Intensive Care and Nursing Development Unit · 2012. 9. 17. · – the tax-payer deserves this at...

Intensive Care and Nursing Development Unit

Annual Report 2010-2011

Contents

Introduction ................................................................................................................................

Foreword..............................................................................................................................................3

Philosophy of cCare..............................................................................................................................4

Patient experience ................................................................................................................................5Patient diaries ............................................................................................................................5Quality Group ............................................................................................................................5Volunteering in the Intensive Care Unit ......................................................................................6Relatives Satisfaction Survey 2010-2011 ....................................................................................8Customer Service Excellence Award............................................................................................9Customer journey mapping......................................................................................................10Patient profiles ........................................................................................................................12End of life care – an update ....................................................................................................13

Safety and clinical effectiveness ..........................................................................................................14Infection control ......................................................................................................................14Tissue Viability Group ..............................................................................................................15Organ Donation Committee ....................................................................................................15Morbidity and Mortality meetings ............................................................................................16Clinical Incidences in the Intensive Care Unit 2010-2011..........................................................17Health and safety ....................................................................................................................19Care bundles ............................................................................................................................20

Financial and environmental sustainability ..........................................................................................21Activity and performance ........................................................................................................21Off-duty Planning team ............................................................................................................24Finance and Supplies Group ....................................................................................................25The Three Peaks Challenge ......................................................................................................26

Teaching and research ........................................................................................................................27Teaching Group........................................................................................................................27The staff development role 2010-2011 ....................................................................................27Experience of the Mentorship course........................................................................................28Experience of the Foundation course........................................................................................29Immediate Life Support teaching ............................................................................................30Research Group........................................................................................................................30Research within ICU ................................................................................................................31Critical Care Physiotherapy ......................................................................................................33AcuBase ..................................................................................................................................34

Staff 2010-2011 ................................................................................................................................35

Acknowledgements ............................................................................................................................37

1 Intensive Care and Nursing Development Unit Report

Introduction

In 2011 two specific eventsmade me proud of Chelsea andWestminster’s Intensive CareUnit (ICU).

The first was the when weachieved the Customer ServiceExcellent Standard Award. Thisreplaced the Charter MarkAward which the unit held since1999.

This standard is about improvingthe customer (patient)experience with particular focuson service delivery, timeliness,information, professionalism andstaff attitude. It helps us tocontinually focus on what isimportant to the patient.

Inside the annual report there isan article explaining what thestandard is and what we did toachieve it.

This year’s annual report isdivided in three distinct sectionson patient experience, safetyand clinical effectiveness. Thereport contains the regularsections about updates on theinter-team projects,development opportunities,research activity and userfeedback.

Completing this annual reportevery year makes us take stock

of what our priorities are, whatchanges have occurred duringthe year and how we haveresponded to them.

For example, in the report aboutperformance we outline theactivity in the unit over the lastcouple of years, which helps toproject and inform activity plans.

Similarly, we have reviewed ourskill mix in order to produce costsavings. This is balanced withopportunities for staffdevelopment so that the unitstaff become the initiators ofchange whether for a financial,quality or research gain.

Producing this annual reporthelps us to focus on eventswhich occurred in the last year –‘a glass half full’ – and allows usto relish and celebrate oursuccess and achievements of theprevious year before movingonto areas to concentrate on inthe coming year. In all of ourbusy lives it is nice to allowourselves to be reflective andthink ‘didn’t do a bad job…’.

I started this introduction byoutlining two events whichmade me proud. The secondwas when I received a letter inMay from the son of a patientwho had died on the unit.

He stated:“You are the mostwonderful … team I haveever come across – the jobthat you do is quiteextraordinary and I hopethat you understand howmuch you touch the livesof your patients andfamilies when they are attheir most vulnerable.

You have taught me somuch about patient care –if I can take even a little ofthat onwards in my careeras a doctor, I shall behugely proud of myself.And I shall never forgetwhere I learnt it.”

RB, May 2011

Jane-Marie HamillHead Nurse Critical Care

2010-2011 2

A Glass Half Full

Foreword

IIt has been a complex year forthe Intensive Care Unit. Wehave not been immune to thewider anxieties sweeping theglobe – financial worries,insecurity and concern for thefuture have loomed largerecently.

Undoubtedly we must examineour practice and seek toeliminate any unjustified waste– the tax-payer deserves this atleast – but such a commitmentcan sometimes feel at oddswith delivering a high qualityservice. This quality has to datebeen exemplary and wasrecognised by an award fromthe Care Quality Commission –a rightly proud moment for theUnit. Will it continue?

All of us working in ICUunderstand how to respondwhen high pressureemergencies demand. Asudden surge in critically illpatients causes us to react – tothe best of our abilities withthe resources available. You cantry and plan for events such asflu epidemics but it is not easy

to adequately plan for multipleburns (a possibility during theriots) or terrorist attacks.

Under those circumstances wewould do our best in theseworst of times, aware that itmight not match the besttreatment one would hope togive in the best of times. This iswhat cataclysmic events cando.

However, the credit-crunch-generated squeeze ongovernment finances trickles allthe way down to us. Budgetswill experience unusualhardships – all the easy savingshave been made, only difficultchoices remain.

Is this going to lead to slippagein standards, corners being cutor the numbers and/or the skillof the staff being reduced? Ireally hope not – and I don’tbelieve anyone at Chelsea andWestminster Hospital isinterested in that, but it isdifficult to see how one cansquare the circle of ever-scarcerresources whilst maintaining

the highest quality of care.

I must particularly praise Jane-Marie Hamill who has workedheroically during this new eraof intense scrutiny. Our focus isquality and will remain so.

We have welcomed severalnew members of staff this yearincluding Dr MarcelaVizcaychipi as a substantive ICUConsultant. New staff candynamise the Unit and bringfresh ideas. I can already feelthat happening – which isexciting.

Ultimately, successful intensivecare is delivered by a team. Thecharacters making up the teamand their cohesion is the singlemost important factor inachieving the best for patientsand the happiness of us, theworkers.

The best one could wish for isa good professional team – andI hope we are.

Dr Rick KeaysConsultant Intensivist


The view from the unit

Philosophy of Care

Many different members ofstaff attend to patients withinthis department. Together weare dedicated to providingcompassionate, exceptionalcare and service throughcontinuity of care. Werecognise the uniqueness ofeach individual and his or herright to dignity, and as suchare dedicated to provide thebest possible, individual care inan environment that iswelcoming, safe and clean.

We respect the rights of ourpatients, and that our caremust be non-judgemental,based on sound ethical andmoral principles. We recognisethat the severity of illnessexperienced by our patientsmay render them incapable ofparticipation in makingdecisions that affect their care.As direct care givers, we mustserve as the patients advocate,in consultation with family andsignificant others. We willprovide care in such a way asto respect the dignity, privacyand confidentiality of patientsand families.

We aim to assist our patientstowards recovery andindependence. When it is notpossible, we try to preparethem for a peaceful,comfortable and dignifieddeath. We feel it is importantnot only to share in the joy ofa patient’s recovery, but also inthe sorrow and pain of apatient’s death, and to easeothers’ grief.

We believe that the caringenvironment we provide forour patients should bereflected in our attitudestowards each other and thateach member of the team is avaluable asset. Staff have theright to be treated withrespect and to go about theirwork without risk tothemselves. Every member ofstaff should have theopportunity to develop theirskills through the provision ofprofessional developmenttailored to their own needs.

We, the intensive care teambelieve that our work makes adifference, benefiting patientsand their loved ones. We feelthat we are in a privilegedposition of trust and that thisprivilege should be repaid bythe provision of the higheststandards of care, delivered bycompetent, questioning andmotivated staff.

2010-2011 4

Patient experience

We introduced patient diariesonto the ICU two years ago asa pilot project.

Initially we only offered diariesto patients in two of ourprimary nursing teams.However, the plan was toexpand this to all appropriatepatients, so we have graduallyincreased the number ofprimary nursing teams involved.

The aims of the diaries includefilling in the potential gaps inthe patients’ memories of theirICU stay by giving theminformation in a chronologicalsequence. Many patients arefrightened by the lack ofcontrol and understanding theyhave of their ICU time and wehope that reading their diariescan help them understand theexperience better.

After discussion with theClinical Governance team, wehave introduced a feedbackform. So far, patients’ feedbackhas been positive and they saythey really appreciate the careand regard that nurses havedemonstrated when writing inthe diaries. They also value theopportunity to return to ICUand meet with a senior nursewho can often answerquestions about their ICU stay.

However, we have had somedifficulties tracing patients orbereaved relatives followingdischarge or death and wehave introduced a book totrace progress and location ofthe diaries. This includescontact details of the patient,their next of kin and GP. Thishas made the process clearer.

Over the next year, we areaiming to offer diaries to allpatients who stay in ICU formore than three days.

Rosalie Le CordeurSister Team F

The Quality Group continues tomonitor and improve the qualityof service delivered by thisIntensive Care Unit. This year wehave been working on reviewingand revising the information weprovide for our patients andtheir relatives.

Admission to intensive care is atraumatic and stressful episodefor patients and their relatives.This can have a huge impact ontheir lives that can last for manyyears and we are all consciousthat we must continue to workto make their time with us morebearable.

The most effective method ofunderstanding the patient andrelatives experience is thegathering of information and wehave been doing this for manyyears in a number of ways.

