Critical Care Manual of Clinical Nursing Procedures E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1918

Veröffentlichungsjahr: 2024

Beschreibung

Critical Care Manual of Clinical Nursing Procedures

The second edition of Critical Care Manual of Clinical Nursing Procedures is a practical overview of essential procedures for the care of critically ill patients. Beginning with chapters outlining the current scope of critical care, the book adopts a systematic stage-by-stage approach from admission to discharge. At each stage, it provides insights into physiology, key procedures, and the relevant evidence base. Now fully updated to incorporate the latest research and best practices, this volume is poised to remain an indispensable resource for the next generation of critical care providers.

Readers of the second edition will find:

• In-depth, beat-by-beat analysis of key procedures in critical care
• Interventions underpinned by the latest evidence
• Content aligned with the National Critical Care Competency Framework and endorsed by the British Association of Critical Care Nurses

Critical Care Manual of Clinical Nursing Procedures is ideal for nurses working in a critical care unit, nurses undertaking post-qualification specialist courses in critical care, or other healthcare professionals working as part of a critical care team.

Leseprobe

Table of Contents

Cover

Table of Contents

Title Page

Copyright Page

About the Editors

List of Contributors

Foreword

Endorsement

CHAPTER 1: Scope and Delivery of Evidence‐Based Care

AIMS AND CHAPTER OVERVIEW

BACKGROUND AND CLASSIFICATION OF CRITICAL ILLNESS AND CRITICAL CARE IN THE UK

OVERSIGHT AND GUIDANCE FOR ADULT CRITICAL CARE PROVISION

EVIDENCE‐BASED PRACTICE

CLINICAL GOVERNANCE

CONCLUSION

REFERENCES

CHAPTER 2: The Critical Care Workforce

AIMS AND CHAPTER OVERVIEW

CONTEXT

CRITICAL CARE WORKFORCE MODEL

CONCLUSION

SUMMARY OF KEY POINTS

REFERENCES

CHAPTER 3: Competency‐Based Practice

AIMS AND CHAPTER OVERVIEW

COMPETENCY

CONCLUSION

SUMMARY OF KEY POINTS

REFERENCES

CHAPTER 4: Recognising and Managing the Critically ill and ‘At Risk’ Patient on the Ward

AIMS AND CHAPTER OVERVIEW

INTRODUCTION

THE CHAIN OF SURVIVAL

BACKGROUND

EARLY WARNING SCORES

RAPID RESPONSE TEAMS

ELECTRONIC EARLY WARNING SCORES

SIGNS AND SYMPTOMS OF PATIENTS ‘AT RISK’ OF DETERIORATION OR WHO ARE CRITICALLY ILL

ASSESSING AND MANAGING THE DETERIORATING PATIENT

ABCDE ASSESSMENT PROCESS

CALLING FOR HELP

CONCLUSION

SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

REFERENCES

CHAPTER 5: Admitting a Critically ill Patient

AIMS AND CHAPTER OVERVIEW

INTRODUCTION

LEVELS OF ADULT CRITICAL CARE SERVICES

ADMISSION OF A PATIENT TO A LEVEL 2 OR 3 CRITICAL CARE AREA/FACILITY

REFERRAL PROCESS, REVIEW AND DECISION MAKING PRIOR TO ADMISSION TO CRITICAL CARE (SEE ALSO CHAPTER 4)

ADMITTING THE PATIENT TO CRITICAL CARE

CONCLUSION

SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

REFERENCES AND FURTHER READING

CHAPTER 6: Assessment, Monitoring and Interventions for the Respiratory System

AIMS AND CHAPTER OVERVIEW

BACKGROUND

ASSESSMENT OF THE RESPIRATORY SYSTEM

RESPIRATORY SUPPORT

AIRWAY MONITORING

RESPIRATORY SUPPORT INTERVENTIONS

MANAGING A PATIENT REQUIRING INVASIVE VENTILATORY SUPPORT

OTHER RESPIRATORY SUPPORT INTERVENTIONS

CHAPTER SUMMARY

PROCEDURE GUIDELINES

REFERENCES

CHAPTER 7: Assessment and Management of the Cardiovascular System

AIMS AND CHAPTER OVERVIEW

ASSESSMENT AND MONITORING

HAEMODYNAMIC INTERVENTIONS

CARDIAC ARREST

CONCLUSION AND SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

USEFUL WEBSITES

REFERENCES

CHAPTER 8: Assessment and Support of the Gastrointestinal System

AIMS AND CHAPTER OVERVIEW

ANATOMY AND PHYSIOLOGY OF THE GI TRACT

COMMON GI PATHOPHYSIOLOGY

NUTRITION IN CRITICAL ILLNESS

NUTRITIONAL SCREENING

NUTRITIONAL ASSESSMENT

NUTRITIONAL INTERVENTIONS

ENTERAL NUTRITION SUPPORT

PARENTERAL NUTRITION SUPPORT

BOWELS: ASSESSMENT AND MANAGEMENT

CRITICAL CARE MANAGEMENT OF GI DISEASES AND COMPLICATIONS

CONCLUSION

SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

REFERENCES

CHAPTER 9: Assessment and Management of Kidney Function

AIMS AND CHAPTER OVERVIEW

ANATOMY AND PHYSIOLOGY OF THE KIDNEYS AND PATHOPHYSIOLOGY OF DISEASE

ASSESSMENT AND MONITORING

INTERVENTIONS

CONCLUSION AND SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

REFERENCES

CHAPTER 10: Assessment and Management of Pain, Anxiety, Delirium and Sleep

AIMS AND CHAPTER OVERVIEW

PAIN

SEDATION

NEUROMUSCULAR BLOCKADE

DELIRIUM

DRUGS USED FOR SEDATION, ANALGESIA AND NEUROMUSCULAR BLOCKADE

SLEEP

CONCLUSION

SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

REFERENCES

CHAPTER 11: Assessment and Management of Neurological Status

AIMS AND CHAPTER OVERVIEW

INTRODUCTION

AIMS AND INDICATIONS

ANATOMY AND PHYSIOLOGY

ASSESSMENT OF NEUROLOGICAL STATUS

ADVANCED NEUROMONITORING

CONCLUSION

SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

REFERENCES

CHAPTER 12: Assessment and Management of Hygiene Needs

AIMS AND CHAPTER OVERVIEW

SKIN CARE

ORAL HYGIENE

EYE CARE

CONCLUSION AND SUMMARY OF KEY POINTS

ACKNOWLEDGEMENT

PROCEDURE GUIDELINES

REFERENCES

CHAPTER 13: Infection Prevention and Control

AIMS AND CHAPTER OVERVIEW

INTRODUCTION

PREVENTING INFECTION TRANSMISSION BETWEEN CCU STAFF AND PATIENTS

CONCLUSION AND SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

APPENDIX 1: AIDE‐MEMOIRE FOR OPTIMAL PATIENT PLACEMENT AND RESPIRATORY PROTECTIVE EQUIPMENT (RPE) FOR INFECTIOUS AGENTS IN HOSPITAL INPATIENTS (BASED ON EVIDENCE FROM WHO, CDC AND UKHSA)

