Monitoring and Supporting Critically Ill Patients

Module details

Title

Monitoring and Supporting Critically Ill Patients

Type

Specialist

Module code

SPS124

Credits

15

Requirement

Compulsory

Aim of this module

This module provides trainees with the knowledge and understanding that underpins the specialist module in Critical Care Science and provides the trainees with the specialist underpinning knowledge and understanding to undertake learning in the workplace. This module will enable critical care trainees to monitor critically ill patients according to the indications for and the selection of suitable methods of monitoring. They will be able to recognise and respond to trends in physiological variables. Additionally, they will be expected to use their knowledge to write a technical specification and a standard operating procedure and undertake a risk analysis. Trainees will be expected to build and extend their professional practice.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1, 2, 3, 4, 5, 6, 7, 9	Competency Perform all tasks in accordance with relevant procedures/protocols/legislation including infection control, health and safety, critical incident reporting ensuring appropriate patient identity checks are performed and the patient is fully identified on each type of recording.	Action View
# 2	Learning outcome 1, 2, 3, 4, 5, 6, 7, 9	Competency Respect the dignity, rights, privacy and confidentiality of patients at all times, taking appropriate action to respond to the specific needs of the patients.	Action View
# 3	Learning outcome 1, 2, 3, 4, 5, 6, 7, 9	Competency Explain the procedure to the patient, if they are fully cognitive, or the relative if present, address any procedure-related questions and gain appropriate consent.	Action View
# 4	Learning outcome 1, 2, 3, 4, 5, 6, 7, 9	Competency Use a range of data management systems and methods to support and improve safe and effective patient care in the critical care environment.	Action View
# 5	Learning outcome 1	Competency Prepare the equipment in readiness for a patient transfer, communicating with the team, patient/relatives to maximise the safety and comfort of the patient during the transfer.	Action View
# 6	Learning outcome 2	Competency Prepare the equipment required to perform non-invasive ventilation (NIV) and perform pre-use checks.	Action View
# 7	Learning outcome 2	Competency Discuss the options available for the patient–ventilator interface when using NIV.	Action View
# 8	Learning outcome 3	Competency Set up a cardiac monitor and monitor heart function in a range of critically ill patients, interpreting and responding to trends in physiological variables and calibrating as necessary.	Action View
# 9	Learning outcome 4	Competency Set up non-invasive BP monitoring equipment in a range of patients, interpreting and responding to trends in physiological variables and calibrating as necessary.	Action View
# 10	Learning outcome 5	Competency Set up oxygen saturation monitoring equipment on a range of patients, interpreting and responding to trends in physiological variables and calibrating as necessary.	Action View
# 11	Learning outcome 6	Competency Set up capnography (CO2) monitoring equipment on a range of patients, interpreting and responding to trends in physiological variables and calibrating as necessary.	Action View
# 12	Learning outcome 7	Competency Set up for invasive blood pressure monitoring for a range of patients interpreting and responding to trends in physiological variables and calibrating as necessary.	Action View
# 13	Learning outcome 7	Competency Assist in monitoring intracranial pressure/electroencephalogram (EEG) monitoring, interpreting and responding to trends in physiological variables and calibrating as necessary.	Action View
# 14	Learning outcome 8	Competency Obtain a blood gas sample from an invasive arterial/venous pressure line in a critically ill patient and interpret the results.	Action View
# 15	Learning outcome 9	Competency Use the following point-of-care testing (POCT) methods/device to specified quality standards to generate accurate, valid results and document the results: blood gas oximetry electrolyte/metabolyte analyser.	Action View
# 16	Learning outcome 9	Competency Interpret the results from near patient testing for a range of critically ill patients.	Action View
# 17	Learning outcome 10	Competency Write a technical specification for the purchase of a mechanical ventilator.	Action View
# 18	Learning outcome 10	Competency Write a clinical/business case for the introduction of a POCT device into a new clinical area.	Action View
# 19	Learning outcome 11	Competency Write an SOP for the set-up of equipment for a technical procedure.	Action View
# 20	Learning outcome 11	Competency Write an SOP for performing a procedure on a POCT device.	Action View

Assessments

You must complete:

• 4 case-based discussion(s)
• 4 of the following DOPS/ OCEs:

Prepare the equipment required for a level 3 patient transfer including pre use checks.	DOPS
Prepare equipment ready for ETCO2 monitoring. Connect to circuit on a ventilated patient. Obtain.	DOPS
Accurately obtain a blood gas measurement ensuring sample quality, measurement accuracy and quality assurance results.	DOPS
Set up the equipment required to obtain an accurate invasive arterial CVP measurement	DOPS
Using local POCT operating procedures, perform a near patient test on for example a Glucose, INR, Hb.	DOPS
Participate in multidisciplinary transfer of ICU patient.	OCE
Demonstrate to HCP the procedure of non invasive measurement of blood pressure on a HDU patient, giving explanation to HCP of safety aspects.	OCE
Explain procedure and connect NIV ventilation to patient.	OCE

Learning outcomes

1. Check and prepare equipment used in high-level transfer of patients.
2. Perform non-invasive ventilation.
3. Perform ECG monitoring, recognising and responding to trends in physiological variables.
4. Perform non-invasive BP monitoring, recognising and responding to trends in physiological variables.
5. Perform oxygen saturation monitoring, recognising and responding to trends in physiological variables.
6. Perform Capnography (CO2) monitoring recognising and responding to trends in physiological variables.
7. Perform invasive pressure monitoring, recognising and responding to trends in physiological variables.
8. Obtains and interprets the results from blood gas samples.
9. Perform a range of near patient tests at the point of care specific to critical care patient requirements, quality assuring the results.
10. Write a technical specification for a specialist critical care item of equipment and evaluate (both clinical and financial), procure and set up maintenance contract arrangements.
11. Write a standard operating procedure and undertake a risk analysis ensuring all relevant patient safety aspects are included.

Learning outcomes

Safe Practice

1. Justify the indications for monitoring, the selection of suitable methods and the hazards associated with inappropriate monitoring.
2. Describe how to interpret information from monitoring devices and identify common causes of error and the principles of monitoring trends of change.
3. Critically analyse the role of the critical care scientist in the monitoring and support of patients within a critical care environment.
4. Recognise the issues governing safe patient transport with reference to current guidelines.

Patient and Haemodynamic Monitoring

5. Describe the methods, indications, complications, precautions and limitations for measuring and monitoring:
i. Temperature
ii. Oxygenation (pulse oximetry)
iii. Carbon dioxide (end tidal CO2 monitoring)
iv. Fluid balance (fluid input-output monitoring)
v. Intra-abdominal pressure
vi Intracranial pressure
vii. Pulmonary arterial pressure
viii. Cerebral Doppler velocities
ix. Cerebral blood flow
6. Describe and evaluate the management of patient and clinical data using information systems.
7. Describe and critically appraise methods for assessing pain and sedation.
8. Describe methods for assessing neurological function, e.g. Glasgow Coma Scale.
9. Explain the principles of invasive and non-invasive systems available for measuring cardiac output and derived haemodynamic variables, and the site of placement of the monitoring device.
10. Describe the use, function and characteristics of pressure amplifiers, catheters, consumables, various transducers and factors that influence the quality of pressure waveform.
11. Describe venous and arterial access techniques, indications, contraindications and complications.
12. Describe cardiac catheterisation, including normal pressure waveforms, normal ranges, limitations and risks, and recognise typical abnormal recordings.
13. Relate the principles of invasive pressure monitoring, including measurement principles and design, indications, limitations and technique to care of the critically ill patient.

Monitoring Ventilation

14. Explain the monitoring capabilities of modern ventilation technology and the principles of monitoring ventilation.
15. Describe the set up and monitoring required to deliver anaesthetic agents safely and effectively.
16. Describe and critically evaluate the techniques used to measure VO2, VCO2, respiratory quotient and resting energy expenditure (REE).
17. Explain the principles of hypo/hyperthermia heating units.
18. Describe the principles, application and interpretation of the measurement of metabolic and nutritional requirements in the critically ill.

(The trainee should produce evidence of completion of immediate or advanced life support training before undertaking any of the learning outcomes.)

