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Intensive and Critical Care Nursing (2004) 20, 116—122 RCN Critical Care Nursing Forum Margaret Connolly It seems that we are nearly half way through 2004 and already a number of key Forum diary dates (highlighted in the February issue of ICCN) have passed. This edition of News and Issues details coverage of our February Link Members meeting and the ‘‘Critical Care United’’ Sharing Event held in March. Although hosted by the Modernisation Agency, this National event was held in conjunc- tion with several critical care organisations and the Forum played a significant role in the conference planning and preparation stages. Read about the success of both events and be sure to book your place for our own critical care conference which takes place on the 4th and 5th of June at St James’s Park, Newcastle. RCN Critical Care Nursing Forum link members day 27th February 2004 RCN headquarters, London National Care Bundles Group The day commenced with an informative and inter- esting talk from Sally Lagan who is the National Spe- cial Projects Manager for Care Bundles. The concept of Care Bundles came from America but has been adapted for use in the UK as part of the Modernisa- tion Agency work looking at service improvement. A Care Bundle is a grouping of care elements for par- ticular symptoms procedures and treatments. This is an initiative to help clinical areas introduce level one evidence into practice. Level one bundle char- acteristics are based on solid science, relatively easy and inexpensive to introduce, the individual components of the bundle are already well-defined, as is the process for introducing them into clinical practice. As an example, the Ventilation Care Bundle was dis- cussed, of which core elements include Deep Venous Thrombosis (DVT) prophylaxis; Gastric ulceration prophylaxis; Head of the bed elevation (>30 ); Sedation holds for each ventilated patient. There is substantial evidence for the effective- ness of each of the above measures alone but as a ‘‘bundle’’ they can be considered to offer a key marker of best practice that critical care units can utilise to improve the delivery of care. Introduc- ing Care Bundles into practice involves a number of stages. These include baseline audit to monitor current compliance with the elements of care, pro- vision of comprehensive and up-to-date guidelines concerning the care that is expected to be deliv- ered, education of staff and further regular audit to ensure sustainability. Other Care Bundles currently in use include a tra- cheostomy Care Bundle, which has been developed by Sohan Bissoonauth at the Hillingdon Hospital in London. Elements of care included in this bundle are Humidification–—each patient should receive ad- equate humidification and this should be checked and documented two hourly. Tube patency/inner tube care–—inner tube to be removed, checked for secretion build up, cleaned and replaced two to four hourly. Suction–—each patient should be assessed for se- cretions at least two hourly and be suctioned as required. Safety equipment–—all bedside equipment relat- ing to tracheostomy care checked at the begin- ning of each shift. Cuff status–—cuff status to be checked each shift. 0964-3397/$ — see front matter doi:10.1016/j.iccn.2004.04.004

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Intensive and Critical Care Nursing (2004) 20, 116—122

RCN Critical Care Nursing Forum

Margaret Connolly

It seems that we are nearly half way through 2004and already a number of key Forum diary dates(highlighted in the February issue of ICCN) havepassed. This edition of News and Issues detailscoverage of our February Link Members meetingand the ‘‘Critical Care United’’ Sharing Event heldin March. Although hosted by the ModernisationAgency, this National event was held in conjunc-tion with several critical care organisations and theForum played a significant role in the conferenceplanning and preparation stages. Read about thesuccess of both events and be sure to book yourplace for our own critical care conference whichtakes place on the 4th and 5th of June at St James’sPark, Newcastle.

RCN Critical Care Nursing Forum linkmembers day 27th February 2004 RCNheadquarters, London

National Care Bundles Group

The day commenced with an informative and inter-esting talk from Sally Lagan who is the National Spe-cial Projects Manager for Care Bundles. The conceptof Care Bundles came from America but has beenadapted for use in the UK as part of the Modernisa-tion Agency work looking at service improvement.

A Care Bundle is a grouping of care elements for par-ticular symptoms procedures and treatments. Thisis an initiative to help clinical areas introduce levelone evidence into practice. Level one bundle char-acteristics are based on solid science, relativelyeasy and inexpensive to introduce, the individualcomponents of the bundle are already well-defined,as is the process for introducing them into clinicalpractice.

