ACCCN’s 2nd edition Critical Care Nursing Doug Elliott QLeanne Aitken QWendy Chaboyer ACCCN’S CRITICAL CARE NURSING ACCCN’S CRITICAL CARE NURSING SECOND EDITION Doug Elliott Leanne Aitken Wendy Chaboyer RN, PhD BAppSc(Nurs), MAppSc(Nurs), ICCert, Professor of Nursing, Faculty of Nursing, Midwifery and Health University of Technology, Sydney, New South Wales RN, PhD, BHSc(Nurs)Hons, GradCertMgt, GradDipScMed(ClinEpi), ICCert, FRCNA Professor of Critical Care Nursing Griffith University & Princess Alexandra Hospital Brisbane, Queensland RN, PhD, MN, BSc(Nurs)Hons, CritCareCert Professor & Director, NHMRC Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Griffith Health Institute, Griffith University Gold Coast, Queensland Mosby is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067 © 2012 Elsevier Australia This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation. This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication. National Library of Australia Cataloguing-in-Publication Data Title: ACCCN’s critical care nursing / [editors] Doug Elliott, Leanne Aitken and Wendy Chaboyer. Edition: 2nd ed. ISBN: 9780729540681 (pbk.) Notes: Includes index. Subjects: Intensive care nursing–Australia. Other Authors/Contributors: Elliott, Doug. Aitken, Leanne. Chaboyer, Wendy. Australian College of Critical Care Nurses. Dewey Number: 616.028 Publisher: Libby Houston Developmental Editor: Elizabeth Coady Publishing Services Manager: Helena Klijn Editorial Coordinator: Geraldine Minto Edited by Melissa Read Proofread by Tim Learner Indexed by Cynthia Swanson Cover design by Lamond Art & Design Typeset by Toppan Best-set Premedia Limited Printed by •• Contents Foreword Preface About the Australian College of Critical Care Nurses (ACCCN) About the Editors Contributors Reviewers Acknowledgements Detailed Contents Abbreviations Section 1 Scope of Critical Care 1 2 3 4 5 Scope of Critical Care Practice Leanne Aitken, Wendy Chaboyer, Doug Elliott Resourcing Critical Care Denise Harris, Ged Williams Quality and Safety Wendy Chaboyer, Karena Hewson-Conroy Recovery and Rehabilitation Doug Elliott, Janice Rattray Ethical Issues in Critical Care Amanda Rischbieth, Julie Benbenishty Section 2 Principles and Practice of Critical Care 6 7 8 9 10 11 Essential Nursing Care of the Critically Ill Patient Bernadette Grealy, Wendy Chaboyer Psychological Care Leanne Aitken, Rosalind Elliott Family and Cultural Care of the Critically Ill Patient Marion Mitchell, Denise Wilson, Vicki Wade Cardiovascular Assessment and Monitoring Thomas Buckley, Frances Lin Cardiovascular Alterations and Management Robyn Gallagher, Andrea Driscoll Cardiac Rhythm Assessment and Management Malcolm Dennis, David Glanville vi vii ix x xi xiii xiv xv xviii 1 12 Cardiac Surgery and Transplantation Judy Currey, Michael Graan 291 13 Respiratory Assessment and Monitoring Amanda Corley, Mona Ringdal Respiratory Alterations and Management Maria Murphy, Sharon Wetzig, Judy Currey Ventilation and Oxygenation Management Louise Rose, Gabrielle Hanlon Neurological Assessment and Monitoring Di Chamberlain, Leila Kuzmiuk Neurological Alterations and Management Di Chamberlain, Wendy Corkill Support of Renal Function Ian Baldwin, Gavin Leslie 325 14 15 16 17 3 18 17 19 38 57 20 78 21 Gastrointestinal, Liver and Nutritional Alterations Andrea Marshall, Teresa Williams, Christopher Gordon Management of Shock Margherita Murgo, Gavin Leslie Multiple Organ Dysfunction Sydrome Melanie Greenwood, Alison Juers 352 381 414 446 480 507 540 563 Section 3 Specialty Practice in Critical Care 579 103 22 581 105 23 133 24 25 156 180 215 251 Emergency Presentations David Johnson, Mark Wilson Trauma Management Louise Niggemeyer, Paul Thurman Resuscitation Trudy Dwyer, Jennifer Dennett Paediatric Considerations in Critical Care Tina Kendrick, Anne-Sylvie Ramelet 26 Pregnancy and Postpartum Considerations Wendy Pollock, Clare Fitzpatrick 27 Organ Donation and Transplantation Debbie Austen, Elizabeth Skewes Appendices Glossary Picture Credits Index 623 654 679 710 746 763 783 790 793 v Foreword As a specialty area of nursing practice, critical care nursing is focused on the care of patients who are experiencing life-threatening illness. Globally, critical care nurses provide care to ensure that critically ill patients and their families receive optimal care. This second edition of the Australian College of Critical Care Nurses (ACCCN’s) Critical Care Nursing is a valuable resource for critical care nursing practice. The editors, who are acknowledged expert practitioners, educators, and researchers in critical care, have organised the book into topics covering the scope of critical care, principles and practice of critical care, and specialty practice in critical care. The content covered in this book, written by established experts in the ﬁeld of critical care, provide a comprehensive overview of critical care nursing concepts and practices. The book provides up-to-date information on evidence-based practices and the chapters incorporate a variety of educational resources including website links, case studies and practice tips. ACCCN’s Critical Care Nursing is a beneﬁcial resource for critical care nurses, regardless of practice setting. In seeking to provide complex high intensity care, therapies and interventions, critical care nurses will ﬁnd that the vi book reviews essential content related to critical care nursing knowledge and skills to provide care to acutely ill patients and their families. Internationally, there are more than 500,000 critical care nurses, representing one of the largest specialty areas of nursing practice. The importance of maintaining knowledge of best practices, utilising evidence-based approaches, and applying research to clinical practice for critical care patients remain essential components of critical care nursing. This second edition of ACCCN’s Critical Care Nursing is a comprehensive resource for critical care nurses seeking to further develop their knowledge and enhance their clinical practice expertise. Ruth Kleinpell PhD RN FAAN FCCM Director, Center for Clinical Research and Scholarship Rush University Medical Center; Professor, Rush University College of Nursing; Nurse Practitioner, Mercy Hospital & Medical Center Chicago Illinois, USA President of World Federation of Critical Care Nurses http://www.wfccn.org Preface Critical care as a clinical specialty is over half a century old. With every successive decade, advances in the education and practices of critical care nurses have been made. Today, critical care nurses are some of the most knowledgeable and highly skilled nurses in the world, and ongoing professional development and education are fundamental elements in ensuring we deliver the highest quality care to our patients and their families. This book is intended to encourage and challenge nurses to further develop their critical care nursing practice. Our vision for the ﬁrst edition was for an original text from Australasian authors, not an adaptation of texts produced in other parts of the world. This writing approach more accurately captures the uniquely local elements that form contemporary critical care nursing in Australia and New Zealand and help to answer the myriad of questions posed by critical care nurses as they practise in the local environment, while still allowing the universal core elements that represent critical care practice internationally. This second edition of ACCCN’s Critical Care Nursing has 27 chapters that reﬂect the collective talent and expertise of 50 contributors – a strong mix of academics and clinicians with a passion for critical care nursing – in showcasing the practice of critical care nursing in Australia, New Zealand, Asia and the Paciﬁc. We also engaged contributors beyond Australasia to reﬂect global practices and to extend the applicability of out text to a wider geographic audience. All contributors were carefully chosen for their current knowledge, clinical expertise and strong professional reputations. The book has been developed primarily for use by practising critical care clinicians, managers, researchers and graduate students undertaking a specialty critical care qualiﬁcation. In addition, senior undergraduate students studying high acuity nursing subjects will ﬁnd this book a valuable reference tool, although it goes beyond the learning needs of these students. The aim of the book is to be a comprehensive resource, as well as a portal to an array of other important resources, for critical care nurses. The nature and timeline of book publishing dictates that the information contained in this book reﬂects a snapshot in time of our knowledge and understanding of the complex world of critical care nursing. We therefore encourage our readers to continue to also search for the most contemporary sources of knowledge to guide their clinical practice. A range of website links have been included in each chapter to facilitate this process. This second edition is again organised in three broad sections: the scope of critical care nursing, core components of critical care nursing, and specialty aspects of critical care nursing. Inclusion of new chapters and signiﬁcant revisions to existing chapters were based on our reﬂections and suggestions from colleagues and reviewers as well as on evolving and emerging practices in critical care. Section 1 introduces a broad range of professional issues related to practice that are relevant across critical care. Initial chapters provide contemporary information on the scope of practice, systems and resources, quality and safety, recovery and rehabilitation, and ethical issues. Content presented in the second section is relevant to the majority of critical care nurses, with a focus on concepts that underpin practice such as essential physical, psychological, social and cultural care. Remaining chapters in this section present a systems approach in supporting physiological function for a critically ill individual. This edition now has multiple linked chapters for some of the major physiological systems – 4 chapters for cardiovascular, 3 for respiratory, and 2 for neurological. Chapters on support of renal function, gastrointestinal, liver and nutritional alterations, management of shock, and multiorgan dysfunction complete this section. The third section presents speciﬁc clinical conditions such as emergency presentations, trauma, resuscitation, paediatric considerations, pregnancy and post-partum considerations, and organ donation, by building on the principles outlined in Section 2. This section enables readers to explore some of the more complex or unique aspects of specialty critical care nursing practice. Chapters have been organised in a consistent format to ease identiﬁcation of relevant material. Where appropriate, each chapter commences with an overview of relevant anatomy and physiology, and the epidemiology of the clinical states in the Australian and New Zealand setting. Nursing care of the patient, both delivered independently or provided collaboratively with other members of the healthcare team, is then presented. Pedagogical features include a case study that elaborates relevant care issues, vii viii P R E F A C E a critique of a research publication that explores a related topic, and learning activities to assist both the reader and those in educational roles to assess knowledge acquisition. Extensive use of tables, ﬁgures and practice tips are located throughout each chapter to identify areas of care that are particularly pertinent for readers. It is not our intention that readers progress sequentially through the book, but rather explore chapters or sections that are relevant for different episodes of learning or practice. The delivery of effective, high-quality critical care nursing practice is a challenge in contemporary health care. We trust that this book will be a valuable resource in supporting your care of critically ill patients and their loved ones. Doug Elliott Leanne Aitken Wendy Chaboyer About the Australian College of Critical Care Nurses (ACCCN) The Australian College of Critical Care Nurses, with over 2400 members, is the peak professional organisation representing critical care nurses in Australia. Membership types include standard membership, international members, life members, honorary members and corporate members. All individual members are eligible and are encouraged to participate in the activities of the College; to receive the College journal and Critical Times publication, in addition to discounts for ACCCN conference registration and for ACCCN publications. Life and honorary memberships are awarded to individuals in recognition of their outstanding contribution to ACCCN and/or to critical care nursing excellence in Australia. ACCCN is a company limited by guarantee and has branches in each state of Australia, with two members from each state branch management committee forming the ACCCN National Board of Directors. Each committee facilitates the activities of the college at a local/state level and provides local and at times national representation. The ACCCN Editorial Committee and Editorial Board, under the leadership of the editor of the Australian Critical Care (ACC) journal, are responsible for the College publications including the journal Australian Critical Care and newspaper Critical Times. There are a number of national advisory panels and special interest groups dedicated to providing the organisation with expert opinion on issues relating to critical care nursing. These include: Resuscitation Advisory Panel: consists of eight members representing each branch of ACCCN, plus a paediatric nurse representative. It has developed a complete suite of contemporary advanced life support and resuscitation educational material and offers its ACCCN National ALS Courses throughout Australia; Research Advisory Panel: in addition to providing expert advice to ACCCN, the panel is responsible for evaluating and making recommendations on research strategy and grant submissions to ACCCN, and for evaluating abstracts submitted to the ANZICS/ACCCN Annual Scientiﬁc Meeting on Intensive Care; Education Advisory Panel: advises ACCCN on all matters relating to education speciﬁc to critical care nursing. This panel has developed a position paper on critical care nursing education and written submissions on behalf of ACCCN to national reviews of nursing education; Workforce Advisory Panel: has represented ACCCN on a number of national health workforce and nursing committees. The panel has also developed position statements on nurse stafﬁng for intensive care and high-dependency units in Australia, and annually reviews the dataset design for national workforce data collection in conjunction with ANZICS; Organ & Tissue Donation & Transplantation Advisory Panel: advises the board and developed a position statement on organ donation and transplantation as it relates to intensive care. It disseminates related information to critical care nurses regarding the promotion and national reform objectives of organ and tissue donation in Australia; Quality Advisory Panel: provides expert knowledge, advice and information to ACCCN on matters relevant to critical care nursing practice relating speciﬁcally to patient management. Paediatric Advisory Panel: provides expert knowledge, advice and information to ACCCN on matters relevant to paediatric critical care nursing in addition to recommending content and speakers for the annual ACCCN conferences. The ICU Liaison Special Interest Group: is a collective group of ACCCN members who have an interest in ICU liaison/outreach and work together to discuss matters relevant to this increasing area of critical care nursing focus. In addition to branch educational events and symposiums, ACCCN conducts three national conferences each year: ACCCN Institute of Continuing Education (ICE); and, in conjunction with our medical colleagues from The Australian and New Zealand Intensive Care Society (ANZICS), the ANZICS/ACCCN Annual Scientiﬁc Meeting on Intensive Care and the Australian and New Zealand Paediatric & Neonatal Intensive Care Conference. ACCCN has a representative on the Australian Resuscitation Council (ARC), and has representation at a federal government advisory level through the Nursing and Midwifery Stakeholder Reference Group (NMSRG) chaired by the Chief Nurse of Australia, and is also a member of the Coalition of National Nursing Organisations (CoNNO). The founding Chairperson of the World Federation of Critical Care Nurses (WFCCN) continues to represent ACCCN on the WFCCN Council, and the College also has representatives on the World Federation of Paediatric Intensive and Critical Care Societies, and is a member of the Intensive Care Foundation. More information can be found on the ACCCN website: www.acccn.com.au ix About the Editors Doug Elliott Doug Elliott is Professor of Nursing in the Faculty of Nursing, Midwifery and Health at the University of Technology, Sydney. During his 25 years as a nurse academic, Doug has been a faculty Director of Research, Clinical Professor, Head of Department and a conjoint hospital appointment as Assistant Director of Nursing – Research. Prior to this, he worked as a clinician in acute and critical care areas in tertiary hospitals in Sydney and Perth. Doug’s clinical and health services research focuses on the health-related quality of life (HRQOL) and illness experiences of individuals with critical and acute illnesses, and the use of technologies to improve patient outcomes. Doug has received research funding from the NHMRC and the Australian Commission on Safety and Quality in Health Care, as well as competitive funding from other national organisations, health service and university funding sources. He has published over 80 peerreviewed articles and book chapters, and is co-editor for two additional books, on nursing and midwifery research, and pathophysiology and nursing practice. Doug became a Life Member of the Australian College of Critical Care Nurses in 2006 in recognition of over 20 years of service to critical care. He has previously been an Associate Editor and on the Editorial Board for Australian Critical Care, was the inaugural Chair of the Research Advisory Panel, a member of the Education Advisory Panel, and also served on the NSW committee. He is currently on the Editorial Board for the American Journal of Critical Care, and peer-reviews for several critical care medicine and nursing journals, and a range of competitive funding bodies. Doug has been an invited speaker to international and national multi-disciplinary critical care meetings on numerous occasions. Leanne Aitken Leanne Aitken is Professor of Critical Care Nursing at Grifﬁth University and Princess Alexandra Hospital, Queensland. She has a long career in critical care nursing, including practice, education and research roles. In all her roles in nursing, Leanne has been inspired by a sense of enquiry, pride in the value of expert nursing and a belief that improvement in practice and resultant patient outcomes is always possible. Research interests include developing and reﬁning interventions to improve long x term recovery of critically ill and injured patients, decision-making practices of critical care nurses and a range of clinical practice issues within critical care and trauma. Leanne has been active in ACCCN for more than 20 years and was made a Life Member of the College in 2006 after having held positions on state and national boards, coordinated the Advanced Life Support course in Western Australia in its early years, chaired the Education Advisory Panel and been an Associate Editor with Australian Critical Care. In addition, she is a peer reviewer for a number of national and international journals and reviews grant applications for a range of organisations including the National Health and Medical Research Council (NHMRC) and Intensive Care Foundation. She is the World Federation of Critical Care Nurses’ representative on a number of sepsis related working groups including an international group who authored a companion paper to the Surviving Sepsis Campaign guidelines to summarise the evidence underpinning nursing care of the septic patient, the revision of the Surviving Sepsis Campaign Guidelines and the Global Sepsis Alliance. Wendy Chaboyer Wendy Chaboyer is a Professor of Nursing at Grifﬁth University and the Director of the Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, funded by the National Health and Medical Research Council (NHMRC) (2010–2015). Wendy has 30 years experience in the critical care area, as a clinician, educator and researcher and she is passionate about the contribution nurses can make to a patient’s, and their family’s, hospital experience. Her research has focused on ICU patients’ transitions and on continuity of care for ICU patients. More recently, she has focused on patient safety, undertaking research into adverse events after ICU, clinical handover and ‘transforming care at the bedside’. Wendy has been active in ACCCN since her arrival in Australia in the early 1990s. She has been a National Board member and member of the Queensland Branch Management Committee. Wendy is a past Chair of the Research Advisory Panel and past Chair of the Quality Advisory Panel of the ACCCN. Wendy played a role in the formation of the World Federation of Critical Care Nurses and continues to support their activities. Wendy reviews for a number of journals and funding bodies such as the NHMRC and the Australian Research Council. Contributors Leanne Aitken RN, PhD, BHSc(Nurs)Hons, GradCertMgt, GradDipScMed(ClinEpi), ICCert, FRCNA Professor of Critical Care Nursing Griffith University & Princess Alexandra Hospital Brisbane, Queensland Debbie Austen RN, BaHSc, Grad Cert Critical Care, Grad Cert Management, JP (Qual) Registered Nurse, Capricorn Coast Hospital and Health Service Queensland Ian Baldwin RN, PhD Post Graduate Educator Intensive Care Unit, Austin Health Victoria Julie Benbenishty MNS Academic Consultant Surgical Division Hadassah Hebrew University Medical Center Jerusalem, Israel Tom Buckley RN(UK), PhD MNRes, BScHlth CertICU, CertTeaching&Assessing Senior Lecturer and Co-ordinator Master of Nursing (Clinical Nursing & Nurse Practitioner) Sydney Nursing School, The University of Sydney New South Wales Wendy Chaboyer RN, BSc (Nu) Hon, MN, PhD Director NHMRC Centre of Research Excellence in Nursing Interventions for Hospitalised Patients (NCREN), Research Centre for Clinical and Community Practice Innovation (RCCCPI) Griffith Health Institute Queensland Diane Chamberlain RN BN BSc MNSc (Critical Care) MPH PhD Senior Lecturer Flinders University South Australia Wendy Corkill RN Clinical Nurse Specialist Alice Springs Hospital Northern Territory Amanda Corley BN, ICU Cert, GradCert HealthSci, M AdvPrac (candidate) Nurse Researcher Critical Care Research Group, The Prince Charles Hospital Queensland Clare Fitzpatrick Registered Nurse, Registered Midwife BA (Hons) Lead for Critical Care Liverpool Women’s NHS Foundation Trust Liverpool, United Kingdom Judy Currey RN BN BN(Hons) Crit Care Cert Grad Cert Higher Ed Grad Cert Sc (App Stats) PhD Associate Professor in Nursing Deakin University Victoria Robyn Gallagher RN, BA (Psych), MN, PhD Associate Professor Chronic and Complex Care Faculty of Nursing, Midwifery and Health University of Technology, Sydney New South Wales Jennifer Dennett RN, MN, BAppSc (Nursing), CritCareCert, Dip Management, MRCNA Nurse Unit Manager Critical Care, Oncology, Cardiology, Renal Dialysis, Central Gippsland Health Service Victoria David Glanville RN, BN, Grad Dip Crit Care Nursing, MN Nurse Educator Intensive Care Unit Epworth Freemasons Hospital East Melbourne, Victoria Malcolm Dennis RN, Bed, CritCareCert(ICU) Bed Field Technical Specialist Cardiac Rhythm Management Division, St Jude Medical New South Wales Christopher Gordon RN, MExSc, PhD Senior Lecturer Director of Postgraduate Advanced Studies Sydney Nursing School, The University of Sydney New South Wales Andrea Driscoll RN, CCC, BN, MN, MEd, PhD Senior Research Fellow Monash University, Melbourne Victoria Michael Graan RN, GradDip CritCare Clinical Nurse Educator (ICU) Epworth HealthCare Richmond, Victoria Trudy Dwyer RN, ICU Cert, BHlth, GCert FlexLrn, MClinEd, PhD Associate Professor School of Nursing and Midwifery, Faculty of Sciences, Engineering & Health Central Queensland University Queensland Bernadette Grealy RN, RM, CritCareCert, BN, MN Clinical Services Coordinator Intensive Care Unit Queen Elizabeth Hospital South Australia Doug Elliott RN, PhD BAppSc(Nurs), MAppSc(Nurs), ICCert Professor of Nursing Faculty of Nursing, Midwifery and Health University of Technology Sydney, New South Wales Rosalind Elliott RN, BSc (Hons), PG Dip (Crit Care), MN PhD candidate University of Technology Sydney New South Wales Melanie Greenwood MN, Grad Cert. UniTeach&Learn, ICCert, NeurosciCert Senior Lecturer, School of Nursing and Midwifery University of Tasmania Tasmania Gabrielle Hanlon RN, Crit Care Cert, BN, GDBL, MRCNA Project Manager Australian Commission on Safety & Quality in Health Care New South Wales xi xii C O N T R I B U T O R S Denise Harris RN, BHSc(Nurs), GradDipHlthAdmin& InfoSys, MN(Res), ICCert Assistant Director of Nursing—Medicine & Critical Care The Tweed Hospital Tweed Heads, New South Wales Karena Hewson-Conroy BSocSci(Hons), PhD candidate Research & Quality Manager, Intensive Care Co-ordination & Monitoring Unit Honorary Associate, Faculty of Nursing, Midwifery & Health, University of Technology New South Wales David Johnson RN, Grad Dip (Acute Care Nurs), MHealth Sci Ed, A&E Cert, MCN Director of Nursing Caloundra Health Service Sunshine Coast Wide Bay Health Service District Queensland Alison Juers RN, BN (Dist), MN (Crit Care) Nurse Educator Brisbane Private Hospital Queensland Tina Kendrick RN, PIC Cert, BNurs(Hons), MNurs, FCN, FRCNA Clinical Nurse Consultant – Paediatrics NSW Newborn and Paediatric Emergency Transport Service New South Wales Leila Kuzmuik RN, BN, DipAdvClinNurs, MN, Grad Cert HlthServMgt Nurse Educator Intensive Care Services John Hunter Hospital, Hunter New England Health New South Wales Gavin D Leslie RN, IC Cert, PhD, BAppSc, Post Grad Dip (Clin Nurs), FRCNA Professor Critical Care Nursing Royal Perth Hospital Director Research & Development School of Nursing & Midwifery, Curtin University Western Australia Frances Lin RN, BMN, MN (Hons), PhD Lecturer & Program Convenor (Master of Nursing – Critical Care) School of Nursing and Midwifery Griffith University Queensland Andrea Marshall RN PhD Sesqui Senior Lecturer Critical Care Nursing Sydney Nursing School University of Sydney New South Wales Marion Mitchell RN, BN (Hon), Grad Cert (Higher Educ), Ph.D. Senior Research Fellow Critical Care Griffith University and Princess Alexandra Hospital Queensland Margherita Murgo BN, MN (Crit Care) Project Officer Clinical Excellence Commission New South Wales Maria Murphy RN PhD, Grad Dip Crit Care, Grad Cert Tert Ed, BN, Dip App Sci (Nursing) Lecturer LaTrobe University Clinical Nurse Specialist Austin Health Victoria Louise E Niggemeyer RN, MEd, BEdSt, IC Cert, MRCNA Trauma Program Manager The Alfred Hospital Senior Researcher Trauma Systems & Education Consultant National Trauma Research Institute Alfred Health Victoria Wendy Pollock RN, RM, Grad Dip Crit Care Nsg, Grad Dip Ed, Grad Cert Adv Learn & Leadership, PhD Research Fellow La Trobe University/Mercy Hospital for Women Victoria Anne-Sylvie Ramelet RN, ICU Cert, PhD Senior Lecturer Institute of Higher Education and Nursing Research Lausanne University-Centre Hospitalier Universitaire Vaudois, Switzerland Professor, HECVSanté University of Applied Sciences Western Switzerland Switzerland Janice Rattray PhD, MN, DipN (CT), RGN, SCM Reader School of Nursing and Midwifery University of Dundee United Kingdom Mona Ringdal RN, PhD, MSc Senior Lecturer Institute of Health and Care Sciences The Sahlgrenska Academy, University of Gothenburg Sweden Amanda Rischbieth RN, Grad Dip (Intens Care), MNSc, PhD School of Nursing University of Adelaide South Australia Louise Rose BN, MN, PhD, ICU Cert Assistant Professor Lawrence S. Bloomberg Faculty of Nursing, University of Toronto Research Director and Advanced Practice Nurse, Prolonged-ventilation Weaning Centre, Toronto East General Hospital, Toronto Ontario, Canada Elizabeth Skewes DAppSc(Nursing), CCRN Senior Nurse of Organ and Tissue Donation St Vincent’s Hospital Victoria Paul Thurman RN, MS, ACNPC, CCNS, CCRN, CNRN Clinical Nurse Specialist R Adams Cowley Shock Trauma Center University of Maryland Medical Center Baltimore, Maryland, USA Vicki Wade Dip Nsg, BHSc, MN Leader National Aboriginal Health Unit Heart Foundation Australia Sharon Wetzig RN, BN, Grad Cert (Critical Care), MEd Clinical Nurse Consultant Princess Alexandra Hospital Queensland Ged Williams RN, RM, CritCareCert, MHA, LLM, FACHSM, FRCNA, FAAN Executive Director of Nursing and Midwifery Gold Coast Health Service District Professor of Nursing, Griffith University Founding President, World Federation of Critical Care Nurses Queensland Teresa Williams RN, ICUCert, BN, MHlthSci (Res), GradDipClinEpi, PhD Research Assistant Professor and NH&MRC Clinical Research Postdoctoral