Critical Care Unit / Intensive Care Unit

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Critical Care Unit /

Intensive Care Unit


Critical / Intensive Care Unit
People with life-threatening injuries and
illnesses need critical care.

Critical care involves close, constant


attention by a team of specially-trained
health professionals. It usually takes place
in an intensive care unit (ICU).

Problems that might need critical care


treatment include complications from
surgery, accidents, infections and severe
breathing problems.
Critical / Intensive Care Unit (contd...)
Intensive care medicine or critical care medicine
is a branch of medicine concerned with the
provision of life support or organ support
systems in patients who are critically ill and who
usually require intensive monitoring.

An intensive care unit, or ICU, is a specialized


section of a hospital that provides comprehensive
and continuous care for persons who are
critically ill and who can benefit from treatment.

An intensive care unit is a specially staffed and


equipped hospital ward dedicated to the
management of patient with life threatening
illness, injuries or complications.
Critical / Intensive Care Unit (contd...)
Critical care is a term used to describe
the care of the patients who are extremely
ill and whose clinical condition is
unstable or potentially unstable.

Critical care nursing refers to those


comprehensive, specialized and
individualized care services which are
rendered to patients with life threatening
conditions and their families.
Critical / Intensive Care Unit (contd...)
Critical care (also known as Intensive Care)
is the multiprofessional healthcare specialty
that cares for patients with acute, life-
threatening illness or injury.

Critical Care refers to patients requiring


Intensive Care or High Dependency Care.

Progressive care units also called high


dependency units or step down units have
been established as intermediate units
between ICU and general care units.
Purpose
Healthcare professionals who work in
the ICU or rotate through it during their
training provide around-the-clock
intensive monitoring and treatment of
patients seven days a week.

Intensive care has been shown to


benefit patients who are severely ill and
medically unstable—that is, they have a
potentially life-threatening disease or
disorder.
Criteria for admission to an ICU
Critically ill patients in a medically unstable state
who require an intensive level of care (monitoring
and treatment).

Patients requiring intensive monitoring who may


also require emergency interventions.

Patients who are medically unstable or critically ill


and who do not have much chance for recovery
due to the severity of their illness or traumatic
injury.

Patients who are generally not eligible for ICU


admission because they are not expected to
survive. Patients in this fourth category require the
approval of the director of the ICU program before
admission.
What kinds of illness and injury
usually require critical care?
Sickest patients (multiple diagnoses, multi-organ failure,
immunocompromised, septic and trauma)

Move less

Malnourished

More obtunded (Glasgow coma scale)

Diabetics and Heart failure

Typical examples of critical illness include heart attack,


poisoning, pneumonia, surgical complications, premature
birth, and stroke.

Critical care also includes trauma care - care of the


severely injured - whether due to an automobile accident,
gunshot or stabbing wounds, a fall, burns, or an industrial
accident.
Contd…..
In general there are following categories
of diseases and disorders that are
regarded as medical justification for
admission to an ICU.
Disorders of the cardiac, nervous,
pulmonary, and endocrine (hormonal)
systems, together with postsurgical
crises and medication monitoring for
drug ingestion or overdose.
Contd…..
Cardiac problems can include heart attacks
(myocardial infarction), shock, cardiac arrhythmias
(abnormal heart rhythm), heart failure (congestive
heart failure or CHF), high blood pressure, and
unstable angina (chest pain).

Lung disorders can include acute respiratory failure,


pulmonary emboli (blood clots in the lungs),
haemoptysis (coughing up blood), and respiratory
failure.

Neurological disorders may include acute stroke


(blood clot in the brain), coma, bleeding in the brain
(intracranial haemorrhage), such infections as
meningitis, and traumatic brain injury (TBI).

Medication monitoring is essential, including careful


attention to the possibility of seizures and other drug
side effects.
Indications for ICU Care
Need for one or both of the following:

Mechanical ventilation to assist in


breathing and respiration

Hemodynamic support to ensure


adequate circulation throughout the
body
CLASSIFICATION OF INTENSIVE CARE UNIT
ICUs can be classified accordingly:

Level I: This can be referred as high dependency and


where close monitoring, resuscitation, and short term
ventilation <24hrs has to be performed.

Level II: Can be located in general hospital, undertake


more prolonged ventilation. Must have resident doctors,
nurses, access to pathology, radiology, etc.