APPENDIX 2: AIDE‐MEMOIRE FOR OPTIMAL PATIENT PLACEMENT AND RESPIRATORY PROTECTIVE EQUIPMENT (RPE) FOR HIGH‐CONSEQUENCE INFECTIOUS DISEASES: INCLUDING LIST OF OPTIMAL PLACEMENTS OF PATIENTS AND THE REQUIRED PPE (NHS ENGLAND, 2023A)

REFERENCES

FURTHER READING

CHAPTER 14: Physical Mobility and Activity Interventions for Critically ill Patients

AIMS AND CHAPTER OVERVIEW

INTRODUCTION

BACKGROUND AND ANATOMY AND PHYSIOLOGY

INTERVENTIONS FOR PATIENTS UNABLE TO SIT ON THE EDGE OF THE BED (‘BED BOUND’)

INTERVENTIONS FOR PATIENTS DEEMED READY TO SIT ON THE EDGE OF THE BED

CONCLUSION

SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

REFERENCES

CHAPTER 15: Psychological and Spiritual Needs of the ICU Patient and Family

AIMS AND CHAPTER OVERVIEW

PSYCHOSOCIAL CARE

DELIRIUM

COMMUNICATING WITH CRITICALLY ILL PATIENTS

SUPPORTING THE FAMILY AND VISITORS IN ICU

SPIRITUAL CARE

SUPPORTING LIFE AFTER CRITICAL ILLNESS

CONCLUSION

SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

REFERENCES

CHAPTER 16: Transfer of the Critically ill Patient

AIMS AND CHAPTER OVERVIEW

DEFINITIONS AND INDICATIONS

BACKGROUND

PHYSIOLOGICAL EFFECTS OF TRANSFER

EVIDENCE AND CURRENT DEBATES

COMPONENTS OF THE TRANSFER PROCESS

CONCLUSION AND SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

REFERENCES AND FURTHER READING

CHAPTER 17: Rehabilitation and Recovery After Critical Illness

AIMS AND CHAPTER OVERVIEW

DEFINITION

AIMS AND INDICATIONS

BACKGROUND

POST INTENSIVE CARE SYNDROME

EFFECT OF CRITICAL ILLNESS ON PATIENTS’ FAMILIES

REHABILITATION AND CRITICAL CARE

ASSESSMENT OF REHABILITATION NEEDS

HOLISTIC REHABILITATION

IMPORTANCE OF MULTIDISCIPLINARY TEAM WORKING IN CRITICAL ILLNESS REHABILITATION

REHABILITATION FOR PATIENTS WITH PRE‐EXISTING MULTI‐MORBIDITY AND FRAILTY

REHABILITATION IN THE OLDER PERSON

OBESITY

FATIGUE RELATED TO CRITICAL ILLNESS

HUMANISING THE CRITICAL CARE UNIT

PERSON/PATIENT‐CENTRED REHABILITATION

FAMILIES’ INVOLVEMENT IN REHABILITATION

CARING FOR THE STAFF PROVIDING REHABILITATION

REHABILITATION POST CRITICAL CARE DISCHARGE

EVIDENCE BASE FOR REHABILITATION POST‐CRITICAL CARE INTERVENTIONS

PSYCHOLOGICAL INTERVENTIONS (SEE ALSO CHAPTER 15)

FOLLOW‐UP AND FOLLOW‐UP CLINICS

PRIORITIES FOR CRITICAL CARE RESEARCH

MANAGING THE PSYCHOLOGICAL IMPACTS OF CRITICAL ILLNESS POST DISCHARGE

COGNITIVE DEFICITS FOLLOWING CRITICAL ILLNESS

KNOWLEDGE IS POWER – THE IMPACT OF COGNITIVE IMPAIRMENT AFTER DISCHARGE HOME

COGNITIVE DEFICITS FOLLOWING A CRITICAL CARE STAY WITH COVID‐19

ECONOMIC/FINANCIAL IMPACT AND RETURN TO WORK

REMOTE/ONLINE REHABILITATION

WEBSITES

CONCLUSION AND SUMMARY OF KEY POINTS

PROCEDURE GUIDELINE: REHABILITATION

REFERENCES

CHAPTER 18: Withdrawal of Treatment and End‐of‐Life Care for the Critically ill Patient

AIMS AND CHAPTER OVERVIEW

DEFINITION

AIMS AND INDICATIONS

BACKGROUND

PRE‐EOLC CONSIDERATIONS

PROGNOSIS

END‐OF‐LIFE CARE IN CRITICAL CARE ENVIRONMENTS

‘DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION’ ORDERS

PROCESS FOR OBTAINING A ‘DO NOT ATTEMPT CARDIOPULMONARY RESUSCITATION’ ORDER

ASSESSMENT OF NEED FOR DISCUSSION OF WITHDRAWAL OF TREATMENT

CARE AROUND WITHDRAWAL: CARE IN THE LAST HOURS AND DAYS

CONSULTATION AND COMMUNICATION WITH PATIENT, NEXT OF KIN AND SIGNIFICANT OTHERS

COMMUNICATION AND BREAKING BAD NEWS: SUPPORTING THE FAMILY

CULTURAL ISSUES

PRACTICAL COMPONENTS OF WITHDRAWAL OF TREATMENT AND END‐OF‐LIFE CARE

BRAIN DEATH/DEATH BY NEUROLOGIC CRITERIA

AFTER‐DEATH CARE

COMPETENCIES

USEFUL WEBSITES

CONCLUSION AND SUMMARY OF KEY POINTS

PROCEDURE GUIDELINES

REFERENCES

Index

End User License Agreement

List of Tables

Chapter 1

Table 1.1 Levels of adult critical care (Intensive Care Society (ICS), 2021...

Table 1.2 Hierarchy of evidence levels

Chapter 3

Table 3.1 The roles of Nursing Associate and registered nurse (NMC, 2022)

Chapter 4

Table 4.1 The ABCDE assessment process

Table 4.2 Normal arterial blood gas values

Table 4.3 Needle gauges and maximum flow rates

Table 4.4 Treatment of hypoglycaemia (BNF, 2023)

Table 4.5 SBAR communication tool

Chapter 6

Table 6.1 Respiratory pathology

Table 6.2 Abnormal adventitious (added) breath sounds

Table 6.3 Problem solving: Pulse oximetry

Table 6.4 Problem solving: Sampling via arterial puncture

Table 6.5 Problem solving: Sampling via arterial cannula

Table 6.6 References ranges for arterial blood gases

Table 6.7 Problem solving: Oropharyngeal airways

Table 6.8 Problem solving: Laryngeal mask airways and tracheal tubes

Table 6.9 Problem solving: Capnography

Table 6.10 Problem solving: Tracheal cuff pressure monitoring

Table 6.11 Problem solving: CPAP and NIV

Table 6.12 Problem solving: Invasive ventilator therapy care

Table 6.13 Readiness to wean criteria

Table 6.14 Criteria to assess weaning failure during a spontaneous breathin...

