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Leading the way in Critical Care Nursing www.baccnconference.org.uk

Oral Abstracts 2010

13th – 14th September 2010 Southport Theatre and Convention Centre

Oral Abstract O02 CHANGING TIMES: A NEW ROLE, THE ZONE LEADER.

Conference theme: Staffing and The Critical Care Team Author S. Boullin1 1 Southampton University Hospital NHS Trust Comprehensive Critical Care (Department of Health, 2000) led to modernisation of critical care services including the growth and development of critical care beds. In 2007 a 13 bedded general intensive care unit in a large university teaching hospital expanded to 21 critical care beds. Through large scale recruitment, nursing skill mix was inevitably diluted leading to increased organisational pressures for the shift leader. The term zone leader (ZL) was developed to identify the role of a nurse (Band 5 post foundation course and above) in a particular zone (3 in total) who would assist the nurse in charge.  No formal training was provided to ZLs who alongside their patient allocation would support admissions/discharges, junior nursing staff and the organisation of staff breaks. One year post introduction of ZLs, a study day was facilitated by the lead clinical educator to debrief nurses following the role change, provide team building and communications exercises and celebrate achievements. Most revealing was the insight for both ZL and shift leader into each other’s respective roles. As critical care units continue to increase in scale, this presentation shares lessons learned from the introduction of the ZL’s dynamic role and demonstrates important recommendations for practice including future ZL education. Reference Information: Department of Health, (2000) Comprehensive Critical Care: A Review of Adult Critical Care Services, London: HMSO.

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Oral Abstract O03 EVALUATION OF TWO INNOVATIVE BLENDED E-LEARNING MODULES: AN EXPLORATORY STUDY OF PARTICIPANTS’ ENGAGEMENT

Conference theme: Education Author J. Gregory1 1 Kingston University & St. George’s University of London The purpose of this presentation is to disseminate the results of a research study exploring participants’ engagement with blended e-learning (the combination of classroom and web based approaches to teaching and learning). Two existing, wholly classroom based modules, the ’12 lead ECG’ and ‘Acutely Unwell Adult’, have been recently ‘blended’; now consisting of a 40/60 online to face-to-face split. An evaluation has been undertaken to explore the engagement of qualified nurses undertaking either of these modules, with a view to informing future practice. A pragmatic approach was adopted and mixed methods employed to collect data, via questionnaires and focus groups. Results were analyzed using descriptive statistics and thematic analysis, including the development of a theoretical model to illustrate relationships in the data. The findings indicated a high degree of engagement and satisfaction in the modules. In particular, participants valued the flexibility they had over the time, pace and place of learning. Outcomes of engagement were noted to be enhanced skills and knowledge, confidence and status in practice. 100% of participants reported the modules had positively impacted on their practice. Reference Information: Original research.

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Oral Abstract O04 STANDARDS FOR CONTINGENCY MANAGEMENT AND DELIVERY OF CRITICAL CARE IN PACU & RECOVERY

Conference theme: Staffing and The Critical Care Team Author C. Hurley1, R. Binks1 1 Airedale NHS Trust Royal College of Nursing Critical Care & In-flight Nursing and Perioperative & Surgical Nursing forums have devised “Standards for contingency management and delivery of critical care in PACU & recovery�. The standards aim to identify the key bases of decision-making when demand for critical care outstrips the available human and material resources on any given hospital site. They are influenced by Comprehensive Critical Care and Levels of Care for Adult Patients documents. In devising the standards we have considered factors including individual patient safety, the accountability of nurses and the objectives of service delivery. We hope the standards will be welcomed as a tool to help organisations, from Strategic Health Authorities (England) and Health Boards (Celtic Countries), through hospital boards to the teams providing perioperative or critical care nursing and support services to identify the safe, timely and effective ways of responding to demand for critical care that exceeds the normal service availability. We would like to take the opportunity afforded by the BACCN annual conference to bring these standards to the attention of a UK-wide audience of critical care nurses. We hope that presenting them may offer delegates the opportunity to discuss issues related to implementation.

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Oral Abstract O05 CARING FOR INJURED BRITISH MILITARY PERSONNEL

Conference theme: Excellence in Practice Author J. Thompson1 1 Selly Oak Critical Care All British military casualties (or servicemen affiliated with the British Armed Forces) are repatriated to University Hospitals Birmingham NHS Foundation Trust (UHB) resulting in a concentration of expertise in battlefield injuries. Most injuries occur as a result of blasts sustained by an activated Improvised Explosive Device (IED) (landmine) which in addition to explosives, can be packed with other ‘improvised’ material to maximise devastation, including human waste. Other injuries result from gun-shot wounds and rocket-propelled grenade (RPG’s) attacks. The most common injuries resulting from an IED is traumatic (or immediate surgical) amputation of the legs as the pressure plate is activated by the person’s/ vehicles weight. Shrapnel is blasted upwards and outwards providing potential for extensive damage. As many of the soldiers are amputees, neuropathic pain is a major problem. Providing adequate nutrition can be very challenging - injured soldiers are already in a very lean state from being in a Forward Operating Base in the middle of nowhere for weeks at a time, leaving very little reserve for the massive catabolism experienced when critically injured. Patient diaries are provided to all sedated critically injured military patients. Entries will begin as soon as possible in Camp Bastion and are written in everyday language. Flashbacks are common & memories of other colleagues being injured. UHB is unique in the concentration of injured military personnel treated in one centre. Even in the US, troops return to the locality of their family or Unit. It is common to receive up to 6 patients at once, coming directly to the unit in a convoy. In this situation, organising critical care beds and staffing becomes similar to initiating major incident procedures. In 2009 there were 127 military patients admitted to SOCC, resulting in 1083 bed-days, a three-fold rise compared with the previous year.

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Oral Abstract O06 SHIFT CO-ORDINATOR HANDOVER ENSURING CONSISTENCY OF INFORMATION

Conference theme: Staffing and The Critical Care Team Author R. Goodrum1 1 The Ipswich Hospital NHS Trust Relocating to a new build critical care unit in 2008 posed many challenges for all mutiprofessional team members. It was identified that the shift co-ordinators would have to manage & organise a larger contemporary designed care area across two clusters. To ensure concise consistency of information between coordinators over the 24hr period the shift co-ordinator handover communication & checklists was redesigned with sections for patient information, staff allocation, shift coverage, sickness, and back to work interviews. This allows information to be passed on between co-ordinators to ensure the smooth running of the service and interface with the hospital requirements. Two poster size laminated floor plans were designed which give precise information of patient admissions, beds requested, discharges, nursing and medical cover for the 24 hour period. The floor plans assist the coordinators with allocation of patients to bed areas, allocation of staff to patients & clusters. The 08:00 handover became multidisciplinary involving medical staff, co-ordinator, physiotherapist and outreach nurse and uses the Clinical information system from the seminar room, allowing this team to form a focused view to the day. Conclusion: The changes have led to improved management, continuity of information and easy reference to requests for information.

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Oral Abstract O07 AN EVALUATION OF A TWO DAY CRITICAL CARE COURSE FOR FINAL YEAR ADULT BRANCH NURSING STUDENTS

Conference theme: Education Author P. Gallagher1, P. Tierney1, BJ. Rice1, K. Page1, A. McKinney1 1 Queens University Belfast Learning Objectives: This study reports on the perceived effect of a critical care course (CCC) on nursing student’s practice. The study evaluated the effect of the CCC on nursing student’s confidence, their knowledge and skills and their ability to relate theory to practice. Methodology: The entire cohort of final year adult nursing students (n=182) were invited to participate in the study. A likert scale questionnaire was used to collect quantitative data from participants. A “free response” section was also included whereby participants could make qualitative statements. Quantitative data were analysed using SPSS V. 17 and descriptive statistics produced. Qualitative responses were analysed thematically.  Results: 134 students completed the questionnaire representing a 73.7% response rate. Participants reported that the CCC assisted them in recognising the critically ill patient and the role of the nurse in managing a rapidly changing situation. Students also stated that the CCC helped them realise the importance of linking theory to practice. Conclusions: This study demonstrates that the CCC is a useful medium for teaching the practical application of caring for critically ill patients. The study has implications for the delivery of critical care training to undergraduate nursing students.

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Oral Abstract O08 THE IMPLICATION OF TEAMWORK AND COMMUNICATION ON THE ICU PATIENT DISCHARGE PROCESS

Conference theme: Research & Development Author F. Lin1, W. Chaboyer1, M. Wallis1 1 Griffith University, Australia Background Modern hospitals are complex work systems that demand effective cooperation across multiple disciplines and departments. Poor communication and teamwork have been associated with poorer ICU patient outcomes, but, the impact of communication and teamwork on ICU patient discharge has rarely been explored. Aim This study explored the influence of communication and teamwork on the ICU patient discharge in an Australian hospital. Method Ethnographic data collection techniques including observations, semistructured interviews, and document analysis were used to track the discharge process. Thematic content analysis was undertaken. Data triangulation techniques were used to enhance the rigour of the findings. All participants consented to the study. Results 17 days of observations of 85 staff, and 56 informal interviews were undertaken. Two themes emerged from data analysis: 1) Communicating ineffectively among teams and departments described the issues of loss of information during handover, and the distrusting relationships and conflicts among teams and departments due to lack of communication; and 2) Working collaboratively to optimise the discharge process described the collaborative teamwork strategies some departments used to optimise the discharge process. Conclusion The results suggested that better communication is needed among teams. Collaborative teamwork should be promoted within the hospital for optimised discharge process.

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Oral Abstract O09 ORGAN DONATION A VIEW FROM BOTH SIDES

Conference theme: Patient & Carers Experience of Critical Care Author R. Spooner1, JA Spooner P1 1 Medway NHS Foundation Trust Every day, three people die whilst waiting for a life saving organ transplant. There are currently nearly 8000 people awating organ transplantation. There are just over 17 million people on the organ donor register (Blood and Transplant 2010). Unfortunately, in September 2004, our daughter Rachael suffered a brain haemorrage at 24 years of age, following which she was pronounced brain stem dead. From the age of 6, she had carried a donor card and had often talked about helping other people if she could. Having this knowledge about her wishes made our decision to go for organ donation much easier. The purpose of this presentation is to explore the feelings elicited by such an event and look at ways that we can improve the care that is given to families in such a situation. Being a Charge Nurse on the Intensive Care Unit that she died on, personal feelings shall be explored, along with narratives on how this has affected the way I carry out my job now, particularly in relation to being involved with the families of patients who have been diagnosed as brain stem dead. Finally we hope to raise awareness to all those present about the need to be on the organ donor register and give the ultimate gift to someone...life. Reference Information: Blood and Transplant (2010) Organ donation information. Available at www.organdonation.nhs.uk. (Accessed 20th April 2010.)

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Oral Abstract O10 THE COMPLEX ARCHITECTURE OF CRITICAL CARE PRACTICE

Conference theme: Staffing and The Critical Care Team Author A. M. Price1 1 Canterbury Christ Church University The aim of this paper is to report the findings of an ethnographic study (Hammersley & Atkinson 1983) examining caring practice within the technological environment of critical care. Observations and interviews were used to collect data and dimensional analysis (Schatzman 1991) was utilised to enlighten the complexity of critical care practice. This approach highlighted that critical care could be viewed as a ‘craft’ that incorporates a range of skills, knowledge, attitudes and experiences to ‘build’ the best outcome for the patient. The aim of different craftsmen depends on their professional focus and effective team working is required to ensure that each role contributes to the building process. The metaphor of a ‘cathedral’ will be used to discuss this detailing the interaction between different craftsmen, architects, inspectors and material being moulded. The priorities and things that make a difference to patients will be included. ‘Presence’ and ‘Engagement’ were key dimensions within the crafting process and these terms will be discussed incorporating the physical, technical, psychological, social and spiritual aspects of practice. The implications are that there needs to be more understanding of the purposes and differences in roles, importance of clear objectives and the need to facilitate development and allow creativity.   Reference Information: Hammersley M and Atkinson P (1983) Ethnography: Principles in Practice New York: Routledge Schatzman L (1991) Dimensional Analysis: notes on an alternative approach to the grounding of theory in qualitative research. In: Maines D (Ed) Social Organization and Social Process (p303-314) New York: Aldine De Gruyter.

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Oral Abstract O11 CHALLENGES, COACHING AND COUNSELLING: A GUIDE TO DEVELOPING AN ADVANCED NURSE PRACTITIONER

Conference theme: Education Author C. Nicholson1, J Mundy1 1 NHS Lothian Aim In June 2008  NHS Lothian supported the option to combine enhanced roles of non-medical staff with additional medical staffing to fill gaps from reduced trainee numbers. This workforce model would replace lost junior trainee hours with advanced nurse practitioner hours. To meet these changing demands, it is essential that health care professionals are offered opportunities to access up to date and relevant education.  Methodology This presentation will demonstrate the collaboration and partnership between key stakeholders in service and education, to develop a trainee advanced critical care practitioner education pathway. This is a novel advanced practice development which combines a robust academic component with a rigorous clinical programme which is targeted to both the service requirements and the participants’ learning needs.    Outcomes In this presenation  we will explain the process whereby this training, teaching and educational assessment is delivered. Examples of the course materials and assessment strategies will be presented.   Conclusion The presentation will draw on the experiences of the authors highlighting issues such as resource implications, writing, editing and student support.

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Oral Abstract O12 CARE AND TREATMENT OF PATIENTS TRANSFERRED FROM CRITICAL CARE TO THE WARD AFTER HOURS, COMPARED TO THOSE TRANSFERRED DURING THE DAY: AN EXPLORATORY, PROSPECTIVE COHORT STUDY

Conference theme: Research & Development Author S. Wood1 1 University Hospital Wales Background It is reported that patients transferred from critical care to the wards afterhours have a higher mortality rate than those transferred during the day (Goldfrad and Rowan (2000), Duke et al (2004)) . The extent of this risk is unconfirmed and the factors to which it can be attributed are unknown.  Objective and Design In this prospective, cohort study using a medical record review in a large NHS teaching hospital, the treatment and care that may impact on mortality rates was compared for patients transferred from critical care to the ward afterhours (18:00-07:59, n=29) with a matched group transferred during the day (08:00-17:59 n=29).  Results The results confirmed that the mortality rate was higher for transfers afterhours (10%) than during the day (6%).  Time from transfer to first clinical observations was significantly longer for patients transferred after-hours (Median 50minutes, Inter-Quartile Range (IQR) 25-130) than during the day (Median 30minutes, IQR 10-45) (p=0.036).  Observations were recorded significantly less frequently within the first 12hours for after-hours patients (Median 3, IQR3-4) than those transferred during the day (Median 4, IQR3-6) (p=0.028).  Conclusion The time to first set of observations and frequency of observations in the first 12 hours are potential factors in explaining the differential mortality associated with transfer time.  Reference Information DUKE, G. J., GREEN, J. V. & BRIEDIS, J. H. (2004) Night-shift discharge from intensive care unit increases the mortality-risk of ICU survivors. Anaesth Intensive Care, 32, 697-701. GOLDFRAD, C. & ROWAN, K. (2000) Consequences of discharges from intensive care at night. Lancet, 355, 1138-42.

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Oral Abstract O13 THE NEWCASTLE INITIATIVE: INCREASING PATIENT & USER INVOLVEMENT IN CRITICAL CARE

Conference theme: Patient & Carers Experience of Critical Care Author L. Anderson1, A M Finley 1 Newcastle upon Tyne Hospitals NHS Foundation Trust Patient’s families and carers should have the opportunity to be involved in decisions regarding care and treatment (NICE, 2009). The Newcastle upon Tyne Hospitals NHS Foundation Trust addresses this issue within critical care through a proactive Patient and User Involvement Group (PUIG), which considers and implements new and established initiatives, aimed at greatly enhancing the patient and user experience. PUIG is multidisciplinary, including medical and nursing staff from all Critical Care areas within the Trust, Chaplaincy, PALS and a representative from the public. Through this presentation, delegates will gain an insight into PUIG history, the current dynamic and ongoing remits. PUIG supports the Trust Nursing and Midwifery Strategy for Success, 20102013, relating to patient and public involvement, through the following initiatives: • • • • • •

Suggestion Boxes Patient Diaries Visitor and relative satisfaction surveys Formats for visitor and relative information ‘Patient Experience’ Conference Annual Memorial Service

Nationally-driven and locally-implemented targets exist to improve service quality and user experience. PUIG hope that by increasing patient and user input into critical care, our service will evolve to meet such challenges in full.   Reference Information: Reference NICE (2009). Clinical Guideline 83: Rehabilitation after critical illness. National Institute for Health and Clinical Excellence, London.

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Oral Abstract O14 THE DETERIORATING WARD PATIENT IN THE HOSPITAL AT NIGHT: A POTENTIAL SOLUTION TO A COMPLEX CLINICAL PROBLEM

Conference theme: Research & Development Author D. Massey1, J Timms2, G Williams2 1 Griffith University 2 Gold Coast Hospital, Qld Health, Australia Background Patients located on hospitals wards are older, often have multiple comorbidities and therefore have more complex care needs, and are at risk of sudden life threatening deterioration. There is increasing evidence that the risk of life threatening clinical deterioration is more likely to occur in the hospital after hours. Method In response to this complex clinical problem the Gold Coast Hospital (480 beds) in Queensland has introduced the Clinical Night Nurse Co-ordinator. This advanced nursing role is complimentary to the after hours Hospital Coordinator and aims to improve the management of the deteriorating ward patient and reduce the incidence of major adverse events in the hospital after hours. There is one CNNC per shift from 2pm - 7am 7 days per week. Results To date, the role has not been formally evaluated. Surveys of medical and nursing staff during the original pilot have been overwhelming positive motivating hospital management to make the role a permanent feature of the staffing establishment. Discussion This presentation will outline the rationale for developing and implementing the role, the aims and objectives of the role, and the initial results of staff surveys and key findings to date. Finally, key performance indicators developed to evaluate the role will be explored.

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Oral Abstract O15 ACUTE KIDNEY INJURY OR ACUTE RENAL FAILURE – FROM WHICH DO YOUR PATIENTS SUFFER?

Conference theme: Excellence in Practice Author K. Dalley1 1 St Georges Hospital, London Following the reclassification of chronic renal failure to chronic kidney disease by the National Kidney Foundation from 2000 onwards, work has been ongoing to redefine acute syndromes and this year, the Acute Kidney Injury Network, AKIN will publish a new definition of acute kidney injury. Research now shows that kidney injury starts at an earlier stage than previously understood and that good basic care can prevent most cases (NCEPOD 2009). With new biomarkers such as NGAL coming onto the market, we may be able to spot injury earlier, predict it accurately and administer prophylaxis appropriately. NICE are currently working on a new clinical guideline for acute kidney injury. This paper will review the latest definitions, biomarkers, infrastructure and recommendations pertaining to acute kidney injury and how they are likely to impact on your critically ill patients.   Reference Information: Acute Kidney Injury Guidelines (2008) Davenport et al for the Renal Association www.renal.org Department of Health (2005) National Service Framework for Renal Services - Part Two: Chronic kidney disease, acute renal failure and end of life care www.dh.gov.uk NCEPOD (2009) Adding Insult to Injury www.ncepod.org.uk.

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Oral Abstract O17 THE ROLE OF THE VOLUNTEER IN DEVELOPING AND IMPLEMENTING A RELATIVE SATISFACTION SURVEY ON AN INTENSIVE CARE UNIT

Conference theme: Patient & Carers Experience of Critical Care Author J. M Hamil1, C. Heslop1 1 Chelsea and Westminster Hospital NHS Foundation Trust The aim of this presentation is firstly to demonstrate how the role of the volunteer can be involved in qualitative initiatives in the intensive care unit, in this case a relative satisfaction survey. Secondly to present the findings of this survey and changes which have occurred as result of it. The relative satisfaction survey has been implemented on the unit for eleven years. It consists of a series of 36 closed questions and it is given to all relatives/ friends of patients on the unit. It is divided into three sections; Communication, Care and Facilities provided. The results are collated every quarter (25-30 reponses on average) and presented to the unit’s quality group by a volunteer who was a relative herself several years ago. As a result of the survey, changes, which have been implemented, include installation of a water cooler, development of a medical information folder, redecoration of waiting room and providing televisions in the overnight rooms. The involvement of the volunteer gives us a personal insight of what it is like to be a relative in ICU. Ensuring the satisfaction survey is collated and presented offers the staff an opportunity to feel appreciated and highlights where improvements can be made.

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Oral Abstract O18 TO CPAP OR NOT TO CPAP THAT IS THE QUESTION?