We ask relatives to complete aRelatives Satisfaction Survey.Over the last year there has beena reduction in returns of theseand on reflection, we concludedthat it had become too long andthat relatives may be put offcompleting them. Our volunteerCaroline Heslop has completelyrevised the format, making itshorter without losing theinformation gathered and wewill be launching this soon. Wewould like to thank Caroline forthe work she has done and hercommitment to this project.We continue to run our focusgroups where we invite former


Quality GroupPatient diaries

patients to come back and talkabout their experiences. This apowerful meeting and we have

learnt a great deal about whatwe do well and what we needto improve on. This waspresented at the Trust’s SeasonalConference this year and waswell received.

Feedback is used to improve theinformation given to patientsand their relatives and we are inthe process of revising ourmaterials.

Our admission booklet providesinformation for relatives aboutthe unit and the hospital. Ourdischarge booklet providesinformation to our patients onwhat to expect after dischargefrom intensive care.There are a number ofinformation boards giving abroad range of information that

is helpful to all visitors. We havealso developed a folder oncommon medical conditions andtreatments that relatives mayhear about, which is presentedin way that is easier for non-medical people to understand.

I would like to thank all themembers of the Quality Groupfor their hard work andcontinuing commitment. Ibelieve it really does make adifference.

Rebecca Hill Sister

Team D

A photo board located in the maincorridor helps patients and visitorsidentify members of the ICU team

Volunteering in the Intensive Care Unit

Why I became Involved withthe ICUMy first encounter with theIntensive Care Unit of theChelsea and WestminsterHospital was the afternoon ofFriday 21 December 2001. Ican’t remember how I got there,but that was not because I was apatient – it was because my 18-year-old daughter Rachel hadbeen admitted to the unit withmeningococcal septicaemia.

For the next three weeks Ivirtually lived in the unit. Weslowly progressed from thedreaded isolation of the sideroom to the main ward in the

ICU. I learnt to cope with centrallines, dialysis machines, heartmonitors and all the otherparaphernalia which until then,as far as I was concerned, hadonly happened on EmergencyWard 10. I know this shows myage, but my age is of somerelevance because it was on my50th birthday that the bigbreakthrough finally came. Shewas taken off the ventilator andher first words were “HappyBirthday”.

So how could I ever say thankyou? Whilst in the unit I hadbeen vaguely aware that therewas a volunteer who appeared

from time to time to do I knewnot what, so once Rachel wasbetter I decided to approachJane-Marie to see if there was afurther opening for voluntarywork. She was very receptive tothe idea and once I had gonethrough all the right channels Iwas welcomed to the unit withmy new identity – now avolunteer rather than a relative.

What I do in ICUI normally work at the hospitalevery Wednesday morning forabout three hours. The first job Ido every week is filing the bloodresults and generally trying tokeep patient records in some

2010-2011 6

Patient experience

kind of order. Next, I look afterthe plants in the corridor outsidethe unit and then there is alwaysthe telephone to be answered!Over time however, I feel mymost important role has becomethat of a relatives’ representativeon the Quality Group, which inturn has led me to becomingresponsible for the RelativesSatisfaction Survey.

Relatives Satisfaction SurveyThere are two aspects to thesurvey. Firstly, we are trying toaudit our nursing practices andsecondly, we are trying to findout from relatives whatimprovements and changesthey’d like to see.

We ask about the cleanliness ofthe unit and I always find it veryreassuring to see that the vastmajority feel, as I do, that theunit is kept immaculate. It is veryuseful to be able to pass thisinformation onto the cleaningstaff, especially when there is sooften bad press about hospitalcleanliness.

We constantly review thequestionnaire in response tosomething that has changed inpractice. For example, wedeveloped an information folderon medical conditions due torelatives asking for it. To date,most people are still not awareof the folder so the survey isshowing us that we must domore to promote it.

The waiting room has alwaysbeen a problem; it is small anddark and not somewhere that

anyone wants to be. At onepoint however, it was suggestedthat it should be moved tooutside the unit beyond thedouble doors, but as a relative Ifelt very strongly that this was anextremely bad idea because itwould have meant that therewere locked doors between therelative and the patient. So wehave left it where it is and doeverything we can to helprelatives understand that it is thebest option.

Other jobsThere are of course other jobsthat I do as a volunteer:

• Every three years we haveapplied for the Charter Mark(now the Customer ServiceAwards) and I have joined inon the interviews anddiscussions with the assessorwho is always most interestedin the interaction between theunit and its users (in this casethe relatives)

• I contribute to the AnnualReport

• I have helped Jane-Mariereorganise various areas of theunit and there’s always filingand photocopying to be done

• Occasionally I will becomeinvolved with other relatives,especially if meningitis isinvolved

• As a non-member of staff it ismuch easier for me to askrelatives for donations andhave produced a leaflet whichcan be used if relatives wish tomake such a donation

• And finally I am, of course,always happy to make the tea

How a volunteer can helpApart from the actual jobs I doon the unit, as an ex-relative Ifeel my main aim is in fact to tryand be a constant reminder ofthe value of the unit’s work.

There are days in hospital lifewhere one thinks: “What am Idoing, why am I doing this?”,and I am well aware that somedays can be incrediblydepressing. I just hope that I canact as a reminder to all staff thatwhat you do is priceless.

Caroline HeslopVolunteer, Intensive Care Unit


The ICU has rooms available for relatives who wish to stayovernight and folders containing information about theunit

Relatives Satisfaction Survey 2010–2011

The Relatives Satisfaction Surveycontinues to be a valuable toolin assessing how the IntensiveCare Unit is perceived bymembers of the public and isused to highlight areas in whichwe may improve our services.

The survey has been based on35 questions broken down intothree sections relating tocommunication, care andfacilities. Respondents are alsoasked to add their owncomments and suggestions. Theresults are tabulated twice a yearand presented to the QualityAssurance Group for discussionand action.

The survey is now in its twelfthyear and as in previous years thevast majority of responses fromrelatives have been veryfavourable. However, thenumber of those responding ismarkedly down on previousyears. In 2010, 18 questionnaireswere completed and in 2011only 11 were completed,compared with 40 in 2008.

As a result of this decrease, theQuality Group has redesignedthe questionnaire and reducedthe number of questions so thatthe survey can fit onto a singlesheet of paper.

As in previous years the resultsfrom the survey show that onthe whole relatives are verysatisfied with the serviceprovided by the ICU, but thatthere are always areas that canbe improved. By enabling directfeedback from relatives, theRelatives Satisfaction Survey willcontinue to be one of the unit’smost useful tools in improvingthe services it offers to thepublic.

2010-2011 8

We have, unfortunately, much experience of intensive care units. This one really stands outfor us because of the friendly helpful staff. ST June 10

We always knew who was "in charge" of our relative and who to approach and askquestions - a great system. SF Sept 10

All the staff were excellent and I must mention Abdul the cleaner who keeps the ward spotless. WE March 11

I lost the light of my life in your hospital. Your facilities here are very good, but Ihave only one word for your staff - STELLAR! Thanks to you all for making such ahorrible experience as bearable as possible. RC Oct 10

I have nothing more to ask. Very satisfied with the services we received. NL Oct 11

More detail needed in the Medical Conditions Folder. Those relatives who are interested will usually want moreinformation not less. Remove the coffee machine in the waiting room - it does not work! Replace it with abookshelf and literature for relatives. Overall we think you guys do an outstanding job! SF Sept 10

I thought everyone was so kind, thoughtful, professional and it was agreat team. Thank you. LW Mar 10

Very happy with care given and friendliness of staff. Treated Mum with dignity and respectand put her at ease. MC July 11

Patient experience


Since 1998 the Intensive CareUnit has applied for, achievedand retained the Charter Mark,which was a Governmentrecognised award for customerservice.

Last year the Charter Mark wasreviewed and changed to theCustomer Service Excellencestandard which assesses theperformance of public services inmaking changes andimprovements driven bycustomers, patients or serviceusers in areas that are importantto them. It is designed tooperate on three distinct levels:

1 As a driver of continuousimprovementIn relation to customer-focusedservice delivery, identifyingareas and methods forimprovement.

2 As a skills developmenttoolBy allowing individuals and

teams within the organisationto explore and acquire newskills in the area of customerfocus and in relation tocustomer-focused servicedelivery, identifying areas andmethods for improvement.

3 As an independentvalidation of achievementBy allowing organisations toseek formal accreditation tothe Customer ServiceExcellence standard,demonstrate theircompetence, identify key areasfor improvement and celebratetheir success.

The five criteria against whichthe Intensive Care Unit wastested during a two-day visit byan assessor in March 2011included customer insight,culture of the organisation,information and access, deliveryand timeliness, and quality ofservice.

We produced a portfolio ofevidence measured against eachof the five criteria and then theassessor took time during hisvisit in March to interviewpatients, relatives and staff tocheck that what was written onpaper in the portfolio wasreflected in practice.

The assessor identified strengthsof the Intensive Care Unitincluding:

• A holistic approach to patientcare by considering all thefactors which could improvecare

• A multidisciplinary approach tomaking suggestions andtaking decisions rather than a‘top down fait accompli’approach

• The determination,professionalism and loyalty tothe unit of staff who areproud of their work and clearlyput patients and their relativesfirst

Customer Service Excellence Award

The unit has been praised for its holistic and multidisciplinary approach to patient care

• Focus groups that enableformer patients and relativesto talk about their experienceson the unit—these groupshelp identify manyimprovements

Areas for development identifiedby the assessor included:

• Developing a more user-friendly philosophy of care byagreeing five or six keystatements and displayingthese at the entrance to theunit

• While adhering to the Trust-wide approach to handlingcomplaints, staff should trywhere possible to take greaterownership so that aspects oftimeliness, promises andprotocols are adhered to

• Celebrating and promotingsuccess and performancethrough the unit’s newlyrevamped section of the Trustwebsite

This award recognises thecompassion, dedication and hardwork that all staff show everyday to ensure that patients andtheir relatives are getting thebest care.

