Why Critical Care?

An Overview
 Raj Kumar Mehta, MSN (Critical Care),
AIMS, New Delhi
HISTORY OF CRITICAL CARE

Critical care evolved from an historical

recognition that the needs of patients with
acute, life-threatening illness or injury could
be better treated if they were grouped into
specific areas of the hospital.
History of Critical Care...
Nurses have long recognized that very
sick patients receive more attention if
they are located near
the nursing station.
Following the Crimean
War (1854-1856),
Florence Nightingale
described the advantages of specialized
areas for the recovery of postoperative
patients
History of Critical Care...
Intensive care began in
the United States in
1920's, when Dr. W.E.
Dandy established the
first 3-bed neurosurgical
ICU at Johns Hopkins
Hospital in Baltimore.
History of Critical Care...
In 1927, the first premature infant care
center was established in Chicago
During World War Il, "shock wards" were
created to resuscitate wounded soldiers
History of Critical Care...
As a result of the nursing shortage that
followed World War Il, postoperative
patients were grouped in "recovery rooms"
to ensure attentive care
The benefits recognized led to establishment of
recovery rooms in
nearly every U.S.
hospital by 1960
In 1947-1948, the
polio epidemic
History of Critical Care...
raged through Europe and the United
States, resulting in a breakthrough in the
treatment of patients dying from respiratory
paralysis.
History of Critical Care...
In Denmark, manual ventilation was
accomplished through a tube placed in
the trachea of polio patients.
Patients with respiratory paralysis and/or
suffering from acute circulatory failure
required intensive nursing care.
History of Critical Care...
With the
efficacy of
centralized care
of the critically
ill proven,
History of Critical Care...
respiratory ICU's were developed in many
hospitals
During the 1950s, the development of
mechanical ventilation led to the organization
of respiratory intensive care units (ICUs) in
many European and American hospitals.
The care and monitoring of mechanically
History of Critical Care...
ventilated patients proved to be more
efficient when patients were grouped in a
single location.
General ICUs for very sick patients, including
postoperative patients, were developed for
the similar reasons,
History of Critical Care...
In 1958, approximately 25 percent of
community hospitals with more than 300
beds reported having an ICU.
By the late 1960s, most United States
hospitals had at least one ICU.
History of Critical Care...
During the 1960's "critical care" developed
as a specialty in response to:
Improved patient outcome with ICU care
Advancements in postoperative resuscitation and
monitoring
Surgeon's willingness to perform more ambitious
surgical procedures
History of Critical Care...
By 1970, most U.S. hospitals had at least one
ICU
In 1970, 29 physicians with a major interest
in the care of the critically ill and injured met
in Los Angeles, California to discuss the
formation of an organization committed to
meeting the needs of critical care patients:
the Society of Critical Care Medicine (SCCM).
History of Critical Care...
In 1986, the American Board of
Medical Specialties approved a
certification of special competence in
critical care for the four primary
boards: anesthesiology, internal
medicine, pediatrics, and surgery.
History of Critical Care...
Between 1990 and the present, critical
care significantly reduced in-hospital
time as well as costs incurred by
patients with diseases such as
cerebrovascular insufficiency and lung
tumors.
History of Critical Care...
The development of new and
complicated surgical procedures, such
as transplantation of the liver, lung,
small intestine, and pancreas, created a
new and important role for critical care
following transplantation.
History of Critical Care...
Widespread utilization of non-invasive
patient monitoring has further reduced
the cost and medical/nursing
complications associated with care of
critically ill and injured patients.
Widespread utilization of pharmacologic
therapy for critical care patients with
History of Critical Care...
specific organ system failure reduced time
spent in both critical care units and in the
health care facility.
In 1997, more than 5,000 ICUs were
operational in intensive care units across
the United States.
CURRENT STATUS

Over 4 million patients are admitted to

the 5000+ U.S. ICU's every year
Average mortality rate is 10-20%
More than 80% of all US hospitals have
at least one ICU
CURRENT STATUS...
The cost of caring for such critically ill
patients has risen as a result of the
specialized care
15-20% of a typical hospital's budget
'0 ICU care costs represent 1% of the U.S.
gross national product
Critical care in
India

Critical care practices in India

have evolved significantly over
the past decade
• As in most other developing nations,
critical care medicine as a specialty has
developed very slowly and only
recently in India.
Critical care in India...
• The coronary care units were developed in
the early to mid-1970s.