Conference theme: Research & Development Author B. Gosling1, D. Laming Macadam2 1 Sister Critical Care Outreach Team, Southampton General Hospital University NHS Trust 2 Southampton General Hospital University NHS Trust Background In October 2009 the British Thoracic Society (BTS) recommended that patients with Community Acquired Pneumonia (CAP) are only treated with non-invasive ventilation, as a bridge to ventilation. A retrospective study was carried out to explore the practice of CPAP (Continuous Positive Airway Pressure) being used, in certain medical conditions to avoid ventilation. It was decided that a retrospective study should be undertaken to review all the patients admitted to a level 2 or level 3 beds with a diagnosis of pneumonia. Analysis explored whether the patients had received CPAP and whether treatment progressed to invasive ventilation. Aim The aim of the study was to explore whether the BTS guidelines were supported, therefore optimising patient care and outcomes by either promoting early invasive ventilation or encouraging early trials of CPAP to avoid invasive ventilation. This would have a beneficial effect on patient outcomes and experience, and have cost saving implications. Results and implications Initial results show that of the patients who have CPAP as their only form of ventilation 67% of those patients survive. In comparison only 50% of the patients who have to progress onto invasive ventilation survive. Further analysis will demonstrate practice implications to improve patient outcome and experience.   Reference Information British Thoracic Society (2009) Guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax Vol 64, supplement III.

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Oral Abstract O19 THE USE OF THE CORTRAK ENTERAL ACCESS SYSTEM TO PROVIDE A TRANS-PYLORIC FEEDING SERVICE IN A DISTRIC GENERAL HOSPITAL

Conference theme: Excellence in Practice Author I. Setchfield1 1 East Kent Hospitals University Foundation NHS Trust In the authors Intensive Care Unit (ICU) we regularly treat patients admitted with acute/ severe pancreatitis. In patients with acute/severe pancreatitis, jejunal feeding is the preferred route of enteral nutrition (UK Working Party on Acute Pancreatitis 2005); although there is some evidence that nasogastric feeding is also suitable (Petrov et al 2008). The CORTRAK enteral access system allows ‘live’ bed side placement of nasogastric/ naso-jejunal tubes by allowing visualisation of the tip by using an electromagnetic sensor device. It also complies with NPSA guidance (NPSA 2005). Unfortunately placing post-pyloric tubes is difficult and is usually performed via endoscopy or in radiological department. Not only this is uncomfortable for the patient, it is also expensive but more importantly delays feeding. We have recently started using this system to place feeding tubes in the Intensive Care Unit (ICU) at QEQM. The system is easy to use, requires minimal training and is an extended role for sisters within the unit. The benefits of this system are that patients do not have to be unnecessarily exposed to radiation, delayed feeding is minimised, placement is guaranteed, and confirmation of the screen can be printed in the patient’s notes. A recent study demonstrated 90% 1st time placement of naso-jejunal tubes using the CORTRAK system (Benne 2006).   Reference Information Bennet M. (2006). Evaluation of a technique for blind placement of postpyloric feeding tubes in Intensive Care – Applications in patients with gastric ileus. JICS. 7(1). 49. NPSA (2005). National Patient safety agency, reducing the harm caused by misplaced naso-gastric feeding tubes. Petrov MS, Correia MI, Windsor JA. (2008). Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and tolerance. JOP. 9(4). 440-48. UK Working Party on Acute Pancreatitis (2005). UK guidelines for the management of acute pancreatitis. Gut. 54. 1-9.

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Oral Abstract O20 WHY DO WARDBASE STAFF NOT ACTIVATE A MEDICAL EMERGENCY TEAM IN RESPONSE TO A HIGH MET SCORE

Conference theme: Research & Development Author M. Francis1, N. Castle2, S. Tote1, K. Wright1 1 Frimley Park Hospital 2 Durban University of Technology, South Africa Learning outcome To identify reasons for non-activation of MET Rationale We introduced a patient scoring system in 1999 initially to be used when staff believed a patient was deteriorating but latterly at each set of observations. A number of non-activations have been noted resulting in delayed care. Methodology 61 patients (10% of acute bed stock) were randomly audited and staff were then asked to identify reasons for not instigating the escalation response to an unwell patient. Results The average MET score was 3.7 with a range of 0-9 (a score of >4 requires action). Over 27% of patients were >80 years. With the exception of urine output (8%) all vital signs were recorded to include 100% for respiratory rate. 40% of patients with a MET score of >4 had not resulted in contacting ICU outreach. In 58% of case an acceptable rationale was given but in 42% of patients no acceptable rationale was expressed. The most common reason (49%) was a lack of understanding of the scoring systems escalating response. Summary Ongoing education and support is required to ensure effective use of an established patient system but the scoring system has had a positive impact on recording of patient’s observations.

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Oral Abstract O21 A 5 YEAR JOURNEY OF DELIVERING ICU CARE IN THE COMMUNITY

Conference theme: Patient & Carers Experience of Critical Care Author T. Andrews1 1 Capital and Coast District Health Board, New Zealand Over a 5 year period ICU Wellington (New Zealand) has managed the discharge and subsequent care of a chronically critically ill patient requiring ventilation at home. This case study will discuss the experience of delivering ICU care in the community from multiple perspectives including that of the patient and her family, the staff involved in supporting her care, and the organisational view in terms of cost benefit.  Caring for patients within the community is a foreign concept within the critical care environment. Discussion will explore the preparatory work required to discharge the patient home. This included training of home carers, community staff, the respite care facility and obtaining funding and necessary equipment. The case study will reflect how the role of ICU Wellington has significantly changed over time. The success of this intervention can be measured in a number of ways. Most importantly the patient has been cared for successfully in her own home and she and her husband report that her quality of life has in fact improved over the years.

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Oral Abstract O22 A SURVEY OF ORAL CARE PRACTICES FOR INTENSIVE CARE PATIENTS RECEIVING MECHANICAL VENTILATION

Conference theme: Research & Development Author A. Tanguay1, I. Reeves, Isabelle1, D. St-Cyr-Tribble, Denise1 1 UniversitĂŠ de Sherbrooke, Quebec, Canada Background Despite strong scientific evidence on the role of oral care in the prevention of systemic infections such as ventilated-associated pneumonia (VAP), oral care practices remain a neglected professional behaviour in intensive care units. Purposes 1. To describe actual oral care practices provided by critical care nurses for mechanically ventilated critically ill patients. 2. To understand, referring to the Theory of Planned Behaviour, the factors influencing this behaviour (intention, attitudes, subjective norms, perceived behavioural control and beliefs). Methodology A descriptive cross-sectional and correlational study design was used. A mail-in self-administered survey was conducted to collect data. A convenient sample was obtained from an available population of 975 subjects using a provincial critical care nurses database. A 69-items instrument was developed and the psychometric properties of the instrument were analyzed for content validity, internal consistency and stability. Data analysis Descriptive statistics were computed. Bivariate and logistic regression analysis were also performed. Results Replies were received from 375 (response rate 38.9%). This study reports indicators describing oral care practices and documents factors influencing professional behaviour among critical care nurses in Quebec. Conclusion A better understanding of this practice may lead to safer and higher quality care for this vulnerable critically ill population.

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Oral Abstract O23 DEMONSTRATING HOW EXCELLENCE IN PRACTICE HAS REDUCED VENTILATOR ASSOCIATED PNEUMONIA RATES IN OUR ITU

Conference theme: Excellence in Practice Author L. Godden1, G. McMahan “1, p” . 1 ITU QEQM, East Kent Hospitals University Background It is widely acknowledged that Ventilator Associated Pneumonia (VAP) increases length of Intensive Care Unit (ICU) stay and ultimately patient mortality. One of the Patient Safety First Initiatives was to improve care for patients in ITU by the implementation of care bundles which are now standard practice for the ventilated patient. Nurse led weaning is shown to positively impact on patient care by decreasing ventilator days therefore minimising VAP risk (Hawe et al 2009). Aim We aim to demonstrate that compliance with the ventilator bundle and faster extubation improves patient outcomes and saves costs, focusing specifically on the effect of length of stay, mortality rates, ventilation days and pharmacy costs.  Method We explored the effects of nurse led weaning and ventilator bundle compliance on reducing ventilator days and the impact of this both clinically and economically. Results Compliance with the ventilator bundle was high and we advocate nurse led weaning. It was felt that this proactive approach and excellence in practice through these measures significantly minimised VAP rates.   Implications Our ICU strives for a nurse lead, proactive approach to patient care and our research indicates that this has an impact on both patient outcome and cost. It is vital that we continue to strive for excellence in practice.   Reference Information: Hawe, C. Ellis, K.S. Cairns, C.J.S. Longmate, A.2009 Reduction of Ventilator Associated Pneumonia Active Versus Passive Guideline implementation. Intensive care Medicine. 35, 7. 1180 -1186.

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Oral Abstract O24 CRITICAL CARE CLINICAL PRACTICE SKILLS IN MEDICAL ASSISTANCE

Conference theme: Excellence in Practice Author F. Pilkington1 1 International SOS, London Nursing skills are highly transferrable to different fields however this may be challenging. The aim of this presentation is to demonstrate the skills and knowledge development and creativity required in field of medical assistance and inflight nursing. As an intensive care nurse, moving into the field of medical assistance has been challenging as the patients are not in front of you when making a medical assessment. Additionally patients can be of any age, have any medical condition and be anywhere in the world. Clinical decisions that may be obvious when in the security of a hospital in the UK are not so clear to make when sitting in a London office speaking with someone in a remote location abroad. Despite the challenges, the skills required need to be of a high quality and sometimes creatively applied in this remote setting in order to enable to medical team to direct patients and source appropriate medical care for the people phoning in. International SOS additionally has the back up of senior staff and a network 28 offices and clinics in 15 countries around the world available 24/7 to support people ensuring a dynamic environment which is sensitive to service users needs.

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Oral Abstract O25 CONSOLIDATING YOUR ITU COURSE - TURNING A CONCEPT INTO REALITY

Conference theme: Education Author M Ford1, M Galpin1 1 Salisbury NHS Foundation Trust Consolidating your ITU course - turning a concept into reality. The impetus behind participating in continuing education programmes ranges from improving professional knowledge to enhancing the chances of promotion and job security. The Intensive Care Course was traditionally delivered over 36 academic taught days however in recent years this has been reduced to 10 study days. The reduction in university based teaching and emphasis on life long learning challenges our assumption that course students will be taught “everything there is to know” and requires us to change the way we support nurses following completion of their academic study.  In 2009 the education team developed and piloted a consolidation programme for nurses immediately following completion of the ITU course. The course runs over six months and provides the essential elements of clinical, professional and personal development with action learning at the heart of the curriculum. Taught by the senior nursing team and supported by the consultants, it enables staff to enhance their ability to explain, predict and evaluate clinical situations and interventions. It also prepares them at a very early stage for promotion into a band 6 role. This paper will focus upon identifying the stages in evolving and evaluating this programme within the intensive care unit at Salisbury District Hospital.

