Human Factors in Critical Care
In the ED chaos is common. In the management of many emergencies the default situation can be chaos unless a concerted effort is made to gain control. A loss of control in a crisis can in turn can lead to dilution in the quality care of our sickest patients and therefore we need training in dealing with crises… Working in a busy Emergency Department and doing a retrieval medicine has taught me that models of care and checklists are complementary to providing good critical care. This is especially true in variable environments with a variety of team members working together often for the first time and in stressful conditions.
Prior to any Medical Emergency assemble a Team as early as possible – complete a P.A.E.D.S. Checklist:
Critical Care is not limited to the ICU.
But the location can be a challenge…
Basic critical care concepts can be confusing and difficult to apply outside of the Intensive Care Unit (ICU) setting. Exposure to Emergency Medicine and pre-hospital environments help in understanding the process of applying critical care concepts in the non-ICU setting. For example placing a central line at 10am after a ward round in ICU in controlled manner is different to placing a central line (with USS to a high-standard of sterility) in the ED prior to moving a critically unwell patient to theatre for urgent surgery. Time pressure, other resuscitation activities and immediate necessity all contribute to difficulties in this example.
To maintain control it is important to consider 3 factors (in advance of managing an Emergency situation):
PRE-HOSPITAL & RETRIEVAL MEDICINE (PHARM)
Here are 4 lessons I am using and will take away from my time in retrieval medicine:
AIRWAY MANAGEMENT CHECKLIST
The use of a Rapid Sequence Intubation (RSI) checklist helps in the sharing of the clinicians thought processes, efficiency of teamwork and preparedness for managing a difficult airway. We use the RSI Checklist from the Excellent GSA HEMS RSI Handbook: CLICK HERE
I plan to continue a checklist for all intubations in the Emergency Department (ED) with the exception of patients in Cardiac Arrest and also plan to recommend this to my ED colleagues too.
Similar models and intubation checklists have been adapted to the ED setting by Dr Toby Fogg at Royal North Shore Hospital: CLICK HERE
- Many of us have heard that a lung protective strategy is the standard care for patients post-intubation in the ED
- This is based on the ARDSnet data and meta-analysis of controlled trials on various ventilation strategies
- How do we best achieve this in the busy ED using our equipment?
It’s easy to forget basics like Patient Positioning (30 degrees) and Adequate Analgesia/Sedation. Analgesia is a good place to start.Involving the ICU doctors at an early stage can be helpfulI also found the Drager Online Program useful – CLICK HERE
- Knowing your equipment is essential to success:
- Intubation Equipment
- Cannulation Equipment, Central Lines, Arterial Lines and Intraosseus Needles
Further Reading – CLICK HERE
During time working in retrieval medicine several concepts were emphasised and now feel more familiar especially the use of Inotropes in the Pre-hospital and Inter-hospital setting:
- Experience Appropriate use of Inotropes included the following:
Noradrenaline is the Inotrope of choice in Septic Shock and SIRS – CLICK HERE
Use of Adrenaline Infusion may be required in Neurogenic Shock – CLICK HERE
In general not using Metaraminol or other Ionotropes in Trauma patients (use blood)
Double Pumping (see 5mins into the the video embedded below discussing patient transfers)
Inter-hospital Patient Packaging
This is also very relevant to moving patients around the hospital (to CT and between departments):
POST INTUBATION AND SUPPORTIVE CARE
“F.A.S.T.H.U.G.” is a commonly used approach to supportive care in the ICU ensuring that basic patient management needs are met on a daily basis. We suggest that you give critically unwell patients a “FASTHUG IN Their BED” both in and out of the ICU.
Additions to ‘F.A.S.T.H.U.G.’ for the Emergency Department
- Skin and Wound Care, Suctioning
- IDC and Continence Care
- NGT or OGT
- Touchy Feely Fluffy Bunny Stuff (Psychosocial Support)
- Bowel Movements
- Deescalation of Care
The original FASTHUG approach: