The most important is to be able to say what you think that HDU or ITU is going to do that Level 1 care can't. Watch for the development of cardiovascular, respiratory and other organ system failure, particularly in patients known to be at risk because of their illness. INVOLVE ICU EARLY
- The Department of Health (UK) produced a document in 2001 called Comprehensive Critical Care in which the levels of care are summarised:
- Level 1:Ward based care where the patient does not require organ support (for example, they may need an IV or oxygen by face mask)
- Level 2:High dependency unit (HDU). Patients needing single organ support (excluding mechanical ventilation) such as renal haemofiltration or inotropes and invasive BP monitoring. They are staffed with one nurse to two patients
- Level 3:Intensive care. Patients requiring two or more organ support (or needing mechanical ventilation alone). Staffed with one nurse per patient and usually with a doctor present in the unit 24 hours per day. A patient needing 15-30 minute obs will really mean that nurses other 11 patients get very reduced attention.
- Before you go asking for a Level 2/3 bed make sure before you pick up the phone that you have the following info as much as is possible. It is very difficult to have a focused rapid phone call discussion at 3 am with someone who has simply not got the information to hand. Sometimes the emergency situation is the reason but at least if you have obs chart, drug chart and notes ready then that is useful. In some hospitals, these are the only consultant to consultant which excludes registrars from the decision-making process and also slows down the process out of hours.
- Important facts to have at hand. The most important is to be able to say what you think that ITU is going to do that you can't. Often time that may simply be high-level nursing care and monitoring can be done more frequently so issues managed better. On the wards, there may be 1 trained nurse to 12 patients whereas the nursing ratio is much better on Level 2/3 so a sick patient will get more attention and care and we know that in some areas nursing numbers have more impact on mortality than medical.
- ITU may send their critical care outreach team and that can be very helpful in moving things on and helping to work out the ideal plan. It will often involve a senior nurse and the ITU registrar who liaise with the consultant.
- Patients Age and Premorbid state - activity, needs carers, frailty
- Co morbidities e.g. cancers, heart attacks and heart disease and strokes
- Level of any disability or other conditions
- Diabetes, hypertension, cognitive loss
- Current medications. Medications already given
- Recent ABG and FIO2, U&E, creatinine , HB, WCC, platelets, coagulation if needed
- Results of any scans - CXR, CT head, CT abdomen
- Patients wishes about HDU/ITU admission if known
- Patients wishes about Intubation/ventilation if known
- Views of family thoughts about what patient's wishes may have been
- Respiratory failure: where high FIO2 can be given. Access to NIV or CPAP or Intubation and ventilation if needed. Tired asthmatic or failure to oxygenate with COVID
- Renal failure: access to renal replacement to manage fluid overload and hyperkalaemia and uraemia
- Sepsis/Shock: manage sepsis and oxygenate and manage complications such as ARDS and renal and multiorgan failure. Use of Inotropes, invasive arterial monitoring. Central venous access for medications.
- Cardiogenic shock - inotropes, oxygen, arrhythmia management, balloon pumping, LV assist. maybe managed in CCU or Cardiac ITU
- Coma: airway protection when GCS < 9, can ventilate if unable to e.g GBS. Treat raised ICP and this can be monitored and ICP lowering strategies followed. Manage patients post head injury or cardiac arrest. Can manage status epilepticus.
- Liver failure: Manage coagulopathy, encephalopathy, sedation, hepatorenal syndrome
- Others: Complicated Diabetic ketoacidosis, post-operative care
- Perforated, ischaemic or infarcted bowel (both upper and lower).
- Acute pancreatitis.
- Sepsis from the gastro-intestinal, biliary or urinary tract.
- Respiratory or cardiorespiratory failure after any operation.
- Significant cardiovascular or respiratory disease in patients
undergoing major surgery.
- Respiratory failure and Pneumonia, acute exacerbation of COPD, severe acute asthma.
- Cardiovascular failure e.g. severe LVF, post-MI.
- Post cardiac arrest (unless rapid return of circulation, ventilation
and consciousness) usually go to CCU.
- GI bleed with haemodynamic instability.
- Severe diabetic ketoacidosis
- Poisoned patients at risk of airway or haemodynamic compromise or cardiovascular issues.
- Weakness and respiratory compromise: large strokes, basilar thrombosis, GBS, Myasthenia gravis