• Perhaps the main pioneer of the field of

critical care in India was Farokh E Udwadia, a
brilliant physician with international training
in pulmonology,
Critical care in India...
In the mid 1970s, Udwadia developed the
first respiratory care units in the country
in two hospitals in Mumbai a community
hospital and a private one.
• The most major achievement of these units
was not only to bring down the mortality of
tetanus, but also to open the eyes of society
to the need for critical care services.
Critical care in India...
These few enthusiastic, trained consultants
came together in 1992 to discuss critical
care on a common platform, and they
formed the national Indian Society of Critical
Care Medicine (ISCCM).
• The society had its teething troubles and has
now established itself very firmly as a
Critical care in India...
representative body of critical care
consultants in India.

The ISCCM has over 2000 members today,

and has 16 city branches.
• Manpower development of the specialists
has been a major issue.
Critical care in India...
• Most of the current directors have been
trained abroad

• The certificate course in critical care, the first

organized training activity in critical care
medicine, was started 4 years ago by the
ISCCM and has been evolving well.
Critical care in India...
• PostdoctoralFellowship in Critical Care
Medicine conducted by the National Board
of Examinations has recently been
announced.

• The training of nurses, technicians, and

therapists has begun in some isolated foci
Critical care in India...
but has not evolved into a meaningful
training activity.
Critical care in India. . .
• Critical care in India is thus at the crossroads of
development.

• The beginning has been made but there is still a

long way to go.

• The field is full of a lot of dynamism, opportunity and

challenges.
History of Critical Care Nursing
• One hopes that all the efforts will lead to a
humane, scientific and meaningful service for the
multitude of critically ill patients.
• Although there have always been very ill
and severely injured patients, the concept
of critical care is relatively modern.
As advances have been made in medicine
and technology, patient care has become
more complex.
History of Critical Care Nursing
To provide appropriate care, nurses
needed specialized knowledge and skills,
and the care delivery mechanisms needed
to evolve to support the patients' needs
for continuous monitoring and treatment.
• The seed of critical care was sown about 140
yrs ago by Florence Nightingale
History of Critical Care Nursing
• The first intensive care units emerged in the
1950s to provide care to very ill patients who
needed one-to-one care from a nurse.

• From this environment the specialty of

critical care nursing emerged.
Overview of critical
care
• Definition
+ Critical care is the care of seriously ill
patients with life threatening illnesses
or trauma, as also of patients who have
the potential to develop life-
Overview of
threatening complications from their
disease.
critical care

Critical care should, correctly speaking,

be reserved for patients with severe but
potentially reversible problems.
Overview of
Patients with chronic terminal illnesses,
with the end close at hand, should be
given every care at home or in the ward of
a hospital, but not in critical care units.
critical care

• Intensive or critical care has blossomed into

a specialty with special training and
Overview of
certification in the west, and also in many
developed or quickly developing East Asian
Countries.

• The specialty is a young but growing one in

our country.
Overview of
critical care

It is important, particularly in a poor country

like ours, that the few good critical care units
we have, admit patients who truly need
appropriate care
Overview of
It is sad to see critical care units cluttered
with patients who are unquestionably
better looked after in the wards, or at home
Conditions require
Intensive/ critical care
• Acute life-threatening illnesses which are
potentially reversible
• Acute illnesses with potential and likely to
occur life-threatening complications
• Monitoring of vital parameters of patients
with symptoms/signs that suggest the
Conditions require
possibility of an evolving life-threatening
illness.
Intensive/ critical care...