Table 6.15 Problem solving: Extubation

Table 6.16 Signs of extubation failure

Table 6.17 Problem solving: IPPB (Bird)

Table 6.18 Problem solving: Cough assist (MI‐E)

Table 6.19 Problem solving: Suctioning

Table 6.20 Problem solving: Manual hyperinflation

Table 6.21 Criteria for diagnosing ARDS using the 2012 Berlin criteria

Table 6.22 Problem solving: Prone ventilation

Table 6.23 Types of chest drain

Table 6.24 Problem solving: Chest drain insertion

Table 6.25 Problem solving: Chest drain removal

Chapter 7

Table 7.1 Problem‐solving: continuous ECG monitoring

Table 7.2 Problem‐solving: arterial cannula

Table 7.3 Problem‐solving: arterial and central venous pressure monitoring s...

Table 7.4 Problem‐solving: central venous catheter insertion

Table 7.5 PAC specific measurement parameters

Table 7.6 Problem‐solving: Pulmonary artery catheter (Adam and Osborne, 200...

Table 7.7 Normal limits of haemodynamic parameters using TPTD calibration

Table 7.8 Problem‐solving: Cardiac output monitoring using Transpulmonary th...

Table 7.9 Problem‐solving: Cardiac output monitoring using lithium dilution...

Table 7.10 Normal limits of haemodynamic status parameters using ODM

Table 7.11 Problem‐solving: Oesophageal Doppler monitoring (ODM) (e.g. Cardi...

Table 7.12 Actions of inotropes and vasopressors

Table 7.13 Converting the infusion of inotropes and vasopressors from milli...

Table 7.14 Abnormal waveforms demonstrating timing errors (Debra L. Wiegand,...

Table 7.15 Nursing care rationale

Table 7.16 Problem‐solving: In‐hospital resuscitation

Table 7.17 Recognition and treatment of reversible causes

Table 7.18 Post‐cardiac arrest care interventions

Chapter 8

Table 8.1 Classification of GI pathophysiology

Table 8.2 Enteral feeding tube types

Table 8.3 Risks for refeeding syndrome

Chapter 9

Table 9.1 Criteria for defining AKI, AKD, CKD and NKD (Kellum et al., 2021)...

Table 9.2 Proposed new definitions of AKI

Table 9.3 Descriptions and characteristics of common biomarkers of AKI (fro...

Table 9.4 Summary of anticoagulants commonly used with KRT in the UK

Chapter 10

Table 10.1 ‘Train‐of‐Four’ (TOF) monitoring for use with neuromuscular bloc...

Table 10.2 Summary of commonly used drugs

Table 10.3 Interventions to improve sleep

Table 10.4 Factors that disrupt and promote sleep

Chapter 11

Table 11.1 List of the twelve cranial nerves with motor and sensory functio...

Table 11.2 Observations of pupil size and shape

Table 11.3 Descriptive assessment of limb powers

Table 11.4 MRC limb strength numerical grading

Table 11.5 Problem solving: ICP monitoring

Table 11.6 Potential causes of raised ICP

Table 11.7 RASS score

Table 11.8 Disorders associated with sodium and water disturbances

Chapter 12

Table 12.1 Braden scale assessment tool

Table 12.2 Summary of risk using the Braden Scale

Table 12.3 Braden (ALB) scale

Table 12.4 The COMHON index

Table 12.5 Summary of risk using the COMHON index

Table 12.6 The CALCULATE seven point pressure ulcer assessment tool (Richard...

Table 12.7 Differentiating pressure ulcers and incontinence‐associated derm...

Chapter 13

Table 13.1 Categories of waste and segregation at source

Chapter 14

Table 14.1 Early mobilisation: considerations for decision making

Table 14.2 Components in the TILE assessment

Table 14.3 Whole‐body positioning, use and location

Table 14.4 Medical Research Council Muscle Testing Scale (MRC, 1981)

Table 14.5 Benefits and precautions of mobility and activity interventions ...

Table 14.6 Transfer and standing equipment

Table 14.7 Seating options for the critically ill patient

Chapter 15

Table 15.1 Communicating with a delirious patient in intensive care (Highfi...

Chapter 16

Table 16.1 List of additional equipment

Chapter 17

Table 17.1 Examples from a short clinical assessment (CSA) that may indicat...

Table 17.2 Examples from a Comprehensive Clinical Assessment (CCA) that may...

Table 17.3 Examples of MDT activities

Table 17.4 Age‐related problems

Table 17.5 The aims of CT‐PTSD (Adapted from Murray et al, 2021)

Table 17.6 Seven lessons from 20 years of follow‐up of critical care surviv...

Table 17.7 Top 3 unanswered questions identified among critical care patien...

Table 17.8 Nine unranked priorities related to rehabilitation and rehabilit...

Chapter 18

Table 18.1 Signs of dying in critically ill patients

List of Illustrations

Chapter 1

FIGURE 1.1 Evidence‐based practice (Hoffman et al. 2016 / with permission of...

FIGURE 1.2 The 17‐year odyssey.

FIGURE 1.3 Four sources of evidence base for patient‐centred practice.

Chapter 3

FIGURE 3.1 Step approach for users (NHS England and NHS Improvement, 2021/He...

Chapter 4

FIGURE 4.1 The Chain of Survival.

FIGURE 4.2 Chain of Survival – The major focus on early recognition and call...

FIGURE 4.3 Conceptual model of the afferent and efferent limbs of the EWS.

FIGURE 4.4 National Early Warning Score 2 (NEWS2) (Royal College of Physicia...

FIGURE 4.5 Outline clinical response to NEWS2 triggers (Royal College of Phy...

Chapter 6

FIGURE 6.1 Lobes of the lung (from Tortora and Derrickson 2011, reproduced w...

FIGURE 6.2 Hb dissociation curve.

FIGURE 6.3 Parasagittal section of left side of head and neck (from Tortora ...

FIGURE 6.4 Nasopharyngeal airway (Dougherty and Lister 2015 / with permissio...

FIGURE 6.5 Oropharyngeal airway. (a) Correct sizing of an oropharyngeal airw...

FIGURE 6.6 Laryngeal mask airway (Dougherty and Lister 2015 / with permissio...

FIGURE 6.7 Endotracheal tube.

FIGURE 6.8 (a) Portex cuffed tracheostomy tube. (b) Kapitex Tracheotwist cuf...

FIGURE 6.9 Normal capnographic waveform.

FIGURE 6.10 Cuff manometer.

