A cardiothoracic critical care unit is a highly complex environment requiring an interplay of multiple medical specialties and allied health professionals involved in the care of those patients recovering from the insult caused by cardiac surgery. Most of these units will treat patients suffering from any organ dysfunction that happens in addition to cardiorespiratory issues. In general, systems and processes will be similar to those used in any critical care unit.
There is very limited room for error in this highly dynamic environment. The complexity of the patients’ needs has driven the development of standardised pathways and protocols to improve outcomes and maximise efficiency. This is supported by the increasing demand by the public and regulatory authorities to provide treatment and support in an environment that operates within a structured framework.
The past 10 years has seen an explosion in the number of guidelines and protocols available to the critical care clinician to aid the management of the individual patient. This has been facilitated by how easy it is now to share electronic documents.
A clinical guideline is a systematically developed statement to assist practitioner and patient decisions about appropriate health care for specific circumstances. Protocols tend to be a more prescriptive set of instructions for the management of a specific condition.
The publication of Rivers’ Early Goal Directed Therapy study in 1999 popularised the development of bundles in critical care. This study showed that the use of a specific bundle of care for the management of severe sepsis in a single centre significantly improved mortality. Although the study has been subsequently exposed to significant criticism, bundles began to be developed for a wide range of situations within critical care.
A bundle is defined by the Institute for Healthcare Improvement (IHI) as a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices – generally three to five – that, when performed collectively and reliably, have been proven to improve patient outcomes.
Advantages and criticisms of care bundles are listed in Table 54.1.
|Advantages of care bundles||Criticisms of care bundles|
|Standardisation between patients||May not take into account individual patient|
|Evidence of improved patient outcomes when bundles are used||May limit individual clinician’s autonomy or independence|
|Promote efficient use of resources by utilising proven and effective interventions||An unintended side effect of standardisation may be that it discourages excellent or exceptional clinical practice|
|Can potentially limit fringe practices which may be unproven or dangerous (and frequently expensive)||May be unduly influenced by external forces such as government or industry|
|Some individual bundle elements may have limited evidence; and evidence may change with time|
|Result in additional administrative burden for staff|
Bundles have now been developed for a wide range of clinical scenarios in the critical care unit. An example of a widely adopted bundle of care is that developed for the prevention of central line associated bloodstream infections (CLABSI) promulgated by the IHI and is shown in Table 54.2. Implementation of the central line bundle in the state of Michigan, USA resulted in a 66% reduction in CLABSI over an 18 month period.
|Central Line Bundle|
|Maximal barrier precautions|
|Chlorhexidine skin antisepsis|
|Optimal catheter site selection – avoidance of using the femoral vein for central venous access in adult patients|
|Daily review of line necessity with prompt removal of unnecessary lines|
Bundles are designed to be adopted as a full package rather than being taken up as single points in a piecemeal approach. It is essential that they are regularly reviewed, as some elements of the bundle may be subject to new research findings – an example being intensive blood glucose control, which was included for a time in ICU care bundles, but has subsequently been shown to be associated with higher mortality than more liberal targets.
The care of patients in the cardiothoracic critical care unit benefits from the input of multiple medical specialists and allied health professionals. Complex patients often suffer from multiple medical comorbidities, and complications following surgery can affect almost every organ system.
There has been extensive research in the general critical care setting into the relative merits of ‘open’ versus ‘closed’ units. ‘Closed’ units have the care directed by specialists in critical care medicine who call on other teams as required. ‘Open’ units allow the primary team to admit and direct the care with (or without) support from critical care specialists. Complex patients may benefit from a shared model of care; however conflict over management strategies and goals of care can easily emerge.
A close and constructive working relationship between all teams, with clear and open communication, are essential to ensure the system works well for the patient.
Most surgical patients admitted in cardiothoracic critical care will move from a very high to a low level of dependency within a few hours. Such patients can be managed in a nurse led unit according to predefined pathways with minimal medical input. However, complex patients require input from a wider multidisciplinary team.
Clinical governance encompasses a variety of measures designed to ensure that health organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
The cardiothoracic critical care unit requires a strong focus on clinical governance, to ensure patient safety, and continuous improvement in quality of care. The key elements of clinical governance as published by the National Health Service (NHS) in England can assist in ensuring a comprehensive programme of quality improvement is in place within individual units.
One approach to developing a robust structure of clinical governance is to consider the so-called ‘pillars’ of a clinical governance as shown in Figure 54.1.