Fellow Discipline of Emergency Medicine (SPARHC) The University of Western Australia Western Australia Denise Wilson PhD, RN, FCNA(NZ) Associate Professor Māori Health Auckland University of Technology Auckland, New Zealand Mark Wilson DipAppSc (Nursing), GDipClPrac (Emergency Nursing), MHScEd Emergency Department Nurse Educator Illawarra Shoalhaven Local Health District New South Wales Reviewers Steven Frost RN, MPH Lecturer, School of Nursing and Midwifery University of Western Sydney New South Wales Holly Northam RN, RM, M Critical Care Nursing Assistant Professor of Critical Care Nursing University of Canberra Australian Capital Territory Melanie Greenwood MN, Grad Cert. UniTeach&Learn, ICCert, NeurosciCert Senior Lecturer School of Nursing and Midwifery University of Tasmania Tasmania Jon Mould PhD candidate, MSc, RGN, RSCN, RMN, Adult Cert Ed Senior Lecturer Edith Cowan University Western Australia Nichole Harvey RN, EM, CritCareCert, BN (Post Reg), MNSt, GradCertEd (TT), PhD Candidate Senior Lecturer School of Medicine and Dentistry James Cook University Queensland Ann Kuypers RN, Med Grad Dip(Clin Ed), Grad Cert (Periop) Lecturer Nursing Academic Language and Learning Unit LaTrobe University, Albury Wodonga Campus Victoria Renee McGill MN, Grad Cert Crit Care, BS(Nurs) Lecturer in Nursing, Academic Advisor School of Nursing, Midwifery and Indigenous Health Charles Sturt University New South Wales Stephen McNally RN, BApp Sc (Nursing), PhD Lecturer, Head of Program University of Western Sydney New South Wales Helena Sanderson RN, BHSc, ICU Cert, MN(Advanced Clinical Education) Lecturer in Nursing School of Health University of New England Armidale, New South Wales Natashia Scully RN, BA, BN, PGDipNSc(Critical Care), MPH(Candidate) Lecturer in Nursing School of Health University of New England Armidale, New South Wales Kerry Southerland RN, ICCert, BSc, MCN, GCTT, MRCNA Lecturer School of Nursing & Midwifery Curtin University Western Australia Peter Thomas RN, BSc, GradDipEd, PhD Lecturer School of Nursing, Midwifery & Indigenous Health University of Wollongong New South Wales xiii Acknowledgements A project of this nature and scope requires many talented and committed people to see it to completion. The decision to publish this second edition was supported enthusiastically by the Board of the Australian College of Critical Care Nurses (ACCCN) and Elsevier Australia. To our chapter contributors for this edition, both those returning from the ﬁrst edition and our new collaborators – thank you for accepting our offer to write, for having the courage and conﬁdence in yourselves and us to be involved in the text, and for being committed in meeting writing deadlines while developing the depth and quality of content that we had planned. We also acknowledge the work of chapter contributors from our ﬁrst edition – Harriet Adamson, Susan Bailey, Martin Boyle, Sidney Cuthbertson, Suzana Dimovski, Bruce Dowd, Ruth Endacott, Paul Fulbrook, Michelle Kelly, Bridie Kent, Anne Morrison, Wendy Swope and Jane Treloggen. Continued encouragement and support from the Board and members of ACCCN, for having the belief in us as editors and authors to uphold the values of the College, is much appreciated. We also acknowledge support from xiv the staff at Elsevier Australia, our publishing partner. Thanks to our Publishing Editor Libby Houston, for guiding this major project; our Developmental Editors – initially Larissa Norrie, and then Elizabeth Coady for the majority of the project; and to Melissa Read our editor. In Publishing Services, Geraldine Minto, thanks for your work with typesetting issues. To others who produced the high quality ﬁgures, developed and executed the marketing plan, and the myriad of other activities, without which a text such as this would never come to fruition, thank you. We acknowledge our external reviewers who devoted their time to provide insightful suggestions in improving the text and contributed to the quality of the ﬁnished product. Finally, and most importantly, to our respective loved ones – Maureen, Kate, Nick and Josh; Steve; and Michael – thanks for your belief in us, and your understanding and commitment in supporting our careers. Doug Elliott Leanne Aitken Wendy Chaboyer Detailed Contents Section 1 Scope of Critical Care 1 2 3 4 5 1 Section 2 Principles and Practice of Critical Care Scope of Critical Care Practice Development of critical care nursing Roles of critical care nurses Clinical decision making Leadership in critical care nursing Developing a body of knowledge Summary 3 3 6 6 7 11 12 Resourcing Critical Care Ethical allocation and utilisation of resources Historical influences Economic considerations and principles Budget Critical care environment Equipment Staff Risk management Measures of nursing workload or activity Management of pandemics Summary 17 Quality and Safety Quality and safety monitoring Patient safety Summary 38 42 49 52 8 Recovery and Rehabilitation ICU-acquired weakness Patient outcomes following a critical illness Psychological recovery Rehabilitation and mobility in ICU Ward-based post-ICU recovery Recovery after hospital discharge Summary 57 58 59 61 66 68 68 72 9 Ethical Issues in Critical Care Principles, rights and the link with law End-of-life decision making Brain death Organ donation Ethics in research Summary 78 78 83 88 89 91 96 17 18 19 20 22 22 23 28 30 33 34 6 7 10 Essential Nursing Care of the Critically Ill Patient Personal hygiene Eye care Oral hygiene Patient positioning and mobilisation Bowel management Urinary catheter care Bariatric considerations Infection control in the critical care unit: general principles Transport of critically Ill patients: general principles Summary Psychological Care Anxiety Delirium Sedation Pain Sleep Summary Family and Cultural Care of the Critically Ill Patient Overview of models of care Cultural care Religious considerations End-of-life issues and bereavement Summary 103 105 105 107 109 110 115 116 117 118 123 125 133 133 136 138 141 145 149 156 157 161 170 172 173 Cardiovascular Assessment and Monitoring 180 Related anatomy and physiology 180 Assessment 190 Haemodynamic monitoring 195 Diagnostics 206 Summary 210 Cardiovascular Alterations and Management 215 Coronary heart disease 215 Heart failure 227 Selected cases: Cardiomyopathy 241 Hypertensive emergencies 242 xv xvi D E T A I L E D C O N T E N T S 11 12 13 14 15 16 Infective endocarditis Aortic aneurysm Ventricular aneurysm Summary Cardiac Rhythm Assessment and Management The cardiac conduction system Arrhythmias and arrhythmia management Cardiac pacing Cardioversion Ablation Summary 243 244 245 245 17 251 251 252 265 280 285 285 18 Cardiac Surgery and Transplantation Cardiac surgery Intra-aortic balloon pumping Heart transplantation Summary 291 291 302 308 319 Respiratory Assessment and Measurement Related anatomy and physiology Pathophysiology Assessment Respiratory monitoring Bedside and laboratory investigations Diagnostic procedures Summary 325 325 333 335 338 341 344 347 Respiratory Alterations and Management Incidence of respiratory alterations Respiratory failure Pneumonia Respiratory pandemics Acute lung injury Asthma and chronic obstructive pulmonary disease Pneumothorax Pulmonary embolism Lung transplantation Summary 352 352 353 357 360 362 Ventilation and Oxygenation Management Oxygen therapy Airway support Intubation Tracheostomy Complications of endotracheal intubation and tracheostomy Tracheal suction Extubation Mechanical ventilation Non-invasive ventilation Invasive mechanical ventilation Summary 381 381 383 384 386 Neurological Assessment and Monitoring Neurological anatomy and physiology Neurological assessment and monitoring Summary 414 414 431 440 364 366 367 369 374 387 387 387 388 389 392 404 19 20 21 Neurological Alterations and Management Neurological therapeutic management Central nervous system disorders Selected neurological cases Summary Support of Renal Function Related anatomy and physiology Pathophysiology and classification of renal failure Acute renal failure: clinical and diagnostic criteria for classification and management Renal dialysis Approaches to renal replacement therapy Summary Gastrointestinal, Liver and Nutritional Alterations Gastrointestinal physiology Nutrition Nutrition support Stress-related mucosal disease Liver dysfunction Liver transplantation Glycaemic control in critical illness Incidence of diabetes in Australasia Summary Management of Shock Pathophysiology Patient assessment Hypovolaemic shock Cardiogenic shock Distributive shock states Anaphylaxis Neurogenic/spinal shock Summary Multiple Organ Dysfunction Syndrome Pathophysiology Systemic response Organ dysfunction Multiorgan dysfunction Summary Section 3 Specialty Practice in Critical Care 22 Emergency Presentations Triage Extended roles Retrievals and transport of critically ill patients Multiple patient triage/disaster Respiratory presentations Chest pain presentations Abdominal symptom presentations Acute stroke Overdose and poisoning Near-drowning Hypothermia 446 450 456 471 473 480 481 484 487 489 492 502 507 507 509 510 514 517 523 526 527 529 540 540 542 543 546 552 555 557 558 563 564 565 568 570 573 579 581 582 586 587 588 589 591 593 594 596 612 614 D E TA I L E D C O N T E N T S Hyperthermia and heat illness Summary 615 615 23 Trauma Management Trauma systems and processes Common clinical presentations Summary 623 623 626 649 24 Resuscitation Pathophysiology Resuscitation systems and processes Management Roles during cardiac arrest Family presence during an arrest Ceasing CPR Postresuscitation phase Near-death experiences Legal and ethical considerations Summary 654 655 655 655 670 670 671 671 671 672 672 Paediatric Considerations in Critical Care Anatomical and physiological considerations in children Developmental considerations Comfort measures Family issues and consent The child experiencing upper airway obstruction The child experiencing lower airway disease Nursing the ventilated child The child experiencing shock The child experiencing acute neurological dysfunction Gastrointestinal and renal considerations in children Paediatric trauma Summary 679 Pregnancy and Postpartum Considerations Epidemiology of critical illness in pregnancy Adapted physiology of pregnancy Diseases and conditions unique to pregnancy 710 710 711 716 25 26 680 684 685 686 686 691 693 695 696 698 700 702 27 Exacerbation of medical disease associated with pregnancy Special considerations Caring for pregnant women in ICU Caring for postpartum women in ICU Summary Organ Donation and Transplantation ‘Opt-in’ system of donation in Australia and New Zealand Types of donor and donation Organ donation and transplant networks in Australasia 0 Identification of organ and tissue donors Organ donor care Donation after cardiac death Tissue-only donor Summary APPENDIX A1 Declaration of Madrid: Education APPENDIX A2 Declaration of Buenos Aires: Workforce 726 729 731 735 738 746 746 747 747 749 755 757 758 758 763 765 APPENDIX A3 Declaration of Vienna APPENDIX B1 ACCCN Position Statement (2006) on the Provision of Critical Care Nursing Education APPENDIX B2 ACCCN ICU Staffing Position Statement (2003) on Intensive Care Nursing Staffing APPENDIX B3 Position Statement (2006) on the Use of Healthcare Workers other than Division 1* Registered Nurses in Intensive Care APPENDIX B4 ACCCN Resuscitation Position Statement (2006) – Adult & Paediatric Resuscitation by Nurses APPENDIX C Normal Values 767 779 780 GLOSSARY LIST OF FIGURES INDEX 783 790 799 773 775 777 xvii Abbreviations 2-PAM pralidoxime 6MWT six-minute walk test A/C assist control A/C MV assist-controlled mechanical ventilation AACN American Association of Critical-care Nurses AATT aseptic non-touch technique ABG arterial blood gas ACCCN Australian College of Critical Care Nurses ACD active compression–decompression ACE angiotensin-converting enzyme ACEM Australasian College of Emergency Medicine ACh acetylcholine AChE acetylcholinesterase ACN advanced clinical nurse ACNP acute care nurse practitioner ACS acute coronary syndrome ACS abdominal compartment syndrome ACT activated clotting time ACTH adrenocorticotrophic hormone ADAPT Australasian Donor Awareness Program Training ADE adverse drug event ADH antidiuretic hormone ADL activities of daily living ADP adenosine diphosphate AE adverse event AED automatic external defibrillator AHA American Heart Association AHEC Australian Health Ethics Committee AIS abbreviated injury score AKI acute kidney infection ALF acute liver failure ALI acute lung injury ALP alkaline phosphatase ALS advanced life support ALT alanine aminotransferase AMI acute myocardial infarction AND autonomic nerve dysfunction ANP atrial natriuretic peptide ANZBA Australian and New Zealand Burn Association ANZICS Australian and New Zealand Intensive Care Society ANZOD Australia and New Zealand Organ Donation Registry AoCLF acute-on-chronic liver failure xviii AODR Australian Organ Donor Register AORTIC Australasian Outcomes Research Tool for Intensive Care APACHE acute physiology and chronic health evaluation APC activated protein C APRV airway pressure release ventilation aPTT activated partial thromboplastin time ARAS ascending reticular activating system ARC Australian Resuscitation Council ARDS acute respiratory distress syndrome ARF acute renal failure ASL arterial spin labelling AST aspartate aminotransferase ATC automatic tube compensation ATCA Australasian Transplant Coordinators Association ATN acute tubular necrosis ATP adenosine triphosphate ATS Australasian Triage Scale AV arteriovenous AV atrioventricular AVDO 2 arteriovenous difference in oxygen AVM arteriovenous malformation AVPU Alert/response to Voice/only responds to Pain/ Unconscious BBB blood–brain barrier BDI Beck Depression Inventory BiPAP bilevel positive airway pressure BiVAD biventricular assist device BIS bispectral index BLS basic life support BMV Bag/mask ventilation BP blood pressure BPS Behavioural Pain Scale BSA body surface area BSLTx bilateral sequential lung transplantation BTF Brain Trauma Foundation BURP Backwards, upwards, rightward pressure BVM bag–valve–mask CaO2 content of arterial oxygen in the blood CABG Coronary artery bypass graft CAM-ICU Confusion Assessment Method – Intensive Care Unit CAP community-acquired pneumonia CAUTI Catheter associated urinary tract infection CAV cardiac allograft vasculopathy CAVH continuous arteriovenous haemofiltration A B B R E V I AT I O N S CBF cerebral blood flow CBG corticosteroid-binding globulin CCF chronic cardiac failure CCU critical care unit—may be intensive care, coronary care, high dependency or a combination