Elaine Manderson Clinical Nurse Specialist

Jane–Marie HamillHead Nurse Critical Care

As part of the Customer ServiceExcellence assessment, the ICUundertook customer journeymapping to better understandwhat it is like to be a patient orrelative using the intensive careservice.

Customer journey mapping canhelp to identify how the ICU‘treats’ its customers during eachcontact that takes place. It isviewed from the standpoint ofhow the customer feels towardsthe Intensive Care Unit duringthe time they use the service.

In terms of customerunderstanding, journey mappinghelps the unit to:

• See things from the customer’spoint of view

• Deliver information, messagesand services at the mostappropriate time

• Deliver a seamless, streamlinedexperience

• Get it right when it reallymatters eg when emotions arehighest or the need is greatest

• Look at the current situationand the ‘ideal’ side-by-side,giving a chance to genuinelyredraw the customer journey

We looked at four ‘journeys’:

• Emergency admission to ICU –patient

• Emergency admission to ICU –relative

• Elective admission to ICU –patient

• Elective admission to ICU –relative

See page 11 for an example.

From undertaking this processwe have gained a greaterunderstanding of what it is likefor our patients and relativesusing our service.

We have fedback the maps tostaff on the unit and all newstarters receive a copy of themap, therefore enabling them togain an understanding of what itis like to use ICU services.

We have also highlighted areasfor future work including furtherwork on delirium in ICU,communication skills training,rehabilitation and discharge fromICU.


2010-2011 10

Customer journey mapping

Patient experience


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Shock; fear of the unknown; anxiety; anger; numb; outof control; lots of questions; tearful; pain; fear of dying;

confusion; lack of cognition; nausea shock;breathlessness; extreme tiredness. These feelings

may be experience

We have recently introduced a‘patient profile’ to augment thecare we provide to our patientswhen they are unable tocommunicate with us. Theprofiles are small summaries ofthe patient, what theylike/dislike, what they do withtheir time, and are completed byrelatives or friends of the patientwho know them well.

They are designed to help thestaff gain a picture of the patientoutside of ICU. An example ofthe profile is below:

Staff have found these useful tobuild up a picture of the patientand helps them to make surethe patient receives care focusedupon their needs and likes whilethey are unable to communicatewith others.


Patient profiles

Name (That they like to be called)

Family and Friends (People who are likely to be visiting and/or phoning. People important to your loved one)

Personality (What sort of person are they? ie happy, anxious etc)

Language spoken (If English is not their first language, will they understand staff speaking to them?)

Background (What do they do? how do they occupy their day?)

Leisure (Describe their hobbies, favourite music, what they like to read, sport interests, club membershipsetc)

We regularly reposition patients to prevent pressure ulcers developing – are there any positionsthat your loved one likes or dislikes, or finds especially uncomfortable due to underlyingconditions or old injuries?

Sometimes massage and touch can help to ease aches and pains and assist people in sleeping. Isthere any type of touch or massage that your loved one likes or dislikes (e.g. ticklish feet)

Your loved one may have unique needs that you may know about that would be useful for us toknow. (Do they sleep in a particular way? Do they have a favourite toy/ pillow, Do they have any phobias?ie needles etc)

Completed by (Name and relationship to the patient)

2010-2011 12

Patient experience

End of life care – an update

The Liverpool Care Pathway(LCP) is a multi-professionaldocument for the care of thedying patient (Ellershaw 2003).Originally developed for thebenefit of cancer patients, theLCP has since been adaptedfor use in other locations, suchas the Intensive Care Unitsetting.

However, the ICU is viewed asa place for saving lives andactive treatment and patientsare admitted with the hope ofrecovery from their illness, yetmortality rates remain high(approximately 16%). Thus,while striving for a curativeoutcome for a critically illpatient, it can be difficult torealise that the patient maynot survive and is insteaddying.

Having completed thePalliative Care in CancerPractice Course at the RoyalMarsden Hospital I reviewedthe current literature relatingto end of life care in the ICUto establish the difficulties thatexist when making thedecision to move from curativeto palliative care for critically illpatients.

Three recurrent themes wereidentified:

• A lack of certainty of apatient’s prognosis, illnessprogression and of death

• The elusive knowledge ofpatient preference andethical dilemmas

• Poor communication

I looked at current practice toidentify new strategies toimprove future practice. Theseincluded:

• Improved communication ina dignified manner with thepatient, family and staff

• Assistance and support forprofessionals so they bemore at ease with death andable to accept that death isa normal process and not afailure

• Ongoing education andtraining for all staff involvedin end of life decisionmaking

Hopefully these strategies willencourage the appropriate useof the pathway in ICU for ourpatients who are dying, andensure the multi-professionalteam delivers high quality carefor dying patients and theirfamilies.

Ann SorrieSister

Team E

ReferenceEllershaw J (2003) ‘Introduction’ (pxi – pxiii). In Ellershaw J and Wilkinson S (2003) ‘Care of the Dying. A pathway to excellence’Oxford University Press


Safety and clinical effectiveness

It has been another productiveyear for the Infection ControlTeam as we continue to establishourselves as one of the newerinter-team projects.

Patients we care for in ICU aremore susceptible to infectionsdue to the interventions deemednecessary for us to give ourpatients the best possible care.

With this in mind, the ICU set upthe Infection Control Teamwhich meets once a month. Ourmain aim is to ensure the

standard of infection controlremains high within the unit.

We attempt to achieve this bycontinually evaluating currentinfection control practices andidentifying improvements thatcan be made. Teaching sessionsare then held to establish aconsistency in infection controlpractices across all staff workingin the ICU. A member of theTrust’s Infection Control Teamregularly joins our meetings toprovide an update on eventselsewhere in the Trust.

Of course these meetings wouldbe fruitless if all the stakeholdersin the ICU did not adhere to theinfection control regulations.While it is imperative that all thedoctors, nurses and support staffwithin the ICU work to protectthe patient, it is also importantthat we educate all healthcareprofessionals and relatives whovisit our patients on how theycan prevent the spread ofinfections.

We have a new infection controlnotice board which is located ina prominent place within theunit. This is used tocommunicate updates oninfection control to all staff inthe ICU.

A big change to the team thisyear has been how we auditinfection control.

The Trust has recently launchedan online auditing tool calledSynbiotix. The types of things weaudit on a monthly basis includehand hygiene and central linecare. Every month the necessarydata is put into Synbiotix and itbecomes a useful tool tobenchmark our progress frommonth to month. The results ofthe audits are posted on theinfection control board so staffcan clearly see if and whereimprovements need to be made.

Over the next year the team willcontinue to strive to provide themost up to date practice withregards to infection control inorder to protect our patients asbest we can.

Katherine ThomasStaff Nurse

Team H

2010-2011 14

Infection Control

A member of the ICU’shousekeeping staff


The Tissue Viability Group wasset up last year to support thenursing team in reducing theincidence of pressure ulcers, andconsider other aspects of tissueviability.

Over the last year, the group feltthere was a need to improve theinformation available for staff.As a result we are currentlydeveloping a folder covering avariety of topics such as whatwound care products arestocked in the unit, how theywork and which type of woundsthey are suitable for.

Another section providescomprehensive guidance (fromKCI) relating to vac dressings.Other sections include a copy ofthe updated tissue viabilitypressure ulcer preventionguideline and information on therole of the European PressureUlcer Advisory Panel (EPUAP)and the organisation’s onlineresearch and learning tools.

Additional information will beadded to the folder over thenext 12 months followingfeedback from the ICU team andin consultation with the Trust’sTissue Viability Nurse.

The group also found a need forimproved understanding inidentifying the earliest level ofpressure damage and how tograde the severity of pressureulcers when they occur. This isimportant because it affects

prevention and managementstrategies. Project members haveenhanced their understanding ofthe EPUAP grading tool and areencouraged to share theirknowledge with their teammembers. A teaching session onpressure ulcer prevention isincluded in the foundations ofcritical care course.

In addition to pressure ulcers,ICU patients are particularlysusceptible to development ofmoisture lesions, for exampledue to discharge from woundsor faecal soiling. It is importantto prevent this where possibleand be aware of differentstrategies in avoiding ormanaging excoriation. Onemember of the group isdeveloping a guidelinesummarising the differencesbetween moisture lesions andpressure ulcers as defined byEPUAP and how they can betreated.

The group is also actively seekingto reduce the cost in wound careproducts and has identified acheaper but effective product toreduce pressure over thepatient’s heels. The group willcontinue to review other woundcare products to minimise wasteand improve cost effectiveness.

Finally, the group will run a‘Pressure Ulcer PreventionAwareness’ week to highlight allthe information available on theunit. We hope that during the

remainder of this year our workwill have a positive impact inimproving patient’s skin andwound care within the unit.

Caroline YoungerSister

Team B


Tissue Viability Group

Organ Donation Committee

As part of the NHS Blood andTransplant (NHSBT) nationalagenda for increasing organdonation rates in the UK, it wasrecommended that each Trustshould have a Clinical Lead forOrgan Donation (CLOD) and anembedded Specialist Nurse forOrgan Donation (SNOD).

