BACCN Abstract Book 2017

32nd Annual Conference

Building Interprofessional Teams to Enhance Safer Critical Care

ABSTRACT BOOK 2017 Conference Partner:

4th & 5th September 2017 Park Plaza Riverbank, London

Contents Keynote Speakers......................................................... Page 3

Workshops.................................................................... Page 6

Concurrents.................................................................. Page 9

Posters.......................................................................... Page 37 

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Keynote Speakers S01: Ultimate Team Collaboration: Xtreme Everest 10 years on Kay Mitchell Senior Research Manager, Critical Care Research Area, NIHR Southampton Respiratory Biomedical Research Unit NMAHP Training Lead - Southampton Academy of Research Honorary Ambassador, World Federation of Critical Care Nurses (WFCCN) BIOGRAPHY Kay is a member of the Xtreme Everest Oxygen Research Consortium executive team. This group organizes medical research expeditions including the Caudwell Xtreme Everest (2007) and Xtreme Everest 2 (2013) expeditions. These expeditions use healthy volunteers to explore the effects of hypoxia, and thus develop treatments to improve outcomes in critically ill patients. Kay is also the Critical Care Senior Research Manager, NIHR Biomedical Research Centre, based at University Hospital Southampton, and the NMAHP Training Lead for the Southampton Academy of Research, established in 2016 to build the research capacity and capability of healthcare researchers at University Hospital Southampton and University of Southampton. She is an honorary ambassador for the World Federation of Critical Care Nurses.

Kay qualified as an RGN at the Oxford School of Nursing before completing a BSc in Human Sciences at UCL. Kay has worked as an intensive care nurse at UCLH, and the Homerton hospital in London, focusing on practice development and education, as well as at University Hospital Southampton. She completed her MSc in Adult Critical Care at Imperial College London in 2007. Now she has moved her base to Southampton. She is reading for a PhD in epigenetic markers of adaptation to hypoxia ABSTRACT This session will use definitions of teamwork from the literature to examine the Caudwell Xtreme Everest medical research team. This team evolved to carry out the largest ever medical research project at high altitude in 2007.

The speaker will describe how individual team members worked together to carry out more than 30 separate research protocols on 250 healthy volunteers, trekking to Everest base camp, and beyond. The results from this, and subsequent expeditions, continue to increase our understanding of how some individuals tolerate low oxygen levels well, and some do not: a key factor affecting outcomes for critically ill patients.

In health care, a systematic concept analysis in 2008 concluded teamwork to be “a dynamic process involving two or more healthcare professionals with complementary backgrounds and skills, sharing common health goals and exercising concerted physical and mental effort in assessing, planning, or evaluating patient care�, Xirychis et al 2008.

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S02: Links in the Chain to Effective Discharge Professor Ruth Endacott Director, Plymouth University/Royal Devon and Exeter Clinical School, Royal Devon and Exeter Hospital Faculty of Health and Human Sciences, University of Plymouth and Professor of Critical Care Nursing, Monash University, Melbourne BIOGRAPHY Ruth Endacott is Professor of Critical Care Nursing at Plymouth University where she is Director of the Plymouth University/Royal Devon and Exeter Hospital clinical school. She also holds a part time Professorship at Monash University, Melbourne. She holds a number of acute and critical care-related research grants in both countries and is a Trustee/Director for NCEPOD. Professor Endacott has particular interests in quality and safety of care, inter-professional learning, simulation, organisational aspects of intensive care and end of life care in ICU. She is also passionate about developing the research skills of clinicians, as evidenced by the number of clinicians involved in her grants and publications.

ABSTRACT A team approach to managing critically ill patients is emphasised from pre-ICU management (for example rapid response or medical emergency teams) through to the implementation of care bundles in the critical care unit, requiring input from different members of the multi-professional team and timely ICU discharge. Clinical skills education has also shifted from a focus on purely technical skills (for example, insertion of CVCs) to nontechnical skills such as teamwork, communication and situation awareness. There is a growing body of evidence that teamwork impacts on patient outcomes and staff wellbeing in critical care. In this presentation we will explore dynamics around teamwork – when it works and what gets in the way – drawing on evidence from studies conducted in critical care and inter-professional education settings.

S03: Working together to Enhance Patient Safety Professor Kim Manley CBE Professor Practice Development, Research and Innovation, Co-Director, England Centre for Practice Development, Faculty of Health and Social Care, Canterbury Christ Church University BIOGRAPHY Kim integrates research and scholarly inquiry, practice development, workplace learning and leadership development to build and sustain effective workplace cultures that are person centred, safe, effective and good places to work.

Her research expertise focuses on using participatory approaches with multiple stakeholders based on the realism and transformation of practice focusing on using he workplace as the main resource for learning, development, improvement and inquiry.

She is committed to whole systems integrated working and is passionate about helping staff to develop their potential and flourish, and for patients and service users to experience excellence. In 2000, she was awarded the CBE for quality patient services and 2015 recognised as one of Nursing Times Top Nursing Leaders ABSTRACT Working together with patients and service users, colleagues and other stakeholders is a key factor that influences not just patient safety but also other outcomes such as quality and learning. A culture of working together is dependent on leadership, teamwork , shared purpose and agreed ways of working as well organisational enablers.

The presentation will draw on the findings of the Safety Culture, Quality Improvement and Realistic Evaluation Project ( SCQIRE) funded by the Academic Health Science Network across four acute NHS Trusts and also other practice development and leadership initiatives to tease out the key factors that enable both the process and outcomes of a patient safety culture to be recognised and achieved. Practice development methodology is an approach that integrates collaboration, inclusion and participation with stakeholders and increasingly is enabling greater opportunities for co-creation and subsequently engagement – a key feature of working together.

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S04: Closing Panel - Sustainability in Excellence: The Future of Critical Care Dr. Simon Ashworth Head of Intensive Care, Imperial College, London Professor Kim Manley Professor Practice Development, Research and Innovation, Co-Director, England Centre for Practice Development, Faculty of Health and Social Care, Canterbury Christ Church University ICUSteps Patient Representative: Peter Gibb, Chief Executive, ICUsteps Against the backdrop of an ageing population and concomitant ageing medical workforce, people simply living longer with chronic illnesses and/or complex health needs, high expectations of the NHS and an apparent lack of a political will to acknowledge the healthcare needs of the population and address these appropriately, critical care within the NHS faces (and will continue to face) more than its fair share of challenges. Added to this mix is a chronic shortage of critical care beds, critical care nurses and equipment, often leading to difficult decisions having to be made about how to ration services in the most compassionate and ethical ways possible.

Clearly, providing comprehensive critical care calls for a comprehensive, increasingly a multi professional and dedicated critical care team. It is tempting to be brazen and suggest that, given how vitally important the provision of proactive, immediate, excellent critical care is to the NHS, the solution to the widespread problem of limited resources is for the Department of Health to just simply fund enough staff, beds and equipment, and to allow frontline staff to use their relevant experience and expertise to decide on what constitutes enough. Wishful thinking indeed. No, it is going to be incumbent on frontline staff to make do, to make things happen and to carry excellence forward.

This is where the question of how to attract, retain and support the critical care team becomes ever more deserving of answers and action. To be invested and effective practitioners requires ongoing training and development, recognition, appreciation and fair remuneration. It goes without saying that the science upon which training and practice is based is crucial to providing the best care. But the art to providing ongoing excellent care is very personal.

Passion, interest, commitment, true caring and the ability to find reward in work which makes a difference to another person’s life cannot be bought or taught. These must be nurtured and valued. Sustaining and building on excellence in critical care is founded on both science and art, but it can be argued that as the need for critical care services increases and resources become ever more limited, it will be personal attributes such as adaptability, flexibility and resilience which will need to be called upon, increasingly, going forward. Finding the right people, supporting the workforce and dealing with burnout (probably inevitable in critical care over time) has to become an essential priority.

This is your opportunity to raise your questions, voice your concerns and or propose / discuss any ideas with our excellent panel of experts who represents not just the medical & nursing critical care practitioners but even more importantly the voice of the patient and their loved ones.

Make your voice heard by posting your questions to our panel on the BACCN 2017 Conference app or live during our Question Time debate on Tuesday 5th of September during the closing session of Conference 2017.

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Workshop Abstracts W01: Critical Care Nurse Education - The

W03: Developing a new board game style

Next Steps

learning tool to enhance shift leadership education as part of a critical care course programme

SPONSORED BY:

Vanessa Compton, Alder Hey Children’s NHS Foundation Trust Description: Understand how a multidisciplinary and united approach to early mobilisation from day 1, can not only improve the patients physiological status but also their Quality of life and psychological well-being.

Studies report that early mobility is safe (1) despite lines and access however there is little evidence supporting what ‘early mobilisation’ should be done.

How can we work together to provide an improved patient experience and potentially decrease recovery time?

This workshop will consist of a short presentation and quiz followed by practical session with the Linet Multi Care bed.

Reference: The Importance of Early Rehabilitation and Mobility in the ICU, 2013 - 4 August - Managing PostIntensive Care Syndrome in the ICU, Ann Parker, MD; Dale M. Needham, FCA, MD, PhD

W02: Let’s Get Physical - The Road to Recovery

Charlotte Pereira, UCL Great Ormond Street Institute of Child Health There’s an ever increasing body of evidence that Intensive Care Unit Acquired Weakness (ICUAW) leads to a poor quality of life and persistent weakness that potentially can last for many years after ICU discharge.

It’s particularly common in patients that were ventilated with 25-60% of those that was ventilated for more than 7 days. ICUAW can include either illness myopathy or critical illness polyneuropathy and in many instances patients suffer from both.

This particular workshop is a highly interactive session facilitated by Critical Care Physiotherapists who specialises in the mobilisation of the critically ill patient within ICU. Come and explore how to get your patients on the road to physical recovery through the use innovative new techniques and good old fashion mobilisation.

Ian Naldrett, University of West London/Royal Brompton and Harefield NHS Foundation Trust, Theresa Famador, University of West London, Jacqui Finch, University of West London/London North West Healthcare NHS Trust, Pauline Timms, University of West London/Imperial College Healthcare NHS Trust This workshop will aim to show attendees how through innovative teaching methods critical care shift leadership can be delivered as part of an ICU course programme.

More and more within the critical care environment junior nursing staff are being asked to ‘take charge’ and ‘lead from the bedside’, this is evidenced both within clinical practice where units are getting bigger with a higher workload and within national competency documents where leadership is a key domain to be assessed as part of Critical care courses. In response to this and input from employers the ICU lecturing team at the University West London developed a board game style format to deliver education in leadership of shifts in a simulated critical care area. This has now been in place for 3 cycles of the intensive care course and has been well evaluated by learners as a highlight of the module.

Learning outcomes: To understand how the game works in educational and clinical practice.

Through playing the game in groups understand the learner experience and how that will affect learning and outcomes.

To understand and share how the concept can be adapted to different clinical practice areas.

Workshop format: Attendees will first hear about the clinical and educational basis of the game, how it was developed and what issues have been seen and resolved.

This will follow by playing a short session of the game in groups to understand how the game is facilitated in the ICU course and also to have some fun!

To close the session a group discussion facilitated by UWL lecturers on group feedback of the game and its applicability to other settings. There will be opportunities throughout to ask the facilitators questions and share ideas for the future development of the resource.

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References: CC3N (2016) National Standards for Adult Critical Care Nurse Education. CC3N. Available online at: www.cc3n.org.uk [Accessed on 30th March 2017]

W04: Pneumonia Prevention in the

Ventilated and Non Ventilated Patient : An Evidence Based Approach SPONSORED BY

suspect that a patient is not capacitous for a particular decision.

How far should we go to persuade an unwilling patient to be washed, turned or to sit out of bed?

Is it acceptable to physically restrain a woman with dementia?

Should we sedate an angry man who attempts to abscond, naked?

Can a person with a learning disability be serious about wanting treatment to stop on a bad day?

Because the answer lies in the particular and not in the generalisation, we shall explore the scenarios within the context they presented to us, looking at the resources available, the precedent of the Ferreira case and the documentation needed to demonstrate the assessment of capacity.

Kathleen Vollman, Advancing Nursing LLC, USA This session will highlight evidence based practice around the prevention of both ventilator and non ventilator associated pneumonia in the ITU patient population.

W05: Manual Handling Techniques for the Plus Size Patient: Enhancing outcomes for Patients and Caregivers

Learning Outcome: Application of the MCA in a scenario setting will inspire confidence for the clinical environment.

Format: Using a case study approach, a range of patient scenarios will be presented for interactive discussion.

SPONSORED BY

Anita Rush, Berkshire Healthcare NHS Foundation Trust The safe care of a plus size patient within the critical care environment can be challenging. The risk of injury to both the patient and caregiver can be significant if appropriate manual handling techniques are not utilised. This workshop will share the expertise of manual handling professionals who will offer delegates guidance on current best practices as well as practical demonstrations of the use of patient handling equipment - including slide sheets, specialist beds and patient lifting systems.

Delegates should afterwards feel able to return to practice with increased confidence in their ability to deliver safer care to their patients, whilst minimising the number of caregivers required to achieve this.

W06: Mental Capacity Assessment in the ICU

References: ICS & FICM (2017) Joint Guidance on MCA/ DoL via http://www.ics.ac.uk/ICS/guidelines-andstandards.aspx R(LF) v HM Senior Coroner for Inner London [2017] EWCA Civ 31

W07: Clear Thinking in ICU – Getting the balance right SPONSORED BY

“A patient’s experience of ICU” Mr James Gough - former ICU patient,

In this session, James will tell his story of his experiences, and that of his family, while in ICU, as well as his longer term and/or ongoing recovery. The insights, particularily around delirium will provide a patient’s perspective of their care and so enhance the healthcare professional’s understanding of what happens.

“The role of alpha 2 agonists in the implementation of sedation and delirium guidelines”

Kathy Dalley and Jane Roe, St Georges Hospital Aim: The aim of this workshop is to explore the assessment of mental capacity in the intensive care setting. The Mental Capacity Act 2005 requires us to assume capacity as a starting point when we discuss care with our patients, but in ICU, there are myriad reasons why we may have to adapt communications and/or

Dr Anna Joseph, Kingston Hospital, Kingston Upon Thames.

In this session Anna will look at her experiences of the management of delirium in intensive care patients, and will cover the practical application of recent sedation guidelines as part of a multidisciplinary approach to

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manage and reduce delirium in patients, so achieving the right balance for patients and staff.

W08: Critical Care Nurse Education –

Development of a Competency Framework – Specialist Competencies Samantha Cook, Critical Care Nurse Education Review Forum, Sarah Leyland, St Georges Hospital, Graham Brant, South West Critical Care Network This workshop will provide a platform to discuss new specialist competency sets from the Critical Care Networks (CC3N). Version 2 of the National Competency Framework was published in 2015i.

It is intended that specialist competencies will be used in addition to the CC3N Step Competencies. ICU managers and educators would select from a nationally available suite of competencies to develop the additional specialist skills that are relevant to care for patients in their service. The CC3N Step One Competencies should be completed first as a pre requisite with the specialist competencies following these either before or after CC3N Step Two and Step Three competencies according to unit requirements.

W09: Bedside Nasojejunal Tube Placement - Nurse Led Service SPONSORED BY Hands on workshop comprising of 3 work stations to demonstrate and practice bedside placement technique for Nasojejunal tube placement and confirmation using the CORTRAK Enteral Access System, securement of feeding tube using CORGRIP nasal retention device and instruction on active and passive gastric drainage and decompression using ENFit drainage feeding tubes, ENFit drainage bags and FARRELL decompression system.

The workshop is designed to provide practical techniques in feeding tube placement, confirmation and management.

It is anticipated that specialist competencies will be written to cover the following topics: · Major Trauma · Burns · Neurological Care · Cardiothoracic · Liver In addition, Step 4 leadership and management competencies are being developed and will be added to the competencies in 2017. All Critical Care Networks in England, Wales and Northern Ireland are encouraged to work with their Local Higher Education Institutes (HEIs) to ensure these are imbedded in critical care award curriculums.

Learning outcomes and format: 1. Provide an overview of the competency framework and progress on Specialist Competencies 2. Launch completed additional competencies 3. Facilitated discussion regarding development of specialist competencies 4. Feedback from participants on use of competencies / future options for development References CC3N (2013) National Competency Framework for Adult Critical Care Nurses. Available at: www.cc3n.org.uk

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Concurrent Abstracts C03: What are the components of a ‘good’

ward round in a large adult critical care unit and how can we make them happen more often? An Appreciative Inquiry Study Clair Merriman, Oxford Brookes University, QMUL PhD Student Background: The ward round (WR) and its place in the promotion of quality care is of particular concern in critical care, where the increasing complexity of work demands excellent communication within the multidisciplinary team (MDT) and effective ways of organising interrelated interventions of critical ill patients. Given the high workloads and emotionally and technically demanding nature of work in critical care, the traditional WR is viewed as too time consuming.

Aim: Study current WR practices in a large regional ACCU and contextualize findings within relevant literature and policy.

Understand and improve multidisciplinary WR practices.

Work with MDTs to prioritise WR practice improvements, propose solutions, develop materials and processes, innovate and evaluate.

Methods: A collaborative service improvementfocused methodology was utilised. Data collection was underpinned by Appreciative Inquiry (AI) (Cooperrider, and Srivastva, 1987) and used contrasting methods to gain a holistic understanding: Ethnographic Observations Key Informant Interviews Recording Quantitative information about the conduct of the WR A pre validated questionnaire: Team Psychological Safety Guided by question from the AI framework qualitative data was scrutinised using iterative thematic analysis (DeSantis and Ugarriza, 2000). Descriptive summaries of quantitative data were provided.

Results: Data analysis identified three themes and a number of subthemes that exemplified a Good Ward Round: ‘Good Use of Time’ ‘Good Use of Expertise’ ‘Good Use of Communication’ Discussions and Conclusions: Unpacking the complexities of the WR provided new ways of ‘looking’ at and reflecting upon WR practices generating new understandings of what the WR ‘is’ and what it needs to look ‘like’ to have an impact on patient safety and

efficiencies of staff time. It is hoped that this work will yield conclusions which are valuable to HCPs, policy makers and future researcher of the WR. By understanding and challenging the different points of view that each healthcare professional (HCP) holds about the WR process, this study unpacked the complexities of the WR. References: Cooperrider, D. L. and Srivastva, S. (1987) Appreciative inquiry in organizational life. Research in organizational change and development, 1, pp.129-169. DeSantis, L. and Ugarriza, D. N. (2000) The Concept of Theme as Used in Qualitative Nursing Research. Western Journal of Nursing Research, 22(3) April 1, 2000, pp.351-372.

C02: Can Focused Efforts Overcome the

Effects of Burnout, Compassion Fatigue, and Vicarious Trauma?

Daniel Doherty, Christiana Care Health System Aim: This work summarizes a completed prospective, quantitative research study examining the relationship between nurses and patients who are critically ill, sick, or dying, and challenges of separating work from one’s personal life. Our research was to evaluate the impact of focused education as a mechanism for proactive coping with effects of burnout, compassion fatigue, and secondary trauma.

Methods: Volunteer registered nurses received three 90-minute sessions at baseline, offered once a week for three consecutive weeks followed by completion of the ProQOL. The ProQOL, a 30-item scale measuring burnout, compassion fatigue, and secondary traumatic stress is the most reliable, vetted tool to assess positive and negative effects of the concepts. Paired t-tests were conducted to determine if focused education offered at baseline and repeated at 6 months could overcome the effects of burnout, compassion fatigue, and secondary trauma for nurses. At baseline versus 6 months, significant differences were measured in the scores of compassion satisfaction M=39.3 versus M= 41.1, t=2.54, p=0.007; burnout M 23.1 versus M 21.3, t=2.83, p=0.003; and secondary trauma M=24.5 versus M=21.8, t=3.06, p=0.00009. All results were in a favorable direction based upon ProQOL metrics Results: Our results reflect that focused education can significantly mitigate the effects of burnout, compassion fatigue and secondary trauma for nurses investing

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oneself in the care of others.

Conclusions: These results are very encouraging and may support the use of this program to reduce negative consequences of working with patients who are ill, sick, dying or experience trauma.

References: Beck, C. (2011). Secondary traumatic stress in nurses: a systematic review. Achieves of Psychiatric Nursing 25 (1). Retrieved on October 10, 2012 from Ovid database. Bradbury-Jones, C,; Tranter, S. (2008).

Inconsistent use of critical incident technique in nursing research. Journal of Advanced Nursing 64 (4). Retrieved on October 10, 2012 from Ovid database. Benoit, L., Veach, P.; LeRoy, B. (2007). When you care enough to do your very best: genetic counselor experiences of compassion fatigue. Journal of Genetic Counseling 16 (3).

Retrieved on October 10, 2012 from Ovid database

C04: Improving Lung Protective Ventilation Compliance Across Lancashire and South Cumbria Critical Care Network Claire Horsfield, Lancashire and South Cumbria Critical Care Network Background: Current literature supports the use of low tidal volume ventilation strategies (6 mls/ kg Ideal Body Weight) in order to reduce the risk of developing acute lung injury (ALI) and furthermore reduce mortality (ARDSnet, 2000 and Faculty of Intensive Care Medicine (FICM) and Intensive Care Society (ICS), 2015).

During March 2015, a case note review was performed of patients admitted to critical care with severe sepsis across 4 units in Lancashire and South Cumbria (n=35), this identified some areas for improvement, notably mechanical ventilation strategies.

Aim: The Critical Care Network established a multi professional group consisting of medical, nursing and pharmacy representatives. The group utilised quality improvement methodologies to implement improvements in relation to lung protective ventilation strategies within adult critical care units across the Network.

