse’s responsibility to provide holistic, family centred care (Nursing and Midwifery Council (NMC, 2008). However, Sharples (2007) has suggested that nurses may not always appreciate caregivers’ needs, despite an almost axiomatic relationship between patient recovery and family support (Moore, 2009). The post-intensive care patient experience has been studied more extensively than that of the caregiver’s experience. Most patients experience problems following discharge (National Institute for Health andClinical Excellence – NICE, 2009) which include both physical and mental health problems, social and relationship difficulties. A new condition of Post Intensive Care Syndrome-Family (PICS-F) has recently been proposed which suggests caregivers may experience similar psychological problems to patients (Davidson, Jones and Bienvenu, 2012; Needham et al., 2012). FINDINGS The post-ICU caregivers experience is variable and whilst some people appear unchanged, many carers are significantly affected by time spent in intensive care and their caring experiences (Alvarez and Kirby, 2006). They encounter positive and negative emotions in addition to the psychological problems identified as part of the PICS-F. However the literature also suggests that carers suffer a number of physical health problems and in addition the experience impacts upon their social activities. The consequences, therefore, of an intensive care experience for the caregiver are greater than suggested by PICS-F. CLINICAL RELEVANCE FOR PRACTITIONERS NICE (2009) highlighted the key role played by carers in Clinical Guideline CG83 and the government is committed to supporting carers (GB. Department of Health, 2008). It is important that nurses are also aware of the possible impact that caring for a post-ICU patient may have and develop a better understanding of caregiver needs and experiences in order to prepare and support them after discharge of the patient. REFERENCES Alvarez, G.F. and Kirby, A.S. (2006) ‘The perspectives of families of the critically ill patient: their needs’, Current Opinion in Critical Care, 12(6),pp. 614-618. Ovid [Online]. Available at: 10.1097/ MCC.0b013e328010c7ef (Accessed: 27 November 2012). Davidson, J., Jones, C. and Bienvenu, O.J. (2012) ‘Family response to critical illness: post traumatic care syndromefamily’, Critical Care Medicine, 40(2), pp.618-624.GB. Department of Health (2008) Carers at the heart of 21stcentury families and communities: A caring system on your side. A life of your own. Summary.Available at:http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/@dh/@en/documents/digitalasset/ dh_085344.pdf (Accessed: 19 January 2013).

Moore, T. (2009) ‘Family Care’, in Moore, T. and Woodrow, P. (eds.) High dependency nursing care: observation, intervention and support for level 2 patients. London: Routledge. pp. 28-36. National Institute for Health and Clinical Excellence (NICE) (2009) Clinical guidelines 83: rehabilitation after critical illness. Available at: http://guidance.nice.org.uk/CG83/ NICEGuidance/pdf/English (Accessed: 23 November2012). Needham, D.M., Davidson, J., Cohen, H., Hopkins, R.O., Weinert, C., Wunsch, H.,Zawistowski, C., BemisDougherty, A., Berney, S.C., Bienvenu, O.J., Brady, S.L.,Brodsky, M.B., Denehy, L., Elliott, D., Flatley, C., Harabin, A.L., Jones, C.,Louis, D., Meltzer, W., Muldoon, S.R., Palmer, J.B., Perme, C., Robinson, M.,Schmidt, D.M., Scruth, E., Spill, G.R., Storey, C.P., Render, M., Votto, J. andHarvey, M.A. (2012) ‘Improving long-term outcomes after discharge from intensivecare unit: report from a stakeholders’ conference’, Critical Care Medicine,40(2), pp. 502-509. Cinahl [Online]. Available at: http://search.ebscohost. com/login.aspx?direct=true&AuthType=ip,shib&db=c8 h&AN=2011463035&site=ehost-live&custid=s4121186 (Accessed: 27 November 2012). Nursing and Midwifery Council (NMC) (2008) The code: standards of conduct, performance and ethics for nurses and midwives. London: Nursing and Midwifery Council. Sharples, N. (2007) ‘Relationship, helping and communication skills’, in Brooker, C. and Waugh, A. (eds.) Foundations of nursing practice. Edinburgh: ElsevierMosby. pp. 221-250.