Acute or immediate life threatening crises or

complications in a chronic illness, even when
the latter by itself is almost certain to cause
of death within a matter of months e.g. A pt.
Conditions require
with cancer at a stage when life expectancy
is 3-6 months.
Intensive/ critical care
An acute complicating pneumonias in such a
pt is a life-threatening emergency which is
treatable, curable, and may well necessitate
critical care.
Conditions require
Therefore, a critical care unit as already
mentioned, should not be used for
terminal cases where the end is close at
hand.
Intensive/ critical care...

The tendency to use a critical care unit

as the last halt or 'stopping station'
Conditions require
before an expected departure from
this world, should be strongly
restricted.
Advantages/ disadvantages of
critical care unit
The chief advantage is that it provides
better and more organized care

The main disadvantage is of a hostile

environment contributing to anxiety,
emotional stress, loneliness, fear and a
greater risk of developing nosocomial
infections.

C040fCülCn
(ICU)
ICU
 ICU
Concept Of
More care Continuous & Intensive
Specialty Care
Source of Areas ( Med, Sur etc )
Open/ Closed
Provides advanced Life support through
the application of Technology
 ICU
Initial Assessment of Airway, Breathing &
Circulation & Intervention
Design of
1 ICU bed/ 100 beds More in tert care
hos
• Unit of 4 -8 beds Occupancy 75%
• Bed Area 200sq ft
 ICU
• Central Nursing Station Changing rooms
• Store, office, lab, Seminar room, Waiting
room
Staffing of

Director- medical + nursing

• Physician/ consultants
 ICU
• Resident Doctors
• Sister I/C
• Nursing sister (1:1)
Physiotherapist
• Technician
• Ancillary staff
Team work

• Physician-Instructions, overall
• Nursing staff-Nursing care,
Assessment
& recording, Physiological, Social,
Therapy
Physiotherapist
• Technician

The Flow Sheet

The Flow Sheet...
• Recording round the clock information of
different organ systems- computerized /
Manual
'I' Vital signs
• Neurological Status
• Haemodynamic Parameters
• Ventilation settings
• Respiratory parameters
• Input/output
• Laboratory Data
• Medication
SYSTEM ORIENTED ROUNDS
ACCURATE TRANSMISSION OF
CLINICAL INFORMATION
 COMPULSIVE
AND FOLLOW EVERY SINGLE
DETAILS
" Head to Toe Format"
The Flow Sheet...
• Identification/problem list
• Major events during the last 24 hrs
Neurological- Mental status, Complaints,
CNS/E
• Cardiovascular System
• Respiratory
• Renal/metabolic
The Flow Sheet...
• Gastrointestinal
• Infectious Diseases Hematological
• Psychological
• Nutrition,
Endocrine,
• Others-Tube, Medication etc
ABOUT CRITICAL CARE
NURSING

Oxford Dictionary gives the

meaning of critical as crucial; as
crisis; of emergency as requiring
immediate action; and of intensive
as thorough and constant
observation.
ABOUT CRITICAL CARE
NURSING...
These are all interrelated, because
those patients who present with life
threatening conditions are in a
'crucial' state/situation, needing
 'immediate action', and requiring
'thorough and constant' observation.
Definition of Critical Care Nursing

• Critical care nursing is that specialty within

nursing that deals specifically with human
responses to life-threatening problems.
• A critical care nurse is a licensed
professional nurse who is responsible for
ensuring that acutely and critically ill
patients and their families receive optimal
care.

Definition of a Critically Ill Patient

Critically ill patients are defined as those

patients who are at high risk for actual or
potential life-threatening health
problems.
The more critically ill the patient is, the
more likely he or she is to be highly
vulnerable, unstable and complex, thereby
requiring intense and vigilant nursing care.
 Critical Care Nurses
Number of in
the United States
Ill According to "The Registered Nurse
Population" study done in March 2000 by
the Department of Health and Human
Services, there are 403,527 nurses in the
 Care Nurses
U.S. who care for critically ill patients in a
hospital setting.
Where Critical Work ?