As an example, the Ventilation Care Bundle was dis-cussed, of which core elements include

• Deep Venous Thrombosis (DVT) prophylaxis;• Gastric ulceration prophylaxis;• Head of the bed elevation (>30◦);• Sedation holds for each ventilated patient.

There is substantial evidence for the effective-ness of each of the above measures alone but asa ‘‘bundle’’ they can be considered to offer a keymarker of best practice that critical care units canutilise to improve the delivery of care. Introduc-ing Care Bundles into practice involves a numberof stages. These include baseline audit to monitorcurrent compliance with the elements of care, pro-vision of comprehensive and up-to-date guidelinesconcerning the care that is expected to be deliv-ered, education of staff and further regular auditto ensure sustainability.

Other Care Bundles currently in use include a tra-cheostomy Care Bundle, which has been developedby Sohan Bissoonauth at the Hillingdon Hospital inLondon. Elements of care included in this bundleare

• Humidification–—each patient should receive ad-equate humidification and this should be checkedand documented two hourly.

• Tube patency/inner tube care–—inner tube to beremoved, checked for secretion build up, cleanedand replaced two to four hourly.

• Suction–—each patient should be assessed for se-cretions at least two hourly and be suctioned asrequired.

• Safety equipment–—all bedside equipment relat-ing to tracheostomy care checked at the begin-ning of each shift.

• Cuff status–—cuff status to be checked each shift.

0964-3397/$ — see front matterdoi:10.1016/j.iccn.2004.04.004

RCN Critical Care Nursing Forum 117

• Tracheostomy dressings/tapes–—to be changed atleast 24 hourly.

Four categories are used to measure improve-ments in tracheostomy care. The first categoryconcerns clinical incidents such as blocked tubes,de-saturation, dislodged tube and respiratory dis-tress. Another category is related to lack of appro-priate equipment-not having spare tubes, trachealdilators, inner tubes and emergency equipment atthe bedside. The final categories relate to interven-tions required by outreach and the total number ofvisits required by outreach. The simplicity of thisCare Bundle makes it appropriate for use in anyarea where critical care is delivered to patientsfrom level one patients on the ward, right throughto those patients being ventilated in the intensivecare unit.

Currently 90% (26) networks in England have com-menced Care Bundles in at least one of their unitsand 28% (8) networks have commenced Care Bun-dles network-wide.

The presentation and further information on CareBundles can be found on the critical care moderni-sation website (www.modern.nhs.uk/criticalcare)click on Programme working areas.

For further information on Care Bundles you canalso contact Sally Lagan at [email protected].

Modernisation Agency (MA) update

Mavis Spencer, lead nurse for the critical care pro-gramme updated the link members on the futureof the critical care networks given that March 2004was the date publicised as the official closure ofthe Modernisation Agency critical care programme.The programme is now expected to continue in areduced format until the end of the year and Mavishighlighted some of the achievements of the Pro-gramme. These included

• Critical Care capacity (levels 2 and 3) has in-creased by 32% since 2000;

• Over 660 improvement projects have been car-ried out across the networks;

• 93% of hospitals have carried out at least one im-provement project;

• Some of these projects have incorporated theintroduction of enhanced decision making rolessuch as

◦ Nurse led weaning in 13 networks including 2network-wide projects.

◦ Nurse led discharge in 5 networks including 1network-wide.

The highest percentage (over 50%) of projects un-dertaken have been concerned with delivery of carewhilst other project themes include creating capac-ity, access to critical care, outreach, patient andcarer experience and staff experience.

Other areas of completed or ongoing work withinthe programme include

• Outreach-170 hospitals across England now haveoutreach established as a service. The NationalOutreach Report was launched by Rosie Win-terton, Minster for Health, on 16th October2003;

• A guide to Commissioning for Critical Care Ser-vices has been made available on the MA website;

• Creation of Neurosciences Working Group whoseremit is to report on the availability and prac-tices of neuroscience critical care servicesacross England. A publication is expected in theautumn;

• A document giving advice and information to crit-ical care services on forming partnerships withindustry has been published;

• Capacity and demand–—a tool to help serviceslook at their flow patterns is currently being pi-loted by the MA and information is available onthe website;

• Care Bundles–—this work will be on-going as a spe-cial project even when the MA critical care pro-gramme formally closes;

• Discovery interviews — work in progress acrossthe networks that will continue to receive supportfrom the MA looking at patient journeys through-out the critical care service.