P16: Novel Intensive Care Unit (ICU)

Outreach Service: Malaysian ICU Nurse Perspectives

Dr Salizar Mohamed Ludin, Noorazizah Mohd Ali, Norasimah Razak, International Islamic University Malaysia INTRODUCTION In a five year period, there was an increase of 81% in Malaysian Intensive Care Unit (ICU) for admissions and readmissions occuring within 48 to 72 hours. This was commonly used as an indicator for premature ICU discharge or substandard ward care (Tong et al., 2011). Studies show the gap between nurses’ communication and inexperienced ward nurses, thus patients did not receive the same care as in the ICU (Elliot & Crookes, Worral & Page, 2010) and thus ICU outreach service is important. In Malaysia however, the introduction of ICU outreach nurse service is rather unclear, despite increasing worries on the deterioration of ICU survivor’s condition in the general wards. AIM This study aimed to examine nurses’ perception on the novel ICU outreach service, determine the relationship between demographic profile and perception and

conceptualize Malaysian nurses’ perception on the novel service.

least 24 hours or more prior to bowel management system insertion.

RESEARCH DESIGN

In conclusion, some skin damage may have been prevented, had the systems been introduced earlier. As a result, the ‘Critical Care Bowel Management Assessment Tool’ was developed,to prompt staff to introduce bowel management systems earlier. A risk score of 6 or more was set to indicate patients at high risk of developing skin damage,with the tool recommending the use of a bowel management system. New barrier cream ‘proshield’ for intact and injured skin associated with incontinence is currently being used across the critical care units in association with the tool, as part of a wider pressure ulcer prevention package for critical care patients.

This study is a mixed method research approach. Data will be collected using self- administered survey questionnaires and in-depth individual interviews in two Tertiary hospitals in Malaysia. Through purposive sampling, ICU nurses who work full time, on shift or office hour basis and understand Malay or English will be recruited for the study. Data will be analysed for descriptive and inferential statistic, and qualitative analysis. EXPECTED OUTCOME This study finding will allow better understanding andconceptualization of nurses’ ICU outreach service in Malaysian hospitals. CONCLUSION Understanding of ICU nurses’ perception on the novel ICU outreach service will reflect on the needs and preparation for the implementation of the service in Malaysian hospitals, in which the status has not been known . This service will facilitate ICU patients discharge, follow up, assessment and support to manage unstable patients and provide optimum critical care resources to general ward staffs. The ICU outreach service may decrease the ICU and hospital readmission rate and finall will aid in reducing medical costs.

P17: An Audit of the Use of Bowel

Management Systems and the Development of an Assessment Tool to Assist Prevention of Moisture and Pressure Damage in the critically Ill

Joanna Peart, Gemma Wightman, Newcastle Hospitals NHS Trust Skin injury to the perineal area can occur within minutes of the onset of incontinence. As a result, patients with faecal incontinence are at high risk of developing moisture lesions or pressure sores, and secondary dermal infection, (Defloor et al, 2005). NICE (2007) recommends the use of faecal collection devices for patients in intensive care settings with faecal incontinence. The use of a barrier film or cream, alongside a faecal management system, is also recommended as best practice by Wounds UK (2012). In 2012, an audit based on 7 patients across 3 critical care units was carried out, in order to identify whether bowel management systems were being introduced promptly, following the onset of incontinence. Data was retrieved from the patient’s nursing notes, on stool type and frequency, up to 72 hours pre-insertion, and on skin integrity before insertion. Results indicated that 6 of the 7 patients had moisture or pressure damage, ranging from categories I-III, and experienced 4 to 5 episodes of type 6 or 7 stool, for at

REFERENCES Defloor, T; Schoonoven, L; Fletcher, J. (2005) ‘Pressure ulcers and moisture lesions’. European Pressure Ulcer Advisory Panel. NICE. (2007) ‘Faecal incontinence: the management of faecal incontinence in adults’. Wounds UK. (2012) ‘Best Practice Statement: Care of the Older Person’s Skin’.2nd ed.

P18: Facilitating Student Learning:

Creative Approaches to Critical Care Placements

Gail Quigley, Brian McFetridge, Martha McColgan, Gerry McMenamin, Western Health and Social Care Trust Stephanie Dunleavy, University of Ulster Our critical care nursing team has developed an approach to nursing student placements, providing additional support in facilitating application of theory to practice and development of transferrable skills and knowledge for use in both critical care and other acute care settings. Our poster shares the approach developed to support student learning and assessment in practice. Enhancements have been based on feedback from students,mentors and Link Lecturer. This identified the need to reduce student anxieties associated with critical care placements, develop further understanding of physiological principles and their application to patient care and understand the needs of patients clinically deteriorating or recovering from critical illness. Our approach includes fostering a partnership in learning with the student from welcome letters which are posted to students prior to the placement. This has served to reduce students’ anxiety regarding a critical care placement and provide them with a sense of welcome and belonging. A structured one day induction programme and associated booklet has been developed to guide and inform their learning. The induction programme is delivered by nursing staff from both the Critical Care Unit and the Critical Care Outreach service. The programme reviews key critical care principles through interactive teaching and simulated practice. Themes from placement evaluation have further enhanced this programme.The importance of students developing transferable skills is