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Oral Abstract O26 REDUCING DETERIORATION BY “DOING THE OBS”

Conference theme: Excellence in Practice Author C. Plowright1, J Assimakopoulos1, M Balcorta1, S Chacko1, C Martin1. 1 Medway NHS Foundation Trust It is well known that the signs of impending critical illness or cardiac arrest are being missed (Franklin and Mathew, 1994). The Patient Safety First Campaign has an aim of reducing in-hospital cardiac arrests and mortality rates through earlier recognition of the deteriorating patient. Like many organisations, Medway NHS Foundation Trust, monitors the number of patients who have physiological observations completed. At our organisation we report these results to all the clinical areas and key healthcare professionals in the Trust on a monthly basis and it has become one of our Commissioning for Quality and Innovation (CQUIN) targets. Every month, every ward with adult in-patients has the observation charts assessed by the Outreach team and this information is reported. We aim to share with you the results of our ongoing audits and how these results are being maintained. We also aim to share the work we have undertaken around ensuring that patients who are at risk of deteriorating have appropriate responses taken by nursing staff, and inform you about ongoing work in this important area of patient care.   Reference Information Franklin., C., Mathew., J. 1994. Developing strategies to prevent in hospital cardiac arrest, analyzing responses of physicians and nurses in the hours before the event. Critical Care Medicine. 22: 244-247. The Patient Safety First Campaign accessible at www.patientsafetyfirst.nhs.uk.

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Oral Abstract O27 INTEGRATING TECHNOLOGY AND CRITICAL CARE RESEARCH

Conference theme: Research & Development Author M. Jenkins1 1 Royal United Hospital, Bath Intensive Care’s emerging research base, with changes to funding through Comprehensive Research Networks, offers intensive therapy nurses opportunities to participate in studies requiring new skills and creativity.  In 2008, the Royal United Hospital, Bath joined OSCAR - a randomised controlled trial comparing positive pressure ventilation with the high frequency oscillatory in patients with acute respiratory distress. With little research experience as a unit, collaborating in a multi-centre randomised control trial our initial challenge was data collection, identifying admissions suitable for inclusion. Paperwork from the trial centre relied on daily screening so as not to miss admissions. Resolution was sought through the integration of our ICNARC database with a software programme designed to capture every patient admitted into the unit, screening them using the set eligibility criteria. The programme was put onto a hand-held computer tablet the simplicity of which enabled others to screen. Any admissions overlooked were on the database and filled in retrospectively. For the future, the data collection process gives us a storage capacity to explore other research issues from the initial data collected. For our 11-bedded unit, the impact of using this programme in this trial, was that we were top recruiters during our participation in the OSCAR trial and we will be monitoring its success in further trials.

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Oral Abstract O28 A CLINICAL AUDIT ON MANAGEMENT OF PATIENTS ADMITTED TO INTENSIVE CARE UNIT WITH SEVERE SEPSIS AND SEPTIC SHOCK

Conference theme: Research & Development Author S. Shrestha1, J. Woods1 1 Frimley Park Hospital NHS Foundation Trust Objective A retrospective clinical audit was conducted to determine the compliance with the Surviving Sepsis Campaign 6- hour resuscitation care bundle (Dellinger et al, 2004) on patients admitted to the general intensive care unit between 1st August 2007 and 31st July 2008. Main results The rate of compliance with the Surviving Sepsis Campaign 6 -hour resuscitation care bundle (Dellinger et al, 2004) was found to be poor but similar to other published studies and  other trust within our critical care network. This audit also highlighted how septic patients were identified, reviewed and managed within our trust and provided baseline data, such as its incidence, associated mortality, length of ICU and hospital stay.  Development In light of this finding, changes have been made on current processes by developing and implementing hospital protocol on sepsis management and delivering continual education programme to improve the compliance with the Surviving Sepsis Campaign resuscitation care bundle.    Reference Information Dellinger et al for the Surviving Sepsis Campaign Management Guidelines Committee (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Critical Care Medicine, 32 (3), 858-873.

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Oral Abstract O30 UPDATING RENAL REPLACEMENT THERAPY

Conference theme: Excellence in Practice Author A. Mizen1, K Charlton1, H Gilbrook P1, S Hunter P1, C Bolwell1, L Howell1, R Fenton1, H Croft1 1 West Suffolk Hospitals NHS Trust Eighteen months ago a renal interest group was formed within our critical care unit. The group was made up of a number of different grades of nursing staff and a technologist who all shared an interest in renal issues. The remit of the group was to examine our current practice, review our unit resources and protocols and find out what was new on the market with a view to updating current practice. During this time we have trialled and introduced new Continuous Renal Replacement Therapy (CRRT) machines and vascular access devices. We have examined current research into the provisions of CRRT and updated our practice accordingly. The aim of this presentation is to show the process that we have been through, highlight the changes that we have made to practice, the problems that we have encountered and what we hope to achieve in the future. Above all, this presentation can demonstrate to other critical care practitioners that a small, highly committed group, who are motivated in improving their practice and enhancing patient care, can achieve significant changes to practice.

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Oral Abstract O31 IMPLEMENTING A NEW CLINICAL INFORMATION SYSTEM (CIS) IN ADULT INTENSIVE CARE (AICU): CELEBRATING 1 YEAR

Conference theme: Research & Development Author S. Ramkissoon1 1 St Mary’s Hospital Using clinical information systems in intensive care is becoming the norm as ICUs are becoming more technologically advanced. The expectations are that nurse’s knowledge, skill and competence advances with technology, providing high quality care (DoH, 2000). CIS have been used for the last 15years, but not much data or research is available about implementing a CIS, or the processes involved, or how nurses deal with such drastic change in practice. How are these then considered for implementation, and how is a CIS incorporated into daily nursing practice, development, and education on AICU? A CIS was implemented due to: its efficiency to enhance clinical decision making, reducing omissions and variations in care and promoting standardized best practice, guidelines and protocols; it stores patient records making them legible and easily accessible to staff in real time; it facilitates auditing, data collecting, and clinical research; the accuracy of costing ICU episode of each patient; it’s environmentally friendly, and it was the perfect time to change practice as a new unit was being built (SMH ITU Business Plan, 2007). Post CIS implementation, AICU is 99% paperless, it’s used for all aspects of documentation from admission to discharge, and  reviewed frequently to ‘perfect’ it.   Reference Information References Publications Policy and Guidelines, DoH, (2000). Comprehensive critical care: a review of adult critical care services. [Online] (Updated date not available) Available at: http://www.dh.gov.uk [Accessed: 29th April 2010] Burgis, S., 2007. SMH ITU Business plan for new ICU, London: St Marys Hospital Bibliograpy Wakefield, D., Halbesleben, J., Ward, M., Qiu, Q., Brokel, J., & Crandall, D., (2007). Development of a measure of clinical information systems expectations and experiences. Medical Care 45(9): 884-890. Available at: Journals@Ovid. [Accessed: 30th April 2010] Gruber, D., Cummings, G., Leblanc, L., & Smith, D., 2009. Factors influencing outcomes of clinical information systems implementation: A systematic review. CIN: Computer, Informatics, Nursing. 27(3): 151-163. Available at: Journals@Ovid [Accessed: 30th April 2010] Cotter, C., 2007. Making a case for clinical information system: the chief information officer view. Journal of Critical Care. 22(1):56-65, March 2007. Available at: Journals: Ovid. [Accessed: 30th April 2010.]

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Oral Abstract O32 TIME OF HOSPITALIZATION FOR CARDIAC SURGERY PATIENTS IN AN ICU OF A PRIVATE AND A PUBLIC HOSPITAL AND THE MEDICATIONS CONSUMPTION AT THE SAME TIME

Conference theme: Excellence in Practice Author I. Nasi1, T Katostaras2 1 Hygeia S.A. 2 Athens University, Greece Heart surgery is a specific strong point of surgery science that has been developed heavily during the last decades. For patients who have undergone heart surgery, their first postoperative hours are monitored in a specialized heart surgery ICU (Intensive Care Unit) at each hospital. Patients who are hospitalized into the ICU consume a large amount of medications, either for their faster recovery or preventively. This inquiring study presents analytically the action and the effectiveness of medications per category which are accorded into the ICU to the patients who have undergone heart surgery. The objective of this study is the comparitive measurement of the consumption percentage of these drugs between the private and the public hospital and the estimate of hospitalization time in the ICU of these patients postoperatively per operations type. Data collected from the medical records showed that there is a difference in the consumption of definite drugs between the two hospitals and the hospitalized time differs between the private and the public hospital, per operation type.   Reference Information 1.RN, ICU, MSc, HYGEIA S.A. 2.Assistant Professor, Nursing Department, Athens University.

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Oral Abstract O33 CREATING A SPACE FOR STUDENTS TO LEARNING FROM THEIR OWN STORIES OF CRITICAL CARE PRACTICE

Conference theme: Education Author S. Edwards1 1 Buckinghamshire New University This paper includes the recommendations drawn from a professional doctorate on researching my own practice, which grew from my personal process of learning from stories of critical care nursing practice. The methodology for this work is found in my own method of investigating my own learning from clinical practice. Therefore, articulating learning from experience. I used my personal process of learning with participants in an attempt to see how it worked and what student nurses might learn from their own experiences when written as stories.  My recommendation is to identify the value of including opportunities in critical care nursing courses for students to learn to use their pre-narrative experiences and to gain insights from their stories of clinical practice experience. It is about the teachers’ working with students sharing and valuing story, creating a space for it. The teachers’ perspective on student learning is absent. Core to this is that story connects students with the nature of nursing, the humanness which is essential in their personal role as a nurse; if you do not achieve the essence of nursing you cannot perform fully in your role. Stories live because they are held by the student who experienced them; these stories come forth as they are unique to the individual.   Reference Information Bruner J (1986) Actual minds, possible words. Cambridge Massachusetts: Harvard University Press McDrury J, Alterio M (2003) Learning through storytelling in higher education: Using reflection and experience to improve learning. London: Kogan Page Mason J (2002) Researching your own practice: the discipline of noticing. London: RoutledgeFalmer Van Manen M (1990) Researching lived experience: Human science for an action sensitive pedagogy. New York: State University of New York Press.

