The difference in the ICU is that health care personnel are working under a constant threat to life. The stress levels are high and responses need to be immediate. Maintaining a constant high standard of intensive care is the greatest challenge for an ICU. The nursing staff is the mainstay in achieving that goal. They are responsible for most of the minute-to-minute monitoring and treatment. In addition to conventional nursing responsibilities, much of the clinical decision making can be decentralized to a skilled nursing staff. This requires investment in teaching, in service programs and audits directed at the bedside nurse.
The permanent senior medical and nursing staff must provide the continuity of care and ensure that standards are maintained within an ICU. They are responsible for the orientation, education and training of new staff. Junior medical staff usually rotate through the ICU for varying periods and this can lead to inconsistency in the care of patients unless standardization is ensured through protocols, supervision and educational programs.
EXPANDED ROLE OF NURSES
The weaning process (e.g. adjusting ventilatory rates and pressures) can be carried out by the nursing staff using laboratory data and bedside monitoring.
Inotropes, vasodilators, sedatives, analgesics, insulin and many other drugs can be given by continuous intravenous (IV) infusion. Adjustments of infusion rates can be decided by nursing staff, based on clinical and laboratory data.
The entire gamut of processes and protocols involving infection control in the ICU revolves around the nurse.
OTHER ASPECTS OF WARD FUNCTION
The nursing staff should be integrated into all aspects of administration of the ICU, in addition to taking care of the patients and dealing with their friends and relatives. Other members of the intensive care staff may include physiotherapists, ward clerks, social workers and ward attendants. They are all essential for an efficiently run team. Although it is difficult to measure the effect on patient outcome of a well-organized team, most experienced intensivists value this aspect of their unit highly and invest time and energy in achieving it.
Ward Rounds and Continuity
There should be at least one comprehensive ward round each day. The half-life of major decisions regarding seriously ill patients is approximately 24 hours, whereas for patients in general wards it is approximately 3–4 days. The medical staff, nursing staff and others involved in a patient's management should formulate a strategy for the next 24 hours. This is a framework around which fine-tuning can occur, depending on changes in the patient's condition and the findings on laboratory tests. Like other strategies, it must be flexible enough to allow changes according to the patient's condition. Rather than using a system that features a provisional diagnosis and final diagnosis, one must take a problem-orientated approach to seriously ill patients.
Detailed handovers with a short- and long-term plan are essential for continuity and optimal management of the patient, especially by senior medical staff.
Relatives and Friends
The condition of a patient should be explained in an honest and forthright manner to relatives and friends. There is no place for false hope and avoidance of difficult explanations— even if it means admitting that many aspects of the patient's disease process are, as yet, unknown. It helps to have a special information pamphlet for the patient's friends and relatives that will explain certain matters such as:
- Relevant aspects of the hospital's function.
- Visiting policy for the ICU.
- The invasive lines and machines that may be encountered.
Labeled photographs of the various pieces of equipment and lines, with a short description of each, can be displayed in the waiting room.
An explanation of the possible time course of the patient's illness must be given. Many relatives wish to maintain an all-night vigil during the early part of a critical illness, when the patient conceivably could remain stable for days or weeks. It is important to inform relatives of such possibilities so that they can arrange their schedules regarding sleep, work and other responsibilities.
Quality assurance (QA), auditing and peer review are all concepts that generally have to do with monitoring and attempting to improve current practice. The idea behind most efforts in this area is that practitioners can demonstrate to themselves and to others the quality and quantity of work they are doing. The principles of QA and total quality management (TQM) readily lend themselves to managing an ICU.
Decision making and autonomy must be decentralized to the bedside. The ability to make decisions comes through education. Making changes is difficult, and many who have been trained in a different way will feel uncomfortable. We need, ultimately, to reach the point at which we begin to feel comfortable with many of the unpredictable aspects of our practice, until eventually we can thrive on the non-routine.
The staff need to be encouraged to be autonomous and to speak out when the system is not working. Senseless rules need to be eliminated. The common good should always be put above one's own. This system will not be the place for large egos that are easily bruised.