Transcript for CCrISP introduction lecture video
[Steve] I've been asked of all the materials, what's the most important material? And certainly for the CCrSIP Course, this is the introductory lecture, which will explain the algorithm. This should be a revision; all surgeons in the UK should have seen and taken part in this course and successfully completed this course. This is revision for most, but we're conscious that other people might be watching this: SCPs nursing staff, medical students, FY1s, this is the core lecture. It's normally a little bit of an interactive lecture, obviously we can't do that here, but I'll try and talk you through it.
So the CCrISP Course is the Care of the Critically Ill Surgical Patient. It was designed twenty years ago on the background of the Hillsborough disaster, with money raised from the Hillsborough fund. And recognition that staff always try and do their best, but in a stressful situation, such as Hillsborough, some of the care could have been, perhaps in retrospect a little bit, slightly better and slightly more structured, and the Royal College of Surgeons got a pot of money to improve care for that. And those structures are still relevant today twenty years later and with the COVID pandemic.
The course has learning outcomes, the core of which is to teach a structured comprehensive approach to managing surgical patients; but as my colleagues already said, it's actually all patients. We try to judge when patients are at risk, and reduce adverse outcomes. That comes with experience anticipating problems. We want to recognise the deteriorating patient. We all know we're poorer at that. Even at senior level, tracking triggers are a reflection of trying to fix that problem and prevent that problem. We're talking about non-operative technical skills, things that are hard to teach, in a curriculum-based way but, talk about human factors, decision making, leadership, leading the team, communication. And, essentially, what we're trying to do is enable training surgeons to deal with the planning and management of critically ill surgical patients. And again, for all patients, not just surgical patients.
Why do we need this course? Well, not what are on the side of the COVID pandemic, and we're all working outside of our comfort zone, and potentially being overwhelmed with care and being personally stressed about our own protection, and our own families' protection. But the world has changed in the last twenty years, expectations are higher, scrutiny is higher, which is a good thing. And the way we work in terms of teams has also changed.
What skills do we develop on the course, and what skills can you develop by reading this material in these extraordinary times? It's about application of knowledge is what I'd say. You should know most of the materials if you had time to look through some of these materials, you might pick up one or two different things. What you won't be as good at is making it happen. And that's really crucial. We can all talk through things, we've all been to med school, nursing school, making it happen is a different thing. And we can all see, experience people making that happen. We want to talk about the complications cascade, absolutely vital is a slide next on that. But if we do simple things at the beginning, of recognising and implementing A to E management effectively, then we'll prevent major complications by internal improved outcomes.
The idea of failure to rescue may be new to some of the audience. That's this idea that we all get complications, patients all have, often have comorbidities; it's recognising that patients need rescuing, and leading the team. And that can involve nursing team, dietician team, cardiology team, intensive team and the surgical team. And rescuing that patient to get the successful outcome. And we try and teach registrars how to lead that team and understand your strengths and weaknesses in that team and leading the whole team.
We want to talk about leadership, communication obviously, absolutely vital, and we'll talk about that in the human factors section later. Judging decisions, when to be made and how to evaluate the decisions, have we gone the wrong track, do we need to change track clinically.
This is a really powerful slide. We've all had experience ourselves, with our own deficiencies, our own errors that we've made. But also, when we see senior people coming in, the people who come in the resus room or come into the operating theatre when things are going badly and exude and air of calm, have done it before. It's not that they're gifted, they may be gifted, it's that they've seen it before, they've learnt from experience. And the tennis player, the golfer, the consultant anaesthetist in the resus room, or the consultant surgeon called in to help a colleague, they have this experience which comes across. And you've got to learn from that.
This is the algorithm, this is what it's all about. And I'll just spend a few minutes talking through this. It's split into separate sections deliberately. In a stressful situation, you can actually talk your way and stick to the system. Where I work on my ward, people know I've got this role in CCrISP. And my heart rate increases when somebody goes off on the ward, and someone pulls a crash bleep, or a nurse runs out for help. And I still feel slightly anxious for a couple of seconds and then think, hold on, A to E assessment, I know how to do that, I'm on the right track. I imagine myself on a railroad track, and somehow relax a little bit and think I can do this. And this is the beauty of the system.
