The interface between AE and ITU How they can play nicely together

1. The interface between A&E and ITU � How they can play nicely together Dr. Rob Galloway A&E and ITU SpR Kent, Surrey and Sussex deanery

2. A&E and ITU do not get on........

3. Why should we play nicely together? 25% of ITU admissions come from A&E Similar attitudes Similar skill mix

4. Working together...........

5. Are we happy with status quo - Case presentation 83 year old male. Admitted at 11pm via 999 to A&E, left sided weakness. Seen by A&E registrar, referred medics Started to fit - Unable to control fitting

6. Case continued..... Anaesthetic SHO called CT scan � no bleed Medical and ITU review requested

7. Case continued....... ITU Dr has to leave unit Appendicitis awaiting on emergency list deteriorates.

8. Case continued ITU Dr accepts patient No ITU beds available at the moment anyway........... Transferred to recovery.

9. Case Continued Patient discharged out of hours from ITU Our patient is transferred to ITU as bed now available Now late at night - plan to extubate in the morning

10. Case Continued Extubated in morning. No complications. Diagnosis of stroke and fit secondary to ischemic focus Patient transfer to stroke ward after 36 hours ITU bed blocked. No more fits. Good recovery on stroke ward.

11. Was patient well managed? Yes Safe care Intubated and extubated without any complications No Put at risk of unnecessary harm Intubated in unfamiliar environment for the SHO Transfers Prolonged ventilation ITU infection risk

12. Was the hospital resources well managed Number of doctors, nurses and ODPs involved Theatres postponed Patients on ITU left without medical cover Tired consultants working the next day

13. Should we accept status quo? It has worked for years this system Doesn't mean that it cant be improved Could better integration of A&E and ITU helped? Could dually accredited A&E/ITU consultants and nurses improve patient management?

14. Scope of talk Links Between A&E and ITU Advantages for patients Trauma patients Post cardiac arrest Sepsis management Patients not appropriate for ITU Advantages to running of ITU Advantages to Hospital efficiency Better patient safety D D D D

15. Scope of the talk Bringing about closer working relationships Effect on ITUs and A&Es Potential Disadvantages of being an ITU/A&E consultant Back to our case

16. Trauma care See Yesterday! Quicker care Definitive imaging early A&E and traum team working in conjunction with ITU

17. Post Cardiac arrest management in A&E

18. 18 Very keen when the cardiac arrest call goes out.....

19. 19 Not so keen once the fun is over

20. 20 Post resuscitation care The goal: Normal cerebral function Stable cardiac rhythm Adequate organ perfusion To restore quality of life

21. Post cardiac arrest management

22. Cooling post cardiac arrest � care bundle approach 1.7 Unconscious adult patients with spontaneous circulation after out-of-hospital VF cardiac arrest should be cooled to 32�34�C. Cooling should be started as soon as possible and continued for at least 12�24 h. Rewarm slowly (0.25�0.5oC/h). Mild hypothermia might also benefit unconscious adult patients with spontaneous circulation after out-of-hospital cardiac arrest from a non-shockable rhythm, or cardiac arrest in hospital

23. How cooling works...

24. Large body of evidence that cooling works Hacker study, Bernard Study NNT of only 6 Care bundle approach works in practice

25. Sunde et al, resuscitation 2007 Care bundles Prior to care bundles � 29% �favourable outcome� After Care bundles � 56% �favourable outcome�

26. How are we doing in Sussex Good figures Excellent ROSC from pre hospital Starting to cool in A&Es in the region Protocols written.......... but Worthing data 7/18 cooled in A&E. Average time from A&E to cooling start � over 2 hours 11/19 discharged from ITU

27. So what do we do nationally? In ITU 2006 � 30% cool in ITU � Laver, Anaesthesia 2006 2009 � 90% cool in ITU � Nolan 2009, unpublished data But in A&E � no known data

28. Survey of A&Es Telephone call to most senior person in A&E 230 A&Es responded 35% would cool in A&E. Of those 55% would cool VF/VT only Care needs to be improved

29. Sepsis in A&E

30. Sepsis Management 27% of ITU admissions Lots of evidence on early goal directed therapy Surviving sepsis campaign A&E role- six hour care bundle

31. Six hour care bundle 6-hour goals Measure the serum lactate Take blood cultures prior to antibiotic administration Administer antibiotics within 3 hours of A+E admission or 1 hour if already inpatient If hypotension or serum lactate >4mmol/L Give 20-30mls/kg fluid bolus Apply vasopressors for persistent hypotension Measure the CVP and achieve >8 Aim for ScvO2 >70%

32. Role of A&E in Sepsis

33. Sepsis management in A&E Performed badly in A&E 18.7% have protocols as of 2007 Double mortality rate for patients who don�t follow early goal directed therapy (Gao 2005 critical care 2005)

34. How well do we do in reality

35. Patients presenting to A&E not appropriate for ITU care

36. Patients presenting to A&E not appropriate for ITU care Very common scenario Use of resources appropriately Dignified care End of A&E SHO referring to ITU team �no goers�

37. Advantages to running of ITU Imagine function of ITU and anaesthetics if A&E didn�t need your staff so much........... Intubated scans Sedation Transfers?

38. Advantages to patient flow Typical �flow� of A&E medical patient A&E SHO.....then A&E reg r/v......needs central line and resucitation..... Medical SHO........then Medical reg review.......... ITU SHO.......... Transfer to ITU......... Sort out patient

39. Problem Patient deteriorated Short term sequale Long term sequale Solutions..... Senior A&E review on arrival...... Institute resuscitation in A&E Refer to ITU once stable

40. Other advantages-patient safety Safer care Familiar environments Familiar equipment Review of major incidents Error reduction Joint audit mortality meetings Better training

41. How we can play nicely together Mind change Break down Barriers Galvanise interest in the critically sick patient in A&E

42. How we can play nicely together.... Better integration of junior doctors My route ACCS route Better integration of nurses � senior and junior Secondments Joint jobs Joint A&E and ITU consultants

43. Joint A&E and ITU consultants 13 nationally 31 registrars No consultants in region 3 Sprs in region 2 acute medical/itu registrars

44. Advantages for A&Es ITU skills in resus � better care for patients Teaching for trainees

45. Advantages for ITUs ITU work not disturbed Generalist working on ITU Readily available advice Specialist skills Ideally placed for ITU outreach

46. Disadvantages Won�t have as much airway expertise as anesthetic trained colleagues Won�t liaise as much with surgeons as anaesthetic colleagues Burnout Annual leave/non clincial PAs Loyalty?

47. Review of first case - Could it be different? Same patient Seen by A&E registrar and A&E/ITU consultant Whilst awaiting medical review, started to fit Unable to control fitting Status epilepticus

48. A&E/ITU consultant supervises the A&E SpR to intubate Resuscitation room nurse has ITU skills Familiar equipment

49. Taken for scan No bleed. Phenytoin started Transferred back to recovery Moved to level 2 unit next to resuscitation room Extubated and Referred to Medics

50. Use of resources 2 doctors 1 nurse Quicker care � just as safe CEPOD list not stopped Consultants not disturbed therefore can work well next day More efficient use of resources

51. Is this achievable? Need collaborative working Need to break down barriers of �who owns what skills� Needs a mind set change � be brave

52. Play nicely and work well together