recognised, as each student spends one week of their placement with the Critical Care Outreach Service. This provides insight into the assessment and management of patients who are clinically deteriorating and those who are recovering from a period of critical illness (NICE, 2007; 2009). Our approach to facilitating student learning not only aims to inspire and develop future critical care nurses, but also to develop transferable skills which nurses may utilise in other acute care settings. REFERENCES NICE. 2007. Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. NICE Clinical Guideline 50.Available online at: <http:// www.nice.org.uk/CG50NICE. 2009. Rehabilitation after critical illness.

therapy” 1. Currently speech and language therapy (SALT) provision to patients in critical care is inconsistent; the majority of services are not specifically funded for this client group 2. The West Suffolk Hospital (WSH) Critical Care Services and SALT team have been working together to build a stronger relationship to highlight the key role that SALT should have within Critical Care. AIM To identify the benefits and boundaries of SALT input by considering referral patterns, case study review and the views of staff on dysphagia and the role of SALT. This will allow reflection on current practice and planning for future developments. METHOD

NICE Clinical Guideline83.Available online at: <http://www. nice.org.uk/CG83

• Retrospective audit of the incidence of aspiration pneumonia in WSH Critical Care and number of SALT referrals over three years

P19: Competencies For Securing the

• A case study review demonstrates the work of SALT with patients and qualitative data identifies staff views on dysphagia and the role of SALT in critical care.

Anchor Fast Device

Tina Stubbs, Homerton University Hospital NHS Foundation Trust The security of a patient’s endotracheal tube is always the number one priority for critical care staff for their patients. There are a limited number of ways to do this and it can prove problematic with restricted access to the oral cavity and the risk of pressure ulceration to the patients’ lip or chin from the tube or the tie itself. There are many psychological effects of a stay in intensive care for a patient but a physical reminder of a pressure ulcer that could have been prevented is untenable.The Anchor Fast device offers an alternative way of securing the endotracheal tube which allows easy access to the patients’ oral cavity and also allows the tube to be moved easily either by a small amount on regular occasions or to the other side of the patient’s mouth completely. To facilitate the introduction of this device to our critical care unit the author wrote competencies for the application of the device that include criteria to identify suitable patients, placement of the device and assessment of its security on a regular basis once in place. Each member of staff is assessed as competent in applying the Anchor Fast and also supervised training of another member of staff to apply the Anchor Fast to pass the competency assessment.

P20: Speech and Language Therapy in Critical Care : Benefits and Boundaries

Janet Thomas, Jessica Bell, West Suffolk NHS Foundation Trust

CONCLUSIONS AND IMPLICATIONS Closer links between WSH Critical Care and SALT has had a positive effect on referral patterns over the last three years. Case studies demonstrate the importance of SALT input in critical care patients, specifically identifying complex dysphagia, prevention of aspiration pneumonia and safe nutritional management. The main boundaries highlighted are limited dyspahgia awareness and SALT waiting times for assessment. It can be concluded that SALT has a key role within critical care. Further development is required to create effective links and ensure best dysphagia practice in this setting.Multi-disciplinary team working, dyspahgia awareness training, dysphagia guidelines, Fibre-optic Endoscopic Evaluation of Swallowing (FEES) equipment and prospective audit will help to improve links between SALT and Critical Care, and support reduced instances of aspiration pneumonia and better patient outcomes. REFERENCES 1. Department of Health. Quality Critical Care. Beyond “Comprehensive Critical Care”. A Report by the Critical Care Stakeholder Forum (2005) England. 2. RCSLT Position paper for Speech and Language Therapy in Adult Critical Care(June 2006).