Level III: Located in a major tertiary hospital, which is a


referral hospital. It should provide all aspects of intensive
care required. All complex procedures should be
undertaken. Specialist intensivist, critical care fellows,
nurses, therapists, support of complex investigations and
specialists of from other disciplines to be available at all
times.
CLASSIFICATION OF INTENSIVE
CARE UNIT (contd..)
There are two types of ICUs, an open
and closed.

Open: Access by multiple doctors who


can admit, treat and discharge.

Closed: Admission, discharge and


referral policies are under the control of
intensivist.
CLASSIFICATION OF INTENSIVE CARE UNIT (contd..)
Specialized types of ICUs include:

Neonatal intensive-care unit(NICU)


Special Care Nursery (SCN)
Paediatric intensive-care unit(PICU)
Psychiatric intensive-care unit(PICU)
Coronary care unit(CCU) for heart disease
Cardiac Surgery intensive-care unit (CSICU)
Cardiovascular intensive-care unit(CVICU)
Medical intensive-care unit (MICU)
Medical Surgical intensive-care unit (MSICU)
Surgical intensive-care unit (SICU)
CLASSIFICATION OF INTENSIVE CARE UNIT (contd..)

Overnight intensive recovery (OIR)


Neuroscience/ Neuro-trauma intensive-care unit
(NICU)
Neuro-intensive-care unit (NICU)
Burn intensive-care unit (BICU)
Trauma Intensive care Unit (TICU)
Shock Trauma intensive-care unit (STICU)
Trauma-Neuro Critical Care intensive-care unit
(TNCC)
Respiratory intensive-care unit (RICU)
Geriatric intensive-care unit (GICU)
ORGANIZATION OF
INTENSIVE CARE UNIT
LOCATION
Should be a geographically distinct area within
the hospital, with controlled access.

No through traffic to other departments


should occur. Supply and professional traffic
should be separated from public/visitor
traffic.

Location should be chosen so that the unit is


adjacent to, or within direct elevator travel
to and from, the Emergency Department,
Operating Room, Intermediate care units, and
the Radiology Department.
Design of ICU
There should be a single entry and exit.

ICU must have areas and rooms for public


reception, patient management and support
services.

Full commitment must be given from


administration and a designated team to work
on various tasks.

There should be sufficient number of lifts


available to carry these critically ill patients to
different areas.
Design of ICU
The total design of the ICU must take into account the following
areas;

• P= Patient care
• N= Nursing
• E= Eating (clean area for food preparation and delivery)
• U= Unclean (dirty linen, equipment)
• M= Medication storage (drugs, I V fluids)
• A= Administration (clerking, stationary)
• T= Teaching
• I= Infection elimination (sterilizing area)
• C= Clean area (fresh linen, equipment)
• S= Storage (back up equipment)
• V= Visitors
BED STRENGTH
The number of ICU beds in a hospital ranges
from 1 to 10 per 100 total hospital beds.

Multidisciplinary requires more beds than


single speciality.

ICUs with fewer than 4 beds are not cost


effective and over 20 beds are unmanageable.

IDEALLY 8 TO 12 BEDS

1 ISOLATION BED FOR EVERY 10 ICU


BEDS
BED SPACE & BEDS
150 – 200 SQUARE FEET PER OPEN
BED WITH 8 FEET IN BETWEEN
BEDS.

225 – 250 SQUARE FEET PER BED IF


IN A SINGLE ROOM.

BEDS - ADJUSTABLE, NO HEAD


BOARD, SIDE RAILS AND WITH
WHEELS.
Patient areas

Single rooms are essential for isolation


and privacy.

The ratio of single room beds to open


ward beds depends on the role and
type of ICU.
Patient areas (contd…)
A central station will have the central monitor,
drug cupboard, telephone, refrigerator and
patient records.

Nursing in ICU is always at the bedside.

Sufficient hand wash areas should be provided.

X-ray views are needed in multi-bed wards.

Proper facilities for haemodialysis such as


filtered water should be incorporated at the time
of ICU planning.
INFRASTRUCTURE
PATIENTS MUST BE SITUATED SO THAT DIRECT
OR INDIRECT (E.G. BY VIDEO MONITOR)
VISUALIZATION BY HEALTHCARE PROVIDERS IS
POSSIBLE AT ALL TIMES.