It was also suggested that adonation committee be set upwith the purpose of wideningthe message and ensuring thatpatients should be given everyopportunity to donate organs inthe event of their death if theyhad expressed that wish in life.

This committee was inauguratedin May 2011 and is chaired byCaroline Heslop. I am the clinicallead for organ donation.

This final act of altruism andgenerosity on the part of one

Multidisciplinary Meetings This section reviews the progressof our established Morbidity andMortality and our newly formedRehabilitation Group.

Morbidity and MortalityMeetings The established Morbidity andMortality Meetings aremultidisciplinary and last for anhour and a half. They are chairedby the consultants on arotational basis and the format

consists of reviewing the deathsof the patients who have died inthe Intensive Care Unit duringthat quarter.

Each patient on admission to theunit is given an Acute Physiologyand Chronic Health Evaluation(Apache) score (severity score).Any patient who scores less than20 but dies, the consultant willreview the reasons and identifypatient cases which arepresented at the meeting. Adiscussion occurs and anylearning is identified.

For example, it was identifiedthat it would be useful to have aregular report from the Coroner’soffice on patients who had diedon the unit. We have alsodeveloped a log book onrecording abnormal blood resultswhich are rung through fromthe laboratory. This details whotook the call and what actionhas taken place.

The second part of the meetingencourages discussion aboutfuture treatments, practices, andensures different staffing groupsare updated with what ishappening on the unit and areable to give their opinions andsuggestions in a constructiveway.

For example, in past meetingswe have discussed visiting times,consultant’s rounds and ideas fordonations. It is also anopportunity to network withcolleagues. Staff are also given

an update on the Liverpool CarePathway and organ donation.

It is extremely well attended bymore than 15 staff, but onelearns that if a meeting includeslunch it is usually well attended.

Rehabilitation Group This group was established in2011 to provide a consistent, co-ordinated approach torehabilitation and dischargeplanning of critical ill patients bythe MDT (multidisciplinary team).

We have developed a proformafor arranging MDTs on the unitand this has been used anddocumented for a number ofpatients. It has helped to involveand include specialties such asspeech therapy and occupationaltherapy in planning short termand long term goals for thepatients. Other goals includesetting up exercise plans for ourpatients and updating ourdischarge booklet.


2010-2011 16

Morbidity and mortality meetings

individual can result in thetransformation of several livesand for this reason must bemanaged with the utmostrespect, care and sensitivity. The specialist nurses have beeninvaluable in this regard.

Organ donation by patients fromour ICU is less common than onother units and this reflects thenature of our patients. Braininjuries, for example, are unusualat Chelsea and Westminster.Nevertheless, communicationfrom the families of the fewpatients who have wished todonate has been very positivedespite the deep sadness thatinevitably accompanies this finalact of giving.

Dr Rick KeaysConsultant Intensivist

Clinical Lead for Organ Donation

Staff prepare to take a chest X-ray


In 2010, 132 clinical incidentswere recorded by staff in theIntensive Care Unit. Table 1divides these incidents intospecific categories.

ProcessWhen a clinical Incident occursin the ICU, a form is filled outand the relevant staff arecontacted depending on theincident. All forms arereviewed by the Head Nursefor Critical Care who fills inthe management section butalso logs them on the ICUdatabase. All drug incidentsare followed up with staff andthe pharmacist is informed.Key triggers which led to theincident occurring and keyareas for development toprevent it happening again areidentified. This is thendocumented in a letter to thestaff member.

Each quarter a summary ofincidents is presented to staffon the unit to reinforce goodpractice, or act on ideas orsuggestions to preventincidents from reoccurring. Anannual review also takes placewhich is presented in theannual report.

Learning in 2010Clinical incidents are a greatway to review practice andthink about where there aregaps in information,knowledge or process. Thefollowing examplesdemonstrate what theIntensive Care Unit has doneto improve practice:• The wrong feed was givento a patient – A list ofdocumented feeds and whatthey are used for was placedin the kitchen to give staffupdated information on whycertain feeds are prescribed

• Patients self-extubation(removing EndotrachealTube) – We looked at howstaff were securing themand trialled different ETholders

• Documenting pressure ulcers– Having heel protectors toprevent pressure anddiscussion of them at the


Table 1 ICU Clinical Incidents 2010

0

10

15

20

25

30

5

Equi

p

Dru

g TV

Dis

char

ge

Line

s

Proc

edur

al

S In

jury

B C

olle

ctio

n

Staf

f

Nut

ritio

n

B Tr

ansf

usio

n

B Re

port

ing

Infe

ctio

n

Com

mun

icat

ion

Fall

Lost

Pro

pert

y

Supp

lies

Spla

sh

Clinical incidents

Table 2 Clinical Incidents Jan-Sep 2011

0

10

15

20

25

30

5

Equi

p

Dru

g TV

Spla

sh

Line

s

Shar

ps

Prop

erty

Tran

sfer

Staf

f

B Tr

ansf

usio

n

Seft

Ext

ub

Proc

edur

e

Infe

ctio

n

B Re

port

ing

Thef

t

Oth

ers

Tissue Viability Group• Updated Drugs Quiz

Table 2 highlights the clinicalincidents that have occurred inthe ICU from January –September 2011. There havebeen 88 incidents documentedby staff during this period.

Drug Incidents There were 29 drug incidentsduring this period, so furtheranalysis was undertaken toidentity themes. These arelisted in Table 3.

In some of these incidents,staff have had to re-do theirTrust booklet to remind themof safe, correct practices indrug administration. We have

also introduced new brightgreen drug labels to be usedon the pumps when we aregiving inotropes so that staffwill think before they alter apump with an inotrope in it,and we have purchased ameasuring funnel to correctlymeasure suspensions in ourCD cupboard.

Blood transfusion is anotherarea in which practice haschanged due to a clinicalincident.

When a patient has multipletransfusions they have anincreased risk of developingantibodies. In order to reducethis risk, the time that thesample is valid for is cut down

to 24 hours which ishighlighted on the bloodcomp ability form. There havebeen a few incidents in theIntensive Care Unit wherepatients have had blood afterthat 24 hour period. The formwas changed and there is nowa red stamp on the form thatstates DO NOT TRANSFUSEAFTER (……….). This is avisible way of getting staff tocheck what they are doing.

Clinical incident monitoringensures safe practice is atransparent process were wecan all learn and changepractice as a result of whathappened and not just wherethe incident occurred.


2010-2011 18

Table 3 Drug incidents

Type Number Details

Drug calculations 3 Mgs to mcgs

Admission 3 Drugs given when omitted

Omission 2 Drugs omitted when they should have been given

Drug administration 2process not followed

Wrong Dose 4

Wrong Drug 1

Wrong mechanism 1 Drug given without filter

Allergy not checked 1

Wrong fluid for transducer 1

Dispensing 1

Labelling incorrect 2

Incorrect Volume 2 Suspension fluid

Cds broke 2

Cd made up and not 1removed

Pumps – wrong pump 2started



Health and safety

I took over as health and safetyrepresentative in September2010.

One of the first things I did withmy predecessor was a Healthand Safety Assessment whichincorporated patient care areas,hazard identification, workingenvironment including control ofsubstances hazardous to health,fire detection, equipment andtraining. It also covered movingand handling of patients on theICU which often involves the useof hoists and sliding sheets.Nurses have training on this intheir update days every otheryear, but the equipment has tobe fit for purpose and available.

Electrical systems were alsoassessed and the UPS(uninterrupted power supply) onthe Burns ICU satellite unit wasfound to be faulty. Electricianscontracted to the hospitalpromptly fixed the problem.

Violence and aggression can beencountered from patients,relatives and visitors and staff aretrained on how to deal with this.We successfully assessed andtrialled the panic buttons locatedin various areas of the ICU. Wealso have a coded security lockon the entrance to the ICU toensure patient and staff safetyand we have areas for relativesto stay to try and decrease theirlevels of stress.

Stress for staff can be an issuedue to the complexity ofpatients’ and relatives’ needs.We try to ensure that staff takeadequate breaks and talk aboutany issues at handover and unitmeetings. Clinical supervision isalso on offer.

An area for improvement Iidentified was staff training infire evacuation. While this is nowincorporated into mandatorytraining it had historically beenon a separate day and staffattendance had been poor. Iorganised for the Fire Officer tocome to the unit to teach fireevacuation during the allocatedteaching time held eachweekday from 2—3pm

(between staff handover period).We have since had evacuationsheets put on all mattresses,which would have provedinvaluable when we almost hadto evacuate the unit recentlyduring the installation of newgenerators for the hospital.

Nurses on the unit areencouraged to fill out riskassessment forms if they feelanything has occurred eitherpotentially or actually. These areused as a learning tool and aresent to our manager who feedsinto the Clinical Risk Team.

Danielle PinnockSister

Team H

The unit has a secure entrance to ensure patient and staff safety

2010-2011 20

Care bundles

Ventilation Care BundleA care bundle is a way ofensuring the evidence-basedclinical care that patients shouldreceive is actually delivered. It is aquick and systematic method ofauditing our therapeuticinterventions.

The process starts by asking thequestion: “What elements ofcare should be delivered to aspecified group of patients100% of the time?”. By doingthis we are reducing theunrecognised omission oftherapy and enhancing equity ofcare for patients. This can leadto reduced morbidity and areduction in length of stay.