Immediate management: note that it's not immediate assessment, it's immediate management. So simultaneously assessing the airway and treating it, assessing breathing and treating it, assessing circulation, D and E. And there's a chapter in the book to look at that. To look at each individual section and talk you through that. If you're a surgeon, look at the CCrISP materials, 'cause that'll revise it for that. If you've not done CCrISP, and you're a nurse or someone who's not a surgical trainee, START materials which will also will provide very useful for that, because it's relevant to all patients, not just surgical patients. And they're also bang up to date, we just revised them all.
So we do A to E management, what we find from teaching this to surgeons, is they're relatively good at this, certainly in the abstract form. And I take Dave's point previously, is that we're probably not as good as we think we are, but often people go around in circles at this point and just keep doing A to E. Which you don't move on.
The next section of the algorithm is very important, is to step back slightly and do a full patient assessment. And there are three elements to that. There's the chart review, and that includes all the charts. So the clocking history, the past medical history, the drug chart, the observation chart, the anaesthetic chart often has the nice synopsis of the patients comorbidities and problems that they face. And anything that's useful from that.
The second component is history and systematic review. So that's to go back and with a structured way examine the whole patient, and take a full history beyond the A to E. And then, finally looking at available results. And that might be blood results, CT scans, anything that you can find that's useful.
The other part of that that can be important of course is collateral history. So that can be a history from the nursing staff, or from relatives, or can even be from GP if there's time to access that. And having done those things in the critically ill patient, again you've stepped back slightly and you're at decide and plan. And now fortunately, most patients are stable, and in that case we go down this daily management plan, which we'll talk about in a moment. And that's the case in most patients. Again, in my experience that's not particularly well done. Patients get a hodgepodge of some review of fluids, some review of nutrition, but probably not the whole package.
If the patient is unstable or if we're unsure, that's when we need to make a diagnosis, and that can involve structured focused investigation. So is a CT scan appropriate? Is going straight to theatre appropriate? Is escalating straight to intensive care appropriate? And obviously instituting definitive treatment can be medical, surgical, can be all three of those things.
Here's this slippery slope I've talked about. So imagine your patient is at the top of this slope here, they are tobogganing down on the ward, and some simple A to E management escalation at that point they get better. And that's what we want to achieve in most of the patients. But how many times have we seen patients go faster and faster down this slope, get admitted to critical care with three organ failure, and the best intensivists in the world, the outcome for those patients is poor and they have a bad death, having had a painful transfer, lots of lines put in, three organ failure, and they die. And in COVID time they die without there family with them, which is also a tragedy.
Increasingly we're recognising, pre-COVID, this idea of a good death, which sounds, a really awkward thing to say, but it's recognising that in some patients, the outcome is going to be the same whatever we do and we should turn our attention from treatments that are trying to improve things but can be injurious to patient and uncomfortable, to recognising they're going to die and try to palliate them and get symptomatic control. Traditionally, I think we've been very poor at that as surgeons. Certainly as a vascular surgeon, my role has changed in the sixteen years I've been a consultant, and I've seen more and more, where we're trying to ensure a good death for our elderly patients who are with potentially critical ischaemia. Who are near the end of their life. And it's recognising that. And this slide is obviously produced pre-COVID and I think during this COVID time its even more relevant to accept that. This is where decision making as a joint team, support each other emotionally and logically with our treatment and using the human factors is going to be really crucial in this situation.
To carry on, here's the algorithm again, having explained it a bit more. The daily management plan should include a structured review, and certainly what we're doing in York in these extraordinary times is setting up a surgical HDU. And we've got some paper work in there to force the team, really or encourage the team I should have said, more politically correctly, to systematically examine patients each day, look at the fluid balance, look at the blood results, in a structured way. Get the drain out, mobilise them. What I try to teach my juniors is, in every patient, why can't this patient go home today? That's where you should be starting from. Now it might be that they're on hemofiltration, on the ICU or they're being ventilated. But you should ask that question of everybody, why can't they go home today? Why can't we de-escalate their care, why can't we make progress? That's how we're going to free up resources.