Mavis also reported that network assessments havebeen performed to look at the ability of individualnetworks to work independently of the Critical Careprogramme. These appear to show that the major-ity of networks are at the point of being ready toreceive, that is, they have the ability to work inde-pendently.

The Programme is currently in the process of de-veloping post programme structures and systems tosupport the continued delivery of appropriate andeffective critical care services. A Stakeholder Ad-visory group is to be set up which will include Fo-rum representation as well as representatives fromother critical care organisations, critical care net-works, the independent sector, strategic health au-thorities and primary care trusts.

118 M. Connolly

The role of the National Patient SafetyAgency (NPSA)

Margaret O’Donovan from the National PatientSafety Agency gave link members an insight intothe background of the NPSA. This was establishedin July 2001 as a special health authority, the pur-pose of which was to implement and operate a newnational system for learning from adverse eventsand near misses in all sectors of the NHS. Its pri-mary purpose thus, is to improve patient safety byreducing the risk of harm through error (building asafer NHS for Patients).The NPSA aim to achieve this goal by

• Collecting and analysing information on adverseevents from local NHS organisations, NHS staffand patients and carers;

• Assimilation of other safety-related informationfrom a variety of existing reporting systems andother sources in this country and abroad;

• Learning lessons and ensuring that they are fedback into practice, service organisations and de-livery;

• Where risks are identified, produce solutions toprevent harm, specify national goals and estab-lish mechanisms to track progress.

Progress to date includes the development and test-ing of a national reporting and learning system, andthe promotion of an open and fair culture that in-cludes the development of toolkits such as the inci-dent decision tree. This is a simple and quick deci-sion tool for all staff that encourages a fair and con-sistent approach across professional groups and fo-cuses key decision makers on systems factors–—thewhy, not the who of the problem. Further infor-mation on the Incident Decision Tree and the RootCause Analysis toolkit and training can be found onthe NPSA website at www.npsa.nhs.uk.

An example given to explain how solutions are de-veloped concerned the use of pre and post theatrebriefing. All members of the theatre team requirebriefing to reduce ‘Wrong site Wrong procedure’surgery, so that everyone feels empowered tospeak up and prevent errors. The proposed stan-dardisation of cardiac arrest numbers is anotherexample of developing a solution that highlightsthat solutions are not necessarily complex but re-quire co-operation and common sense from allmembers of the health service. However, one solu-tion that caused lively debate on the day, was theremoval of potassium from the ward environmentand containment in CD cupboards in the criticalcare environment.

While it was emphasized that removing potassiumfrom ward areas may promote a safer working en-vironment, link members were able to discuss theirpractical difficulties experiencedwith having potas-sium locked away in relation to the critical careenvironment. Margaret assured those present thattheir views would be fed back to the appropriatepersonnel and we wait to see if a review of this pol-icy is possible.

Critical care competencies

The development of competencies for critical carenursing was the last topic of the day and MauraMcElligott outlined the aims and objectives of aDepartment of Health commissioned project look-ing at the Development of Team Competencies forPerson-centred Adult Critical Care Services.

Further information on this is detailed elsewhere inthe news and issues pages.

The meeting ended with link members being se-lected to attend the RCN Congress in Harrogatewhich takes place from 9th to 14th, May and theCritical Care Nursing Forum conference in Newcas-tle on 4th to 5th, June 2004.

There will be a link members day for Welsh mem-bers on the 7th October at RCN Offices in Cardiff(although any forum members are welcome to at-tend).

The next link members day is on the 12th Novemberat RCN HQ in London.