Methods: The group reviewed national recommendations and local audit data to inform improvements. Through achievement of consensus, identification of local unit quality improvement leads and a programme of regular audit and feedback, members have developed and shared various resources to support improvements.

Results: Baseline data indicated that only 31% of tidal volumes recorded were 7ml/kg of ideal body weight or below. 49% of recorded tidal volumes were above 7ml/ kg, with 20% having no data recorded or being related to

augmented tidal volumes.

Through consensus achievement, the group has developed a variety of resources to support improvements in relation to lung protective ventilation.

Activities and resources include; • Poster campaign –‘Blow Low’ • Monthly audit programme • Development of a ‘Tidal Tape’ to provide instant tidal volume requirements.

• Feedback at network forums Quality Improvement methodology training Presentation at local conference Findings: Through the establishment of a multi professional group of critical care practitioners, and utilising quality improvement methodologies, the group has applied a multi-faceted approach in order to drive improvements in relation to lung protective ventilation.

References: ARDSnet (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The New England Journal of Medicine (342) 18, pp.13011308. FICM and ICS (2015) Guidelines for the Provision of Intensive Care Services. First Edition. ICS, London

C05: Quality improvement for critical

care: improving staff engagement in the provision and completion of patient diaries to assist psychological recovery Asya Veloso Costa and Olivia Padfield, King’s College London, Sarah Elliott, Medway NHS Foundation Trust Background: Patients surviving critical illness are at risk of developing psychological problems after discharge, with as many as 10% reporting symptoms of posttraumatic stress disorder (Wake & Kitchener, 2013).

This has been shown to positively correlate with length of intensive care unit (ICU) stay. NICE recommends commencement of rehabilitation as soon as clinically possible in this group. Diaries have been shown to assist patients with fragmented delusional memories and difficulty recollecting their experience, and are hypothesized to work similarly to cognitive behavioural therapy. Factors including lack of awareness, time constraints and the non-compulsory nature have led to inconsistent staff engagement with the patient diary system at Medway Maritime Hospital.

Aim: This project aimed to increase provision, consistency and overall multidisciplinary team (MDT) engagement with diaries for patients admitted to ICU for over 72 hours.

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Methods: Trialled methods included adding reminders to the online patient note system (Metavision), providing education sessions and raising awareness, and introducing a bedside guidance document to facilitate entry completion. Data was recorded on and collected from Metavision; 129 patients were sampled over 105 days, with 77 receiving diaries.

Findings: Baseline average diary provision (26%) increased to 83% after Plan-Do-Study-Act (PDSA) cycle one. Cycle two saw a further increase to 100%, with a subsequent decrease to 75%. However, final changes saw a return to 100% by the end of cycle three.

Frequency of daily entry completion also increased, and physiotherapists (engaged in cycles one and two) and an occupational therapist (engaged in cycle two) completed entries alongside nurses.

Discussion: On three distinct data collection points, all patients admitted for over 72 hours received diaries.

Furthermore, a greater number and variety of the ICU MDT completed more regular diary entries. Although additional methods may be warranted to ensure long term sustainability, we hope to have implemented effective changes.

Methods: We have established an innovative, window of opportunity feasibility trial, to evaluate a two-week exercise programme, delivered between diagnosis and surgery.

Following consent, patients undergo a baseline CPET. We use their recorded anaerobic threshold and VO2 maximum to tailor individualised, interval training sessions on a stationary bike. Sessions are 3 minutes at moderate intensity and 2 minutes at high intensity, repeated six times. Patients attend six sessions over two weeks, then just before surgery, they undergo a second CPET to assess changes to physical fitness. The same clinician reviews the repeat CPET, but is blind to patient identity. This ensures reliability while minimising interpretation bias.

Results: We will present outcome data and implementation experience from our 20 patient trial.

Interim analysis has revealed promising changes to physiological fitness, exercise adherence and patient perception. Although a single-arm feasibility trial, we will also examine post-operative morbidity and mortality, Critical Care length of stay and return to surgery.

References: Wake, S. and Kitchiner, D. (2013). Post-traumatic stress disorder after intensive care. BMJ, 346, p.f3232.

C06: EDICT: A feasibility trial to examine

how a prehabilitation exercise programme may help to prevent post-operative complications for patients with colorectal cancer Andrew Bates, Professor Tamas Hickish and Dr Richard Green, Royal Bournemouth and Christchurch Hospital, Dr Sandy Jack, University Hospital Southampton Background: Colorectal cancer is the third most prevalent cancer in the world. In 2014, the United Kingdom saw 41,265 new diagnoses with over 25,000 patients undergoing a major surgical resection.1 Poor physical fitness, measured by Cardiopulmonary Exercise Test (CPET), reflects reduced physiological reserve and is predictive of post-operative complications.2 Consequently, CPET has become established as a perioperative risk assessment tool.3 Less fit patients are supported by placement in Critical Care for an extended post-operative recovery.

Aim: We propose that physiological variables derived

from CPET, can be used to design a prehabilitation exercise regimen. This is an attempt to improve physical fitness prior to surgery and may help to prevent postoperative morbidity and mortality, reducing Critical Care bed occupancy.

Discussion: We will describe how our work has informed the design of a Randomised Controlled Trial and how this may translate to future service provision.

References: 1: Cancer Research UK: http://www.cancerresearchuk. org/health-professional/cancer-statistics/statistics-bycancer-type/bowel-cancer#heading-Two Accessed: March 2017 2: West M. A., Lythgoe D., Barben, C.P., Noble, L., Kemp, G.J., Jack, S. and Grocott, M.P.W. Cardiopulmonary exercise variables are associated with postoperative morbidity after major colonic surgery: a prospective blinded observational study. British Journal of Anaesthesia 112 (4): 665–71 (2014) 3: Levett, D.Z.H. and Grocott, M.P.W., Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery (ERAS) Can J Anaesth. 2015; 62: 131–142.

C07: Eliminating pressure ulcers caused by Nasogastic (NG) Tubes in Intensive Care

Nicola Allison, Warrington and Halton NHS Trust Background: Reducing rates of pressure ulcers is a nursing priority and key quality indictor as monitored by the NHS Safety Thermometer (CQUIN, 2014). Medical device related pressure ulcers can be difficult to prevent

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as they often perform essential role in a patients treatment (Fletcher, 2012). The rigid materials NG tubes are made from such as rubber, silicone or plastic can create pressure or cause rubbing upon the soft tissues (Jaul, 2011) and due to the lack of adipose tissue to the nose the area can deteriorate rapidly. Within a 20 bedded general Intensive Care Unit (ICU) high incidences of pressure ulceration of the nostril were reported relating to the positioning or fixation of the NG tube.

From an audit of DATIX submissions 9 cases of pressure ulcer damage were reported between November 2014 and November 2015. Therefore research was undertaken to find a new way to secure NG tubes to the patients reducing harm and improving patient experience.

Aim: This service improvement aimed to prevent and eliminate pressure ulcers caused by NG tubes.

Methods: After researching alternative NG securing devices and dressings an adaptation of another NHS Trusts method was implemented with a slight modification. The design involved using Durapore tape to ‘hammock’ the NG in the centre of the nostril therefore ensuring the device was not in contact with the skin and allowing for easy inspection of the nostril. Nurses were educated on the new design and feedback obtained Results: Since implementation of the new method there have been zero cases of pressure damage from NG tubes to date. The method is now being disseminated to the general ward areas References: Commissioning for quality and innovation (CQUIN): 2014/15 guidance. Available at: https:// www.england.nhs.uk/statistics/wp-content/uploads/ sites/2/2013/09/CQUIN-Guidance-2014-15-PDF-751KB. pdf [Accessed February 2017] Fletcher, J. (2012) Device related pressure ulcers made easy. Wounds UK [online], v.8 (2) p. 1-4 Available at http://www. wounds-uk.com/pdf/content_10472.pdf [Accessed 20th November 2016] Jaul, E. (2011) A prospective pilot study of atypical pressure ulcer presentation in a skilled geriatric unit. Ostomy Wound Management [online] 57(2) p. 49–54 Available at: https://www.researchgate. net/profile/Efraim_Jaul/publication/50196298_A_ Prospective_Pilot_Study_of_Atypical_Pressure_Ulcer_ Presentation_in_a_Skilled_Geriatric_Nursing_Unit/ links/00b4952c3189e5b6c9000000.pdf [Accessed January 2017]

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C08: Incidence and prevalence of pressure

‘bed days’ and ‘level 3 patients’ increased, therefore the patients were sicker and stayed longer. Data relating to the incidence and prevalence of specific pressure ulcers will be presented at conference.

Sarah Farnell-Ward, St George’s University Hospitals NHS Foundation Trust

References Coyer F M, Stotts N A, Blackman V S. A prospective window into medical device-related pressure ulcers in intensive care. International Wound Journal. 2013; 656664.

Tayyib N, Coyer F, Lewis P. Pressure ulcers in the adult intensive care unit: a literature review of patient risk factors and risk assessment scales. Journal of Nursing Education and Practice. 2013; 3(11):28-42.

VanGilder C, Amlung S, Harrison P, Meyer S. Results of the 2008-2009 International Pressure Ulcer PrevalenceTM Survey and a 3-Year, Acute Care Unit Specific Analysis. Ostomy Wound Management. 2009; 55(11):39-45.

ulcers: A longitudinal retrospective audit and service improvement evaluation

Background: Pressure ulcers cause a huge amount of unnecessary suffering and place an enormous financial burden on an already overstretched National Health Service. Due to severity of illness and other complicating factors such as immobility, hypoxia, hypotension and incontinence, intensive care patients have a 10-42% incidence of pressure ulcers (Cooper, 2013). Pressure ulcers can occur anywhere on the body where there is prolonged exposure to pressure (Tayyib et al, 2013), as such medical device-related (MDR) ulcers account for approximately 10% of pressure ulcers acquired in intensive care patients (VanGilder, 2009).

Aim: To identify the incidence and prevalence of pressure ulcers acquired in GICU (General Intensive Care Unit) since September 2013.

To identify the incidence and prevalence of MDR pressure ulcers (such as nasogastric tubes, oxygen therapy, endotracheal tubes and Non-Invasive Ventilation).

To evaluate a pressure ulcer prevention service improvement project (Hotspots).

Methods: In August 2014 a pressure ulcer prevention ‘Hotspot’ project was launched in GICU. The aim was to raise awareness of device related pressure ulcers and identify preventative measures. Since September 2013 incident reports (Datex), relating to pressure ulcers acquired in GICU, have been collated and analyzed.

Results: Following the implementation of the Hotspot project the incidence of pressure ulcers acquired in GICU has reduced by 12.3% and there has also been a reduction in prevalence (Table 1). However, the number of MDR ulcers has risen by 18.3% and this is thought to be due to previous under reporting and an increased awareness of MDR ulcers (Coyer et al, 2013).

Table 1 While the numbers of patients treated during this audit decreased it is important to note that the number of Date

01/09/13-31/08/14 01/09/14-31/08/15 01/09/15-31/08/16

No of patients treated 2084 1983 1878

Pressure ulcers acquired in GICU Incidence 81 71 71

Prevalence 3.9% 3.6% 3.8%

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Medical device related (MDR) pressure ulcers Incidence Prevalence 24 (29.6%) 1.2% 34 (47.9%) 1.7% 34 (47.9%) 1.8%

C09: The Implementation of a Web-based

Pathway for Patients requiring ECMO Extracorporeal Membrane Oxygenation (ECMO) for Severe Acute Respiratory Failure (SARF) Rebecca Langley, Joanna Keating, Adrienne Cottam and Dr Gillian Halley, Royal Brompton and Harefield NHS Foundation Trust Background: Hospital to Home at Royal Brompton and Harefield NHS Foundation Trust (RBHT) designs builds and implements web-based pathways for complex needs patients. In 2015, in collaboration with the ECMO Multidisciplinary Team (MDT), a pathway was developed for ECMO patients. This aims to enhance information sharing across organisational and inter-professional boundaries, therefore improving the efficiency, quality and safety of communication (Data Services for Commissioners, NHS England 2016, Oakley, Hunter 2017, Honeyman, Dunn et al. 2016).

Methods: The pathway was launched at RBHT in January 2016. Over the last calendar year implementation support has been provided with the aim to embed the pathway into business as usual.

This included: Delivery of pathway awareness sessions at RBHT and to the associated referral network, including travelling to referring hospitals Delivery of pathway training Changes to RBHT and the Critical Care Network websites Development of training resources via a variety of media (video, online downloadable documents) Telephone helpdesk support Pop in pathway support clinics Results: Since go live, a total of 189 referrals to RBHT have been recorded on the pathway. Referrals have come from 62 different hospitals with the number completed directly onto the pathway increasing month by month.

The electronic pathway has allowed for improvements in data quality and completeness of referral information received through the online pathway is greater than the previous paper format. Users report that the pathway saves time in gathering information and enhances accurate patient centred decision making.

Conclusion: A web-based pathway for ECMO patients was implemented that accessible across organisational boundaries. Using digital technology has improved the communication between teams and the quality of data received, this ensures appropriate decision making and enhances the service provided. This data can be used more effectively for service evaluation as well as reporting nationally and internationally.

References: Data Services for Commissioners, NHS England, 2016. Local Commissioning Data Quality Guidance. Data Services for Commissioners (DSfC), NHS England. Honeyman, M., DUNN, P. and McKenna, H., 2016. A Digital NHS? An Introduction to the digital agenda and plans for implementation. England: The Kings Fund. Oakley, B. and Hunter, J.B., 2017.

Implementing an electronic patient handover system.

British journal of hospital medicine, 78(1), pp. 16-19.

C10: Management of Optiflow Therapy

By A Critical Care Outreach Service And Analysis Of Patient Outcomes Rosemary Zippo and Suzannah Hughes, King’s College Hospital Background: The ‘iMobile Team’ is a multi-disciplinary, consultant-led critical care outreach service. The team brings critical care support to the ward, including initiating and managing Optiflow as an iMobile lead therapy. Optiflow provides high flow oxygen with heated humidification for type one respiratory failure (Nishimura 2015), or symptom relief of dyspnea.

Patients requiring Optiflow fall into different categories depending on indications for Optiflow and ceilings of treatment determined by their team.

Aim: To examine critical care admission rates and survival to discharge for patients receiving Optiflow on the ward, within sub-categories (full escalation, level 2 treatment, ward based management).

Methods: A retrospective audit was carried out on all patients commenced on Optiflow by iMobile from January-December 2016.

Results: 368 patients were treated with Optiflow. 269 patients were for full escalation, 162 (60%) required admission to Critical Care and 77% survived. 107 were managed on the ward and 95% survived.

28 had level 2 ceilings of treatment, of these, 9 (32%) required critical care admission 44% survived. 19 (68%) were not admitted and 74% survived.

50 had ward-based ceilings of care; however 24% were admitted to critical care and 50% survived. 38 (76%) were not admitted, 45% survived and 2 were palliative.

19 had unknown escalation plans.

Implications: Optiflow is a trial of therapy rather than a denial of critical care admission for those eligible.

There are a number of benefits of ward based initiation of Optiflow, including offering a critical care therapy to those patients with a ceiling of ward based treatment.

Optiflow continues to be an effective therapy for management of type one respiratory failure and symptom control of dyspnoea. For therapy that is

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initiated and managed by a critical care outreach service we were able to demonstrate successful outcome date.

This included patients with a variety of indications for therapy and limitations of treatment escalation.

References: Nishimura, M (2015) High-flow nasal oxygen therapy in adults, Journal of Intensive Care, 3 (15).

(2013) Intensive care and home artificial ventilation.

How do nurses experience artificial respiratory care in the home of patients? “ published in Pflege Z, 2013 Apr;66(4):226-30

C12: Introducing Morbidity & Mortality

C11: I’m a long term ventilated patient -

(M&M) conferences to Promote InterProfessional Partnerships and Enhance Quality of Care in Critical Care

Lesley Howlett, Warrington and Halton NHS Trust

Claire Wilcox and Dawn Stephenson, Lancashire Teaching Hospitals Trust

Get me out of here

Godecke and Kohlen ( 2013 ) stated “ Bringing “intensive care” to the home of people challenges original understandings of home care. While intensive care and artificial respiration are technology-oriented, home-care is social-oriented, respecting the familiar environment of the patient “. The Five Year View published by NHS England in 2014 calls for better collaborative working between acute care and social care, calling for as many people to be cared for in their own homes.

Dan was an inpatient on Warrington ICU for 319 days – he needed long term ventilation for a deteriorating neurological condition. His family were desperate for him to go home and be cared for by themselves. We as a unit were adamant we were going to do this for Dan and his family Lesley one of senior sisters began the mammoth task of coordinating Dan’s complex discharge – this would involve the coordination of all community services Dan would access on discharge home and application for the funding of these services. Carers were appointed to care for Dan in his own home on a 24 hour 7 day per week basis. A competency based training package was developed . The carers and members of Dans family were trained for several weeks prior to his discharge in caring for Dan – this included tracheostomy care, tube changes, suctioning and being competent in dans ventilation.

The carers worked alongside the ICU team for several weeks before Dans discharge. With this the carers felt supported in a safe positive learning environment.

Dan’s home environment was adapted in order for him to be ventilated at home – consumables and equipment needed were sent home prior to his discharge. GP, pharmacy, home ventilation team services were also put in place.

Dan was finally discharged home on 15th August 2016 .

He has just celebrated his 25th Birthday with a big party in his home where all ITU staff were invited to attend.

Lesley has just also won the Trusts employee of the year award for tireless commitment to getting Dan home to his family.

References: NHS England (2014) “ Five Year forward view “ published by NHS England. Godecke C and Kohlen H

Background: Following a medication error and subsequent coroner’s inquest, M&M meetings were introduced to discuss all deaths on Critical Care (CRCU) within 7 days to learn from experiences, share ideas and examine where improvements may be made.

Aim: CRCU sought to promote Multidisciplinary working through weekly M&M conferences by improving working relationships, assessing quality and standards of care whilst ensuring patient safety remains our top priority.

We aim to review all deaths, examine patient safety incidents within 7 days, and provide care plans for patients whose length of stay is over 14 days.

Methods: We embarked on a literature search to discover what evidence was available to support MDT involvement in M&M meetings to ensure it was structured and gave opportunity to include opinions from all Allied Health Professionals (AHP), unfortunately only a small number of results were identified. A new Clinical Lead was keen to include the MDT, but it was the nurse’s responsibility to promote this across the teams.

Findings: A trend in the literature shows M&M conferences improve quality of care by learning from adverse effects through reflection, discussion, education and training; however one of our main findings was inconsistency in the format used for meetings and proved difficult in assessing the impact of the meetings.

There is little evidence on the role of the MDT; we found more evidence to support reduction of patient safety incidents and education. General consensus in the literature indicated M&M conferences allow for discussion and reflection in a “blame-free” environment Conclusion: We introduced a new style of M&M meetings in August 2016. Although we hold weekly meetings with regular attendance from some MDT members it can be patient specific and there is still work to do to promote nurse involvement. We have improved communication and relationships within the MDT to enhance the care our patients receive. Patient Safety Incidents are discussed to increase awareness among the MDT and generate trust-wide improvements.

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References: George J, 2016. Medical Morbidity and Mortality Conferences; past, present and future..

Postgraduate Medical Journal.

Bal G, Sellier E, Tchouda S, Francois P., 2014. Improving quality of care and patient safety through morbidity and mortality conferences. Journal for Healthcare Quality, 36(1), pp. 29-36.

implementation of InS:PIRE nationally.

References: National institute for Health and Care Excellence (2009) Rehabilitation after critical illness in adults NICE Clinical Guideline 83 London: NICE. 

C14: Improving communication and team

work by introducing a new bay leader role

C13: Initial experience of implementing the and safety huddle: A quality improvement intensive care rehabilitation programme InS:PIRE

project

Pauline Murray, Geraldine Ovens and Dr Peter O’Brien, NHS Ayrshire & Arran

Vicky Thwaites, Agnieszka Wypych-Zych, Sue Mather and Peter Doyle, Royal Brompton and Harefield NHS Trust (RBHT)

Background: Rehabilitation of critical care survivors is a national recommendation [NICE]. As the first roll out site for InS:PIRE (Intensive care syndrome: promoting independence and return to employment) we report our initial experience of successfully implementing the programme in a district general hospital setting.

Methods: Following identifying of patients, key stakeholder involvement and creating the multidisciplinary team the first programme cohort ran over five consecutive Monday afternoons in May 2016.

Using improvement methodology throughout, feedback was gathered from staff, patients and carers at the end of each meeting. Using the model for improvement we embraced continuous improvement and altered the programme either immediately or for future cohorts.

Each of those changes was subsequently tested.

Results: Patient selection criteria were based on invasive ventilation >48 hours and age range 18-75years. A four month selection period (November 2015 – February 2016) was chosen based on running three cohorts per year. Following exclusion of current inpatients, 16 patients fulfilled the criteria, of these 13 were invited. Exclusions were due to psychiatric admissions elsewhere and a recent diagnosis that would preclude rehabilitation. 8/13 (62%) invited patients attended on day one. A further 2 patients were invited and attended at their request. Of the total 10 patients, 9 patients completed the entire five week programme (90%). All participating patients rated the value of InS:PIRE as either five or six on a scale maximum of six.