of these CCU coronary care unit CDSS clinical decision support system CEO2 cerebral oxygen extraction CES–D Center for Epidemiologic Studies–Depression CFI cardiac function index CFM cerebral function monitoring CHD coronary heart disease CHF chronic heart failure CI cardiac index CI critical illness CIM critical illness myopathy CINM critical illness neuromyopathy CIP critical illness polyneuropathy CIPNP critical illness polyneuropathy CIS clinical information system CK creatine kinase CLAB Central line associated bacteremia CLD chronic liver disease CLF chronic liver failure cLMA classic laryngeal mask airway CLRT continuous lateral rotation therapy CMV controlled mechanical ventilation CMV cytomegalovirus CNE clinical nurse educator CNPI checklist of nonverbal pain Indicators CNS central nervous system CO carbon monoxide CO cardiac output CO2 carbon dioxide COAD chronic obstructive airways disease COPD Chronic Obstructive pulmonary disease CPAP continuous positive airway pressure CPB cardiopulmonary bypass CPDU clinical practice development unit CPG clinical practice guideline CPM cuff pressure monitoring CPOE computerised physician (provider) order entry CPOT Critical Care Pain Observation Tool CPP cerebral perfusion pressure CPP coronary perfusion pressure CPR cardiopulmonary resuscitation CRASH corticosteroid randomisation after significant head injury CRF chronic renal failure CRH corticotrophin-releasing hormone CRP c-reactive protein CRRT continuous renal replacement therapy CSF cerebrospinal fluid CSSU central sterile supply unit CSWS cerebral salt-wasting syndrome CT computerised tomography CTG clinical trials group (of ANZICS) CVC central venous catheter CVD cardiovascular disease CvO2 central venous oxygenation CVP central venous pressure CVVH continuous veno-venous haemofiltration CVVHDf continuous veno-venous haemodiafiltration CXR chest X-ray DAI diffuse axonal injury DASS Depression Anxiety and Stress Scale DAT decision analysis theory DCD donor after cardiac death DCM dilated cardiomyopathy DDAVP 1-deamino-8-D-arginine vasopressin (Vasopressin) DKA diabetic ketoacidosis DO2 oxygen delivery DPL diagnostic peritoneal lavage DRG diagnosis-related group DSC (MRI) dynamic susceptibility contrast DVT deep venous thrombosis EBI electrical burn injury EBN evidence based nursing EBP evidence based practice EC ethics committee EC extracorporeal circuit ECC external cardiac compression ECG electrocardiograph/y ECMO extracorporeal membrane oxygenation ED emergency department EDD extended daily diafiltration EDD-f extended daily dialysis filtration EDIS Emergency Department Information System EEG electroencephalogram EGDT early goal-directed therapy EMD electromechanical dissociation EMS emergency medical system EN enteral nutrition ENID emerging novel infectious disease EPAP expiratory positive airway pressure ePD emancipatory practice development EQ-5D Euroquol 5D ERC European Resuscitation Council ESBL-E extended-spectrum beta-lactamase-producing Enterobacteriaceae ESLD end stage liver disease ESLF end-stage liver failure ETC (o)esophageal–tracheal Combitube ETCO2 end-tidal carbon dioxide ETIC-7 experience after treatment in intensive care ETT endotracheal tube EVLW extravascular lung water FAED fully automatic external defibrillator FAST focused assessment with sonography for trauma FBC full blood count FDA (US) Food and Drug Administration FES fat embolism syndrome FEV1 forced expiratory volume in 1 second FFA free fatty acid xix xx A B B R E V I A T I O N S FFP fresh frozen plasma FI fear index FiO2 fraction of inspired oxygen fMRI functional magnetic resonance imaging FRC functional residual capacity FTE full-time equivalent (equivalent to 76-hour fortnight) FVC forced vital capacity FWR family witness resuscitation GABA gamma-aminobutyric acid GAS general adaptation syndrome GCS Glasgow Coma Scale GEDV global end-diastolic volume GGT gamma-glutamyl transpeptidase GI gastrointestinal GIT gastrointestinal tract GM1 monosialoganglioside GTN glyceryl trinitrate HCO3− sodium bicarbonate H2CO3 carbonic acid H+ hydrogen HADS hospital anxiety and depression scale HAI Healthcare acquired infection Hb haemoglobin HbF fetal haemoglobin HCM hypertrophic cardiomyopathy HDU high-dependency unit HE hepatic encephalopathy HFA Heart Foundation Australia HFNC high flow nasal cannuala(e) HFOV high-frequency oscillatory ventilation HH heated humidification HHNS hyperglycaemic hyperosmolar non-ketotic state Hib Haemophilus influenzae type b HIT Heparin-induced thrombocytopenia HME heat–moisture exchanger HPA hypothalamic–pituitary–adrenal HRC Health Research Council (New Zealand) HRQOL health-related quality of life HRS hepatorenal syndrome HSV herpes simplex virus HTLV human T-lymphotropic virus I:E inspiratory:expiratory (ratio) IABP intra-aortic balloon pump IAC interposed abdominal compression IAP intra-abdominal pressure ICC intercostal catheter ICD implantable cardioverter defibrillator ICDSC Intensive Care Delirium Screening Checklist ICG indocyanine green ICH intracranial haemorrhage ICP intracranial pressure ICT information and communications technologies ICU intensive care unit ICU-AW intensive care unit acquired weakness ICU LN intensive care unit liaison nurse IDC indwelling catheter I:E inspiratory:expiratory (ratio) IES impact of events scale IgE immunoglobulin E IHD intermittent haemodialysis IL interleukin ILCOR International Liaison Committee on Resuscitation IMA internal mammary artery INR International Normalized Ratio IO intraosseous IPP information privacy principles IPPV intermittent positive pressure ventilation IPT information-processing theory ISS injury severity score ITBV intrathoracic total blood volume IVC inferior vena cava IVIg intravenous immunoglobulin JE Japanese B encephalitis LAD left anterior descending coronary artery LAP left atrial pressure LDL low-density lipoprotein LDLT living donor liver transplantation LFTs liver function tests LMA laryngeal mask airway LN liaison nurse LOC level of consciousness LOC loss of consciousness LP lumbar puncture LVAD left ventricular assist device LVEDV left ventricular end-diastolic volume LVEF left ventricular ejection fraction LVF left ventricular failure LVP left ventricular pressure LVSWI left ventricular stroke work index MAP mean arterial pressure MARS molecular adsorbent(s) recirculating system MASS Motor Activity Assessment Scale MCA middle cerebral artery MED manual external defibrillator MET medical emergency team MET(s) metabolic equivalent(s) MEWS medical early-warning system MIDCAB minimally invasive direct coronary artery bypass MIDCM minimally invasive direct cardiac massage mmHg millimetres of mercury MODS multiple organ dysfunction syndrome MRI magnetic resonance imaging MRO Multi-resistant organisms MRS magnetic resonance spectroscopy MRSA methicillin-resistant Staphylococcus aureus MVC motor vehicle collision MVE Murray Valley encephalitis NAC N-acetylcysteine NAS nursing activities scale NASCIS National Acute Spinal Cord Injury Study NAT nucleic acid testing NDE near-death experience NDU nursing development unit NE norepinephrine A B B R E V I AT I O N S NFκB nuclear factor kappa B NGT nasogastric tube NHBD non-heart-beating donation NHMRC National Health and Medical Research Council NHP Nottingham Health Profile NIBP non-invasive blood pressure NIRS near-infrared spectroscopy NIV non-invasive ventilation NMB neuromuscular blocking NMDA N-methyl-d-aspartate NMJ neuromuscular junction NO nitrous oxide NO2 nitric oxide NOC Nurse observation checklist NOK next of kin NP nurse practitioner NPA nasopharyngeal aspirate NPP national privacy principles NPY neuropeptide Y NSAIDS Non-steroidal anti-inflammatory drugs NTS national triage scale NTT nasotracheal tube NYHA New York Heart Association O2 oxygen ODIN organ dysfunction and/or infection OEF oxygen extraction fraction OHCA out-of-hospital cardiac arrest OLTx orthotopic liver transplantation OSA Obstructive sleep apnoea OTDA Organ and Tissue Donation Agency PA alveolar pressure Pa arterial pressure PaCO2 partial pressure of carbon dioxide in arterial blood PaO2 partial pressure of oxygen in arterial blood Paw peak airway pressure Pv venous pressure PAC pulmonary artery catheter PAF platelet-activating factor PALS paediatric advanced life support PaO2 partial pressure of arterial oxygen PAOP pulmonary artery occlusion pressure PAP pulmonary artery pressure PART patient-at-risk team PAWP pulmonary artery wedge pressure PbtO2 brain tissue oxygen PCI percutaneous coronary intervention PCT dynamic perfusion computed tomography PCV pressure-controlled ventilation PCWP pulmonary capillary wedge pressure PD peritoneal dialysis PDH pulmonary dynamic hyperinflation PDR plasma disappearance rate PDSA plan, do, study, act PDU practice development unit PE pulmonary embolism PEA pulseless electrical activity PEEP positive end-expiratory pressure PEFR peak expired flow rate PET positron emission tomography PETCO2 positive end-tidal carbon dioxide pH acid–alkaline logarithmic scale PI pulsatility index PICC peripherally inserted central catheter PiCCO pulse-induced contour cardiac output PICU paediatric intensive care unit PN parenteral nutrition PND paroxysmal nocturnal dyspnoea PNS peripheral nervous system Pplat plateau pressure PPE personal protective equipment PROWESS (recombinant human-activated) protein C worldwide evaluation in severe sepsis PRVC pressure-regulated volume control PSG Polysomnography PT prothrombin time PTA posttraumatic amnesia PTCA percutaneous transluminal coronary angioplasty PTSD posttraumatic stress disorder PTSS posttraumatic stress symptoms PTT partial thromboplastin time Pv venous pressure PvO2 mixed venous oxygen pressure PVR peripheral vascular resistance QI quality improvement QOL quality of life QOL–IT quality of life–Italian version QOL–SP quality of life–Spanish version QUM quality use of medicines QWB quality of wellbeing RAAS renin–angiotensin–aldosterone system RASS Richmond Agitation–Sedation Scale RAS reticular activating system RBC red blood cell RCA root cause analysis RCA right coronary artery RCSQ Richards-Campbell Sleep Questionnaire REM Rapid eye movement RICA Right Internal Carotid Artery ROSC return of spontaneous circulation RRS rapid response system RR respiratory rate RRT rapid response teams RRT renal replacement therapy RTS revised trauma score RVF right ventricular failure RVP right ventricular pressure RVSWI right ventricular stroke work index SaO2 saturation of oxygen in arterial blood SpO2 saturation of oxygen in peripheral tissues SvO2 venous oxygen saturation SA sinoatrial SAC safety assessment coding SAED semiautomatic external defibrillator SAFE Saline versus Albumin Fluid Evaluation (trial) xxi xxii A B B R E V I A T I O N S SAH subarachnoid haemorrhage SAI State Anxiety Inventory SAPS simplified acute physiology score SARS severe acute respiratory syndrome SARS-CoV severe acute respiratory syndrome coronavirus SAS Sedation Agitation Scale SBE serum base excess SBP systolic blood pressure SCA sudden cardiac arrest SCI spinal cord injury SCUF slow continuous ultrafiltration SE status epilepticus SEI sleep efficiency index SF-36 Short Form 36 SGRQ St George’s Respiratory Questionnaire SIADH syndrome of inappropriate antidiuretic hormone secretion SICQ Sleep in Intensive Care Questionnaire SIG strong ion gap SIMV synchronised intermittent mandatory ventilation SIP sickness impact profile SIRS systemic inflammatory response syndrome SjvO2 jugular venous oxygen saturation SLTx single lung transplantation SOFA sepsis-related/sequential organ failure assessment SPECT single photon emission computed tomography SR systematic review SSG surviving sepsis guidelines STAI State Trait Anxiety Inventory STEMI ST-elevation myocardial infarction SVDK snake venom detection kit SVG saphenous vein graft SVR systemic vascular resistance SVT supraventricular tachycardia SVV stroke volume variation SWS Slow wave sleep TAFI thrombin-activatable fibrinolysis inhibitor TB tuberculosis TBI traumatic brain injury TCD transcranial Doppler TEG thromboelastograph TIPS transjugular intrahepatic portosystemic shunt/stent TISS therapeutic intervention scoring system TLC total lung capacity TNF[alpha] tumour necrosis factor alpha TNS Tumour Necrosis Factor TOE transoesophageal echocardiograph/y tPA tissue plasminogen activator tPD technical practice development TPN total parenteral nutrition TPR temperature, pulse, respirations TSANZ Transplant Society of Australia and New Zealand TSC trauma symptom checklist TSH thyroid-stimulating hormone TST Total sleep time TT thrombin time TV tidal volume TVI time velocity interval UEC urea, electrolytes, creatinine UO urine output URTI upper respiratory tract infection V ventilation V/Q ventilation/perfusion V T tidal volume VALI ventilator-associated lung injury VAP ventilator-acquired pneumonia VAS Visual analogue scale VAS-A Visual analogue scale – Anxiety VC Vital capacity VC volume-controlled (ventilation) VCV volume controlled ventilation VE minute ventilation VF ventricular fibrillation VICS Vancouver Interaction and Calmness Scale VO2 oxygen consumption VRE vancomycin-resistant Enterococcus VT ventricular tachycardia VTE venous thromboembolism VV veno-venous WBC white blood cell WCC white cell count WFCCN World Federation of Critical Care Nurses WHO World Health Organization WOB work of breathing XeCT xenon-enhanced computed tomography SECTION 1 Scope of Critical Care Scope of Critical Care Practice 1 Leanne Aitken Wendy Chaboyer Doug Elliott Learning objectives After reading this chapter, you should be able to: ● describe the history and development of critical care nursing practice, education and professional activities ● discuss the influences on the development of critical care nursing as a discipline and the professional development of individual nurses ● outline the various roles available to nurses within critical care areas or in outreach services ● discuss the potential impact of clinical decision-making processes on patient outcomes ● consider processes in the work and professional environment that are influenced by local leadership styles. Key words critical care nursing roles of critical care nurses clinical decision making clinical leadership INTRODUCTION There is unprecedented demand for critical care services globally. In our region, there are approximately 119,000 admissions to 141 general intensive care units (ICUs) in Australia per year; this includes 5500 patient readmissions during the same hospital episode. In New Zealand, there are 18,000 admissions per year to 26 ICUs, including 500 re-admissions.1 Patients admitted to coronary