Ellie Wilson(Link Member Co-ordinator, Forum Steering Com-mittee member)

Critical Care United National SharingEvent 5th March 2004, The InternationalConvention Centre, Birmingham,hosted by the Modernisation Agency inconjunction with British Associationof Critical Care Nurses, Intensive CareSociety and RCN Critical Care NursingForum

Overview

This event was an overwhelming success with an at-tendance of in excess of 1300 delegates. The open-ing session was enacted by a theatre company, whogave an illuminating performance of some of the

RCN Critical Care Nursing Forum 119

landmark achievements within Critical Care overthe last 4—5 years. During the day, delegates hadthe opportunity to select from 102 breakout ses-sions that celebrated and detailed many new criti-cal care developments that have taken place withindistinct Trusts across the country. The exhibitionhall displayed numerous poster presentations frommany Trusts and critical care networks highlightingthe progress they had made and spanning the di-verse remit of critical care.

One of the plenary sessions took the form of aquestion and answer session, which was chaired byNiall Dickson, BBC correspondent. The panel con-sisted of a representative from the ModernisationAgency, RCN Critical Care Forum Chair, Chair ofBritish Association of Critical Care Nurses (BACCN),representative of the Allied Health Professionalsand a member from the Council of the IntensiveCare Society. Five questions were put to the paneland this session engaged a lively discussion betweenthe delegates and the panel members. The ques-tions included topics such as, are consultant nursesvalue for money; whose responsibility are criticalcare patients in ward areas; retention and fundingissues and how to ensure the future and continuedsuccess of the critical care networks given thatthe MA critical care programme is drawing to aclose.

The Minister for Health, Rosie Winterton deliv-ered a comprehensive speech on the advances andsuccesses of Critical Care. The speech detailedchanges that had occurred since 1999 when theNHS Plan was published and in particular since thereport Comprehensive Critical Care, published in2000, which looked at changing the way that crit-ical care was delivered. This report identified thekey role that Critical Care Networks would playin bringing together NHS Trusts to enable themto take responsibility for the planning, implemen-tation and the provision of critical care services.The minister saw the conference as a marker ofthe success of the networks and emphasized theimportance of sharing information and recognitionof the patient’s journey as a hospital-wide experi-ence, involving everyone from emergency care tocommunity follow-up. The outreach report (Crit-ical Care Outreach 2003: Progress in DevelopingServices) was also recognised as evidence of theprogress that had been achieved in improving thecare of patients both within critical care units andelsewhere in the hospital. Over £299m of addi-tional funding specifically for critical care has beeninvested over the last 3 years in order to expandcapacity and the minister reported that there hasbeen a 32% increase in adult critical care beds

since January 2000 and also a fall in the number ofcritical care transfers over this past winter.

In regard to future developments the ministerannounced that over the next 18 months the Mod-ernisation Agency will commit £900k to support anumber of New Ways of Working Pilot Sites. Thesepilot sites will develop both assistant and advancedpractitioner roles in critical care and serve as goodpractice models with ideas that can be shared andutilised by other areas across the country. The suc-cessful pilot sites were announced at the end of theconference by Ginny Edwards from the MA. In futureissues we hope to update you further on the Depart-ment of Health Changing Workforce programmeand bring you detailed reports on the progress ofthese new developing roles in critical care.

Margaret Connolly, Forum Steering Committeemember

A personal perspective

The day was very hectic given there were over 100presentations to attend and nearly 100 posters toview in the exhibition hall. Not only this but out-side the main entrance to the Convention Centrethere were also displays from the National BloodTransfusion services, UK Transplant, West Midlandsambulance service and the military. The day wasso busy that there was little time to view all theposters, however, I found the day interesting andinformative.

The focus of the day was on plenary sessions thatdiscussed local projects from many networks thathad made improvements in care. The sessions I at-tended included a discussion on the levels of care,noting that these are still poorly defined and thatward services do not consider how many level oneor two patients are regularly admitted to the area.This could have huge cost and staffing implicationsif level one and two patients are a regular featureof the ward mix.

Other sessions focused on benchmarking at a net-work level which can improve care across the net-work and enables sharing of ideas and experience.A competency framework, that has been developedby the London Standing Conference was presentedand highlighted much detailed work that is nowavailable on CD Rom. Several presentations focusedon Outreach and perhaps unsurprisingly ward staffwanted the service available 24 h a day, 7 days aweek. Some of the problems of introducing Out-reach and the perceptions of ward staff were alsodiscussed. Care bundles were used to improve tra-

120 M. Connolly

cheostomy care, an issue that is pertinent in manyhospitals.

