BACCN Abstract Book 2018

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33rd Annual Conference

Sustainability in Excellence: The Future of Critical Care

ABSTRACT BOOK 2018 Conference Partner:

17th & 18th September 2018 Bournemouth International Centre

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

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

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

Posters.......................................................................... Page 30 

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Keynote Speakers S01: “999 - What’s your emergency?” Dale Harrison Fire Officer National Fire Chiefs Council Emergency Service Network Team, Home Office BIOGRAPHY Dale Harrison is an Operational Fire Officer with 24 years experience, he has attended many incidents as a fire officer often working in difficult and challenging environments, he is currently seconded to the Home Office as part of the National Fire Chiefs Council Emergency Service Network Team. Dale has responsibility for National Operational ESN Training and National Fire Service Transition. Before joining Staffordshire Fire and Rescue Service he was in the Armed Forces. Dale was the Fire Service Incident Commander at the Smiler Crash incident at Alton Towers on the 2 June 2015. He has recently had his account of the Smiler Incident in the Crisis Response Journal and has been to many services and organisation to ensure as many operational firefighters and responders have an opportunity to hear the lessons learnt by him and his team during and after the incident.

S02: The Challenge of the “Difficult to Wean” Patient Dr Louise Rose Professor of Nursing at Kings College London, UK and TD Nursing Professorship in Critical Care Research based at Sunnybrook Health Sciences Centre, Toronto, Canada BIOGRAPHY Dr Rose is an honorary professor at the Lane Fox Respiratory Unit at St Thomas’ Hospital in London and also is the Research Director for the Provincial Centre of Weaning Excellence at the Michal Garron Hospital, Toronto, Canada. She is a PhD prepared nurse with an active research program and over 110 peer-reviewed publications focused on improving outcomes and experience of the ventilated patient in diverse settings including the intensive care unit, emergency department, specialized weaning centre, long-term care, and the community. 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.

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S03: Psychological Recovery Post Critical Illness Dorothy Wade Chartered Health Psychologist in the Critical Care Unit at University College Hospital, London BIOGRAPHY Dorothy Wade is a chartered health psychologist working with patients, families and staff in the critical care department at University College Hospital, London. She is a registered practitioner psychologist, and has a PhD in psychology and health care evaluation from University College London. She represents psychology on UK and European critical care bodies, and has worked with NICE on the role of psychology in rehabilitation after critical illness. She frequently writes and speaks about the psychological impact and outcomes of critical care, with emphasis on acute stress, hallucinations and delusions and posttraumatic stress disorder. Her research includes development of a psychological assessment tool for patients in critical care (IPAT); and developing and evaluating psychological interventions to reduce long-term morbidity. She is lead clinical investigator of the POPPI study, a multi-site clusterRCT funded by the National Institute of Health Research Health services and delivery research programme, to evaluate nurse-led provision of psychological support for critical care patients.

S04: The Sustainability of the Critical Care Workforce Dr Julie Highfield Consultant Clinical Psychologist in Critical Care (Adult and Paediatric), University Hospital of Wales BIOGRAPHY Dr Julie Highfield is the Consultant Clinical Psychologist in Critical Care for Cardiff and Vale University Health Board. She works clinically with patients and visitors in critical care and has special interests in rehabilitation and the psychological impact of delirium. In addition to this, Julie is the lead for staff wellbeing, and is involved in ongoing research into staff wellbeing in critical care. She is part of the Intensive Care Society Burnout Working Group, and has recently been involved in advising the wellbeing aspects of the Faculty of Intensive Care Medicine annual survey. In addition, Julie is the secretary for the British Psychological Society Division of Clinical Psychology, Wales, and through this work has delivered a number of national sustainable workforce events. Julie has a long experience of working as a psychologist in medical and health settings, and works closely with staff in their experience of working in healthcare, as well as advising managers on matters of workforce wellbeing. ABSTRACT In this time of austerity there is increasing uncertainty in what is an already complex system of the NHS. Startling figures have emerged over recent years of medical and nursing staff struggling with high levels of burnout and stress. This is also the case in critical care. In addition, with ongoing advances, intensive care medicine is changing, and our workforce are dealing with increasing complexity. How do we ensure our workforce wellbeing during these ongoing challenges? The ethos of this presentation is to take a step back from individual approaches that we are so often drawn to, and instead to consider the impact of the system on the individual. It will offer ideas about what leads to unhelpful behaviours and dynamics in organisations and what can sustain helpful behaviours, particularly within critical care, although the underlying approach applies across all of healthcare. The presentation will bring new ways of understanding team culture, and establishing a workplace that enables wellbeing via trust, safety, belonging, and autonomy. This is a step away from colluding with the “fix the individual approach� that the resilience agenda can unfortunately promote. Page 4

S05: Advancing Critical Care: Safe staffing, workforce planning and new roles - ACP/ANP credentialing

Professor Mark Radford Director of Nursing - Improvement, NHS Improvement BIOGRAPHY Mark Radford is Director of Nursing (Improvement) for NHS Improvement with a portfolio that covers workforce, quality improvement and Governance. Mark has worked in Perioperative, Emergency and Intensive care in the UK and Europe. He was previously been a Chief Nurse of a University Teaching Hospital and Consultant Nurse in Emergency & Trauma care. Mark is Professor of Nursing at Birmingham City and Coventry Universities, and has published research on staffing, advanced practice, perioperative and trauma care. ABSTRACT The NHS England Five Year Forward View (2014) and the NHS England Next Steps on the Five Year Forward View (2017) set out the current challenges experienced by the NHS, its possible future and choices to be made. It is recognised in England that the increase in demand for services is intensifying the pressure on the workforce. It is also acknowledged that there are several issues throughout England and at a regional and/or local level, which have resulted in some significant gaps in the workforce. However, there are significant opportunities to develop the workforce to respond to these challenges, including expanding the development of Advanced Clinical Practice. The new National multi-professional Advanced Clinical Practice (ACP) framework set out a new and bold vision in developing this critical workforce role in a consistent way to ensure safety, quality, and effectiveness. It has been developed for use across all settings including primary care, community care, acute, mental health and learning disabilities. This framework recognises that the health and care system rapidly evolves to deliver innovative models of care, health and care professionals have adapted, to meet the increasing demands of individuals, families and communities.

S06: Moral Courage: Standing up for your patient’s rights - what would you do? Alex Wubbels Clinical Nurse Educator, Burn Trauma Intensive Care Unit, University of Utah Hospital

BIOGRAPHY Alex Wubbels is a two-time Olympian in Alpine skiing, 1st ever recipient of University of Utah Excellence Award, BSN, RN, Clinical Nurse Educator, Burn Trauma Intensive Care Unit, University of Utah Hospital and mother. Alex has worked for the University of Utah since 2004, beginning as an EMT at the University of Utah Redstone Clinic. In 2009 she graduated from the University of Utah College of Nursing and was inducted into Sigma Theta Tau International-Gamma Rho. After completing the Critical Care Internship at the University Hospital, Alex began her nursing career as a bedside nurse in the Burn Trauma ICU, where she has worked for the last 8 years. Wubbels’ life changed dramatically on July 26, 2017, when she was assaulted and arrested by a police officer for upholding the University of Utah’s hospital policy on blood draws from an unconscious patient. The video was shown all over the world, from Afghanistan to England to China. Being a nurse means protecting and advocating for your patient even in extreme circumstances. Having the moral courage to do that can be challenging, but it is possible with the empowering support of your team. Alex is passionate about patient advocacy and patient safety. Alex believes that it is imperative that all nurses know their resources so that they are empowered to do the right thing. She hopes that her story can drive a national conversation and make lasting impact. Alex’s high standards for nursing care exist because of the mentorship and leadership she has received since becoming a nurse. Page 5

Workshop Abstracts W01: Recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS) incorporating ECMO

At the University of Portsmouth, nursing students have lectures on pharmacology and drug errors, including the anticipated physiological response. These drug errors were then replicated in simulation using high fidelity simulators.


Dr. Miguel Garcia - Consultant in Cardiothoracic Anaesthesia, Cardiothoracic ICU & ECMO, University Hospital of South Manchester Outlining the new guidelines and recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS) incorporating Extra-corporeal membrane oxygenation (ECMO) as an adjunct to protective mechanical ventilation for patients with very severe ARDS.

Study Design/Methodology: The simulated monitor was switched off to encourage the development of the novice’s eye gaze to recognise the deteriorating patient from visual cues. In order to develop visual cues, we designed 4 drug error scenarios; asthma, hyper-kalemia, pulmonary embolism and anaphylaxis. All four scenarios ran simultaneously. Groups of 4 nursing students rotated between the stations, each having the opportunity to take the role of: recording the patient’s history, completing the National Early Warning Score (NEWS) 2 (Royal College of Physicians, 2017) completing a physical examination and asking debrief questions. The scenarios had a 10 minute time limit to encourage teamwork. Summary of results: All 84 students were able to identify the correct medical condition for all 4 of the drug error scenarios.

W02: Freedom in Critical Care SPONSORED BY:

Conclusion/Major Findings: The informal student feedback was positive and indicated that the session was perceived to be beneficial. The time limitation factor encouraged good teamwork, leadership skills, good communication, decision making, task management and time management.

Nathan Thompson, Care-Med UK The word freedom is not one that is always or often associated with Critical Care but let’s examine how we learnt about its importance and why it’s central to everything we do. We’ll be telling a story through the lens of a customer and explaining why we believe that patient seating needs to work just as hard for the carer as it does for the “cared for”.

W03: Acute Care Across Care Settings: Teaching Novices Expert Eye Gaze in Simulation Kirsty Harris, University of Portsmouth Introduction/Learning Outcomes: The learning outcome for this activity was to teach novices to recognise the deteriorating patient using simulation and to advocate the “end of the bed look”, as nurses often develop visual skills over time by anticipating patient’s decline before objective evidence becomes available (Douw, Schoonhoven, Holwerda, Huisman-de Waal, Zanten, Achterberg & Hoeven, 2015).

References: Douw, G., Schoonhoven, L., Holwerda, T., Huisman-de Waal, G., van Zanten, A.R., van Achterberg., T. and van der Hoeven, J.G. (2015). Nurses’ worry or concern and early recognition of deteriorating patients on general wards in acute care hospitals: a systematic review. [online] Available at: pubmed/25990249 [Accessed 14 Mar. 2018]. Royal College of Physicians (2017). National Early Warning Score (NEWS 2). Standardising the assessment of acute-illness severity in the NHS. [online] Available at: [Accessed 14 Mar. 2018].

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W04: Championing new ways of working to improve environmental sustainability in critical care Heather Baid and Lesley White, University of Brighton, Rute Monteiro de Oliveira, East Surrey Hospital, Redhill Surrey Aim: The purpose of this workshop is to explore the role of sustainability champions in leading new ways of working for critical care practice to be ‘greener’ with a reduced environmental impact. The workshop is underpinned by the concept of stewarding, which is an altruistic ethic to use resources responsibly and in a sustainable manner. Format: • Introduction – short presentation and interactive online quiz highlighting key issues with environmental sustainability in critical care. Case studies will be shared about critical care units with champions steering green projects based upon stewardship principles. • Small groups – exploration of new ways of working for critical care practice to be more resourceful, less wasteful and have a reduced environmental footprint with the cobenefit of financial savings. Each small group will have a facilitator to guide the discussion and take notes of ideas, questions and comments. • Large group - sharing of the main points from the small group discussions to make recommendations for future clinical practice, research and education related to improving the environmental sustainability of critical care. Outputs: Participants and facilitators can use their mobile phones or tablets throughout the workshop to post suggestions and questions about championing environmental sustainability in critical care onto a freely accessible online message board. They will also be encouraged to use the hashtag #greencriticalcare while interacting on social media during the workshop. Participants will leave the workshop with the following outputs: • Summary of the small and large group discussions and recommendations for future practice. • Online message board using padlet. • Collection of social media content for #greencriticalcare using wakelet. • List of workshop attendees who consent to sharing email contact details for continued networking and collaboration after the conference. • Reference list prepared by workshop organiser including key resources from the Centre for Sustainable Healthcare (2018), NurSus (2018) and Sustainable Development Unit (2014).

Centre for Sustainable Healthcare. 2018. Sustainable specialities. Viewed 8 June 2018, https:// NurSuS. 2018. SLCFrameWork. Viewed 8 June 2018, Sustainable Development Unit. 2014. Sustainable development strategy for the health and social care system 2014-2020, Viewed 8 June 2018, https://www. aspx

W05: Mitigating the risk of hospitalacquired pneumonia with oral hygiene SPONSORED BY Come and hear Jan Powers, PhD, RN, CCRN, CCNS, CNRN, FCCM, talk about how you can mitigate the risk of hospital-acquired pneumonias with comprehensive oral hygiene from your facility today.

W06: The 5 R’s of Ready-to-Use Injectable Medicines SPONSORED BY:

Gillian Cavell, formerly Consultant Pharmacist and Deputy Directo of Pharmacy, Medication Safety, King’s College Hospital NHS Foundation Trust In addition to the 5 rights for the safe use of medicines this presentation will highlight how the use of Ready-toUse injectable medicines promotes 5 more R’s: Reliability, Reproducibility, Reduces Risk and Releases time to care for patients.

References: Page 7

W06: HOTT Topics: management of burns and inhalational injury in the General ICU Elaine Manderson and Ben Harold, Chelsea and Westminster Hospital NHS Foundation Trust Caring for a burns patient outside of a specialist ICU is unusual, but it can happen. The Burns and Intensive care team at Chelsea and Westminster Hospital NHS Foundation Trust will present to during this session how you can manage a severely burned patient on your general ICU, including the patient with an inhalation injury.

W07: “Let’s Get Physical” Workshop SPONSORED BY

Gareth Cornell - Critical Care Physiotherapist, Sheffield University Hospital Trust, ACPRC Critical Care Champion Laura Breach - Critical Care Clinical Specialist, University Hospital of Leicester, ACPRC Public Relations Officer Helen Sanger - Critical Care / Medicine Physiotherapist, Newcastle Upon Tyne, ACRC Newsletter Editor 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. In conjunction and with support from our industrial partners Care Med and Medi-Motion delegates will be able to explore how to get their patients on the road to physical recovery through the use innovative new techniques and good old fashion mobilisation.

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Concurrent Abstracts C01: Technology allows us to understand specifically ‘what’ not simply ‘how’ patients feel

C02: The SWIFT-R approach to the prevention of intensive care readmission

Timothy Baker and Vilas, Cambridge University Hospital

Andrea Turner and Karin Gerber, Royal Berkshire NHS Foundation Trust Hospital

Aim: To understand if an electronic symptom reporting tool impacts on clinical care.

Background: Suitability for discharge from an Intensive Care Unit (ICU) is often based on a combination of physiological parameters and clinical assessment. Unplanned readmission can adversely affect morbidity and mortality, be resource-intensive and distressing for patients and family. (DeSautels et al 2017). The Critical Care Outreach (CCOR) team are part of the multidisciplinary discharge planning process on the day of planned transfer from the intensive care; how this is achieved can be dependent on the individual CCOR practitioner. Discharged patients are reviewed by the CCOR service once, within 24 hours of transferring from ICU, irrespective of the patient’s length of ICU stay or dependency on transfer. Some patients appear to ‘fall through the net’, which may result in multiple crisis referrals to CCOR or readmission to ICU.

Method: The inability to communicate has been demonstrated to be the most stressful aspect of critical illness.(1) We developed software (myICUvoice), to improve our ability to understand the needs of our ventilated patients. By involving our patients in the development process we learnt a valuable lesson. All patients, even those who can talk, find “how are you feeling?” difficult to answer. We routinely, very specifically ask “what” and NOT “how” our patients feel. Our electronic system allows us to continuously evaluate the symptomatic burden for our patients. Results: In ventilated patients the tool meant emotional needs and levels of discomfort were 52.4% and 25.7% better understood and patients were 26.1% less stressed. Our database showed xerostomia was reported occurring twice as frequently as any other symptom. Discussion: Working with our patient focus group has changed the way we appraise and improve the quality of our care. We have developed an electronic system that allows us to continuously evaluate the symptomatic burden of critical illness for our patients. When we are sick every symptom is felt, reflected on and it impacts on everything we do. Our methodology allows us to really understand symptoms and to respond; for example, we now provide a range of artificial saliva’s. Conclusions: We now know in real time what, where and for whom we need to focus resources to improve the quality of care we provide. References: Khalaila R, Zbidat W, Anwar K, et al.: Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation. Am J Crit Care 2011; 20:470 - 479

Aim: To develop a ‘readmission risk’ screening tool by combining the validated Stability and Workload Index for Transfer score “SWIFT” (Gajic et al 2008) in combination with locally agreed high-risk factors, the “SWIFT-R (R=Reading)”. To retrospectively test its effectiveness and ultimately design a graded response to streamline discharge planning, bringing a tailored approach to postICU reviews. Methodology: Retrospective chart review over three months looking at all patients discharged from ICU. Findings: 141 patients reviewed. Of these: 73 (52%) Patients screened as low risk 51 (36%) Patients screened as moderate risk score 17 (12%) Patients screened as high risk. Of these, 7 were readmitted to ICU Conclusion: The findings suggest that our proposed screening tool is effective in predicting patients at greater risk of readmission to ICU. The CCOR team have now agreed a graded response to the SWIFT-R triggers which will be developed and modified through a prospective audit. to streamline discharge planning, bringing a tailored approach to post-ICU reviews e.g. planning in more post-discharge reviews in a timely way. References: Desautels T, Das R, Calvert J, et al (2017)

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Prediction of early unplanned intensive care unit readmission in a UK tertiary care hospital: a crosssectional machine learning approach; BMJ Open; 7:e017199; Available on: content/7/9/ [Accessed 30/03/018]. Gajic O et al (2008) The Stability and Workload Index for Transfer score predicts unplanned intensive care unit patient readmission: initial development and validation. Critical Care Medicine 36 (3): pp 676-682

C03: Bring your pet to work: staff engagement strategies to improve performance

prior, including 2 critical events due to insufficient devices to safely run the system. Implementing simple and innovative engagement strategies can markedly improve system performance and staff satisfaction. References: Anitha J. (2014) Determinants of employee engagement and their impact on employee performance. International Journal of Productivity and Performance Management: 63(3): 308-323 Krueger J. & Killham E (2007) The Innovation Equation. Gallup Management Journal:

C04: Nurse-led eye care in the Intensive Care Unit: A protocol for practice

Mandy Odell, Royal Berkshire NHS Foundation Trust The Critical Care Outreach (CCO) team in a Southern UK hospital took over management of the Hospital at Night (H@N) team. This involved organising the outof-hours work flow to the on-call clinical teams, via a computerised system using android phones. The co-ordination and balance of work flow between the speciality teams was challenging, and safely monitoring the android devices was a difficult. To address these issues a staff engagement innovation was implemented. Staff engagement strategies have been shown to transform work performance in innovation and creativity (Krueger and Killham 2007). The most influential factors in engaging staff have been found to be working environment and team relationships (Anitha 2014). The project involved the implementation of three new initiatives: centralising the H@N co-ordinating centre; personal engagement with the individual clinicians, and personification of the android phones. The aim was to provide a single space to promote belonging, promote face to face contact to improve personalisation, and create empathy and improved responsibility for the android phones by naming them after the CCO teams’ pets. The addition of pet photos and stories about the animals helped promote a personal responsibility to look after the equipment. We surveyed the clinicians to assess their views on the quality of teamwork, patient safety and workload before and after the engagement initiatives. We also monitored the rate of problems with the android devices between the two time frames. The majority of responders reported that the quality of team work and patient safety had improved, with an equivocal response to workload. None of the android devices have been damaged or gone missing since the inititiave, compared to 11 incidents

Emily Howe, Manchester Royal Infirmary Background: Critically ill patients are at high risk of corneal injury as their normal ocular protective mechanisms are compromised (Alansari et al., 2015). The provision of high quality eye care is therefore essential in order to reduce incidences of ophthalmic complications such as exposure keratopathy (Zhou et al., 2014). It was noted that on the author’s ICU eye care was inconsistent and not in line with Ophthalmic Service Guidance (Royal College of Ophthalmologists (RCOphth) (2017) which advocates the rigorous application of protocolised eye assessment and intervention. This approach has been shown to reduce rates of corneal damage from 21% to 2.6% (Kousha et al., 2018). Aims: The aims of this project were to establish the eye care needs of intensive care patients; evaluate local eye care practices and identify areas for improvement; and to develop an evidence-based protocol to inform care provision as per current guidelines (RCOphth, 2017). Methods: In addition to a comprehensive literature review, a staff survey was undertaken to establish trends in practice and learning needs. Patient functionality data was used to assess how effective care provision was in preventing visual complications post-discharge. Results: 40-50% of survivors interviewed reported deterioration in their eyesight at 3 month follow-up, and nursing knowledge of eye care was low. A protocol based on current best available evidence was therefore developed to standardise interventions. All patients are now screened daily for risk factors for ocular surface damage. Those at risk receive a four hourly eye assessment and care comprising of eye hygiene and ocular surface protection. Where there are concerns a fast-track referral can be made by the bedside nurse to

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an Advanced Nurse Practitioner in ophthalmology for specialist assessment and care planning.

contrast of perceptions contributed to the genesis of this research.