Discussion: Our aim was to implement InS:PIRE, a patient-centred, multidisciplinary, goal directed rehabilitation programme created within a busy city centre adult ICU. As the first roll out site, we were testing the success of implementation within a smaller district general setting accepting that it may be unsuccessful. Our experience to date, has been to the contrary evidenced by both patient and staff positive feedback. Our experience supports the wider successful

Aim: As a cardiothoracic intensive care which is extending from 23 to 29 level 3 patients we wanted to improve team working and communication. According to Goldsworthy (2016) the need to develop initiatives which will improve nurses working environments is urgent as it will reduce staff turnover, improve moral, productivity and patient safety.

As part of a quality improvement initiative we implemented the role of bay leaders and started huddling. The huddle process utilised a SBAR communication tool which enables nurses to succinctly summarise their patients to other nurses within that area and provide an action plan for the day.

Huddling improves patient safety and can be used as a preventative tool by ensuring key information is communicated, such as pressure areas care plans, difficult airways, falls risk etc (Corbally and Timmins, 2016).

Methods: The initiative was audited initially a few months after introduction with a sample of 62 respondents which represented a cross section of nursing bands, reaudited a year later with 70 respondents and again 9 months later with 98 respondents. The audit comprised of asking nurses to anonymously complete questionnaires which looked at compliance and their opinion on current support and teamwork.

Findings: We found that compliance with the bay leader role and huddling improved with each measure, communication has improved and nurses felt they were getting more help and support. The findings and feedback from each measure were used to further develop and improve the initiative and we plan to continue this process in future.

Conclusions: The bay leader role and use of huddling within our intensive care has helped to strengthen our nursing teams and will aid the transition to a bigger unit.

Although the aim was to improve the nurses working experience, patient care has also been improved as a result.

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References: Corbally M, Timmins F. (2016) The 4S approach: a potential framework for supporting critical care nurses’ patient assessment and interprofessional communication BACCN; 21: 64-67 Goldsworthy S. (2016) Deteriorating work environments for critical care nurses: how urgent is this issue and what can be done?

BACCN; 21: 6-7

C15: Researching NAVA technology via a NIHR doctoral fellowship

Daniel Hadfield, King’s College London/King’s College Hospitals Neurally Adjusted Ventilatory Assist (NAVA) technology is a complex intervention comprised of a monitor of diaphragmatic activity and a neurally triggered, proportional ventilation mode. Clinical effectiveness has not been demonstrated and feasibility data are required prior to larger definitive randomised controlled trials.

The RESTUS study compares the use of NAVA to standard care in a randomised pilot study. Here, I will discuss the study progress to date and I will discuss my personal journey from initial protocol development to clinical trial and NIHR Fellowship

C16: Developing a clinical academic career in the Emergency Department

Edward Baker, King’s College London Patient centred research is the pinnacle of effective critical care evidence based practice. Despite the successes of our medical colleagues, developing clinicalacademic working remains a challenging and complex process for nurses and allied health professionals. The overt and covert barriers between clinical practice and the research/education paradigm often makes the transition unappealing and difficult.

The National Institute of Healthcare Research (NIHR) is a UK government body that receives Department of Health funding to direct and co-ordinate translational research programmes for the benefit of National Health Service (NHS) patients. The NIHR offers opportunities to develop clinical academic working through fellowships, training and mentorship.

I will introduce and discuss my own research considering the treatment pathways for patients with blunt thoracic trauma using a transitional and reflective approach. In this session, I will also explore the development of a clinical academic career through the doctoral fellowship route considering the intrinsic motivation, surviving the application process and factors that influence progression.

C17: Developing an NIHR Programme Grant to examine safe staffing in ICU

Professor Ruth Endacott, Plymouth University/ Royal Devon and Exeter Clinical School, Royal Devon and Exeter Hospital and, Monash University, Melbourne In this session, we will focus on how a programme of research is developed. We will examine how the clinical and academic team is drawn together, how research teams build in opportunities for clinical-academic career development and what makes ICU nurses and AHPs attract to research teams. We will use the programme grant currently under development – safe staffing in ICUs – to address some of these questions and draw on examples from other critical care research programmes.

C18: Simulation in-situ - An extra patient on the ward round

Hayley Gilbrook and Vicky Rutherford, West Suffolk Hospital Introduction: Using simulation in education is nothing new, it has shown to be profoundly effective in undergraduate education, resuscitation and learning within the Critical Care environment. It is well recognised that team training using high-fidelity simulation could help improve patient safety by promoting effective communication, team collaboration and clinical competence (Meurling et al, 2013).

Methodology: At the West Suffolk Foundation Trust we actively admit Sim-Man onto our critical care unit once a month for a duration of 3 days. This allows us to run a variety of scenarios that involve the multidisciplinary team including physiotherapists, midwives and blood transfusion nurses. Scenarios are developed by the education team and lead consultant, they range from simple everyday patient assessments to rare and complex emergency situations. Scenarios are sometimes generated based on specific incidents that have previously occurred on the unit.

The advanced technology provided by the Sim-Man allows these events to be recreated as realistically as possible. Sim-Man is admitted onto the CIS, complete with observations, blood results, CXR, and medical notes.

The participants are asked to treat him as they would any other patient and use their equipment and colleagues as normal. The scenario then unfolds accordingly. The process is recorded and used in a de-brief that follows.

The de-brief is essential to the learning process, the team discuss their actions and look at what they would or would not change about their practice. Following the de-

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brief staff complete an evaluation forms asking them to score the experience. It includes a series of 10 questions about the simulation, knowledge gained, lessons learned to take forward and the benefits of this type of learning.

Findings: Having run these scenarios for over a year now, we have learnt valuable lessons around technical and non-technical skills that has benefited the whole of the Multidisciplinary Team including: • Leadership • Teamwork • Situational awareness • Decision Making • Task management • Communication From the evaluations, and also from discussions during the debrief, changes have been made in practice, mainly around communication and processes, all vital in maintaining safe and effective patient care References: Meurling, L., Hedman, L., Sandahl, C. Fellander-Tsai, L. and Wallin, C. J. (2013) ‘Syatematic simulation-based team training in a Swedish intensive care unit: a diverse response among critical care professions’, BMJ Quality and Safety, 22, pp.485-494

C19: Paediatric In-Situ Simulation on Adult Intensive Therapy Unit

Mark Hatch, Mike Dickinson, Andrew Henson and Liz Gooderham, Blackpool Teaching Hospitals NHS Foundation Trust Introduction: Blackpool Teaching Hospitals Simulation and Skills Centre have a range of high-fidelity simulation manikins that can be used in actual or recreated clinical environments to provide a clinical training experience without posing any risk to real patients.

In situ simulation is conducted in the clinical area, using the available staff, resources and equipment. It can be used to reinforce clinical team training, involve human factors, such as such as leadership, situational awareness, decision making and teamwork, and help to identify latent safety threats and systems errors (Patterson et al., 2013). Simulation also offers the opportunity to formally debrief the members of the multiprofessional team, something that occurs rarely in practice, and has been shown to be the most important element in providing effective learning in simulationbased education.

Aim: In Blackpool, critically ill children are occasionally managed in the adult Intensive Therapy Unit (ITU) for stabilisation and initial treatment, prior to transfer to regional specialist paediatric centres. The aim was to run a paediatric in-situ simulation on adult ITU to with the multiprofessional team, the environment, equipment,

systems and protocols currently in place to deal with such an emergency, leading to improvement in patient safety outcomes (Fent et.al, 2015).

Methods: The poster summarises the planning, implementation, evaluation and recommendations that were identified as the result of an in-situ simulation of a child with meningococcal septicaemia, and how it led to improvements in practice. Careful planning and risk assessment ensured the scenario ran smoothly and had no impact on patient care on the unit and the hospital as a whole. A post-scenario debrief was held for the team to reflect on their performance and identify learning points.

Results: From debrief, the following learning points were identified by the team: 1) Team role allocation: team lead, airway and breathing, fluids, drugs, disability and exposure, and scribe.

2) Cognitive aids: WETFlAG, CrashCall, B@EASE Rapid Sequence Induction Checklist - not immediately available or visible to the team.

3) Paediatric emergency trolley: quickly became overcrowded with equipment, leading to delay with preparation of airway equipment.

4) Communication: communication breakdown due to stress and cognitive load.

5) Psychological support for parents/carers: delayed due to fidelity error.

6) Team Reaction: Staff found the experience interesting, some loved it, some felt like crying, some felt like it was a test.

Conclusion: From the in-situ simulation the following: * Prior allocation staff roles – more effective team working * WETFlAG and CrashCall calculations visible on the wall or a whiteboard. * Ergonomics of paediatric emergency trolley/airway tray to be reviewed. * Emphasise closed loop communication, SBAR handover * Regular future in-situ simulation * Incorporate Human Factors into staff training * Review and adjust systems & protocols for paediatrics References: Fent, G., Blythe, J., Farooq, O., & Purva, M. (2015). In situ simulation as a tool for patient safety: a systematic review identifying how it is used and its effectiveness. BMJ Simulation and Technology Enhanced Learning, Published online Patterson, M.D., Geis, G.L., Falcone, R.A., LeMaster, R., & Wears, R.L. (2013). In situ simulation: detection of safety threats and teamwork training in a high risk emergency department. British Medical Journal Quality & Safety, 22, 468-477

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C20: Visual Learning Aid Nicole Lee, MID Essex Aim: To teach non burn specialist multi dispensary team members (MDT) how to calculate a burn percentage area using the rule of nines, with the ability to add smaller areas to the percentage calculation. This training aid aims to achieve maximum effect within minimal time, in order to get the target audience to commit to learning burn specialist care Methods: With the growth of the social media being used by medical staff. Twitter and Facebook shifting the way in which staff network and access medical learning aids, I decided to create a short film that would be accessible from mobile devices. I create a story board to tell the story of the rule of nines and contacted our hospital medical photography department to see if they could help then pitched the idea to the MDT. The film was created quickly taking 3 hours to film and a further 3 hours of editing, adding visual effects and voice overs. It took some time to gain trust approval working closely with the head of communications within the trust looking at RCN, GMC, NMC and trust Social media policy’s making edits accordingly (Ventola, 2014).

Findings: Following release of the film there has been a snowball effect to learning with the use of twitter and Facebook to MDT members, other regional burn services and beyond to other medical personals.

published the clinical guidelines for the management of PAD in Intensive Care Units (ICU), integrating evidencebased and patient centered protocols. Pain is the most common memory people report from their ICU stay.

Critically ill patients may be unable to self-report their pain due to the use of mechanical ventilation or sedative agents that alter the level of consciousness. Agitation in critically ill patients may result from inadequately treated pain, anxiety or delirium. Delirium is associated with increased mortality, prolonged ICU stay and cognitive impairment. Nurses should routinely monitor ICU patients for PAD. The main aim of this project was to audit how frequently nurses are assessing PAD on GICU, as well as what assessment tools are being used. The results have shown that there is still a lack of knowledge about PAD and PAD assessment tools and consequently Pain Agitation and Delirium are not being monitored as often as guidelines currently recommend. It is important to implement a protocol in ICU for assessment of PAD that includes valid and reliable assessment tools for nurses to assess PAD and nurses should be educated in view to correctly use them.

Following these results, teaching on the tools will be established and a chart sticker added to the ICU Observation Chart to remind and encourage the staff to assess PAD throughout their shift.

References: Barr J, Gilles, LF, Puntillo K, et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Crit Care Med. 2013; 41:263-306.

Conclusions: The concept of a short catchy fun film that people would watch laugh and forward on to others would create a snow ball effect to learning on this topic was correct. There has been a realisation of the effects of learning in this manner being so influential in the age of social media and possibly an extra aid to training.

C22: A person centred approach to

https://www.youtube.com/watch?v=oFe-SL_6C28

Jennifer Howie, Janice Cumming and Stephanie Frearson, NHS Ayrshire and Arran

References: Ventola, L C,. 2014. Social Media and Health Care Professionals: Benefits, Risks, and Best Practices.

Pharmacology and therapeutics. Vol 39 issue 7 pp.491 499

C21: Use of Pain Agitation Delirium (PAD)

assessment tools to assess PAD in a General Intensive Care Unit Joel F Cardoso Pereira, St George’s University Hospitals, NHS Foundation Trust Background: This presentation will share results of an audit of the Pain, Agitation and Delirium (PAD) tool in a General adult Intensive Care Unit (GICU).

In January 2013, the Society of Critical Care Medicine

improving pain assessment within ICU

Introduction: Systematic pain assessment is often associated with reduction in the duration of mechanical ventilation and length of Intensive Care Unit (ICU) stay (Rose et al, 2013) Within our ICU we have never used a specific pain scoring tool geared towards assessing pain in the non-verbal, ventilated critically ill patient. The Critical Care Pain Observation Tool (CPOT) is a valid and reliable pain scoring tools for assessing and monitoring pain in the adult ICU patient unable to self report pain (Barr et al, 2013).

Methodology: Using Improvement methodology/Model for Improvement we devised a driver diagram defining our improvement plans.

Phase 1 - Education and awareness of CPOT for all ICU staff

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Phase 2 - Introduction of the tool using PDSA methodology Phase 3 – Outcome measure compliance

Phase 3 – Outcome measure compliance Our outcome measure was to ensure our patients had a CPOT Score of 2 or less and were therefore deemed to be essentially pain free.

From the data collected we can demonstrate compliance with use of the CPOT tool on most of our patients and of those patients scored, the majority were found to be pain free throughout their ICU stay.

Aims/Objectives: In accordance with the 2020 Vision of Health and Social Care (2011) care will be provided to the highest standards of quality and safety, with the person at the centre of all decision therefore our improvement project focused on the introduction of the CPOT within our ICU. Main Findings: Phase 1 Education and Awareness/ Learning Needs Analysis Results from our Learning Needs Analysis showed there were mixed feelings amongst staff how we assessed, managed and treated patient’s pain therefore the majority of staff felt the introduction of a pain scoring tool would greatly improve patient care.

Phase 2 - Introduction of the tool using PDSA methodology Baseline data highlighted that almost 100% of our patients receive regular analgesia however none were regularly assessed using a pain assessment tool.

We have now rolled out the CPOT within ICU and have the following process measures in place to monitor compliance: 1. How many patients have had CPOT scoring 2 hourly during the day?

2. How many patients have had CPOT scoring 4 hourly overnight?

References: Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, Coursin DB, Herr DL, Tung A, Robinson BR, Fontaine DK, Ramsay MA, Riker RR, Sessler CN, Pun B, Scrobik Y, Jaeschke R; American College of Critical Care Medicine.

Clinical Practice Guidelines for the Management of pain, Agitation and Delirium in adult patients in the intensive care unit. Critical Care Medicine. 2013 Jan; 41 (1): 263306 Rose L, Haslam L, Dale C, Knechtel L, McGillon M. Behavioural Pain Assessment Tool For Critically Ill Adults Unable To Self-Report Pain. American Journal of Critical Care. 2013; 22:246-255 The Scottish Government, 2020 Vision for Health and Social Care, 2011

C23: Implementing the ‘SPADES’ (Sepsis,

Pain, Abbreviated Mental Test, Decision, Escalation/ECG, Stable NEWS) safety round to improve standards of care in the Emergency Department Joanna McBride and Emma Greenwood, Belfast Health and Social Care Trust Aims: To ensure compliance of the ‘SPADES’ safety round in the Majors area of the Emergency Department once a day (8.00 am) Monday -Friday 80% of the time.

Methodologies: The Model for improvement (aim, measures and changes) used several Plan, Do, Study, Act cycles to test the design of the ‘SPADES’ safety tool. The primary measurement was to identify the number of days per week the ‘SPADES’ safety round was completed, and to identify any outstanding actions.

Findings: The ‘SPADES’ safety round was completed 80% of the time at 8.00 am Monday to Friday since the launch of the tool after 10 weeks. A variety of paper documents and electronic devices were used to test the tool. Since the introduction of the ‘SPADES’ safety round the percentage of patients over 75 years of age who have had the 4-AMT (Abbreviated Mental Test) completed has increased, and patients who required pain relief have been identified earlier and appropriate analgesia prescribed in a timely manner. The ‘Decision’ is most common element of the ‘SPADES’ safety round that has

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C25: Using implementation research to

required the most actions.

Conclusion: The SPADES round has increased the number of patients that have documented actions regarding the identified elements and Emergency Consultant and Senior Nurse review. Further data collection is required to confirm that ‘SPADES’ is making a positive impact to the completion of the 4-AMT and recognition and treatment of severe sepsis. Next steps are to ensure the ‘SPADES’ round is completed twice daily, every day and on all time critical patients.

References: Rhodes, A et al. (2017) Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016 45 (3) Royal College of Physicians (2015) National Early Warning Score (NEWS).

Standardising the assessment of acute-illness severity in the NHS. Report of a working party July 2012

C24: Improving psychological well-being after critical care: the role of mixed methods research

Leanne M Aitken, City, University of London Background: There is widespread recognition that survivors of critical illness experience compromised psychological well-being, including anxiety, depression and post-traumatic stress disorder in isolation or in combination. Recovery is known to span months to years after critical care, although not all patients follow a similar timeline with some experiencing greatest compromise early after hospitalisation and others experience compromise much later. Further, some patients recover of their own accord without the need for health care intervention while others need extensive support to improve their well-being. Some of the risk factors that have been associated with psychological dysfunction include demographic and socioeconomic factors, chronic illness, past psychological history and clinical factors such as sleep deprivation, early deep sedation, agitation and mood in ICU, although relationships have not been consistently demonstrated across all cohorts.

Development and evaluation of strategies to assist recovery of psychological well-being after critical illness requires consideration of a range of patient factors including the patient’s personal preference, availability of social and healthcare support and severity of dysfunction. Given this complexity, use of mixed methods research is ideally suited to inform the development and guide the evaluation of potential interventions. Case studies from my own, and others’ research, will be used to illustrate application of mixed methods research in this setting.

evaluate the implementation of an ICU telemedicine programme in the UK Dr. Andrea Xyrichis, King’s College, London

Background: Telemedicine programmes offer significant novelty and visibility, as well as the transformational potential to impact on service delivery, patient outcome and experience. To date, uptake of critical care telemedicine has largely been limited to North America, but international interest in its application is growing.

Objectives: To evaluate implementation of this system in the first UK site.

Methods: Data collection during the pilot period followed ethnographic design principles; contemporaneous field notes consisting of over 150 hours of observational data (visits to US sites, implementation meetings, staff training and PPI workshops), documentary and staff survey (n=87) data from an NHS urban Trust.

Results: Data collected so far reveal the complex adaptation work involved in making a US-based technology and organisational practice ‘fit’ the UK NHS. A number of inter-related political, organisational and professional factors needed to be addressed to ensure progression. Occupational and organisational boundary issues, technical representations of clinical work, space and proximity, professional jurisdictions, and the disciplinary power of the video-gaze emerged as themes influencing implementation.

Conclusion: Implementation research enables a rich understanding of the balance between local adaptation and fidelity, and processes associated with managing large scale implementation. Ethnographic insights can help inform knowledge regarding replicability and scale up of programmes internationally.

C26: Using Phenomenology to explore

student nurses’ experiences of spiritual care Ann Price, Canterbury Christ Church University Background: Spiritual care is viewed as integral to holistic nursing practice but studies suggest that most nurses feel unprepared to deal with spiritual needs (Cooper et al 2013). Initial findings of this phenomenological study, where student nurses discuss their experiences of spiritual care, will be outlined in this presentation including exemplars that are relevant to critical care practice.

Aim: The presentation will focus on phenomenology as

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a methodological approach and initial findings around student nurses’ experiences that have transformed their understanding of spiritual care.

Methods: Phenomenology (Van Manen 2014) was chosen for this study as it draws of the lived experience of participants to develop an understanding of the phenomena being explored. This approach fits with the research aim to understand aspects that transform students understanding of spiritual care.

The methodology uses a hermeneutic interpretative approach which explores the underlying meaning that is expressed by participants.

Students volunteered to participate in the study and were interviewed using a semi structured schedule.

Ethical approval was gained before starting data collection.

Analysis: The use of interpretative analysis will be discussed considering the benefits and limitations when used in phenomenological research (Todres & Holloway 2010). Exemplars from the study will be used to demonstrate the inductive approach in phenomenological work and potential implications for critical care practice will be outlined.

Results: Phenomenological methods produced some rich descriptions exploring spiritual care by students. Results using Van Manen (1990) approach are presented as a way of finding areas of wonder and meaning within the texts. The philosophy underpinning this and usefulness of this for practice will be explored.

Summary: This presentation should enable delegates to consider the use of phenomenology as a research approach, particularly related to spiritual care practices.

References: Cooper, K.L.; Chang, E.; Sheehan, A.; Johnson, A. (2013) ‘The impact of spiritual care education upon preparing undergraduate nursing students to provide spiritual care’. Nurse Education Today. 33. 1057-1061.

Todres, L. & Holloway, I. (2010) ‘Phenomenological Research’. In: Gerrish, K. & Lacey, A. (Eds) The Research Process in Nursing. 6th edition. Chichester: John Wiley & Sons. pp 177-187.

Van Manen, M. (1990) Researching lived experience: human science for an action sensitive pedagogy. Albany, N.Y.: State University of New York Press.

Van Manen, M. (2014) Phenomenology of Practice. USA: Left Coast Press.

C27: Critical Care Nurses’ experience of a Compassion Focused Therapy workshop

Joao Bastos da Fonseca and Afonso Varela, The London Clinic

Introduction: Compassion Focused Therapy is a relatively new form of psychotherapy used to support individuals suffering from high shame and self-criticism (1). Recently has also being used to work around individual anxiety and stress through the development of self-compassion (2). Due to significant changes and challenges within the nursing team it was decided to support the staff by providing them with a full day psychological session where the concepts of resilience and self-compassion were covered. The workshop included discussion, meditation and experimental exercises.