FIGURE 6.11 Oxygen delivery devices.

FIGURE 6.12 High‐flow oxygen circuit.

FIGURE 6.13 Full face and nasal masks.

FIGURE 6.14 CPAP helmet.

FIGURE 6.15 Ventilator waveform shapes.

FIGURE 6.16 Waveform display on a ventilator.

FIGURE 6.17 Pressure and flow waveforms in volume‐controlled ventilation.

FIGURE 6.18 Pressure and flow waveforms in pressure‐controlled ventilation (...

FIGURE 6.19 Gas trapping or air leak.

FIGURE 6.20 Pressure‐volume loop showing reducing compliance with a shift to...

FIGURE 6.21 (a) Pressure‐volume loop in volume‐controlled mode, (b) Pressure...

FIGURE 6.22 Pressure‐volume loop. (a) Pressure‐volume loop showing a typical...

FIGURE 6.23 Leak in the ventilator circuit (Yartsev, 2015).

FIGURE 6.24 (a) normal flow‐volume loop, (b) air trapping (Dhand, 2005).

FIGURE 6.25 Flow‐volume loop showing airway secretions (Dhand, 2005).

FIGURE 6.26 Passy Muir speaking valve.

FIGURE 6.27 Cough assist machine.

FIGURE 6.28 Closed circuit suction catheter (Dougherty and Lister 2015 / wit...

FIGURE 6.29 Heat and moisture exchange filter (HME).

FIGURE 6.30 Bacterial‐viral filter.

FIGURE 6.31 Mapleson C circuit and reservoir bag.

FIGURE 6.32 Prone ventilation (McGurk et al., 2020 / John Wiley & Sons).

FIGURE 6.33 Mesentery or omental dressing.

FIGURE 6.34 Heimlich flutter valve.

FIGURE 6.35 Underwater seal system.

FIGURE 6.36 Two‐bottle drainage system.

Chapter 7

FIGURE 7.1 Structure of the heart: anterior view of frontal section showing ...

FIGURE 7.2 The conduction system of the heart (from Tortora and Derrickson, ...

FIGURE 7.3 Cardiac cycle (from Tortora and Derrickson, 2017, reproduced with...

FIGURE 7.4 Rhythm strips showing normal sinus rhythm (a) generated rhythm (b...

FIGURE 7.5 ECG demonstrating atrial fibrillation.

FIGURE 7.6 Components of an ECG electrode (reproduced with permission from E...

FIGURE 7.7 Orientation of limb leads.

FIGURE 7.8 Orientation of 3‐lead ECG electrodes.

FIGURE 7.9 Orientation of 5‐lead ECG electrodes.

FIGURE 7.10 Frank–Starling curve.

FIGURE 7.11 Diagram of oscillations from non‐invasive blood pressure measure...

FIGURE 7.12 Transducer set ready for priming.

FIGURE 7.13 Anatomy of the radial and brachial arteries.

FIGURE 7.14 Anatomy of the femoral artery and vein.

FIGURE 7.15 Illustration of an arterial waveform. The shape can change consi...

FIGURE 7.16 Arterial pressure waveform (Saugel et al., 2020/Springer Nature/...

FIGURE 7.17 Anatomy of the internal jugular and subclavian veins.

FIGURE 7.18 Illustration of a CVP waveform. The shape can differ considerabl...

FIGURE 7.19 Pulmonary artery catheter (Lisa Dougherty & Sara Lister. 2011 / ...

FIGURE 7.20 Waveforms on floating a pulmonary artery catheter.

FIGURE 7.21 Normal arterial waveform followed by an augmented waveform.

FIGURE 7.22 The coronary circulation (from Tortora and Derrickson, 2017, rep...

FIGURE 7.23 The Chain of Survival (from Nolan et al., 2006, reproduced with ...

FIGURE 7.24 In‐hospital resuscitation algorithm. ABCDE – airway, breathing, ...

FIGURE 7.25 Head tilt/chin lift manoeuvre (from Lister et al., 2020, reprodu...

FIGURE 7.26 Adult advanced life support algorithm (reproduced with the kind ...

FIGURE 7.27 Two‐person technique for bag‐mask ventilation (Resuscitation Cou...

Chapter 8

FIGURE 8.1 Right lateral view of the head and neck and anterior view of the ...

FIGURE 8.2 Layers of the gastrointestinal tract

FIGURE 8.3 Phases of critical illness and nutritional consequences.

Chapter 9

FIGURE 9.1 Anatomy of the kidney.

FIGURE 9.2 Anatomy of the nephron.

FIGURE 9.3 Structure of the renal corpuscle, looking into the Bowman’s capsu...

FIGURE 9.4 Acute kidney injury in the critically ill: an updated review on p...

FIGURE 9.5 Different phases of AKI development and progression and associate...

FIGURE 9.6 Prognosis of CKD by GFR and albuminuria category. https://els‐jbs...

FIGURE 9.7 The three steps of renal management. Green, yellow and red boxes ...

FIGURE 9.8 Acute kidney injury bundles of care (derived from the KDIGO AKI m...

FIGURE 9.9 Fluid management in acute kidney injury (https://www.nature.com/a...

FIGURE 9.10 Demand and capacity – a conceptual model. Reprinted with permiss...

FIGURE 9.11 Diagram of peritoneal dialysis internal set‐up and external manu...

FIGURE 9.12 Results of randomised controlled trials on timing of KRT in pati...

FIGURE 9.13 Proposed algorithm for starting renal‐replacement therapy for cr...

FIGURE 9.14 Steps necessary to provide kidney replacement therapy (KRT).

FIGURE 9.15 Summary of underlying mechanisms that contribute to HIRRT. Mecha...

Chapter 10

FIGURE 10.1 The pain pathway.

FIGURE 10.2 Critical Care Pain Observation Tool (CPOT)...

FIGURE 10.3 WHO analgesic ladder.

FIGURE 10.4 Richmond Agitation and Sedation Scale (RASS)

FIGURE 10.5 The neuromuscular junction.

FIGURE 10.6 Train‐of‐Four Stimulator attached to electrodes placed over the ...

FIGURE 10.7 Causes of sleep disruption in ICU

Chapter 11

FIGURE 11.1 The brain (Gerard J. Tortora & Bryan H. Derrickson. 2020 / Repro...

FIGURE 11.2 The meninges (from Tortora and Derrickson, 2020, reproduced with...

FIGURE 11.3 Ventricular pathways and cerebrospinal fluid (from Tortora and D...

FIGURE 11.4 Cerebral circulation (from Patestas and Gartner, 2006, reproduce...

FIGURE 11.5 Changes in cerebral blood flow in response to changes in cerebra...

FIGURE 11.6 Pressure volume curve (from Woodward and Mestecky, 2011, reprodu...

FIGURE 11.7 Glasgow Coma Scale, from Teasdale et al, 2014b / Elsevier.