Indicative content

Safe monitoring practice, indications for and the selection of suitable methods of monitoring

• Advantages
• Disadvantages
• Accuracy
• Convenience
• Reliability
• Safety
• Cost
• Relevance to the patient’s condition

Anatomy and physiology

• Cardiovascular anatomy and physiology
• Coronary artery influences on cardiac
• Myocardial / cell electrophysiology and apply knowledge to cardiac rhythms and
• Principles of metabolism
  • nutrients: carbohydrates, fats, proteins, vitamins and minerals
  • metabolic pathways
  • lactate metabolism
  • energy production and enzymes
  • metabolic rate
  • hormonal control of metabolism: regulation of plasma glucose

 Underpinning measurement principles, limitations and artefacts with respect to:

• Pressure
• Flow
• Temperature
• pH
• Oxygen
• Carbon dioxide

Pressure measurement including catheterisation

• Components and functions of an electromanometer system
  • Catheter
  • Tubing
  • Transducer
  • Amplifier and display unit
  • Zero and calibration techniques
  • Dynamics of the system
    • Natural frequency
    • Damping

Cardiac catheterisation

• MRSA screening and pre-assessment for cardiac catheterisation procedures
• Pathophysiology related to cardiac catheterisation
• Influence of coronary artery anatomy and patency on cardiac rhythm
• Indications, contraindications, limitations and risk factors associated with the procedure
• Importance of ECG, blood pressure and O2 saturation monitoring during the procedure
• ECG abnormalities and required interventions
• Normal pressure waveforms and normal value ranges
• Abnormal recordings and associated pathology
• Haemodynamic measurements made during cardiac catheterisation
• The influence of equipment and consumable characteristics on the quality of pressure recordings
• Techniques for venous and arterial access, indications, risks and complications
• Characteristics and use of catheters and connecting tubing
• Recognition of normal and abnormal oxygen saturation measurements and their relationship to common abnormalities
• Immediate/advanced life support in line with Resuscitation Council UK
• Production and structure of findings and storage of results

 Hypo/hyperthermia heating units

• Devices used for patient and fluid warming
• Decontamination
• Operation

Ventilation

• Monitoring capabilities of modern ventilation technology
• Principles of monitoring ventilation
• Significance of:
  • respiratory rate
  • tidal volume
  • minute volume
  • mean, peak, end expiratory and plateau pressure
  • intrinsic and extrinsic PEEP
  • inspired oxygen concentration
  • arterial blood gas
  • acid-base status
• Basic features and principles of operation of a range of makes, models and software revisions of ventilators
• Decontamination, set-up and self-testing of ventilators
• Troubleshooting and reporting of faults
• Document control and traceability
• Modes of ventilation for non-invasive therapies
• Gas/agent monitoring
• Scavenging
• Anaesthetic agents
• Techniques used to measure:
  • VO2
  • VCO2
  • respiratory quotient and resting energy expenditure (REE)
• Advantages/disadvantages of measuring REE as opposed to using calculations
• Relationship between mode of ventilation and choice of parameters monitored; airflow and airway pressure waveforms

Monitors

• Service modes and touch calibration
• Menu navigation
• Operation and atypical faults
• Fault reporting procedures

 Temperature

• Normal values
• Variance from normal – clinical and non-clinical reasons
• Safety

 Capnography

• Mainstream
• Sidestream/microstream
• Equipment
• Clinical uses 

Metabolic measurement

• Resting energy expenditure

 Monitoring of EEG and derivatives

• Cerebral function analysis monitor (CFAM)
• Bispectral index (BIS)
• Compressed spectral array (CSA)
• Evoked potentials

Activities

• Observe the preparation and planning for the transfer of an acutely unwell patient, including the pre-transfer communication, and assist in the transfer of critical care patients, reflecting on how the critical care team can minimise the risk and maximise patient safety.
• Observe and assist in performing pathology tests that are commonly required to manage critically ill patients and discuss the role of life sciences in the care of the critically ill patient.
• Observe the work of haematology in blood typing, cross matching and transfusion therapy and discuss the safety processes and possible complications from incorrect use of blood transfusion products.
• Observe and assist in obtaining appropriate microbiological samples and interpretation of the results, discuss with your training officer how clinical findings are integrated with laboratory investigations to form a differential diagnosis.
• Observe the use of fluid management and drug support to treat hypo- and hypertension, and discuss the importance of fluid management in a range of critical care situations with your training officer.
• Attend a meeting at which the outcome of a clinical audit, research, innovation, or service development is presented and discuss with your training supervisor how evidence-based practice is implemented with respect to critical care.
• Observe the application of temperature control devices and assess benefit versus risk of the different modalities.
• Take part in a multidisciplinary meeting and reflect on the way the multidisciplinary team contributes to the care of critically ill patients and their relatives.