care, paediatric or other specialty units not classiﬁed as a general ICU are not included in these ﬁgures, so the overall clinical activity for ‘critical care’ is much higher (e.g. there were also 5500 paediatric admissions to PICUs).1 Importantly, critical care treatment is a highexpense component of hospital care; one conservative estimate of cost exceeded $A2600 per day, with more than two-thirds going to staff costs, one ﬁfth to clinical consumables and the rest to clinical support and capital expenditure.2 Critical care as a specialty in nursing has developed over the last 30 years.3,4 Importantly, development of our specialty in Australia and New Zealand has been in concert with development of intensive care medicine as a deﬁned clinical specialty. Critical care nursing is deﬁned by the World Federation of Critical Care Nurses as: Specialised nursing care of critically ill patients who have manifest or potential disturbances of vital organ functions. Critical care nursing means assisting, supporting and restoring the patient towards health, or to ease the patient’s pain and to prepare them for a digniﬁed death. The aim of critical care nursing is to establish a therapeutic relationship with patients and their relatives and to empower the individuals’ physical, psychological, sociological, cultural and spiritual capabilities by preventive, curative and rehabilitative interventions.5 Critically ill patients are those at high risk of actual or potential life-threatening health problems.6 Care of the critically ill can occur in a number of different locations in hospitals. In Australia and New Zealand, critical care is generally considered a broad term, incorporating subspecialty areas of emergency, coronary care, highdependency, cardiothoracic, paediatric and general intensive care units.7 This chapter provides a context for subsequent chapters, outlining some key principles and concepts for studying and practising nursing in a range of critical care areas. The scope of critical care nursing is described in the Australian and New Zealand contexts, which in turn have some inﬂuence on clinical practice in Southeast Asia and the Paciﬁc. Development of the specialty is discussed, along with the professional development and evolving roles of critical care nurses in contemporary health care, including clinical decision making and leadership. DEVELOPMENT OF CRITICAL CARE NURSING Critical care as a specialty emerged in the 1950s and 1960s in Australasia, North America, Europe and South Africa.4,8-11 During these early stages, critical care consisted 3 4 SCOPE OF CRITICAL CARE primarily of coronary care units for the care of cardiology patients, cardiothoracic units for the care of postoperative patients, and general intensive care units for the care of patients with respiratory compromise. Later developments in renal, metabolic and neurological management led to the principles and context of critical care that exist today. Development of critical care nursing was characterised by a number of features,4 including: ● ● ● ● ● the development of a new, comprehensive partnership between nursing and medical clinicians the collective experience of a steep learning curve for nursing and medical staff the courage to work in an unfamiliar setting, caring for patients who were extremely sick – a role that required development of higher levels of competence and practice a high demand for education speciﬁc to critical care practice, which was initially difﬁcult to meet owing to the absence of experienced nurses in the specialty the development of technology such as mechanical ventilators, cardiac monitors, pacemakers deﬁbrillators, dialysers, intra-aortic balloon pumps and cardiac assist devices, which prompted development of additional knowledge and skills. There was also recognition that improving patient outcomes through optimal use of this technology was linked to nurses’ skills and stafﬁng levels.12 The role of adequately educated and experienced nurses in these units was recognised as essential from an early stage,8 and led to the development of the nursing specialty of critical care. Although not initially accepted, nursing expertise, ability to observe patients and appropriate nursing intensity are now considered essential elements of critical care.12 As the practice of critical care nursing evolved, so did the associated areas of critical care nursing education and specialty professional organisations such as the Australian College of Critical Care Nurses (ACCCN). The combination of adequate nurse stafﬁng, observation of the patient and the expertise of nurses to consider the complete needs of patients and their families is essential to optimise the outcomes of critical care. As critical care continues to evolve, the challenge remains to combine excellence in nursing care with judicious use of technology to optimise patient and family outcomes. CRITICAL CARE NURSING EDUCATION Appropriate preparation of specialist critical care nurses is a vital component in providing quality care to patients and their families.5 A central tenet within this framework of preparation is the formalised education of nurses to practise in critical care areas.13 Formal education – in conjunction with experiential learning, continuing professional development and training, and reﬂective clinical practice – is required to develop competence in critical care nursing. The knowledge, skills and attitude necessary for quality critical care nursing practice have been articulated in competency statements in many countries.14-16 Critical care nursing education developed in unison with the advent of specialist critical care units. Initially, this consisted of ad-hoc training developed and delivered in the work setting, with nurses and medical ofﬁcers learning together. For example, medical staff brought expertise in physiology, pathophysiology and interpretation of electrocardiographic rhythm strips, while nurses brought expertise in patient care and how patients behaved and responded to treatment.12,17 Training was, however, fragmented and ‘ﬁtted in’ around ward stafﬁng needs. Postregistration critical care nursing courses were subsequently developed from the early 1960s in both Australasia and the UK.4,8 Courses ranged in length from 6 to 12 months and generally incorporated employment as well as speciﬁc days for lectures and class work. Given the local nature of these courses developed for the local needs of individual hospitals and regions, differences in content and practice therefore developed between hospitals, regions and countries.18-20 During the 1990s the majority of these hospital-based courses in Australasia were discontinued as universities developed postgraduate curricula to extend the knowledge and skills gained in pre-registration undergraduate courses. A signiﬁcant proportion of critical care nurses now undertake specialty education in the tertiary sector, often in a collaborative relationship with one or more hospitals.4 One early study of students enrolled in university-based critical care courses in Australia21 identiﬁed a number of burdens (workload, ﬁnancial, study– work conﬂicts), but also a number of beneﬁts (e.g. better job prospects, job security). Within Australia and New Zealand, most tertiary institutions currently offer postgraduate critical care nursing education at a Graduate Certiﬁcate or Graduate Diploma level as preparation for specialty practice, although this is often provided as a Master’s degree.22 In the UK, similar provisions for postgraduate critical care nursing education at multiple levels are available, although some universities also offer critical care specialisation at the undergraduate level (for example, King’s College, London). Education throughout Europe has undergone signiﬁcant change in the past 10 years as the framework articulated under the Bologna Process has been implemented.23 In relation to critical care nursing, this has led to the expansion of programs, primarily at the postgraduate level, for specialist nursing education. Critical care nursing education in the USA maintains a slightly different focus, with most postgraduate studies being generic in nature, including a focus on advanced practice roles such as clinical nurse specialists and nurse practitioners, while specialty education for critical care nurses is undertaken as continuing education.24 Employment in critical care, with associated assessment of clinical competence, remains an essential component of many universitybased critical care nursing courses.22,25 Both the impact of post-registration education on practice and the most appropriate level of education that is required to underpin specialty practice remain controversial, with no universal acceptance internationally.26-29 Globally, the Declaration of Madrid, which was endorsed Scope of Critical Care Practice ‘beginner’ Induction/ orientation to critical care nursing Postgraduate education ‘competent’ ‘specialist’ ‘expert’ continuing experience/experiential learning Practice Training short courses/skills updates/in-service education initial competencies increasing complexity of competencies Graduate Certificate Graduate Diploma Education Masters FIGURE 1.1 Critical care nursing practice: training and education continuum. by the World Federation of Critical Care Nurses, provides a baseline for critical care nursing education (see Appendix A for the position statement).5 A range of factors continue to inﬂuence critical care nursing education provision, including government policies at national and state levels, funding mechanisms and resource implications for organisations and individual students, education provider and healthcare sector partnership arrangements, and tensions between workforce and professional development needs.13 Recruitment, orientation, training and education of critical care nurses can be viewed as a continuum of learning, experience and professional development.5 The relationships between the various components related to practice, training and education are illustrated in Figure 1.1, on a continuum from ‘beginner’ to ‘expert’ and incorporating increasing complexities of competency. All elements are equally important in promoting quality critical care nursing practice. Practice- or skills-based continuing education sessions support clinical practice at the unit level.30 (Orientation and continuing education issues are discussed further in the context of stafﬁng levels and skills mix in Chapter 2.) Many countries now incorporate requirements for continuing professional development into their annual licensing processes. Speciﬁc requirements include elements such as minimum hours of required professional development and/or ongoing demonstration of competence against predeﬁned competency standards.31,32 SPECIALIST CRITICAL CARE COMPETENCIES Critical care nursing involves a range of skills, classiﬁed as psychomotor (or technical), cognitive or interpersonal. Performance of speciﬁc skills requires special training and practice to enable proﬁciency. Clinical competence is a combination of skills, behaviours and knowledge, demonstrated by performance within a practice situation33 and speciﬁc to the context in which it is demonstrated.34 A nurse who learns a skill and is assessed as performing that skill within the clinical environment is deemed competent. As noted above, a set of competency statements for specialist critical care practice comprises 20 competency standards grouped into six domains: professional practice, reﬂective practice, enabling, clinical problem solving, teamwork and leadership14 (see Appendix B). The validity of this structure of six domains has been questioned, however, as a number of competency statements are linked to several domains.35 Further research is therefore required to reﬁne the structure of a competency model with improved construct validity.35 Other competency domains and assessment tools have also been developed.25 Although articulated slightly differently, the American Association of Critical-Care Nurses (AACN) provides ‘Standards of Practice and Performance for the Acute and Critical Care Clinical Nurse Specialist’,36 which outlines six standards of practice (assessment, diagnosis, outcome identiﬁcation, planning, implementation and evaluation) and eight standards of professional performance (quality of care, individual practice evaluation, education, collegiality, ethics, collaboration, research and resource utilisation) (see Online resources). CRITICAL CARE NURSING PROFESSIONAL ORGANISATIONS Professional leadership of critical care nursing has undergone considerable development in the past three decades. Within Australia, the ACCCN (formerly the Confederation of Australian Critical Care Nurses) was formed from a number of preceding state-based specialty nursing bodies (e.g. Australian Society of Critical Care Nurses, Clinical Nurse Specialists Association) that provided professional leadership for critical care nurses since the early 1970s. In New Zealand, the professional interests of critical care nurses are represented by the New Zealand Nurses Organisation, Critical Care Nurses Section, as well as afﬁliation with the ACCCN. The ACCCN has strong professional relationships with other national peak nursing bodies, the Australian and New Zealand Intensive Care Society (ANZICS), government agencies and individuals, and healthcare companies. Professional organisations representing critical care nurses were formed as early as the 1960s in the USA with the formation of the American Association of Critical Care Nurses (AACN).37 Other organisations have developed around the world, with critical care nursing bodies now operating in countries from Australasia, Asia, North America, South America, Africa and Europe. In 2001 the inaugural meeting of the World Federation of Critical Care Nurses (WFCCN) was formed to provide professional leadership at an international level.38,39 The ACCCN 5 6 SCOPE OF CRITICAL CARE was a foundation member of the WFCCN and a member association of the World Federation of Societies of Intensive Care and Critical Care Medicine, and maintains a representative on the councils of both these international bodies. (See the ACCCN website, listed in Online resources, for further details about professional activities.) ROLES OF CRITICAL CARE NURSES As the discipline of critical care has developed, so too has the range of roles performed by specialty critical care nurses.40,41 The continuum of critical illness (see Chapter 4) includes pre-crisis/proactive care, management of the critical illness, and follow-up care in hospital, clinic and home settings.42 