THE PREFERRED DESIGN IS TO ALLOW A DIRECT


LINE OF VISION BETWEEN THE PATIENT AND THE
CENTRAL NURSING STATION.

MODULAR DESIGN – SLIDING GLASS DOORS &


PARTITIONS TO FACILITATE VISIBILITY.
ENVIRONMENT
SIGNALS & ALARMS – ADD TO THE SENSORY
OVERLOAD; NEED TO BE MODULATED.

FLOOR COVERINGS AND CEILING WITH


SOUND ABSORPTION PROPERTIES.

DOORWAYS – OFFSET TO MINIMISE SOUND


TRANSMISSION.

LIGHT & SOFT MUSIC (EXCEPT 10 PM TO 6


AM).
Contd..
LIGHTING – FOCUSSED & CENTRAL LIGHTING.

AIRCONDITIONING (SPLIT / CENTRAL) : 25 + OR – 2


DEGREES CENTIGRADE.

CLEANING – VACUUM CLEANING & WET MOPPING OF


THE FLOOR. FUMIGATION IS NO LONGER
RECOMMENDED.

NATURAL ILLUMINATION AND VIEW - WINDOWS ARE


AN IMPORTANT ASPECT OF SENSORY ORIENTATION;
HELPS TO REINFORCE DAY/NIGHT ORIENTATION.

WINDOW TREATMENTS SHOULD BE DURABLE AND EASY


TO CLEAN, AND A SCHEDULE FOR THEIR CLEANING
MUST BE ESTABLISHED.
Contd…

ADDITIONAL APPROACHES TO
IMPROVING SENSORY
ORIENTATION FOR PATIENTS MAY
INCLUDE THE PROVISION OF A
CLOCK, CALENDAR, BULLETIN
BOARD, AND/OR PILLOW SPEAKER
CONNECTED TO RADIO AND
TELEVISION.
ACCESSORIES
3 OXYGEN OUTLETS, 3 SUCTION OUTLETS
(GASTRIC, TRACHEAL & UNDERWATER SEAL),
TWO COMPRESSED AIR OUTLETS AND 16
POWER OUTLETS PER BED.

STORAGE BY EACH BEDSIDE (BUILT IN /


ALCOVE).

HAND RINSE SOLUTION BY EACH BEDSIDE.

EQUIPMENT SHELF AT THE HEAD END (MIND


THE HEIGHT OF THE CARE GIVER).
Contd…

HOOKS & DEVICES TO HANG


INFUSIONS / BLOOD BAGS –
SUSPENDED FROM THE CEILING WITH A
SLIDING RAIL TO POSITION.

INFUSION PUMPS TO BE MOUNTED ON


STANDS / POLES.
UTILITIES
ELECTRICAL – ADEQUATE SOCKETS
(5AMPS & 15 AMPS), GENERATOR SUPPLY
& BATTERY BACK UP.

MEDICAL GAS & VACUUM PIPELINE –


COLOUR CODED AND NOT
INTERCHANGEABLE.

WATER FROM A CERTIFIED SOURCE


ESPECIALLY IF USED FOR
HAEMODIALYSIS
Contd…..
HANDWASHING AREAS – UNINTERRUPTED WATER
SUPPLY, DISPOSABLE PAPER TOWELS / HAND DRIER. (NO
CLOTH TOWELS PLEASE)

TELEPHONES & COMPUTERS FOR COMMUNICATION.

STERILISING AREA – LARGE WATER BOILER / GEYSER &


EXHAUST FANS.

CLEAN AND A DIRTY UTILITY WITH NO


INTERCONNECTION.

SHELVING & CABINETS OFF THE GROUND FOR STORAGE.

WASTE & SHARPS DISPOSAL.


Contd…..
WORK AREAS AND STORAGE FOR CRITICAL SUPPLIES
SHOULD BE LOCATED IMMEDIATELY ADJACENT TO
EACH ICU.

ALCOVES SHOULD PROVIDE FOR THE STORAGE AND


RAPID RETRIEVAL OF CRASH CARTS AND PORTABLE
MONITOR/DEFIBRILLATORS.