FIGURE 11.8 (a) Fingertip pressure (b) Trapezius pinch.

FIGURE 11.9 Normal flexion/abnormal flexion/extension.

FIGURE 11.10 Normal and abnormal ICP waveforms in comparison to the arterial...

FIGURE 11.11 ICP devices situated in the lateral ventricle, intraparenchymal...

FIGURE 11.12 Fluid‐filled system draining CSF and monitoring ICP pressure (f...

Chapter 12

FIGURE 12.1 Layers of skin.

FIGURE 12.2 Waterlow scoring table.

FIGURE 12.3 Stage I: Non‐blanchable erythema.

FIGURE 12.4 Stage II: Partial thickness skin loss.

FIGURE 12.5 Stage III: Full thickness skin loss.

FIGURE 12.6 Stage IV: Full thickness tissue loss.

FIGURE 12.7 Unstageable – depth unknown.

FIGURE 12.8 Suspected deep tissue injury – depth unknown.

FIGURE 12.9 Potential pressure ulcer risk sites that staff need to be aware ...

FIGURE 12.10 (Benjamin J Hearne et al. 2018 / Reproduced from Sage Publicati...

Chapter 13

FIGURE 13.1 Five moments for hand hygiene (WHO 2023a / World Health Organiza...

Chapter 14

FIGURE 14.1 Resting hand splint.

FIGURE 14.2 In‐bed passive cycling.

FIGURE 14.3 Active exercises using resistance bands while sitting.

FIGURE 14.4 Respiratory muscle training devices.

FIGURE 14.5 Sitting over the edge of the bed.

FIGURE 14.6 Ambulation while being mechanically ventilated.

Chapter 15

FIGURE 15.1 PICS ( Needham et al, 2012 / Society of Critical Care Medicine a...

FIGURE 15.2 Personal and professional elements of spiritual care (Price 2019...

Chapter 16

FIGURE 16.1 Representation of the effects of gravitational force on a patien...

FIGURE 16.2 Example of a critical care transfer trolley, with secure housing...

Chapter 17

FIGURE 17.1 PICS and PICS‐F (Needham et al, 2012 / Society of Critical Care ...

FIGURE 17.2 PICS infographic (copyright ICS, ICUsteps, Brunel University and...

FIGURE 17.3 Rockwood Frailty Scale.

FIGURE 17.4 Health Education core skills education and training framework.

Guide

Cover Page

Table of Contents

Title Page

Copyright Page

About the Editors

List of Contributors

Foreword

Endorsement

Begin Reading

Index

WILEY END USER LICENSE AGREEMENT

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Critical Care Manual of Clinical Nursing Procedures

SECOND EDITION

Edited by

Suzanne Bench, Nicki Credland, and Chris Hill

This edition first published 2025© 2025 John Wiley & Sons Ltd

Edition History[John Wiley & Sons, Ltd., 1e, 2013]

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Library of Congress Cataloging‐in‐Publication Data Applied for:Paperback ISBN: 9781119841234

Cover Design: WileyCover Image: © Kiryl Lis/Adobe Stock Photos

About the Editors

Dr Suzanne Bench PhD, RGN

Dr Suzanne Bench is the director of nursing for ACORN (A centre of research for nurses and midwives) at Guy’s and St Thomas’ NHS Trust (GSTT). She is seconded one day a week to London South Bank University (LSBU), where she is a Professor of Critical Care Nursing, co‐leading the NHSE‐London post‐doctoral bridging scheme for healthcare professionals outside of medicine. Suzanne also holds an honorary senior lecturer role at King’s College London.

Suzanne is an experienced critical care nurse and researcher, working in intensive care since 1990 and as a clinical academic nurse since 2001. She currently supports the critical care recovery team @ GSTT half a day a week.

Suzanne’s research interests centre on two areas: supporting the recovery of patients and families following critical illness and developing the future critical care nursing workforce. She has extensive experience of publication and conference presentation. She is an associate editor for the Intensive & Critical Care Nursing journal and sits on the executive board of the British Association of Critical Care Nurses (BACCN).

Following completion of the NIHR senior nurse and midwife research leader programme (NIHR 70@70), Suzanne is a member of the CNO‐England Research transformation group and the UK Clinical Academic Roles Implementation Network (CARIN) focusing on increasing nurse and midwife research engagement locally and nationally.

For more, please see https://orcid.org/0000‐0002‐4499‐2959

Nicki Credland MMEdSci, PFHEA, NTF, RN

Nicki Credland is a reader in Critical Care at the University of Hull, England, UK.

She is a fellow of the British Association of Critical Care (BACCN) after a six‐year term of office as Chair of the organisation. She is now chair of the UK Critical Care Nursing Alliance (UKCCNA). Nicki is a nurse advisor to the Department of Health Adult Critical Care Clinical Reference Group and is a specialist advisor in critical care nursing to National Health Service England.

Nicki has significant experience and impact in education holding a principal fellowship of the Higher Education Academy and was awarded a National Teaching Fellowship in 2022. She was appointed as director for Education at the NHS Nightingale Hospital Yorkshire and the Humber during the Covid pandemic. Her national leadership over the pandemic was recognised by the Intensive Care Society with an “Outstanding Leadership” award.

Nicki is an experienced critical care nurse working both in intensive care and critical care outreach. She has extensive experience of publication and conference presentation, speaks widely about the critical care nursing workforce and has contributed to a number of position statements and key documents around these issues. She is an associate editor for the Nursing in Critical Care journal and sits on the editorial board for RCNi journals.

Chris Hill MSc, FHEA, RN

Chris Hill is a senior clinical practice educator at the Royal Free Hospital in Hampstead, London, and a senior lecturer at Brunel University London. With nearly three decades of experience in Critical Care across various units, Chris has dedicated much of his career to education, alongside roles as a matron and network nurse lead.

At the Royal Free Hospital, Chris leads the Intensive Care Nursing Qualification in Specialism course, a program adopted by hospitals in North Central London and across the city. His enthusiasm for networking is evident in his former role as nurse lead for the North Central and North East London Critical Care Network. He chaired the National Critical Care Nurse Education Review Forum, where he led development of the 2024 edition of the National Standards for Critical Care Nurse Education.

He is particularly interested in integrating technology into teaching and assessment where this can enhance student learning or experience. He helped develop the CapitalNurse online Critical Care IV therapy teaching and assessment tools, and also interactive 360VR virtual reality videos. During the Covid‐19 pandemic, Chris developed and led an online London‐wide ICU nursing course.

At Brunel University, Chris is the theme lead for the Critical Care MSc program. He is also committed to sharing his expertise internationally, having collaborated with the teaching staff at Lusaka University College of Nursing in Zambia during several visits.