Recommendations: Ongoing audit is required to monitor compliance with the protocol. It is hoped that research can be undertaken to evaluate the effectiveness of the intervention in reducing rates of ophthalmic complications in the critically ill, and improving outcomes for ICU survivors post-discharge.

Methodology: This research takes a qualitative approach eliciting views from individual interviews with students who access CAAL. Discussions are recorded, transcribed, analysed and organised into themes. Thus, detailed, narrative accounts will inform and illuminate our understanding of student perceptions of CAAL.

References: Alansari, M. A., Hijazi, M. H., Maghrabi, K. A. (2015). Making a difference in eye care of critically ill patients. Journal of Intensive Care Medicine. 30(6), pp. 311-317. Kousha, O., Kousha, Z., Paddle, J. (2018). Incidence, risk factors and impact pf protocolised care on exposure keratopathy in critically ill adults: a two-phase prospective cohort study. Critical Care. 22(5). [Online] [Accessed 7th June 2018] DOI: 10.1186/s13054-0171925-5. The Royal College of Ophthalmologists. (2017). Ophthalmic services guidance: Eye care in the Intensive Care Unit (ICU). London: Royal College of Ophthalmologists.

Main Findings: Data gathering is in progress. Results will be available by September.

C05: Exploring perceptions of “Canine Assisted Academic Learning”: New ways of working in higher education Jennie Faithfull-Lloyd, C. Atherton and S. Beer, Bournemouth University Bournemouth University (BU) is believed to be the first UK university to have a full-time dog on campus to work with students with learning support needs. The ‘learning assistance dog’ works within the on-campus Additional Learning Support (ALS) Department, which provides academic support to university students with a variety of learning needs. Since the launch of this initiative, a plethora of anecdotal student accounts have reported benefits of canine support at BU. However, relatively little is known about the impact of canine assistance for student learning in higher education. Our current research explores this provision, identified by the researchers of this study as ‘Canine Assisted Academic Learning’ (CAAL) (Faithfull, 2017). Aims: The aim of this research is to explore perceptions of ALS students at BU who access CAAL sessions. Anecdotally, students have reported CAAL has beneficial effects including on mood, concentration, focus and, further, has positive implications for their academic learning. However, the inclusion of a working dog in a higher education environment has not been without controversy, characterised by some as a ‘gimmick.’ This

Conclusion: This research explores if students perceive CAAL affects their learning. If so, to describe what are the perceived effects and how these may contribute to academic learning. Further, to explore if CAAL impacts on the wider student university experience. We hope this may illuminate if, when and how to most effectively weave CAAL into academic learning support for BU students. References: Abrahamson K, Cai Y, Richards E, Cline K & O’Haire ME (2016) Perceptions of a hospital-based animal assisted intervention program: An exploratory study. Complement Ther Clin Pract. 25:150-154 Amerine JL & Hubbard GB (2016) Using Animal-assisted Therapy to Enrich Psychotherapy. Adv Mind Body Med. 30(3):11-1 Borrego JLC, Franco LR, Mediavilla MAP, Pinero NB, Roldan AT & Picabia AB (2014) Animal Assisted Interventions: Review of Current Status and Future Challenges. International Journal of Psychology and Psychological Therapy, 14 85-101 May DK, Seivert NP, Cano A, Casey RJ & Johnson A (2016) Animal Assisted Therapy for Youth: A Systematic Methodological Critique. Human-Animal Interaction Bulleting Vol. 4:1, 1-18 O’Haire ME, Guerin NA, Kirkham AC. Animal-Assisted Intervention for trauma: a systematic literature review (2015). Front Psychol. 6:1131.

C06: The challenges of moving from senior ECMO specilaist to novice academic Samantha Harris-Fox, University of Derby Aim: The aim of this session is to reflect on the process of making the transition from working as a senior ECMO specialist in intensive care to a University Lecturer in Prequalifying Adult Nursing. Method: Using Smyths (1989) four stage reflective model the author will explore and analyse this transition. This model has been advocated as a useful tool for novice academics.

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Discussion/Results: Stage 1- Description The author had worked for 17 years in a senior clinical role involving managerial, education and research responsibilities amongst others. The challenges of transitioning and transferability of skills into the role of academic, had been underestimated by the author. Stage 2- Analysis A major challenge was the author’s sense of identity and confidence with the new role. In previous research senior clinicians felt their extensive clinical and managerial experience was not relevant to their new role in academia as the role, culture and organisation of high education was so different. It can often be difficult for experienced nurses to move away from the comfort zone of a role where they have been regarded as an expert (Barnes 2015). Stage 3- Self Awareness The problems of self-identity and role originates from working within a culture where senior nurses have a strong motivation to maintain clinical credibility alongside other roles and in the early days of the transition this was critical to the author. Morgan (2012) suggests this is due to the association between clinical credibility and the individual’s fundamental principles for entering the nursing profession. Stage 4- Reconstruction The author embarked upon the process of redefining their identity as an academic, this involved developing new areas of research interest and focusing on skills and strengths which could be transferred to this new role. Adopting the view of themselves as a nurse committed to the credibility of the nursing profession through nurse education, was critical to a successful transition. Conclusion: The process of reflection has in itself promoted confidence and facilitated a sense of belief and the author believes as successful transition has been achieved. References: Barnes H. (2012) Exploring the Factors That Influence Nurse Practitioner Role Transition. The Journal for Nurse Practitioners; 11: 178-183. Morgan A. (2012) Call yourself a nurse! Defending the clinical credibility of educators and managers in intensive care. Critical Care; 17: 271-274. Smyth J. (1989). Developing and sustaining critical reflection in teacher education. Journal of Teacher Education; 40: 2-9.

C07: You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face: A training package for the ICU

Julie Darbyshire and Paul R Greig, University of Oxford, Peter Edmonds, Patient, Carolyn Barrett, Oxford University Hospitals NHS Foundation Trust, Lisa Hinton and J Duncan Young, University of Oxford Introduction: The intensive care unit (ICU) is a cacophony of unfamiliar noises, terrifying to patients. Up to 75% of patients experience ICU-acquired delirium (Salluh et al., 2015). These patients remain longer in hospital, and can have long-term psycho-social problems when they go home (Ely et al., 2001). Noise levels in ICUs are ~ 60dBA, as loud as a busy restaurant. The World Health Organisation recommends noise levels in patient care areas should be <35dBA, comparable to a library. Methods: Using the AEBCD framework (Locock et al., 2014) we developed an intervention to address noise levels in the ICU. This included replacing metal bins with plastic, initiating an alarms management policy, and raising awareness through an educational programme. We worked closely with a medical educationalist and drew on theories of adult learning (Kolb and Fry, 1975, Honey and Mumford, 1986). An e-module includes patient interviews and evidence-based information on the effects of noise. An experiential session includes recorded sounds combined with live action so that staff experience the patient perspective. Results: Of the 116 individuals who have completed the training 100% found it useful, 97% said that they would change their practice, and 95% thought staff could do more to create a less stressful environment for patients. The most frequently selected words by participants are ‘worrying’, ‘frightening’, ‘stressful’, ‘confusing’, ‘uncomfortable’, ‘scared’, ‘afraid’ and ‘alone’. This mirrors patient experiences. Post-intervention measures indicate a reduction in sound levels of ~4dB. Conclusion: Staff are unaware of how much noise normal activities create until they experience the ICU from the patient perspective. Measurable change was achieved through robust theoretical design, a patient-focused approach, and innovative binaural recording techniques which increased the realism of the experience. We are now evaluating sustained cultural change and knowledge transfer through ethnographic observations. References: Ely, E. W., Siegel, M. D. & Inouye, S. K. 2001. Delirium in the intensive care unit: an under-recognized syndrome of organ dysfunction. Semin Respir Crit Care Med, 22, 115-26.

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Locock, L., Robert, G., Boaz, A., Vougioukalou, S., Shuldham, C., Fielden, J., Ziebland, S., Gager, M., Tollyfield, R. & Pearcey, J. 2014. Using a national archive of patient experience narratives to promote local patientcentered quality improvement: an ethnographic process evaluation of ‘accelerated’ experience-based co-design. Journal of Health Services Research & Policy, 19, 200207. Salluh, J. I., Wang, H., Schneider, E. B., Nagaraja, N., Yenokyan, G., Damluji, A., Serafim, R. B. & Stevens, R. D. 2015. Outcome of delirium in critically ill patients: systematic review and meta-analysis. BMJ, 350, h2538.

C08: Challenging conversations in neonatal intensive care: Working with simulated relatives

- Giving positive feedback To ascertain participants’ views and knowledge surrounding communicating in challenging situations before and after training, a questionnaire containing eleven 5-point Likert-format items was utilised. Data were analysed using Wilcoxon singed-ranks or sign tests (Pett 1997). Findings: Seventeen participants completed the questionnaire; all felt their knowledge had increased following the training. The observed differences between the scores that were given before and after training were statistically significant in all eleven items (all p<0.01). The highest score change was observed in participants confidence in changing their personal communication style. Conclusions: Experiential learning is a powerful and effective tool in preparing neonatal intensive care preceptees for challenging conversations.

Carrie Hamilton, SimComm Academy, Kim Edwards, Health Education England, Marjolein Woodhouse, University of Portsmouth References: MacLean, S., Kelly, M., Geddes, F. and Background: Registered nurses are expected to communicate effectively with patients and relatives. To improve this, education programmes are increasingly turning to simulation modalities including scenarios with simulated patients/relatives (SPs) (MacClean et al 2017). Patient and public involvement has become an integral part of healthcare; SPs play an essential role in being the patient/relative proxy and advocate. Wessex Network Neonatal Preceptorship Programme has preceptees that are newly qualified child-branch nurses and adult-trained nurses, from nine neonatal units. Research has identified that preceptees are ill equipped to have challenging conversations (Whitehead et al. 2013). Wessex preceptees corroborated further and identified that they would benefit from simulated training to gain a better understanding from the relatives’ perspective. Aim: Present the effectiveness of incorporating the ‘lived experience of relatives’ through simulation, within neonatal intensive care/unit settings Method: Scenarios were developed with specific learning outcomes based on relatives’ experiences. SPs from an established SP programme, were selected and then trained to portray the roles; the debrief included the participants, the SP and facilitator. The scenarios, underpinned by the NHS values and the NMC Code of Conduct, covered: - Responding to relatives’ complaints - Supporting relatives after unanticipated transfer of patient - Patient safety - Professionalism and accountability

Della, P. (2017). Use of simulated patients to develop communication skills in nursing education: An integrative review. Nurse Education Today, 48, pp.90-98. Pett, M.A. (1997). Nonparametric statistics for health care research: statistics for small samples and unusual distributions. Sage Publications: Seven Oaks. Whitehead, B., Owen, P., Henshaw, L., Beddingham, E. and Simmons, M. (2016). Supporting newly qualified nurse transition: A case study in a UK hospital. Nurse Education Today, 36, pp.58-63.

C09: I am your patient but do you know me? Helen Whiting, West Suffolk NHS Foundation Trust Background: In healthcare we always thrive to provide compassionate and patient-centred care (NMC 2015). But how can we provide patient-centred care to our critically Ill patients if these personal details are not documented? (Broderick 2013). Knowing more about our patient individually by the implementation of a Patient Profile Form (PPF), along with their clinical details will potentially go a long way in delivering that care. As a healthcare provider it would be nice to know what patients are scared of, what they like to be called and so much more. Aim: The presentation will focus on the PPF and initial findings of a nursing staff survey. Method: The confidential paper, PPF, is a form the patient, families or carers voluntarily complete. The form

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belongs to the patient and has been used in the Critical Care Unit for the past three years; it is an established part of our care. The survey monkey format was offered to all Critical Care nursing staff which considered the design, patient centred care and relatives. Analysis: A survey was undertaken among 39 of our 49 Critical Care nurses on the implication of using PPF in Critical Care. Some of the findings showed that 100% agreed that the form was easy to complete from patient/relatives side. 95% agree that the patient or relative requires minimal help from the nursing side to complete it, and 79% believes that it has improved their conversation with patients, thus helping in patientcentred care.

stories and narratives helps raise awareness and understanding for healthcare professions in supporting patients and their families in recovery from critical illness. This has also been demonstrated through patient videos used with the InS:PIRE (Intensive Care Syndrome: Promoting Independence & Return to Employment) programme. Key themes emerged in listening, volunteering roles and education of the impact of recovering from critical illness. Results: Feedback from using patient videos and peer support will be demonstrated using quotes from evaluation of the InS:PIRE programme. Key themes emerged in listening, volunteering roles and education of the impact of recovering from critical illness.

Conclusion: Innovative ideas do not need to be resource consuming or expensive. The results of the survey showed that the PPF can help deliver compassionate patient-centred care in a Critical Care environment, It is a simple but effective form which can also be dissipated to other clinical ward areas.

Summary: Patient stories and video narratives can play an important role in understanding a lived experience and importantly in peer support of patients rehabilitation from a variety of critical illnesses, not only encephalitis. This has been demonstrated through the InS:PIRE programme in how it can support critical illness recovery.

References: Broderick M, Coffrey A, (2013) ‘PersonCentred Care In Nursing Documentation’. International Journal of Older Nursing. 8(4) 309-318 The Code, Professional Standards of Practice and Behaviour for Nurses and Midwives. (2015) Prioritise People, pp 4-6. Nursing and Midwifery Council

References: Dalmau J, Graus F (2018) AntibodyMediated Encephalitis New England Journal of Medicine, 378:p840-851 Easton (2016) Life after Encephalitis a narrative approach Oxon Routledge, p176.

C11: The outcomes and experiences of relatives of patients discharged home after critical illness

C10: Living with Auto-immune Encephalitis - an ICU nurses experience

Louise Stayt, Oxford Brookes University, Trevor Venes, Oxford University Hospital Trust

Pauline Murray, Crosshouse Hospital Introduction: “Encephalitis is a severe inflammatory disorder of the brain with many possible causes and a complex differential diagnosis. Advances in auto-immune encephalitis research in the past 10 years have led to the identification of new syndromes” Dalmau and Graus (2018). Yet understanding of the disease and its long term consequences is still underestimated. Acquired brain injury (ABI) can become a complication of the illness to the extent that isn’t always fully understood and may become an issue for the patient and their family when discharge from hospital has occurred. Through my own personal experience of ABI and Encephalitis along with being an InS:PIRE (Intensive Care: Promoting Independence and Return to Employment) nurse in Critical care rehabilitation; raising awareness and education of staff has become key in improving patient and family outcomes for this condition. This is also supported by Easton (2016).

Introduction: Patients discharged from Intensive Care (ICU) may experience psychological, cognitive, and physical deficits resulting in a long and complex rehabilitation upon discharge (Warren et al. 2016). Patients’ relatives are also vulnerable to psychological pathologies and diminished health-related quality of life following the patients’ critical illness. Relatives often provide informal care during the patients’ rehabilitation (McPeake et al. 2016) which may influence their health status. The aim of this systematic integrative review is to provide a comprehensive report of the outcomes and experiences of relatives of patients’ discharged home after critical illness.

Aim: Through my own lived experience, using patient

Findings: Twenty-five studies were included in the data

Design: This review adopts the five-stage systematic integrative review strategy suggested by Whittemore and Knafl (2005): Problem Identification, Literature Search, Data Evaluation, Data Analysis, and Data Presentation.

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analysis: 19 quantitative, 4 qualitative and 1 mixed method study. Three key themes were identified: Health and Wellbeing, Employment and Lifestyle, and Caregiving Role. Health and Wellbeing report the incidence and significance of psychological morbidity such as PTSD, Anxiety and Depression. It also discusses fatigue and sleep and reports risk factors of psychological morbidity. Employment and Lifestyle describes the impact of caregiving on the relative’s ability to work and engage in usual social activities. The final theme describes and discusses the care-giving role in terms of time, knowledge and skills, and burdens encountered. Conclusions: The impact of supporting a patient through critical illness and their rehabilitation on relatives is farreaching in terms of psychosocial, emotional and physical health. If informal care giving is to be sustainable there is an identified need to design effective strategies of supporting families through all stages of the critical illness trajectory. References: McPeake, J., Devine, H., MacTavish, P., Fleming, L., Crawford, R., Struthers, R., Kinsella, J., Malcolm, D., Shaw, M. & Quasim, T. (2016) Caregiver strain following critical care discharge: An exploratory evaluation. Journal of Critical Care, 35, 180-184. Warren, A., Bennet, M., Rainy, E., Weddle, R., RodenForeman, K. & Foreman, M. (2016) The Intensive Care Unit Experience: Psychological Impact on Family Members of Patients With and Without Traumatic Brain Injury. Rehabilitation Psychology, 61(2), 179-185. Whittemore, R. & Knafl, K. (2005) The integrative review: updated methodology. Journal of Advanced Nursing, 52(5), 545-553.