THERE SHOULD BE A SEPARATE MEDICATION AREA OF


AT LEAST 50 SQUARE FEET CONTAINING A
REFRIGERATOR FOR PHARMACEUTICALS, A DOUBLE
LOCKING SAFE FOR CONTROLLED SUBSTANCES, AND A
TABLE TOP FOR PREPARATION OF DRUGS AND
INFUSIONS.
EQUIPMENT
MONITORING EQUIPMENT

THERAPEUTIC EQUIPMENT

DIGITAL & ANALOGUE DISPLAY

AUDIO & VISUAL ALARMS

BATTERY BACK UP & CHARGING


Contd…..
Common equipment in an ICU includes:
mechanical ventilator to assist breathing through an
endotracheal tube or a tracheotomy opening;

cardiac monitors including telemetry, external


pacemakers, and defibrillators;

dialysis equipment for renal problems;

equipment for the constant monitoring of bodily


functions;

a web of intravenous lines, feeding tubes, nasogastric


tubes, suction pumps, drains and catheters;

a wide array of drugs to treat the main condition(s).


Contd…..
Monitoring Radiology
• Bed side and central • X ray viewers
monitors, 12 lead ECG • Portable x ray machine
recorders, intravascular • Image intensifiers
and intracranial
pressure monitoring Respiratory therapy
devices • Ventilators, bedside
• Cardiac output &portable
computer • Humidifiers, oxygen
• Pulseoxymeter therapy devices
• Pulmonary function &airway circuits
monitoring devices • Intubation trolley
• Expired CO2 analyzers • Manual self inflating
• EEG monitors resuscitators
• Fibre-optic
• Patient/ bed weighers bronchoscope
• Enzymatic blood • Anaesthetic machine
glucose meters
Contd…..
Cardiovascular therapy Laboratory
• Cardiopulmonary • Blood gas analyzer
resuscitation trolleys • Selective ion electrode
• Defibrillators analyzers
• Temporary transvenous • Osmometer
pacemaker • Hematocrit centrifuge
• Intra-aortic balloon • microscope
pump Hardware
• Infusion pumps and • Dressing trolleys
syringes
• Drip stands
Dialytic therapy
• Bed restraints
• Haemodialysis machine
• Heating/ cooling
• Peritoneal dialysis
equipment blankets
• Pressure distribution
• Continuous arterio
venous hemofiltration mattresses
setts • Sterilizing equipments
Storage areas/Service areas
Most ICUs lack storage space.

They should have a total of 25-30% of all patient and


central station areas for storage.

Clean and dirty utility rooms should be separate each


with its own access.

Disposal of soiled linen and waste must be catered for.

A lab, which estimates blood gases, electrolytes,


haemoglobin, is a must.

Good communication systems, staff lounge, food


areas must be marked out.

There should be an area to teach and train students.


Who are the members of a
multidisciplinary critical care team?
The critical care team includes a diverse group
of highly trained professionals who provide
care in specialized care units and work toward
the best outcome possible for seriously ill
patients.

All members of the team may be asked to


teach patients and their families various
strategies to improve health, healing, coping,
and well being specific to their area of
expertise.

The members could vary between hospitals.


Staffing
Large hospital requires bigger team.
Medical staff
Carrier intensivists are the best senior medical
staff to be appointed to the ICU. He/she will be
the director.

Less preferred are other specialists viz. from


anaesthesia, medicine and chest who have
clinical commitment elsewhere.

Junior staff are intensive care trainees and


trainees on deputation from other disciplines.
Who is an intensivist?
An intensivist (also known as Critical Care Specialist) is a
doctor with subspecialty training, or equivalent
qualifications, in critical care.
An intensivist directs the care of critically ill and injured
patients and works in collaboration with other health care
professionals necessary for the care of patients in critical
care units.
Intensivists may be assigned to the ICU on a full-time
basis.
These physicians know how specific treatments affect all
the organ systems, avoid duplication of procedures and
medications, and honour the patient's preferences
regarding medical treatment as well as End of Life care
(when appropriate).
Intensivists may also coordinate the administrative
environment of the ICU by setting policies, developing
protocols, and facilitating communication among primary
care physicians, specialists, patients, and their families.
Nursing staff
The major teaching tertiary care ICU will
require trained nurses in critical care.

The number of nurses ideally required for


such units is 1:1 ratio. 1 nurse for two
patients is acceptable. In complex
situations they may require two nurses
per patient. The number of trained nurses
should be also worked out by the type of
ICU, the workload and work statistics and
type of patient load.