Aim: To evaluate the team’s experience of a Compassion Focused Therapy workshop and review its appropriateness to support teams facing changes or challenges.

Methods: A questionnaire was completed by 20 intensive care nurses after the workshop. This included a mix of Likert scales and open-ended questions.

Results: Our findings demonstrate that the majority of the team was mostly satisfied with the workshop and the learning taken from it will help them dealing more effectively with their problems at work. All staff members agreed that this was the type of support that they wanted to be provided with by their employer, although not everybody felt that all their needs have been met.

From the different areas covered, the compassion focused therapy model was the one which interested most staff. Breathing exercises were perceived by some staff members as difficult to adjust to.

Conclusions: New ways to support staff throughout change or challenges are currently available. Compassion Focused Therapy demonstrated to be a positive alternative to consider as it modulates the response of the individual to stress and anxiety during a period where resilience is needed. Larger studies and studies which focus on the effects of the therapy in healthcare teams are needed to better justify the application of Compassion Focused Therapy on a wider scale.

References: 1. Leaviss, J., Uttley, L. (2015).

Psychotherapeutic benefits of compassion-focused therapy: an early systematic review. Psychological Medicine, 45, pp. 927-945. 2. Allen, A.B., Leary, M.R. (2010) Self-Compassion, Stress and Coping. Social Personality Psychology Compass, 4(2), pp. 107-118

C28: National Critical Care Rehabilitation Survey

Claire Horsfield, Karen Cotton and Michele Platt, Critical Care National Networks Nurse Leads Background: Over the last decade there has been a Page 22

growing interest in patient recovery after an episode of critical illness. The National Institute for Health and Excellence, (NICE), (2009), NHS England (2014) and The Faculty of Intensive Care Medicine, (FICM) with The Intensive Care Society (ICS),(2015) have all published guidelines and standards which have raised the profile of the physical and non-physical sequelae that patients experience during their intensive care stay and beyond.

This poster reports the findings from a recent national survey.

C29: Family Support Nurse Group - Cardiac Intensive Care Unit

Carol Howley, Blackpool, Fylde & Wyre NHS Trust

Aims and Objectives: A multi professional subgroup of the national Critical Care Network Lead Nurses Forum (CC3N), was convened to carry out focussed work around compliance and interpretation of rehabilitation requirements, the first stage was to develop and perform a national survey.

Background: Patients admitted to Cardiac Intensive Care Unit (CITU) often cannot speak for themselves; thus, family members become the spokesperson for the critically ill patient. Fox (2014) suggests that family members experience high levels of anxiety and feelings of disorganisation in response to critical illness both during the hospital stay and months after the event (Hardicre, 2003). Poor communication has been a common feature of complaints received so to address this, we have formed a Family Support Group which consists of experienced CITU nurses.

Methods: The survey was distributed by National network Nurse Leads to all critical care units across England, Wales and Northern Ireland. Returns were analysed by a small group of critical care professionals and recommendations developed.

Aim: To provide emotional, communication, decision and anticipatory grief support to families of patients in CITU. To target all patients/families in CITU for >5 days To improve documentation of communication and reduce related incidents.

Results: A return rate of 45% (n=102) was achieved, and there was relatively good compliance evident with initial rehabilitation assessment (75%), rehabilitation prescriptions (53%) and delirium screening (78%).

There was however varied interpretation for a number of areas including the use of tracking tools to monitor rehabilitation progress and what constitutes 45 minutes of ‘active therapy’. Only 28% of units reported swallowing assessments for tracheostomy patients being performed by speech and language therapists, and only 2/3 of units offer a follow up clinic provision.

Methods: Questionnaires were distributed to 24 past patients and their families asking for information about the effectiveness of communication and the support they received whilst on the unit. A poster was developed outlining the role of the Family Support service, for staff and for families.

A patient/family information booklet was developed specifically for Cardiac/thoracic Surgery Patients.

MDT meetings were established for all patients who are in the unit for > 5 days.

We re-designed communication documentation We improved interaction with patients and families through regular meetings.

We commenced a diary to be used between the family support nurse groups.

We follow up each patient/relative with a phone call, 2 weeks post discharge.

Conclusion: This survey has highlighted the need to clarify standards required for rehabilitation of critical care patients. There is also an opportunity to explore the feasibility and development of standard documentation with regard to prescriptions and rehabilitation tracking tools. Links with Allied Health Professionals (AHP’s) will help to further develop resources to guide and support critical care staff in delivering meaningful rehabilitation to patients.

References: FICM and ICS (2015) Guidelines for the Provision of Intensive Care Services. First Edition.

ICS, London NHS England (2014) D16 (D5) Service Specification for Adult Critical Care. Found at https:// www.engage.england.nhs.uk Last accessed 09/01/17 NICE (2009) Rehabilitation after critical illness. NICE clinical guideline 83 Found at https://www.nice.org.uk/ guidance/cg83 Last accessed 09/01/17

Results: From the results of the first questionnaires we found all respondents agreed that a written booklet would have been of benefit. All respondents felt that although they were given support and information on a daily basis from the staff looking after their relative, a dedicated team of nurses would provide continuity of communication and support.

Conclusion: This development has improved communication between patients, families and staff.

References: Fox, Maria Yolanda (2014). Improving Communication with Patients and Families in the Intensive Care Unit: Palliative Care Strategies for the Intensive Care Unit Nurse; Journal of Hospice and Palliative Nursing. 16(2):93-98. Hardicre, J (2003) Meeting the needs of families of patients in intensive

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C31: Critical Care Nurses’ Knowledge of

care units. Nursing times 99(27): 26-27

C30: Factors influencing nurses’s intention

Alarm Fatigue and Attitudes, Perceptions and Practices towards Clinical Alarms

Nadeem Khan, Oxford |Brookes University and Oxford University Hospitals NHS Foundation Trust

Siobhán Casey, University College Hospital Galway, Dr Maura Dowling and Gloria Avalos, National University of Ireland, Galway

to leave critical care areas

Aims: To present findings of a systematic literature review looking at factors influencing nurses’ intention to leave adult critical care settings.

Background: The shortage of specialist nurses has been an ongoing issue for many decades. Although all areas of nursing are affected, critical care areas are especially vulnerable to recruitment and retention issues. A greater understanding of the factors influencing nurse’s intention to leave the critical care environment is required as research in this area is lacking.

Design: Systematic review Data sources: Databases searched were ; BNI, CINAHL, PubMed, PsycINFO, Embase and Health B Elite.

Supplementary searching was performed using the inclusion criteria.

Methods: A broad and systematic search of computerized databases focusing on articles published during 2005–2016 was completed. Papers were critically appraised using a NICE checklist (2012). Data were analysed using Braun and Clarke (2006) thematic analysis.

Results: Fifteen articles met the inclusion criteria. Two main themes emerged from data analysis. These were organisational issues comprising working environment, lack of empowerment and feeling devalued and relational issues which included relationships with colleagues, personal characteristics and end of life care.

The literature review highlights the need for further research and greater understanding of organisational and relational issues affecting nurses in a highly skilled environment.

Conclusions: Based on the findings, hospital leaders and managers need to pay attention to the organisational and relational issues causing nurses to leave critical care areas.

References: Braun, V. & Clarke, V. (2006) Using thematic analysis in psychology. Qualitative research in psychology,3(2), pp. 77-101. Breau, M. & Réaume, A. (2014) The relationship between empowerment and work environment on job satisfaction, intent to leave, and quality of care among ICU nurses. Dynamics, 25(3), pp. 16-24. Cartledge, S. (2001) Factors influencing the turnover of intensive care nurses. Intensive and Critical Care Nursing, 17(6), pp. 348-355.

Aim: Alarm Fatigue (AF) results from practitioners’ sensory habituation to excessive numbers of false or non-actionable clinical alarms. This phenomenon is responsible for numerous deaths and adverse events in the US (Weil, 2009). This study aimed to determine critical care nurses’ knowledge of AF, their attitudes, perceptions, and practices towards clinical alarms.

Methods: A cross-sectional survey targeted a population of 250 critical care nurses in 6 acute hospitals across 10 departments in the West of Ireland. The US based Health Technology Foundation (HTF) Clinical Alarms Survey (Funk et al, 2014) was adapted (with permission) for the study.

Findings: A response rate of 66.4% (n=166) was achieved, representing 12% of the Irish public sector Critical Care Nurse Population. Adverse patient events related to clinical alarms were reported from all hospital sites. The majority of nurses (52%/n=86) did not know, or were unsure, how to prevent alarm fatigue. The majority of nurses reported that non-actionable alarms were frequent (90%/n=148), disruptive to patient care (91%/ n=145), and reduced trust in alarms causing nurses to switch off alarms (81%, n=132). Nurses who knew how to prevent alarm fatigue customised patient alarm parameters frequently (p= 0.037). Frequent false alarms leading to reduced attention or response to alarms was ranked the number one obstacle to effective alarm management. Only 31% (n=50) of nurses believed that alarm management policies and procedures were used effectively, while less than half (48%/n=77) felt that alarm management practices incorporated best available evidence to prevent adverse events.

Conclusion: This is the first known study of AF using the HFT survey among nurses in Europe. Nurses demonstrated a knowledge deficit regarding alarm fatigue prevention indicating the need for education regarding alarm fatigue prevention strategies. Alarm management practices should be evaluated and tailored to mitigate the risks associated with alarm fatigue to protect patient safety.

References: Funk, M. Clark, J.T. Bauld, T.J. Ott, J.C. Coss, P. (2014) Attitudes and practices related to clinical alarms.

American Journal of Critical Care; 23(3):e9-e18.

Weil, K. M. (2009) Alarming monitor problems; Nursing; 39(9):58

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C32: Nursing the Critically Ill Tetanus

pregnancy and their additional needs compared to other patient groups e.g pre and post-natal care.

Patient

Chris Carter and Sue Viveash, British Army Background: This case study explores the care of a tetanus patient in an intensive care unit in Zambia, a Low Middle Income Country in sub-Saharan Africa. The global incidence of tetanus has been gradually reducing, with improvements in vaccination, health education programmes and the World Health Organisation aim to eradicate Maternal and Neonatal Tetanus have all resulted less presentations globally. Unfortunately, tetanus mortality remains a significant problem for many developing countries, due to inadequate vaccination programmes, or due to conflict or humanitarian disasters vaccination programmes are stopped or sporadic in cover.

In Zambia, vaccination programmes have been effective in reducing the incidence of tetanus, however, patients continue to present and often require admission to intensive care units, throughout the country. This case study will explore the presentation, diagnosis and management of an adult patient with tetanus and identify the key nursing considerations for nurses working in resource limited environments. In this case study, key challenges included diagnosis, airway management due to risus sardonicus and trismus and the management of seizures.

Whilst the prevalence of tetanus in the UK is rare. In 2015, five tetanus cases were diagnosed in England, therefore this presentation may be interest to nurses who have limited experience of dealing with this condition.

References: Aksoy M. Celik EC. Ahiskalioglu A. Karakaya MA. (2014). Tetanus is still a deadly disease: a report of six tetanus cases and reminder of our knowledge, Tropical Doctor. 44. 1. 38-42. Muteya MM. Kabey AK. Lubanga TM. Tshamba HM. Mwembo A. Mkoy T. (2013).

Prognosis of tetanus patients in the intensive care unit of Provincial Hospital Jason Sendwe, Lubumbashi, DR Congo. Pan African Medical Journal. 14: 03. Rodrigo C. Fernando D. Rajapakse S. (2014). Pharmacological management of tetanus: an evidence based review.

Critical Care. 18: 217. http://ccforum/content/18/2/217

Aim: To develop a set of guidelines to support bedside nurses when caring for an obstetric patient and establish a group of experienced critical care nurses with an expressed interest in caring for obstetric patients to develop and maintain close working relationship with the midwives.

Methods: The first phase of the project was to develop a working group, formed of midwives and the critical care team, to identify the aim of the guidelines and key areas for development. Both departments agreed that working collaboratively and with open communication would improve the obstetric patient experience in critical care. After a number of meetings, the guidelines were designed, agreed and implemented into practice.

Results: In June 2016, the critical care department in King’s College Hospital (50 beds over 3 units) adopted a set of guidelines to help support nurses when caring for obstetric patients. The guidelines included what to do in the initial 24 hour phase, what to expect from the Obstetric/ Midwifery team and how to facilitate mother baby bonding/ feeding after delivery.

Conclusion: Following implementation of the guidelines, the group has offered support and guidance to nurses when caring for obstetric admissions. Over the 3 units there have been 16 Obstetric admissions in the period July 2016- May 2017. The bedside nurses have found the guidelines to be a helpful tool in guiding their care of this patient group, particularly in the immediate admission phase. It should be noted that 44% of these admissions were under the joint care of Obstetrics and another parent team. This fact compounds the complexities of caring for this patient group. An audit on the use of the guidelines will be carried out and feedback on the patient experience will be evaluated.

References: Hinton, L., Locock, L., Knight, M., Maternal critical care:what can we learn from patient experience?

A qualitative study. BMJ Open 2015;5:e00676. doi:10.1136/bmjopen-2014-006676 Flacking, R., Ewald, U., Nyqvist, K.H. and Starrin, B. 2006. Trustful bonds: A key to ‘becoming a mother’ and to reciprocal breastfeeding. Stories of mothers of very preterm infants at neonatal unit. Social Science & Medicine, 62 (1):70-80

C33: Guidelines for caring for obstetric patients in critical care

Charlotte Whittaker, King’s College Hospital Introduction: Obstetric admissions are a challenging patient group. They can be among the sickest patients in critical care due to the physiological changes during Page 25

C34: An audit of cerebral perfusion

pressure monitoring in a level one trauma neurointensive care unit: target CPP and transducer positioning Shayda Karimi and Paul Candler, Queens Medical Centre Introduction: The Brain Trauma Foundation recommends that cerebral perfusion pressure (CPP) is measured in all patients with severe traumatic brain injury. There is evidence that doing so decreases 2 week mortality from 22% to 13%.1 The Brain Trauma Foundation recommends a target CPP of 60-70mmHg. Aggressive attempts to maintain CPP above 70 poses a risk of adult respiratory failure.2 To calculate CPP, the mean arterial pressure (MAP) used must be transduced at the level of the tragus. 3 Methods: There were 48 data collection episodes from brain injured patients at Queens Medical Centre Intensive Care Unit between September and December 2016.

Results: In 23% of cases the arterial line transducer was not correctly placed and therefore the CPP was measured incorrectly. 15% of measured CPPs were below the target of 60mmHg. This increased to 21% when the transducer was moved to the correct position (tragus).

27% of those patients whose transducers were incorrectly placed had CPPs measured that were within range, but their actual CPP was below target when correctly measured.

Also of note, 22% of patients had a CPP of above 80mmHg, well above the upper target of 70mmHg. Over 80% of these patients were on noradrenaline indicating that in some cases CPP is being over aggressively treated.

Limitations: Single point study- data captured at specific moments only. Eg. Transducers position may have been incorrect for a few minutes only, noradrenaline could have been recently titrated etc.

with severe traumatic brain injury. J Neurosurg. Dec 2013;119(6):1583-1590. PMID: 24098983. http://thejns. org/doi/abs/10.3171/2013.8.JNS13276?url_ver=Z39.882003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_ pub%3Dpubmed& 2 Brain trauma foundation, Guidelines for the Management of Severe Traumatic Brain Injury 4th Edition https://braintrauma.org/uploads/03/12/ Guidelines_for_Management_of_Severe_TBI_4th_ Edition.pdf 3 Joint position statement by the Councils of the Neuroanaesthesia Society of Great Britain and Ireland (NASGBI) and the Society of British Neurological Surgeons (SBNS) with regards to the calculation of cerebral perfusion pressure in the management of traumatic brain injury. 2014. http://www.sbns.org.uk/ files/8914/3282/6634/Final_Revised_NACCSGBI__SBNS_ statement_Aug_2014.pdf

C35: Subarachnoid haemorrhage’s

readmissions to critical care. Are they preventable?

Joao Amaral and Rebecca Gorf, UCLH/NHNN Aim: The Critical Care Outreach Team (CCOT) sees every patient who is discharged from neuro critical care (NCC) within 24 hours of discharge. One of the CCOT goals is to avoid re-admissions (within 48 hours) to NCC. It is also a quality standard that may identify premature discharge, incorrect use of ward care, or deficiencies in the hand over process during the discharge from Critical Care (FICM/ICS, 2015). Our aim was to analyse and determine if these readmissions could have been prevented and identify any possible recommendations to prevent such readmissions in the future.

Methods: Data was collected through electronic and paper patient’s notes including nursing and medical entries for the previous year. Parameters focused on were blood pressure, fluid balance, investigations for presence of DCI/vasospasm, length of stay on both NCC and general wards. We looked also into length of stay for readmission, reason for readmission and use of vasodilators once readmitted. A snapshot audit was performed prior to data collection to assess nurse compliance of the hospital’s subarachnoid haemorrhage (SAH) protocol.

Recommendations: Greater awareness is needed that transducers should be placed at the level of the tragus when measuring CPP. Transducer position should be rechecked regularly, especially after patient repositioning. The cost effectiveness of a dual transducer system should also be investigated; this would allow simultaneous monitoring of the ‘true’ MAP (at heart level) and the CPP MAP (at tragus level). Finally care should be taken not to over titrate norad to avoid the risk of respiratory problems.

Findings: A retrospective audit showed that in one year 114 patients were admitted to a tertiary neurological and neurosurgical hospital with diagnosis of SAH. Of these 114 patients, 81 [71%] were seen by CCOT. 18 of these patients [22%] required readmission to NCC, accounting for the largest number of readmissions to NCC after respiratory complications.

References: 1 Gerber LM, Chiu YL, Carney N, Hartl R, Ghajar J. Marked reduction in mortality in patients

Conclusions: A SAH Care Bundle could be introduced.

Devised by the multidisciplinary team (MDT), it would Page 26

ensure both nursing and medical staff deliver evidence based care tailored for this patient group. With the MDT following best practice guidelines we can ensure we deliver patient focused, individualised care for patients, and hopefully prevent readmissions to critical care due to secondary complications of SAH. References: Faculty of Intensive Care Medicine and Intensive Care Society. (2015). Guidelines for the Provision of Intensive Care Services. 1st edition.

Retrieved March 29, 2017, from https://ficm.ac.uk/sites/ default/files/gpics_-_ed.1_2015_v2.pdf

C36: Endotracheal tube cuff pressure

deflations during monitoring by ICU staff – a simulation study Catherine Peutherer and Vikesh Patel, University of Cambridge, Emily Hodges, Maryanne Mariyaselvam and Peter Young, Queen Elizabeth Hospital, Kings Lynn Introduction: Ventilator associated pneumonia (VAP) is a leading cause of nosocomial mortality in the intensive care unit (ICU). High volume low pressure (HVLP) endotracheal tubes (ETT) allow pulmonary aspiration even when correctly inflated (Mariyaselvam et al. 2017).

Loss of cuff pressure increases pulmonary aspiration and continuous cuff pressure monitoring reduces VAP (Nseir et al. 2015). Four hourly monitoring and adjustment of HVLP ETT cuff pressure (20-30 cmH2O) is recommended (Department of Health), and is done by ICU staff using a handheld manometer/inflator. Poor control of the pressure release button on such devices leads to transient deflation, resulting in the possible bolus aspiration of upper respiratory tract secretions and VAP. Aim: To determine whether ICU staff transiently deflate the ETT cuff to below 20 cmH2O, on routine checking of the ETT cuff pressure using a handheld manometer/ inflator device.

Methods: Following institutional approval and written consent, medical (n=10) and nursing staff (n=10) normally responsible for cuff monitoring participated in a simulation study. An intubated mannequin was attached to a ventilator with an ETT cuff pressure set at 50 cmH2O. Participants were asked to identify an appropriate pressure, check the pressure and correct as appropriate with a familiar inflation gauge (Portex, Hythe, Kent). The target and lowest pressure attained was recorded.

Results: Three doctors were unfamiliar with the equipment and did not attempt measurement. Cuff pressure fell unintentionally to below 20 cmH2O during the check, requiring reinflation, for 57% of doctors and

60% of nurses. All doctors (100%) and 8 nurses (80%) readjusted the cuff pressure to a final value of 20-30 cmH2O. Conclusions: National recommendations, suboptimal device design and poor technique for checking the ETT cuff pressure easily leads to 4hrly unintentional cuff deflation. This is a risk for VAP. Training, improved measuring devices and ideally continuous pressure control is advisable.

References: 1. Mariyaselvam, M., Marsh, L., Bamford, S., Smith, A., Wise, M., Williams, D. (2017). Endotracheal tubes and fluid aspiration: an in vitro evaluation of new cuff technologies. BMC Anesthesiology, 17(1), p36. DOI: 10.1186/s12871-017-0328-0 2. Saad, N., Lorente, L., Ferrer, M., Rouze, A., Gonzalez, O., Bassi, G., Duhamel, A., Torres A. (2015). Continuous Control of Tracheal Cuff Pressure for VAP Prevention: A Collaborative Meta-Analysis of Individual Participant Data. Annals of Intensive Care, 5, p43. doi: 10.1186/s13613-015-0087-3 3. Department of Health (2011) High Impact Intervention Care Bundle to reduce ventilation-association pneumonia. Available from: http://webarchive. nationalarchives.gov.uk/20120118164404/hcai.dh.gov. uk/files/2011/03/2011-03-14-HII-Ventilator-AssociatedPneumonia-FINAL.pdf [Accessed 30/3/2017]

C37: Evaluation of a Tracheostomy Safety Training Day

Katrine Nehyba, Cathy Haddock and J Anderson, Fiona Stanley Hospital, Australia, A Chakladar, Brighton & Sussex University Hospitals NHS Trust, K Katsoulis, T Leahy, S Lennon and M Westwood, Fiona Stanley Hospital, Australia Aims: A multidisciplinary team (Allied Health Education, Anaesthetics, ENT Surgery, Nursing, Physiotherapy and Speech Pathology) at Fiona Stanley Hospital (Perth, Australia) lead a Tracheostomy Safety Training Day, which is dedicated to promoting safety management for patients with an altered airway. There is increasing evidence demonstrating the relationship between education and training for staff and the reduction and prevention of significant adverse events for this patient group.1 The content of the day is based on the UK National Tracheostomy Safety Project, with a focus on promoting the use of emergency algorithms. The aims of this study are to determine the effect of the course on participant’s self-rated knowledge and skills, and whether the course is effective at promoting a multidisciplinary approach to patient care.