C12: Improving patient discharge from Intensive Care Unit (ICU): Using a quality improvement methodology approach Lucy Glasgow, Pauline Murray and Stephanie Frearson, Crosshouse Hospital Background: Patient and family feedback gathered from a recent project in ICU follow up: InS:PIRE (Intensive care syndrome: Promoting Independence and return to employment) suggested discharge processes from ICU required to be reviewed and improved on . Communication being cited as one of the main barriers for both staff and patients/carers. This is in accordance with NICE guideline CG83 (2009) who supports a comprehensive structured handover. Description: A quality improvement plan was developed, the aim was to alleviate patient and relative stress

and improve communication by implementing a new discharge process/package and achieve 95% by June2018. Methodology: Using Improvement methodology we devised a Driver Diagram defining our Improvement plans. Crosshouse ICU Improving Discharge Process and Communication Improvement Project Aim / Outcome

Primary Drivers

Critical Care Within Crosshouse ICU we aim to alleviate patient/relatives stress and improve communication by implementing a new discharge process/package. We aim achieve 95% compliance

Secondary Drivers

Improved communication with relatives. Discharge Pack

Improved ward transition for patients. Raised awareness of Clinical Improvement for Ward staff. Standardise ERT referral system.


by June 2018

Develop family/patient feedback questionnaire. Pt discharge summary

Improved discharge process.


Change Ideas for Testing

Family Debrief/discharge template.

LNA (ICU staff) LNA (ward staff) InS:PIRE/ICU study days: ward staff presence. Develop daily ERT involvement (safety brief) Develop process to enable follow up visits.


Peer support group.

A questionnaire to ICU and ward staff helped identify areas for improvement with discharge process; thereafter a discharge/checklist sticker was developed and tested using Plan, Do, Study, Act (PDSA) cycles.

Crosshouse ICU Patient Discharge Checklist Date Time


1. N.O.K informed of transfer Y / N 2. Medical & Nursing notes present Y / N 3. Medical Summary plan present Y / N 4. ERT Informed of discharge Y / N 5. Medications list updated Y / N 6. ENT Nurse Specialist informed Y / N / NA 7. ICU Stepps booklet given Y / N / NA 8. Delerium Booklet given Y / N / NA 9. Name band present Y / N 10. Biwave mattress ordered Y / N / NA 11. Valuables returned Y / N / NA 12. Risk assessments completed Y / N 13. Outstanding investigations

Transferring nurse

A SBAR (Situation, background, action and recommendation) nursing handover transfer summary was modified following feedback from ward staff. Inviting ENP (Extended Nurse Practitioner) to ICU safety brief to discuss discharge was also implemented. Additionally we have developed a patient/family questionnaire to measure satisfaction following an ICU stay. Conclusion: Communication is an essential process for patient outcomes including safety and psychological wellbeing. Using improvement methodology and its processes has demonstrated improvement in a change process to improve satisfaction of staff, patients and carers. Summary and Results: We are currently auditing both compliance with the checklist and questionnaire. Anecdotally early data would suggest some aspects of compliance is good. However to achieve full compliance

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within the components of the sticker requires several areas to be improved on. Using PDSA this will require further education and awareness with staff.

Conclusion: Currently, the app is in continued development on our general surgical/medical adult ICU however its principles are transversal across all areas of critical care. Patients are keen to use the app, regardless of their technological knowledge, and express their symptoms, needs or concerns which we can act upon. We hope, in the future, this will reduce long-term psychological morbidity for all ICU patients not just our own.

References: NICE (2009) Rehabilitation after critical illness in adults CG83 1.12 guidance/cg83 (accessed 25/03/2018)

C13: Introducing myICUvoice, an innovative communication tool to improve communication and symptom management in ventilated patients on an adult Intensive Daniel Harris, Sara Coentro, Hugo Ferreira-Paula, Dr Timothy Baker, Petra Polgrova, Sinead How and William Thompson, Cambridge University Hospitals Aims: To share our experience working with MyICUvoice in adult patients who have ineffective communication while in critical care due to an artificial airway. Background: Impaired communication is considered a major factor of enhancing anxiety and frustration in critical care (Pennock et al., 1994). Surviving critical care represents a stressful phenomenon with one in five patients developing Post Traumatic Stress Disorder (Parker, et al., 2015). Many patients in ICU have an artificial airway and thus unable to communicate verbally which is frightening and distressing (Khalaila, et al., 2011). MyICUvoice is an iPad app for symptom surveillance and improving communication that is integrated with unique backend of data analytics. It has been developed to improve communication within the patient-familyhealthcare professional triad. It eases: symptom identification and control, enhance psychological wellbeing and assist rehabilitation in critical care. It embodies a unique opportunity to understand our patient’s feelings and experiences against our own perception of their situation. Main Findings: A local quality improvement assessment demonstrated an uplift in satisfaction regarding the attempts and effectiveness of patients’ communication. Most patients felt able to communicate their needs and interact with families and staff; but most importantly they felt that staff better perceived their needs. It also improved nurses’ perception of the patient’s needs as they are easier to identify, improving the provision of a safer and kinder care. Patients are enthusiastic whilst using MyICUvoice for their rehabilitation and practising the prescribed exercises by physiotherapy.

References: Khalaila R, Zbidat W, Anwar K, et al.: Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation. Am J Crit Care 2011; 20:470 - 479. Parker AM, Sricharoenchai T, Raparla S, et al.: Posttraumatic Stress Disorder in Critical Illness Survivors. Crit Care Med 2015; 43:1121 - 1129. Pennock BE, Crawshaw L, Maher T, et al.: Distressful events in the ICU as perceived by patients recovering from coronary artery bypass surgery. Heart and Lung The Journal of Acute and Critical Care 1994; 23:323 - 327.

C14: Using the non-injectable arterial connector (NIC) to extend the use of the arterial transducer set Julie Allen, Emily Hodges, Mark Blunt, Peter Young and Maryanne Mariyaselvam, The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust Aims: The Royal College of Nurses recommends arterial transducer sets are changed every 4 days (RCN, 2016). This requires a dressing change, risking blood contamination, cannula loss, infection and increased nursing time and cost, however NICE recommends the use of anti-microbial dressings on the arterial cannula site for 7 days (NICE MTG25, 2015). The noninjectable arterial connector (NIC), is a safety device which creates a closed arterial sampling system, prevents accidental arterial injection and bacterial contamination (Mariyaselvam et al., 2015) and is currently provided cost-free to UK hospitals funded by the NHS. We microbiologically examined arterial giving sets to determine whether contamination occurs during extended use, when using NICs on the transducer and sampling luer ports. Methodologies: With institutional approval (IRAS compliant), following clinical use, we collected arterial transducer sets (Codan, Germany) from critically ill patients. Sets were protected during clinical use by NIC connectors on both luer hubs. A representative saline sample from the arterial set was plated onto growth media and incubated for 48hr. Arterial sets used for a duration of 1-3 days (standard; n=18) and 4-7 days

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(extended n=35) were compared. Contamination was classified as >3 colony forming units (CFU, lab standard). An economic cost analysis was also conducted. Main findings: No contamination was found from the standard or extended time samples (p<0.001). Changing to 7 day arterial sets, reduces transducer usage from 1512 to 944 annually, saving £9888.88 (13 bed ICU). In addition, this also saves nursing time by 95 hours (2 nurses, at 5 mins each). Conclusion: When the NIC is used at both transducer and sampling ports, the arterial set can be used for upto 7 days, preventing infection, mis-injection and providing cost savings. Adoption of this change of practice across the NHS could save £4m annually. References: National Institution of Clinical Excellence (NICE). (2015) The 3M Tegaderm CHG IV securement dressing for central venous and arterial catheter insertion sites. Available from: guidance/mtg25 [Accessed 30 March 2018]. Mariyaselvam, M., Heij, R., Laba, D., Richardson, J., Hodges, E., Maduakor, C., Carter, J. and Young, P. (2015). Description of a new non-injectable connector to reduce the complications of arterial blood sampling. Anaesthesia, 70 (1), 51-55. Royal College of Nursing (RCN). (2016). Standards for infusion therapy, Fourth edition. Available from: https:// documents/publications/2016/december/005704.pdf [Accessed 30 March 2018].

C15: Transformation of Critical Care Services at UHNM Lesley Smith and Claire Hughes, University Hospital of North Midlands Aim: To share experience and successes of transforming Adult Critical Care Services from ‘inadequate’ to ‘outstanding’ through a bespoke transformation programme. Background: UHNM Critical Care was a failing service acknowledged as inadequate for responsiveness by the CQC in April 2015. With an increasing demand for the service, critical care patients were regularly nursed outside of the unit, length of stay identified as an outlier and an outreach service suspended 50% of the time. Poor staff retention rates coupled with high vacancy factors, resulting in skills deficit and service provision - a radical change was required to improve both patient and staff experience. Method: A comprehensive systems review of

multidisciplinary working, utilising General Provision of Intensive Care Services (2015) was undertaken, along with a benchmarking strategy to establish service deficits and opportunities. The Creation of a multidisciplinary Critical Care Transformation board followed the principles of Aspire Managing Successful Programmes (2015). Discussions were held regarding individual projects where stakeholders including service users and clinical commissioning groups participated. Four project streams were identified to realise ambition for deliverance of quality improvement and efficiency gains. A Project Initiation Document (PID) was developed along with a Gantt chart to monitor both programme performance and key performance indicators (KPI’s) for measurable benefits. Outcome: The transformation programme has been successful in delivering efficiencies which has significantly improved patient experience and quality indicators. The programme presented opportunity for considerable financial investment, achieved through business case realisation. Key improvements included: recruitment and retention plans, an education strategy investing in staff, a prescribed rehabilitation pathway, implementation of a Patient Data Management System and sustained outreach provision. UHNM Adult Critical Care Services are now rated outstanding by the Care Quality Commission (2018). References: Aspire Ltd. (2015). Managing successful programmes foundation course. London. (Accessed in May 2015). Care Quality Commission (2018). The University Hospitals of North Midlands Inspection Report – Date of Inspection 3rd October to 16th November 2017. Date of publication 26/01/2018. (Accessed in January 2018). Faculty of Intensive Care Medicine & intensive Care Society (2015). Guidelines for the Provision of Intensive Care Services. Faculty of Intensive Care Medicine. London. (Accessed in April 2015).

C16: Resilience in critical care nurses: An exploratory analysis of data from the “WellNesS” feasibility study Louise McCallum, University of Glasgow, Dr Janice Rattray and Professor Martyn Jones, University of Dundee Background: Resilience is a personal resource allowing individuals to succeed despite adverse circumstances1. Critical care nurses (CCNs) with higher resilience have a lower prevalence of emotional exhaustion (EE), a component of burnout syndrome3. Job resources are components of the job2 that enable an employee to

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achieve work goals and minimise job demands2. There is a need to observe the effect of job resources on EE in CCNs, whilst examining whether resilience buffers this relationship. Aim: To observe the relationship between job resources and EE in CCNs, whilst examining the influence of resilience on this relationship. Methodology: This was a cross-sectional study from two UK intensive care units. Participants were invited to complete a range of questionnaires. Job resources (autonomy’ and ‘feedback from supervisor) were assessed using the Questionnaire on the Experience and Evaluation of Work 2.03. Resilience was assessed using the Connor Davidson-Resilience Scale4 and the outcome measure EE was captured using the Maslach Burnout Inventory-Human Services Scale5. Cronbach’s alpha assessed reliability of scales. Relationships between variables were explored using Pearson product-moment correlation. Results: The response rate was low (24%; n=54), but completion rates were excellent (99.5%). Internal consistency of scales was excellent (α =.743-.905). All job resource variables correlated significantly with EE and resilience. For example, high levels of ‘feedback from supervisors’ were related to decreased EE (r=.326, p=.016). High levels of ‘feedback from supervisor’ were associated with increased resilience. Resilience was related to EE, but this was not significant (r=-.249, p=.070). Conclusion: The influence of ‘resilience’ on the relationship between job resources and EE could not be tested due to the small sample size6. The results indicate that this is worthy of further exploration in a larger sample of CCNs. References: Connor, K. & Davidson, J. (2003). Development of a new resilience scale: the ConnorDavidson Resilience Scale (CD-RISC). Depression & Anxiety, 18(2), pp. 76-82. Maslach, C. & Jackson, S. (1981). The measurement of experienced burnout. Journal of Organizational Behaviour. 2, pp. 99–113. Van Veldhoven, M., Prins, J., Van Der Laken, P. & Dijkstra, L. (2015). QEEW 2.0 42 short scales for survey research on work, wellbeing and performance. SKB: Amsterdam. Available at: file:///C:/Users/McCallum/Downloads/ QEEW2.0_42_short_scales_for_survey_research.pdf

C17: Resiliency within a grounded theory about sustainability in critical care practice

Heather Baid, University of Brighton Aims: Due to limited resources, the National Health Service (NHS) has sustainability plans to reduce its financial and environmental cost, while still delivering high-quality care from a resilient workforce (Sustainable Development Unit 2018). Sustainability in critical care practice is a pertinent topic (Batchelor et al. 2017; Faculty of Intensive Care Medicine 2018). However, there is a lack of literature about 1) what sustainability means to people working in critical care, and 2) what social processes influence sustainability being a component of critical care practice. A research study addressed these questions with this presentation focusing on the theme of staff resiliency. Methodology: The constructivist grounded theory study collected qualitative data from in-depth, semi-structured interviews with 11 participants. The sample was made up of nurses, physiotherapists and a technician who worked in NHS critical care units in the South of England. Grounded theory methods and procedures for data generation and analysis were used, along with dimensional analysis. Main findings: For the participants, sustainability meant maintaining the resources needed for critical care practice into the future including financial, environmental and social resources. This presentation will explain findings related to the conference theme of resiliency, as found in the data about social sustainability and staff well-being. Participants viewed resiliency as an essential personal attribute to sustain team members as a ‘people resource’, and to prevent burnout and job dissatisfaction. Resiliency involved the ability to recover from stressful situations in clinical practice. Other attributes required to sustain people in critical care were agility (ability to adapt to change) and durability (strength to tolerate the mental, emotional and physical pressures of practice). Conclusions: The theory generated from this research offers a new understanding of sustainability in critical care practice, including the implications for staff resiliency of the critical care team. References: Batchelor, A., A. Pittard, A. Ripley, D. Waeland, and C. Waldmann. 2017. Critical futures: A report on the first wave survey. London: Faculty of Intensive Care Medicine. Faculty of Intensive Care Medicine. 2018. Critical capacity: A short research survey on critical care bed capacity, Viewed 8 June 2018, sites/default/files/ficm_critical_capacity.pdf Sustainable Development Unit. 2018. Sustainable development in health and care – health check 2018. Cambridge: Sustainable Development Unit.

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C18: Factors influencing nurses’ intentions to leave adult critical care areas: A mixed method study Nadeem Khan, Oxford Brookes University and Oxford University Hospitals Background: The shortage of critical care and 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 problems. Although high nursing turnover in critical care areas is evident, research into the factors that influence nurses’ intentions to leave adult critical care areas is limited. Aim: To explore views and experiences of nurses about their working conditions and possible factors that may influence staff nurses’ decisions to continue or discontinue their employment in adult critical care areas. Method: A sequential mixed method study design was used. Data collection was completed in two phases; Phase 1: A cross sectional survey design was used via an online self-administered questionnaire using Qualtrics. The study was conducted from November 2017 to February 2018 at 263 adult critical care units across England. Surveys were distributed to nurses currently working in adult critical care areas across England. Phase 2: Phase 1 was followed by in depth telephone interviews. Participants were interviewed until data saturation was achieved. Ethical considerations: Ethics committee approval was obtained from Oxford Brookes University faculty research ethics committee. Results: It was assumed that the survey was distributed to all nurses, 345 surveys were returned. Qualitative data was collected from 15 participants. Findings and recommendations from both phases of the study will be presented following data analysis. Conclusions: High nurse turnover in critical care areas is a global issue with financial implications in addition to its impacts on staff morale, productivity, patient safety and quality patient outcomes. Nurse Managers need to consider the findings and recommendations of this study when developing strategies to improve nurse retention in adult critical care areas. References: Eckman J A (2014) Nursing Retention in Critical Care (Doctoral dissertation, Gardner Webb University. Available from http://gradworks.umi. com/15/67/1567749.html accessed 15/04/2017). Duffield C M, Roche M A, Homer C, Buchan J, Dimitrelis S (2014) A comparative review of nurse turnover rates and costs across countries. Journal

of Advanced nursing, 70(12), 2703-2712. Yurumezoglu, K., Karabey, B. and Koyunkaya, M.Y ( 2017) Shadows constructing a relationship between light and color pigments by physical and mathematical perspectives. Physics Education, 52(2), p.025008. Aiken, L.H. and Patrician, P.A ( 2000) Measuring organizational traits of hospitals: the Revised Nursing Work Index. Nursing research, 49(3), pp.146-153. Creswell, J.W., Plano Clark, V.L., Gutmann, M.L. and Hanson, W.E ( 2003) Advanced mixed methods research designs. Handbook of mixed methods in social and behavioral research, 209, p.240.

C19: Incorporating human factors into insitu simulation training Cara Godfrey, Manchester Foundation University Trust Aims: To provide non-technical skill training to Simulation Training. Methods: After attending a train the trainer course in Human Factors in Health Care, I have adapted our simulation training. Discussion: Utilising clinical incidents and Root Cause Analysis, I provide insitu simulation. This provides a real time experience of a Multidisciplinary team in emergency situ. There is an issue surrounding activity on the unit when perform these tasks, however emergencies do not wait until the unit is quiet. The Human Factor element too these depends on the situation and how the team is coming together. I will provide distraction both physical and emotional (pretending to be an upset relative etc) I will turn the lights out to pretend its dark. Results/conclusion: Feed back from the multidisciplinary is encouraging and the emphasis on debrief after simulation (Patel et al 2008). References: Mary D. Patterson, MD, George T. Blike, MD, and Vinay M. Nadkarni, MD (2008) Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 3: Performance and Tools). The Children’s Hospital of Philadelphia, University of Pennsylvania.