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Oral Abstract O35 CRITICAL TO SUCCESS: LESSONS LEARNED TO MAINTAIN STANDARDS OF CARE IN THE FACE OF RECRUITMENT CHALLENGES

Conference theme: Staffing and The Critical Care Team Author S. Boullin1, A. Barnes1, C. Guyer P1, E. Hodgson1 1 Southampton University Hospital NHS Trust The challenges posed for unit leaders to recruit appropriately experienced nurses in expanding critical care units are ever increasing. A 13 bedded general intensive care unit in a large university teaching hospital recently expanded to 21 critical care beds. A major recruitment drive generated nurses from diverse backgrounds, many with little critical care experience, including newly qualified nurses. The units pre-existing nurse induction was initially utilised. However, knowledge and skill deficits were evident leading to the conclusion that the current induction and mentorship programme was no longer appropriate for the large number of new, inexperienced recruits. To promote recruitment, retention and ensure patient safety an urgent and extensive review of orientation and training was conducted by key personnel. Through dynamic leadership a new induction strategy was created. Fundamental changes included a new starter assessment to direct learning needs, an early focused education programme, and mentorship workshops to develop guidelines for support. Currently pre-registration nurse education does not provide the requisite level of knowledge and skills to be a competent practitioner in critical care (Dawson, 2006). These changes have resulted in positive evaluations from nursing staff, strengthening cohesion in an ever evolving team, and may be key in future staff retention.   Reference Information Dawson, D. (2006). The art of nursing: a hidden science? Intensive and Critical Care Nursing. 22(6), 313-314.

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Oral Abstract O36 “AN NHS CRITICAL CARE NURSES’ EXPERIENCE OF WORKING WITHIN THE CRITICAL CARE TEAM AT CAMP BASTION HOSPITAL, AFGHANISTAN – IT’S NOTHING LIKE M.A.S.H”

Conference theme: Staffing and The Critical Care Team Author S. Cox1, C Ellis P2. 1 Southampton University NHS Hospital trust 2 Royal Bolton Hospital NHS Foundation Trust NHS Support to Operations (NHS– S2O) is an initiative that has grown through collaboration of the MOD and NHS, to provide nurses for the critical care team at Camp Bastion Hospital, Afghanistan. NHS– S20 initiative aims to utilise the specialist skills and expertise from the NHS to support the MOD’s continuing presence globally, with specific reference to critical care trained nurses being deployed to war zones. In addition it aims to ensure that lessons learnt in situations like Afghanistan are transferred to the NHS (Governments Defence select Committee 7th Report). This presentation examines the experiences of two deployed critical care nurses, with no previous military experience, and is based on a report which was presented to both the MOD and NHS trusts involved. It will focuses upon challenges and skills developed whilst on deployment, and how these skills have been successfully transferred to their NHS practice. It will additionally reflect on how their NHS training was used to benefit their military colleagues through education and training whilst on deployment. It also identifies areas for further development that will inevitably benefit both MOD and NHS in releasing their nurses for deployment to ensure adequacy in staffing the MOD critical care team.

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Oral Abstract O37 BELIEF AND SELFCARE EXPERIENCE OF POSTPARTUM CESAREAN SECTION AMONG THAIMUSLIM WOMEN

Conference theme: Patient & Carers Experience of Critical Care Author K Vineekarn1, K Virot2, S Srisipan3 1 Faculty of Nursing,Prince of Songkla Unversity 2 Naradhiwasrajanagarindha Hospital 3 Princess of Naradhiwas University The purposes of this phenomenological study were to describe and explain belief and self-care experience of postpartum cesarean section. Eleven participants, postpartum Thai-Muslim women were selected by purposive sampling. The data were obtained using non-participant observations, in-depth interviews over a period of 3 months. Health status is the majority causes related to mother’s health status (n=7); hypertension, history of convulsion, no dilatation of cervix and premature rupture of membrane. Fetal’s problem (n=6) consisted of large fetus, twin pregnancy, abnormal presentation, and placenta previa (n=1). Belief and self-care experience were found in 7 aspects; 1) having meal and nutritional status 2) caring of reproductive organ and having a period 3) cleaning body 4) body massage and breast massage 5) having a sexual relationship and skip interval of having child 6) exercise behaviour, taking a rest and working 7) religion belief. Basic factors promoting efficiency of self-care post operative cesarean section can be explained in 3 features; 1) belief and previous important experience 2) family and relative society 3) health service system which support belief and experience. The suggestion is to study experimental research by developing a self-care pattern of Thai-Muslim mothers post partum cesarean section based on belief and valuable experience combined with modern medicine.   Reference Information Downs DM, Hausenblas HA. “Women’exercise beliefs and behaviors during their pregnancy and postpartum”. Journal of Midwife and Women’s Health2004; 49 (2): 138-144. Leveno KJ, Cunningham FG, Alexander JM, Bloom SL, Casey BM, Dashe JS, Sheffield JS, & Roberts SW. “Williams Manual of Obstetrics: Pregnancy Complications”. 22nded. Mc Graw Hill Medical: New York, 2007. Orem DE. “Nursing: Concepts of practice”. 6th ed. St. Louis, MO: Mosby, 2001. Pfeifer SP. “NMS Obstetrics and Gynecology”. 6th ed. Lippincott Williams & Wilkins:Philadelphia, 2008. Rubin Rita. “Answers prove elusive as Cesarean section rate rises”. Retrieved on December 30, 2008, from www.usatoday.com. Sakala EP. “Board review series: Obstetrics and gynecology”. 2nd ed. Philadelphia:Lippincott William & Wilkins, 2000. Taylor SG. “Theoretical Foundations of Self-Care Capabilities”. Paper presented at the 10th World-Congress on Self-Care and Nursing: Reflecting the Past-Conquering the Future. (26-29 June), Vancouver BC: Canada, 2008. Van Manen M. “Writing in the dark: Phenomenological studies in interpretive enquiry”.London, Ontario: Althouse Press, 2002.

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Oral Abstract O38 STANDARDS IN PRACTICE: TRANSFORMING EDUCATION AND TRAINING FOR CRITICAL CARE NURSES

Conference theme: Education Author S. Clarke1, M Jordan1 1 Cheshire and Mersey Critical Care Network Background Undergraduate programmes for nursing have led to fractionalisation of training, and disparity between staff education levels, whilst much of the post registration training for critical care staff does not fulfill specialist needs. Aim To develop a coherent, transferable, education and training programme for critical care nurses that can be adapted for all non-medical critical care professionals. Methods The Project Manager worked with front line practitioners to: • Identify critical care patient needs along the patient pathway. • Identify specific competences and map these to the pathway. • Identify a core curriculum. The project utilised the national Skills for Health competence-based career framework. Results • Competence maps were developed, assigned to career framework levels and mapped to the KSF. • Template job descriptions were produced for career framework levels 5, 6, 7 and 8. • An education programme with flexible modes of delivery was designed. Benefits • Improved patient outcomes by addressing skill gaps and shortages to ensure a consistent, best-practice approach to education and training. • Training pathways are aligned with clinical pathways • Improved quality, effectiveness and productivity of service delivered to patients • Improved staff satisfaction with increasing opportunities for critical care staff to gain skills and enhance career progression.

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Oral Abstract O39 THE MECHANICS OF RESPIRATORY SYSTEM, THE GRAVITY AND OUTCOME OF ELDERLY PATIENTS WITH EARLY ARDS

Conference theme: Excellence in Practice Author C. Dimitrakopoulou1, A. Koutsoukou2, C. Routsi2, E. Andrianakis Elias2 1 Hygeia S.A, Greece 2 Evaggelismos Hospital 3 Evgenidio Hospital Aim The mechanical properties, the gravity and the outcome of the elderly and non-elderly patients with early ARDS (1st-3rd day) treated in ICU with mechanical ventilation were studied. Results There was a statistically significant difference between the two patient groups for age, APACHE II and SAPS II score. The correlation of age and sex had no statistical significance. There was no difference of the cause of ARDS in both patient groups. From the comparison of the ventilator settings between the elderly and non-elderly, there was a statistically significant difference in Ti/Ttot ratio and the respiratory rate. The comparison of the mechanical properties of the respiratory system and blood gases revealed a statistically significant difference in PO2. There was no statistically significant difference in outcome between the two patient groups.   Reference Information 1. RN ICU, ΜSc, Assistant Head Nurse, HYGEIA Hospital 2. Assistant Professor of Internal Medicine, 2nd Department in Training of Internal Medicine, Evaggelismos Hospital 3.Anesthetist – Attending Physician, Evgenidio Hospital.

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Oral Abstract O40 ORGAN DONATION AFTER CARDIAC DEATH

Conference theme: Patient & Carers Experience of Critical Care Author K. Dalley1, J Coles1 1 St George’s Hospital, London While practice of organ donation following brain stem death is well established in the UK, it is not a big growth area. In order to increase the number of organs available for transplantation, we are increasingly asked to focus on non-heart-beating donation, now known as donation after cardiac death, or DCD, which can occur following planned withdrawal of treatment in the A&E or ICU (DH 2008). This session will explore the complexities and pitfalls of identification of suitable potential donors. Using example cases, we will discuss the difficulty with futility, the confusion that can occur with DNAR orders and the changing face of ‘best interests’. We shall also highlight the practical issues that arise, physiologically, politically and emotionally during the referral, approach to the family, management of the potential donor and the process of retrieval.   Reference Information Department of Health (2008) Organs for Transplants Central Office for Information www.dh.gov.uk/publications Department of Health (2009) Legal Issues Relevant to Non-heartbeating Organ Donation (web only) www.dh.gov. uk/publications.