We have been auditing ourventilator care bundle for thepast few years. The care bundleis made up of four elements,each of which has been foundto improve care and outcomesfor patients on ventilators:

• Head of bed elevation to 30° –to help prevent aspiration intothe lungs

• Upper GI tract ulcerprophylaxis – to prevent stressulcers

• Thrombo-embolismprophylaxis – to prevent DeepVein Thrombosis

• Daily sedation holds – toreduce time spent on aventilator

We have consistently achievedmore than 90% compliance andfrequently achieved much higherresults as seen in the resultstable from 2010-2011.


Table 4 Preventative Ventilator Associated Pneumonia

80%

85%

90%

95%

100%

105%

Actual Min target Stretch Target

Jul

Aug Sep

Q2

sum

mar

y

Oct

Nov

Dec

Q3

sum

mar

y

Jan

Feb

Mar

Q4

sum

mar

y

Financial and environmental sustainability

Performance 2010-11When used effectively,measurements of performancecan give us insight into theservice we are trying to deliver –from the number of patientsadmitted, to the time patientsare discharged, to the number ofstaff working on the unit. Thisgives a balanced picture into theservice and identifies areas werewe need to improve in order tobe more efficient.

However, services do not sit inisolation within the Trust andsometimes what affects the flowmaybe outside the control of theunit. We are responsible forknowing what those pressuresare and highlighting them in aconstructive way.

ActivityChelsea and WestminsterHospital’s Intensive Care Unitconsists of eleven beds whichare flexible to provide Level 3(intensive) or Level 2 (highdependency) care depending onthe needs of patients. In additionthere are two burns intensivecare beds.

Income for critical care activity isdependent on critical care beddays. Table 5 outlines thenumber of bed days per yearfrom 2007 to this year.Fluctuations in activity can anddo occur. This may be due to aparticularly bad winter when flumeans there are a lot of patientsrequiring specialised respiratorymanagement.

Fluctuations in 2010-11 haveoccurred in April-July with lowlevels of intensive care (Level 3)activity. This subsequently pickedup towards the end of the year.A key challenge is to respond tothese fluctuations while at thesame time using resourceseffectively.

Quality Measurements 2010-11We collect a lot of data on theIntensive Care Unit and Table 6outlines quality measures we useto indicate the effectiveness ofour service. Some of thesemeasures are within our controland others depend on the flowwithin the hospital

Activity and performance

Table 5 Intensive Care Occupied Bed Days

Level 2 Level 3 Total

2007/8 2008/9 2009/10 20010/11

0

500

1000

1500

2000

2500

3000

3500

Table 6 Quality Measurements 2010-11

Description Number Notes

Number of patients 21 It is seen as a clinical incidentdischarged between when patients are discharged22:00–08:00 between these times as there may

not be the proper follow up. This would have occurred due to thelate availability of a bed.

Number of delayed discharges 48 48 patients waited longer than 24greater than 24 hours hours to be discharged from ICU

Number of patients cancelled 4 Only a small number of patientsdue to no critical care bed cancelled within the year due to

no beds

Number of patients 5 Numbers of readmissions hasreadmitted within 5 days been low as well

Number of patients transferred 2 Only low numbers of patientsto another hospital due to no transferred out due to lack ofcritical care beds critical care capacity


In response to the delayeddischarges we are reviewing thedischarge process with theinvolvement of the Clinical SiteManagers, critical care outreachand ward staff.

FinanceActivity was high in 2011 whichresulted in a lot of devolvedincome for the unit. Althoughbank and agency spend washigh, this was related to activity.The financial analyst for clinicalsupport helped to introduce aweekly sitrep form whichenabled us to fill in the staffused, against the number ofpatients on the unit. Thisdemonstrated the amount ofincome received for over activityand how this could be balancedby the cost of agency or bank.We fill in these forms every weekand therefore can explain moreprecisely the reasons forunder/over spend in the budget.

Intensive Care Trust FundThe Intensive Care Unit has aTrust Fund and at the end of2010/11 we have a surplus of

£5,000. Most of the moneycomes from donations and in2011 we had a particularly largedonation which was raised bythe wife and friends of a patientwho died on the unit.

Ideas for spending the funds areraised with staff through thefinance and supplies group. In2011 we funded:

• An Echo probe for ourultrasound machine

• An ice machine• A portable DVD player forpatients

• Sound Ears that highlightwhen the noise reaches acertain level

• Staff to go to conferences• The staff Christmas night out

The fund is also used to providelunch for our quarterlymultidisciplinary meetings andour information booklets on theunit. We are extremely gratefulfor all the donations we receiveand we always let the familiesknow what we have purchasedwith their donation.

Recruitment In 2010-11, one of thechallenges of staffing the unitwas the high number of staff offon maternity leave. At one stagethis resulted in the equivalent ofeight whole time equivalent(WTE) staff off at one period. Acost pressure was highlighteddue to paying for permanentstaff on maternity leave and atthe same time paying for

2010-2011 22

Table 7 Intensive Care Unit Leavers and Joiners 2011

Leavers Joiners

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec0

1

2

3

4

There is no doubt that thesingle biggest cost is staffingthe unit and the biggestchallenge is recruiting andretaining appropriately trainedstaff to provide safe andeffective care to critically illpatients and their families.

The ICU staff provide expertnursing care to look afterpatients on the general andburns Intensive Care Unit.

Currently the unit consists ofseven Level 3 (intensive care)beds and four Level 2 (highdependency) beds, as well astwo Level 3 adult burnsintensive care beds. These canbe used flexibly depending onthe needs of the patient.

We also have a policy of notrefusing any admissions unlessthe staffing levels are such thatpatient safety is compromised.

Staffing on the Intensive Care Unit



temporary staff to cover theirposts. As these posts were atsenior level, fixed term contractswere not an option.

This year 2011-12 the numberof staff on maternity leave hasreturned to the usual numbers.

It is extremely importanttherefore to keep on top ofrecruitment and be aware thatthe process can take a minimumof six weeks and maximum fourmonths. On the unit we capturethe number of leavers andjoiners that occur in the year (asoutlined in Table 7), which helpsus to identify if there are anytrends.

In 2011 the number of leaverswas spread out over the year.Time spent on the unit is shownin the table below.

The reasons staff gave forleaving were to relocate toanother country, change of job,to go travelling and to gainexperience in another specialisedIntensive Care Unit. One staffmember felt that intensive carenursing was not the job theywanted and subsequentlychanged to health visiting.

If activity is high on the unit wehave to supplement our staffwith temporary staffing.Therefore, although our usagefrom April-August 2011 was

high this was related to highlevels of activity. Table 8 showsthe agency and bank usage onthe unit in 2011-12

One change that has beenintroduced is a weekly sitrepreport devised by the clinicalsupport financial analyst. Eachweek the number of patients onthe unit and total number ofstaff including sickness,maternity leave and cost oftemporary staff is updated onthe spreadsheet.

This information highlightswhether activity is down andtherefore there should be notemporary staffing used, orwhether activity is high andexplains the use of temporarystaff.

In 2011 we have also identifiedsome savings by changing ourskill mix. Table 9 shows that wehave reduced Band 7 and 6posts and increased our Band 5posts.

Changes to Staffing 2011As a result of these changes wechanged our Band 6 jobdescription to include acompleted and passedmentorship course. We nowhope only to externally recruitfor Band 5 posts and internallyrecruit for Band 6 posts.

Retention When talking about staffing,equally important are plans forretaining staff and ensuring theyreceive the training and skills todo the job.

Each new recruit to the ICU isplaced on a pathway relevant totheir band. For example, a newBand 5 nurse will commence theBand 5 pathway which involvescompleting the foundationsprogramme that will lead to theintensive care course. After aperiod of consolidation they mayundertake the mentorshipcourse. These pathways providethe structure for staff to developtheir knowledge and skills

Time spent on the unit

Less than 2 years 4

2-5 years 6

More than 5 years 1

Table 8 Agency/Bank in ICU in 2011-12

Bank Agency Total

Jan Feb MarApr May Jun Jul Aug Sep Oct Nov Dec

A

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

through formalised courses,project work and mentoring,and helping others.

The aim of these structuredpathways is to producecompetent, confident, expertnurses with excellentobservational skills. This isimportant because the effectiveuse of critical care nurses cangreatly improve patient care andreduce the incidence ofcomplications for patients. Forexample, their observationalskills can reduce the impact ofsudden patient decline and theirholistic approach to care can

change the experience of carefor both patients and theirfamilies.

On our Intensive Care Unit wewant the critical care nurses todevelop skills in stepping up andstepping down care,interventions and treatments, sothat we intervene when thepatient requires more supportbut equally speed up the processof discharge.

In addition, the structuredpathways encourage and retainstaff so that they are exposed todifferent situations and develop

different skills. For example, atBand 6 level, staff on the unitare expected to activelyparticipate in inter-team projects.One project is the off-duty.Exposing staff to learning howto create a rota and balancingthe needs of the unit withindividual requests gives insightinto the complexity of this taskand indirectly helps theindividual gain skills in conflictmanagement.

In relation to critical care units, itis imperative that local strategiesare adopted to counter thepressure that exists and providea supportive workingenvironment to enable thedelivery of an efficient andeffective critical care service. Weare therefore thinking andimplementing further plans for2012.