P21: A Safety Conventional Arterial System - Simulation Pilot Study

BACKGROUND

Emily Hodges, Dr Damian Laba, Dr Robin Heij, Dr Peter Young, The Queen Elizabeth Hospital NHS Foundation Trust

The Department of Health reports that “key professions in a critical care setting include…speech and language

Intrav-arterial injection of drugs intended for intravenous delivery is a potentially devastating complication of

managing an arterial line in patients. The standard system provides no impediment to intra-arterial injection. To assess the probability of inadvertant intra-arterial injection amongst junior doctors, we conducted a simulation study. We recruited junior doctors from different specialities and seniority level.They were asked to deal with a patient with severe bradycardia. Atropine was available on request and paticipants were asked to administer the drug themselves. All participants recognised severe bradycardia in the compromised patient and all advocated the use of Atropine. 10 out of 15 respondants (66.6%) injected Atropine directly into the arterial cannula. 5 out of 15 doctors (33.33%) injected Atropine either into an intravenous cannula or into the central line. Doctors as junior as foundation trainees may start their rotation in Critical Care. When acting under stress in an unfamiliar environment they may inject drugs directly into the arterial system. The only preventative strategies to distinguish an arterial line at present are colour coding and labelling which are not always instituted and may be missed or accidently removed.

P22: A Multi-Faceted Approach to

Introducing an Innovative New Process For Recognition and Response to Deterioration in Acutely Ill Adult InPatients

with the tools was audited and the number of referrals and MET calls examined. RESULTS Results demonstrated improved compliance in recording observations and calculating NEWS scores when compared with MEWS. The number of referrals to CCO also increased significantly when compared to the number received in previous months. CONCLUSION Introducing a more sensitive track and trigger tool (NEWS) alongside a communication tool (SBAR) enhanced recognition and referral of deteriorating adult in-patients to CCO and the MET, as well as improving accuracy when recording observations and calculating scores. REFERENCES Audit Commission (1999) Critical to Success the place of efficient and effective critical care services within the acute hospital. London: Audit Commission. Critical Care Stakeholder Forum (2005) Quality Critical Care: Beyond Comprehensive Critical Care. London: Department of Health. Department of Health (2000) Comprehensive Critical Care: A review of Adult Critical Care Services. London: The Stationary Office.

Debbie Van Der Velden, Liz Staveacre, North West London Hospitals NHS Trust

Department of Health (2005) Beyond Critical Care. London: The stationary Office.

AIM

Intensive Care Society (2002) Guidelines for the Introduction of Outreach Services. Standards and guidelines. Intensive Care Society.

The aim of the process was to improve recognition of acutely ill adult in-patients, standardise the clinical response to deterioration and to improve and standardise communication when escalating concern. METHODOLOGY The process began with a points prevalence study to investigate compliance with the existing modified early warning score (MEWS) over a two day period, both in terms of recording appropriate observations and accurate calculation of scores. The results demonstrated that both issues had poor compliance. Subsequently,the Critical Care Outreach (CCO) team elected to introduce the National Early Warning Score (NEWS). Alongside this, a communication tool based on SBAR was developed. A medical emergency team (MET) consisting of an acute medical registrar and members of the CCO team (accessible via the emergency bleep) was established in order to respond to high level triggers generated by the new tools. An intense period of face to face teaching and training followed. 79 nurses were instructed on effective use of the tools. Medical and surgical teams were informed via various teaching and governance forums. The tools were piloted on 3 wards: an acute medical admissions ward, a shortstay medical ward and a mixed medical and surgical gastro-intestinal specialist ward. The initial trial lasted for 4 weeks, following which compliance

National Confidential Enquiry into Patient Outcome and Death (2005) ‘’An Acute Problem’’. NCEPOD. National Confidential Enquiry into Patient Outcomes and Death (2012) Cardiac Arrest Procedures: time to intervene? London: NCEPOD. National Institute of Clinical Excellence (2007) Clinical Guideline 50: acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital. London: NICE. National Patient Safety Agency (2005) An Acute Problem? London: NPSA. National Patient safety Agency (2007) Recognising and responding approriately to early signs of deterioration in hospitalised patients. London. Royal College of Physicians (2012) National Early Warning Score (NEWS): Standardising the Assessment of AcuteIllness Severity in the NHS. Report of a working party. London.

P23: Is Anchor Fast Oral Endotracheal Tube Fastener Cost Effective?