ICU NURSE MANAGER


Critical care nurses
Critical care nurses provide a high level of skilled
nursing for total patient care and often facilitate
communication between all of the people involved
in the care of the patient.

Their expertise and continuous presence allows


early recognition of subtle, but significant,
changes in patient conditions, thereby preventing
worsening conditions and minimizing
complications that arise from critical illness.

Because of their close contact with the family and


the patient, critical care nurses often serve as the
patient's advocate and become integral to the
decision-making process of the patient, family,
and critical care team.
Allied services
Physiotherapy, social workers, dieticians, radiology
services, respiratory therapists are a useful work
force responsible for patient management and
equipment maintenance.

Biomedical department services are required on a


regular basis to service and repair and develop
equipment.

Adequate secretarial assistance and reception


category makes the functioning smooth.

For transport of patients it is ideal if one can have


separate teams to lift critically ill patients and
transport them to different areas.

Trained staff in this area would be very valuable


contribution.
Pharmacist or Clinical Pharmacologist
A pharmacist or clinical pharmacologist
is a certified specialist in the science
and clinical use of medications.

The pharmacist with specialty training in


the ICU is equipped in recognizing the
needs and problems specific to the
critical care patient and work with
members of the health-care team to
foster effective and safe medication
therapy.
Registered Dietician
A registered dietician is a vital part of the
medical team that consults with
physicians, nurses, therapists, and
family members in the ICU.

The registered dietician works to improve


the nutritional health and promotes
recovery of the critical care patient.
Social Worker or Patient Care Co-ordinator
A social worker is a licensed professional
that works with the ICU interdisciplinary
team to provide a link between treatment
plans for the critical care patient and
family members.

Special knowledge that is acquired


through formal, professional social work
education, welfare policies and services,
and social welfare systems and
community resources guide the practice
of social work.
Respiratory Therapist or ICU technicians

Respiratory therapists work with the


critical care team to monitor and promote
airway management of the critical care
patient.

This may include: oxygen therapy,


mechanical ventilation (breathing
machine) management, cardio-respiratory
monitoring, and patient and caregiver
education.
Physiotherapist and Occupational Therapist
The physical therapist provides services that
restore function, improve mobility, relieve
pain, and prevent or limit permanent physical
disabilities.

The occupational therapist is trained to make a


complete evaluation of the impact of the
disease on the activities of the critical care
patient at home, in work situations, and
recreational activities.

Both members work cooperatively with other


disciplines of the healthcare team to reduce
physical and psychological disability of the
patient.
Principles of critical care
nursing
Constant monitoring

Rapid skilled intervention

Teamwork
Principles of critical care nursing (contd….)
The patient population treated varies with
the type of ICU.

Regular clinical examination should never


be neglected.

Simple physical signs such as respiratory


rate, the appearance of restlessness,
conscious level and indices of poor
peripheral perfusion (pale, cold skin,
delayed capillary refill in the nail bed) are
just as important as a set of blood gases or
numbers impressively displayed on
expensive monitors.
Principles of critical care nursing (contd….)
If there is conflict between clinical
assessment and the information on a
monitor, the monitor should be
presumed to be wrong until all potential
sources of error have been checked
and eliminated.

Changes and trends are more


important than any single
measurement.
Principles of critical care nursing (contd….)
Many monitors have alarms which will activate
if certain maximum and minimum values are
reached. This is a crucial safety feature and
may help to identify the fact that a patient has
become disconnected from the ventilator.
Despite the understandable desire to avoid
extra noise, the alarm limits should always be
set to define physiologically ‘safe’ limits for
the variable being monitored.

Sophisticated monitoring systems are often


invasive and pose certain hazards, particularly
infection. Always ask ‘Is it necessary?’ and
cease monitoring as soon as possible.
POLICIES & PROTOCOLS
Clearly defined goals and written protocols for the ICU
are essential to avoid confusion and improve co-
ordination.

The minimum protocols available should be for;

a) Admission, Discharge and withdrawal of support.

b) Infection control

c) Equipment sterilization

d) Procedures in ICU

e) LEGAL & ETHICAL GUIDELINES & MLC POLICIES

f) STANDING ORDERS.

g) ORGAN DONATION.
POLICIES & PROTOCOLS (cont...)
The efficient use of expensive resources in the ICU is a priority.