Jason TatlockAdministrator andInformation Officer

Table 9 Changes to Staffing 2011

Post Budgeted Changes DifferenceEstablishment

Band 3 1 1

Band 5 (admin) 1 1

Band 5 (nurse) 25 30 +5

Band 6 30 25.5 -4.5

Band 7 8 7.5 -0.5

Band 8a 1 1

Band 8b 1 1

Totals 67 67 0

Off-duty Planning team

The purpose of the Off-dutyPlanning Team (ODPT) is toadequately staff the IntensiveCare Unit with an appropriateskill mix of nursing staff. There iswell known recognition of thestress of working rotating shiftsand attempting a good work/lifebalance. The ODPT aims topromote this to each nurse

through self-rostering whichallows for equality and flexibility.

The roster is created a month inadvance. An off-duty template isdisplayed for staff to put in theirrequests ahead of time to allowstaff some flexibility on theirrota. Staff are reminded of theirinter-team involvements

(meetings) and the team andskill mix covers while drafting.The Trust is planning to provideevery staff member access to theManpower Software System(MAPS) system to enter theirown rota and the ODPT willprovide training to all ICU staffprior to this being piloted.

2010-2011 24

This group was set up to allowstaff other than the ClinicalNurse Lead (CNL) to take anactive role in the overall budgetand finances of the unit. Thegroup includes a member ofstaff from each team, the CNL,unit administrator, technicianand healthcare assistant.

The purpose of the group is tomonitor expenditure and agreeallocation of funds from theIntensive Care Trust Fund, and

improve awareness of costs, forexample bank and agency staff,disposable items and equipment.We aim to save money wherepossible without sacrificingquality, and negotiate betterdeals with healthcare companies.We organise the trialling andevaluation of new products andaddress any problems with stocklevels.

This financial year the unit hashad to find a saving of

£322,000. We have saved£25,000 on the drugs budget byusing some cheaper drugs, forexample prescribing Ranitidineinstead of Pantoprazole (unlessthe patient is high risk), reducingthe types of dialysate fluids fromthree to two, and reassessingthe types and sizes of naso-gastric feeds.

Staffing levels remain the same,but Band 5 staff need tocomplete the mentorship course

Finance and Supplies group



MAPS is the computerisedprogramme currently usedwithin the Trust to create andmanage the off-duty. This systemhas effectively eased theworkload of the team whencreating rotas for the unit. Auseful example of this is thatMAPS highlights the skill mixincluding the number of co-ordinators on a particular shiftand gives quick access tomonitoring sickness, annualleave and study leave allocations.The system automaticallycalculates staff working hours,so shortfalls can be readilyaddressed on the current rotabeing created.

From January 2011 the ODPTdeveloped a new system ofbooking annual leave andupdated the annual leave policy.A dedicated file contains the‘read only’ template for annualleave on a specified computerwithin the unit. This displays the

availability of annual leave totake. Every member of staff hasaccess to this template. If they see a space and wish tobook, they are required to emailthe ODPT who will enter thename of the member of staff onthe date requested. Requests areon a first come, first served basisdepending on time and date ofemail. The request will mostcertainly be successful as long asthe unit has adequate skill mix,team cover and co-ordinators.

The ODPT will then update eachmember of staff’s computerisedannual leave card which willdisplay the remaining days left totake. Each staff member also has‘read only’ access to the annualleave cards so they can managetheir own leave and ensure theytake their allocated leave in atimely manner.

All members of the ODPT aretrained as rota creators and each

person rotates every threemonths to become key rotacreator. Each member also rotatesthrough other key responsibilitiesof the ODPT, for example hourkeeper, annual leave bookingsand the co-ordinators rota. Therota updater is now included asone of the competencies in theco-ordinators pack for Band 6nurses in the unit, which allowsthem to update the rota on adaily basis, for example bankbookings and/or cancellations,updating sickness absence andensuring skill mix on each shift.

Neil AndersonSenior Staff Nurse

Team I

Thank you to all Off-dutyPlanning Team members for theircontinued hard work.

Amanda DixonSisterTeam J

before they can apply for Band 6posts and therefore remain Band5 for longer.

We have reviewed the types ofdressings we use, trialled somenew ones and replaced those forour usual stock. We have trialledother new products includingventilator tubing, filters andendo-tracheal tapes, some ofwhich we have changed to.

We have agreed funding fromthe Trust Fund for a newrehabilitation chair, carbondioxide monitors, an ultrasoundprobe for central line insertionand echocardiograms, an icemachine and noise detectionmonitors. We have also revampedour information booklets.

Service contracts for equipmentare being updated so we knowwho is responsible for each pieceof equipment.

Our main store rooms have beenrevamped and labelled – includingprices – to make it easier forpeople to find things and makeeveryone more aware of costs.

We have increased recycling witha new green bin, to tie in withthe Trust’s recycling target.

And last but not least we haveorganised the Christmas andsummer nights out with somefunding for food and drinks forstaff.

Danielle PinnockSister

Team H

Outdoor activities are wellpromoted by our society andthey are an excellent way tobuild up and prove team spiritwhen adversities come to light.

Outdoor activities also arechallenging from the physicaland psychological point of view.The challenge bursts theadrenaline and makes one’sheart pump fast, which alsowakes up one’s fear of failure.

So one day, I found myselfinvolved in charity events whichwere a great challenge as I hadto not only train myself physicallybut expose myself to acompletely new world.

The idea of approaching peopleand asking them to fund me,terrified me. A colleague of mineonce said: “Marcela, you will notmake a difference, do not wasteyour energy”. I think thiscomment made me realise andreinforce my belief in manpower.

From then on I started takingpart in events to support goodcauses and make people awarethat they can make a differenceif they believe in themselves.

The most extraordinary event Itook part in so far was the ThreePeaks Challenge in June 2010which involved climbing thethree highest peaks on mainlandUK within 24 hours. There wereeight of us and we wererequired to walk 24 miles,

climb 10,000ft and travel over700 miles.

Apart from the physical aspect,the preparation consisted ofhosting a BBQ for more than 50people, contacting the local Tescoabout displays and tin rattlingand of course twisting the armsof friends, colleagues andacquaintances.

The minibus was also a challengein itself, as the governor limitedthe speed to a maximum of62mph! Fortunately the roadswere clear and Saxon was a gooddriver so we advanceduneventfully between Ben Nevisand Scarfell Pike. Unfortunatelywe hit a traffic jam along theNorth Wales Coast so we wereleft with less than five hours tocomplete Snowdon. But we did itand completed the Three PeaksChallenge within the stipulatedtime. It was formidable – theexperience, the team, the greatfinancial support…the challenge.

One thing this experience taughtme is that we must follow ourdreams and that by sharing themwith others makes them real.When one applies this concept todaily activities one can make adifference and achieveunimaginable things.

Anything is possible; we justneed to believe in ourselves.

Marcela ViscaychipiIntensive Care Consultant

2010-2011 26

The Three Peaks Challenge

“The challenge is courage. Courage is resistance to fear,mastery of fear, not absence of fear.” Mark Twain


Teaching and research

The Teaching Group meetsmonthly and co-ordinates theteaching activities on the ICU.The group is made up ofrepresentatives of each of theprimary nursing teams.

Each month the group receivesupdates on progress of courses,ensures that the teachingsessions for the 2–3pm teachingslots have been filled andreviews any ongoingdevelopmental work.

The two main projects the grouphas been working upon are:

1 Developing a workbook forstudent nursesThis is a self-directedworkbook that helps studentnurses navigate themselvesthough ICU. It is designed to

work alongside the learningthey gain at university and alsofrom working with theirmentor.

2 Reviewing the ICU Band 6programmeThe programme has beenreviewed and shortenedslightly to reflect the needs ofthe nurse who has recentlybeen promoted to a Band 6role. The topics covered areadvanced patientmanagement skills, advancedcommunication skills andcoaching and co-ordination ofthe ICU. The group hopes tostart running the study daysfor the programme in early2012.


Teaching Group

I have been the Foundation ofCritical Care (FOCC) course co-ordinator from September 2010to September 2011.

During that time we have hadtwo cohorts with four studentsstarting each course. There havealso been some students fromprevious cohorts who have beengiven an extension and we havehad some Band 5 nurses andphysiotherapists attend individualstudy days. The cohort sizeswere optimal – big enough toenable discussion and small

enough to encourage thestudents to get to know andsupport each other well.

The summative assessments area critical analysis essay andcompetencies. Throughout thesix months, the students alsoneed to complete workbooks(which prepare them for thestudy days) and pass a final test.They present a patientassessment and participate inclinical supervision. As the StaffDevelopment Sister, I alsoregularly worked clinically with

the students, which gave themthe opportunity to care for morecomplex patients. All thestudents passed their FOCC;indeed, some of them arealready continuing their ICUstudies at Kings College London!

From a personal point of view,this was a great learningexperience. Not only did Iimprove my clinical skills, but Iwas also asked some challengingquestions which encouraged meto think differently aboutsituations. Running the FOCC

The staff development role 2010-11

A member of the ICU team

has given me more insight intothe new ICU nurse’s experienceand hopefully I can use thisknowledge to support andchallenge these nurses moreeffectively, especially when I co-ordinate the unit. I enjoyedworking so closely with thestudents in a supernumerarycapacity and it was a pleasure tosee the dedication of thestudents’ preceptors.

The most rewarding aspect ofthis role is observing junior ICUnurses developing professionally.I have really enjoyed seeing theirconfidence grow, particularlywhen they cared for more

complex ICU patients such aspatients receiving renalreplacement therapy or BurnsICU patients.

