HDU/ICU REFERRAL CONSIDERATIONS

This is a four-page document outlining key considerations in the history taking, investigation and management of critically ill patients surrounding the time of discussion with the HDU/ICU team.

THIS IS A WORK IN PROGRESS - FEEL FREE TO CONTACT AND CONTRIBUTE!

1. It's a teaching & learning tool, rather than a document where people actually sit down and fill it in
2. It is intended to provide a structure/framework for thought processes around referrals to HDU/ICU

RATIONALES

1. As a specialty, I feel we are working harder to demonstrate appropriate responses to colleagues who seek our help and expertise. We also have an educational obligation, like the rest of you, to ensure that all relevant staff outside intensive care understand the thought processes surrounding the referral process.
   This can lead to better decisions by the whole team.
   
   
2. Checklists are common in anaesthesia and intensive care medicine. Our daily reviews of ICU patients (usually) are done by proforma; either written or electronic, to ensure key but easily overlooked bits of information are not left out. This is why I have chosen to  create an educational resource that includes a 'checklist' approach with key considerations. It is not meant to patronise  anyone. In the same way that ICU assessment/review proformas, used by consultant team-members, do not feel undermining. 
   This aims to reduce error and improve safety.
   
   
3. Quite often, most of the elements on the documents are already done - but sometimes this is over a longer period of time with frequent back-and-forwards from senior to junior staff.  By having an 'aide-memoire', the whole team could realistically ensure that many appropriate key and utilisable pieces of information are available in an expedited fashion. Many of the less-considered blood tests and investigations often get left until quite late in the referral and transfer process. Being able to start specific treatments in a timely fashion is better for patients.
   This aims to speed up the time to results being available.
   
   
4. A general resource for ICU referral considerations, is likely to reduce some of the stress in sometimes particularly fraught scenarios. Anecdotally, it is sometimes nice to have something that can focus your thoughts on a patient who more often than not, is incredibly complex.
   This aims to reduce stress and error in the referral process.
   
   
5. The importance of 'baseline functional assessment' cannot be overstated. Discussions with patients, colleagues and family can provide excellent insight into the functional limitations of patients, which may change the entire course of a referral.
   This aims to provoke discussion about realistic goals of ICU intervention.
   
   
6. This resource could be considered as being more beneficial to  junior members of a team, and is in no way intended to teach 'veterans' how to suck eggs; but there should be something in it for everyone.
   This aims to provide a source of education that is potentially useful to all members of staff.
   
   
7. I have also made a nursing section that is integral to this document. Ward nurses provide the cornerstone of care and assessment to all sick patients and are nearly always the first port of call when a patient is deteriorating. A lecturer in nursing contacted me to ask that I make 'SBAR' (Situation, Background, Assessment and Recommendation) a key recommendation when discussing patients with colleagues.
   This aims to be an educational tool for nursing staff and students.
   
   
8. The global aim of this educational resource is to add to patient safety, reduce delays, minimise errors and promote a shared mental model of approach to the assessment of the critically ill.

WHAT THIS IS RESOURCE IS NOT
These documents are NOT guidelines or policies and have not been ratified/tested for clinical use.

These documents do not replace the need for:
Seeking help immediately, if required
Clinical judgement and assessment
Discussing patient's with the patient's consultant (on-call)

'Referral algorithms' are a tricky business - which is why, this is not one - it's a learning resource, and not a clinical guideline or mandate. Documents and checklists should not prevent you from seeking skilled help early. The documents do suggest things you should be mindful of, in sick patients. 

It is impossible to predict every eventuality - but many of these principles are ubiquitous to all referrals.

With thanks given to Dr. Jonny Wilkinson, Dr. Adrian Wong and Dr Segun Olusanya for their thoughts on this project, as well as to everyone who has already commented on Twitter.

Hover over the infograph below and you will see four slides of content you can peruse through.

• PAGE ONE = An assessment of the patient's current condition, history and baseline
• PAGE TWO = A broader consideration of basic tests
• PAGE THREE = Key advice about general considerations in the critically ill
• PAGE FOUR = Important nursing considerations​

PDF Download Available here.

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