C20: The Advanced Critical Care Practitioner journey, developing new roles and ways of working? Stuart Cox, Queen Alexandra, Portsmouth, Lee Berry, University Hospitals Southampton

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This presentation will illustrate the journey of a trainee through to a qualified Advanced Critical Care Practitioner (ACCP) discussing the highs, lows, role benefits, whilst considering new ways of working in critical care within the United Kingdom. In 2015, the Faculty of Intensive Care Medicine (FICM) developed a curriculum for training ACCPs. It was informed by, and aligned to, the National Education and Competence Framework for ACCPs (Department of Health, 2008) and the Advanced Practice Toolkit for Scotland (Scottish Government, 2008). The training of an ACCP is undertaken over two years at a higher education institution whilst working with a medical mentor to complete a Postgraduate Diploma level qualification. During this time, a FICM curriculum document is completed. There are three parts: Part I, a handbook with an overview of competency-based training in ACCP; Part II, the Assessment System provides the outcome paperwork for ACCP trainees demonstrating their development as they progress through the ACCP training programme and Part III, the Syllabus, which details the ACCP competencies including core science, common competencies along with relevant assessment tools. On successful completion, the ACCP becomes an associate member of the FICM. The ACCP role requires an in-depth knowledge of intensive care medicine and a number of specialist skills including resuscitation, advanced physiological monitoring and provision of advanced organ support. ACCPs in training and qualified manage critically ill patients, supporting the family, collaborating with the critical care team and co-ordinating specialist and multispecialty care. The impact of ACCPs in critical care has not been evaluated widely due to the role evolution. However, a few published studies demonstrate the positive benefits of ACCPs in prospective cohort studies (Costa et al, 2014 and Landsperger et al, 2016). This presentation will cover: • History of role evolution • Selection and backgrounds of ACCP trainees • Higher education interface • FICM portfolio • The training References: Costa DK, Wallace DJ, Barnato AE, et al (2014). Nurse practitioner/physician assistant staffing and critical care mortality. Chest; 146: 1566-1573. Department of Health and Skills for Health (2008). The national education and competence framework for advanced critical care practitioners. Landsperger JS, Semler MW, Wang L, et al (2016). Outcomes of nurse practitioner delivered critical care: A prospective cohort study. Chest; 149: 1146-1154.

Lee G, Gilroy J-A, Ritchie A, Grover V, Gull K, and Gruber P. (2017). Advanced Critical Care Practitioners - Practical experience of implementing the Advanced Critical Care Practitioner Faculty of Intensive. Journal of the Intensive Care Society; 0 (0): 1-8. Scottish Executive. Advanced Practice Toolkit (2008).

C21: Compliance with Lung Protective Ventilation (LPV) in mechanically ventilated patients - Local audit Alexandre Marques, Maidstone and Tunbridge Wells NHS Trust Background: The concept of LPV is well recognized and established as standard of care and best practice by several randomized controlled trials. The Guidelines for Provision of Intensive Care Services (GPICS) recommend that all patients requiring mechanical ventilation should be subjected to a LPV strategy. Adopting these strategies has showed that: improves lung mechanics and gas exchange; Minimizes risks of Ventilator Induced Lung injury (VILI) and development of Ventilator Associated Events (VAE’s); Increases number of ventilator free days, reducing length of stay in ICU; Improves outcomes and reduces indices of mortality and morbidity and subsequent associated medical complications and costs to the National Health Service. Aims: Primary: Monitor compliance with safe ventilation strategies delivered to mechanically ventilated patients in a General Adult Critical Care Unit in England. Secondary: Compare Compliance with LPV: Adaptive Support Ventilation (ASV) Versus Pressure-Synchronized Intermittent (PSIMV). Mandatory Ventilation Methodologies: Data collection: Retrospective data collection from patients observation chart of Tidal volumes (Tv) and Peak Airway Pressures (PAP). Data collected between the months of February to July 2017. Inclusion criteria: Adult Patients Ventilated via ETT (Hamilton G5 Ventilator), ventilated on ASV or PSIMV mode, showing no signs of spontaneous breathing effort or breath triggering activity. Main findings: Overall Compliance with LPV was present 48.72% of the times. Compliance with both Tv & PAP was better in the ASV Group (ASV = 53.85%; PSIMV = 43.59%). Compliance with tidal volumes was better in the ASV group 53.85 Versus 46.15% (PSIMV); Overall mean Tv=8.02 ml/kg (PBW); Tv≤6ml/kg(PBW)=10.26%; T≥10ml\kg(PBW)=10.25%; ASV group showed 100% compliance with PAP ≤30cmH2O (PSIMV 85%). Conclusions: A review of recent National and

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International Audits have reflected similar results and demonstrated that non-compliance isn’t solely a local problem and evidentiates the existence of significant practice variation. Emergent interventions are required and barriers to Implementation of safe mechanical ventilation strategies should be identified and targeted References: ARDSNet (Acute Respiratory Distress Syndrome Network) 2000. Ventilation with lower tidal volumes as compared with traditional tidal volumes for Acute Lung Injury and Acute Respiratory Distress Syndrome. The New England Journal of Medicine 342(18): 1301-1308. Bellani, G., J.G. laffey, T. Pham, et al. 2016. Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. Journal of The American Medical Association 315(8): 788–800. GPICS (Guidelines for Provision of Intensive Care Services) 2015. [Online]. Available from: cKtRgu [14 July 2017].

C22: Introduction of sedation management tool on sedation holds and spontaneous breathing trials Cath Applewhite, Central Manchester University Hospital The aim was to introduce a sedation management tool on sedation holds and spontaneous breathing trials. It is known that daily interruption of sedatives reduce the duration of mechanical ventilation without compromising patient comfort or safety, and spontaneous breathing trials reduce the duration of mechanical ventilation in acute respiratory failure. Heavy sedation is directly indicated to length of stay in Critical Care, increased stress, risk of ventilator acquired pneumonia, risk of sepsis and low incidence of recall which can then lead to psychological distress. However sedation holds and spontaneous breathing trials are not always performed. A baseline audit in January 2017 of 20 intensive care beds on 7 days demonstrated that only 36% (12/33) of eligible opportunities for sedation holds were performed and no spontaneous breathing trials were conducted despite 12 suitable opportunities. A nurse led steering group was developed which focussed on bite-sized teaching, on line teaching resources and education with a nurse led protocol and trolley. This incorporated sedation holds and spontaneous breathing trials as part of daily practice with safe simultaneous patient sedation holds.

The barriers to change included working patterns, breaks and care activities. Safety concerns of more than one hold happening synchronously. Equipment preparedness, a change in culture and doctor and nursing education. The on-going audit of sedation holds and spontaneous breathing trials have demonstrated that in October 2017 84% (72/86) of patients deemed suitable received an appropriate sedation hold and 97% (64/66) of those eligible received a spontaneous breathing trial. In conclusion there has been a demonstration of improvement in sedation hold and spontaneous breathing trial compliance, with a change in attitude to sedation. There remains on-going concern regarding safety around communication and re-intubation rates. Future work is to focus on on-going revision of progress, communication, refinement of flowchart and nurse led References: 1. Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine 2000; 342(20):1471-7 2. Girard TD, Kress JP, Fuchs BD et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371(9607):12634

C23: Collaborative work to reduce device related pressure sores in Adult Critical Care Sarah Wood, Leeds Teaching Hospitals Trust Aim: To reduce device related pressure sores in Adult Critical Care (ACC) Methodology: A faculty of interested and key personnel was formed within ACC. We used a PDSA model to explore the issues related to device related sores. Up to November 2017 there had been 53 Category 2 sores (NPUAP/ EPUAP, 2009) developed on patients across ACC since April 2017 with 18 of these being to patients lips. We focused on practice on 2 of our units and audited current practice to give a baseline. Education and a change in practice were then initiated and number of sores monitored to show change Findings: It was found that mouth care was not being correctly documented and mouth scores were not being used on initial audit. Endotracheal (ET) tubes were being moved 2 hourly but this was documented

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only as a tick on the 24 hour observation chart and the faculty suggested that this should be documented as a position in the mouth i.e. Right, Middle, Left to allow ease for all personnel to see where the tube had been and where it should be next. This was implemented in November 2017 and the number of sores following the change documented. Since implementation we have only had 2 sores related to ETT reported, both found to be unavoidable on investigation. Conclusions: By highlighting the need for mouth care to staff through education and by making a small change to documentation of practice, a reduction in pressure sores has been seen across ACC. This small scale change has made a big impact to our Prevention of harm to our patients and since the formation of the faculty we have seen an impact in the numbers of all Category 2 pressure sores across ACC with only a further 15 reported to March 2018. References: National Pressure Ulcer Advisory panel (NPUAP) / European Pressure Ulcer Advisory Panel (EPUAP), 2009, Pressure Ulcer Classification System

C24: Building resilience, overrecruiting, and reducing turnover in a unit once labelled as a shanty town Jane Platt, LTHTR Aims: To present a combination of factors introduced on our Critical Care unit which are influencing our ability to build resilience, over –recruit and reduce staff turnover. Background: Retention is preferable to recruiting, employing and training new staff. The National Critical Care Nursing and Outreach Workforce Survey (2018), states that average staff turnover is 10.1%. Historically our nursing turnover has been up to 14.8%. Methodology: The culture of our unit is embodied in the following: Education and training: funding for Critical Care Course, University modules and national conferences. Three educators who are clinically based. Supernumerary status for all new starters ranging from 1 to 3 months. Health and Wellbeing and building resilience: dedicated band 7 lead for staff support, stretching exercises held on unit, running group led by band 6 sister, major trauma psychology debrief sessions, time out for mindfulness, stress risk assessment, stress burnout survey, proactive management of health promotion. Engagement from Consultants with Health and Wellbeing. Social events/staff engagement: Our social events are inclusive of all the MDT and include:

Award ceremony (Critawards) in September 2017 to celebrate and reward staff. Regular coffee mornings meet and greet buffets for junior doctors, new starter support meetings, Bollywood night, sporting events. Main findings: Our nurse staffing turnover figures have reduced from 14.8% in Aug 2017 (LTHTR, 2017) to 4.85% in April 2018 (LTHTR, 2018). We are currently in a position where the unit has been able to over recruit staff nurses and we have a waiting list of staff who want to be contacted when the next band 5 advert is published. Additionally our sickness rates have reduced from 9.9% (CC3N, 2016) to 6.5% (CC3N, 2018). Conclusion: A collaborative approach led by the full MDT has resulted in exceptional figures allowing us to future proof a skilled nursing workforce. References: Critical Care Network (CC3N). (2016). National Critical Care Non-Medical Workforce Survey CC3N. (2018). National Critical Care Nursing and Outreach Workforce Survey Lilley, R (2017). I take my hat off. Published 13th March 2017. Available at:

C25: An evaluation of staff debriefings to support staff resilience Lisa Enoch, Joanne Outtrim, Vicky Carr and Jill Hyde, Addenbrookes Hospital Aims: Addenbrookes Hospital has three Critical Care areas with 55 beds and encompasses 350 staff. Staff are repeatedly exposed to work related stresses which can lead to impaired physical and mental health (Turner 2014). We wanted to find interventions to help improve resilience in health care professionals within Critical Care. We held 5 debriefing sessions across critical care over a year focusing on individual cases or specific topics, such a youth suicide. Sessions were facilitated by clinical psychologist and/or ICU Consultant, and attended by 30 clinical staff. Methods: To evaluate the debrief sessions we sent out an electronic anonymous survey to all staff across the critical care areas asking for their feedback. Results: We received 13 responses in total, 2 had not yet attended a debrief and answered questions regarding their expectations. 11 attended more than one debriefing session with the majority of attendees wanting to gain closure and clarity over particular events and hoped it would improve team

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work and communication. Nursing staff felt that debriefs should be held for every patient we withdraw treatment on. One found the experience ‘completely unhelpful’. Nine participants said they would attend again with the majority finding the experience positive and felt they had gained knowledge. Two were concerned that relations between staff may have been damaged. Staff have recommended that debriefs are more structured, facilitated by independent member of the clinical team, and held for all long term patients. The two who had not attended felt it would build confidence in team communication and a useful environment to give constructive feedback. Conclusions: Withdrawal of treatment in young people is a very emotive subject. Valuable Learning points were the need for an independent facilitator so all disciplines can speak freely within professional bounds. 1-1 discussions with colleagues may be more beneficial for some, different interventions may be necessary to reach all individuals. References: Turner, S. (2014) The resilient nurse: An emerging concept. Nurse Leader. https://doi. org/10.1016/j.mnl.2014.03.013

C26: Being prepared: anticipating the unexpected Karen Hill, Amy Everton and Sheila Xavier, University Hospitals Southampton NHS Foundation Trust Aims: This presentation will provide an understanding of the emergency planning theory which underpins the practical events which occurred at night time in the largest University teaching hospital on the south coast of England. It will explore the events of the night identifying the critical decision points, patient safety decisions and need for resilience and leadership from those in charge of the intensive care. Method: This descriptive session will present the unfurling events of the night of the 1st March 2018 within the twenty five bedded General Intensive care unit. It will take the conference delegate through a journey of decision making, prioritisation and leadership which was dynamic as each event arose. Starting out with the initial challenge of having the adequate number of staff to safely care for the patients, as staff were challenged with getting into work due to heavy snow and chaos in the surrounding road networks. Discussion: It will move through to the collapse of the General Intensive care ceiling due to the break of water

pipes in the service area on the roof of the hospital resulting in an extensive flood on the unit. Thus leading to the emergency evacuation of seven critically ill patients across the hospital. The session will discuss the complexities of communication, patient safety, prioritisation, mobilisation of patients and staff together with the involvement of those least expected. Results: Consideration will be given to the extended consequences of a flood within an area dependent upon electrical devices and how the affects of one incident can lead to the next – the smell of electrical burning and need to move a patient to safety. Conclusion: The presentation will identify the lessons learnt and need to share these across intensive care units and further afield to the wider critical care network. References: Crichton, M., Cameron, G., and Kelly, T 2009. Enhancing organisational resilience through emergency planning: learnings from crosssectorial lessons. Journal of Contingencies and Crisis Management. February, 17. 1. Wiley.

C27: A service transformation presentation of critical care outreach, to meet the challenge of ever increasing Critical Care Admissions Christopher Beckett, University Hospitals of North Midlands Aim: To share the experience of transforming an Outreach service on a background of competing services. Background: The Critical Care unit at the University Hospital has seen an ever increasing demand on its services. The Critical Care unit is a national outlier for unplanned admissions, with outreach not being part of the escalation plan in deteriorating patients as the Trust employs acute care practitioners. CCOT traditionally would deal with post ICU follow-ups, assistance with transfers to critical care and surge capacity, alongside its major trauma call commitments and follow ups. Through the use of ICNARC data, anecdotal evidence and experience, it was identified that potentially the right team was not in place at the right time. In order for this to be managed, the outreach team was required to be re-designed in order to meet the 3CO core elements “PREPARE” (The National Outreach Forum, 2012) and integrated into the deteriorating patient pathway. Method: A new data tool was designed, uplift of staff

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and changes in working practices implemented. The National Outreach Forum (NOrF) operational standards and competencies (2012) was utilised to transform the service alongside NICE Guideline CG50 (National Institute for Health and Clinical Excellence, 2007). The NOrF RAG tool was also utilised to benchmark current trust wide working practices for critical care outreach and acute care practitioner provision (The National Outreach Forum, 2012). Expected Outcome and Conclusion: Service changes remain ongoing at time of writing. It is expected through various changes and implementations, a reduction in unplanned ward admissions to the critical care unit can be realised. Findings from the core data set will be shared within the presentation to show improvement outcome, alongside challenges faced and how we have met the “PREPARE� elements. References: National Institute for Health and Clinical Excellence, 2007. NICE Natioanal Institute of Health and Clinical Excellence. [Online] Available at: [Accessed 31st October 2015]. The National Outreach Forum, 2012. Operational standards and competencies for critical care outreach services. [Online] Available at: Documents/NOrF%20CCCO%20and%20standards/ NOrF%20Operational%20Standards%20and%20 Competencies%201%20August%202012.pdf [Accessed 1 March 2018].