List of Contributors

Annesha ArchyangelioRegional Director of NursingNHS England, North East and Yorkshire

Sophie BenchSpecialist Respiratory Physiotherapist, Intensive CareSt Bartholomew’s Hospital, London

Suzanne BenchDirector of Nursing (Research)Guy’s and St Thomas’ NHS Trust andProfessor of Critical Care NursingLondon South Bank University, London, UK

Claire BurnettCritical Care Outreach Nurse and Lead Nurse for SepsisThe Royal Berkshire NHS Foundation Trust, Reading, UK

Julie ByeClinical Nurse EducatorAdult Critical Care Unit, Barts Health NHS TrustHonorary LecturerCity, University of London

Chris CarterAssociate ProfessorBirmingham City University

Usha ChandranSenior Staff NurseGeneral Intensive Care Unit, St George’s Hospital andSenior Lecturer (Adult Nursing)London South Bank University

Elaine CoghillDeputy Chief NurseSheffield Teaching Hospitals NHS Foundation TrustSheffield, UK

Julie CombesDeputy Director, Workforce and EducationNHS Elect, UK

Nicki CredlandReader in Critical CareUniversity of Hull, Hull, UK

Penelope FirshmanPatient Experience Lead and Occupational TherapistSurrey and Sussex Healthcare NHS Trust, Redhill, UK

Karin GerberClinical Nurse SpecialistRoyal Berkshire NHS Foundation Trust, Reading, UK

Simon HamiltonClinical Specialist Physiotherapist, Intensive Care and ECMOSt Bartholomew’s Hospital, London

Georgia HardySenior ICU DietitianNutrition Department, Alfred Health, Melbourne, Australia

Julie HighfieldConsultant Clinical PsychologistCritical Care, Cardiff and Vale NHS University Health Board, UK

Chris HillSenior Clinical Practice EducatorRoyal Free London NHS FTSenior LecturerBrunel University London, UK

Claire HorsfieldManager and Lead NurseWest Yorkshire Critical Care & Major Trauma OperationalDelivery Networks and South Yorkshire & Bassetlaw CriticalCare ODN

Sally HumphreysPhD Student/Research NurseUniversity of Hertfordshire/West Suffolk NHS Trust

Christina JonesResearch ManagerICUsteps

Peter JulianICU patient representative (COVID‐19)

Mina Long‐JohnLead Nurse (Education)Critical Care, Imperial College Healthcare NHS Trust

Claire LynchSenior Lecturer Adult NursingBirmingham City University

Natalie McEvoyLecturer in Critical Care NursingRoyal College of Surgeons in Ireland, University of Medicineand Health Sciences, Ireland

Jackie McRaeAssociate ProfessorCentre for Allied Health, St George’s University of London,England

David McWilliamsProfessor of Critical Care and RehabilitationUniversity Hospitals Coventry & Warwickshire NHS TrustCoventry, UK

Ian NesbittConsultant in Anaesthesia and Critical CareFreeman Hospital, Newcastle upon Tyne, UK

Athanasia NiarrouLecturer in Advanced Clinical PracticeSchool of Health and Psychological Sciences, City, Universityof London

Lilian OyatabangRegistered Nurse and LecturerSchool of Nursing and Midwifery, London South BankUniversity, London, England

Matthew ParkinSite Nurse PractitionerGuy’s and St Thomas’ NHS Foundation Trust

Natalie A PattisonProfessor of Clinical NursingUniversity of Hertfordshire/East and North Herts NHS Trust

Julie PlattenNetwork ManagerNorth of England Critical Care Network

Catherine PlowrightHonorary FellowBritish Association of Critical Care Nurses

Ann PricePrincipal LecturerSchool of Nursing, Midwifery & Social WorkCanterbury Christ Church University, UK

Alwin PuthenpurakalSenior Lecturer in Adult NursingSchool of Health Sciences, University of Greenwich, UK

Pam RamsaySenior LecturerSchool of Health Sciences, University of Dundee, UK

Louise StaytReader in Clinical ResearchOxford Brookes University andAcademic AdvisorBACCN

Carolyne StewartLecturer in Adult NursingFlorence Nightingale Faculty of Nursing, Midwifery andPalliative Care, King’s College London, UK

Kate TantamSpecialist Sister in ICU RehabilitationDerriford Hospital, Plymouth

Amanda ThomasAdvanced Clinical Specialist Physiotherapist, Critical CareOutreach TeamThe Royal London Hospital, Barts Health NHS TrustLondon, UK

Linda ToveyCritical Care Renal SisterGuy’s & St Thomas’ Hospitals

Ruth TroutSenior Lecturer in Acute CareBuckinghamshire New University

Musie TsehayeClinical Lead Physiotherapist, Adult Critical CareThe Royal London Hospital, Barts Health NHS TrustLondon, UK

Gezz Van ZwanenbergChief Operating Officer, HCRG Health and Social Care andCritical Care Nurse Lead, North West London CriticalCare Network andPrincess Mary’s Royal Air Force Nursing Service (Rtd)

Simon M WhiteleyConsultant ICMLeeds Teaching Hospitals NHS Trust, Leeds, UK

Karen WilsonLead NurseCheshire and Mersey Critical Care Network

Foreword

It is a pleasure to write the foreword to the second edition of Critical Care Manual of Clinical Nursing Procedures. When Professor Suzanne Bench and colleagues first approached me about this textbook and asked if I would write the foreword I said yes with great delight. This was for many reasons which you will have to indulge me a little. First, Professor Bench, Ms Credland and Mr Hill are all leaders in critical care nursing and the opportunity to read the work firsthand was an honour and I felt like a child at Christmas. To lead in critical care takes advance education, years of practice, knowledge and experience. Congratulations to all three editors you have done this and to your contributing authors who have all demonstrated the criteria expected of a critical care nurse. If you are reading this book, chances are either you are a critical care nurse or on your way to becoming one. A critical care nurse is someone who has undertaken additional education and training post qualification as a registered nurse. The post registration or advance training and education equips them to comprehend and care for patients that require care from life‐threatening illness, injuries or major surgery.

WHAT IS CRITICAL CARE NURSING?

My first exposure to critical care nursing was during my pre‐registration nursing education, I had two placements: one in a coronary care unit (CCU) and the other in an intensive care unit (ICU) and I knew there and then I wanted to be a critical care nurse and gained all my initial critical care post registration experience at the world‐renowned Guys and St Thomas’ Hospital. I specialised as a cardio‐thoracic ICU nurse caring for patients undergoing heart bypass, valve replacement and heart and lung transplant surgeries. Enough about me!

The Covid‐19 pandemic made the world aware of critical care nurses and what we do. The world was given insight into the settings a critical care nurse may work in for example, intensive care, high dependency, accident and emergency, post‐anaesthesia operative care units commonly called recovery rooms and coronary care wards. The world learnt that critical care nursing involves assessing and continuous assessment of a patient, and planning the care delivery based on that assessment. This care is operationalised by working with the multidisciplinary team, administering medication, assessing respiratory function and need for invasive or non‐invasive mechanical ventilation, maintenance of catheters, e.g. central venous, arterial, peripheral. Critical care also involves the management of multiple drugs administered by intravenous infusions (sometimes based on calculations involving the patient’s weight) and equipment that helps maintain life, e.g. renal replacement therapy, cardiac monitoring and external pacing devices. Important to ensure effective critical care nursing is the communication with the patient, their family and the wider care team.