Methods: Mixed methods analysis of course evaluation forms from 159 participants. Simple statistical analysis was performed on numerical data and comparisons were

Page 27

made between professions. Content analysis was used to identify categories and codes in the qualitative data.

Findings: Eighty-six percent of participants reported their knowledge and skills in managing tracheostomy airway emergencies as poor or average prior to attending the course. Post course, 75% of participants rated their knowledge and skills as very good or excellent.

Participants ranked the importance of adopting a multidisciplinary approach to the care of patients with a tracheostomy as the 8th most valuable learning outcome from the course.

Participants expressed appreciation for the interprofessional nature of the course, and the ability to learn with, from and about the roles of their colleagues.

Conclusions: A course that is run by a multidisciplinary team of clinicians, and is attended by a multidisciplinary group of participants, is effective at increasing participants knowledge and skills regarding the emergency management of patients with a tracheostomy.

References: National Confidential Enquiry into Patient Outcome and Death, (2014). On the Right Trach? a review of care received by patients who underwent a tracheostomy.  

patient care. (iii) Using an evidence based approach to care of the critically ill patient can improve patient outcomes.

Conclusions: Using a continuous professional development model can contribute to new knowledge and development of critical care nursing skills. Reflection can aid in guiding decisions on interventions that are considered life saving for critically ill patients. Clinical placements in critical care centers of excellence can help in developing and fostering best practice (Daly & Carnwell 2003). Using case studies has high value for transference of skills and patient safety with future patient care.

References: Helyer, R. (2015) Learning through reflection: the critical role of reflection in work-based learning (WBL). Journal of Work-Applied Management 7:1, 15 - 27 Daly, W.M., Carnwell, R. (2003) Nursing roles and levels of practice: a framework for differentiating between elementary, specialist and advancing nursing practice.

Journal of Clinical Nursing 12: 2, 158 - 167

C39: Developing an elearning

pathophysiology module: maintaining standards in an era of cuts Leonie White, Kings College Hospital

C38: Using continuous professional

development to advance critical care nursing knowledge and skills acquisition Alexandra Costa, The London Clinic Hospital Aims: To develop a skills and knowledge in critical care nursing via post registration nursing education.

Methods: Using a continuous professional development model I registered onto a critical care-nursing course at university academic level six for eight months with clinical placements in a large London Teaching Hospital exposed to neurological trauma and cardiothoracic critically ill patients. Six patient case studies were used from the placements to demonstrate knowledge and skills used in providing care based on the dynamic nature of the critically ill patient and intensive care units. A reflective model was used to examine the care provided and aided in examining and reflecting on best practice (Helyer, 2015) in each case study. It used a structured approach to demonstrate learning, knowledge and skills acquisition while providing care for the patient(s).

Findings: Three main themes emerged (i) Using live patient scenarios for learning reinforces the nature of intensive care nursing. (ii) Working with an experienced mentor aids development of critical care skills and provides a platform to discuss clinical decisions on

Introduction: The educational pathway for nurses intending to pursue a career in critical care at King’s College Hospital (KCH) includes the completion of a post-registration pathophysiology module as an essential preparatory course. On average, KCH commissioned 40 nurses per year at a higher education institution (HEI), costing £1,100 per student. In recent years there have been significant cuts to the education budget, despite an increase in the nursing workforce, patient numbers and acuity. In order to maintain high educational standards despite reducing budgets, a new e-learning pathophysiology course was designed, tailored to junior critical care nurses following completion of their Step 1 competencies.

Aim: To reduce the costs associated with nurse education, without compromising on quality or patient safety.

Methods: The KCH Critical Care Practice Development Team created an online e-learning programme under the guidance of a learning technologist. The online course consists of 6 key modules: Cellular Function Advanced Respiratory Haemodynamics and Blood Pressure Regulation Neural Regulation and Neural Transmission The Renal System and Endocrinology

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Immunology and Thermoregulation Each module contains links to educational resources and a workbook for completion. On completion of the six core modules, a multiple choice exam is undertaken. The course was validated by internal and external nurses of mixed levels of experience and academic background.

Results: In the first cohort, 25 nurses enrolled and passed the course supporting their critical care educational pathway to proceed to the next step. For one term the savings were £27,500.

Conclusions: Based on positive feedback and all nurses successfully completing the course material, the aim is to continue to accommodate approximately 30 nurses 3 times a year on this online education package, saving the trust approximately £99,000 annually. In addition to cost savings, this e-learning module facilitates more nurses to be able to undertake the module and allows greater flexibility for their study.

References: Competency-cc3n (2012) competency framework available at http://cc3n.org.uk/competencyframework. [accessed 23rd March 2017]

C40: Nursing the Critically Ill Malaria Patient

Chris Carter, British Army Background: Malaria is a significant cause of mortality in many countries and remains the most prevalent parasitic tropical infection. Using a case study approach, this presentation explores the management of an adult malaria patient on an intensive care unit, in Zambia, a low middle income country, in sub-Saharan Africa. This includes the presentation, diagnosis and treatment of this condition. Within Zambia, the World Health Organisation identified 4077547 confirmed cases and 3257 deaths in 2013, although they estimate the rates could be higher. Within the UK, all malaria is imported, and considerably less common, with 1400 cases and 6 deaths reported in 2015.

Case studies provide an opportunity to practically translate theory into practice. For nurses working in High Income Countries (HIC) such as the UK, this case study provides an insight into the realities of working in a resource limited environment and common conditions seen. Finally, this session will be of interest to nurses who may have limited experience of managing a critically ill malaria patient a condition not commonly seen in the UK. References: Bates K. (2008). A case study of severe malaria: implications for practice. Nursing in Critical Care.

13. 5. 278-280. Beeching N. Gill G. (edts). (2014). Tropical

Medicine: lecture notes. 7th Edition. Wiley Blackwell.

Carter C. Snell D. (2016). Nursing the critically ill surgical patient in Zambia. British Journal of Nursing. 25. 20.

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C41: “Grow Your Own” – Network

approach to developing our future leaders Julie Platten, North of England Critical Care Network Introduction: Leadership development and succession planning is a challenging task for any organisation but essential for the development and sustainability of the NHS. Therefore there is an importance to build future leadership capability (NHS, 2016) and there is correlation between good leadership and making a positive difference to patient care, experience and outcomes (HEE, 2015). The North of England Critical Care Network (NoECCN) recognised the absence of availability of training opportunities and developed a short programme to help facilitate senior staff nurses with the transition into management and leadership roles.

Aim: The objectives of the programme are: To explore the theory of groups and teams and the importance of emotional intelligence.

To raise awareness of important current issues impacting on practice in the ever changing NHS. To explore theories pertaining to management and leadership and apply to own practice.

To discuss critical issues in practice from a management perspective.

To introduce change management theories to facilitate planning and initiating a positive change.

Methods: The programme is over 1.5 days and is open to registered nurses who would like to develop their leadership and management skills.

Day One – delivered day covering topics including: human factors, national drivers, I-resilience, generation gap, introduction into management and leading theories and change management theories. The group then go away and undertake a service improvement project.

Day Two (1/2 Day) – the service improvement projects are presented to the group.

Conclusion: The programme evaluates very well from the candidate and also from the units as there have been some excellent service improvement projects which have significantly improved patient safety e.g. tracheostomy care, central line care.

In the future plans: Develop the faculty to provide resilience.

Review and refresh the content to ensure it is current.

Work in collaboration with the Critical Care National

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Education Review Forum (CCNERF) to develop Step 4 competencies (Leadership and Management).

References: Health Education England, (2015), Raising the Bar - Shape of Caring: A Review of the Future Education and Training of Registered Nurses and Care Assistants, Health Education England. NHS England (2016), Leading Change, Adding Value – A framework for Nursing, Midwifery and Care staff. NHS England

C42: Introduction of a tighter APTTr control

using a nurse led anti-coagulation algorithm during renal replacement therapy Julia Rutherford, Rhona Hewett, Pippa Martin and Wendy Carlton, Torbay and South Devon NHS Foundation Trust Aims: It is recognised that most patients require some form of anti-coagulation to prevent clotting of the circuit which interrupts treatment. This can have a clinical and financial implication (Kidney Disease Improving Global Outcomes, 2012).

The aim was to develop a nurse led anti-coagulation algorithm to achieve tighter APTTr control to optimise treatment and improve staff confidence in administering anti- coagulation therapy.

Methods: A literature search was conducted to identify other anti-coagulation algorithms and like Ostermann (2010) it was found that most Intensive care units (ICU) have no specific guidelines to assess and administer patient specific doses of anti-coagulation (Ostermann et al, 2010).

On evaluation of what was available in relation to the clinical area, an anti-coagulation algorithm was developed.

An audit tool was designed to look at average APTTr, average filter life and number of blood products used for each patient requiring renal replacement therapy (RRT). The tool was used to audit all patients for the year prior to the introduction of the changes. Currently this is being re audited following the introduction of the tighter APTTr control and the nurse led algorithm.

Findings: The units’ previous practice utilised a standardised systemic intravenous nomogram not specific for renal replacement therapy. Staff felt this was not suitable in helping to achieve the desired APTTr range.

The pre introduction audit showed our average APTTr was 2.2, average filter life was 35 hours and average number of blood products used was 1.1 based on 60 patients.

During this process it has been noted that staff have reported finding the algorithm helpful in increasing their confidence in the administration of heparin therapy.

Conclusions: On completion of the post introduction audit we hope to show that tighter APTTr control and a nurse led anti-coagulation algorithm will increase filter life which will positively improve the quality of our care.

References: 1 - Kidney Disease Improving Global Outcomes (2012) ‘Clinical Practice Guideline for Acute Kidney Care’ Kidney International, Vol. 2, No. 1, pp 87 – 115. Published online www.kidney-international.org 2- Ostermann, M., Dickie, H, Tovey, L, Treacher, D. (2010) ‘Heparin Algorithm for Anticoagulation during Continuous Renal Replacement Therapy.’ Critical Care, Vol. 14, 419. Accessed: 16/02/2016.

C43: Is nursing led protocols evolving with

new automated mechanical ventilation weaning strategies: a systematic review

Bradley Chesham, Sunshine Coast Health Service Background: The primary aim of this review was to compare automated weaning against protocol based weaning. The second objective was to discover how nurses are getting involved and what is their application to the new technology?

A systematic review was carried out using electronic databases as well as other sources including Google scholar. A detailed inclusion and exclusion criteria was then constructed and applied for screening and the quality of the included studies was thoroughly assessed.

3 studies met the associated criteria for analysis totalling a patient population of 284.

Automated ventilator weaning proved to be beneficial over protocol based weaning. The results showed an improved outcome towards a decrease in mechanical ventilation and in ICU length of stay. No immediate impact was noted on hospital length of stay or ICU mortality. Cultural and organisational variables were noted throughout the data, generating notable heterogeneity. The decision making process related to extubation, staffing, compliance with the delivery of the protocols and medical cover and structure across the ICU were revealed to impact data. In no study did nursing play a primary role. As the secondary outcome it was investigated that nursing does have an extensive role to play but is yet to feature in the implementation of automated ventilation and research regarding its impact on clinical practice.

Conclusion: In conclusion automated ventilation is beneficial over protocol based weaning. This benefit is limited and the lack of strength within the evidence results in minimal external validity. Nursing has a role to play within the process of weaning but has not yet thoroughly investigated the new technology and its

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possible applications.

References: Burns, K.E.A., Meade, M.O., Lessard, M.R., Hand, L., Zhou, Q., Keenan, S.P. and Lellouche, F. 2013c.

Wean Earlier and Automatically with New Technology (the WEAN Study): A Multicenter, Pilot Randomized Controlled Trial. American Journal of Respiratory and Critical Care Medicine 187(11) 1203-1211. Lellouche, F. and Brochard, L. 2009a. Advanced closed loops during mechanical ventilation (PAV, NAVA, ASV, SmartCare). Best Practice & Research Clinical Anaesthesiology 23(1) 81-93.

Liu, L., Xu, X., Yang, Y., Huang, Y., Liu, S. and Qiu, H. 2013.

Computer-driven automated weaning reduces weaning duration in difficult-to-wean patients. Chin Med J. 126

C44: Innovative ECMO Configurations in

Adults: Practice at a Single Center with Platinum Level ELSO Award for Excellence in Life Support Monika Tukacs, NYP- Columbia University Medical Center Introduction: Over the past two decades, extracorporeal membrane oxygenation (ECMO) evolved from salvage therapy into an essential life support tool in severe cardiac and/or pulmonary dysfunction in adult critical care. Advances in ECMO technology allow for a compact circuit, while advances in medicine and methodology of ECMO configurations allow for more diverse therapy.

The objectives of this practice review are to summarize and analyze the most innovative ECMO configurations in adult patient population at an institution designated an ECMO center of excellence- Platinum level by Extracorporeal Life Support Organization (ELSO).

Methods: A retrospective medical record review was completed to obtain quantitative and qualitative data regarding ECMO configurations at the presenting organization between March 2014 and March 2017.

Analysis of data with the ECMO team revealed two innovative ECMO configurations commonly utilized in the presenting organization.

Results: The two innovative configurations are the “ECMO System” and the “Central Sports Model.”

The “ECMO System” is minimally invasive, does not necessitate a median sternotomy, and consists of an external ventricular assist device and oxygenator. This configuration is beneficial for patients with refractory cardiogenic shock, who are not suitable for sternotomy.

The “Central Sports Model” requires a mini-sternotomy to sew a graft onto the innominate artery. Blood is drained from the internal jugular vein, through the blood pump and into the oxygenator and an incision is made on the neck for the reinfusion ECMO cannula to be inserted.

This method does not need a traditional full sternotomy,

and allows greater mobilization and ambulation of the patient.

Conclusion: The identified ECMO configurations are revolutionary. They necessitate a very refined surgical technique for commencement and strong teamwork among the ECMO team for management. The result is an innovative use of ECMO to treat complex patients, while allowing greater mobility and improved outcomes.

References: Chicotka, S. et al. 2016. ‘The ‘Central Sport Model’: Extracorporeal Membrane Oxygenation Using the Innominate Artery for Smaller Patients as Bridge to Lung Transplantation’, ASAIO J, [Epub ahead of print] Makdisi, G. and Wang, I. (2015) ‘Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology’, Journal of Thoracic Disease. 7(7):E166-E176. doi:10.3978/j.issn.2072-1439.2015.07.17.

Takeda, K. et al. 2016. ‘Novel Minimally Invasive Surgical Approach Using An External Ventricular Assist Device And Extracorporeal Membrane Oxygenation In Refractory Cardiogenic Shock’, European Journal of Cardio-Thoracic Surgery, ezw349. [Epub ahead of print]

C45: Learning from medication incidents in

Adult Critical Care

Mary Beckenham, Nottingham University Hospitals NHS Trust Background: Critical Care at NUH NHS Trust encompasses 2 campuses; including level 3 and 2 patients totalling 66 beds and 420 nursing staff. In April 2014 – March 2015 there were 145 reported incidents relating to medicines; 2 causing moderate harm, 12 causing low harm and 131 causing no harm.

A high reporting rate should not be interpreted as an unsafe organisation, and may actually represent a culture of greater openness. 97% of medication errors reported to NHS result in no or low patient harm.

Aim: To understand why medication errors occur and identify processes to improve medicine errors, develop learning and reduce recurring themes.

Method: Medication incidents were reviewed on Datix including numbers reported, harm, nursing practice observed. Any problems identified to the Band 7 team.

The Governance Lead Nurse focussing on medicines, Medicines Safety Champions and Service Improvement Champions Band 5 & 6, close working with the pharmacy team ensured dissemination to the rest of the team. 6 monthly reports on common themes were distributed to all nursing staff & consultants.

Implementation: Recurrent themes were included in 14 day handover document read to all staff at the beginning

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of each shift; the focus for 6 weeks. It was evaluated on the Daily Patient Safety Walk round (a tool used by the Band 7’s to monitor quality & processes of the identified categories). This showed an increase in incidents but infrequent themes; however the reason why errors occurred included increased workload and complexity of patients, lack of following policy & education of staff.

This led to observational audits which were carried out showed noncompliance with Medicines Management Policy; common themes audited included 2nd checking of drugs; controlled drugs and infusion rate changes.

These were often not completed by the same 2 nurses.

The pilot audit was of 10 patients per month in each area for 6 months.

C46: Improving Food Service on a General ICU/HDU for patients able to maintain volitional oral intake

Catherine Jones, St. George’s University Hospitals NHS Foundation Trust Introduction: Expansion of the level 2 critical care population results in greater numbers of patients able to maintain volitional oral intake. The common perception that critical care patients will receive enteral &/or parenteral nutrition limits facilities available to support food service – food preparation areas, hostess service, equipment (cutlery, crockery & tables). We undertook a service improvement initiative in response to increasing (but unpredicatable) numbers of patients maintaining oral volitional intake using a Plan, Study, Do, Act methodology (MacKenzie, 2015) Aim: Identify weaknesses in food service on GICU. Do: Nursing Focus Group (10 nurses – Band 2-7) Nurses preparing food as part of clinical care had following implications: Food given to patient late due to clinical pressures; inconsistent application of food hygiene standards; menu choice limited to that immediately available & patients eating with plastic cutlery. Nurses in a good position to understand individual needs & appetite.

Observation: Food Ordering: Housekeeper able to adjust order on daily basis to reflect number of patients.

Food Preparation: Inappropriate or malfunctioning equipment and lack of dedicated area for patient food preparation.

Food Service: Subject to delay & inconsistent application of standards (due to lack of familiarity with microwave equipment & ready meals)

Learning points: Multi professional engagement; Short messages at handover; Reinforce when clinical; Measure improvement by audit; Don’t expect 100% in your results; the unexpected can occur Conclusion: The ongoing work has shown a reduction in the amount of incidents reported April 2015 – March 2016 to 129 and no moderate harm events. There was 1 Never Event; wrong route resulting in low harm; policy not followed and April 2016 – March 2017 reduction to 110 with no moderate harm events or Never events.

References: National Reporting and Learning Systems (April 2015) Supporting Information for Organisation Patient Safety Incident Reports

Audit: Great variability in number of patients eating & drinking both across days & within the day.

Study: Results reviewed with MITIE & management.

Agreement achieved to trial a hostess for food service, new equipment & review of current menu to reflect needs of critical care population.

Act: Food service is now delivered by hostess at lunch & dinner. Functional equipment supports the safe delivery of food. Patients eat with metal cutlery. Segregation of food preparation areas for patients & staff improved.

Interprofessional menu-tasting sessions produced a streamlined & population appropriate menu.

References: MacKenzie S. (2015) Quality Improvement in Critical Care. In Critical Care London 2015 Rhodes A., Ball

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J. & Cecconi M. (eds). London: Critical Care London, pp.

9-16

C47: Staff awareness of the error of using

both a heated humidifier and a heat and moisture exchanger in the same ventilation circuit

in less than 24 hours. Journal of Critical Care, 30(4), p. 863. doi: 10.1016/j.jcrc.2015.03.033 Patient Safety Alert (2015) Stage One: Warning. Risk of using different airway humidification devices simultaneously. MHRA, NHS England. Reference number NHS/PSA/W/2015/012.

Available at: https://www.england.nhs.uk/patientsafety/ wp-content/uploads/sites/32/2015/12/psahumidification-devices.pdf [Accessed 30 March 2017]

C48: Patient – ventilator dyssynchrony

Vikesh Patel and Catherine Peutherer, University of Cambridge, Emily Hodges, Peter Young and Maryanne Mariyaselvam, Queen Elizabeth Hospital, Kings Lynn

Chris Hill, Royal Free NHSFT

Introduction: Mechanical ventilation circuits require an artificial humidification system in order to ensure that gas exchange mirrors normal lung physiology. Currently, two systems are commonly used in intensive care units (ICU’s); heated humidifiers (HH’s) and heat and moisture exchangers (HME’s). However, only one of these systems should be used in any one circuit, as the simultaneous use of both can lead to adverse outcomes including critical airway occlusion (Doyle et al., 2015).

Aim: This study aims to assess whether experienced ICU staff notice the dual use of both a HH and a HME in a simulated ventilation circuit and correct the error.

Methods: We set up a simulated ventilation circuit with both a HH and a HME system in place. Twenty staff with experience of working in the ICU were asked to assess the circuit and report on whether they were happy with the set up. If they were not, they were encouraged to make any changes that they deemed necessary. There were also other clinical tasks for participants to complete during the study, in order to simulate a busy ICU environment.

Findings: Five of the 20 participants (25%) identified and removed the incorrectly placed HME. A further 3 participants (15%) indicated the abnormally placed HME but did not recognize a safety issue nor wished to remove it from the circuit when prompted. One participant initially removed the HME to inspect its patency, before then placing it back into the circuit.