1. MDT Questionnaire survey Survey was conducted to all the stakeholders and multidisciplinary team. The survey consisted of anonymised questions focussed on the ACCP job description, usefulness and safety. 2. Local data from ICNARC data bank on patient length of stay and mortality before and after the start of the ACCP model. Results: 1. The ACCPs are involved in early review of the patients in critical care, facilitation of ward rounds and optimization of management. This increased the throughput of the patients and significant reduction in the business ward round time. The average length of stay decreased from 9.4 to 8.3 days. The mortality rate decreased from 23.5 to 22. 9. 2. The survey demonstrated that the MDT were extremely satisfied by the high quality service provided by the ACCPs. The critically-ill patients and their families recognized that they are been treated by the ACCPs and are highly thankful for their services. 3. ACCP facilitated high-quality educational activity including national teaching programs. Some were invited to deliver both regional and national lectures Conclusion: ACCPs clearly have demonstrated a significantly high quality service in all dimensions. They increased the productivity and efficiency in ICU. The survey demonstrates how valuable the ACCP role is within critical care. References: FICM (2018)Advanced Critical Care Practitioner. accessed 01/04/18

C28: Advanced Critical Care practitioners: An innovative workforce C29: To a Better Recovery: Developing model has proven safe and effective a patient orientated multidisciplinary Amii Knight, University Hospitals of North Critical Care rehabilitation service Midlands, Royal Stoke

Background and Aims: Significant and rapid developments through major trauma etc. and other tertiary referrals have increased activity of the criticalcare. Limited resources into the Critical Care Medical Workforce impacted on the ability to provide highquality clinical care in an efficient and safe manner. Therefore we developed an innovative and highly efficient workforce model, the ACCP based on guidance from the Faculty of Intensive Care Medicine (FICM) (2018). The purpose of this project is to demonstrate the safety and effectiveness of the ACCPs Methodology: Methods adopted to explain the safety and effectiveness of the new model were:

Lucy Powell, Joanne Steele and Ramprasad Matsa, Royal Stoke Hospital, University Hospitals of North Midlands Background: Critical illness has significant impacts on physical, psychological and cognitive dysfunction in the short and long-term. Evidence suggests that morbidity could be significantly reduced through a structured multidisciplinary approach to care [NICE, 2009]. Recommendations from NICE [2009] and GPICS [Faculty of Intensive Care Medicine, 2015] act as drivers to promote high impact early rehabilitation for best patient outcomes. However, resource restrictions, culture and financial implications remain challenges in developing and delivering such services. The purpose of this project is to demonstrate how we as a team developed an

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integrated patient-centred, multi modal, multidisciplinary rehabilitation team despite such challenges. Methods: A team with a rehabilitation focus was formed that included medical, nursing and physiotherapy staff. Strategic and stakeholder meetings were held as well as a comprehensive scoping exercise to agree the rehabilitation pathway and best practice. There was a recognition of the need to shift from a predominantly physiotherapy led rehabilitation service to a fully integrated multidisciplinary approach. A three-month pilot weekly multidisciplinary rehabilitation ward round demonstrated a reduction in mechanical ventilation days. The ‘perfect rehabilitation team’ was agreed including Physiotherapists, Occupational Therapists, Medical staff, Speech and Language Therapists, Dietitians, Clinical Psychologist and a Rehabilitation Coordinator to oversee the delivery of the service. Result: A successful business case was granted to provide a fit for purpose, fully funded multidisciplinary Critical Care rehabilitation workforce, enabling improved patient outcomes with a focus on the development of an enhanced rehabilitation pathway. Seven-day therapies services, patient-centred goal setting, timely specialist referrals and numerous other strategies have resulted in reductions in patient length of stay and released capacity to meet upcoming departmental demands. Provisional outcome data is as documented [Table.1]. Further data is awaited which evaluates the service in full. Table 1: Outcome Description Manchester Mobility Score at Critical Care discharge 8 hourly assessment of ICU Delirium using CAM-ICU screening tool Nutritional Adequacy

Pre- Rehab Post Rehab Achievement Service Service 6 7.35 22.5% improvement. 53% improvement since Dec 2010 <50% of >85% of Enabling early applicable patients inter-ventions patients identified to manage assessed at risk of delirium delirium measured & treated 25% of 52% of 27% improvepatients patients ment achieved achieved 80% of 80% of their their estimated estimated nutritional nutritional requirerequirements ments

CG 83 and Quality Standards 158


Partial Risk Assesscompliance ment & goal setting within 4 days of admission, ‘At risk’ patients receive formal handover of care on discharge to ward & additional information

Conclusion: Whilst challenging, we have developed a new integrated multidisciplinary rehabilitation service, focussed on improving patients’ functionality, reducing the physical and psychological impact of critical illness, reducing overall length of stay and ensuring compliance with NICE [NICE, 2009] and GPICS [Faculty of Intensive Care Medicine, 2015] rehabilitation recommendations. References: Faculty of Intensive Care Medicine & Intensive Care Society [2015] Guidelines for the Provision of Intensive Care Services. Faculty of Intensive Care Medicine: London National Institute for Clinical Excellence [2009] Rehabilitation after Critical Illness: Clinical Guideline 83. National Institute for Health and Care Excellence: London

C30: Bereaved families’ experiences of controlled donation after circulatory death in the ICU Wendy Walker, University of Wolverhampton Introduction: Donation after circulatory death (DCD) represents a major source of organs for expansion of transplantation practice. In the UK, the number of DCD donors has increased substantially since the turn of the 21st Century. Controlled DCD (cDCD) refers to organ retrieval after anticipated cardiac arrest, which follows the planned withdrawal of life-sustaining treatments considered to be of no overall benefit to a critically ill patient (NHS Blood and Transplant 2018). Families are necessary partners in the organ donation process, and their related experiences are known to influence donation decisions. Aim: This presentation provides insights into bereaved families’ experiences of cDCD in the ICU. The reported findings are drawn from a national study, funded by the British Department of Health (Sque et al. 2018). Methods: The study was implemented via single,

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retrospective, qualitative interviews, which generated rich, informative data. The sample comprised 24 participants from 18 families who consented to cDCD. Participants were recruited from eight NHS Trusts in England. Interview data were subjected to qualitative content analysis. Main findings: Overall, families appeared impressed with the high standards of care and communication in the ICU and appeared well informed about the cDCD pathway. Few families gave indication of being present at the time of treatment withdrawal, but most appeared to understand what this entailed. There were eight cases of non-proceeding organ donation, and associated family descriptions of a distressing futile experience. The concept of waiting was a significant finding. In particular, the length of time it took from giving consent to donation to organ retrieval was stressful for some families. Conclusions: The study findings contributed an indepth understanding of cDCD care processes. Practice development initiatives are required to address families’ negative perceptions of waiting. Further research is essential to identify the bereavement support needs of families faced with non-proceeding cDCD. References: NHS Blood and Transplant (2018) Donation after circulatory death. Available at: https://www.odt. donation-after-circulatory-death/ Sque, M. Walker W. Long-Sutehall T. Morgan M. Randhawa G. Rodney A. (2018) Bereaved donor families’ experiences of organ and tissue donation, and perceived influences on their decision making. Journal of Critical Care 45: 82 - 89.

Methods: Using the Model for Improvement we developed a driver diagram and progressed as follows: Phase 1 Staff learning – needs questionnaire/ study day Phase 2 Implementation of care plan – PDSA cycles Phase 3 Process measure audit Phase 4 Family involvement in patient care before and after death (current) Results:

We acknowledge the difficulties involved in measuring the quality of EOL care provided however focussing on completed documentation allowed us to ensure that appropriate care had been provided. Discussion: The last hours and days of life care plan was implemented within our ICU in Oct 2016. To promote relationship centred care, we are currently offering families the opportunity to be involved with the care of their loved ones before and after death. The next steps in this project will be capturing relative feedback and development of a follow up service to ensure relative satisfaction and engagement. References: 1. New obstacles to improving the quality of end-of-life care in ICU Bocharov and Kahn Critical Care 2012, 16:304 2. NHS Scotland (2017). Scottish Palliative Care Guidelines. Available ; uk/guidelines/end-of-life-care/Care-in-the-Last-Days-ofLife.aspx

C31: The introduction of a personal care plan for last days and hours of life, to ensure all patients are comfortable and free from pain and distress Diane Bowler, University Hospital Crosshouse Despite end-of-life (EOL) care being recognised as an important component of intensive care there appears to be compelling evidence of the need to improve standards of care provided. Locally a structured multidisciplinary approach was required to improve the care offered and delivered to patients and families. Our aims were to develop a multidisciplinary holistic care plan to ensure patients who die in ICU do so peacefully and with dignity.

C32: From Critical Care to Hospice at End of Life Victoria Carr, Cambridge University Hospitals Introduction: When focus of care changes from curative to end of life in ICU, capacity issues mean that patients are increasingly being transferred to a ward for the last few hours and days. Infection control challenges on the ward mean this is often a shared bay, lacking privacy and dignity.

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The Critical Care Clinical Nurse Specialists at Cambridge University Hospitals have been working with the Hospital Palliative Care Team to facilitate transfer to nurse led beds at a hospice 1.4 miles away and have since transferred 5 patients there, this details the first of those transfers. Case Description: A 50 year old male patient with a medical history of Type 2 Diabetes and Schizophrenia was admitted to ICU with multi-organ failure and subsequently diagnosed with Hepatocellular Cancer and metastatic disease. Discussion with Oncology concluded that there would be no treatment options and pending family discussions treatment would be withdrawn. After terminal extubation and discontinuation of other supportive therapies the patient remained stable 24 hours later on medication to control agitation and restlessness, he was referred to the Palliative care Team who assessed and accepted him for a hospice bed, he was transferred that afternoon and died 3 days later. The hospice has 9 beds criteria for which is; patient is expected to die within two weeks, needs met by nurse led service (reviewed by medical staff once per week) Process; end of life care patients discussed at morning bed meeting, referrals made via Palliative care team, visited by hospice nurse to assess Discussion: •Should we be transferring our patients out of ICU at end of life? •What if the patient dies en route? •Transfer to hospice on nasal hi-flow, NIV and inotropes? References: Kiyota, A, Bell, C, Masaki, K, Fischberg, A (2016) What’s the Plan? Needing Assistance with Plan of Care Is Associated with In-Hospital Death for ICU Patients Referred for Palliative Care Consultation Hawaii J Med Public Health. 2016 Aug; 75(8): 235–241.

C33: Contributing to care: the essential role of the pressure ulcer prevention nurse Maria Rebouco, Barts Health NHS Trust, Debra Gaffey, Barts Health NHS Trust Background: Pressure Ulcers (PU) are more likely to occur in people who are seriously ill and preventative measures are required to reduce the risk for patients. A variety of quality improvement initiatives including education, enhanced documentation, accurate recognition, reporting and multidisciplinary team input are important aspects of addressing PU prevention (PUP) and management1.2. The involvement of collaborative staff2 such as the PUP nurse is essential to support these

quality improvement initiatives. Aim: To explore how the role of the PUP nurse has standardised the approach to prevention, management and reporting of PU’s within one critical care unit. Role development: In 2015, 3 experienced staff with an interest in PUP received in-depth wound training on all aspects of PUP. A number of role responsibilities were established including a review of all PU, moisture lesions and medical device related (MDR) PU with weekly evaluation until no longer required, along with focused education for critical care staff to improve recognition, grading and reporting of PU. The PUP Team was also tasked with review of all Datix reports ensuring correct classification. An anonymous questionnaire was utilized to assess staff knowledge of PUP and perception of the role. Main outcomes: Questionnaire analysis shows that staff have a good insight into the role responsibilities highlighting education, prevention, patient assessment and specialist advice as key activities. Staff who attended training found it relevant to their daily practice in terms of prevention, classification, treatment and datix reporting. Equally staff appeared to have gained confidence and knowledge in the differentiation between PU, moisture lesions and MDR PU. Conclusion: The presence of a small focused group in PUP has positively influenced the recognition, management and reporting of PU. On-going education is required to ensure staff continue to risk assess, identify and categorise wounds appropriately. Regular audit of PU incidents provides critical information for the development of preventative strategies. References: 1. NICE (2014) Pressure Ulcers: prevention and management. NICE clinical guideline 179. Available at: [Accessed 31 March 2018] 2. NHS Improvement (2017) National Stop the Pressure programme: one year on- our focus for improvement. [pdf] NHS Improvement. Available at: Pressure_one_year_on.pdf. [Accessed 2 April 2018]

C34: Trauma simulation: Working ethically with child simulated patients Carrie Hamilton, SimComm Academy, John Perry, University of Southampton, Gill Clarkson, SimComm Academy

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Background: Everyone working with children should have a common set of skills and knowledge and be able to effectively communicate (DoH, 2003). Involving children in simulation-based-education (SBE), hearing their unique perspective and listening to their feedback is vital in shaping health care professionals’ effective communication skills. Aim: Our aim was to be ethically responsible when working alongside child simulated patients (cSPs) in trauma simulation and be compliant with the national simulation standards. Methods: A regional trauma training for multiprofessional trauma teams has involved cSPs for several years. A review of the literature revealed that the ethical implications of working with simulated patients focusses on adults with a paucity of information on engaging with children (Gamble et., 2016). We sought a wide range of advice and considered best practice internationally, nationally and regionally; we consulted with children, their families and their schools. We found that respect for autonomy, nonmaleficence, beneficence and justice (Beauchamp and Childress, 2009) can legitimately be used in the context of cSPs. This led to the creation of the ‘Adapted Ethical Framework’ (AdEF) which is underpinned by these ethical principles and links with UKs national simulation standards (ASPiH, 2016). Findings: We tested the AdEF, adding to the descriptors, whilst consulting with parents, teachers, litigation specialists, ethics committees, organisations and current and former cSPs. Filmed interviews with the cSPs provide a unique and meaningful perspective on being involved in SBE: the impact, the challenges and the benefits. The framework, which is highly transferable, guides us in safe practice and has reduced adverse incidents. Conclusion: Adherence to the AdEF, with ongoing scrutiny of practicalities and governance, a safe ethical environment can be maintained. We believe that the benefit to the child, their family, their friends, to health care professionals and to society, should not be underestimated. References: Beauchamp TL, Childress JF. (2001). Principles of Biomedical ethics. 5th edition, Oxford: Oxford University Press Department of Health (2003). Every Child Matters. London, The Stationary Office Ltd Gamble A, Bearman M, and Nestel D. (2016). A systematic review: Children and adolescents as simulated patients in health professional education. Advances in Simulation, 1(1), p1

C35: Going home to die from critical care: a reflection on the journey to safe uncertainty Lesley White, University of Brighton Introduction: This reflection will look at the decision making, planning and risk involved in preparing for a terminally ill patient, who was inotrope and high flow oxygen dependant, to go home to have treatment withdrawn there instead of in the hospital. This was to fulfil his wish to die at home. Acts like these can be unique for the practitioners involved and require decision making with very uncertain outcomes, which happened here. Methods and Results: Assessment of the situation presented a patient who was critically ill, aware of the futility of treatment and desperate to go home. This was inherently risky as he may die on the journey home or the community palliative care team may not have the resources to care for him. Planning involved robust communication and collaboration with the palliative care team, transport, finance and others to draw on their expertise and explore potential options. But crucially in this case, honest communication with the patient and his family. Reflecting how this uncertain situation was managed to achieve the desired outcome, literature exploring safe uncertainty in family therapy was explored (Mason, 1993). He advocated decisions being made in a structured way but without absolute solutions. Tolerating uncertainty means the possibility of more than one answer when there is limited knowledge and unpredictable patient responses. Oversimplifying this clinical reasoning can be converse to patient centred care (Simpkins and Schwartzstein, 2016). Throughout this process of preparing to send the patient home, decisions were made with fluidity as information became available. Conclusions and discussions: Sending a patient home to die was a relatively unique event but uncertainty is a defining feature of critical care. Therefore, uncertainty management, decision making, and effective communication are skills that are transferrable to other situations and can be developed by healthcare practitioners and healthcare educators. References: Mason, B. (1993). Towards positions of safe uncertainty. Human Systems: The Journal of Systemic Consultation and Management, 4, pp.189-200. Simpkin, A. and Schwartzstein, R. (2016). Tolerating Uncertainty — The Next Medical Revolution?. New England Journal of Medicine, 375(18), pp.1713-1715.

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C36: Exploring experiences of service user involvement in critical care

the literature. International Journal of Consumer Studies 42 (2): 217-231.

Dr Suzanne Bench, London South Bank University, Professor Annette Boaz, Kingston University and St George’s University of London, Dr Konstantina Poursanidou and Dr Constantina Papoulias, Kings College London

C37: The value of a rehabilitation programme following Critical Illness

Introduction: Despite the growing body of evidence around the benefits of involving patients and the public in health research, little is known about the best way to actively involve people with critical illness experience or the impact that their involvement has. The few studies from critical care that have been published tend to focus on describing case examples and on the experiences of staff and/or researchers as opposed to those of the service users. Aims: The aim of this presentation is to share the findings of the first known qualitative study designed to 1. Explore patient and family members’ experiences of involvement in research and/or quality improvement; 2. Highlight areas of strength and challenge; 3. Identify recommendations for future involvement. Methods: Ten former adult ICU patients and relatives were recruited from across England, all of whom had experience of active involvement in research or quality improvement projects. Data were collected using semi structured, audio-recorded telephone interviews. Anonymised interview transcripts were uploaded into NVIVO11 and subjected to a standard process of inductive thematic analysis.Transcripts were first coded by the interviewer, who generated draft themes and final themes were agreed using a consensus approach by all members of the research team. Findings: Data analysis resulted in the identification of a final four themes: Making it happen; Overcoming hurdles; It helps; Respect and value. Discussion and conclusion: The presentation will discuss each of these themes and conclude with some recommendations for the future involvement of former patients and family members in critical care research drawn from the study findings. References: Denegri S. (2015) Going the Extra Mile: improving the nation’s health and wellbeing through public involvement in research. National Institute for Health Research (NIHR). 2015. documents/about-NIHR/NIHR-Publications/Extra%20 Mile2.pdf. Bench S., Poursanidou K. & Eassom E. (2017) The nature and extent of service user involvement in critical care research and quality improvement; a scoping review of

Suzahn Wilson, University of East Anglia, Helen Stewart, Janet Thomas and Helen Else, West Suffolk Hospital NHS Trust, Dr Jane Cross, University of East Anglia Objective: To evaluate a six-week physical rehabilitation service for critical care survivors in a district general hospital and describe the changes in physical, psychological and general health states of participants. Background: The physical and psychological effects of recovering from critical illness are well documented with patients subject to prolonged bed rest and hours of mechanical ventilation. Discharge from critical care and hospital can be the start of an uncertain journey to recovery characterised by a range of challenges which can last more than 18months. Currently, there are variable rehabilitation strategies nationally with many patients not routinely referred for routine follow up. More patients are surviving critical illness due to advances in medicine and technology, indicating a growing need for robust, evidence-based, patient centred rehabilitation strategies. Methods: This service evaluation used a mixed-methods design with existing auditable outcome measures matched with interview data to give context to findings. Existing audit data was used between June 2016 and June 2018 with wider admission and referral data giving context to findings. 787 patients survived ICU in this period, with 55 patients referred to the programme and 16 patients completing the full six-weeks. Interviews were conducted with critical care survivors (n= 8), transcribed, and analysed using a grounded theory methodology. Findings: Critical care survivors struggled for independence and described the physical, psychological, and social functioning challenges associated with this. Participants described the challenge of engaging with the outside world after discharge home and experienced feelings of isolation and abandonment. Significant improvements were observed in physical function, anxiety, depression, and most of the SF-36 subsections after the six-week programme compared to before. Participants described several benefits to attending the rehabilitation programme, describing both physical improvements and the impact of a social environment and group cohesion on their motivation to succeed.

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Poster Abstracts P01: Nurse are pivotal to facilitating research in the intensive care unit

role in high-quality care. Nursing Times, 13. Ozdemir, B. A., Karthikesalingam, A., Sinha, S., Poloniecki, J. D., Hinchliffe, R. J., Thompson, M. M., Gower, J. D., Boaz, A. & Holt, P. J. 2015. Research activity and the association with mortality. PLoS One, 10, e0118253.