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Oral Abstract O41 THE USE OF TOUCH BY INTENSIVE CARE NURSES

Conference theme: Education Author T. Simpson1 1 University of Lincoln Verity (1996) outlines a strong case for the use of touch as a means of communication between nurses and patients in intensive care.   The study sought to determine the amount of touch used by a cohort of nurses and to look in more detail for the type of touch being employed. The two category labels utilised in the study was instrumental and caring touch. To describe these two types of touch the work of Henricson et al (2009), Wilkin (2003) and Adomat and Killingworth (1994) was employed.   The methodology utilised was participant observation for the use of touch during care and semi-structured interviews for the understanding of touch by participants.   The results found significantly more instrumental touch was employed compared to caring touch (t=7, P<0.01). In addition, the more experienced nurses felt able to utilise touch in a more confident manner. However, these were the nurses who spent the least amount of time with patients.   These findings have implications related to the importance placed on touch and communication during pre and post registration learning in critical care clinical areas   Reference Information Adomat, R and Killingworth, A (1994) Care of the Critically Ill Patient: the impact of stress on the use of touch in intensive therapy units. Journal of Advanced Nursing 19 (5) pp912-922. Henricson, M Segesten, K Berglund, A and Määttä, S (2009) Enjoying tactile touch and gaining hope when being cared for in intensive care - a phenomenological hermeneutical study. Intensive & Critical Care Nursing 25(6) pp323-31. Verity, S (1996) Communicating with sedated ventilated patients in intensive care: focusing on the use of touch. Intensive & Critical Care Nursing 12(6) pp354-8. Wilkin, K (2003) The meaning of caring in the practice of intensive care nursing. British Journal of Nursing 12(20) pp1178-80, 1182-5.

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Oral Abstract O42 CLINICAL GOVERNANCE & SPECIALTY NURSING PRACTICE

Conference theme: Education Author M.B Naylor1 1 SWAHS, Australia Aim is to explain 1. How clinical governance was introduced to specialty nurse education 2. What graduates and educators achieved over ten years 3. How service users are benefiting from education and efforts to enhance practice  Background The concept of clinical governance in Australia was formulated by New South Wales Health to manage the quality of health care services in 1999 (NSW Health 2003). Different initiatives and changes were introduced with limited success over ten years including an invested of $55 million in frontline clinical care and enhancement funds to expand existing resources and support clinical staff (NSW Health 2005). Yet when 178 root cause analysis from NSW Public hospitals were reviewed the top 3 reasons for inadequate patient management were clinician failure to properly diagnose (31%), failure to institute the appropriate treatment (19%) and management of complications (15%) (Clinical Excellence Commission & NSW Quality & Safety Unit, 2007) Project Against this background Sydney West Area Health Service developed a Graduate Certificate in Specialty Nursing with clinical governance and leadership for front line registered nurses in different specialties including critical care prioritised. Positive results are evident in clinical improvement activities, graduates’ career progression and educators’ knowledge enhancement and collegiality.  Reference Information NSW Health (2003) The clinician’s toolkit-for improving patient care, cited in NHS 1998, The new NHS: Modern & dependable. NSW Patient Safety & Clinical Quality Program, Implementation Plan, (2005) NSW Health Clinical Excellence Commission & NSW Quality & Safety Unit, (2007), Commonwealth Government, Australia.

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Oral Abstract O43 SPIRITUALITY IN CRITICAL CARE

Conference theme: Patient & Carers Experience of Critical Care Author S. Kerai (p)1, S. Sohani (p)1 1 Aga Khan University, School of Nursing Karachi, Pakistan Introduction The Human body is a unique combination of mind, body and soul. This significant triad marks the essential need of spirituality which creates a therapeutic and soothing atmosphere in health arena. Unfortunately, this facet of care has often been overlooked in intensive care where special attention is required in all aspects. Besides, it is often challenging to put in equilibrium of holistic care, the spiritual needs of client along with other stresses of critical care. Objective To discuss the significance of spirituality in critical care and role of nurses in its provision Method Systemic review of literature from 2004- 2010 Findings Spirituality promotes satisfaction, decreases stress and helps in self awareness. Moreover, it is mostly desired by the clients during care and its provision impacts the way they cope with illness. Additionally, it can be integrated by proper assessment using bio-psycho-socio-spiritual approach. It requires mere therapeutic communication which humanize the care and decrease mechanization. However, its provision has certain challenges like lack of support, time, skills etc. Conclusion Spirituality promotes healing environment and contributes to the satisfaction of both staff and patient. Thus, it can help to change the paradigm of nursing care by exploring oneâ&#x20AC;&#x2122;s philosophy of life.

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Oral Abstract O44 REDUCING CARDIAC ARREST: INTRODUCTION OF MEDICAL EMERGENCY TEAM IN OUR TRUST

Conference theme: Excellence in Practice Author R. Anslow1, K Sheppard1 1 Dudley Group of Hospitals Background When the NICE Guidance on ‘Acutely ill patients in hospital’ was published, the Trust already had in place a Cardiac Arrest Team, and an Outreach service which covered 7 days a week but only 10 hours a day. What changes could we make to implement the Guidelines. Objective To improve the early recognition of patients who became acutely ill, and to reduce the number of patients who have cardiac arrest. Project A multi-disciplinary project team was set-up and three main strategies were taken; a change of Cardiac Arrest Team to Medical Emergency Team (M.E.T.) which included both senior medical and nursing staff; 24/7 Critical Care Outreach cover and alteration of the observation chart to colour coded system with red banding (trigger) requiring calling the M.E.T. Results Increase in M.E.T. calls, but reduction in Cardiac Arrests by 30%  on previous years since commencing the changes. Discussion What further advances are needed to reduce the numbers further.  Reference Information National Institute for Health and Excellence (2007) Acutely ill patients in hospital.NICE clinical guideline 50. London: National Institute for Health and Clinical Excellence.

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Oral Abstract O45 LET’S GET PHYSICAL! THE IMPORTANCE OF REHABILITATION DURING AND AFTER CRITICAL ILLNESS

Conference theme: Research & Development Author N. Doherty1, C. Steen1 1 University of Manchester Evidence suggests that more patients are surviving critical illness with an adverse cost to their physical, psychological and social functioning. Physical complications such as critical illness polyneuropathy (CIP) and myopathy (CIM) are poorly identified and managed in this group of patients resulting in long term neuromuscular disability. Diagnosis of CIP/CIM is rarely made as assessment is difficult to undertake and often not performed during routine clinical examination during the acute phase of critical illness. Current strategies employed are aimed at controlling the associated risk factors and rehabilitation. This presentation reviews the literature and offers two approaches in nursing management to resolve these conditions. Firstly, prevention of the development of CIP/CIM during the acute phase of the illness will be discussed. Strong evidence suggests early mobilisation in the critical care setting can improve patients’ functional outcome by reducing the length of critical care and hospital stay, increasing ventilator free time and improving limb and respiratory muscle strength through passive range of movement therapy and early mobilisation. Secondly, literature pertaining to post discharge rehabilitation programmes will be critically appraised to limit the long term affects of the disease and recommendations for practice will be offered.   Reference Information Oral presentation or poster presentation.

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Oral Abstract O46 MIND THE GAP: WHAT DOES A CRITICAL CARE PROBLEMBASED LEARNING MODULE DO FOR NURSING STUDENTS?

Conference theme: Education Author H. Luckhurst1, R Dudley P1 1 University of Worcester Background Within the HEI setting it is crucial for students to recognise and link the application of module sessions’ to real nursing practice (Cooke and Moyle (2002).  Aims 1) to obtain and explore the perceptions of student nurses in terms of the PBL process, their everyday practice and learning, 2) to enable the author to research their own teaching, 3) to obtain evidence to inform the curriculum Methods An Action Research study obtained and examined the student perspective. Final year students participated pre and post their PBL module experience. PBL was also used as an assessment method. Qualitative and quantitative data was obtained from a student questionnaire. SPSS analysis was employed in addition to themed responses from open ended questions. Results Students agreed that PBL will influence their everyday practice; impacting on teamwork, communication and confidence.  A significant shift in student attitude was evident from pre to post PBL in terms of being a suitable way of learning. Students declared that PBL should be included in the pre-registration programme. Implications/Conclusions Students have been involved in shaping the future curriculum. The  perceived ‘added value’ of PBL (Savin-Baden 2001) is evident. The impact on confidence, teamwork ability and communication address the emphasis within the NMC Draft standards for Pre-registration nursing (2010).   Reference Information Cooke M. Moyle K.(2002) Students evaluation of problem-based learning. Nurse Education Today 22 330-339 NMC (2010) Standards for pre-registration nursing education:Draft for consultation London NMC Savin Baden M (2001) Problem based learning in Higher Education:Untold Stories Buckingham Open University Press.

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Oral Abstract O47 NURSING EXPERIENCES OF CARING FOR CHRONICALLY CRITICALLY ILL PATIENTS IN ICU

Conference theme: Research & Development Author A. Butt1 1 Wellington Regional Hospital, New Zealand Aim The aim of this study was to explore and describe the experiences of intensive care (ICU) nurses caring for chronically critically ill (CCI) patients. Method A qualitative approach was used to generate knowledge about the experience of these nurses. Five ICU nurses were recruited from two ICUs in New Zealand. Semi-structured interviews were conducted, audio-taped then transcribed. A thematic analysis was carried out using Burnardâ&#x20AC;&#x2122;s framework (1991). Findings Overall, nurses negatively described their experiences of providing care to CCI patients. Six key themes were identified during analysis: ICU culture, the CCI patient in ICU, teamwork and nursing practice, autonomy and control, work related stress and compassion fatigue, and withdrawal of care/palliation. A key finding, and the focus of this presentation, was that ICU nurses caring for CCI patients have limited peer support, resources and training and this contributes to work-related stress and compassion fatigue. Conclusions and Implications Several factors were identified as contributing to the negative experiences. The nurses described a cycle where a lack of autonomous decision making led to work related stress and avoidance responses which in turn led a task and nurse centred approach rather than a patient centred approach. This in turn develops into compassion fatigue and emotional withdrawal from CCI patients.

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Oral Abstract O48 RESUSCITATION: A REVIEW OF THE EDUCATION AND TRAINING OF A CLINICAL SERVICE

Conference theme: Education Author T. Richards1 1 Southampton University Hospital Trust The main purpose of the review was to develop a resuscitation service fit for purpose and fit for the future demands of the trust. Patient safety and the delivery of quality patient care were paramount. The objective of the project was to improve the early recognition of critical illness and develop skills to respond rapidly to resuscitate patients wherever they were in the hospital. The main key points involved analysis with the Resuscitation Officers of their service provision. We examined the previous years training percentages, scrutinised the needs of trust personnel, reviewed the supply and demand of all courses and considered who should access what training course. We explored the concept of dovetailing acuity education into the ward based courses to provide a more rounded training ensuring quality service provision for the acutely and critically ill patient. Prior to the review, training percentages for trust employees were 40%, after implementation they have improved. Provision of formal clinical support from the resuscitation team and training programmes tailored for specific clinical need were devised in line with NICE and NPSA guidelines offering the workforce, education not only to perform patient resuscitation competently but also to develop skills of anticipation, recognition of signs of patient deterioration and prevention. Reference Information National Institute for Health and Clinical Excellence. (2007) Clinical Guideline 50 â&#x20AC;&#x201C; Acutely Ill Patients in Hospital. Recognition of and Response to Acute Illness in Adults in Hospital. National Institute for Health and Clinical Excellence. National Patient Safety Agency. (2007) The Fifth Report from the Patient Safety Observatory: Learning from Serious Incident. National Patient Safety Agency.