Samantha Westbrook, Frimley Park Hospital NHS Foundation Trust INTRODUCTION With the healthcare profession striving to be more cost effective but still maintaining patient safety, an alternative endotracheal tube (ETT) holder was considered. BACKGROUND Mechanical ventilation (MV) exposes the patient to an increased risk of developing a ventilator associated pneumonia (VAP). It is reported that VAP occurs in up to 15% of patients receiving mechanical ventilation (Ibrahim et al 2001). VAP care bundles are used in critical care departments to reduce this risk and one element of this bundle includes oral antiseptic as part of the oral hygiene regime. MV also requires the patient to have an endotracheal tube (ETT) placed in their mouth. This presents a potential risk for the development of avoidable pressure damage around the mouth from the securing fastener which holds the ETT inposition. THE LOCAL PICTURE The department was experiencing pressure damage around the patientâ&#x20AC;&#x2122;s mouth from the existing method of securing the ETT. It was also recognised that the ETT fastener was not conducive to facilitating adequate oral hygiene care. FINANCIAL COMPARISON A business case was presented to the department to consider trialling Anchor Fast as an alternative for securing the ETT. A materials cost comparison was completed, comparing the current method of securing the ETT verses the Anchor Fast. The Anchor Fast was found to be fractionally more expensive. OUTCOME The department decided that the cost of the Anchor Fast outweighed the financial costs of treating VAP, treating pressure damage and the nursing time needed for the task. Following the trial of Anchor Fast it was positively evaluated and considered as a cost effective alternative.We also found that Anchor Fast has helped to improve compliance with the oral hygiene regime and it was observed that the patientâ&#x20AC;&#x2122;s mouths had little or no pressure damage. The department now routinely uses Anchor Fast on all patients ventilated over 24 hours. REFERENCES Ibrahim, EH. Tracy, L. Hill, C. Fraser, VJ. Kollef, MH. (2001) The occurrence of ventilator associated pneumonia in a community hospital: risk factors and clinical outcomes. Chest Journal 120:555-561.

P24: Nurses Role in Immediate

Care of Patients Undergoing Liver Transplantation

Anan Purushothaman, Jayanthi Shamalee Patabendige, Kings College Hospital NHS Foundation Trust Today, liver transplantation is recognized as a effective therapeutic approach for the treatment of patients with acute and chronic liver diseases. Advances in the treatment modalities and in immunosuppressive medications have contributed to the current success of liver transplantation. Transplantation is classified as either deceased-donor or living donor transplantation depending on the source of the donor liver. After transplantation, careful management and early intervention is essential to avoid complications as the early post operative period is a crucial time. Common post operative complications include graft dysfunction, vascular thrombosis, biliary complications, infection, rejection, neurological injury, electrolyte imbalances and drug interactions. Liver nurses should be able to apply an in-depth knowledge of organ transplantation to assess, plan and implement an evidence based approach to evaluate care interventions necessary to care for patients after liver transplantation. Maintaining haemodynamic stability and preventing complications are vital for an effective post operative nursing care. Post liver transplant compliance is an important aspect of the care process. Nurses caring for transplant patients must be an expert, not only in hepatology and critical care medicine but also in immunology. Moreover, optimal treatment of patients requires a multidisciplinary approach to allow early identification and treatment of associated co-morbidities. In the care of immediate post liver transplant patients, there are well defined guidelines and treatment options adapted to offer flexible and individualised treatments with the aim of improving outcomes. Nurses play a vital role for successful long term outcomes in the care of post liver transplant patients.

P25:

Procedural Sedation : Best Practice in any Clinical Arena

Marcia Bixby, Consultant USA What started as conscious sedation in the Operating Room for minor procedures under local anesthesia has morphed into nurse administered sedation for procedures in multiple settings. The number of these procedures are difficult to capture as moderate sedation is performed on so many different clinical areas. These areas include Operating Rooms, Emergency Departments, ICUâ&#x20AC;&#x2122;s, Endoscopy, Interventional Radiology, Cardiac Cath and EP labs, and free standing clinics in the community. All these areas provide sedation for diagnostic, interventional or surgical procedures. Nurses providing non anesthesia administered sedation

must complete education and competency training. This includes being aware of the American Society of Anesthesia (ASA) definitions and JCAHO standards to provide safe care to their patients. Education includes knowledge of equipment to rescue patients who demonstrate adverse reaction to sedation such as hypotension and respiratory depression. Knowledge of medications used for sedation as well as reversals are key elements of competency training. Assessing and monitoring patients undergoing sedation is the responsibility of the physician and nurse both to be vigilant to changes in vital signs that could be from sedation or from the procedure itself. This pre conference will include evidence based practice utilizing standards and practice guidelines from ASA, AORN, ASPAN and AACN. Discussions will include identifying patients at risk for sedation, pre procedure assessment screening, medication doses, considerations related to age and co mordibities such as children or elders. Providing care to patients post procedure and utilizing scoring tools for discharge to other nursing areas or home will be included. Adherence to established protocols and safety guidelines will allow nurses to administer procedural sedation, in any environment, safely and competently. These concepts will be reinforced through use of case studies.