This continuum also includes the practice of palliative care in the ICU environment.43 Clinical (bedside) roles and nurse-to-patient ratios for various levels of critical care unit, as well as the roles of unit manager and clinical nurse educator, are discussed in Chapter 2. Practice issues for critical care clinicians are detailed in the remaining chapters of this book. Roles that apply to all nursing professionals are speciﬁcally highlighted; for example: ● ● ● carer, in Chapters 6, 7 and 8, all practice-related chapters in Section 2, and the specialty chapters in Section 3 patient and family advocate, in Chapters 5 and 8 educator, in Chapter 3. This section focuses on the scope of critical care nurses’ roles inside and external to the critical care area, and provides links to other speciﬁc chapters.44 These roles include: ● ● ● consultant45-47 advanced practice48/nurse practitioner roles in ICU,46 trauma,49 emergency50 (Chapter 22), critical care outreach51/ICU liaison52-54 (Chapter 2) research/quality coordinator (Chapter 3). Developing a body of knowledge and the integral role of research and nurse researchers in that process is described in a later section of this chapter. CONSULTANT Expert clinicians in one of the subspecialties of critical care – emergency, general ICU, cardiology, cardiothoracic, neurosciences – play important roles in facilitating improvements in clinical practice for both critical care and non-critical care patients. The consultant’s role involves clinical practice, education, quality improvement and research activities.55 Within these work portfolios, leadership and the development and dissemination of knowledge45,46 within a multidisciplinary team are integral to effective practice.47 Practice includes role-modelling of expected behaviours, policy and clinical guideline development to support clinical care, and facilitating professional development of colleagues in collaboration with the nurse educator role. The beneﬁts that this role brought to the critical care area led to the introduction of a similar service for non-critical care areas, particularly in the context of clinical deterioration of patients or for patients recently discharged from the ICU, with the development of critical care outreach or ICU liaison nurse roles (see Chapter 2 for further discussion of these services). In practice, the role of clinical consultant and that of an advanced practice nurse or nurse practitioner can become blurred, with hospital administrators believing that one role can replace the other. Clearly, however, the consultant’s role has a broader portfolio, with a focus on supporting clinical colleagues in providing safe, quality patient care, while the role of advanced practice nurse or nurse practitioner has a direct patient care focus (see below). ADVANCED PRACTICE NURSE/NURSE PRACTITIONER Processes for authorisation to practise as a nurse practitioner (NP) have been introduced by professional registration agencies in Australia and New Zealand, with similar roles present in the UK and USA prior to this.48 Nurse practitioner roles in ‘critical care’ (or high dependency) range from emergency department practitioners through to community-based cardiac failure specialists, and, as noted above for the nurse consultant’s role, often lack clarity regarding their scope of practice.56,57 Factors inﬂuencing the establishment of these roles include the accrediting process, deﬁning the scope of practice through speciﬁc clinical practice guideline development, prescribing rights and the prevailing medical views, and the level of support provided by health service administrators for the implementation, development and evaluation of the role.48,56 Advanced practice roles in the emergency department are the most well-established in the critical care domain (see Chapter 22). CLINICAL DECISION MAKING Clinical decision making is integral to critical care nursing practice and forms part of the clinical reasoning process. Clinical reasoning is the cognitive processes and strategies that nurses use to understand the signiﬁcance of patient data, to identify and diagnose actual or potential patient problems, and to make clinical decisions to assist in problem resolution and to achieve positive patient outcomes.58 Clinical information and prior knowledge are therefore used to inform a decision. This section focuses on the decision-making component of clinical reasoning. A brief overview of the theoretical perspectives that have been used to understand clinical decision making is provided and then studies that focus on critical care nursing are reviewed. Finally, strategies for developing clinical decision-making skills are provided. THEORETICAL PERSPECTIVES ON DECISION MAKING There are numerous theoretical perspectives on decision making, but they can be grouped into two main categories: 1. analytical or rationalist 2. intuitive or humanistic. Scope of Critical Care Practice The analytical approaches arise from a positivist or rationalist perspective and focus on analysing behaviours and the steps involved in problem solving. Some of the speciﬁc theories that fall into this category include information-processing theory (IPT)59 and decision analysis theory (DAT).60 Fundamental to IPT is the premise that reasoning consists of a relationship between the problem solver and the context within which the problem occurs. This theory asserts that relevant information is stored in one’s memory and that problem solving occurs when the problem solver retrieves information from both short- and long-term memory. Additionally, IPT claims that there are limits to the amount of information that can be processed at any given time. Thus, IPT focuses on understanding how information is gathered, stored and retrieved. DAT focuses on the use of decision trees, mathematical formulas and other techniques to determine the likelihood of meaningful clinical data. These rationalist approaches focus on diagnosing a problem, intervening and evaluating the outcome.61 Contrary to the analytical approaches, intuitive approaches (also termed humanistic, hermeneutic or phenomenological) focus on the importance of intuitive knowledge and context in clinical decision making.40,62,63 That is, expert intuition develops with experience and can be used to make complex decisions. Both intuitive knowledge and analytical reasoning contribute to clinical decisions.63 Intuitive approaches to decision making therefore focus on understanding the development of intuition, the role of experience and articulating how nurses use intuition to make a decision. In addition, Australian authors64 have described a naturalistic framework to examine critical care nurses’ decision making, describing it as a way of considering how people use their experience when making real-life decisions. RESEARCH ON DECISION MAKING IN CRITICAL CARE NURSING Critical care nursing practice has been the focus of many studies on decision making. As multiple, complex decisions are made in rapid succession in critical care, it is an ideal setting for studying clinical decision making.61 The seminal work by Benner and colleagues40,63,65 focused on critical care nurses. Table 1.1 summarises 10 studies (11 publications) conducted on critical care nurses’ decision making over the past decade. Of note, 7 of the 10 studies were conducted in Australia, with two multinational studies also including Australia. All but two studies66,67 used qualitative approaches such as observation, interviewing and thinking aloud. Two studies reported the types and frequency of decisions made during the time period and identiﬁed that critical care nurses’ decisions were related to interventions and communication,61,68 evaluation,61 assessment, organisation and education.68 A further study demonstrated that critical care nurses generate one or more hypotheses about a situation prior to decision making.69 All three studies highlighted the importance of enabling expert nurses to provide a narrative account of their practice. Other studies indicated that experienced and inexperienced nurses differ in their decision making skills,67,70,71 and that role models or mentors are important in assisting to develop decision making skills.72 RECOMMENDATIONS FOR DEVELOPING CLINICAL DECISION MAKING SKILLS Several strategies can be used to help critical care nurses to develop their clinical decision-making abilities (Table 1.2).73-75 These strategies can be used by nurses at any level to develop their own decision-making skills, or by educators in planning educational sessions. In summary, clinical decision making is a component of the clinical reasoning process that is part of everyday critical care nursing practice. It involves gathering and analysing information in order to arrive at a decision about a particular course of action. The analytical or rationalist perspective of clinical decision making focuses on analysing behaviours and the steps in solving a problem, while the intuitive or humanistic approach centres on intuitive knowledge and the context of the decision. In this specialty area nurses are making clinical decisions at a rate of two to three per minute.61,68 Given this, it is important that clinical decision-making skills be developed through experience, training and education. Previous research has demonstrated that a number of strategies, such as case studies and reﬂection on action, can be used to assist nurses in developing these important skills. LEADERSHIP IN CRITICAL CARE NURSING Effective leadership within critical care nursing is essential at several organisational levels, including the unit and hospital levels, as well as within the specialty on a broader professional scale. The leadership required at any given time and in any speciﬁc setting is a reﬂection of the surrounding environment. Regardless of the setting, effective leadership involves having and communicating a clear vision, motivating a team to achieve a common goal, communicating effectively with others, role modelling, creating and sustaining the critical elements of a healthy work environment and implementing change and innovation.76-79 Leadership at the unit and hospital levels is essential to ensure excellence in practice, as well as adequate clinical governance. In addition to the generic strategies described above, it is essential for leaders in critical care units and hospitals to demonstrate a patient focus, establish and maintain standards of practice and collaborate with other members of the multi-disciplinary healthcare team.76 Leadership is essential to achieve the growth and development in our specialty and is demonstrated through such activities as conducting research, producing publications, making conference presentations, representation on relevant government and healthcare councils and committees, and participation in organisations such as the ACCCN and the WFCCN. As outlined earlier in this chapter, we have seen the ﬁeld of critical care grow from early ideas and makeshift units to a well-developed and 7 8 SCOPE OF CRITICAL CARE TABLE 1.1 Australian and international critical care nurses decision-making research Author [Country] Sample Data collection 18 CC nurses (range of levels and experiences; all had completed a CC course) Observation (2-hour periods) Currey & Worrall-Carter, 200168 [Australia] 12 CC nurses with 2+ years’ CC experience from 3 units Clinical decision record (of 2-hour periods) and focus groups Aitken, 200369 [Australia] 8 expert CC nurses with 5+ years’ CC experience Thinking aloud (2-hour periods) and follow-up interview Hypotheses developed as a framework for decision making A combination of strategies used to gather data Currey & Botti, 200670 [Australia] CC nurses from 2 metropolitan hospitals; 18 inexperienced (≤3 years) and 20 experienced CC nurses (>3 years). Observation followed by semi-structured interview Clinical processes that affected decision making following the settling in phase post cardiac surgery were: ● handover from anaesthetists ● settling in procedures ● collegial assistance. 15 nurses (13 inexperienced) felt daunted by decision making while 7 nurses (1 inexperienced) felt challenged with a sense of being stimulated, excited and positive. Currey, Browne & Botti (2006)70 [Same study as above] [Australia] Same as above Observation in 2 phases: 1st phase comprised unstructured, narrative observational data; 2nd phase comprised a 2-page structured observation checklist. Followed up by interview. Quality of haemodynamic decision making in the 2 hours post cardiac surgery was influenced by decision complexity, nurses’ level of experience, and forms of decision support provided by nursing colleagues. Experience was a dominant influence in recognising patterns of haemodynamic cues that were suggestive of complications. Adherence to evidence-based practice also influenced quality of decision making. Aitken, 2008102 [Australia] 7 CC nurses with a CC qualification, >5 years CC experience, and working ≥2 days/week Observation and/or thinking aloud, along with follow-up interviews A range of concepts related to the assessment and management of sedation needs. Assessment included: ● patient’s condition ● response to therapy ● multiple sources of information during assessment ● consideration of relevant history ● consideration of the impact on physiology and pathophysiology ● implications of treatment ● options in treatment. Hough, 2008103 [USA] 15 CC nurses from 4 units, with varied experience and education levels In-depth, semi-structured interviews The presence of a role model or mentor to help guide the ethical decision-making process, through reflection-in-action, was critical for focused ethical discourse and the decision making. Enhanced ethical decision making occurred through experiential learning. Thompson, 200867 [various countries] 245 Dutch, UK, Canadian and Australian registered nurses working in surgical, medical, ICU or HDU Vignettes with decision whether or not to contact a senior nurse/doctor. The proportion of true positives (the patient is at risk of a critical event and the nurse takes action) and false positives (the nurse takes action when it was not warranted) was calculated. Time pressure significantly reduced the nurses’ decision tendency to intervene. There were no statistically significant differences in decision-making ability between years of generic clinical experience. There were statistically significant differences in decision-making ability between years of critical care experience when participants were not under time pressure: those with greater critical care experience performed better. Under time pressure, there were no differences in decision-making ability between years of critical care experience. Bucknall, 2000 [Australia] 61 Findings Three types of decision: evaluation (51%) ● communication (30%) ● intervention (19%) Average: 238 decisions/2 hours (i.e. 2.0/min) ● Five types of decision: intervention (40%) ● communication (26%) ● assessment (19%) ● organisation (13%) ● education (2%) Average: 395 decisions/2 hours (i.e. 3.3/min) ● Scope of Critical Care Practice TABLE 1.1, Continued Author [Country] Sample Data collection Findings 8 CC nurses: 4 novice and 4 expert Thinking aloud (during 2-hour period of care); interview ● Ramezani-Badr, 2009104 [Iran] 14 CC nurses from 4 hospitals, currently working in the CCU, with ≥3 years CC experience and holding at least a bachelor of nursing. In-depth, semi-structured interviews ● Thompson, 200966 [Various countries] 245 Dutch, UK, Canadian and Australian registered nurses working in surgical, medical, ICU or HDU. Judgement classification systems, Continuous (0–100) ratings or dichotomous ratings on 3 nursing judgements were used Hoffman, 2009 [Australia] 71 Cue usage and clustering during decision making: Expert nurses collected 89 different cues, while novices collected 49 different cues. ● Expert nurses clustered a greater number of cues when making decisions regarding the patient’s haemodynamic status. ● Expert nurses were more proactive in collecting relevant cues to anticipate problems and make decisions. 