The priority can be graded to 4 levels:


1. Priority 1: This includes critically ill, unstable patients who need
the monitoring, nursing and medical care available in an ICU. These
include patients who are previously well and have an acute
problem- post operative patients and those with acute respiratory
failure.
2. Priority 2: These include patients with chronic co-morbid
conditions who develop an acute deterioration.
Patients in the above two categories usually have no
limits set on therapy which is to be given.
3. Priority 3: These are patients with co-morbid conditions or acute
illness that reduce their likelihood of recovery. In this group of
patients, limits may be set on the therapy to be given (such as no
invasive ventilation, dialysis or CPR).
4. Priority 4: This group includes two extremes- those ‘too well to
benefit’ and those ‘too sick to benefit’. They do not benefit from
ICU care and their admission should be on an individual basis
under unusual circumstances.
POLICIES & PROTOCOLS (cont...)
Anticipation: It involves ability to
predict the needs of a situation.
1. Adequate sedation or restraint to
prevent self extubation.
2. In resuscitation, the defibrillator should
be ready to use.
3. Patients on Vasoactive drug infusions
should have refill syringes ready to use
before the syringe on flow becomes
empty.
Ethical and legal aspects of
critical care
Beneficence: Our actions are directed
towards “doing good”; saving patient’s life,
relieving suffering, preventing complications.

Nonmalefescence: “Doing no harm”. E.g.


Restraint.

In the critical care setting, both principles are


simultaneously employed to guide patient
care.
Ethical and legal aspects of critical care (contd…)
Veracity: “Telling the truth”.

Autonomy: patient has the right to accept or


refuse care.

Paternalism (Parentalism): certain individuals are


better able and have the right to make decisions
for other.

It is practiced in circumstances when we make


decisions for patients in non-life-threatening
situations or when we attempt to influence unduly
the patient’s decision making to follow the
practitioner’s objectives.

Justice: Fairness; providing resources so that all


will benefit to the level of equity.
Legal issues
Some of the general legal principles that
critical care nurses should know about are in
the area of civil law, specially tort law.

Negligence: When harm comes to someone


because the professional has failed to conform
to an identified standard of care or practice.

Malpractice: When a negligent act or omission


in care or practice causes harm or injury.

Traditionally, nurses employed by an


institution have been provided with
professional insurance and would be protected
and represented by the institution. It is the
nurses responsibility to know what coverage
and services the hospital will provide.
Reasons for lawsuits
Failure to;
Observe or monitor a patient adequately.
Record or communicate significant changes in
patient’s condition.
Perform a procedure properly.
Follow a physician’s order promptly and correctly.
Make prompt, accurate entries in a patient’s chart.
Give medications correctly.
Report another professional’s deviations from
accepted practice.
Use equipment properly.
Resuscitate a patient properly.
Protect the patient from avoidable injuries.
Take a complete nursing history.
Function within the scope of the nurse’s education
and job description.
Protection against lawsuits
Know your job.
Document properly, completely, clearly
and accurately.
Never be too busy to talk to the patient
or family.
T H

U A

O N

Y K
Communication with the patient in
critical care unit and family
To develop a level of comfort and expertise in
communicating with critically ill patients and their families
nurse should first consider their own experiences with and
values concerning illness.

Throughout the course of a serious illness, patients and their


families encounter complicated treatment decisions, bad
news about disease progression and recurring emotional
responses.

In addition to the time of initial diagnosis, lack of response to


the treatment course, decisions to continue or withdraw
particular interventions and decisions about hospice care are
examples of critical points on the treatment continuum that
demand patience, empathy and honesty from nurses.
Contd…
General guidelines for nurses;

Deliver and interpret the technical information


necessary for making decisions without hiding
behind medical terminology.

Realize that the best time for the patient to talk


may be when it is least convenient for you.

Being fully present during any opportunity for


communication is often the most helpful form
of communication.

Allow the patient and family to set the agenda


regarding the depth of the conversation.
Contd…
If the patient wishes to have family present
for discussion, arrangements should be
made to have the discussion at the time that
is best for everyone.

A quiet area with a minimum of disturbances


should be used.

The most important intervention the nurse


can provide is listening empathetically.

Resist the impulse to fill the “empty space”


in communication with talk.
Keys to effective listening
Allow the patient and family sufficient
time to reflect and respond after asking a
question.