of medications nurses administer during sedation is crucial, but just as crucial is knowledge of monitoring equipment used during procedures that help us maintain safety. ETCO2 monitoring has been proven to be the early indicator of respiratory insufficiency, even before the pulse oximetry measurements change. Although adding additional monitoring equipment for nurses and physicians to be comfortable with and be able to trouble shoot for accuracy during procedures, it is equipment that should be initiated on all patients during procedures that require nurse administered sedations. This presentation will include why and how to use ETCO2 equipment, identification of key aspects of waveforms during the respiratory cycle, and how to troubleshoot measurements. Targeted audience is all acute and critical care nurses who monitor patients during procedural sedation Objectives At the completion of this session the learner will be able to: 1. Identify appropriate patient selection for nurse administerd sedation 2. Discuss utilization of ETCO2 information to assess

Targeted audience All acute and critical care nurses who are involved with all aspects of moderate sedation: pre procedure assessment, intraprocedure monitoring and medication administration, post procedure monitoring and preparation for discharge

patient response to sedation medications

Prerequisite: Knowledge of sedation medication and pharmacokinetics, airway and hemodynamic assessment.

P27: Glycaemic Control in the Intensive Care: Tight, Loose and Automated

Purpose The purpose of this presentation is to review the standards of care related to moderate sedation as defined by the national organization standards and guidelines. These standards will be reinforced through use of case studies. Objectives 1. Become familiar with definitions and standards as identified by expert organizations 2. Identify patients at risk for undergoing nurse administered sedation. 3. Familiar with pre procedure assessment, intra procedure assessment, documentation,, and discharge criteria for patients who have undergone procedures with sedation

P26:

End Tidal CO2 ( ETCO2 ) Monitoring: Is it Just Another Number?

Marcia Bixby, Consultant USA End Tidal CO2 ( ETCO2 ) Monitoring has been identified as a standard of care for procedural sedation since 1999 by the American Society of Anesthesiologists (ASA), yet we still have not embraced this technology. Knowledge

3. Review ETCO2 waveforms during inspiration and expiration phases

Deborah Ebsworth, S.P Booth, K.Sim, McIndoe Burns Centre, Queen Victoria Hospital Blood sugar control has become a major issue within the field of critical care. Hyperglycaemia is known to be related with poor wound healing, increased systemic infection and mortality. Hypoglycaemic events are commonly a complication of insulin therapy in critically ill patients and are also associated with increased risk of mortality. Several large studies have compared outcomes between tight and loose control of blood sugar.Âšâ&#x20AC;&#x2122;Â˛ Initial optimism that intensive insulin therapy and tight blood sugar control could reduce inpatient mortality has been tempered by the publication of other large multi centre, multi national studies which have shown contrary results. We reviewed past glycemic control methods in the burns intensive care which included paper based prescriptions and protocols. We compared the data taken from our arterial blood gas analyser, and presented this along with our current data using a computer assisted algorhythm, automated control device. During this process we also audited our experiences of using the automated system through staff questionnaires. Approximately two thirds of the burns patients developed persistent hyperglycaemia requiring insulin therapy. Rapidly developing insulin resistance provoking high

insulin dose requirements, repeated surgical interventions complicated feeding regimes, all adding to insulin dose variability. Daily variance between the groups was significant (P>0.05), the smallest range being during automated control. Our experience has been positive using the automated system. Prior to the automated system inconsistent clinical direction of insulin protocols encouraged swings in glucose levels – this is now much less common. The mean blood glucose concentration is equivalent to the pre-automated era but patients spend more time in the target range and there is dramatically reduced blood sugar variability. Most importantly, we believe that even short periods of hypoglycaemia in critically ill patients are harmful. Our previous incidence of hypoglycaemic samples (less than 4 mmol/l) whilst attempting tight glycaemic control was 3.3%. This has reduced to 1.6% for patients managed with the automated system, and we are increasingly able to identify risk situations for hypoglycaemia through review of the automated systems data. The current controversy around glucose control revolves around the avoidance of iatrogenic hypoglycaemic episodes. Hyperglycaemia may be accepted as a maladaptive response and consequence of critical illness. However, there is increasing evidence that controlling aberrant blood sugar promotes wound healing and recovery in critically ill trauma patients.