3 themes were involved in reasoning strategies: intuition ● recognising similar situations ● hypothesis testing. 3 other themes regarding participants’ criteria to make decisions: ● patient’s risk-benefits ● organisational necessities (i.e. complying with organisational policy even if it meant they were capable of doing more) ● complementary sources of information (e.g. research papers and pharmacology texts). Critical care experience was associated with estimates of risk, but not with the decision to intervene. Nurses varied considerably in their risk assessments, this being partly explained by variability in weightings given to information. Information was synthesised in non-linear ways that contributed little to decisional accuracy. TABLE 1.2 Strategies to develop clinical decision-making skills Strategy Description Iterative hypothesis testing74 Description of a clinical situation for which the clinician has to generate questions and develop hypotheses; with additional questioning the clinician will develop further hypotheses. Three phases: 1. asking questions to gather data about a patient 2. justifying the data sought 3. interpreting the data to describe the influence of new information on decisions. Interactive model74 Schema (mental structures) used to teach new knowledge by building on previous learning. Three components: 1. advanced organisers – blueprint that previews the material to be learned and connects it to previous materials 2. progressive differentiation – a general concept presented first is broken down into smaller ideas 3. integrative reconciliation – similarities and differences and relationships between concepts explored. Case study75 Description of a clinical situation with a number of cues, followed by a series of questions. Three types: 1. stable – presents information, then asks clinicians about it 2. dynamic – presents information, asks the clinicians about it, presents more information, asks more questions 3. dynamic with expert feedback – combines the dynamic method with immediate expert feedback. Reflection on action74 Clinicians are asked to reflect on their actions after a particular event. Reflection focuses on clinical judgments made, feelings surrounding the actions and the actions themselves. Reflection on action can be undertaken as an individual or group activity and is often facilitated by an expert. Thinking aloud74 A clinical situation is provided and the clinician is asked to think aloud, or verbalise his/her decisions. Thinking aloud is generally facilitated by an expert and can be undertaken individually or in groups. highly organised international specialty in the course of half a generation. Such development would not have been possible without the vision, enthusiasm and commitment of many critical care leaders throughout the world. Leadership styles vary and are inﬂuenced by the mission and values of the organisation as well as the values and beliefs of individual leaders. These styles of leadership are described in many different ways, sometimes using theoretical underpinnings such as ‘transactional’ 9 10 S C O P E O F C R I T I C A L C A R E and ‘transformational’ and sometimes by using leadership characteristics. Regardless of the terminology in use, some common principles can be expressed. Desired leadership characteristics include the ability to: ● ● ● ● ● ● ● ● articulate a personal vision and expectations act as a catalyst for change establish and implement organisational standards model effective leadership behaviours through both change processes and stable contexts monitor practice in relation to standards and take corrective action when necessary recognise the characteristics and strengths of individuals, and stimulate individual development and commitment empower staff to act independently and interdependently inspire team members to achieve excellence.80-85 Personal characteristics of an effective leader, regardless of the style, include honesty, integrity, commitment and credibility, as well as the ability to develop an open, trusting environment.85 Effective leaders inspire their team members to take the extra step towards achieving the goals articulated by the leader and to feel that they are valued, independent, responsible and autonomous individuals within the organisation.85 Members of teams with effective leaders are not satisﬁed with maintaining the status quo, but believe in the vision and goals articulated by the leader and are prepared to work towards achieving a higher standard of practice. Although all leaders share common characteristics, some elements vary according to leadership style. Different styles – for example, transactional, transformational, authoritative or laissez faire – incorporate different characteristics and activities. Having leaders with different styles ensures that there is leadership for all stages of an organisation’s operation or a profession’s development. A combination of leadership styles also helps to overcome team member preferences and problems experienced when a particularly visionary leader leaves. The challenges often associated with the departure of a leader from a healthcare organisation are generally reduced in the clinical critical care environment, where a nursing leader is usually part of a multidisciplinary team, with resultant shared values and objectives. CLINICAL LEADERSHIP Effective critical care nurses demonstrate leadership characteristics regardless of their role or level of practice. Leadership in the clinical environment incorporates the general characteristics listed above, but has the added challenges of working within the boundaries created by the requirements of providing safe patient care 24 hours a day, 7 days a week. It is therefore essential that clinical leaders work within an effective interdisciplinary model, so that all aspects of patient care and family support, as well as the needs of all staff, are met. Effective clinical leadership of critical care is essential in achieving: ● ● effective and safe patient care evidence-based healthcare ● ● satisﬁed staff, with a high level of retention development of staff through an effective coaching and mentoring process.81,86 Effective clinical leaders build cohesive and adaptive work teams.84 They also promote the intellectual stimulation of individual staff members, which encourages the analysis and exploration of practice that is essential for evidence-based nursing.85 Clinical leadership is particularly important in contemporary critical care environments in times of dynamic change and development. We are currently witnessing signiﬁcant changes in the organisation and delivery of care, with the development of new roles such as nurse practitioner (see this chapter) and liaison nurse (see Chapter 3), the introduction of services such as rapid response systems, including medical emergency teams (see Chapter 3), and the extension of activities across the care continuum (see Chapter 4). Effective clinical leadership ensures that: ● ● ● critical care personnel are aware of, and willing to fulﬁl, their changing roles personnel in other areas of the hospital or outside the hospital recognise the beneﬁts and limitations of developments, are not threatened by the developments and are enthusiastic to use the new or reﬁned services patients receive optimal quality of care. The need to provide educational opportunities to develop effective clinical leadership skills is recognised.80 Although not numerous in number or variety, programs are beginning to be available internationally that are designed to develop clinical leaders.79,87 Factors that inﬂuence leadership ability include the external and internal environment, demographic characteristics such as age, experience, understanding, stage of personal development including self-awareness capability, and communication skills.80,82,87 In relation to clinical leadership, these factors can be developed only in a clinical setting, so development of clinical leaders must be based in that environment. Development programs based on mentorship are superbly suited to developing those that demonstrate potential for such capabilities.80 Mentorship has received signiﬁcant attention in the healthcare literature and has been speciﬁcally identiﬁed as a strategy for clinical leadership development.88-90 Although many different deﬁnitions of mentoring exist, common principles include a relationship between two people with the primary purpose of one person in the relationship developing new skills related to their career.91,92 Mentoring programs can be either formal or informal and either internal or external to the work setting. Mentorship involves a variety of activities directed towards facilitating new learning experiences for the mentee, guiding professional development and career decisions, providing emotional and psychological support and assisting the mentee in the socialisation process both within and outside the work organisation to build professional networks.89,91 Role modelling of occupational and professional skills and characteristics is an important Scope of Critical Care Practice 1. randomly allocating patients to receive either a new intervention (the experimental or intervention group) or an alternative or standard intervention (the control group) 2. delivering the intervention or alternative treatment 3. measuring an a priori identiﬁed patient outcome. component of mentoring that helps develop future clinical leaders.89,92 DEVELOPING A BODY OF KNOWLEDGE Development of a body of knowledge is a key characteristic of both professions93-95 and the specialties within professions. One criterion for a specialty identiﬁed over two decades ago by the International Council of Nurses (ICN)96 is that it is based on a core body of nursing knowledge that is being continually expanded and reﬁned by research. Importantly, the ICN acknowledges that mechanisms are needed to support, review and disseminate research. RESEARCH As noted above, research is fundamental in the development of nursing knowledge and practice. Research is a systematic inquiry using structured methods to understand an issue, solve a problem or reﬁne existing knowledge. Qualitative research involves in-depth examination of a phenomenon of interest, typically using interviews, observation or document analysis to build knowledge and enable depth of understanding. Qualitative data analysis is in narrative (text) form and involves some form of content or thematic analysis, with ﬁndings generally reported as narrative (where words rather than numbers describe the research ﬁndings). In contrast, quantitative research involves the measurement (in numeric form) of variables and the use of statistics to test hypotheses. Results of quantitative research are often reported in tables and ﬁgures, identifying statistically signiﬁcant ﬁndings. One particular type of quantitative research, the clinical trial (randomised controlled trial, or RCT), is used to test the effect of a new nursing intervention on patient outcomes. In essence, clinical trials involve: Statistical analyses are used to determine if the new intervention is better for patients than the alternative treatment. Mixed methods research have now emerged as an approach that integrates data from qualitative and quantitative research at some stage in the research process.97 In mixed methods approaches, researchers decide on both priority and sequence of qualitative and quantitative methods. In terms of priority, equal status may be given to both approaches. Priority is indicated by using capital letters for the dominant approach, followed by the symbols + and → to indicate either concurrent or sequential data collection. For example: ● ● ● QUAL + QUANT: both approaches are given equal status and data collection occurs concurrently. QUAL + quant: qualitative methods are the dominant approach and data collection occurs concurrently. QUAL → quant: the qualitative study is given priority and qualitative data collection will occur before quantitative data collection. Irrespective of which type of research design is used, there are a number of common steps in the research process (Table 1.3), consisting of three phases: planning for the research, undertaking the research and analysing and reporting on the research ﬁndings. Clinical research and the related activities of unit-based quality improvement are integral components in the practice, education and research triad.98 Partnerships TABLE 1.3 Steps in the research process Step Description Identify a clinical problem or issue. Clinical experience and practice audits are two ways that clinical issues or problems are identified. Review the literature. A comprehensive literature review is vital to ensure that the issue or problem has not yet been solved and that the proposed research will fill a gap in knowledge. State a clear research question. A concise question includes both the phenomenon of interest and the patient population. Write a research proposal. Clear description of the proposed research design and sample and a plan for data collection and analysis. Ethical considerations and the required resources (i.e. budget) for the research are identified. Secure resources. Resources such as funding for supplies and research staff, institutional support and access to experienced researchers are needed to ensure a study can be completed. Obtain ethics approvals. Approval of the proposed research by a human research ethics committee (HREC) is required before the study can commence. Conduct the research. Adequate time for recruitment of participants and data collection are crucial to ensure that accurate data are obtained. Disseminate the research findings. Conference presentations and journal publications are two common ways that research findings are disseminated and are vital to ensure that both nursing practice and nursing knowledge continue to be developed. 