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Oral Abstract O49 DEVELOPING USER CENTRED CRITICAL CARE DISCHARGE INFORMATION

Conference theme: Research & Development Author S. Bench1 1 King’s College London Objectives This presentation will describe the development of a user centred discharge information package developed by service users for adult critical care patients and their families and discuss evaluation of its feasibility  and effectiveness.  Design This two stage research project follows the Medical Research Council guidelines for development of complex interventions. Phase I consisted of a focus group study involving patients, relatives and health care professionals. Data from this study and a meta synthesis of qualitative research (Bench and Day, 2009) were then used to develop the discharge information pack which is currently undergoing evaluation using a phase II RCT.     Results The phase I study supported previous findings regarding discharge information needs. It also indicated a need for information to assist patients and families to recognise their own progress and to play an active part in meeting individual information needs. The importance of a lay patient discharge summary was further highlighted. These data were used to develop a user centred discharge information pack, which is currently undergoing evaluation. Prelimary results of this RCT will also be presented       Reference Information Bench S, Day T (2009) The user experience of critical care discharge; a metasynthesis of qualitative research. International Journal of Nursing Studies. Epub: DOI: 10.1016/j.ijnurstu.2009.11.013.

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Oral Abstract O50 NEWLY QUALIFIED NURSES IN ICU

Conference theme: Research & Development Author C. O’Kane1 1 Leeds Teaching Hospitals Aim The aim of this research was to investigate newly qualified nurses (NQN) experiences of starting their career in the Intensive Care Unit (ICU). From a comparative prospective, the feelings of senior nurses about this experience. Background NQN in ICU has little substantive research to support their employment. There is a current demand to investigate this topic, particularly in relation to issues such as time management, support and supernumerary time. Method A comparative, qualitative study using a mixed method approach. The study was conducted over two phases. PHASE I, used semi structured interviews with NQN. PHASE II used a focus group to interview senior nurses in ICU. Findings NQN’s lack of ward experience led to anxiety about time management, accountability and lack of hospital knowledge. Senior nurses felt NQN coped well with the demanding aspects of ICU but aware that preceptors are under a lot of pressure to facilitate this learning. The competency based practice came under scrutiny particularly in a failure to recognise the importance of record keeping and its associated legal implications.   Conclusion NQN cope well with the complexity of ICU. Having student placements in this area seems to ease this transition and reduce some reality shock , therefore  better equipped to deal with the steep learning curve.   Reference Information REFERENCES Bench, S. Crowe, D. Day, T. Jones, M. Wilebore, S. (2003) Developing a competency framework for critical care to match patient need. Intensive and Critical Care 19 pp 136-142. Charnley, E. (1999) Occupational stress in the newly qualified staff nurse. Nursing Standard. 13 (29) p 33-36 Delaney, C. (2003) Walking a Fine Line: Graduate Nurses’ Transition Experiences During Orientation.

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Oral Abstract O51 DEVELOPING A PATIENT CENTRED MODEL OF CARE FOR THE FUTURE

Conference theme: Patient & Carers Experience of Critical Care Author A. Kingsbury1 1 ACT Health, Australia In 2008, ACT Health announced a redevelopment plan for public health facilities in the Australian Capital Territory (ACT). Simultaneously, models of care were developed to provide a roadmap for patient care in the future. The critical care units of the ACT were amongst the first areas to engage in the process. The process for developing new models of care included analysing current practices, patient and family experiences, investigating evidence based practice for patients, intensive care and hospital design. Patients and their families with recent experience in ICU were interviewed to gather information about patient and family experiences. Interviews were semi structured, allowing patients and families to tell their stories, with interviews analysed for common themes. A consumer representative was included as a member of the project user group, ensuring a patient and family voice in the decision making process. Themes included visiting and access to loved ones, communication and physical environment. We now face the challenge of turning our vision into reality, using the model of care to assist in the architectural design of the new units and the development of new systems and initiatives to improve patient care.

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Oral Abstract O52 AN EVALUATION OF THE IMPACT OF INTRODUCING A NEW MODEL FOR RECOGNISING AND RESPONDING TO EARLY SIGNS OF DETERIORATION IN PATIENTS AT THE ROTHERHAM NHS FOUNDATION TRUST

Conference theme: Research & Development Author K Bray1, D Adsetts1, D Bainbridge1, A McDonnell2, A Tod2 1 Rotherham Hospital NHS Foundation Trust 2 Sheffield Hallam University Background This project (funded by Yorkshire and Humber SHA) evaluates the impact of a new scoring system to help nurses detect and respond appropriately to deteriorating patients. Aims • To evaluate the impact of the new system on nurses’ knowledge and confidence to recognise and manage acutely ill patients • To understand the reasons for any observed changes Method Stage 1. A before and after survey of nurses (n = 328) Stage 2. A before and after qualitative consultation with nurses (n = 15). Results 84% (n = 271) of staff attended training and completed baseline questionnaires. Final number of paired responses = 213. Confidence to recognise a critically ill patient increased from 7.5 (SD 1.8) to 8.2 (SD 1.4), 95% CI 0.55 - 0.92, p < 0.01. Level of knowledge increased from 7.3 (SD 1.8) to 8.0 (SD 1.5), 95% CI 0.52 0.91, p < 0.01. Total number of concerns decreased from 4.3 (SD 2.68) to 3.7 (SD 2.3), 95% CI -0.91 - -0.26, p < 0.01. Qualitative data provides insights to explain this including the nature of the training and scoring system.

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Conclusions The findings support the use of scoring systems and raise important issues regarding training.   Reference Information Featherstone B, Smith GB et al (2005). Impact of a one day inter-professional course (ALERT) on attitudes and confidence in managing critically ill adult patients. Resuscitation, 65: 329-336. National Institute for Health and Clinical Excellence (2007) Acutely ill patients in hospital NICE Guideline 50. London, NICE. National Patient Safety Agency (2007) recognising and responding appropriately to early signs of deterioration in hospitalised patients. London, NPSA.

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Oral Abstract O53 OXHEAD: OXFORD HEAD INJURY EVALUATION AND AUDIT DATABASE

Conference theme: Research & Development Author C. Sweasey1, J Tailor1, H Madder1, T Lawrence1, RSC Kerr1 1 John Radcliffe Hospital, Oxford Background Traumatic brain injury (TBI) is the leading cause of disability in people under 40 years of age. It is estimated that 200 - 300 per 100,000 population have a significant disability as a result of head injury. In 2007 both NICE and the Brain Trauma Foundation issued guidelines that have the potential to improve outcome. Monitoring the impact of clinical management is vital if we are to address this epidemic. To date there is scant data available; there is no national UK database for head injured patients. Aim OxHEAD will determine the epidemiology of TBI in the Oxford region including the long term functional outcome of these patients. Method All patients admitted to the John Radcliffe Hospital, Oxford with TBI are registered for OxHEAD. Consent is obtained from the patient or their relative. Data from time of injury through to discharge is entered onto the database and stored securely. Patients are then followed up at 1, 3 and 5 years. Results Recruitment of these patients commenced in September 2008 and follow up began in September 2009. To date in excess of 300 patients have been registered. The study is ongoing. Reference Information National Institute for Clinical Excellence (2007). Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults. Brain Trauma Foundation Guidelines (2007). Guidelines for the Management of Severe Traumatic Brain Injury.

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Oral Abstract O54 CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

Conference theme: Patient & Carers Experience of Critical Care Author A. Dimech1 1 Royal Marsden NHS Foundation Trust Continuous Positive Airway Pressure (CPAP) is a common treatment modality for acute respiratory failure in critical care and acute settings. Historically a tight fitting mask is used to provide non-incvasive respiratory support. This however is not without risks to the patient including facial pressure areas, pain and discomfort. The Helmet CPAP is a medical device that provides the same treatment with a different method of delivery (Fabrizio et al 2005). The aim of this research study was to explore critical care patient’s experience of Helmet CPAP.  A qualitative approach was taken utilising descriptive phenomenological methodology. In order to obtain rich data, interviews with cues provided the platform for data generation and collection. A thematic framework adapted from Attridge-Stirling (2007) was utilised with emergent themes manually analysed using a constant comparative technique to express the experiences or phenomena of a particular event or experiences.  The study included six patients who had developed acute respiratory failure upon admission or during their inpatient stay in a critical care unit. The overall experience was unique to each patient. The patients entrusted the healthcare team which made the experience more tolerable. Paradoxical themes such as entrapment, liberation, relief and apprehension were experienced during treatment. The desire to survive the acute illness proved to be a driving factor.   Reference Information Attridge-Stirling J. (2007) Thematic networks: an analytic tool for qualitative research. Qualitative Research 1(3) 385-405. Fabrizio R, Appendini L, Gregoretti C, Stra E, Patessio A, Donner CF, Ranieri VM. (2005) Effectiveness of mask and helmet interfaces to deliver noninvasive ventilation in a human model of resistive breathing. Journal of Applied Physiology 99 1262-1271.

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Oral Abstract O55 CALL 4 CONCERN (C4C): PATIENT AND RELATIVE INITIATED CRITICAL CARE OUTREACH (CCO)

Conference theme: Patient & Carers Experience of Critical Care Author M. Odell1 1 Royal Berkshire NHS Foundation Trust We set up a system that enables patients and relatives to directly access the CCO team, and studied its effects. A Pittsburgh hospital has a similar Condition H(elp) system, but no published evidence was found on the subject. Supporting literature reported the value of patients and relatives input into the early recognition of deterioration (Cioffi 2000, Minick and Harvey 2003).  Over 6 months (Sept 09 – Mar 10), all patients transferring out of the intensive care unit (ICU) were given information about the C4C service. Patients and relatives were asked about their experiences of the service, and all C4C referrals were evaluated by the CCO team. Of 147 patient transferred, 26 patients and relatives gave feed back on the service, the majority of which was positive. The CCO team received 12 C4C referrals and these were grouped into 5 categories: critical clinical intervention (2), clinical intervention (2), investigations (3), communication and clarification (3), reassurance (2). As well as having positive feed back from patients and relatives, critical deterioration of the patient was prevented in at least two cases. In the words of a relative, C4C provided ‘…a better quality of care… and…reduces the risk of death’.   Reference Information Cioffi, J. (2000a) Recognition of patients who require emergency assistance: a descriptive study. Heart and Lung, 29, 262-8. Minick, P. Harvey, S. (2003) The early recognition of patient problems among medical-surgical nurses. Medsurg Nursing, 12, 291-7.