Prompt gently: “Do you need more time to


think about this?”

Avoid distractions (noise, interpretations).

Avoid the impulse to give advice.

Avoid canned responses: “I know just


how you feel.”
Transitional Care
What is Transitional Care?
Patients who suffer from a variety of
health conditions often need health care
services in different settings to meet their
many needs.

"Transitional Care" refers to when they


move across settings.

When they "transition" they often are


treated by many different health care
professionals.
Transitional care
Transitional care is a broad term that
encompasses a variety of intermediate care
services, including subacute, skilled, and
rehabilitative care services.

Medically stable patients requiring skilled


care beyond the acute phase can be managed
in a hospital-based transitional care unit
(TCU) or a skilled nursing facility (SNF).
Transitional care
Transitional care serves those who have been
discharged from the hospital but still require
short-term rehabilitation and special care in
order to make the transition from hospital to
home.

It is ideal for patients who are too ill and/or


technology-dependent to receive home care,
but who do not need to remain in a
medical/surgical bed.

Transitional care bridges the gap between


hospital and home for patients with complex or
multiple problems.
Transitional care
Transitional care is defined as a set of actions designed
to ensure the coordination and continuity of health care
as patients transfer between different locations or
different levels of care within the same location.

Representative locations include (but are not limited to)


hospitals, sub-acute and post-acute nursing homes, the
patient’s home, primary and specialty care offices, and
long-term care facilities.

Transitional care is based on a comprehensive plan of


care and the availability of health care practitioners who
are well-trained in chronic care and have current
information about the patient’s goals, preferences, and
clinical status.
Medical conditions which frequently require
transitional care include, (but are not limited to):
• Head injuries
• Stroke • Brain tumors

• Orthopedic surgery • Pulmonary emphysema

• Amputation • Muscular dystrophy

• Cerebral palsy
• Heart disease
• Patients who require
• Diabetes intravenous therapy, wound
• Cancer care or other special nursing
care
• Neurological illness, • Post-operative observation
including
Parkinson’s Disease • Plastic surgery recuperation
What Types of Problems Occur When
Transitions Are Poorly Managed?
During transitions, patients are at risk for medication
errors and for not receiving the right services.

They may end up in the hospital or in the emergency


room because of the poor care they received during their
transition.

After leaving a particular care setting, patients may not


understand how to manage their health care conditions
or who to call if they have a question or if their condition
gets worse.

Poorly managed transitions can lead to physical and


emotional stress for both patients and their caregivers.
contd,….

During a transition, the patients' preferences


or personal goals in one setting may not be
passed on to the next setting.

Adverse patient outcomes include


continuation or recurrence of symptoms,
temporary or permanent disability, and death.

Healthcare utilization outcomes for patients


experiencing poor transitional care include
returning to the emergency room or being
readmitted to the hospital.
What Can be Done to Ensure
that the Transitions Go
Smoothly?

Although health care practitioners in


different settings should communicate
with one another, it is a good idea to
take steps to make sure that each
health care professional has the
information they need about patient’s
conditions and treatments.
Contd…
 Following are some advices to be given the
patient;

Keep your own personal file of important health


information and show this to each new health care
professional.

You should keep a list of your health conditions,


the names and phone numbers of your health care
professionals, medications you are taking, and
any allergies that you may have.

Take charge of your medications (both prescribed


and over-the-counter) and know why you take
each one, how to take each one, and any possible
side effects to watch for.
Contd…
Make sure that you understand what
services you will get at each new setting
and how these will benefit you.

Once you arrive at each new setting, let


people know your preferences and ask that
these become part of your overall care
plan.

Bring a friend or relative with you to be


your advocate.
Contd…
Before leaving each setting, write down the name and
telephone number of the health care professional you
can contact if you have any questions or should your
condition get worse.

Before leaving each setting, ask what type of follow-


up care you will need and how this will be scheduled.

Schedule an appointment with your primary care


physician or case manager to discuss how your needs
would be met if you could not care for yourself for a
few days or long-term.

Planning ahead and knowing what Medicare (and any


other insurance you may have) covers is a positive
step towards making sure that any future transitions
go smoothly.
Transitional Care Model (TCM)
Unique Features

Care is delivered and


coordinated
…by same nurse
…across settings
…7 days per week
…using evidence-based protocol
…with focus on long term outcomes

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