Patient – ventilator dyssynchrony describes a mismatch between patient demand (neural inspiration and expiration) and ventilator breath delivery. It is associated with patient morbidity, though no causal link has been demonstrated. This presentation will describe instances of dyssynchrony apparently caused by sedation, including one where recognition of this led to a patient being extubated at least a day earlier than would otherwise have occurred.

Underlying causes of dyssynchrony include a high respiratory drive, for instance in acute respiratory failure; or at the other extreme, sedation or hyperventilation causing a reduced respiratory drive. What is actually observed varies, for instance: the patient trying to take a breath, but none being delivered; an autotriggered breath - supposedly triggered by the patient, but with no actual patient trigger; a breath being delivered but being terminated early or late compared with the patient’s effort, and other possibilities.

Dyssynchrony has been associated with discomfort and dyspnoea, increased need for sedative and paralytic agents, prolonged mechanical ventilation and ICU stay, and increased likelihood of respiratory muscle injury and tracheostomy (Blanch et al, 2015), though a causal link has not been demonstrated. It may be recognised by observing the patient, but inspection of ventilator flow and pressure waveforms is a widely described method. However dyssynchronies are often missed and the prevalence and consequences may be largely underestimated because of a lack of monitoring (Dresa et al, 2016).

Conclusion: There is currently poor retention of knowledge of the potentially fatal error of using both a HH and a HME in a single ventilation circuit. This is despite an educational episode following an NHS England warning issued to hospitals in December 2015 (Patient Safety Alert) highlighting the error and tasking hospitals to take preventative action.

This presentation will review currently described dyssynchronies such as ineffective triggering efforts, autotriggering and reverse triggering, and will also describe a form of dyssynchrony caused by sedation, with practical descriptions of how recognition of this led to early extubation.

References: Doyle, A., Mariyaselvam, M., Wijewardena, G., English, N., Gent, E., Young, P. (2015). The simultaneous use of a heat and moisture exchanger and a heated humidifier causes critical airway occlusion

Dyssynchrony is often missed, and although a causal link with patient morbidity has not been demonstrated, it is possible that wider knowledge and detection skills related to dyssynchrony could reduce patient morbidity.

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References: Blanch L, Villagra A, Sales B, Montanya J, Lucangelo U, Luján M, García-Esquirol O, Chacón E, Estruga A, Oliva JC, Hernández-Abadia A, Albaiceta GM, Fernández-Mondejar E, Fernández R, Lopez-Aguilar J, Villar J, Murias G, Kacmarek RM (2015) Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med. 41(4):633-41 Dres M, Rittayamai N, Brochard L (2016) Monitoring patientventilator asynchrony. Curr Opin Crit Care. 22(3):246-53

C49: End of Life Care in the ICU Catherine Hyland, Beaumont Hospital Aims: A literature review exploring the lived experience of bereaved relatives of patients who die in the Intensive Care Unit (ICU).

Introduction: 29,000 people die in Ireland each year, leaving 290,000 people bereaved, according to the Office of the Ombudsman (2014). Even though 67% of people would prefer to die at home, only 26% actually do. 43% of people in Ireland die in acute hospitals, with 20% of hospital deaths occurring in the Intensive Care Unit.

Given the advent of Intensive Care Units and advances in healthcare, attempts made to resuscitate patients and prevent sudden death can lead to decisions regarding end of life care being made within the ICU (Cook and Rocker 2014). Families are at greater risk of developing Post Traumatic Stress Disorder (PTSD) or major depressive symptoms when a relative experiences death in the ICU, as opposed to death at home with hospice care (McAdam et al. 2012). Death is understood to be a deeply emotive experience, whether sudden or expected (Office of the Ombunsman 2014). As death is an inevitable occurrence, the importance of managing the process of dying empathetically is central in preventing undue distress in the lives of bereaved families. The lasting impact of a good death was vocalised by a bereaved family member at the Forum on End of Life 2013, “Because of the support he received, my husband died well. Because he died well, I live well”.

Recommendations: A structured literature review addressing the experiences of relatives when planning for death in the ICU, the dying process in such a clinically advanced environment and bereavement after an ICU death will be discussed. Allowing for a better understanding and empathetic view on the experiences of relatives, when their loved one dies in the ICU. References: Cook, D. and Rocker, G. (2014) “Dying with dignity in the intensive care unit”, New England Journal of Medicine, 370 (26), pp2506-2514. Fridh, I., Forsber, A. and Bergbom, I. (2009) “Close relatives’ experiences of caring and of the physical environment when a loved one dies in an ICU”, Intensive and Critical Care Nursing, 25 (3), pp111-119. McAdam, J. L., Fontaine, D. K., White, D.

B., Dracup, K. A. and Puntillo, K. A. (2012) “Psychologial symptoms of family members of high-risk intensive care unit patients”, American Journal of Critical Care, 21 (6), pp386-393

C50: Humanising the critical care unit using

live music therapy

Natalie Mason, Jo Cooper and Donna Cummings, Central Manchester Foundation Trust Background: There is little known about the beneficial effects that music therapy has on the critical care population due to limited studies, most of which are conducted outside of the UK. However, from evidence, so far live harpist music has demonstrated that it has the ability to reduce the perception of pain in the ICU patient by 27% (Chaisson et al 2013).

Objectives: The critical care environment is a clinical area that is daunting to most, especially patients and relatives that have never experienced this type of environment previously. One of the aims was to look at how we could humanise the critical care unit, allowing it to appear less frightening and isolated.

Methods: Live acoustic music in the critical care unit was piloted at the Manchester Royal Infirmary. Two Music in Hospitals ™ (MiH) musicians were chosen specifically for their gentle musical repertoire, sensitivity and their previous experience in peadiatric critical care.

Results: This pilot project took place during four afternoons at 3pm, each session lasting one hour during relative visiting time between 29 July 2016 and 7 September 2016. The music sessions were split between the Intensive Care unit (ICU) and the High Dependency Unit (HDU) Given that many former patients describe their critical care unit stays as ‘traumatic’ and ‘stressful’, it is rare to find post critical care patients describing any part of their experience as ‘enjoyable’.

Did you enjoy listening to the music?

Type of music played appropriate for the environment?

Volume suitable for the environment?

Did you feel relaxed whilst listening to the music?

Would you listen to the music again?

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Yes

No

Unsure

98.6%

-

1.35%

97.2%

1.4%

1.4%

98.6% 1.35%

-

98.6% 1.35%

-

97.2% 1.35% 1.35%

Conclusion: The initial feedback indicates overwhelmingly, that we are indeed ‘doing the right thing’. Indications are that all patients, relatives and staff can potentially benefit from soothing music.

delirium on patients.

Patient diaries have demonstrated that small changes can have a significant impact on quality of care. While on a wider scale the project has helped to enhance the person-centred care and continues to evolve.

References: Chaisson AM, Baldwin AL, McGlaughlin C, Cook P, Sethi G Effects of live spontaneous harp music on patients in the Intensive Care Unit. Evidence based complimentary & alternative medicine, 2013. https:// www.theguardian.com/voluntary-sector-network/2016/ aug/30/i-help-bring-music-to-patients-in-intensive-care http://www.itv.com/news/granada/update/2016-10-24/ could-music-be-beneficial-to-hospital-patients

References: Guba, E. G. and Lincoln, Y.S. (1989) Fourth Generation Evaluation. Newbury Park: Sage Manley, K. (2000) Organisational culture and consultant nurse outcomes: Part 1: organisational culture, Nursing Standard. Vol. 14. No. 36. pp 34-38. Tevendale, F. and Armstrong, D.(2015) Using patient Story Telling in Nurse Education Nursing Times; 111:6,15-17

C51: Recovery and Wellness post ICU:

C52: Frailty and the ICU

Using Patient Diaries

Kathy Dalley and Jane Roe, St Georges Hospital

Lianne Humphries and Samantha Hagan, South Eastern Trust Staff in ICU noticed patients were describing concerning issues including sleep deprivation and hallucinations.

These contributed to them being unable to adjust to leading a regular family life. Therefore to improve the psychological support for patients, staff explored the value of patient diaries. Intensive care patient diaries are a simple but valuable tool in helping patients come to terms with their critical illness (Bäckman et al., 2010). A successful application was submitted to the Patients First Programme at the Foundation of Nursing Studies (FoNS) for support with the project.

Aims: To develop a tool to record patient’s stay in ICU that can be used to aid psychological recovery Objectives: • To engage with key stakeholders • To gather information to guide the development and implementation of the tool • To use PD methodologies to enhance culture in ICU so that the project is embedded into practice Methods and Approaches: A number of methods and approaches were used within the project in order to facilitate change.

• Values Clarification Exercise: This method was used to explore the values and develop a shared vision. (Manley 2000) • Claims Concerns and Issues: This method was used to establish views of all the stakeholders and develop an action plan. (Guba and Lincoln 1989) • Patient/Relative Stories: Involving the patient was vital and stories are a powerful method of including the patients’ values. (Tevendale and Armstrong 2015)

Aims: We aim to explore the concept of determining frailty and the relevance this may have in a critical care environment.

Methods: This paper will review the measurement options with respect to frailty and examine their validity in terms of prognostic implications.

Discussion: As we introduce a measurement of frailty index on referral and discharge for older patients at our hospital, we thought it would be a good time to explore some questions, illustrating with some of our cases.

What is frailty? The NHS has suggested quality measures of our care for frail patients. Are these appropriate and sufficient?

Results: We shall compare the published evidence with our experience in clinical practice Conclusion Frailty indices are likely to become a more important part of decision making around critical care.

References: Clegg et al (2016) Development and validation of an electronic frailty index using routine primary care electronic health record data Age & Ageing 45(3):353-60 Sprung CL et al (2012) The Elicus prospective, observational study of triage decision making in European intensive care units. Part II: intensive care benefit for the elderly Crit Care Med. 40(1):132-8

Findings and Conclusions: This project has demonstrated to nursing staff the severe psychological trauma that critically ill patients may endure and there is a greater awareness amongst staff within the unit of the effects of Page 35

C53: Educating the team, improving the

patients with spinal cord injury. This learning opportunity provides for the MDT to develop teamwork and acquire specialised knowledge and skills. There is however, the need to disseminate this style of learning to other centres that provide care for patients with spinal cord injury

experience of patients’ with spinal cord injury: A multiprofessional approach to learning on a Spinal Cord Injury Centre Mary Licup and Allan Seraj, Royal National Orthopaedic Hospital NHS Trust

C54: Developing Staff Support for Critical

Background: Spinal cord injury has a profound impact on the psychological, physiological and psychosocial status of a person. We at the London Spinal Cord Injury Centre (LSCIC), a 24 bedded Unit, provide immediate care and rehabilitation for over 300 patients (2014/2015) with spinal cord injury. Our catchment spans into the Northeast and Southwest of London and Surrey. We are also linked to two major trauma centres in London.

The complex needs of these patients are managed by the multidisciplinary team (MDT): medical team, nurses (including ward and Clinical Nurse Specialist), physiotherapist, occupational therapist, speech and language therapist, dietetics, psychologist and community liaison team However, we acknowledge that specialised knowledge, skills and attitudes are required to manage the complex needs of these patients from every member of the MDT. In order to meet this need, the ‘Multidisciplinary Management of Spinal Cord Injury Patients’ course was developed in-house.

Aims: (i)To facilitate for the diverse learning requirements of the team caring for these patients (ii) Improve the quality of care that is delivered to our patients with complex care needs (iii) To provide a more cohesive MDT approach (iv) To appreciate the value of each discipline in the MDT. Method: The ‘Multidisciplinary Management of Spinal Cord Injury Patients’ course is facilitated twice a year by the LSCIC Clinical Nurse Educator and is open to all members of the MDT within the department and referral centres. The course accommodates 25 staff over a twoday period utilising lectures, workshops and groupwork.

Experts, from each discipline present taught sessions on the course. The evaluation of the course’s content is done using a structured Likert scale together with open ended questions to generate qualitative feedback by the delegates on their last day of attendance. Themes are gleaned and developed from their responses.

Care Nurses

Nicola Oldcroft, Cicely Saunders Institute Aims: To research and develop a support group for staff support on Critical Care Evaluate usefulness of group support for nurses at Band 5 and Band 6 level Methods: Practical running of groups for 6 sessions Mixed method approach to evaluating the group Collate quantitative data on effectiveness of the group directly from nurses Analyse quantitative data about attendance at the group Main findings: Staff support for nurses is beneficial when led by a non-clinical member of staff Psycho-social approach of social worker enables nurses to share Challenging to attend due to shift work De-brief sessions for specific cases were still requested by staff Useful to be open to all intensive care wards and not just separate groups for each ward Death and dying is one of the most challenging areas to work with on the units Conclusions: There is a need for consistent staff support for critical care nurses There should be more than one monthly session Critical care nurses face a high emotional cost in working in this environment References: Valentin, A, Ferdinande, P. Recommendations on basic requirements for intensive care units: structural and organizational aspects.

Intensive Care Med. 2011;37:1575–1587.

Results: (26 delegates): The overall course sessions was rated as ‘Very Good to Excellent’ Themes from the participants’ responses: (i) Positive Praxis (ii) Motivation (iii) ‘Spread the word’ Discussion/Conclusion: Multidisciplinary team learning promotes positive informed action and motivates the team towards improving the experience and journey of Page 36

Poster Abstracts P01: Making the case for education in

P02: Using reflection to improve critiical

critical care

Claire Shaw and Claire Mead, University Hospitals of Morecambe Bay NHS Trust A common theme across all critical care units across the country is the ever increasing junior workforce.

Historically most nurses developed post registration skills and experience on surgical and medical wards prior to transitioning to critical care.

Placement opportunities provided to nursing students within critical care areas has seen the potential to work within this speciality much sooner than traditionally deemed appropriate.

With this however the ever increasing junior workforce and change in nurse education demonstrates the need to address training and education in these areas due to the nature of the speciality. All this is happening at time when NHS education budgets are being reduced by up to 45% (RCN 2016).

GPICS (2015) identified that all units must have a dedicated clinical nurse educator responsible for coordinating the education, training and CPD frame work for critical care nursing staff. Our recent PEER review and national critical care workforce survey highlighted that we fell short of these recommendations in that we do not have a practice educator.

Currently the education of new staff is being addressed through key trainers and a clinical leader taking on the role of educator to support those new starters and ensure completion of step 1,2 and 3 competencies in a timely manner. This is with the absence of a supernumerary co-ordinator, and with limited time to complete again highlights the need for an educator in accordance with GPICS. However the process has encountered many issues including financial constraints, vacancy rates and justification of the need for the role to those outside of critical care.

This poster presentation will detail the journey our unit experienced in developing the role and how we overcame the obstacles.

References: Faculty of Intensive Care Medicine (2015) Guidelines for the Provision of Intensive Care Services.

Faculty of Intensive Care Medicine. London Royal College of Nurses. 2016. Cuts to CPD funding risk patient care. [ONLINE] Available at: https://www.rcn.org.uk/ news-and-events/news/cuts-to-cpd-funding-risk-patientcare. [Accessed 13 March 2017]

care nursing skills, knowledge and patient care Lorena Sanz Ortega, The London Clinic Aims: To develop skills and knowledge in critical care nursing through a viva voce and essays on proactivity and problem solving approaches to patient care.

Methods: As part of a course on intensive care nursing two real patient case studies were used. Case study 1 was a viva voce on a patient with respiratory pathologies leading to the development of acute respiratory syndrome (ARDS) (Wright 2014) that involved presenting the case study and defending the episodes of care in reference to ARDS. Case study 2 was formed of two parts of a paper on problem solving and proactivity of a bleeding patient using a reflective model with Carpers ways of knowing in nursing (Johns 1995). They involved presenting the case studies the care actions undertaken and why and alternative actions that could be taken.

Main findings: Three main themes emerged (i) Using a reflective model can help to improve patient care and practice of critical care nurses. (ii) Managing hypoxia in ARDS patients. (iii) Maintaining safety in complex critically ill patients.

Conclusions: Using case studies can help nurses to reflect in and on practice. Different modes of academic assessment can help critical care practitioners to examine how they care for patients in intensive care and examine their practice based on interventions and patient outcomes. There is value for patient, hospital and staff in undertaking continuous academic development courses.

References: 1. Wright, B. (2014). Lung-protective Ventilation Strategies and Adjunctive Treatments for the Emergency Medicine Patient with Acute Respiratory Failure. Emergency Medicine Clinics of North America, 32(4), pp.871-887. 2. Johns C (1995) Framing learning through reflection within Carper’s fundamental ways of knowing in nursing. Journal of Advanced Nursing. 22, 2, 226-234  

P03: A Host of Golden Daffodils -

Warrington Intensive Care Unit Memorial Service Sophie Liu, Warrington NHS Foundation Trust,

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P04: The Effect of a Critical Care Outreach

Helene Hazzard, Warrington and Halton NHS Foundation Trust The death of a loved one in the ICU is often an unexpected and traumatic event, characterised by difficult decisions regarding withholding or withdrawing life-sustaining therapy (Berry , Brink and Metaxa 2015).

The loss of a family member is a truly devastating experience for any family to have to go.The critical care memorial service was the idea of the nursing staff who wanted to show that they remember the patients who have died on the unit and their loved ones long after they have gone. The aims of the the service are to celebrate their lives, to recognise the courage and dignity of those left behind and solidarity with others. Families find comfort in the fact they are able to share their loss with other people who have gone through a similar experience to them.

All the relatives of the patients who died on the critical care unit the prior year are invited to the service. A label is included with the invite, relatives are asked to personalise this with a message, memory, photograph or thought about their loved one and asked to bring the label along to the service to attach to a bunch of daffodils which are given to them at the service. The service consists of readings, performances by school children, a piper and also a soloist during which relatives are asked to bring the daffodils forward and place them on the table in front of the screen which shows the names of all who have sadly passed away the year before.

Daffodils are believed to bring hope to someone going through a difficult time. Afterwards, relatives are offered refreshments and home-made cakes donated by staff.

Relatives are able to view the memorial book, discuss patient diaries and talk to the members of staff.

98 people attended this year and the feedback received for the organisation of the service was excellent. Many relatives commented on the comfort knowing they are not alone in their grief. The service has been recognized as thoughtful with a personal touch.

Overall, the service expresses the care and compassion that critical care nurses have for patients and relatives, even when they are no longer in critical care. Feedback has identified the positive impact the service has on relatives and close friends of those who have passed away. In 2016 the ICU memorial service gained recognition by the trust and won team of the year, which in itself is a huge achievement and proves how essential this service is to the critical care unit.

References Berry M, Brink E and Metaxa V Bereavement care in UK ICUs: a national survey published in CritCare 2015; 19(Suppl 1): P578  

Service Intervention on Patient Outcomes in the Management of Acute Kidney Injury in Hospital Linda McDaid, Western Health and Social Care Trust This study set out to evaluate the service carried out by the Critical Care Outreach Service, in a Trust in Northern Ireland. The author wanted to investigate what impact interventions by the team would have on specific outcomes of patients with Acute Kidney Injury.

A retrospective quantitative approach was adopted. A note trawl was carried out for patients who had been identified as having an Acute Kidney Injury as per Kidney Disease Improving Global Outcomes guidelines and who subsequently were reviewed by the Critical Care outreach Service.

The findings illustrated that review of patients with AKI in hospital by the CCOS shows a reduction in mortality at 30 days, an increased length of hospital stay and an increased number of days until death in those that died following AKI alert.

This study demonstrated that review of patients with AKI by the Critical Care Outreach Service resulted in no admissions to Critical Care or no need for Renal Replacement Therapy. Preventing the progression of AKI to kidney failure requiring dialysis is of paramount importance.

Recommendations include dissemination of findings locally to those involved in managing this group of patients. The need for further research on the outcomes of this group of patients is highlighted. Educational needs have been identified and highlighted to the Nephrology Service within the hospital.

References: Acute Kidney Injury Network (AKIN) (2016) Why is acute kidney injury important? Available at: www. londonaki.net (Last Accessed 26th June 2016). Joslin, J., Wilson, H., Zubli, D., Gauge, N., Kinirons, M., Hopper, A., Pile, T. and Ostermann, M. (2015) Recognition and management of acute kidney injury in hospitalised patients can be partially improved with the use of a care bundle, Clinical Medicine, 15(5): 431-436. Kerr, M., Bedford, M., Matthews, B. and O’Donoghue, D. (2014) The economic impact of acute kidney injury in England, Nephrology Dialysis Transplantation, 29(7): 1362-1368. Available at: http://ndt.oxfordjournals.org/ content/29/7/1362.long (Last Accessed on 30th June 2016).  

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P05: End of Life Care within Critical Care Jo Tillman, Anoma Gunawardena, Ashoka Jayasinghe and Luis Teixeira, The Royal Brompton Hospital Within the Adult Intensive Care Unit (AICU) at the Royal Brompton hospital there is an interest in advancing End of Life Care (EoLC) practice to ensure that we maintain the highest standards for patients, families / carers and to enable our nurses to be best equipped to deal with this challenging area of practice.

A group of AICU nurse champions set up a working group to focus on this. This group meets monthly and includes members of the wider interprofessional working team. The first thing the group did was to conduct a questionnaire among the AICU nursing staff to gain an understanding of how nurses working on the unit felt delivering EoLC. Key themes from the questionnaires focused on concerns around inconsistencies in practice, a lack of polices and guidelines to inform practice and a desire for more training and education. The sample size was 68 which is greater than 50% of the AICU nursing establishment. The Likert scale was used to analyse results with responses of less than 5 graded as a negative response; • Availability of adequate policies and guidelines, 4.36 • Training and education, 4.04 • Consistency of decision making, 3.98 • 69% of respondents did not feel EoLC was carried out well To address these findings a number of systems are being developed which all focus on patient centred coordinated care and address documentation, policies and guidelines, education and training and family / carer support.

