Inter-departmental banter and rivalry between ICU and ED nurses is as old as the NHS is still young. If you happen to have been working under a rock or never ventured outside of your department, I highly recommend finding a friend from another ward. Go for a cup of tea and call it clinical supervision if you like, share your experiences (and some of the jokes) and I can guarantee a rewarding conversation unlike any you will have in your own ‘echo chamber’ of a department.
It was one of these conversations that lead me to this blog post and what I hope will build on a beautiful relationship between critical care and ED education.
Picture the scene; its 3pm and an empty critical care bed is awaiting a pneumonia patient who has been intubated in ED. As there was a delay in the bed becoming free, he has had a CVC and ART line inserted by the critical care reg on call. ED porters, an ED nurse and the ICU reg wheel the patient in and once they are transferred over to the ICU bed, the fight with pumps, ventilators and monitor cables begins. What is the priority of events in this scenario? Should we first verbally handover the patient? Is it best to move from the transfer equipment to the ICU equipment or should we physically assess the patient for any changes in their condition? The truth is that there is no right or wrong answer and the reality will be simultaneous activity of moving equipment and handover but it raises an interesting issue in relation to patient safety. At what point is the transferred patient no longer an ED nursing responsibility and now an ICU nursing responsibility?
Human factors
The BMJ have recently conducted a literature review into patient handovers, their effectiveness and techniques for improvement [1]. Miscommunication is commonly seen as a leading cause of adverse events in patient care. A poor handover can result in treatment delays, medication errors and distress when patients or family members have to explain the same thing multiple times. The World Health Organisation suggest the use of standardised tools and most UK trusts have implemented the SBAR approach (see Liz's blog post on SBAR here). Whilst you won't often hear critical care nurses formally using SBAR and preferring to focus on an A – E assessment, the utility of the tool should not be underestimated and makes a solid basis for communication. Consider that your handover isn’t just a transmission of information but a transference of clinical responsibility.
In todays scenario, a squeaking pump with a low battery forced the decision making and the equipment was transferred first. Anecdotally, in my alternate world of transfer medicine, responsibility for the patient lies with the team whose equipment is monitoring the patient. Without a handover, our pneumonia patient finds themselves in a dangerous limbo where the ED nurse knows them best but our ICU equipment makes critical care accountable for them. Within minutes of putting the patient on the ICU monitor the patients blood pressure had gone from a solid 115/75 (88) to a scary 80/40 (53). After checking the accuracy of the reading, the ICU nurse reaches for the noradrenaline pump to increase the rate only to discover that the transferring nurse has switched off the pump and removed the syringe to transfer into an ICU pump…..
Noradrenaline
Catecholamines such as noradrenaline prepare the body for physical activity and are often referred to as the bodies fight or flight response. Acting on the sympathetic nervous system, noradrenaline mainly effects the a1receptors in peripheral, renal and coronary circulation causing vasoconstriction and raising systemic vascular resistance (SVR). This increase in SVR, or afterload, results in an increased mean arterial pressure (SVR x CO = MAP). For more information on inotropes and vasopressors see this useful RPS article online [2]. With a half life of only 2 – 2.5 minutes, noradrenaline is changed over using a ‘double pump’ technique. A commonplace task in ICU, the ‘double pumping’ of noradrenaline should result in a seamless infusion. Poor techniques can lead to extreme swings in blood pressure and there are many different procedures for the task.
Rarely seen in the ED, I would imagine, who could blame the transferring nurse for the confusion during the melee of handover? More commonly seen in ED will be metaraminol which unlike noradrenaline, can be infused peripherally and has a much longer half life. The medications longer half life make it the drug of choice for short term use where bolus administration is appropriate and its prolonged effect won’t be detrimental to the patient when hypotension causing factors such as anaesthesia are discontinued. Bottom line for ED is that neither drug will replace effectively filling the septic patient but once you have filled, where do you go next? Check out the Best Evidence Topic Report from the EMJ for a look at the current thoughts on the subject [3].
With our patient safely back on noradrenaline and fully handed over, similar situations will be happening throughout the NHS and will be a result of both systems and human failures. In scenarios where level 3 patients are being cared for outside of critical care would it be better if critical care retrieved or ED staff were given critical care skills? Intra hospital transfers (between wards) should be treated with the same care as if transferring outside the hospital (inter hospital) but do nurses receive enough training in this area? Your thoughts and comments are very welcome and could inform future blogs. Let me know if there is anything specific you would like to discuss and remember; between the lines, whether they are tidy or tangled is a patient and nursing is a team sport.
Holly : )
[1] Merten, H., Van Galen, L. and Wagner, C. (2017) ‘Safe Handover’, BMJ, 359 [online]. Available at: https://doi.org/10.1136/bmj.j4328 (Accessed: 2 September 2018)
[2] Berry, M. and McKenzie, C. (2010) ‘Use of Inotropes in Critical Care’. Clinical Pharmacist, Vol 2 [online]. Available at pharmaceutical-journal.com (Accessed: 2 September 2018)
[3] Anderson, K. and Chatha, H. (2017) ‘BET 3: Peripheral Metaraminol Infusion in the Emergency Department’, EMJ, Vol 34(3) [online]. Available at http://dx.doi.org/10.1136/emermed-2017-206590.3(Accessed 2 September 2018)
RCN Emergency Nurse Competencies-
GNP 3.1.4 (L1& L2)
GNP 3.2.1 (L1 &L2)