• According to "The Registered Nurse

Population" study, 59% of all nurses work in
the hospital setting, and critical care nurses
 Critical Care Nurses
work wherever critically ill patients are found
— intensive care units, pediatric ICUs,
neonatal ICUs, cardiac care units, cardiac
catheter labs, telemetry units, progressive
care units, emergency departments and
recovery rooms.
Where Work?
 Care Nurses
• Increasingly, critical care nurses work
in home healthcare, managed care
organizations, nursing schools,
outpatient surgery centers and clinics.
What Critical Care Nurses Do?

• Critical care nurses practice in

settings where patients require
complex assessment, high-intensity
therapies and interventions, and
continuous nursing vigilance.
The Roles
What Care Nurses

Critical care nurses rely upon a specialized

body of knowledge, skills and experience
to provide care to patients and families
and create environments that are healing,
humane and caring.
 Critical
Foremost, the critical care nurse is a patient
advocate
of Critical Care Nurses

Critical care nurses work in a wide variety

of settings, filling many roles.
The Roles
They are bedside clinicians, nurse
educators, nurse researchers, nurse
managers, clinical nurse specialists and
nurse practitioners.
The Roles of Critical Care Nurses...

With the onset of managed care and the

resulting migration of patients to
alternative settings, critical care nurses are
caring for patients who are more ill than
ever before.
The Roles of Critical Care Nurses...

Managed care has also fueled a growing

demand for advanced practice nurses in the
acute care setting.
Advanced practice nurses are those who
have received advanced education at the
master's or doctoral level.
The Roles of Critical Care Nurses...

In the critical care setting, they are most

frequently clinical nurse specialists (CNS)
or acute care nurse practitioners (ACNP).
A CNS is an expert clinician in a particular
specialty - critical care in this case.
The Roles of Critical Care Nurses...

The CNS is responsible for the identification,

intervention and management of clinical
problems to improve care for patients and
families.
They provide direct patient care,
including assessing, diagnosing, planning
and prescribing pharmacological and
The Roles of Critical Care Nurses...

nonpharmacological treatment of health

problems.
ACNPs in the critical care setting focus on
making clinical decisions related to complex
patient care problems.
The Roles of Critical Care Nurses...

Their activities include risk appraisal,

interpretation of diagnostic tests and
providing treatment, which may
include prescribing medication.
Critical Care Nurse Certification

Although certification is not mandatory for

practice in a specialty like critical care in
everywhere, many nurses choose to become
certified.
Future of Critical Care
Certified critical care nurses (CCRN) must have
been in critical care practice for a minimum of two
years to be eligible for the examination.
Nursing Shortage More Pronounced
for Critical Care Nurses
The growing nursing shortage is especially acute
in the specialty areas of nursing,
e.g. adult critical care units, pediatric and neonatal
ICUs and emergency departments.
Hospitals are offering critical care nurses ever more
attractive incentives, including sign-on bonuses,
relocation bonuses, reimbursement for continuing
education and certification, and other attractive
benefits.
Future of Critical Care
Nursing
Rapid advances in healthcare and technology
have contributed to keeping more people out
of the hospital.

However, patients in critical care units are more

ill than ever before.
Many patients who would have been cared for
in a critical care unit five years ago are now
being cared for on medical floors or at home.
Future of Critical Care
Nursing

Many patients in today's critical care units

would not have survived in the past.

It has been proposed that the hospitals of the

future will be large critical care units, and
other types of care will be provided in
alternative locations or at home.
Future of Critical Care
Nursing...
Critical care nurses will need to keep
pace with the latest information and
develop skills to manage new
treatment methods and technologies.
As issues relating to patient care become
increasingly complex and new
technologies and treatments are
Future of Critical Care
introduced, critical care nurses will need
to become ever more knowledgeable.
Seven Cs of Critical Care
Compassion
• Communication (with patient and family).
Consideration (to patients, relatives and
colleagues) and avoidance of Conflict.
• Comfort : prevention of suffering
• Carefulness (avoidance of injury)
• Consistency
• Closure (ethics and withdrawal of care).
CONCLUSIONS
An organized, intensivist-led patient care
model
Improves patient care
 Decreases resource utilization Results in
fewer complications
Decreases mortality
Lowers total hospital costs
Improves and continually updates non-
intensivist physician/nurses critical care
knowledge