Joanne Outtrim, Cambridge University Hospitals NHS Foundation Trust Aims: NHS England aims to support improvements in patient outcome through research, and thankfully patients are now surviving critical illnesses, from which they would have previously died. It is essential that research be established as part of the culture of intensive care and part of normal clinical practice, as patients benefit from attending hospitals that are research active (Ozdemir et al., 2015). Method: In the UK, the National Institute Health Research (NIHR) provides support and education for funded clinical research nurses through the Clinical Research Network. The recent NIHR Clinical Research Strategy (Hamer, 2017) aims to create a clinical research culture focused on patients and the public, whilst encouraging research nurses to promote innovation in practice whilst improving patient care. Pivotal to the delivery of high-quality research care are highly skilled research nurses (Meachin, 2017), such as those in critical care. Main findings: Studies in the intensive care unit have an added complexity with patients who acutely ill and potentially unable to consent for themselves, with families often asked for their advice regarding enrolment into a study. To be able to deliver studies in the intensive care unit (ICU), research nurses not only need to have in-depth knowledge and skills in research but also of their speciality. This is where critical care research nurses excel, as they are often experienced nurses who are looking to inform their own practice and improve patient care. Conclusions: As such research nurses working in the ICU develop a wide range of skills, autonomous working, whilst often taking the lead in implementing studies in the ICU. Coming their clinical experience with research often experience inspires them to develop their own studies. In our Trust, critical care research nurses are encouraged to conduct their own studies, share their expertise, ensuring that research doesn’t continue to be seen as an added extra. References: Hamer, S. 2017. Clinical Research Nursing Strategy 2017-2020. National Institute of Health Research. Meachin, C. 2017. Clinical research nurses have a vital

P02: Big data and critical care nursing research Chris Hill, Royal Free Hospital ‘Big data’ doesn’t have an actual size, basically it’s databases that are so large they’re challenging to work with. Critical Care produces big data from physiological monitoring and electronic records – the ‘Mimic III’ database contains records from 60,000 patients admitted to critical care units of the Beth Israel Deaconess Medical Centre in Boston between 2001 and 2012 (Johnson et al, 2016). This size makes it impractical to review any aspect of the data by ‘hand’, and generally a team is needed to analyse big data that together have computer programming skills for the analysis, and clinical knowledge to develop the research question and interpret the results. Fuchs et al (2017) used the Mimic III database to look at the effect of a ‘Do not resuscitate’ (DNR) order on 28 day mortality. They matched patients with a DNR in place on day 1 of ICU admission, and who survived at least 48 hours, with patients who did not have a DNR on day 1. Mortality at 28 days was significantly higher in the DNR group. This may reflect severity of illness not captured by other clinical factors, but the perceptions of the treating team related to do-not-resuscitate status could also be causally responsible for increased mortality in patients with do-not-resuscitate status Big data is also used in nursing research; Westra et al (2017) reviewed big data research applied to nursing practice. One project took place partly in critical care units and aimed to investigate the influence of nurse continuity on the prevention of hospital acquired pressure ulcers. However the use of big data by critical care nurses appears to be limited. Given the big data resources potentially available to critical care nurses, this research technique could be used more to try to enhance patient care. References: Fuchs L, Anstey M, Feng M, et al. (2017) Quantifying the Mortality Impact of Do-Not-Resuscitate

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Orders in the ICU. Critical Care Medicine. 45(6):10191027 Johnson AEW, Pollard TJ, Shen L et al. (2016) MIMIC-III, a freely accessible critical care database, Scientific Data. DOI: 10.1038/sdata.2016.35. Available at: http://www. Westra BL, Sylvia M, Weinfurter EF et al. (2017) Big data science: A literature review of nursing research exemplars. Nursing Outlook 65:549-561

P03: Empowering nurses and encouraging bottom up change through a band five forum Daniel Harris, Cambridge University Hospitals Aims: This Poster will outline how a band five forum works to empower nurses and encourage bottom-up change within our ICU (The King’s Fund, 2014). Utilising a Plan, Do, Study and Act (PDSA) cycle this poster will analyse what has worked well and what has been achieved. Background: The band five forum has been running since 2013. Since then it has developed into a hub of change. It is voluntary for band fives and below, but staff are paid for their time. The forum is led by a band five and overseen by a band seven. The forum has been used to discuss issues in the department: encouraging candour, speaking up, escalating concerns and examining different ways of working to improve patient care. It provides a platform to improve care and work as a team. In addition, a unique opportunity to provide teaching and education with invited specialists. Thus providing collaboration and promoting an open and patientcentred culture through teamwork (The Kings Fund, 2013). Plan: To assess the effectiveness and gather feedback to further improve the band five forum. Do: Undertake anonymous feedback after the band 5 forum utilising open questions. Study: Band fives felt able to introduce: the pod leader role, admission checklist, bereavement boxes and shift management sheets. The forum was receptive, encouraged pro-activeness and was interactive. However, staff wanted more teaching sessions. Act: For further forums we introduced an extra hour to incorporate teaching. Conclusion: The band five forum has allowed changes to be led by band fives, developing their leadership skills, empowering and motivating them as well as giving

them the experience required to bring about change in modern healthcare. In addition has provided a platform to discuss issues on the unit in an open manner and ensure we come to an appropriate solution (Gluyas, 2015). References: Gluyas, H. (2015) Effective Communication and teamwork promotes Patient safety. Nursing Standard 29 (49):pp.50-57. The King’s Fund (2013) Patient-centred leadership Rediscovering our purpose. The King’s Fund: London. The King’s Fund (2014) Reforming the NHS from within: beyond hierarchy inspection and markets. The King’s fund: London.

P04: Delirium screen and prevention audit Patricia Coelho, Maidstone and Tunbridge Wells NHS Trust Aim: Audit delirium screening of critical care patients using Intensive Care Delirium Screening Checklist (ICDSC) within 24 hours of admission and practices of delirium prevention at 72 hours. Methodology: Retrospective collection of data from patient’s records and charts from the 1st of June-15th of August 2017at Tunbridge Wells Hospital ICU. Inclusion criteria: Patient’s ≥ 18 years old admitted to ICU. Exclusion criteria: patients under 18 and/or discharged before 72 hours. Results: - Sample size: 42 patients - Patient with Delirium: 22% - Non-screened patients: 2%. - Sedated and ventilated: 28% - Bowel protocol was not followed in 52% of patients. - Pain score ≤ 3 (Verbalizing patients only): 50% - Antipsychotics use to treat delirium: 44% - Patients’ medications not reviewed by the unit’s pharmacist: 7%. - Access to an analogue clock: 100% - Mobilized patients: 100%. Discussion: The Standard was not achieved on 100% of the admitted patients leaving 2% non-screened. Moderate to severe pain are possibly still undertreated; pain levels were not audited on sedated patients. Sleep quality was not audited. Noise level audit was initially planned but abandoned. Almost half of delirium cases were treated pharmacologically. Pharmacological interventions are costly and have shown no significant benefit for delirium prevention. Unit’s pharmacist has reviewed patient’s medications within 24hours of admission in 93% of the patients. Bowel management

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has an important role on the prevention of Delirium– unit’s bowel management protocol was not followed in half of the population. Nevertheless, early rehabilitation and mobilization, reorientation strategies recommended are being achieved. References: Barr, J., Fraser, G.L., Puntillo, K., Ely, W.E., Gélinas, C., Dasta, J.F., Davidson, J.E., Devlin, J.W., Kress, J.P., Joffe, A.M., Coursin, D.B., Herr, D.L., Tung, A., Robinson, B.R.H., Fontaine, D.K., Ramsay, M.A., Riker, R.R., Sessler, C.N., Pun, B., Skrobik, Y. and Jaeschke, R. (2013) ‘Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit’, Critical Care Medicine, 41(1), pp. 263 - 306. doi: 10.1097/ccm.0b013e3182783b72. (2017). Delirium: prevention, diagnosis and management | Guidance and guidelines | NICE. [online] Available at: [Accessed 28 Jun. 2017].

Conclusions: Although patients from all specialties are at risk of developing MDRPUs, critically ill patients are especially vulnerable to injury from pressure. There are encouraging results to support the use and development of aSSKINg Together. Greater understanding of contributing factors is required, as research is scarce. References: Black, J.M., Cuddigan, J.E., Walko, M.A., Didier, L.A., Lander, M.J. & Kelpe, M.R. (2010) Medical device related pressure ulcers in hospitalized patients. Int Wound J. 7 (5): 358-365. Mallet, J., Albarran, J.W. & Richardson, A. (ed.) (2013) Critical Care Manual of Clinical Procedures and Competencies. Willey, Chichester. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Cambridge Media, Osborne Park.

P05: aSSKINg Together: assessment, prevention, management and evaluation of pressure injury care in adult critically ill patients Joao Azoia, Cambridge University Hospitals NHS Foundation Trust Aims: To share a quality improvement project looking at medical device related pressure ulcers (MDRPU) in critically ill adults. Background: Pressure ulcers (PU) are a prevalent adverse event in hospitals, particularly among vulnerable people and special groups, e.g. critically ill patients. Started at an East of England university hospital in response to a couple of unstageable MDRPUs from nasogastric tubes, this project aimed at reviewing current practice and support tissue viability care to patients in intensive care. Methods: Systematic review (Embase). Articles retrieved were assessed for methodological validity prior to inclusion. Results: Informed by the broad evidence base supporting the NPUAP/EPUAP guidelines (2014) and the literature reviewed, we have adapted the SSKIN framework adding an ‘a’ for the fundamental ‘risk assessment’ and a ‘g’ for ‘give information’, to enhance communication among the multidisciplinary team and between clinicians and patients: aSSKINg Together. Discussion: As MDRPUs result from the use of devices,

the term refers to an aetiology rather than to a physiopathological entity and the mechanisms behind it are not fully understood. The use of specific prevention strategies needs further evidence with the exception in the use of prophylactic dressings to pad oxygen delivery devices. The practice development team produced educational resources to promote on-going teaching on prevention and treatment of MDRPUs and there has been fruitful collaboration with different clinical areas. There has been an improvement in the number of MDRPUs in relation to NG tubes and continuous monitoring of the number of PUs is carried out by the Trust’s Tissue Viability Team.

P06: Making Moisture Manageable: Introducing a moisture lesion prescription sticker across adult critical care Nikki Sarkar, Nottingham University Hospitals NHS Trust Aims: Patients receiving critical care often go through a period of critical illness making their skin vulnerable to moisture damage, which in turn can lead to further tissue deterioration. This moisture damage is identified as a moisture lesion. For patients, a moisture lesion can be extremely painful and distressing, affecting patients’ physical and psychological wellbeing (Bianchi 2012). Within Adult Critical Care at Nottingham University Hospitals NHS Trust, it was identified that there were variations in moisture lesion practice. On identifying this, a moisture lesion prescription sticker was designed to standardise current, best practice.

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Methodology: The sticker was introduced following a PDSA cycle. Moisture lesion incidents from the previous year were captured to provide a baseline. The sticker was designed to be quick and simple to use for the prescriber and care deliverer. The expectation during its introduction was that all patients who had a moisture lesion would have the sticker implemented and prescribed, with the correct course of treatment commenced. Three months after its introduction, an audit was conducted to monitor its compliance and impact in practice.

Main Findings: The data collection was carried out over a three-month period, with fifty seven patients, all with a moisture lesion captured. Patients with a moisture lesion continue to be reported and since the sticker’s introduction, we saw a 41% decrease in incidents in the first 7 months. We continue to capture this data and at the time of writing this abstract, we have not seen increase in numbers of incidents since the sticker’s introduction. This data is subject to change.

P07: The use of a clinical IT system in an Oncology Critical Care Unit to improve patient safety and nursing practice in the prevention of PUs and medical device related skin damage Sally-Anne Bradbury, The Christie NHS Foundation Trust Background: Patients in the critical care unit have multiple factors that increase the risk of skin damage; mechanical ventilation, medical devices and the infusion of vasoactive agents (Makic, 2015; Chaboyer et al., 2016). The use of a clinical IT system — Metavision — within the Oncology Critical Care Unit (OCCU), enhances the potential to streamline and automate the task of collecting and measuring data linked to pressure ulcers (PU) and medical device related pressure damage. Metavision allows us to examine the incidence of PU and medical device related damage in real time enabling us to react and adapt to measures which are barriers to change, reducing occurrence, incidence and patient harm. Aim: To reduce the incidence of PU and medical device related skin damage through a clinical IT system by prompting frontline nursing staff to reposition patients and medical devices. Methods: Data was retrospectively collected for all patient admissions on the OCCU from 2013 to 2017. Data collected included all PU’s ≥ stage II and all nursing documentation that related to wound care and medical device and patient repositioning on Metavision. Results: A total of 34 PU’s ≥ stage II developed in 1118 patient admissions over 5 years, with a cumulative incidence of 2.66%. Nasogastric (20.59%) and sacral region (50%) related PU’s were most prevalent for the patient population admitted to the OCCU. Reactive changes to Metavision increases nurse awareness of pressure related damage, reducing the total incidence of PU’s by 169%, over the 5 years.

Conclusion: The sticker was designed to standardise practice, not as a preventative tool. The guidance it provides may be improving overall moisture lesion awareness and practice. Alongside ongoing education, this may be a significant factor to the change in perceptions in our staff regarding moisture lesions. References: Bianchi J (2012) Causes and strategies for moisture lesions. Nursing times. 108 (5), 20-22.

Conclusion: Metavision allows for live, reactive changes to nursing practice when issues are identified. Identifying the prevalence of PU’s and medical device related pressure damage by specific location enables the Metavision team to adapt and develop the system to change practice, improving and enhancing patient safety. References: Chaboyer W, Bucknall T, Webster J, McInnes E, Gillespie BM, Banks M, Whitty JA, Thalib L, Roberts S, Tallott M, Cullum N, Wallis M. (2016). The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): a cluster randomised trial Links. Page 33

International journal of nursing studies, 64: 63-71 Makic, MB. (2015). Medical Device - Related Pressure Ulcers and Intensive Care Patients. Journal of Perianesthesia Nursing, 30(4): 336-337

accessed 25/03/18 < content/2/1/34> Sole, M et al, (2011). ‘Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range’. American Journal of Critical Care Vol 20, No 2, pp 109-117 accessed 25/03/18 <http://ajcc.>

P09: Releasing the pressure: Finding a solution to low tracheostomy cuff pressures in ward based patients

P11: The role of the healthcare assistant in the ICU

Hayley Allen, Royal Victoria Hospital, Belfast Health & Social Care Trust Joao Bastos Da Fonseca and Paulo Santana, The London Clinic Problem: The checking of cuff pressure in the tracheostomies of ward based patients using manometers, showed a pattern of extremely low readings. This was in the absence of any other sign of a cuff leak; no desaturation, no gurgling or airway noise, no audible voice or air leak. The Outreach Team had been recording pressures of 5-8 cmH2O on patients who had been inflated to 28 cmH2O the previous day.

Background: Evidence suggests that the pressure checking process itself releases air from the cuff (Asai et al. 2014). I contacted our tracheostomy tube supplier and requested information about expected cuff leaks over set time periods. They advised that every time the cuff pressure is checked, between 1.5- 3 mls air is released, from a cuff volume of perhaps 7-10 mls in total. This in addition to any leak over time (Sole et al. 2011). Over 5 months, 3 patients had 6 unscheduled tubes changes due to a suspected cuff leak. 5 of those tube changes were based on recorded low cuff pressures only. Solution: Whilst researching the problem I found the SMART cuff manager by Tracoe. This product remains connected to the pilot balloon. It consistently maintains the cuff pressure between 20-30cmH2O and only needs a visual check of a balloon- i.e. no connecting and disconnecting like the manometer. It is not mechanical or pneumatic like devices used within critical care areas. Findings: During the 2 month trial, staff reported a decrease in the frequency of suctioning and no antibiotics were prescribed for LRTI in a patient who frequently had aspiration pneumonia. No unplanned tube changes due to possible cuff failure occurred therefore reducing discomfort and risk to the patient. We aim to prevent unscheduled tube changes due to low cuff pressures alone and avoid aspiration incidences in future. References: Asai, S et. al, (2014). ‘Decrease in cuff pressure during the measurement procedure: an experimental study’. Journal of Intensive Care Vol 2:34,

Aims: A Narrative literature review was conducted to determine the current role of healthcare assistants (HCA) in the intensive care unit (ICU) to gain directions for skills and career development. Methods: A literature search was conducted using multiple electronic databases, focused on publications between 2000 and 2018. Keywords with Boolean operators used were: “The role of the healthcare assistants IN ICU”; “Nursing assistants AND ICU”; “Healthcare assistant AND critical care OR acute care OR ICU”. The search yielded XX publications after applying inclusion and exclusion criteria 7 publications were selected. After further analysis 3 publications were selected, based on their relevance in relation to the objectives. Main Findings: There is a wide range of activities performed by healthcare assistants in the ICU setting (Hogan and Playle, 2000). The activities identified in the review included those related to hygiene care, patient feeding, equipment checks/set up and quality control checks. These can be performed independently or by assisting a registered nurse (Hogan and Playle, 2000). This review identified that a wide range of job titles and descriptions exist for HCA and this can lead to confusion among staff and patients and their families and carers. Individual approaches to HCA development programme have had positive feedback from both HCA´s and registered staff (Hancock and Campbell, 2006). Conclusions: Currently, one third of the NHS workforce is made of healthcare assistants, distributed over different areas and services, such as intensive Care Units (Cavendish , 2013). HCA´s have been working in intensive care settings with different roles and different levels of autonomy, very much dependent on individual hospital policy. Further research is needed to understand the job role of the HCA in the ICU, in particular what tasks they should be performing independently and supervised. References:

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1. Cavendish, C (2013). The Cavendish Review: An Independent Review into Healthcare Assistants and Support Workers in the NHS and social care settings. 2. Hogan, J. and Playle, J. (2000). The utilization of the healthcare assistant role in intensive care. British Journal of Nursing, 9(12), pp.794-801. 3. Hancock, H. and Campbell, S. (2006). Developing the role of the healthcare assistant. Nursing Standard, 20(49), pp.35-41.