Implementation has been a staged process throughout the trust. IMPLEMENTATION There are three intensive care units within Leeds Teaching Hospitals all requiring training on how to administer citrate anticoagulation. This added up to be around 300 nurses. Out of this 300 sixty had, had some training during the trial period. Implementation on this unit would be instigated first with a robust training package aiming to have full implementation commencing within one month. Prior to commencement, systems that needed to be put into place included: • Protocol training sessions • Prescription and nursing documentation • Competency packages • Key trainers After an imbedding period, training will commence on the other two units. This will prove to be more complicated than the first as none of the nurses have had any exposure to the machine and treatment. To aid the smooth transition the machines will be introduced first without citrate during which time training will be given regarding citrate anticoagulation. RESULTS

1 Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, et al. (2001) Intensive Insulin therapy in the critically ill patients. N Engl J Med 345:1359-1367.

There have been a number of issues regarding implementation mainly concerning documentation and trust policies. Otherwise it has been a smooth transition and early indications show a vast improvement in filter length time.

2 Finfer S, et al. (2005) The NICE-SUGAR study investigates. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 360(13): 1283-1297

P29: The Quality Improvement of

P28:

Ariesta Milanti Endang, Pauliina Mansikkamaki, University of Indonesia

REFERENCES

Implementation of Citrate Anticoagultion Throughout Critical Care at Leeds Teaching Hospital Trust

Charlotte Trumper, Leeds Teaching Hospitals NHS Trust INTRODUCTION A critical care implementation of citrate anticoagulation using the Fresenius Multifiltrate machine was implemented as a change of treatment to improve standards and patient outcomes for patients within critical care who required continuous renal replacement therapy by improving the length of treatment times. METHODOLOGY Before commencing implementation a trial over a period of months on one ICU took place. This showed through audit an increase in filter length time from 35 hours to an average of 88 hours. With the incidence of clotting filters reducing significantly. A business case was put forward and approved to acquire 18 MultiFiltrate machines all capable of administrating citrate anticoagulation.

Palliative Care in the Intensive Care Unit

AIM There are evidences of failure and challenges in incorporating a holistic palliative care into the nursing care plan in the critical care setting (Davidson et al., 2002: Dudgeon et al, 2009). The aim of this study was to assess the interventions made to improve the quality of palliative care in the intensive care unit. METHOD An online search of electronic nursing databases was conducted. Five studies met the inclusion criteria. The data was then extracted and analyzed through content analysis. RESULTS The thematic analysis revealed three major interventions aimed for quality improvement of palliative care in the ICU. The interventions are integrating palliative care into the intensive care,promoting palliative care consultation and enhancing collaboration between the palliative care by the ICU team and the palliative team.

DISCUSSION Quality improvement of the palliative care in the intensive care unit is a collaborative work that can be implemented in several approaches. A strong nursing leadership and managerial ability is needed to address the common challenges of the group change process in the quality improvement. Key words: palliative care, intensive care, quality improvement, nursing

P30: Effect of Fecal Management

System (FMS) on Critically Ill Patients in Hong Kong

Grace Lau, Nora Kwok, Lan Lau, Sze Wah Ng, Chun Fai Wong, Paul Wong, Yuen Fan Tam, Lin Mui Fung, Pamela Youde, Nethersole Eastern Hospital, Hong Kong INTRODUCTION Diarrhea is a common symptom among hospitalized patients, particularly in intensive care units (ICU). It is one of the most common associated risk factors for pressure ulcers. Diarrhea is also a risk of environmental and staff contamination during handling. In addition, it places a heavy burden on nursing time. A fecal management system (FMS) had been adopted for critically ill patients with diarrhea in an ICU in Hong Kong. The FMS allows liquid or semi-liquid stool to be diverted from wounds and surrounding skin, hence reducing the risk of both skin breakdown and nosocomial infections. The purpose of this study was primarily to evaluate the effectiveness of FMS on the patients with diarrhea in ICU. OBJECTIVES (1) To evaluate the effectiveness of FMS associated with pressure ulcer (2) To evaluate the effectiveness of FMS associated with the environmental contamination (3) To evaluate the effectiveness of FMS associated with the nursing time consumption METHODOLOGY A repeated cross-sectional design was employed to evaluate the effectiveness of FMS on the patients with diarrhea. Outcome measures were categorized as: (1) Incidence of pressure ulcers and healing status (2) Duration of using FMS and the amount of fecal waste being collected (3) Nursing time consumption RESULTS A total of 35 patients with diarrhea had been adopted by a FMS within 3 years. The duration of FMS ranged from one day to twenty three days (mean = 6). The Amount of fecal waste was collected in a close system from 220 ml