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Oral Abstract O56 ACUTE OUTREACH FOR SPINAL CORD INJURIES

Conference theme: Patient & Carers Experience of Critical Care Author H. Aldridge1 1 Salisbury Foundation Trust The Duke of Cornwall Spinal Treatment Centre situated at Salisbury District Hospital comprises a purpose built unit which specialises in caring for people who have spinal cord injury and serves patients in the South & South West of England. It is estimated that 10-15 per million of the population sustain traumatic spinal cord injuries in the UK every year (Grundy and Swain 2002) and a significant proportion of those spend time on an intensive care unit. The acute spinal outreach service was set up in 2009 with the aim of providing support to the patient, family and the multidisciplinary team caring for the patient prior to admission to a specialist centre. It aims to provide quality, timely and patient focussed consultancy making support and information accessible to everyone. Through assisting the referring team in devising a plan of care including respiratory weaning, manual handling, pressure area care, bladder and bowel management the nurse led outreach service at Salisbury District Hospital has helped to reduce some of the distressing physical and psychological problems associated with spinal cord injuries. Developing a seamless service that extends beyond the physical boundaries of the spinal centre has meant that early intervention, support and education has prevented many complications associated with the injury. Reference Information Grundy, D., Swain.A.(2002) ABC of Spinal Cord Injury, 4th Ed, London, BMJ Publishing Group.

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Oral Abstract O57 ARDS - PAST, PRESENT AND FUTURE

Conference theme: Research & Development Author R. Spooner1 1 Medway NHS Foundation Trust Since Acute Respiratory Distress Syndrome (ARDS) was first described in the 1960’s (Ashbaugh et al 1967) the mortality rate has remained high, with some commentators giving figures of up to 38% (Rubenfeld et al 2005). There have been a wide variety of treatments used in an attempt to reduce this mortality rate, ranging from drug treatments such as steroids and prostaglandins, to the use of different ventilatory strategies such as low tidal volumes and high peep (Bream-Rouwenhorst et al 2008).  Proning has also been used with varying degrees of success and failure. There has also been a move to look at high frequency oscillation ventilation. Although no one treatment  has been shown to significantly reduce mortality rate. The aim of this presentation will be to: • Look at the patho-physiology of ARDS • Provide an overview of  treatments in use at this time • Ventilatory Strategies • Current clinical trials • What the future holds   Reference Information Ashbaugh DG, Bigelow DB, Petty TL, Levine BE (1967) Acute respiratory distress in adults. The Lancet; 2: 3, 319 - 323 Bream-Rouwenhorst HR (2008) Recent developments in the management or acute respiratory distress syndrome. Am J Health-Syst Pharm, 65: 29 - 36 Rubenfeld GD, Caldwell E, Peabody E (2005) Incidence and outcomes of acute lung injury. New England Journal of Medicine; 353; 1685 - 1693.

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Oral Abstract O58 RAPID RESPONSE SYSTEMS â&#x20AC;&#x201C; A CURE FOR SICK HOSPITALS?

Conference theme: Research & Development Author D. Massey1 1 Griffith University, Australia Technological developments, an increasingly aged population and economic rationalisation are factors responsible for increasing patient acuity in hospital wards. Patients located in hospital wards have complex care needs. Timely access to appropriate interventions is crucial to improve the morbidity and mortality of acutely ill patients. It is imperative that patient management in the ward setting is optimised by more judicious identification of clinical deterioration of the acutely ill ward patient. RRS have been developed to meet these objectives. Rapid Response Systems (RRS) are a hospital wide system approach that provide a safety net for ward patients who suddenly become acutely ill. At a minimum, an RRS must have an afferent (case detection and response-triggering) limb and an efferent (response) limb to attempt to prevent deterioration. The key aims of RRS systems are averting admission to critical care units, facilitating discharge from a critical care facility, and the sharing of critical care skills throughout the hospital. This presentation provides a critical analysis of the literature on RRS. It aims to improve knowledge and understanding of these systems. Through this analysis strategies for promoting the effectiveness and efficacy of these systems will be illuminated and the challenges and resistance these systems may face in clinical practice will be revealed.

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Oral Abstract O59 THE DEVELOPMENT OF AN INTEGRATED CARE PATHWAY FOR THE MANAGEMENT OF EXTERNAL VENTRICULAR DRAINS (EVD) AIMED AT REDUCING CEREBRAL SPINAL FLUID (CSF) INFECTIONS WITHIN A NEUROSURGICAL INTENSIVE CARE UNIT (ICU).

Conference theme: Excellence in Practice Author A. Neumann1, E Johnson1, E Bloomfield1, J Galea1, L Anderson1, S Chinari1, 1 Salford Royal Hospitals NHS Foundation Trust Aim The aim of this project was to develop and introduce a pathway to aid the managment of EVD’s. Background A recognised complication of an EVD is Ventriculitis; this can cause a significant increase in the morbidity and mortality of critically ill neurological patients (Beer et al 2008). Over twelve months the microbiologist had reported CSF infections potentially as high as 30% in patients with EVD’s, which is 5% higher than that recognised in Dasic et al (2006). This high incidence leads to increased use of Intratheacal (IT) antibiotics and greater lengths of stay. Results An MDT was formed to develop and implement a ‘change agent’ to address the findings; this resulted in the development and implementation of a pathway in conjunction with an updated policy and the establishment of an audit tool. This standardised EVD care and improved surveillance of infection and use of IT antibiotics. Evaluation of the ‘change agent’ saw a significant reduction in CSF infections and the use of IT antibiotic, thus reducing length of stay and ensuring clinical excellence. Implications The introduction of this pathway has improved quality and continuity of patient care and has assisted staff to adopt a proactive approach to the management and relating issues surrounding the care of EVD’s within the ICU. Reference Information Beer R, Lackner P, Pfausler B, Schmutzhard E (2008) Journal of Neurology,255 (11):1617-1624 Dasic D, Hanna SJ, Bojanic S, Kerr RSC (2006) British journal of Neurosurgery, 20 (5):296-300.

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Oral Abstract O60 MULTIDISCIPLINARY EDUCATION IS THE KEY TO DELIRIUM MANAGEMENT

Conference theme: Excellence in Practice Author M. L. Mitchell1, 2, L. Aitken1, 2, J. Abbey1, 2 1 Griffith University, Australia 2 Princess Alexandra Hospital Background Delirium occurs in 11-87% of critically ill patients and is a risk factor for increased hospital stay and mortality. Although there is widespread recognition of the problem, routine screening and specific management of delirium is not well implemented in many intensive care units (ICUs).  Method A literature review was undertaken to identify salient factors that may improve diagnosis and management of delirium. Keywords included confusion, delirium, critical care, intensive care and critically ill. The Cumulative Index to Nursing and Allied Health Literature, Cochrane and Medline databases were searched from 2000 onwards. Results Assessment tool issues and clinicians’ knowledge and understanding of delirium were identified as the primary impediments to successful delirium management. Although multiple assessment tools are available, the Confusion Assessment Method – ICU, which incorporates the Richmond Agitation Sedation Scale, has been shown to have high specificity and sensitivity and has been validated in non-verbal, intubated patients. Educational strategies to promote multidisciplinary understanding and awareness of the detrimental effects of delirium and possible management strategies are crucial to the successful implementation of clinical guidelines. Conclusion Delirium is widespread in ICU and multidisciplinary educational strategies have the potential to improve patient outcomes by optimising the assessment and early treatment of the delirious patient.

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Oral Abstract O61 INDUCED THERAPEUTIC HYPOTHERMIA POST CARDIAC ARREST

Conference theme: Excellence in Practice Author S. Wallace1 1 Gloucestershire Hospitals NHS Foundation Trust I was driven to create a protocol, a care based plan, that was structured and standardised in its approach to provide myself and other qualified clinicians a framework, underpinned by evidence and best possible research, to provide interventions for post cardiac arrest patients for use within the critical care environment. Research has suggested cooling post arrest from a cardiac aetiology may improve outcome and implementation of a protocol may decrease mortality rate . Induced hypothermia is defined as the controlled lowering of core temperature for therapeutic reasons .To successfully apply induced hypothermia, the clinician should have experience in using and adherence to a strict protocol, vigilance and pay attention to the prevention of side effects to the patient. A protocol was developed to ensure that through a structured approach, induced therapeutic hypothermic treatment guidelines and appropriate nursing interventions for post cardiac arrest patients within the critical care environment would be standardized, thus promoting quality of care for those patients.The creation of a protocol, a care based plan, that is structured and standardised in its approach will support practitioners in providing interventions for post cardiac arrest patients within the critical care environment. This will enhance improvement in the care given, clinical effectiveness and safety of treatment.   Reference Information Arrich, J (2007) Clinical application of mild therapeutic hypothermia after cardiac arrest European Resuscitation Council Hypothermia After Cardiac Arrest Registry Study Group ERCHACA-R Critical Care Medicine, 35 (4), pp1041-1047 Bernard, SA, Gray, TW, Buist, MD et al (Feb 2002) Treatment of comatose survivors of out of hospital cardiac arrest with induced hypothermia New England Journal Medicine, 346 (8) pp. 557-563 Bernard, S, Buist, M, Monteiro, O & Smith, K (2003) Induced hypothermia using large volume, ice-cold intravenous fluid in comatose survivors of out-of-hospital cardiac arrest: a preliminary report Resuscitation, 56,pp913 Bernard, SD (2004) Hypothermia after cardiac arrest: How to cool and for how long? Critical Care Medicine, Vol 32 (3), pp897-899 Bernard, SA & Buist, M (2003) Induced hypothermia in critical care medicine: A review. Critical care Medicine, Vol 31,No 7, p2041-2051 Hypothermia Network (2007) [online] Cardiopulmonary Resuscitation after cardiac arrest. Acute treatment with hypothermia www.hypothermianetwork.com accessed Aug 2009 Institute for Health Care Improvements (2007) [online] www.ihi.org.

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BACCN 2010 Oral Abstracts