The Patient Journey | Undergrad Crit Care

THE PATIENT JOURNEY THROUGH CRITICAL CARE

Patients are referred to critical care from all parts of the hospital. Normally, when a patient becomes unwell in the hospital, they are reviewed by medical staff from other teams, who then refer the patient on to the intensive care registrar who is carrying the referrals page.

We always approach unwell patients using a systematic A-E format. This helps us prioritise interventions and ensure nothing pertinent is missed during the assessment

Watch the video below. Mr Fleming is a patient who was admitted with cough and SOB, who has become acutely unwell on the ward. Take note of the assessing doctor's structured approach to him, and the use of structured SBAR handover tools to aid communication.

The Acutely Unwell Patient

Mr Fleming was transferred to Intensive Care, where his respiratory function continued to deteriorate. He required intubation and invasive ventilation.

As part of their stay in intensive care, patients are reviewed daily by medical staff prior to the ward round. This daily assessment allows for identification of new clinical issues, housekeeping to be performed, and for a provisional clinical plan to be made. You will likely be involved in the daily assessment of critically ill patients during your attachment.

Watch the videos below for a demonstration of how to perform a thorough daily assessment of an ITU patient, and to gain an insight into the importance of daily housekeeping for patients in critical care.

Daily Assessment of the Critically Ill patient

Difficult Conversations in Critical Care

Throughout the course of their disease, critically ill patients and their families look to the intensive care team to support and guide them as they come to terms with the impact of critical illness. The impact of critical illness is profound and involves physical, emotional and financial challenges for patients and their families. In addition, many families rely on the information provided to them to balance maintaining hope of recovery with realistic outcomes.

Unfortunately, despite huge advances in supportive care, about 30% of patients admitted to a critical care unit will die during their admission. For other families, they may receive multiple episodes of breaking bad news.

The ability to communicate sensitively and compassionately with patients and families is a fundamental skill of a doctor. In breaking bad news situations, it is often useful to make use of a framework, such as the SPIKES framework.

Baile W, Buckman R, Lenzi R, Glober G, Beale E and Kudleka A (2000) SPIKES – a six step protocol for delivering bad news: application to the patient with cancer,. Oncologist, 5, pp.302-311.

It is now many weeks later and Mr Fleming has suffered a further deterioration. The intensive care team have been unable to wean him from the ventilator and he remains in multiple organ failure, with no signs of improvement. The nursing staff have noted that at times he seems distressed. Following discussion between all the multi-disciplinary team members, there is agreement that Mr Fleming is very unlikely to recover from his critical illness.

The Consultant in Charge of his care makes arrangements to speak to his family. Watch the video below and reflect on how the doctor makes use of the SPIKES framework to sensitively and compassionately communicate with his family.