Teaching and updates are now provided on team days, an in house study day has been developed, a set of EoLC observations are to be launched and policies and guidelines are being written.

In having a group of AICU staff champions for EoLC and regularly reviewing and auditing EoLC practice within the unit it allows for effective patient care to be provided and appropriate support for the families / carers and staff.

References National Institute for Health and Care Excellence (NICE) (2015) Care of dying adults in the last days of life (online) Avaliable at https://www.nice.org.uk/guidance/ng31/ resources/care-of-dying-adults-in-the-last-days-of-lifepdf-1837387324357 (Accessed 24.07.17) Department of Health (DoH) (2008) End of life Care

Strategy, promoting high quality care for all adults at end of life (online) Avaliable at https://www.gov.uk/ government/uploads/system/uploads/attachment_ data/file/136431/End_of_life_strategy.pdf (Accessed 24.07.17)

P06: Sharp’s Disposal using the WireSafe

during Central Venous Catheter Placement Emily Hodges, James Gooch, Thomas Swan, Samuel Keable, Maryanne Mariyaselvam, Peter Young, Queen Elizabeth Hospital, Kings Lynn Background: Despite low reporting rates sharps injuries have a recorded incidence as high as 99% in final year surgical trainees and have a human and economic burden on healthcare systems estimated as high as £0.5M per Trust/Year (Roy and Robillard, 1995, Makary, 2007). Factors decreasing the rate of sharps injuries include safety devices, needle type and disposal method. The WireSafe (Venner Medical, Singapore) is an engineered safety solution being implemented by NHS England through the NHS innovation Accelerator programme. The WireSafe is designed to prevent the never event of guidewire retention,and allows for convenient point of care sharps and wire disposal securely into the WireSafe itself.

Methods: We conducted an observational study of Anaesthetists disposing of sharps following central venous line insertion, before (Control) and after the implementation of a safety solution (WireSafe).

Sequential procedures were observed in the ICU and theatres. Investigators informed the staff that they were observing the whole procedure for quality improvement purposes.

Safe technique was defined as following hospital policy, with a sharps bin brought to the clinician or the procedure trolley wheeled to the sharp’s bin. Unsafe technique involved throwing sharps, hand carriage to sharps disposal or leaving sharps for nursing staff to clear up.

Results: Safe disposal of sharps was increased from 60% (control, n=54) to 100% (WireSafe, n=7). The total average placement time was similar in both groups (standard 16mins v WireSafe 14.5min, p=non-significant) and the sharps clear up time was less in the WireSafe group (standard 11.6min v WireSafe 9.5min, p<0.05).

There was one sharps injury in the control group period requiring extended occupational health surveillance.

Discussion: Despite clear guidance, sharps disposal practice is poor. The WireSafe encouraged better decision making at the bedside. This observational study of the first implementation of the WireSafe showed both ease of use and improved practice.

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References: 1. Roy. E., Robillard, P. (1995) Underreporting of accidental exposures to blood and other body fluids in healthcare settings: an alarming situation. Adv Expo Prev 1 (11) 2. Makary, M., Al-Attar, A., Holzmueller, C., Sexton, B., Syin, D., Gilson, M., Sulkowski, M., Pronovost, P. (2007). New England Journal of Medicine. 356, p 26932699 DOI: 10.1056/NEJMoa070378

P07: Adult Intensive Care Unit nurse

to extracorporeal life support nurse practitioner, where does the future lie?

Anoma Gunawardena and Jo Tillman, The Royal Brompton Hospital The Royal Brompton Hospital (RBH) is a nationally commissioned extracorporeal life support (ECLS) center.

On the Adult Intensive Care Unit (AICU) the service was initially set up as a consultant led service which worked well for implementation but as the nursing team gained more expertise there was a desire to further develop the nursing role and their autonomy. With the model used at RBH this was feasible as all nursing staff were trained and competency assessed to look after this patient group which had resulted in the development of a highly skilled workforce.

In June 2016 there was a change in the medical personal at RBH and this was used to review and restructure the nursing model for ECLS and develop the nursing team into a more integral part of leading and driving this service forward.

This opportunity has strengthened the nursing role. From nurses who could safely and competently look after this patient group on the unit there is now a highly skilled group who have a pivotal role in what has become a highly nurse centered approach to providing ECLS that is strongly supported by the other disciplines.

The nursing role is central to the care of the patients that are on the AICU but now also in coordinating and discussing referrals, retrievals, weekly clinical meetings, overseeing the ECLS governance and coordinating other disciplines.

P08: Development of an electronic patient and relative diary app

Louise Roberts, Cambridge University Trust Hospital Background: NCCU is a busy 23 bedded Neuro Critical Care and Major-trauma unit in Cambridge, admitting over 900 patients a year. Over the last 5 years we have not been successful in introducing paper based patient diaries. When surveyed, staff reported not having enough time, forgetting to write them or not being considered a priority.

Aim : The aim is to develop a secure, user friendly electronic diary which is easy to access and able to be printed out and given to the patient.

Methods: CUH has recently invested in electronic patient records. Creating an electronic patient diary seemed to be a natural progression. Mosa et al (2012) The format of the electronic diary is based on the current paper based diary. The diary content will be stored securely on the NHS IG complaint server and accessed either via a webpage or itunes/android app. This will enable the Multi-disciplinary team to complete the diary via the bedside computer, with the ability to upload photographs. Photographs will be kept securely until the patient is able to give consent for release.

Discussion: KPI reports will be built into the app along with the ability to edit entries if required.

Phase 2 of the diary development will provide password protected access for the patientsâ&#x20AC;&#x2122; relatives who can add entries to the diary as they wish.

Initially the patient diary will only be used within critical care, but we do plan for the diary to continue being used by the patient and their family when they are discharged to the ward, continuing to support their recovery.

We have identified potential for use within other areas e.g. PICU & NICU Conclusions: This is an on-going project which is in development at the time of writing, therefore the conclusions of this project are yet to be made.

References: Mosa AS, Yoo I, Sheets L. A systematic review of health care apps for smartphones. BMC Med Inform Dec Mak. 2012 Jul;12:67

This has been achieved through strong nursing leadership and the use of structures to ensure robust processes for compliance with the ECLS standards and staff training and competency assessment.

This evolving nursing role has been exciting and has positively contributed to the experience of this patient group and their families. High quality patient care will always require multiple disciplines and nursing is pivotal in this, the focus now lies on how this role will further develop.

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P09: Improving Cumulative Fluid Balance

P10: Multi-Visceral Bowel Transplants

Monitoring

(MVBT) for Patients with Pseudomyxoma Peritonei (PMP)- A Pragmatic Solution to Improve The Standard of Nursing Care in the Immediate Post-Operative Period

Reyhana Roberts and Jacqui Jocelyn, ELHT NHS Trust Background: Administration of intravenous fluids is one of the most recognised forms of life saving therapy in critically ill patients. Recent literature however, suggests that excessive use of these intravenous fluids may actually compromise critically ill patients, resulting in poorer patient outcomes (Acheampong and Vincent, 2015). Within the Critical Care Unit (CCU), daily fluid balance is recorded and monitored, however monitoring of cumulative fluid balance since a patients’ admission varies greatly.

Aim/Objective: The CCU has implemented daily observation charts with a cumulative fluid balance section. This tool aims to highlight cumulative fluid balance since a patients’ admission to the CCU, thus prompting doctors and nursing staff to consider a change in treatment, i.e. changing intravenous medication to an alternative route.

Methods: Nursing staff on the CCU are encouraged to monitor daily fluid balance and cumulative fluid balance.

Additionally, they are required to ensure that cumulative fluid balance does not exceed more than 10% of a patients’ admission weight using the notion that 1 litre of fluid weighs 1 kilogram. Staff education consisting of bedside teaching has been conducted by Quality Improvement Leads. Additionally, senior members of staff have been asked to cascade information and prompt junior members of staff during ‘safety huddles’ and handover. Furthermore, a newsletter highlighting all quality improvement projects has been produced and disseminated via email to all staff within the department.

Results: Initial conversations highlighted that staff were not aware that the observation charts had changed.

After prompting and educating staff, cumulative fluid balance monitoring has been improved however compliance varies greatly amongst staff. Additionally, discrepancies in cumulative fluid balances have been identified prompting the need for further training.

Conclusion: Through staff education within the CCU, cumulative fluid balance monitoring has been implemented and improved in practice. There is however, still room for improvement.

References: Acheampong, A. and Vincent, J.L. (2015). A positive fluid balance is an independent prognostic factor in patients with sepsis. Critical Care. 19(251).

Alice Warwick and Emily Cheshire, Oxford University Hospitals Background: The focus of this practice development project was to review, revise and implement the MultiVisceral Bowel Transplant (MVBT) care plan for patients suffering from Pseudomyxoma Peritonei (PMP). The driver to revise this document was elicited by feedback from MDT members (McSherry and Douglas, 2011).

The Project: Patients’ requiring a MVBT secondary to PMP is an increasing event within the Churchill Intensive Care, a specialist transplant unit. The incidence of PMP has been estimated to be 2 to 3 cases per million per year (Moran et al. 2015). The Churchill Intensive care unit, working in collaboration with Basingstoke is currently the only centre in the UK using MVBT for PMP. Between 2008 and 2015 the unit has cared for 8 MVBT patients with no evidence of discordant rejection and in the last six months, a further two patients. The nature of the MVBT is complex requiring Level 3 care immediately post operatively (The Intensive Care Society, 2009). In the past year local exposure and insight into this patient groups’ progress has led to the revision of the care plan and associated protocol to improve the standard of care delivered.

Conclusion: This effort has produced a means for new staff and those infrequently exposed to this group of patients to provide a minimum standard of care. It is also envisaged that there will be an increase in levels of confidence in nursing staff with the new care plan. The care plan will be disseminated to nursing and medical staff through email. There will also be a printed version in patient bed spaces.

Recommendations: I will aim to survey the response of nursing staff to see if confidence levels have improved after using the revised care plan compared with the previous one.

References: McSherry R and Douglas M (2011).

Innovation in nursing practice: a means to tackling the global challenges facing nurses, midwives and nurse leaders and managers in the future . Journal of Nursing Management. 19 (2), 165-169. Moran B, Cecil T, Chandrakumaran K, Arnold S, Mohamed F and Venkatasubramaniam A. (2015). The results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1200 patients with peritoneal malignancy. The Association of Coloproctology of Great

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Britain and Ireland. 17 (1), 772-778. The Intensive Care Society (2009). Levels of Critical Care for Adult Patients.

The Intensive Care Society. 1 (1), 1-12

P12: The Value of the Critical Care

and Why

Outreach Team: An Examination and Evaluation of the Responses to a Questionnaire for the Ward Nursing Staff at a Specialist Cardiothoracic Hospital

Sheelah Ainsworth, Leeds Teaching Hospitals NHS Trust

Jane Durrant and Sarah Mitchell, Royal Brompton and Harefield NHS Foundation Trust

P11: Which Personal Protective Equipment

Background: There is the need for source isolation of patients for a number of reasons including, respiratory infections and contact precaution infections.

It was observed that staff were sometimes unsure on the correct personal protective equipment (PPE) to use for source isolation.

When undertaking walk rounds and audits it was not always clear as to the type of PPE requirements needed when entering a source isolation room and whether it was a contact precaution or respiratory precaution or both.

Objectives: Staff had a clear understanding of which PPE to wear and the type of precautions required.

Actions: A questionnaire was used to assess staff’s knowledge of requirements of personal protective equipment.

Observation took place of PPE provision and use by staff.

Photos were taken of different PPE items.

Discussion with infection prevention re correct use of terminology and PPE Liaised with medical illustration department to produce a wipe clean poster advising staff on which PPE was required when entering the source isolation room.

Information was also provided on which PPE to use for certain infections. The poster is currently being piloted across critical care.

Result: Staff have a greater understanding of the type of isolation a patient is requiring and the associated PPE required. This improves patient and staff safety for infection prevention with the correct use of PPE in source isolation.

References: References Infections That Require Source Isolation. Leeds Health Pathways ID 1671 (Feb 2017) Isolation Policy. Leeds Health Pathways ID 678 (April 2014) D0H (2011) Isolating patients with healthcare associated infection: A summary of best practice. http:// hcai.dh.gov.uk/files/2011/03/Document_Isolation_Best_ Practice_FINAL_100917.pdf

Background : The Critical Care Outreach Team (CCOT) at Harefield Hospital was established in 2003 following the publication of two reports by the Department of Health (DOH); ‘Critical to Success’ (1999) and ‘Comprehensive Critical Care’ (2000). It had four principle aims, the fourth of which was to share critical care skills and provide experienced support to ward staff caring for acutely ill patients.

Now in its 13th year, does our CCOT deliver the service it was set up to provide, and is it the best possible as perceived by our service users?

Method: We distributed a questionnaire to the nurses and HCAs across the wards, which asked them nine closed questions about the CCOT, and a further tenth questioned their observed benefits from the ALERT Course provided by the CCOT. The choices of responses were: A- strongly agree, B-agree, C-neither agree nor disagree, D- disagree, E- strongly disagree. A space for comments provided additional qualitative data. The questionnaires were made available for a total of seven consecutive days and nights to ensure we reached as many of the ward staff as possible.

Findings: Overall, 35% of all ward nursing staff returned a questionnaire, with the return rate around the same (28-43%) across each of the five areas surveyed. The overall response from the 103 questionnaires was overwhelmingly positive, with the majority of answers to all questions being either ‘A- strongly agree’ or ‘B- agree’.

In fact the questionnaire showed that an overwhelming 95% of scores given were either A or B responses.

Conclusion The CCOT are clearly a vital resource for the ward nursing staff at our hospital, who depend on the team for a variety of reasons. This audit of our questionnaire showed that patient care is significantly improved when the CCOT resource is utilised.

References: DoH (1999) Critical to Success. The Stationary Office, London DOH (2000) Comprehensive Critical Care: a review of adult critical care services. The Stationary Office, London

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P13: Nursing leadership and resilience during unprecedented change

Jo Tillman and Anoma Gunawardena, The Royal Brompton Hospital Background: Royal Brompton Hospital (RBH) cardiothoracic adult intensive care unit (AICU) faced multiple changes between 2015-16 including management of an outbreak of a new, unknown and emerging organisim, change in senior nurse management and simultaneous departure of a number of AICU consultants.

Aim: To describe the management of the leadership and resilience challenges during this period of significant change within a high acuity clinical setting.

Methods: Regular high-level meetings between consultant, management and nursing staff, together with infection control and PHE where required. Components of these meetings included: * Task force for management of Candida Auris outbreak * Strategy for temporary relocation of AICU * Senior management involvement in rapid refurbishment of the AICU * Change in patient flow, in collaboration with recovery and Level 2 areas in the Trust * Strategy for recruitment of high-level AICU consultants including induction and integration into nursing teams and the wider multidisciplinary team * High-level management and consultant input into regular nursing team days * Restructuring of some of our highly-specialised commissioned services, including development of a new nurse specialist role These changes were managed with a view to supporting the teams decisions, at all times in a way to ensure safety and high quality care for the patients in AICU and also the whole Trust.

Results: There was no change in surgical throughput or outcomes throughout the period of change, with a significant increase in patient flow through Recovery and Level 2 areas.

Highly specialised extracorporeal membrane oxygenation (ECMO) referral rates increased, with an improvement in terms of transfusion rates, costs and survival.

The AICU was refurbished and re-opened, with eradication of the new pathogen (Candida Auris) with presentation of the infection control strategy at a national intensive care meeting, and publication in peerreview journal.

Consultant recruitment and training continues, with enhanced team-working and improved staff morale commended at an external enhanced peer-review by NHSE.

Discussion: Managing change in the highly-complex structure that is a quarternary AICU whilst maintaining patient outcomes is challenging. Use of strategies including multidisciplinary/multiprofessional leadership, structured implementation of team-working and shared-problem solving, including recognition of crisis management and leadership styles required to manage wicked problems are all required in such circumstances.

No single strategy could be considered key in managing these challenges, as all contributed to a successful outcome.

Conclusion: In order for the AICU to continue to function as an effective and safe unit, for staff morale, team building, nurse and consultant recruitment and retention and to achieve the desired results in patient and unit quality markers and outcomes the leadership team had to display high levels of resilience to support the whole interprofessional team through this period of unprecedented change. In such circumstances, transformational leadership styles where required are vital.

References: Brennan, E, J (2017) Towards resilience and wellbeing in nurses, British Journal of Nursing 26, (1), 43 Turner, S, B (2014) The resilient nurse; An emerging concept, Nurse Leader, ISSN: 1541-4612, 12, (6), 71-90

P14: ECMO Retrieval Nursing One Year On Mary Uku and Anoma Gunawardena, Royal Brompton Hospital During 2015 it was realised initially that Royal Brompton Hospital one of the nationally commissioned extracorporeal membrane oxygenator (ECMO) centres was the only UK centre which did not have an ECMO trained retrieval nurse. Following a successful trial period and with major changes to both the managerial structure and to the provision of the medical team in 2016 the decision was made to make the nurse a key member of the retrieval team.

There followed a period of training engagements and simulation, as national institute for health and clinical excellence (NICE) had clearly mentioned that ECMO should be carried out by clinical teams with specific training and expertise NICE (2011). There were a few constraints within this period concerning the nurse’s roles which had nothing to do with the nurses’ knowledge and expertise these were the feelings of uncertainties fear of the unknown, working within an unfamiliar team and the learning of new skills. These challenges have since been addressed and now we have a team of nurses serving the rota that are equipped with skills and knowledge to handle the process of ECMO retrieval.

One year on the ECMO retrieval nursing team is well established. The process includes the nurse’s

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responsibilities and duties to the Doctors the Patient and to the unit. There is increased knowledge and shared learning from the other members of the ECMO retrieval team, including factors as to why certain patients are considered suitable candidates for ECMO and some are not. Our skills and expertise have improved, we as nurses are more confident to troubleshoot the ECMO circuit, we have grown more confident in ourselves and in our communication especially when dealing with consultants during referrals and in encouraging them to use our online web based pathway.

References: NICE (2011) Treating adults with severe acute respiratory failure using an artificial ‘lung’ to oxygenate the blood outside the body http://www.nice. org.uk/guidance/IPG391. Accessed [9th March, 2017]

We also carried out a learning needs analysis in the form of a questionnaire for the medical staff who have utilised the microbiology sticker. These results demonstrated that the sticker is a positive clinical development.

P15: Improving multi-disciplinary team

communications in critical care through the introduction of a structured and standardised ward round approach Lorna Copeland, Geraldine Ovens and David Kimmett, Crosshouse University Hospital Aim: The Intensive Care Unit (ICU) within University Hospital Crosshouse is similar to others in that increased unit activity can negatively impact on communication and the ability of staff to deliver care in a person centred, safe manner. In an attempt to overcome this we embarked on an improvement project to standardise the daily ward round. We incorporated the following into an initial bundle: • Daily goal setting and review • Implementation of a unit safety brief • Review of Daily Goals (PM ward round) • Microbiology sticker

Results Compliance with the ward round bundle has been encouraging with sustained improvement in three out of 4 of the elements.

Methodology: Using improvement methodology and the model for improvement we devised a project charter and encouraged staff engagement and clarity through the development of a driver diagram

Additionally we had various PDSA tests of change: Page 44

and responsive but unable to speak due to respiratory tract intubation/NIV. Methods: National network engagement and collaboration with a critical care psychological support practitioner from Whipps Cross University Hospital.

Quantitative questionnaires were delivered for patients to rate their ability to communicate using picture boards and then using the ICU APP (see graph below)

Balancing measure: Cost of device, nursing time required to implement device and educate staff and patients.

Conclusion: ICU is dedicated to supporting the delivery of the Quality Strategy through ongoing developments and improvement in our clinical practice. PDSA testing of the daily goals review continues to try and improve compliance. Additionally, we have introduced a new element to the bundle in the form of a daily weight sticker.

References: S R Heard, C Roberts, S J Furrows, M Kelsey, L Southgate (2003) Corridor Consultations and the Medical Record: Is patient safety at risk? Journal of Clinical Pathology. 56:43-47 The Scottish Government (2011).

2020 Vision for Health and Social Care.

P16: Improving the ICU patients ability to communicate

Stacey Needham and Rebecca Herron, UHMBT Background: Problems associated with the inability to speak during critical illness are well known. Research shows communication difficulties are associated with greater severity of illness and feelings of anger, frustration, panic, anxiety and sleeplessness. (Magnus and Turkington, 2008) (Tembo et al 2015) The use of out dated inadequate picture boards lead to constant failure to understand patient’s attempts to communicate resulting in poor patient involvement in care planning/delivery.

Results: Baseline data (see graph above) Following implantation of the ICU APP results increased as indicated in graph below.

Conclusion: Through stakeholder engagement (patient/relatives/nursing /medical workforce & IT) and staff training, 90% of patients rated the ability to communicate with the APP was good and 10% adequate.

This has enabled a much more collaborative approach to patient care planning/delivery and reduced frustration and anxiety.