in one day to 7990 ml in 23 days, an average volume of approximately 530 ml fecal waste was isolated from the environment per day. On the other hand, a total of 10 patients (29 %) acquired pressure ulcers in stage 1 to 2 before the FMS insertion. All of them were improved or healed after that. No new pressure ulcer was found in the recruited population. Finally, nursing time was decreased almost in half (p=0.001) in the group of FMS (mean = 6.9) which compared with the traditional method (mean =13.1). CONCLUSIONS The study found that the FMS was beneficial to prevent pressure ulcer on patients with diarrhea. It also reduced the chance of fecal contamination to the environment and health care worker. In addition, it demonstrated the direct cost benefits on nursing time. However, further studies are recommended to measure clinical and economic outcomes associated with the FMS. REFERENCES Echols J, Friedman BC, Mullins RF et al. Clinical utility and economicimpact of introducing a bowel management system. Journal of Wound, Ostomy andContinence Nursing. Journal of Wound, Ostomy and Continence Nursing. 2007;34(6): 664-6702. Junkin J, Selekof JL. Prevalence of incontinence and associated skin injury in the acute care inpatient. J Wound Ostomy Nurs. 2007;34(3):260-269.3. National Institute for the Health and Clinical Excellence, Faecalincontinence: The management of faecal incontinence in adults . ClinicalGuideline 2007; 52 NICE, London. Tan JY, Chan M, Tjandra JJ. Evolving therapy for fecal incontinence. Dis Colon Rectum. 2007; 50:1950 -1967. World Health Organization. Health topic: Diarrhoea. 20126. ConvaTec: Flexi-seal Fecal Management System Directions for Use

P31: The ICU Nurse Coordinator Role

in a Multi- Disciplinary Team Caring for Patients Treated With Ventricular Assist Device (VAD)

Miriam Abuhazira BACKGROUND With the continuing rise in the age of the population and the advent of medical technology there is a constant rise of patients suffering from end stage congestive heart failure (CHF).The ideal solution for end stage CHF is a heart transplant, but, due to a shortage of organs for transplant a ventricular assist device (VAD) can be usedthis is a mechanical pump (an external power supply) which pumps blood from the failing ventricle to the main artery. Here it is possible to support only the left ventricle (LVAD) or both ventricles(BiVAD).The implantation of a VAD allows the patient to ambulate again and to return to activity at home and in the community. METHODS A nurse was set as a coordinator for VAD patients.

The nurse has three key roles, the first is about patient empowerment and education, assessment and escorts from the pre operative phase throughout the operation, post op, and at home, including continuous contact with the community team. The second role is about staff education, writing guidelines, protocols, collecting data, and the third is about equipment, supplies, maintenance, monitoring and logging. Intensive Surveillance Protocol (ISP) was selected as a follow-up method. The protocol is based on three areas of practice:

• Operating a clinic according to intensive surveillance protocol (ISP) for VAD patients improves patient’s satisfaction regarding quality of care and the relationship with the caregivers • Most VAD patients are satisfied with the surgery and report improvement in quality of life indices • Community caregivers are content with connection between them and the clinic but they need more knowledge

• A multidisciplinary clinic (cardiologist, cardiothoracic surgeon and a VADcoordinator). • ‘Weekly phone call conducted by the VAD coordinator’ • Visit and checkup protocol in order to examine the satisfaction of patients and community teams from the clinics activity and the interaction with the community team, a primary surveywas conducted. The answers are given on a Likert scale of 1-4 (1- don’t agree at all, 4 -strongly agree) RESULTS Patient results: • Response: 10 replied - 8 men, 2 woman, aged 49-66, 1-36 months after VAD implantation • Satisfaction from the device (3.9)better ADL compared to pre op(3.6) • Satisfaction of treatment’s quality (4) • VAD team’s Availability(4) • Doing exercise(2.5) • Backto work(1.6) • Free of CHF symptom(3.5) • Use help from your care giver(3.2) • Independency in ADL(3.1) • See yourself us a candidate to heart transplant(2.7) Community team results: • Response: 6 community clinics. 6 doctors, 4 nurses. • Satisfaction of contact frequency (3.1) • Satisfaction of contact character (3.3) • Knowing VAD before (1.2) • Knowing VAD now (2.5) • Awareness to complication (2.2) • Continuing non cardiac medicine (3.3) • VAD team’s Availability (3.7) CONCLUSIONS • The VAD coordinator role is necessary for the success of the program • An ICU nurse is considered more authoritative and professional

Notes