There was a thought provoking talk from Dr Griffithswho focused on the psychological needs of patientsand noted that post traumatic stress disorder (PTSD)is worse in patients that have no recall of events. Hesuggested moving away from sedation and possiblyconsidering restraint. I think this would be a hugeculture shift for the UK if it were found to be morebeneficial to patients. Dr Griffiths had also foundthat quiet withdrawn patients were often sufferingfrom delusions but this was sometimes mistaken fordepression.

The day finished with an excellent debate entitled‘From Bedside to Business Park’–—do we need bed-side critical care staff in the future? Given the short-age of critical care staff the debate focused on thefuture role of information technology and some ofthe solutions currently being adopted in the USA.In several hospitals in the USA, developing technol-ogy has meant that ICU physicians and experiencednurses are removed from the bedside and leave ma-chines watching the patient. Any emergency is thenresponded to by a specialist team in a ‘‘call centre’’linked to individual units by video cameras and tele-phones. Most of the audience felt that staff by thebedside were essential to provide appropriate carebut you couldn’t help but think that, with the tech-nological advances and shortages of staff, the tech-nical approach will come in some form in the future.

Ann Price, Forum Link member

Critical care competencies

I last wrote about critical care nursing competen-cies in the February issue of ICCN. At this time, theNHS Modernisation Agency had just completed ascoping exercise of critical care competency workthat was currently available throughout the 28 crit-ical care networks in England. Although this was byno means a finite exercise (no attempt was madeto capture competency work from educationalinstitutions, medical professions, other UK coun-tries), it did portray a snapshot of just how muchcompetency work was already in existence (thiswork can be viewed at the Modernisation Agencywebsite www.modern.nhs.uk/criticalcare. Lookin ‘‘programme working areas’’ and then under‘‘competencies’’).

The challenge remains to make sense of all thiscompetency work, however, diverse. The messagefrom our Forum members remains clear, they wish

to have some kind of national standards developed.Perhaps by highlighting the common core themesfrom work already undertaken it may be possible toprovide a meaningful framework that all can utilisebut there are also other influences on the directionand development of this work to consider. Theseinclude the impact of the forthcoming Agenda forChange1. This will link the salaries of nurses andother healthcare professionals in the UK to a ca-reer ladder based upon a knowledge and skillsframework. There is also talk of ‘‘advanced nursepractitioner’’ status being recognised formally bythe Nursing and Midwifery Council (NMC). A movethat would involve (we all hope) clearer definitionsof the numerous terms to describe the expandedand specialist roles that many UK nurses under-take, and clarification of the diversity of levels atwhich they practice.

Department of Health project2

Set against this background, and closely linked toits Changing Workforce Programme, in January ofthis year the Department of Health commissioneda project looking at developing team competen-cies for adult person-centred critical care serviceswithin England. The project is multi-professionaland involves a range of stakeholders, in fact any-one with an interest or involvement in critical careservices. Kim Manley, Head of Practice Develop-ment at the RCN Institute and Visiting Professorat Bournemouth University is leading the project.Kim has a background in critical care and a his-tory of working with teams/organisations to deliverperson-centred evidence based health care.

Project objectives

The development of team competencies will be apioneering piece of work that values all of the stake-holders involved and allows them to develop a com-mon vision and ownership of the work involved.From this project it is hoped to produce a set of in-dicators of team effectiveness that may then be ap-plicable across all areas of healthcare where teamsare working with patients. The project will also un-dertake a detailed mapping exercise to integrateclinical and team competencies that are already inexistence for critical care. All this work will be de-

1 Further information on Agenda for Change and the Knowl-edge Skills Framework can be found on the new Depart-ment of Health website www.dh.gov.uk/policyandguidance/humanresourcesandtraining/modernisingpay/agendaforchange.

2 Further details of this project can be found on theDepartment of Health website.

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Box 1. Project objectivesDeveloping the competency frameworkValues clarification exerciseThematic analysis

Developing indicators of team effectivenessSystematic review

Integrating clinical and team competenciescurrently existing

Obtaining existing competenciesThematic analysisMapping against framework

Continous evaluation, identifying stakeholderissues and future directionsConcerns, claims and issuesReport

tailed in the final project report, which may give usor certainly move us further down the path to ob-taining the much sought after core national frame-work. This could then be adapted as necessary tomeet local need (Box 1).