References: Magnus VS, Turkington L (2008) ‘Communication interaction in ICU-Patient and staff experiences and perceptions’ Intensive Critical Care Nursing. 24 (4) pp 264 Tembo A, Higgins, Parker V (2015) ‘The experience of communication difficulties in critically ill patients and beyond intensive care: Findings from a larger phenomenological study’ Intensive and Critical Care Nursing 31 (3) pp171-178

Aim/Objectives: To improve the adult ICU patient’s ability to communicate through the use of an electronic device, using an ICU APP on an IPad for patients who are awake

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P17: Quality Improvement Across a

P18: A service improvement in the critical

Elizabeth Ellis, Mid Yorks NHS Trust, Andrea Berry, WYCCODN, Sheelah Ainsworth, Leeds Teaching Hospitals, Linda Brennand, Airedale NHS Trust

Sarah McMullan, Lancashire Teaching Hospitals Trust

Network

The West Yorkshire Critical Care Operational Delivery Network (WYCCODN) Service Improvement Lead (SILs) lead nurses have worked on numerous projects to improve quality and service across our network.

The group is made up of representatives from all the Trusts in West Yorkshire plus the network manager and meet approximately 4-5 times in a year to develop, implement and share service and quality improvements within critical care. These meetings also allow the SILs team the opportunity to benchmark practice and produce guidelines which are available for all units to utilise.

During the past 12 months the WYCCODN SILs team have identified the need to produce an infection control (IPC) booklet for visitors to critical care, a Falls assessment tool which has relevance to critical care patients, information cards to direct patients/visitors to the network website and an up to date VAP bundle.

A decision was made to look at producing a Falls assessment tool which had relevance to critically ill patients as all the Network’s units found that their Trust paperwork did not reflect the patients we were caring for. It was also recognised that nationally there was a lack of an appropriate Falls tool for critical care. The tool has now been developed and is currently being trialled in one of our larger Trusts with a plan to role out to the whole Network over the coming months. CC3N are plan to review the tool with a view to making it available nationally.

Work on the IPC booklet has been completed and the booklets are now available in all of West Yorkshire’s critical care units.

The VAP care bundle has been redeveloped and is awaiting the role out of an education package for staff prior to its introduction.

References: Ham et al (2016) Improving Quality in The English NHS – A strategy for action The Kings Fund Available at: https://www.kingsfund.org.uk/sites/files/ kf/field/field_publication_file/Improving-quality-KingsFund-February-2016.pdf Accessed January 2017

care (CRCU) discharge process, developed in line with the delayed discharge CQUINN

Aim: To reduce delayed transfers of care (DTOC’s) from critical care to ward level care, by improved relationships with bed management and the wider hospital thus removing delays and improving patient flow into and out of critical care. There is a national standard that all discharges from CRCU should happen within 4 hours of a clinical decision to discharge and within daytime hours.

Method: By embracing the CQUINN and working towards achieving it we will be improving the patient experience by ensuring that we get the right patient in the right place at the right time. We could therefore reduce hospital length of stay, reduce risk of hospital acquired infection create better flow into and out of CRCU and ensure that discharge begins on admission. By being more proactive in preparing patients for the ward and working together with the whole of the MDT in forward planning we will achieve a service improvement.

The role of Discharge coordinator was introduced to critical care and tasked with improving the quality of patient discharge from CRCU both physically and psychologically. This role has also improved MDT working and ensures a more joined up approach to discharge planning.

Results: Within critical care we have developed a standard procedure to follow in order to provide consistency and improve patient flow on a daily basis.

The SAFER care bundle has been adapted to fit critical care. In order to highlight the triggered patients we developed the Red,Amber,Green system and changed the way in which we present the unit status at the capacity meetings.

Conclusion: Discharge planning within critical care is a complex procedure particularly with demands on hospital beds. Therefore effective discharge planning is crucial to ensure a timely discharge and continuity of care. A pre-planned patient discharge inputted by all members of the MDT and understanding of the wider network outside of critical care can achieve a 4 hour qualit References: NICE , 2009. Rehabilitation after critical illness in adults, s.l.: NICE Clincial Guideline CG83.

NHS England, 2016. Revised Adult Critical Care Timely Discharge, s.l.: NHS England

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P19: Preventing falls in Critical Care Sheelah Ainsworth, Leeds Teaching Hospitals NHS Trust, Andrea Berry, West Yorkshire Critical Care and Major Trauma Delivery Networks Background: The use of a generic falls care plan is audited as part of monthly ward metrics (LTH 2013). It was demonstrated through the audit of the care plan and feedback from staff that most of the care plan was not relevant to critically ill patients. A national query was sent out across the critical care network to see if anyone had a critical care specific falls care plan and none was identified.

Aims: To reduce the incidence of falls in critical care. To raise the awareness in staff of factors contributing to falls in critical care.

Method: The service improvement leads collated all of the falls care plans from across West Yorkshire and reviewed literature and had a brainstorming session. A care plan was devised in a layout similar to the generic falls care plan. The care plan was taken to the Trust falls group for approval of use. There was a critical care falls campaign with some focused education on falls including the importance of 1:1 supervision for at risk patients, bed settings and sight lines. The care plan was initially piloted in one general ITU, adjustments were made to the wording following feedback and the plan was then piloted across the whole of critical care.

Results: Feedback from staff has been positive, there has been an increased use of alarm settings on the beds.

There have been no instances of falls as yet since the new care plans were piloted.

Future work: Further work on sight lines and placement of mirrors. Introduction of CAM ICU as formal delirium assessment to improve the assessment of delirium.

References: Leeds Teaching Hospitals Ward Healthcheck Metrics Programme. LTH Nov 2013 Slips, Trips and Falls in Hospital NPSA (March 2007) http://www.nrls.npsa. nhs.uk/resources/?entryid45=59821

P20: Improving safety when caring for the critically ill child in an adult ICU

Lianne Harrison and Sarah McHenry, Blackpool Teaching Hospitals Every year a small amount of critically ill children are admitted onto adult intensive care units. In Blackpool ICU on average there are 2 paediatric admissions each month. “This often causes difficulties for adult nurses because they are required to utilize specialist paediatric

knowledge and skills that are practised on an infrequent basis only,” (Offord 2010). Caring for a critically ill child often causes a lot of stress and anxiety for the nurses involved. To address this after attending the AQUA quality improvement course I introduced the WETFLAG tool onto Blackpool ICU. This is filled in before the child is admitted onto the unit and is displayed for all those involved in the child’s care to see. The purpose of WETFLAG is to work out appropriate weight based drugs and equipment the child may need quickly. This enables a safe and structured approach to be used. A training package is now also used which involves both teaching and simulation, since all of these have been put in place the confidence and knowledge of the nurses has increased when caring for these patients.

References: Offord, R.J, (2010) Caring for critically ill children within an adult environment- an educational strategy. Nursing Critical Care Nov-Dec;15(6):300-7 BACCN

P21: Patient Diaries in the ICU Catherine Hyland, Beaumont Hospital Aims: An overview of Patient Diaries for use in supporting patients’ psychological recovery after discharge from the ICU. Introduction: “Primum non nocere”, meaning “First, do no harm”, is a basic understanding of the ethical principle on non-maleficence, and a guide for all nursing practice.

Recovery from critical illness can be a challenging process. It is informally noted that every day spent in ICU with a critical illness, can result in one month’s recovery.

The physical recovery is challenging, however the psychological recovery can be the most distressing.

With advances in healthcare and improvements in clinical treatments, more and more patients survive ICU. Their experiences in ICU can often be harrowing and frightening, as they battle critical illness in an effort to survive. The memory of ICU therapies, the recollection of being unable to move, to speak or to communicate is daunting for many survivors. Memories can be fragmented and influenced by hallucinations, lack of sleep, the noise of the environment and the use of anxiolytic agents.

Daily diary entries can help document the day to day occurrences, for the patient to read during recovery.

With guiding literature on prevention of delirium and the PAD Guidelines, it is hoped that the psychological effect of ICU will lessen. In the meantime, it is important to acknowledge the risk to patients, and prevent long term debilitating psychological outcomes where possible.

Recommendations: The aim of this literature review is to establish an evidence base to support the introduction

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of patient diaries to the ICU. As we become aware of the psychological impact of an ICU stay on the long term outcome of patients, it is important we prevent harm where possible. The introduction of patient diaries could be a simple solution.

References: Jones, C., Backman, C., Capuzzo, M., Egerod, I., Flaaten, H., Granja, C., Rylander, C., Griffiths, R. and the RACHEL group (2010) Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial. Critical Care 14(5), pp1-10. Ullman, A.J., Aitken, L.M., Rattray, J., Kenardy, J., Brocque, R.L., MacGillivray, S. and Hull, A.M. (2015) Intensive care diaries to promote recovery for patients and families after critical illness: A Cochrane Systematic Review. International Journal of Nursing Studies 52(7), pp1243-1253

P22: Implementing a Non-Injectable

Connector (NIC) in an Intensive Care Unit (ICU) Emily Hodges, Patsy Tipene, Natalie English, Peter Young and Maryanne Mariyaselvam, Queen Elizabeth Hospital, Kings Lynn Introduction: The WHO recommends that arterial lines should not have injection ports (WHO Safety Guidance).

Arterial lines carry considerable risk if they are injected into, with patients sometimes experiencing vasospasm or permanent injury as a result. Staff can experience blame following investigation to find a root cause.

However, these incidents are due to a system error, a simulation study has shown a high incidence of this error, with trained staff, when under time pressure and stress (Mariyaselvam et al, 2015). There is now a simple, easily implementable solution to allow compliance and protect patients and nursing staff. The NIC arterial connector (KLIPSuk.com) is being implemented across NHS England by the NHS Innovator Accelerator programme and is now subject to full reimbursement by the Department of Health (Innovation and Technology Tariff) to facilitate and support its national implementation. An arterial line also has the potential of harboring bacteria and the NIC has been shown to minimize this compared to open ports.

Methods: The NIC was implemented in 11 ICUs in the East of England into theatres and ICUs. Staff training was minimal, via a train the trainer approach.

Results: Feedback was collated from >250 nursing and medical staff using the NIC. Responses showed the NIC was easy to introduce, use and important for patient safety.

Conclusions: NHS England and the WHO support

the protection of arterial transducer sets from injection. The NIC now is on a national tariff to facilitate implementation. Responsibility for the error shifts from the bedside to those accountable for safety implementation. Introducing the NIC, the risk of accidental intra-arterial injection and bacterial contamination is all but eliminated. Staff are not facing blame for an avoidable event, patients are not at unnecessary risk, and national recommendations are met. There are NHS ICUs remaining who do not yet comply.

References: 1. Patient Safety Solutions (2007). Avoiding Catheter and Tubing Mis-Connections. The World Health Organisation, The Joint Commission, Volume 1, Solution 7, p 1-3. Available from http://www.who.int/ patientsafety/solutions/patientsafety/PS-Solution7. pdf. [Accessed 30/3/17) 2. Mariyaselvam, M., Heij, R., Laba, D., Richardson J., Hodges, E., Maduakor C., Carter J., Young, P. (2015). Description of a new non-injectable connector to reduce the complications of arterial blood sampling. Anaesthesia, 70(1), p51-55. doi: 10.1111/ anae.12884

P23: Oral care: promoting awareness and

providing an education for critical care nurses

Claire Harcourt Watkins, Hywel Dda University Health Board Introduction: The consequences of oral infection in critically ill patients are widely acknowledged (Hua et al (2017). Munro (2014) advocates the need for education to promote awareness and raise standards in the quality of oral hygiene care to improve patient comfort and dignity and in addition reduce the risk of ventilatorassociated pneumonia.

Research by Munro (2014) identified that the delivery of oral care within critical care was inconsistent and focussed primarily on maintaining patient comfort in preference to reducing oral infection. In creating a poster promoting mouth risk assessment and oral hygiene care is to raise awareness and enhance critical care nurses’ knowledge and improve standards of care by following evidence based protocols.

Background: Mouth assessment within 4-6 hours of admission into a health care environment is advocated by (G.B. Welsh assembly Government (WAG, 2013). As too is the use of a care plan which is selected according to the identified level of risk.

An additional impetus for developing this poster was a need to promote the use of these documents and facilitate the appropriate selection of care plans which

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are incorporated into the Units electronic observation and documentation system.

Purpose: The utilisation of graphic information in poster format acts as an aid memoir accessible to all staff, reinforcing the understanding of and need for quality oral hygiene assessment and care. Further, it will facilitate the appropriate use and selection of assessment tools and care plans consequently reducing the risk of ventilator associated pneumonia in patients deemed at high risk. In conjunction utilisation of ventilation bundle to further minimise these risks to ventilated patients.

References: (G.B. Welsh assembly Government (WAG, 2014). Critical care mouth assessment form/Version 8/08/14 and Critical care mouth care plan A, B or C. http://www.1000livesplus.wales.nhs.uk/mouthcare (Accessed 30/03/17) Hua F, Xie H, Worthington H V, Furness S, Zhang Q, Li C (2017) ‘Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia’. (Review).

Cochrane Collaboration. Wiley & Sons Ltd Munro, C. L. (2014) Oral health: something to smile about. American Journal of Critical Care. Vol 23, (4) pp.282-288

developed and support of the key stakeholders ensured.

An outline of what is required for implementation and mainstreaming of the pathway, through the structure of the newly formed hospital groups is put forward.

References: Prospectus Report. (2009). Towards Excellence in Critical Care Review of adult Critical Care Services in the Republic of Ireland. accesible at: http:// www.hse.ie/eng/about/Who/clinical/natclinprog/ criticalcareprogramme/critcarrep09.pdf Twigg, D., & McCullough, K. (2014). Nurse retention: A review of strategies to create and enhance positive practice environments in clinical settings. International Journal of Nursing Studies, 51(1), 85–92. HSE. (2016).

National Adult Critical Care Capacity and Activity Census 2015, Acute Hospitals Division HSE. accesible at: http://www.hse.ie/eng/about/Who/clinical/ natclinprog/criticalcareprogramme/publications/ CriticalCareCapacityCensus2015%20.pdf

P25: Procalcitonin (PCT) Joanna Davies and Susie Henwood, Hywell Dda Health Board “Enhance patient care through nursing staff education in the appropriate use and interpretation of Procalcitonin levels within the critical care setting”.

P24: Critical Care Nurse Career Pathway

Derek Cribbin, Una Quill and Dr. Michael Power, Critical Care Program Ireland The aim of this organisational development project is to put in place an implementable plan for the delivery of a standardised critical care nursing career pathway across all Hospital Groups in the Republic of Ireland.

The pathway relates to the professional development of critical care nurses at every stage of their career, from new graduate to advanced practitioner. This will enable there to be a substantial increase in the number of nurses doing accredited education, through implementation of the pathway across the hospital groups. This will be through the establishment of working groups consisting of key stakeholders to explore and develop methods of implementation and the formulation and delivery of a National Foundation education Programme in Critical Care nursing. An agreed governance structure for these working groups will ensure standardisation. To understand requirements the annual Critical Care Census will be updated to recognise what is required to ensure that the correct supports are in place to prevent burnout of both the new entry nurses to critical care but also the senior staff.

Standardisation of professional development for critical care nurses has been recommended in Ireland and the pathway represents this. Utilising the Irish Health Service Executive change model, the initiation and planning stages are discussed where a shared vision was

Aim: This poster is aimed at empowering nursing staff to deliver proactive patient management through increasing knowledge and understanding of the use of Procalcitonin in the diagnosis and management of the bacterial infection.

Background: Procalcitonin is proposed to be the most sensitive and specific biomarker to aid the diagnosis of bacterial sepsis and differentiates sepsis syndrome from systemic inflammatory response and viral infections (Meisner, 2014; National Institute for Health and Care Excellence {NICE}, 2015). Procalcitonin monitoring helps guide antibiotic stewardship by monitoring the levels on a regular basis, allowing the evaluation of the effectiveness of the antibiotic therapy (Meisner, 2014; Viallon, 2016). However, Procalcitoning test is expensive and must not be used alone. Clinical judgment, C-reactive protein, blood cultures and various proinflammatory cytokines must also be used to help guide clinical decisions (Viallon, 2016).

By increasing understanding in this matter, nurses will able to facilitate appropriate use and interpretation of results to help inform clinical decision making. Health care professionals are aware of the importance of preventing microbial resistance, timely Procalcitonin testing has been shown to inform antibiotic therapy preventing unnecessary antibiotic use which can lead to antibiotic resistant, unnecessary side effects and

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unnecessary expenditure (Meisner, 2014; NICE, 2015: Viallon, 2016).

References: Meisner, M. (2014). Update on procalcitonin measurements. Annals of Laboratory Medicine, 34, 263-273.

National Institute for Health and Care Excellence. (2015). Procalcitonin testing for diagnosing and monitoring sepsis (ADVIA Centaur BRAHMS PCT assay, BRAHMS PCT Sensitive Kryptor assay, E;ecsys BRAHMS PCT assay, LIAISON BRAHMS PCT assay and VIDAS BRAHMS PCT assay). London: National Institute for Health and Care Excellence.

Viallon, A. (2016).

Procalcitonin used in the emergency room. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4071182/

P26: A review of the evidence-base for

of the nursing interventions to reduce ventilator acquired pneumonias. Can education for nurses on the evidence behind ventilator-acquired pneumonia prevention methods, improve compliance and therefore, the prevalence of pneumonia’s in the critical care setting?

impact on mortality rates, which were seen to be due to co-morbidities. Nursing compliance was found to be a common barrier in research, and was often highlighted as an area further requiring research (Bouadma et al, 2010).

Conclusion: Nursing compliance was found to be the area most in need of further research. A brief research proposal for a longitudinal study is therefore proposed, researching the effect of a nurse-led education programme on improving nursing compliance with VAP prevention methods. It will be hypothesised that an education program on VAP prevention would improve nursing compliance and thus reduce VAP prevalence.

References: Aveyard, H. (2010). Doing a Literature review in Health and Social Care: A practical guide. 2nd Edition. Berkshire: Open University Press. Bouadma, L. Deslandes, E. Lolom, I. (2010) Long-term impact of multifaceted prevention program on ventilator associated pneumonia in a medical intensive care unit.

Clinical Infectious Diseases. 51: 1115-1122

P27: Non-invasive Ventilation on COPD Patients

Abigail Ratcliffe Law and Maurice Nagington, University of Manchester

Freeta Jamile and Mable Anu, Mid Essex Hospital

Background: Ventilator-acquired pneumonias (VAPs) are an increasing problem in intensive care settings, increasing the length of stay for the patient as well as their number of days requiring ventilation. Recent evidence into VAP prevention has brought to light the use of subglottic suctioning and oral hygiene, as well as other interventions in preventing VAPs. Method: A research strategy was developed using PICO (Aveyard, 2010) to define the key search terms.

Databases such as Medline, CINHAL and the British Nursing Index were then used to find the literature. A review of the found literature was conducted discovering the themes in the current research and highlighting further areas of research needed. The four themes identified were; VAP diagnosis, Nursing Knowledge and Compliance, Impact of VAP in different co-morbidities, and the effect of a VAP on ICU length of stay, number of days on a ventilator and mortality rates.

Findings: Subglottic suctioning and oral hygiene were found to be effective in reducing VAP prevalence.

However, other interventions became apparent following the literature search, such as cuff pressure monitoring and head of the bed elevation. VAP diagnosis is found to be poor among a number of the papers, with definitions differing, depending on the region of study. There was found to be an increase in length of ICU stay and number of days on a ventilator following a VAP diagnosis, but no

This systematic review (SR) aims to find evidence for early use of non-invasive ventilation among hypercapnic COPD patients compared to standard therapy and implement evidence-based practice in clinical settings.

Aim: SR will be discussed, followed by the implications for early use of NIV among hypercapnic COPD patients in clinical settings and recommendations for future research.

Methods: Systematic reviews have advantages over traditional methods of literature review. No SR has been undertaken on the following question: “Is early use of NIV effective in managing hypercapnic COPD patients in comparison to standard therapy?”

Study Design: Only RCTs are included to evaluate whether early use of NIV among hypercapnic COPD patients is effective compared with ST. Discussion: From the four studies selected in this SR, NIV effectiveness was also assessed. Patients with COPD have a high PaCO2 due to their impaired airflow. In order to rebalance the PaCO2 levels, NIV is used. All four studies demonstrated the effectiveness of NIV. Overall, it can be concluded that NIV is effective since its use is associated with a marked reduction in intubation requirement, decreased complications, reduced dyspnoea, improved survival rate, improved oxygenation, and decreased

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hospitalisation.

Result: All four selected studies looked at different outcomes. The results were analysed and discussed normatively. All four studies examined COPD in adults.

In these studies, patients treated with NIV in emergency department in conjunction with pharmacological interventions clearly show an improvement in PaCO2 levels and decreases in respiratory distress/dyspnoea in hypercapnic COPD patients.

Conclusion: COPD patients receiving NIV benefit greatly through improved blood gas levels, which can also improve dyspnoea, survival rate and quality of life .Early use of NIV among hypercapnic COPD is beneficial when initiated in the Accident and Emergency Department.

References: Bhatt, S.P., Peterson, M.W., Wilson, J.S. & Durairaj, L. (2013). “Noninvasive positive pressure ventilation in subjects with stable COPD: a randomized trial”, International Journal of COPD, 8, 581-589. De Backer, L., Vos, W., Dieriks, B., Daems, D., Verhulst, S., Vinchurkar, S., Ides, K., De Backer, J., Germonpre, P. & De Backer, W. (2011). “The effects of long-term noninvasive ventilation in hypercapnic COPD patients: a randomized controlled pilot study”, International Journal of COPD, 6, 615-624. Keenan, S.P. & Mehta, S. (2009). “Noninvasive ventilation for patients presenting with acute respiratory failure: the randomized controlled trials”, Respiratory Care, 54(1), 116-126.

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