B Guidelines for the Provision of Intensive Care Services Critical Care Network British Association of UK Critical Care Royal College of Speech Nurse Leads Critical Care Nurses Nursing Alliance & Language Therapists Association of National Outreach ICU Steps United Kingdom UK Dietitians Forum Clinical Pharmacy Association NHS Blood and Neuroanaesthesia Association of College of Transplant Society of Great Cardiothoracic Occupational Britain and Ireland Anaesthetists Therapists Edition1.1 2016 GPICS Edition 1.1 / 2016 Contents CONTENTS GPICS UPDATES ....................................................................................................................................................5 Overview ...............................................................................................................................................................7 Endorsing Organisations .......................................................................................................................................9 CHAPTER ONE: DESCRIPTION OF SERVICE 10 1.1 Levels of Critical Care ................................................................................................................. 11 1.2 Clinical & Financial Burden ......................................................................................................... 12 1.3 Workforce Projections ................................................................................................................ 13 1.4 Access to Critical Care ................................................................................................................ 15 1.5 Delivery of Critical Care in the UK .............................................................................................. 16 1.6 Interactions with Other Services ................................................................................................ 18 1.7 Outcomes ................................................................................................................................... 20 CHAPTER TWO: CRITICAL CARE SERVICE – STRUCTURE 22 2.1 Physical Facilities .............................................................................................................. 23 2.1.1 Levels 2 & 3 Physical Facilities .................................................................................................... 23 2.2 The Critical Care Team: Staffing Numbers and Work Patterns ............................................ 26 2.2.1 Consultants ................................................................................................................................. 26 2.2.2 Trainee Medical Staff ................................................................................................................. 28 2.2.3 Nurse Staffing ............................................................................................................................. 31 2.2.4 Advanced Critical Care Practitioners .......................................................................................... 34 2.2.5 Physiotherapy ............................................................................................................................. 36 2.2.6 Pharmacy ................................................................................................................................... 38 2.2.7 Dietetics ...................................................................................................................................... 41 2.2.8 Occupational Therapy ............................................................................................................... 44 2.2.9 Speech and Language Therapy ................................................................................................... 47 2.2.10 Practitioner Psychologists .......................................................................................................... 51 CHAPTER THREE: CRITICAL CARE SERVICES – PROCESS 55 3.1 Patient Pathway ............................................................................................................... 56 3.1.1 Admission, Discharge and Handover .......................................................................................... 56 3.1.2 Critical Care Outreach ................................................................................................................ 59 3.1.3 Rehabilitation ............................................................................................................................. 62 3.1.4 Outpatient Follow Up: Rehabilitation after Critical Illness ......................................................... 65 3.1.5 The Patient and Relative Perspective ......................................................................................... 67 CHAPTER FOUR: CRITICAL CARE SERVICE – ACTIVITY 70 4.1 Disease Management ....................................................................................................... 71 4.1.1 Sepsis .......................................................................................................................................... 71 4.1.2 Acute Respiratory Failure ........................................................................................................... 75 2 GPICS Edition 1.1 / 2016 Contents 4.1.3 Cognitive Impairment ................................................................................................................. 79 4.1.4 Acute Kidney Injury .................................................................................................................... 82 4.1.5 Acute Renal Replacement Therapy ............................................................................................ 85 4.1.6 Anaemia ..................................................................................................................................... 89 4.1.7 Sedation ...................................................................................................................................... 92 4.1.8 Post-cardiac arrest management ............................................................................................... 95 4.1.9 End of Life Care........................................................................................................................... 99 4.2 Disease Prevention ......................................................................................................... 102 4.2.1 Venous thromboembolism ....................................................................................................... 102 4.2.2 Ventilator-associated pneumonia ............................................................................................ 106 4.2.3 Line Related Sepsis ................................................................................................................... 109 4.2.4 Infection Control ...................................................................................................................... 112 4.3 Specialised Critical Care .................................................................................................. 115 4.3.1 ECMO ........................................................................................................................................ 115 4.3.2 Cardiothoracic Surgery ............................................................................................................. 119 4.3.3 Neurocritical Care ..................................................................................................................... 121 4.3.4 Trauma ..................................................................................................................................... 126 4.3.5 Weaning and Long Term Home Ventilation Services ............................................................... 129 4.3.6 Burns ......................................................................................................................................... 132 4.3.7 Transfer Medicine .................................................................................................................... 135 4.3.8 Organ Donation ........................................................................................................................ 138 CHAPTER FIVE: CRITICAL CARE SERVICE – ADDITIONAL KEY COMPONENTS 142 5.1 Training, Education and Reflective Learning .................................................................... 143 5.1.1 Assessment of Competence ..................................................................................................... 143 5.1.2 Assessment of Competence: Registered Nurses ...................................................................... 145 5.2 Appraisal and Revalidation ............................................................................................. 147 5.2.1 Consultant Appraisal and Revalidation .................................................................................... 147 5.3 Improving the Service ..................................................................................................... 150 5.3.1 Research and Development (R&D) ........................................................................................... 150 5.3.2 National Data Collection System .............................................................................................. 152 5.3.3 Patient Safety in ICU 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