The FOCC is accredited with theUniversity of West London untilMarch 2012, after which we aregoing to trial running it as an in-house course. This will give usmore freedom to make changesto the course content orassessment strategies. We arehoping to make the workbooksand perhaps even the study daysmore patient-scenario based.This is based on feedback fromstudents which is collected everystudy day, as well as mid-point

and at the end of the course.

In the past year, we have revisedthe competency book adding“transfers” to the existing ones.Having the physiotherapistsattend and teach on one of ourstudy days was good and wehope to have more multi-disciplinary team involvement.

I am now returning to my clinicalrole and have handed over toCharlie Brown. The next cohortstarts November 2011.

Rosalie Le CordeurStaff Development Sister

Experience of the Mentorship course

I have been working in theIntensive Care Unit for the lasttwo years. I decided toundertake a Mentorship coursein May 2011, which ran at theKings College University ofLondon. During the module Ideveloped my teaching skills andconfidence.

I learnt how to create andestablish an effective workingenvironment for the studentsand acknowledged the fact thatsome students need to beapproached with differentteaching styles to facilitate theirlearning. I identified theimportance of being structuredand specific when deliveringteaching and the demand toexpand my own knowledge inorder to be well prepared forteaching. I learnt the

importance of creating alearning contract with studentsto set up smart, realistic andachievable learning goals.

During this course I became asupport for the students andfrequently reviewed theirperformance by giving regularfeedback and opportunities todiscuss any issues. I also neededto be approachable and toarticulate comprehensively to thestudents when they asked mequestions.

The key responsibilities as amentor are to support learningand assessment in practice, andmake judgements relating tostudents’ registration and fitness.

As a mentor, I have accepted myprofessional accountability within

the Nursing and MidwiferyCouncil code of professionalconduct and to facilitatestudents of nursing, midwiferyand others to develop theircompetences.

I really enjoyed the Mentorshipcourse. We had very proactiveteaching sessions with greatlectures. There were many groupactivities such as team exercises,video projection, preparing amini teaching session for a smallgroup of colleagues anddiscussions.

This course was very interestingand I gained a lot of knowledgewhich helped me to develop myexpertise.

Lucie StepovaSenior Staff Nurse

Team F

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Experience of the Foundations course

Foundation of Critical Care:Views from the outside

My experience of the Foundationof Critical Care (FOCC) coursewas by far not that of youraverage candidate.

The course is primarily designedfor the junior intensive carenurse in order to consolidatewhat has been learnt prior toarrival in the ICU and establishwhere their skills will be takingthem and how to better oneselfto benefit the team andultimately the patient.

As a Resuscitation Officer withminimal (at best) ICU experienceand more specifically a paediatricnurse entering the world ofadult medicine, it was suggestedto me by my manager andcolleagues that it would benefitme to attend the theory aspectof the course to refresh anddevelop my understanding ofcritical nursing and gain agreater understanding of adultmedicine.

This was an opportunity Ijumped at and have to say thatoverall I really enjoyed theexperience. I approached thecourse with trepidation, realisingI would be working alongsidemembers of staff I have alreadytaught, or will eventually teacheither in nursing updates orImmediate Life Support courses.This bothered me somewhat as Iam always aware of my lack of

adult experience and thereforefear for my credibility.

I was happy to realise that myprior training and“brainwashing” (for want of abetter word) of standardisedABCDE assessment carried methrough quite a bit.

The content and delivery of eachmodule was always done verywell and having to do the pre-course material was a great help.I do feel that I am now muchmore aware of how the body’ssystems interact with oneanother. It has made mequestion practice I have just“done” for years and made meaware of why I’m doing whatI’m doing. With this in mind, ithas made my understanding andneed for more informationrelating to medicine and nursingmuch more enjoyable.

It has benefited my teaching andI can see how what I have learntcan be easily passed onto others.

The formal assessment of thecourse was a double-edgedblade. I was concerned that Iwould fail my exam, however Isurprised myself by getting ahigh score, much better than Ithought.

The assignment was difficult forme. Not being in the ICU, andtherefore not having exposure toLevel 1 patients on a daily basis,resulted in my patient choice

being severely limited.Unfortunately, my exposure toadult patients is only when apatient is either in peri-arrest orcardiac arrest. I’m often onlywith the patient for 30–60minutes and then I have nofurther contact. Therefore Ibelieved I was at a severedisadvantage when it came tomy assignment. My colleagueson the course had days’ worthof exposure to their chosenpatient, enabling full and easyaccess to their notes andtreatment and (from my point ofview) easier critique of the carebeing delivered to their patient.

However, I was given lots ofsupport from the FOCC tutorsand I was able to scrape a passenabling me to walk away fromthe course with 60 credits atLevel 3, which I am hoping willhelp me towards my currentMSc application.

I’d like to take this opportunityto thank the FOCC tutors fortheir unwavering support duringthe course and I hope I canreturn the favour soon andcome and teach on some of theFOCC study days.

Andy WinterResuscitation Officer


Immediate Life Support teaching

Research Group

I recently became anIntermediate Life Support (ILS)Instructor. This is a newchallenge, but it will allow me todevelop within my role as aSenior Staff Nurse on the ICU.

It all started while I was doingmy ILS course and theResuscitation Officer said that Iperformed well on the day withmy knowledge and how Iinteracted with the othermembers of the team doing thecourse. They felt that I would bea good instructor and shouldundertake the Intermediate Life

Support Instructor Course, whichI completed.

It has been an extra challenge tomy role, which helps me toassess others and improve myteaching skills. You work closelywith the resuscitation team whocontinually assess you onteaching, demonstration, yourknowledge and how you assessothers. It has been a greatopportunity as it is somethingthat is of great interest to me.

I have also recently completedmy Advanced Life Support

course (ALS) and have beenasked to do my instructor coursefor this – another new challengewhich I hope to fulfil soon. I’mlooking forward to learning inmy new role and it has beengreat doing something differentin my career.

My line manager gives me studyleave each year and they havebeen very supportive of me withmy love for ICU and resuscitation.

Karen SiskSenior Staff Nurse

Team E

The Research Group has had avery productive year and itwould appear from reviewingthe past year’s work it can bedivided into four areas.

1 The generation of guidelinesready for ratification by theICU clinical governance group

The process for ratification forour guidelines was described inlast year’s annual report. Theguidelines ready for ratificationover the past year have includedthe Handover and BladderIrrigation guideline and theLiDCO and Flotrac (EdwardsVigileo) guidelines.

2 The presentation of guidelinesin the process of developmentto the Research Group forfeedback

The presentation of guidelinesentailed reviewing the PassyMuir Speaking Valve and Intra-abdominal PressureMeasurement guidelines and theTotal Parental Nutrition guideline.All were in various stages ofdevelopment and each raisedquestions about our currentpractice, promoting a healthydiscussion within the group inthe quest for best practice.

Debate still surrounds theDelirium guideline as theBloomsbury Sedation ScoringSystem was replaced by theRichmond Agitation ScoringSystem, and there wasdiscussion around how toidentify if a critically ill patient isdelirious before introducingpharmacological treatments.Also, the Capnography guidelineis awaiting consensus regardingwhen it should be used, forexample all the time or just fortransfers and intubation.

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Research within ICU

3 The review and ratificationevery two years of existingguidelines

The two-yearly review of guide-lines ensures that all existingguidelines are revisited to ensurethey are up to date. For example,we are reviewing the MechanicalVentilation guideline and havefound that our practice hadchanged considerably over atwo-year period with the use ofnew ventilator tubing andhumidification sets.

The Research Group needs toreview the oral care, pronepositioning, inotropes, neuro-logical assessment, suctioningand sedation guidelines duringthe forthcoming year.

4 The generation of new ideasfor guideline formulation

As existing staff attendconferences and new membersof staff come from other trusts,current clinical practices can bechallenged and questioned,creating the opportunity for us to

examine our clinical procedures.Two areas that have requirednew exploration are the timeintervals for changing the innercannulas for tracheostomy tubesif patients are on significantsupport from a ventilator.

The Enteral Feed guideline is alsounder review so we can ensureour patients receive their targetcalorie intake. Thus, how longwe stop feed prior to surgery or

other procedures is under reviewand this is especially pertinentfor our patients in the Burns ICU.

Finally, I would like to thank allthe members of the ResearchGroup for their hard work andcommitment.

Ann Sorrie Sister

Team E

Research in Intensive Care atChelsea and WestminsterHospital: My journey so far…

It all started at medical school inCorrientes, Argentina. DrBrallard-Poccard and Dr Popescuinspired me and made me realise

that there is a greater purposewhen one joins medical school.I remember meeting them out ofhours to read in the library andwrite down our ideas on a pieceof paper and then we tried toconnect the ideas like treebranches connecting to their

leaves. It was a fascinatingmental exercise and an amazingexperience.

I will never forget how thrilled Iwas when I was invited to takepart in a clinical study. My firstclinical project was on diabetic


A member of the ICU team

2010-2011 32

patients looking at the effect ofGlucose-Insulin-Potassiumsolutions on postoperativeoutcomes. In fact, my job was togo to hospital at 5:30am toinsert intravenous lines, takeblood samples and start thetreating solution or placebo.

One may think: “Why was thatso exciting?”…but for me it wasa different world. It was greatinteracting with patients andphysicians; it was an amazingexperience. Patients’ trust inscience and belief that we couldpotentially improve their careand the course of their diseasemade me approach medicine ina completely different way.