Project stages

By June, the project should be well-established. Animportant initial stage was the facilitators work-shop held in March. I attended on behalf of the RCNCritical Care Nursing Forum. The day brought to-gether nominated individuals from the key stake-holder groups to share their vision of critical careservices and discuss how they would engage theirown professional organisations in the project. Thestakeholder groups included allied health profes-sional and medical colleagues. Multi-professionalgroup work, debate and discussion was stimulatingyet complex and we were all challenged to articu-late our values and beliefs about critical care ser-vices. Reassuringly, it was encouraging that we allshared at least one common vision, which is thatcritical care should be a patient not a place-centredservice.

As the RCN Critical Care Nursing Forum facilitator, Ihope that we will be able to engage as many criticalcare nurses as possible in this work and detailedbelow you will find several options to enable you tohave a voice and opportunity to get involved.

The project ensures that it is not just professionalorganisations that will participate in this workthrough their facilitators. Four regional workshopshave also been arranged. These workshops will en-able different stakeholder groups to come togetherand allow maximum access for all interested indi-

Box 2. Project timeframeMarch Facilitators workshopMay—June Four regional workshopsMarch—August Continuing analysis,

mapping, development offramework

March—August Systematic reviewAugust—October Consultation on

framework andcompetenciesDevelopment of draftreport

November—December

Consultation on draftreport

End of December Final report submission

viduals to share in this work. All those who wish toparticipate in this exercise to define the purposeand content of critical care competencies will bewelcome at any one of these workshops. The datesand venues of the workshops are detailed below.

Box 2 highlights the timeframe of the project. Cur-rently, work is ongoing on both a systematic reviewof the literature in relation to indicators of teameffectiveness and also work in relation to analysing,mapping, cross-referencing and developing thecompetency framework. The final stages of theproject will include a consultation process beforethe final report is submitted to the Department ofHealth by December of this year.

How to get involved

• Attend a regional workshopWorkshop 1 20 May St James Hotel, LondonWorkshop 2 7 June Queens Hotel, LeedsWorkshop 3 17 June Hilton Bristol Hotel BristolWorkshop 4 1 July Hyatt Regency Hotel,

BirminghamThe workshops will run from 10:00 am to 03:30 pm,lunch and refreshments provided.

Anyone is welcome to attend but please confirmyour attendance in order to receive further infor-mation and accommodate catering.

Submit all names, roles and contact details ofthose wishing to attend via e-mail, or telephoneto Kim Manley or her assistant Jo Odetola by atleast 1 week prior to each of the workshops.

Contact details: Kim Manley

Telephone:+44-207-647-3673 (assistant Jo Odetola),or e-mail: [email protected]

122 M. Connolly

• You can contribute to the Competency MappingExercise

In order to achieve this, we would like to obtain anycritical care competency work already in existence.This will be utilised within the project timeframeby Kim Manley to undertake the mapping exercise.If you are willing to share your work andhave competencies for the care of criticallyill patients (levels 1, 2 and/or 3) and wouldlike them to be included in the work-pleasesend them to Kim at [email protected]

• Attend the RCN Critical Care Nursing ForumAnnual Conference

This will take place on 4th and 5th of June atNewcastle United Football Club, St James’ Park,Newcastle upon Tyne. During the conference pro-gramme there will be an opportunity to share yourviews and be involved in this work. To obtain yourcopy of the conference programme or to registeryour attendance at this years conference pleasecontact [email protected].

• Wales, Northern Ireland and ScotlandIt should be noted that the project is funded bythe Department of Health in England but partici-pants from anywhere in the UK are very welcometo attend any of the four regional workshops inEngland. However, the Forum is currently workinghard to establish some dates/venues for under-taking similar project work in Wales, NorthernIreland and Scotland. If you work in these coun-tries, and wish to receive an email notifying youof relevant dates and venues please email me on:[email protected]

Please also email me (address as above) should yourequire further information or clarification on anyaspect of this project.

Maura McElligott, Chair, RCN Critical Care NursingForum

Confirmed date for Welsh competency meeting isJuly 14th at RCN Cardiff.