IMPORTANCE OF THIS MANUAL

First, in a changing healthcare landscape where nursing practice is advancing, it is great to have a manual written by nurses for nurses. The area of critical care nursing is one that demands not only a high level of technical skill, expertise and knowledge but also a deep sense of compassion and dedication. As I write this foreword the Paris Olympic Games 2024 is in progress and critical care nurses are like Olympians, they rely on team effort, they spend hours in the field fine‐tuning their practice and utilise reflection to improve practice. The Critical Care Manual of Clinical Nursing Procedures is an essential resource for all nurses (from novice to expert) who are committed to providing the highest standard of care to critically ill patients and their families.

Today’s healthcare environment is often challenged by technological advancement, AI (artificial intelligence) decision and algorithm and emerging diseases, e.g. Covid‐19. Therefore, the need for evidence‐based practice is paramount. This manual serves as a comprehensive guide, ensuring that critical care nurses are equipped with the latest information, best practices, and fundamentals of critical care nursing to practice safely and confidently. It provides practical evidence‐based guidelines on core critical care competencies that practitioners can use as a guide to undertake self‐assessment, which can help with revalidation activities required by the Nursing and Midwifery Council in the United Kingdom. The content of the manual is aligned with the National Critical Care Competency Framework and endorsed by the British Association of Critical Care Nurses. The British Association of Critical Care Nurses is the only nursing association in the United Kingdom to have an explicit statement on social justice in nursing and its importance to critical care nursing.

The structure of this manual is thoughtfully organised to help you navigate the multifaceted landscape that critical care nursing presents. It covers a broad range of critical care needs and practices.

Chapter 1, “Scope and Delivery of Evidence‐Based Care,” lays the foundation by discussing the classification of critical illness needs and providing an overview of key national policies. It introduces competency frameworks that support the delivery of high‐quality, evidence‐based critical care. This chapter meticulously presents the necessary competencies required for effective evidence‐based practice.

Understanding the critical care workforce is fundamental, as discussed in Chapter 2. The dynamics of nurse staffing, patient safety and the roles of various healthcare providers are crucial components of a well‐functioning critical care unit. This chapter emphasises the importance of highly educated registered nurses and the integration of registered nursing associates into the critical care team.

Chapter 3, “Competency‐Based Practice,” delves into the essential competencies needed for critical care nursing. It discusses staffing levels, patient safety and the critical care staff's broader roles. The chapter also introduces the CC3N Steps competence framework, which underpins each chapter of this manual, providing a structured approach to competence development.

Subsequent chapters (Chapters 4–18) cover a wide range of critical care aspects, from the initial recognition and management of critically ill patients to the assessment and support of various bodily systems. Each chapter offers detailed guidance on procedures and interventions, ensuring that nurses can provide comprehensive care. Topics such as infection prevention and control, physical mobility, psychological support, sleep and rest, management and control of pain, spiritual care, critical care related to the five main organs supported and the transfer and rehabilitation of critically ill patients are thoroughly explored.

Particularly important are the topics covered in the chapter on end‐of‐life care and the withdrawal of treatment (Chapter 18). These sections provide invaluable discussions and guidance into managing the delicate balance between extending life and ensuring the quality of that life in its final stages.

This manual is not just a collection of procedures; it reflects the collective wisdom and experience of its contributors. It will help critical care nurses to decolonise the care they provide, develop cultural competencies, address the health disparities that the pandemic made people more aware of and help to apply social justice principles to critical care nursing. This manual serves as both a reference and a guide, supporting nurses in their ongoing professional development and commitment to excellence in critical care.

I encourage every reader to delve deeply with curiosity and an open mind into this manual, to learn from it, allow it to challenge their thinking, and to let it inform their practice. The knowledge contained within these pages is designed to empower you, the critical care nurse, to make informed, compassionate, and safe and effective decisions in the care of your patients.

Sincerely yours

Professor Calvin Moorley, RN PhD

Chair of Diversity and Social Justice

Endorsement

One of the fundamental foundations of being a critical care nurse is the knowledge and skill of being able to look after the whole patient at their time of greatest need and most risk. This book symbolises the ever‐evolving body of evidence that informs our practice as critical care nurses, from its first edition to this edition it has been a source of critically appraised knowledge that has and is informing critical care nurses across the UK and beyond. The British Association of Critical Care Nurses (BACCN) has been involved from its inception, and this edition is no different with many of our members contributing to the different chapters. In an uncertain world, it is important to hold on to good scientific principles of using evidence to inform practice, it is our duty as critical care nurses to reflect and appraise our practice constantly moving forward with advances in knowledge and understanding through sources of high quality, well written and balanced literature. This book encapsulates that with the latest evidence‐based updates by well respected and experienced authors from a multitude of professional backgrounds reflecting the diverse practice of critical care nursing. BACCN’s mission as a charity is that of education and advocacy, this book symbolises that mission and as the chair and trustee of that charity I fully endorse the content of this edition as an evidence‐based source of knowledge that will continue to inform work of critical care nurses in the United Kingdom and beyond.

Ian Naldrett RN(A) BSc, MSc

– Chair of the British Association of Critical Care Nurses

CHAPTER 1Scope and Delivery of Evidence‐Based Care

Suzanne Bench1, Nicki Credland2, and Chris Hill3

1 Director of Nursing (Research) Guy’s and St Thomas’ NHS Trust and Professor of Critical Care Nursing London South Bank University, London, UK

2 Reader in Critical Care, University of Hull, Hull, UK

3 Senior Clinical Practice Educator, Royal Free London NHS FT and Senior Lecturer, Brunel University London, UK

AIMS AND CHAPTER OVERVIEW

About 200,000 people per year in the UK require critical care for many different reasons, ranging from acute medical emergencies, to major trauma incidents such as serious road accidents (Batchelor, 2021). People who develop a critical illness and their families deserve the best treatment and care that can be provided, to optimise their health outcomes, experiences and quality of life. Excellence, however, requires appropriate interventions with a strong evidence base and practitioners1 who are competent to deliver treatment and care. The aim of Critical Care Manual of Clinical Nursing Procedures, 2nd edition is to detail the latest research and rationale for evidence‐based procedures and competencies related to the provision of adult critical care. As such, the manual is ideally placed to be used as a reference and resource for advancing critical care practice and education for nurses and the wider multi‐professional team. This chapter describes how critical illness needs are classified, provides an overview of key national policies and discusses the role of the manual in the introduction of evidence‐based practice. Whilst mainly focused on the context of critical care nursing within the United Kingdom (UK), the content is relevant to critical care practitioners worldwide.