P12: Critical skills for non-clinical staff within critical settings Carrie Hamilton, SimComm Academy, Lesley Smith and Sara Reed, Hampshire Hospitals NHS Foundation Trust, Marjolein Woodhouse, University of Portsmouth Background: Over 500,000 of 1.2 million NHS staff, work in the vital range of fields that support clinical care. These staff receive 0.01% of the NHS training budget, yet they have a significant interface with patients, the public and colleagues (Cowper, 2016). Communications (18.6%) and values/behaviours (13.9%) were the highest and third highest categories of complaints to the NHS in 2015-2016 (NHS statistics, 2016). Senior managers at an acute Trust acknowledged that no standards guide non-clinical staff (e.g. clerks, receptionists, secretaries), additionally, this staff group were not routinely complying with their organisational values: caring-accountability-respect-encouraging. A multiprofessional group developed a ‘simulation and standard setting’ workshop underpinned by the organisations’ values. Aim: Illustrate the positive outcome of providing simulation-based education to non-clinical staff Methods: A multiprofessional group developed a programme of workshops for non-clinical staff, underpinned by the NHS and organisations’ values. Demonstration, immersion, and feedback through 3.5hours of simulation involved simulated patients/ relatives/colleagues (actors). The scenarios focused on four domains of telephone, email, letter and face-toface communication. Emphasis on giving (and receiving) positive feedback was a vital thread. A roundtable workshop followed where participants were asked to draft ‘standards’, linked to the organisations’ values in the four domains. Findings: A total of 280 administrators have attended the 10 development workshops, with 4 managers (line/ senior), 2 facilitators and 4 actors per workshop. Simulation activities led to rich input to setting standards. Investment in training resulted in key

outcomes, all created by the workforce: • Workplace standards • Orientation package • Quarterly newsletter • Standards pledge • Meaningful appraisals Conclusion: Non-clinical staff from critical care areas would benefit greatly in specialised communication skills training and involvement in setting their own standards of best practice. Within critical care, making a connection between the value of these non-clinical roles with clinical value is essential. References: Cowper, A., (2016) Maximising the Contribution of NHS Non-Clinical Staff: The forgotten 500,000 Health Service Journal Guide May 2016 NHS Statistics, (2016) Data on written complaints: (2015 – 2016): Ref: ISBN 978-1-78386-804-9 http://digital.nhs. uk/pubs/nhscomplaints1516

P13: WebEx study event Nicole Lee, Anglia BACCN Committee Aim: A trial of WebEx technology across Anglia BACCN region to deliver a study event encompassing both taught lectures and discussion forum. Methodologies: WebEx links were set up between Broomfield Hospital, Queen Elizabeth Hospital King’s Lynn, Ipswich Hospital and one external viewer. Regional BACCN member and non-members were invited to attend the event within the different hospitals. Two power point presentations were presented from Queen Elizabeth Hospital on regional research which had been carried out within their unit. Firstly, on arterial catheter duration and secondly the introduction of the PneuX ET tube within their unit. Following these two discussion topics were launched, firstly around difference in infection control procedures across the regions, secondly about current mouth care protocols across the region. Main findings Attendance: • Broomfield-7 + 1 committee • Ipswich-5 + 3 committee • Queen Elizabeth-6 + 1 committee • From home-1 Feedback: • Presentations-clear and relevant to ITU • Discussions-Positive, Nice relaxed atmosphere, Felt they could ask questions Committee enjoyed the experience feeling that we had highlighted differences between care of patients across

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the region, leading to staff going back into their areas with fresh ideas challenging ritualistic practice looking for evidence behind care. Conclusion: Using WebEx technology the Anglia region delivered a study event over 4 sites to 24 staff with positive feedback. We are encouraged to hold further events using this technology using more host sites making it easier for delegates and speakers to attend in their local hospitals and reducing overall costs of events to BACCN and Delegates. References: Cisco WebEx. The world is your classroom. [online] Available At: < products/elearning-and-online-training.html>. C. Georg, N. Zary, 2014. Web-Based Virtual patients in nursing education :Development and validation of theory-Anchored design and activity models. [online] Available at: < articles/PMC4004162/>. T. Calinici, 2015. Virtual patients in emergency nursing training. Nursing and care. [online] Available at: <> [accessed 12 April 2018].

open for 24 hours. In total 20 people participated in the debates, discussions and feedback. Further feedback was that people hadn’t understood the concept and would have participated should they have realised what the idea of the virtual event was. In addition, one of the participants was on maternity leave, highlighting the increased level of inclusivity to all staff created via the online platform. Conclusion: Concerns around social media and the NMC code of conduct were overcome with closed access and mediation. The increased engagement of 20 attendees versus 3 in a face-to-face meeting suggests that the platform is a success. The staff involved in the virtual event were interactive, productive, respectful of others and the debate. In the future, this will be a regular platform for staff engagement, the amount of information and ideas generated has successfully overcome barriers to engagement in a busy and time pressured environment. References: NMC (2015) The Code: Professional standards of practice and behavior for nurses and midwives (the Code). NMC London. NMC(2017) Guidance on using social media responsibly. NMC London

P14: Overcoming the barriers to staff engagement through virtual platforms P15: Improving Critical Care Handovers- a reflection on my Kelly Fielding, Lancashire Teaching Hospitals Trust checklist creation Introduction: When nursing demand is high, it is difficult to engage staff in additional activities such as feedback for quality improvements or change. Aims: To increase the amount of communication, engagement and feedback within Critical care by making communication platforms more accessible, less time dependant and more interactive. Methodology: A quality improvement event was held to discuss the hand overs in the shift overlap time enabling better attendance. The Critical care department was busy and therefore only 3 people were released to attend. No one attended in their own time despite time back being offered. Handovers couldn’t be changed without more staff engagement and therefore a closed event on Facebook was created with only critical care staff invited. It was mediated and ground rules and topics were established. Staff could write any comments and subject headings as well as comment within the pre-organised subject. Main Findings: Staff asked for the event to remain open longer than the 6 hours planned and the event was left

Joanne Lomax, Cambridge University Hospital Addenbrookes Aims: Whilst caring for patient’s in the critical care setting I recognised that the unit didn’t have a standardised handover and saw this as something I could improve on. I applied the PDSA cycle (plan; do; study; act) and created a structured and concise task list for the management of the critical care patient throughout the shift. Background: The handover from nurse to nurse allows the receiving nurse to begin their shift with the information they need to ensure their patient’s safety and wellbeing. Malekzadeh et al (2013) states that poorly communicated information with a nonstandard and ineffective shift handover may endanger patient safety and that the primary goal of shift handover between nursing staff is to communicate the patients’ clinical information and to provide safe and high-quality patient care. Main Findings: Using the PDSA cycle I identified what I felt I could change and devised this handover model for

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the unit to implement. Once introduced, I conducted a study of my colleagues to find out who uses it and how effective they feel it is. Of 37 respondents, 25 use the handover and of the 25, 88% thought the list had a positive impact (12% thought the impact was neutral).100% (n=25) would recommend the handover to new colleagues on ICU and 83% to other wards and units. Of the 22 who thought the list had a positive impact, 91% thought it improved handover and 73% thought it improved time management. Conclusion: The introduction of the structured handover model has ensured that handover between nursing staff is properly documented and that tasks are completed in good time. There has been no recommendation for change to act on; however following on from the results of the study the handover has now been introduced to other critical care areas in the trust. References: Malekzadeh, J., Mazluom, S.R., Etezadi, T. and Tasseri, A. (2013) A Standardized Shift Handover Protocol: Improving Nurses’ Safe Practice in Intensive Care Units. Journal of Caring Sciences. Vol 2 (3) pp. 177185 Smeulers, M., Lucas, C., Vermeulen, H. (2014) Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients doi/10.1002/14651858.CD009979.pub2/ abstract;jsessionid=F4EF5B575AC9736F0F28CE9B4040B 0B4.f04t03 [Accessed 3.6.17]

P16: Glycemia control and neurological outcome in Intensive Care Manuel Gala del Rio, Oxford University Hospitals Aim: The aim of this poster is to explore the impact of Moderate Insulin Therapy (MIT) and Intensive Insulin Therapy (IIT) in the neurological outcome of critically ill patients. Several studies found no benefit of IIT over MIT, and even found greater risks such as increased severe hypoglycemia risk. However, some studies indicated that there may be a benefit of the neurological outcome in patients receiving IIT. IIT therapy would aim to maintain an average glycemia range of 80-100mg/dl (4,4-5,6mmol/L ), while MIT would aim for a range of 180-200mg/dl (10,0-11,1mmol/L) (Clain et Al, 2014). Methodology: A review of the most recent documents regarding glycemia control in Intensive Care found in pubMed,

NCBI, and the American Journal of Respiratory and Critical Care Medicine was done. The focus of this review was the recommendations regarding implementing IIT or a MIT approach and their outcomes, comparing risks and benefits of each approach. Discussion: While it is widely agreed that IIT increases the risk of hypoglycemia and risk of death due to it, some studies have shown benefits over the MIT. Van den Berghe et al (2005) results shown a reduction of Critical Illness Polyneuropathy in patients receiving IIT, as well as a reduction of the mean and maximal Intracraneal Pressure (ICP). This study also shown a higher percentage of recovery twelve months post ICU discharge. The NICE-SUGAR trial (2009) shown an increased mortality risk in patients receiving IIT. Because of it, the wide recommendation across the UK is to avoid a tight glycemia control, hence using an MIT approach for most of our patients. Conclusion: Despite the interesting benefits of IIT over MIT shown by different studies, the risks of the former are not to be ignored. Because of that, the recommendation of this poster is to follow the NICESUGAR trial’s recommendations and use a Moderate Insulin Treatment approach. In the future, as new blood glucose monitoring are developed, it may be possible to better study the benefits of IIT over MIT in a safer way for our patients (Clain et al., 2015). References: Clain, J., Ramar, K., & Surani, S. R. (2015). ‘Glucose control in critical care’. World Journal of Diabetes, 6(9), 1082–1091. Van den Berghe G., Schoonheydt K., Becx P., Bruyninckx F., Wouters P.J. (2005). ‘Insulin therapy protects the central and peripheral nervous system of intensive care patients’. Neurology, April 26, 2005 vol. 64 no. 8 13481353 The NICE-SUGAR Study Investigators (2009). ‘Intensive versus Conventional Glucose Control in Critically Ill Patients’. N Engl J Med 2009; 360:1283-1297. DOI: 10.1056/NEJMoa0810625

P17: Our Units exprerience interegrating Plasma Exchange on ECMO patients with severe sepsis Cara Godfrey, Manchester University Hospital, Wythenshaw Site Aim:Present data on our first 10 patients who have received Plasma Exchange whilst on ECMO and discuss changes to practice.

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Method: Retrospective study by case notes. Discussion: We utilised the services of NHS Blood and transplant services for our Plasma exchange. It became clear that a policy/protocol was needed to ensure the patients safety was not compromised. A clinical incident happen where communication breakdown from the ECMO Specialist Nurse and the Plasma Nurse resulted in the Plasma Circuit clotting off whilst running through the ECMO circuit. After meetings with the Lead Nurse for Plasma Exchange we put in place a checklist to prevent further incidences. A list of tests to be taken prior to commencing a Plasma exchange as may of these where missed, leading to over or under treating. checklist below. One treatment of Plasma Exchange is three cycles on 3 consecutive days. Plasma Exchange Checklist Initial/ Date/Time Patient Name: DOB: Height / Weight Diagnosis: VAS Cath required? Y / N Is the Oxygenator safe to use as access? Apheresis nurse contacted Time TPE started and Time Finished Heparin: Y / N If no inform apheresis nurse Make the Apheresis Nurse aware latest coagulation Exchange ratio: Products ordered Contact Blood bank (every day for 3 days) Date/ time:

plasma exchange. We treated 3 streptococci, 3 Klebisella, 2 eosphillia pneumonia and 2 staph PVL infections of which 1 eosphillia pneumonia and 2 streptococci survived. 2 patients had more then 1 treatment neither patients survived ECMO. 3 patients received IgI before Plasma Exchange of which 2 survived, both streptococci infections. Conclusion: By having a policy and checklist in place we increase safety of the new combined services. Our results would indicate streptococci a/b have had he best outcomes, however this would have been multifactorally. There are 5 ECMO centres within England, the future plan would be to combine our data and ways of working provide national guidelines. References: Murphy, D et al (2012) ECMO with plasma exchange in a patient with alveolar haemorrhage secondary to Wegener’s Granulomatosis. Internal Medicine Journal. Royal Australasian College Physicians. 2012

P18: How should the multidisciplinary team manage the risks associated with agitation within the Adult Critical Care Unit environment? Samantha Freeman, University of Manchester Aim: The aim of the study is to establish how agitation is managed in critically ill adult patients and its effectiveness, evidence base and impact.

Products to be prescribed on MFT Blood Product prescription and photocopied at the end of each exchange for the Apheresis Nurses.

Background: An admission to an Adult Critical Care Unit is a traumatic and potentially life altering event. The presence of patient agitation is common among this patient group (Whitehouse, 2014) Its presence is associated with the potential for harm as the patient may inadvertently or purposefully remove their lifesupporting devices (Burk et al., 2014). Despite the safety risk, little research has been conducted in relation to patient agitation in adult critical care.

Bloods to be sent Request as Urgent Call 4762 when sending ADAMT13 (repeat after the 3rd cycle of TPE) (Sample to be sent to Liverpool) Anti nuclear abs Cardiolipin antibody (repeat after the 3rd cycle of TPE) Antibody to ENA DNA Antibodies ANCA (repeat after the 3rd cycle of TPE) Rheumatoid factor

Research: Design A cross-sectional web-based survey.

The Apheresis Nurse will inform us what products we need for subsequent days; it is our responsibility to ensure products are requested via the blood request forms. Results: Out of 10 patients only 3 survived to discharge home. 9 patients had a reduction in SOFA score by on average 3 points however this could have been due to oxygenation and reduction in vasoactive drugs along with

Results: Data were collected between November 2016 and February 2017. There was a response rate of approximately 47.8%. Following removal of incomplete questionnaires there were 163 valid responses reducing the usable response rate to 32.6%. Nine statements where presented and participant could respond via a Likert scale. Three of these being An agitated patient is at risk of harm 79.4% strongly agree and 19.1% agreed Having family member present reduces agitation 14.5%

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strongly agree, 48.9% agree 29.8% neither agreeing nor disagreeing 6.9% disagrees or strongly disagreeing. I don’t believe in the use of physical restraint in the critical care environment 66.4% either disagreeing or strongly disagreed, 25.2% neither agreeing nor disagreeing and 8.39% agreeing or strongly agree with this statement Emergent themes from free text data: • Importance of the timeliness of care • Perception that staff lacked the skills and knowledge to manage an agitated patient and staff stress • Uncertainty in the use of physical restraint • The inconsistent approach to care Conclusion: Healthcare teams appear to be navigating agitation management with a limited evidence base and no clear practice guidance. The data in this phase and the subsequent two phases aims address this evidence gap and inform the development of guidance. References: Burk, B. R. S., Grap, M. J., Munro, C. L., Schubert, C. M., & Sessler, C. N.(2014). Predictors of agitation in critically ill adults. American Journal of Critical Care, 23(5), 414–423. ajcc2014714 Whitehouse, T., Snelson, C., Grounds, M., Willson, J., Tulloch, L., Linhartova, L., Shah, A., Pierson, R., & England, K. (2014). Intensive Care Society Review of Best Practice for Analgesia and Sedation in the Critical Care. 1–84

P19: Planning, preparing and proceeding with transferring critically ill patients: A case study on nursing resilience Kevin Murphy and Joanne Gunner, St Bartholomew’s Hospital Aim: Exploring the nursing resilience when it comes to plan, prepare and proceed with transferring a critically ill patient, receiving central VA ECMO, open chest cavity, and intra aortic balloon pump therapy. Methods: Using a reflective approach, the nursing contribution is multi factorial. Discussion with senior nursing staff, ECMO consultants and presentation of this case study to explore the 3 P’s of transfer. Results: Successful transfer involved planning transport, with the necessary medical staff being present. Preparing to transfer was completed in line with the organisation’s trust policy and bedside safety checklists(ICS,2011).

Discussions with the MDT and transport team ensured safe transfer. Proceeding to transfer occurred with MDT agreement. Discussion: Transfers occur on a regular basis within London. The 3 P’s utilised in this case proved helpful. Planning the transfer took a considerable amount of time involving the transport team and ensuring the right amount of space in an ambulance including power supply and emergency equipment available. Preparing for the transfer involved gathering equipment, emergency drugs and patient information. Proceeding only occurred once safety checks were performed, oxygen supplies were satisfactory and equipment was functioning after self checks. Local policy requires regular review and amendments to incorporate new patient case loads, such as Central ECMO, open chest cavity and the level of skill required from a nurse undertaking the transfer. Conclusion: The nurse going on a critical transfer has a large responsibility to ensure they are adequately prepared to face any complications in transit. While this case study was successful, the nurse must ensure they look at risk, the safety of transferring and are updated regularly on medical devices to be able to troubleshoot equipment. Resilience is a major factor for the nurse to be able to deal with an ever changing environment while planning and preparing for transfer. References: Intensive Care Society (2011)., Guidelines for the transport of the critically ill adult (3rd Edition) Association of Anaesthetists of Great Britain and Ireland (2006) Inter - hospital transfer of the critically - ill patient in the Republic of Ireland (An Irish Standing Committee Publication)

P21: Patient & Family Involvement within Critical Care Joanne Tillman and Anoma Gunawardena, Royal Brompton Hospital Background In 2010 Royal Brompton Hospital (RBH) adult intensive care unit (AICU) became one of the nationally commissioned respiratory ECMO centres. As a result of this there was an increasing demand for isolation facilities to appropriatly manage the respiratory patient. Funding was secured from the Trust to build two new isolation rooms to not only help match this demand but also that comply with the latest building regulations and that accommodate families which was especially important as a lot of our families live far away.

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Aim To create two modern isolation rooms to accommodate patient, family and staff requirements. A strategy of engagement of previous patients and families was undertaken to ensure service user involvement in the project. Methods Multimodal methods of partnership were explored with patients, such as through follow up appointments and the annual ‘patient day’ to provide the design team with a clear vision of what an ‘ideal’ environment for a critical care patient and their family would look like. The team then took this vision along with staff feedback and translated it in to a plan to develop two modern, patient centered side rooms that meet patient, family and staff requirements to provide world class cardiothoracic critical care. Results Two state of the art patient centered side rooms were delivered, on time and on budget. The input from patients and relatives thourghout the process was crucial to achieving work spaces that were both practical, evidenced based and patient focused with a dedicated area for family to openly vist and reside near the patient whilst they are critically ill. Discussion & Conclusion Ongoing involvement of families has ensured the highest level of partnership can be achieved, ensuring the power is distributed to service users who continually shape the future of our unit. Service user feedback in this project was paramount in striving to achieve the correct design, colours and images to create a calming environment in which to care for our patients. The designated space for families is a unique feature which allows them to feel more involved and engaged in their loved ones ICU stay. References: Arnstein, Sherry R. ‘A ladder of citizen participation’ JAIP, Vol 35, No. 4, July 1969, pp. 216-224.