11 12 S C O P E O F C R I T I C A L C A R E Research program Practice issues Patient outcomes Practice development Health status/ HRQOL Clinical information systems Competencies Commonwealth & state policies Evidencebased practice Patient/family experiences Product evaluation Credentialling Impact of international factors Resource utilisation Economic evaluation Impact of technology on patient care Program evaluation Ethical & legal issues Technology assessment Education & training Policy issues FIGURE 1.2 Example of critical care nursing research program. between clinicians and academics, and the implementation of clinical academic positions, including at the professorial level,99 provide the necessary infrastructure and organisation for sustainable clinical nursing and multidisciplinary research. A strong research culture in critical care nursing is evident in Australasia, transcending geographical, epistemological and disciplinary boundaries to focus on the core business of improving care for critically ill patients. Our collective aim is to develop a sustainable research culture that incorporates strategies that facilitate communication, cooperation, collaboration and coordination both between researchers with common interests and with clinicians who seek to use research ﬁndings in their practice. A sample of a guiding structure for a coherent research program that highlights the major issues affecting critical care nursing practice is illustrated in Figure 1.2, with identiﬁed themes and topic exemplars. A number of resources are available to critical care nurses interested in undertaking research. For example, the ACCCN provides funding for research on a competitive basis, with its Research Advisory Panel assessing grant applications and providing feedback to applicants. The Intensive Care Foundation, whose members are drawn from the Australia and New Zealand Intensive Care Society (ANZICS), the College of Intensive Care Medicine (CICM) and ACCCN, also has a research funding scheme. Additionally, the ANZICS Clinical Trials Group (CTG) holds regular meetings where potential research can be discussed and research proposals reﬁned. There is great value in receiving a critical review of proposed research before the study is undertaken, as assessors’ comments help to reﬁne the research plan. Over the years, various groups have identiﬁed priorities for critical care research. A review of this literature identiﬁed the following research priorities: nutrition support, infection control, other patient care issues, nursing roles, stafﬁng and end-of-life decision making.100 While not all nurses are expected to conduct research, it is a professional responsibility to use research in practice.101 Chapter 3 provides a detailed description of research utilisation approaches, with a description of evidence-based practice and the use of evidence-based clinical practice guidelines. In addition, each chapter in this text contains a research critique to assist nurses in developing critical appraisal skills, which will help to determine whether research evidence should change practice. SUMMARY This chapter has provided a context for subsequent chapters, outlining some key issues, principles and concepts for studying and practising nursing in a range of critical care areas. Critical care nursing now encompasses a wide and ever-expanding scope of practice. The previous focus on patients in ICU only has given way to a broader concept of caring for an individual located in a variety of clinical locations across a continuum of critical illness. The discipline of critical care nursing, in collaboration with multidisciplinary colleagues, continues to develop to meet the expanding challenges of clinical practice in today’s healthcare environment. Critical care clinicians also continue their professional development individually, focusing on clinical practice development, education and training, and on quality improvement and research activities, to facilitate quality patient and family care during a time of acute physiological derangement and emotional turmoil. The principles of decision making and clinical leadership at all levels of practice serve to enhance patient safety in the critical care environment. ONLINE RESOURCES American Association of Critical-Care Nurses, www.aacn.org Annual Scientiﬁc Meeting on Intensive Care, www.intensivecareasm.com.au Australian College of Critical Care Nurses, www.acccn.com.au Australia and New Zealand Intensive Care Society, www.anzics.com.au British Association of Critical Care Nurses, www.baccn.org.uk College of Intensive Care Medicine, www.cicm.org.au Intensive Care Foundation (Australia and New Zealand), www.intensivecareappeal.com King’s College, London, www.kcl.ac.uk/schools/nursing World Federation of Critical Care Nurses, http://en.wfccn.org Scope of Critical Care Practice Research vignette Aitken L, Marshall AP, Elliott R, McKinley S. Critical care nurses’ decision making: sedation assessment and management in intensive care. Journal of Clinical Nursing 2008; 18: 36–45. Abstract Aims This study was designed to examine the decision-making processes that nurses use when assessing and managing sedation for a critically ill patient, specifically the attributes and concepts used to determine sedation needs and the influence of a sedation guideline on the decision-making processes. Background Sedation management forms an integral component of the care of critical care patients. Despite this, there is little understanding of how nurses make decisions regarding assessment and management of intensive care patients’ sedation requirements. Appropriate nursing assessment and management of sedation therapy is essential to quality patient care. Design Observational study. Methods Nurses providing sedation management for a critically ill patient were observed and asked to think aloud during two separate occasions for two hours of care. Follow-up interviews were conducted to collect data from five expert critical care nurses pre- and postimplementation of a sedation guideline. Data from all sources were integrated, with data analysis identifying the type and number of attributes and concepts used to form decisions. Results Attributes and concepts most frequently used related to sedation and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; post, 9%) and treatment (pre, 31%; post, 26%) aspects of care. Conclusions Decision making in this setting is highly complex, incorporating a wide range of attributes that concentrate primarily on assessment aspects of care. Relevance to clinical practice Clinical guidelines should provide support for strategies known to positively influence practice. Further, the education of nurses to use such guidelines optimally must take into account the highly complex iterative process and wide range of data sources used to make decisions. Critique The study aim was to identify the concepts and attributes used by Australian critical care nurses in their decision making before and after the implementation of a nurse-initiated sedation protocol. A number of educational strategies were used to support implementation of the sedation protocol including: individual and group education; protocol and its supporting evidence placed on the intranet; laminated copies of the protocol available in the patient care areas; poster reminders; and audit and feedback. The aims of the study were easy to identify and clearly stated, but the inclusion of definitions of attributes and concepts would have been helpful, because some phrases (such as level of sedation, comfort and level of consciousness) were labelled as both attribute and concept. Three methods of data collection were used: ‘think aloud’, observation and interviews. Specifically, during the think-aloud approach, nurses wore a collar-mounted microphone attached to an audiorecorder and were asked to verbalise their thought processes during the data collection period. At the same time, an observer recorded the activities that the nurses were undertaking while thinking aloud. A follow-up interview was then undertaken to help clarify the activities that were observed. Two observers were used to collect the data. The qualitative nature of the study and the data collection methods are accepted methods to examine decisionmaking processes. The researchers are to be commended for training the participants in the think-aloud method and for piloting various forms of observational data collection. The data from the think-aloud method and the observations were analysed independently by the data collector who had collected the data for that particular nurse. As part of this analysis, the think-aloud, observation and interview data were integrated for each nurse. The actual analysis involved identifying concepts and attributes related to three predefined categories: assessment, physiology and treatment. All analyses were assessed by the chief investigator and any differences were resolved by consensus. The sample size – five nurses observed twice each (i.e. before and after implementation of the sedation protocol) and two nurses observed once in the pilot study – is appropriate. It is obvious that a very large amount of data was generated. While selection criteria were described to identify ‘expert’ nurses, and included the need to have critical care qualifications and more than five years experience, the fact that they self-nominated as expert means that it is always possible that some would not have been judged to be ‘expert’ by their peers and superiors. It was not clear, however, how the data of the two pilot nurses was actually incorporated into the findings. That is, as their data was only pre-protocol, the reported number of attributes after protocol was implemented could be expected to be influenced by two fewer participants. This issue was not addressed in the report. The fact that a number of strategies were used to educate the nurses about the sedation protocol should be applauded, as it is generally recognised that didactic education is not effective in getting clinicians to use guidelines with multi-mode strategies, as in this study. The method used for analysing data – that is, having the observers analyse the data they collected, and the investigator also assessing the analysis – is a strength of the study. The researchers note that they integrated the think-aloud, observation and interview data but do not elaborate how this was done, possibly because of the word limit imposed by the journal. Anyone interested in how this actually occurred would have to contact the researchers. In their discussion, the researchers note that they were not able to determine the path between attributes and concepts (i.e. which came first) or the actual decision-making methods used. They note, however, that that they were able to identify relationships between attributes and concepts. They suggest that their findings can be used by educators when designing educational activities such as concept mapping to help to develop decisionmaking skills in nurses. The findings were clearly reported, the table was easy to understand and the discussion considered the implications of the main findings. Overall, this study provides additional evidence about the concepts and attributes that critical care nurses draw on when they are making decisions about sedation. 13 14 S C O P E O F C R I T I C A L C A R E Learning activities 1. Consider the leaders to whom you are exposed in your work environment and identify the characteristics they display that influence patient care. Reflect on whether these are characteristics that you possess or how you might develop them. 2. Mentors are generally individuals who have excelled in their chosen profession and who are willing to share their experiences and expertise with others. Think about your aspirations in your career as a critical care nurse. With the help of others, try to identify a potential mentor. Consider asking this person to meet you on a regular basis to discuss your professional goals and your strategies to meet these goals and to provide you with advice. 3. Review the strategies outlined in Table 1.2 and develop a plan of how you might improve your clinical decisionmaking skills. Approach a mentor in your clinical environment and ask him/her to provide feedback over a period of months on any changes observed in your clinical decisionmaking skills. 4. Consider the role that you have within critical care and examine the influence that research has on that role. How might you use research to inform your practice more effectively? Are there strategies that you could implement to influence the research that is undertaken so that it meets your needs? 5. Reflect on your practice in terms of the ACCCN competency domains14 of professional practice; reflective practice; enabling; clinical problem solving; teamwork; and leadership. To what extent does your current practice address these domains? What strategies can you implement to enhance your practice in these domains? FURTHER READING Andrew S, Halcomb EJ. Mixed methods research for nursing and the health sciences. Oxford: Wiley-Blackwell; 2009. Thompson C, Dowding D. Essential decision making and clinical judgment for nurses. Edinburgh: Churchill Livingstone; 2010. REFERENCES 1. Drennan K, Hicks P, Hart GK. Intensive care resources and activity: Australia & New Zealand 2007/2008. Melbourne: Australian and New Zealand Intensive Care Society; 2010. 2. Rechner I, Lipman J. The costs of caring for patients in a tertiary referral Australian intensive care unit. Anaesth Intensive Care 2005; 33(4): 477–82. 3. Hilberman M. The evolution of intensive care units. Crit Care Med 1975; 3(4): 159–65. 4. Wiles V, Daffurn K. There’s a bird in my hand and a bear by the bed – I must be in ICU. The pivotal years of Australian critical care nursing. 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