BACKGROUND AND CLASSIFICATION OF CRITICAL ILLNESS AND CRITICAL CARE IN THE UK

Critical care is defined as a ‘multi‐professional, multidisciplinary service which must deliver an integrated care pathway focused on patient need whilst addressing quality, governance and supporting optimal outcomes for patients’ (NHSE, 2022).

‘Critical care’ is an umbrella term encompassing both intensive and high dependency care for adults. Critical care provision has developed considerably over many years. A defining moment was publication of the Department of Health policy document entitled ‘Comprehensive Critical Care’ (Department of Health, 2000). This strategy document led to a restructure of the organisation of critical care services by advocating that provision of care should extend beyond the walls of an intensive care unit (ICU). It set out the vision for how critical care should be delivered, replacing the division of intensive care and high dependency beds with a classification system focused on levels of care. Whilst the original classification has since been updated (Table 1.1), the principle remains.

As in the original publication by the Department of Health (2000) and the 2009 Levels of Care document published by the Intensive Care Society (ICS), the 2021 Levels of Adult Critical Care (ICS, 2021) describes the care a patient requires, based on need. It merges the original level 0 and level 1 categories into one for people requiring ward level care, enabling ‘level 1’ to represent the need for Enhanced Care, and levels 2 and 3 the need for critical care. Levels 2 and 3 have also been amended to reflect contemporary needs of critically unwell people.

Table 1.1 Levels of adult critical care (Intensive Care Society (ICS), 2021 / with permission from Intensive Care Society)

Classification

Definition

Ward Care

Patients whose needs can be met through normal ward care in an acute hospital.

Patients who have recently been relocated from a higher level of care, but whose needs can be met on an acute ward with additional advice and support from the critical care outreach team.

Patients who can be managed on a ward but remain at risk of clinical deterioration.

Level 1 Enhanced Care

Patients requiring more detailed observations or interventions, including basic support for a single organ system and those ‘stepping down’ from higher levels of care.

Patients requiring interventions to prevent further deterioration or rehabilitation needs which cannot be met on a normal ward.

Patients who require on going interventions (other than routine follow up) from critical care outreach teams to intervene in deterioration or to support escalation of care.

Patients needing a greater degree of observation and monitoring that cannot be safely provided on a ward, judged on the basis of clinical circumstances and ward resources.

Patients who would benefit from Enhanced Perioperative Care.

Level 2 Critical Care

Patients requiring increased levels of observations or interventions (beyond level 1), including basic support for two or more organ systems and those ‘stepping down’ from higher levels of care.

Patients requiring interventions to prevent further deterioration or rehabilitation needs, beyond that of level 1.

Patients needing two or more basic organ system monitoring and support.

Patients needing one organ system monitored and supported at an advanced level (other than advanced respiratory support).

Patients needing long‐term advanced respiratory support.

Patients who require Level 1 care for organ support but who require enhanced nursing for other reasons, in particular maintaining their safety if severely agitated.

Patients needing extended postoperative care, outside that which can be provided in enhanced care units: extended postoperative observation is required either because of the nature of the procedure and/or the patient’s condition and co‐morbidities.

Patients with major uncorrected physiological abnormalities, whose care needs cannot be met elsewhere.

Patients requiring nursing and therapies input more frequently than available in level 1 areas.

Level 3 Critical Care

Patients needing advanced respiratory monitoring and support alone.

Patients requiring monitoring and support for two or more organ systems at an advanced level.

Patients with chronic impairment of one or more organ systems sufficient to restrict daily activities (co‐morbidity) and who require support for an acute reversible failure of another organ system.

Patients who experience delirium and agitation in addition to requiring level 2 care.

Complex patients requiring support for multiple organ failures, this may not necessarily include advanced respiratory support

The organisation of care for different categories of need varies according to patient requirements and how this is accommodated by the local service. Adults with level 3 needs are generally cared for in a clinical area that is designated primarily for this category of patient and is often referred to as an intensive care unit (ICU). This is because this group need high levels of monitoring, intervention and organ support, which requires specialist expertise and equipment. Sometimes the level 3 care facility is also a ‘specialty only’ unit (such as patients with neurological problems or burns).

Patients defined as requiring level 2 or level 1 support are cared for in a wider variety of settings, with an increase in the number of enhanced care beds currently being developed. Settings include designated units (which may or may not include specialist‐only beds); specific area/beds within a level 3 facility (which may or may not include specialist‐only beds); and specific area/beds within a ward level care facility (which may or may not include specialist‐only beds). Patients cared for in a ward‐based facility are often there on a temporary basis with the support of the multidisciplinary critical care outreach team.

While the levels of critical care are clearly defined, allowing for a joint understanding of the needs of patients and the required level of care, a variety of designations and terms have been used to describe critical care facilities; these include intensive therapy (or care) unit (ITU or ICU), critical care unit (CCU), high dependency unit (HDU), special care unit (SCU) and post‐anaesthetic care unit (PACU). It is important, therefore, that the patient’s needs and the care facility are clearly and accurately identified and that all involved in service planning and provision and delivery of care have a shared understanding to effectively and efficiently meet the patient’s requirements. For the purposes of this manual the term ‘critical care’ refers to patients requiring care at levels 2–3, whereas ‘enhanced care’ refers to patients requiring level 1 care.

As well as the varying levels of critical care required and the locations where this care can be delivered, the characteristics of the patient population are important in determining the level of care required.

The varying patient characteristics and the complexity of caring for the critically ill requires teams of multidisciplinary specialist critical care practitioners to deliver the care, including: doctors, nurses, advanced critical care practitioners, physiotherapists, dieticians and psychologists, alongside registered and unregistered support staff engaged in patient care. Although at times specific individuals within the team are involved in particular aspects of care, the overall delivery of critical care is highly reliant on teamwork.

OVERSIGHT AND GUIDANCE FOR ADULT CRITICAL CARE PROVISION

Each of the four countries in the UK has its own national health service, which governs the provision of critical care service delivery. For example, the NHS in England (NHSE) Adult Critical Care Planning Programme supports critical care to restore and strengthen services, providing tools and guidance for commissioners, networks and providers to plan and deliver services across their footprints.

In England, the Adult Critical Care Clinical Reference Group (CRG) is responsible for developing service specifications, which clearly define the standards of care expected from organisations funded by NHS England to provide specialised care. The most recent service specification for adult critical care was published in 2022: www.england.nhs.uk/publication/adult‐critical‐care‐services/. Similar structures exist in the other thee UK nations.

ADULT CRITICAL CARE NETWORKS

Adult critical care in the UK is organised into geographical networks, called adult critical care networks. These networks support hospitals providing adult critical care services through sharing knowledge, expertise and practical support across different units. The role of the networks is to support the monitoring and consistency of service delivery as outlined in the service specification (NHSE, 2023b