I prepared myself through theyears to be were I am today. Thisis the beginning of a longjourney that has been started bymy colleagues Dr Neil Soni in theIntensive Care Unit at Chelseaand Westminster Hospital andProfessor Masao Takata, Sir IvanMagill Chair in Anaesthetics atImperial College London.

We at Chelsea and WestminsterHospital are privileged to have afantastic team, eager to developand push boundaries betweenscience and clinical care. We aredeveloping bridges between thetwo worlds.

Currently, I am closely involved inbasic science research trying tounderstand the effect ofanaesthesia and surgery onmemory. With Dr Daqing Maand our collaborators Dr MikeJohnson at Charing Cross

Hospital and Dr MagdalenaSastre at Hammersmith campus,we are trying to elucidate themechanisms by which memory isimpaired and how these changesare expressed genetically and arelinked to dementia. We are alsotargeting specific proteins toprevent this phenomenon.

From the clinical point of viewwe started translating some ofour results into clinical practice.In collaboration with Dr ValeriePage at Watford, Professor JoseSantos-Gracia from Cuba andProfessor Lars Eriksson fromStockholm, we have developedproof of concept studies and arenow trying to identify the role ofstatins and magnesium onmemory.

In parallel to basic scienceresearch and in view of the factwe are a tertiary centre for highrisk HIV and burns patients, inconjunction with Dr MichelleHayes and Dr Suveer Singh, andin collaboration with King’sCollege Hospital and our burnssurgeons at Chelsea andWestminster Hospital, welaunched a new line ofinvestigation to get a betterunderstanding of these groupsof patients.

We have a data manager, clinicalfellows and trainees working onthese projects to elucidate ourperformance over the years andalso identify areas needingfurther development to improvethe delivery of care to thesepatients. This research will alsohelp us generate data for future

prospective studies, whichhopefully will lead us to a betterunderstanding of these diseases.

The Trust’s objectives are toimprove patient safety andclinical effectiveness, to improvethe patient experience, to deliverexcellence in teaching andresearch and to ensure financialand environmental sustainability.

I personally think if we deliverexcellence in teaching andresearch by default, we willimprove patients’ care andexperience and secure financialsustainability. These will result ina happy and safe environmentfor patients and staff.

We must enjoy the process, asthe result is the consequence ofour actions.

Look me up in 10 years time andI am sure there will be plenty toupdate you on, new members ofthis fabulous team to introduceand future avenues to explore.

Marcela VizcaychipiConsultant in Intensive Care


Patients who survive criticalillness frequently developsignificant muscle wasting whichcan lead to long term disability.One of the roles of the criticalcare physiotherapy team is to tryto minimise this muscle loss andpromote early activity, which hasbeen shown to improve long-term outcomes for patients. Thisissue was highlighted in theNational Institute for Health andClinical Excellence (NICE)guidelines for rehabilitation aftercritical illness in March 2009.

Since the publication of thisdocument, the multidisciplinaryteam in critical care has formeda Rehabilitation Steering Group,whose objective is to ensureefficient and effectivemanagement of long-termpatients. To facilitate this, thephysiotherapy team hassuccessfully raised funds throughthe Friends of Chelsea andWestminster Hospital topurchase two bikes for the unit,which enable patients to exerciseeven when bed bound. They arealso in the process of purchasinga Neuromuscular ElectricalStimulation machine which helpsto maintain and improve musclebulk, even when the patient isso weak that they cannot triggera muscle contraction themselves.

From a research perspective, thephysiotherapy team has alsobeen working on developingand implementing a scoringsystem which enables cliniciansto grade physical recovery from

critical illness. This tool is calledthe Chelsea Critical Care PhysicalAssessment tool (CPAx) and isinnovative and unique in itsability to plot patients’ physicalrecovery from critical illness. Thishelps us to identify problemareas and helps patients torecognise the smallimprovements they have madein their physical recovery.

Current research is aimed atusing the CPAx tool to see if it isable to predict a patient’s long-term outcome and dischargelocation, which may helppatients to plan their lives afterdischarge and reduce hospitallength of stay. This work hasbeen presented at both national

and international conferencesand has been awarded withthree peer-reviewed prizesincluding the Chelsea andWestminster Hospital TherapyClinical Excellence Award 2010,which generated £1,000 for theteam to invest in newequipment.

The CPAx tool is now beingadopted by acute trusts acrossthe UK, Ireland and Australiaand it is hoped that it willbecome a standardisedassessment tool used throughoutcritical care units.

Eve CornerSenior Critical Care

Physiotherapist and CLAHRC fellow


Critical Care Physiotherapy

Chelsea Critical Care Physical Assessment Tool

GripStrength

Stepping

4

1

2

5

3

0

CPAx

© Copyright of Chelsea andWestminster Hospital

34

Transferringbed to chair

Sit toStand

Cough

StandingBalance Dynamic

Sitting

Supine to sittingon the edge ofthe bed

RespiratoryFunction

Moving withinthe bed

2010-2011 34

AcuBase

The ICU has traditionally usedAcuBase for local activity andperformance review. Thedatabase is critical care specificand is able to run reportsrelating to occupancy, morbidityand mortality, and severityscoring to name a few.

The benefits include local datamanagement and comparisonbetween other units who alsouse AcuBase. We currently havean interface between AcuBaseand the hospital’s ElectronicPatient Record (EPR) system fordemographics, which includespatient hospital number, next ofkin, GP and NHS number.

Accomplishments in the last yearinclude using the database for:

• Admission and dischargesummaries andmultidisciplinary team (MDT)daily notes (printed after eachentry and placed in the patientnotes)

• Severity scoring (Apache II)• Past medical and medicationhistory including antibioticusage

• Occupancy and thesummarisation of operationalstructure

• Accurate standard mortalityratio (SMR)

• Research

Looking to the year ahead, weintend to:

• Have AcuBase available at allbed sides via our Draegermonitors

• Introduce training for nursingstaff to review notes at thebed side

• Interface microbiology resultsand the critical care minimumdataset via EPR

• Continue to use the databasefor pre and post critical careactivity to provide a fullassessment of the patientjourney

Jason TatlockUnit Administrator


Staff 2010-11

Members of the ICU team discuss business planning ideas

Dr Neil Soni Dr Nicholas Fauvel Consultant Anaesthetist and Intensivist Consultant Anaesthetist and Intensivist

Dr Rick Keays Dr Michelle Hayes Consultant Anaesthetist and Intensivist Consultant Anaesthetist and Intensivist Director of Intensive Care

Dr Jonathon Handy Dr Surveer Singh Consultant Anaesthetist and Intensivist Consultant Intensivist and Respiratory Medicine

Dr Marcella Vizcaychipi Dr Berge Azadian Consultant Anaesthetist and Intensivist Consultant Microbiologist

Jane-Marie Hamill Elaine Manderson Jason TatlockHead Nurse – Critical Care Clinical Nurse Specialist Administrator

Mark Costello Charlene Brown Blanche Tawki Technician Staff Development Sister Healthcare Assistant

Caroline Heslop Claudia Thompson Chris Chung Volunteer Volunteer Pharmacist

Sarah Price Emer Delaney Eve Corner Dietician Dietician Physiotherapist

Abderrahmane Benkhdda Mavis Kyeremeteng Charafeddine Bouchnafa Housekeeper Housekeeper Housekeeper

2010-2011 36

Team A Team B Team CHazel Boyle Caroline Younger Elaine Manderson Emma Long Nerissa Verdejo Saowanit KampinijHwee Leng Lim Imelda San Miguel Katy Seymour Alicia Bott Helen Foley Paula Lyons Toyin Ajayi Aurelien Giouse Janice Basquerosa Clara King Shelia Menshah Leigh Paxton Simon Bateman Rhonda Peters

Robert Donkor

Team D Team E Team F Rebecca Hill Jiji Evans-Bien Rose le Cordeur Bass Reyes Karen Sisk Gerry Fitzgerald O’Connor Daisy Maralit Corazon Basbas Marites Velasco Maria Prous- Alcaraz Irene Dizon Mark Whitehouse Michelle Abad Lucie Stepova Carolyne StewartEunice Mwiti Sophie Holmes Shona Brophy Helen Power Joel McIlveen Saskia Peerdeman

Zainab Marrah

Team H Team I Team J Dany Pinnock Joanne Learney Amanda Dixon Ann Sorrie Charlene Brown Rubina Vard Maria Briones Laura Giron Lennie Buslay Jamie Carungcong Neil Anderson Sally-Anne McNae Juliana Kachikoti Kiaw Lee Bridget Flynn Kathryn Thomas Samsam Saeid Flores Cordeo Ewa Sobelewska Christie Magallon Matthew Harrison Alessia Dessi Mitzie Rafada

Acknowledgements

The nursing staff of the ICU would like to acknowledge and thank the following people for theircontinued support:

Dr Rick KeaysDirector of ICU

All the members of the ICU multidisciplinary and the Critical Care Outreach teams

Karen Robertson Divisional Director of Operations - Clinical Support

Dr Mike Weston Divisional Medical Director, Clinical Support

The Trust’s Nursing and Quality teams

George VasilopoulosPhotography

Amanda Dixon – Sister ICUEditor


2010-2011 38

© 2012 Intensive Care & Nursing Development Unit

Chelsea and Westminster Hospital NHS Foundation Trust369 Fulham Road, London, SW10 9NH

Cover: Jane-Marie Hamill (Clinical Nurse Lead), Rebecca Hill (Sister),Rosalie Le Cordeur (Sister) and Caroline Heslop (Volunteer)

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