P22: Developing a clinically relevant academic critical care degree/masters level course with a new education partner/provider Vicky Burch, Nottingham University Hospitals NHS Trust The Critical Care Nurse Education team is passionate about providing an academically relevant course which is pertinent to practice, with a focus on the ever-changing clinical skills as a tool for ensuring safe, quality patient

care. The work required to validate a course of this level with a new academic provider has been a challenge. Reduction in regional education funding indicated the need to provide the course ourselves, with a partner to sustain the academic validation. The curriculum, together with academic assessments, has been written and planned by the clinical lead and education team based on the CC3N National Competencies Step 2 & 3 for Critical Care (1). The rationale is to ensure the nurses educated are fit for purpose with the skills required in everyday practice. The first cohort of the Course graduates in July 2018. Two further courses have commenced this year, with the intention of 45 students per year gaining their post registration qualification. The trajectory for national guidance of 50% (2) will be achieved by Spring 2020. Adherence to this trajectory and CQC requirement provides assurance to stakeholders of the quality of care and improvement in nursing practice within the area. The course will be formally evaluated by students via the University tool; however for continued improvement and curriculum evaluation, the course is evaluated locally at each session, day and overall module and course. The Likert scale used explores themes such as professional development, retention and provision of improvements in care. It is hoped the continuous cyclical evaluation of the course by the education team will also ensure its relevance to fast-changing practices, together with incorporating governance principles with local relevance. Despite minimal data, there was a marked rise postcourse in empowerment and increased opportunities for promotion, with staff believing they were providing higher quality evidence based care compared to pre course. Future data will support this more thoroughly and themes will be identified, together will potential mapping to patient safety incidents. There has been a recent request from the local Critical Care Network to understand more about content and application to practice, and the success of the course and University partnership has attracted much interest from other specialities. References: Critical Care Networks-National Nurse Leads (CC3N) 2015. Available at: competency-framework/4577977310 (Downloaded: 05 June 2018) Guidelines for the Provision of Intensive Care Services (GPICS) 2015. Available at: standards-and-guidelines/gpics (Downloaded: 05 June 2018)

P23: Delivering a CC3N compliant ICU course within a specialist

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cardiothoracic hospital setting in partnership working with a local university provider

P24: Educational provision for patients following a spinal cord injury; a service evaluation

Ian Naldrett, Royal Brompton Hospital/University of West London, Dr Claire Anderson, University of West London, Marina Nicholas, Kathryn Farrow, Moya Piper and Itayi Chinehasha, Royal Brompton and Harefield NHS Foundation Trust

Hayleigh Carey-Byrne and Sian Rodger, Royal National Orthopaedic Hospital

Within the past 6 years since the initial publishing of the CC3N National Standards for Adult Critical care education 2012 there has been an emphasis on standardizing critical care education across the UK. Within these standards the need for Courses run at academic level 6 and 7 and the requirement for 60 UK Academic credits have put emphasis upon organisations to fund these courses to ensure the minimum of 50% of staff are trained in critical care nursing (ICS 2015). This is within an increasingly hostile financial environment which has seen severe cuts to CPD education budgets. In response to these conditions a partnership was formed in May 2017 between The Royal Brompton and Harefield NHS Foundation Trust and University of West London to provide a critical care course that both meets the needs of a specialist cardio thoracic critical care unit and the National CC3N standards, delivered within the Hospital setting at a reduced cost per student. The First cohort of students start this partnership working course in April 2018, where they will have the opportunity to study for a PGCert in Intensive care nursing, meeting the CC3N standards and be fully funded by the hospital trust. It has taken considerable partnership working between 2 geographically distant Intensive care units and the local HEI provider. A novel franchised style of delivery eliminated the need for validation of new modules, which is often costly and labour intensive. Using the existing Module structure and Learning outcomes delivered through a joint appointed post of Lecturer Practitioner, it has enabled the course to have parity with the cohorts running concurrently at the university and represent significant cost savings for the hospital trust enabling more nurses to be trained, exceeding the 50% threshold for trained critical care nurses on both sites. References: CC3N (2016) National Standards for Adult Critical Care Nursing Education; 2nd edtion Accessed on 03/04/2018. Available from: uk/education-training/4577977309 Intensive care society (2015) Guidelines for the Provision of Intensive Care services. Accessed on 03/04/2018. Available at

Background and rationale: A vital element of rehabilitation is the provision of formal and informal education. Patient education optimises patients’ involvement in their own decision making and care aiming to promote adherence to agreed plans, reduce post injury complications, promote independence, participation and improved quality of life. Design and Methods: A questionnaire survey collected data from a purposive convenience sample of 90 in patients, out patients (up to 2 years post injury) and healthcare staff actively involved in the rehabilitation of people with a SCI at The London Spinal Cord Injury Centre (LSCIC), . Data were collected between September-November 2017. Participants completed a locally designed paper or online questionnaire, which included Likert style questions and opportunity for free text comments. Different education resources (book, 1:1 and group sessions) were evaluated. Results: 98% of healthcare staff found giving education an enjoyable part of their role with most agreeing (45/48) it is the responsibility of all healthcare staff. Barriers to giving education were identified such as time and inadequate staffing, as were themes that healthcare staff considered important when giving education such as communication and barriers to learning. The formal education programme was valued by both inpatients and outpatients, sessions were graded to inform future programme. Face to face education sessions was the preferred delivery method for 80% of outpatients and inpatients followed by an App/online e learning. 65% of outpatients said they had used their education pack post discharge. More detailed results of education topics and feedback will be presented. Conclusions and recommendations: Findings will inform development of the local education programme, with a particular focus on reducing post discharge complications and development of an App designed for this patient group. References: Qin Liu, L, Moody, J, Traynor, M, Dyson, S and Gall, A (2014) ‘A systematic review of electrical stimulation for pressure ulcer prevention and treatment in people with spinal cord injuries’ The Journal of Spinal Cord Medicine 37 (6) pp 703-718.

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P25: Factors influencing the recognition and appropriate management of the deteriorating patient in acute hospitals Michelle Treacy, University of West London Aim: To identify the factors which influence the recognition and appropriate management of the deteriorating patient in acute hospitals. Background: Previous research has established that there are patients who receive sub-optimal care in the UK’s healthcare system because their deterioration is not recognised, or acted upon in a timely manner. The increasing demand on intensive care beds is reaching crisis point, while previous research has identified that patients may avoid the need for ICU admission should their deterioration be recognised in a timely manner and managed effectively on level 1 and level 2 areas (RCP, 2017). Research Design: Integrative review using Whittemore and Knafl (2005) methodology.

P26: “Could it be Sepsis?” Raising confidence and awareness to ask the question & complete a Sepsis proforma Benjamin Gray, Barts Health NHS Trust Background: A new 2016 definition of Sepsis was introduced to help the recognition and management of Sepsis1. Identifying Sepsis indicators within critical care can be challenging for nurses, where observations can already be outside ‘normal’ parameters. In 2017 a Trust-wide Sepsis proforma was introduced and an education programme was commenced, building on the principle that early recognition and treatment of Sepsis can save lives2.

Data Sources: CINAHL, PubMed and Web of Science. Methods: A systematic search was carried out and all reference lists of the included papers. All studies were critically appraised using the Coughlan et al., (2007) tools. Data was analysed using a thematic analysis. Findings: 3 main themes emerged, these were; lack of education, poor communication and failings within the organisation themselves. Findings revealed that basic vital sign assessment was not always completed with competence or accuracy. In particular a patient’s respiratory rate and conscious level. Many nurses lacked the advanced assessment skills required to identify when a patient was deteriorating. The communication between nurses and doctors was often problematic with evidence of hierarchy, which negatively impacted on patient outcomes. Failure to comply with protocols, which may be due to an inability to follow correct protocol or failure it initiate a protocol. Conclusions: This integrative review identified several modifiable factors which exist in the acute health care setting which are negatively impacting on patient safety. Further education is required for post qualifying education, along with structural changes to improve the protocols within acute care settings. References:

Donaldson, L.J., Pansesar, S.S. and Darzi, A. (2014) ‘Patient safety related hospital deaths in England: Thematic analysis of incidents reported to a national database’, PLOS Medicine, 11(6), p. e1001667. doi: 10.1371/journal.pmed.1001667. Royal College of Physicians (2017) National Early Warning Score (NEWS) 2 Standardising the assessment of acute-illness severity in the NHS. Available at: https:// (Accessed: 09 January 2018). Whittemore, R. and Knafl, K. (2005) ‘The integrative review: updated methodology’, Journal of Advanced Nursing, 52(5), pp. 546-553.

Aim: To evaluate staff knowledge of Sepsis; develop training to address identified needs and to gain insight into staff views on the use of the Sepsis proforma within critical care. Methodologies: 80 staff completed an anonymous questionnaire which was analysed to identify common gaps in knowledge of Sepsis recognition and management and to assess confidence to ask the question ‘could it be Sepsis?’ From the evidenced learning needs, an education intervention strategy was developed using the Sepsis proforma and ‘Sepsis box’. 70 staff received a focussed teaching session on Sepsis, with 30 staff completed a follow up questionnaire. Main findings: The initial questionnaire found that staff had a good awareness of the mortality associated with Sepsis, however knowledge of the proforma and triggers such as SIRS were inconsistent. 62.6% of staff questioned indicated reasonable confidence in asking ‘Could it be Sepsis’. Following teaching confidence rose to 75%,

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knowledge of the SIRS criteria improved significantly, however confusion between SIRS and Sepsis 6 remained. Staff found the proforma difficult to interpret within critical care, as deterioration may be secondary to underlying pathology or masked by clinical interventions. Conclusions: Sepsis recognition remains challenging, even within critical care environments, and the need for continued training is paramount. Support for nurses and multi-disciplinary consistency in managing Sepsis and the desire for proformas to be tailored to the critical care environment could increase the nurses’ confidence in asking ‘could it be Sepsis?’ References: NICE (2016). Sepsis recognition, diagnosis and early management. NICE national guideline 51. [online] Available at: [Accessed 1st April 2018]. The UK Sepsis Trust (2017). The Sepsis Manual. 4th ed. Birmingham. Sepsis Trust.

P27: The powerful impact of our patient focus group on clinical practice in our intensive care unit Gayle Brunskill, Vilas Navapurkar and Timothy Baker, Cambridge University Hospital Our Intensive Care Unit Patient and Relatives Focus Group first met in May 2013. The Group consists of former patients, their relatives and ICU clinicians. It integrates the patient and relatives experience of critical illness into the fabric of care. It does not provide treatment for Group members but care today by applying lessons learned from their experience. The emphasis was to collate and analyse information from challenging multivariate questioning. These were: Your time on the ICU: - From what you can remember what was the single most important thing to you during this stage of your time in hospital? - What worked well for you? - What things need to be improved? Staff on ICU: - What did the staff do that made the most difference to you? - What extra things do you wish the staff could have done? - Is there anything in particular areas that you would like more training given to ICU staff? Discharge from ICU: - What was the most important thing to you when you

were transferred to the ward? - What worked well for you? - What aspects need to be improved? Your relative’s and visitor’s opinions: - If you had any family or friends visit you while you were on ICU, what did they think of your care there? - Were your relatives given as much information as they wanted when you were in ICU? Outputs were immediate clinical utility and real time relevance to the whole patient and relatives’ population. The primary results were that the inability to report symptoms and peri ICU psychological damage caused the most distress. This opinion reflects the experience published in the literature(1-3). To treat these problems we developed “myICUvoice” a software system for patients to communicate and embedded a psychological support service on the ICU. Both have made patients and relatives feel better. References: Fink, R. M., Flynn Makic, M. B., Poteet, A. W., Oman, K. S., Makic, M. B., Poteet, A. W., & Oman, K. S. (2015). The Ventilated Patient’s Experience. Dimensions of Critical Care Nursing, 34(5), 301–308. Dziadzko, V., Dziadzko, M. A., Johnson, M. M., Gajic, O., & Karnatovskaia, L. V. (2017). Acute psychological trauma in the critically ill: Patient and family perspectives. General Hospital Psychiatry, 47, 68–74. Merchan-Tahvanainen, M. E., Romero-Belmonte, C., Cundin-Laguna, M., Basterra- Brun, P. San MiguelAguirre, A., & Regaira-Martinez, E. (2017). Patients’ experience during weaning of invasive mechanical ventilation: A review of the literature. Enfermeria Intensiva, 28(2), 64–79.

P28: Development of Critical Care Follow Up Clinic Services (CCFUCS) using Quality Improvement Helen McGuire, Katie Stallwood and Helen Veale, Harefield Hospital Introduction: The CCFUC started at Harefield in 2014 to identify and manage patients with post intensive care syndrome (PICS). Initially patients who stayed 7 days or longer were invited to clinic 2 months after discharge. Patient diaries were introduced aiming to further aid psychological recovery. During the first year we identified poor attendance, DNA’s, missing patients who met the 7 day stay criteria, no access to local mental health services. Last year our clinical psychologist started leading to faster, improved local management of mental health

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P29: Patient Diaries - Are we using them?

needs and better identification of those with PICS. Aim: Improve the quality of the CCFUCS Method: Using PDSA cycles and a QI approach we introduced the nurse-led telephone clinic. This allowed us to reach patients outside the local area and those unable or unwilling to physically attend appointments. We commenced patient diaries and facilitated their return via clinic. Diaries have progressed to being a bespoke design and include patient photos. Currently we are forming a focus group as part of our PPI initiative to gain feedback and further develop the follow up service. Additionally we have changed our booking process and documentation becoming the first paperless clinic in our outpatients department. Results: We adapted our clinic invitation letter and changed screening tools to encourage attendance and detect PICS. Attendance has increased from 94 patients to 126 last year. We are now also able to offer EMDR (Eye Movement Desensitisation and Resynchronisation therapy) with our psychologist. We have returned 204 diaries offering a personalised account of a patients stay. Conclusion: Our clinic has made significant changes including the introduction of our telephone clinic, commencement of our psychologist and emphasis on the use of patient diaries. We continue with forming our focus group combining patient and medical input to facilitate changes to both clinic and our unit. References: Jones, C.; Backman, C.; Capuzzo, M.; Egerod, I.; Flaaten, H.; Granja, C.; Rylander, C.; Griffiths, R.D.; 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. R168 National Institute for Clinical Excellence (2009) Rehabilitation after critical illness in adults [online]. Available from: [Accessed 2nd April 2018] O’Gara, G. and Pattison, N. (2016) ‘A qualitative exploration into the long-term perspectives of patients’ receiving critical care diaries across the United Kingdom’, Intensive and Critical Care Nursing, 36, pp. 1-7.

Alexandra Chary, Freeman Hospital Aims: The aim of the initial audit was to assess the use of patient diaries in the Integrated Critical Care Unit (ICCU). 7 months later a re-audit was completed to highlight any improvement. Methods: A prospective clinical audit of engagement with patient diaries among staff and relatives on the ICCU Discussion: Data was collected over 14 days on all patients who met the inclusion criteria over two audit cycles. An intervention of staff education and review of patient diary guidelines was implemented after completion of the first audit cycle. Results: Data was available for 25 patients during the first cycle and 17 patients during the second cycle. The proportion of patients for whom a diary was used increased from 36% during the first cycle to 58% in the second cycle. (p=0.21, Fisher’s exact test). Conclusion: After education on the significance and use of the diaries along with a review of the current guidelines, the use of patient diaries improved. Further audits and data collection are required to strengthen the study. References: North of England Critical Care Network (2016). Patient Diary Guidelines. Faculty of Intensive Care Medicine & Intensive Care Society. (2016). Guidelines for the Provision of Intensive Care Services.

P30: Introducing a bereavement box to promote better bereavement care for families in the ICU Daniel Harris, Sara Coentro and Nicola Chambers, Cambridge University Hospitals Aims: This poster will introduce our bereavement box as an initiative to promote better bereavement care for families within the general ICU. Explaining different ideas and choices we offer. Background: Bereavement care is important, yet underdeveloped, in UK ICUs (Berry, et al., 2017). NICE (2017) stresses the importance of involving the family in the care of their loved one. Bereaved family members frequently experience depression, anxiety and post-

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traumatic stress disorder which can impact on their quality of life due to sudden or unexpected loss. The Intensive Care Society (1998) outlines the standards ICUs should meet for bereavement care – yet it doesn’t answer the question of what to offer the bereaved family. Main Findings: Historically our unit had taken fingermoulds (which can be turned into jewellery afterwards) and snippets of hair. Yet its use was intermittent and not offered to all families due to the heterogeneous nature of a medical/surgical ICU. After a literature search, discussion at a staff meeting and further discussions we dedicated a box for bereavement. This box contains: heart shaped key rings (the solid heart goes with the deceased leaving the empty heart for them to carry – or vice versa), organza bags for hair, finger-moulds, hand printing equipment, speakers and information. In addition to this, a children’s bereavement box with memory boxes, books and further information. We also developed handmade cards to help the bereavement process. Feedback has been positive, relatives are grateful to have something physical to remember their loved one and have been appreciative of the handmade cards. Conclusion: It is valuable to empower the multidisciplinary team to identify patient’s and families’ needs and develop appropriate and kind care, ensuring good bereavement care in critical care. Further analysis is needed to measure the impact of the bereavement box in the care perceived by families in ICU. References: Berry, M., Brink, E. and Metaxa, V. (2017) Time for change? A national audit on bereavement care in intensive care units. Journal of the Intensive Care Society 18(1): pp.11-16. Intensive Care Society (ICS) (1998) Guidelines for bereavement care in Intensive Care units. London: ICS. National Institute for Health and Care Excellence, 2015. Care of Dying Adults in the Last Days of Life (NG31). [pdf] NICE Guideline. Available at: [Accessed 19 October 2017].

P31: Improving Patient Safety through Early detection of Deterioration Emma Coutts, Medway NHS Foundation Trust Aims: To present how service reconfigurations the critical care outreach team (CCOT) has impacted on patient safety. There will be a focus on early detection and prevention of deteriorating patients, and review how this has decreased avoidable admissions to critical care in keeping with the conference theme of Quality

Improvement Projects. Background Analysis of deteriorating patients within acute care highlighted a need for change in identifying deteriorating patients improving intervention times. National Institute for Clinical Health and Care Excellence (NICE) Clinical guideline (2007) recommends a robust strategy should be implemented so that hospital staff can appropriately escalate patients who are deemed at risk of deterioration in order to prevent it. NICE (2007) and The National Outreach Forum Standards and Competencies (2012) both identify that Track and Trigger systems should be implemented to identify patients but without this in place a strategy needed be designed. Method: The CCOT was increased and reconfigured with guidelines to use when conducting observations emphasising escalation with National Early warning Score (2012) of 4 and above. Whilst NEWS as (2012) was widely used throughout the hospital there were no guidelines for when to escalate deteriorating patients to CCOT which became the focus for service development. Results: Referrals increased by 30% of which showed an increase of referrals with a news of 4-5 and decrease of referrals with a news greater than 7. Avoidable critical care admissions were reduced from 8 patients a month to 1 patient in 6 months. Admission from patients under the care of CCOT to critical care more than halved. Conclusion: Whilst staff recognised deteriorating patients, they had no guidance on how to escalate and whom to. The new guidelines and emphasis on early intervention improved safety by decreasing deterioration and critical care admissions. References: National Outreach Forum (2012) NOrF Operational Standards and Competencies for Critical Care Outreach NOrF%20CCCO%20and%20standards/NOrF%20 Operational%20Standards%20and%20Competencies%20 1%20August%202012.pdf Accessed 23/05/2018 National Institute for Clinical Health and Care Excellence (2007) Acutely ill adults in hospital: recognising and responding to deterioration Guidance/CG50 Accessed 23/05/2018 National Outreach Forum (2012) National Early Warning Score (NEWS) 2 Accessed 23/05/2018

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