So this scenario here, we normally talk through, and get the audience to interact. Obviously we can't do that when you're watching this. But it's really illustrating a real life case that one of our CCrISP faculty contributed, 'cause he saw this as an example of how not to do it essentially. This is a young girl who got admitted with abdominal pain for twelve hours, she's previously be fit and well, she's got peritonitis in the right iliac fossa. The observations are really important, and they show tachycardia, so in this young fit person once they get physiological derangement, this person is in in trouble. These young fit people have great reserve, and once they get deranged physiology, they're really quite sick. This lady has got apparent tachycardia, we don't know what rate it is, but I can tell you it's a regular rate, it wasn't arrhythmia. The blood pressure seemingly looks okay, from a kind of simplistic assessment of it, but in fact someone who's in pain, you could argue it's a bit lower that blood pressure actually. And if you look at the difference between the diastolic with what we call the pulse pressure, you could could argue that's perhaps probably slightly wider and that can be sign of being dehydrated, or could maybe be a sign of being septic, being vasodilated. And again, a GCS score, that the range is agitated, that's a really bad sign. This girl's in trouble, she's ill.
So they take her to the theatre, I think not unreasonably from a surgical point of view, thinking it might be an appendicitis. But in fact the appendix is normal. This is a really good surgical team, 'cause it doesn't just say 'well we've done our bit,' it recognises this girl's very ill, she's got physical derangement there must be a source from it and we haven't found it. So they get an intervention radiologist to the theatre who does renal tract ultrasound, and spots renal pelvic dilation, which is, in retrospect, an alternative explanation for her problems. And they've put an Nephrostomy in to get the pus out. That's a really good thing to do, it's a surgical principle: there's an abcess, lets drain the abcess. We need an interventional radiologist to drain it safely. So all this is good. And then we'd turn to the audience we'd ask them to say what do you think next then? So, the surgeons right in the upmost, feeling quite pleased with themselves. And they think, I've drained the abcess, that's it. But in fact the urology centre is not on this site, it's kilometres away. And the protocol is that the patient should go to urology. Is this plan reasonable?
Slightly awkward without an audience, but the danger here of course is that why are we transferring patients? As a vascular surgeon, I transfer patients into my main hospital all the time with ruptured aneurysms because they can't be fixed in the base hospital. And what I can offer is fixing aneurysms and saving a life. In here, the question is what are they going to benefit from going to the urology centre? They've got a Nephrostomy in, they've got deranged physiology. What they actually need is A to E assessment and management and support thereafter. They need the algorithm. And going to urology isn't going to achieve that. 'Cause the Nephrostomy has been placed already. So this is where the plan falls down slightly.
So what actually happened in this real case, NEWS Score, I won't go through this in detail, but the NEWS Scores indicates that this lady is ill. If we had stuck to an algorithm, we'd at this point, we'd have been thinking about stepping back a bit, doing this full patient assessment, deciding she was unstable and coming up with a plan. But in fact what happened in this case was that she got sent to the surgical ward, in other words just not an HDU facility. The ambulance crew are waiting, the nurse who was looking after her, noticed that the patient appeared flush, and had a temperature. Minimal pain, this should ring some alarm bells here guys that this girl should be in pain. The fact she's not in pain should indicate a conscious level deterioration, which is a bad sign. I'll let you look at the results yourself, and physiology but my take on that is that they're worse, and that this is definitely a widened pulse pressure here, this is a very septic patient. And again, if these things, you're thinking, I don't understand about sepsis, please look at the relevant chapter in the CCrISP or START materials. Sepsis has changed quite a lot in the last twenty years, and how we manage it. And those chapters, if you're thinking I'm a bit hazy on this, please look up those chapters.
She's still agitated, what's missing here of course is what time scale this urine is produced, probably we don't know that, it's not been charted. She's got a Nephrostomy placed, it's important to check this, because one reason she might have deteriorated is that the Nephrostomy has been displaced. And in fact the Nephrostomy is in the right place. The FY is busy, so kind of almost by default, because nobody's taken ownership, the patient got taken to the ambulance. And again, when I read this, I can just imagine it. I've seen these things happen in my institution as well.
When she arrives at the base hospital, her NEWS Score is now 11. Now what we can't show you on here if you flip to the back of the chart it will tell you that this is a really bad thing if you don't know that already, and it will say that it should be escalated to a senior because this person's really ill. And again, the track and trigger enables, empowers people to ring senior people, to say 'I think this person's ill' and this track and trigger is telling me to ring a senior people. And that's what you need to be, you need to listen to our nursing staff. And actually she got to the Urology Centre, she was put in a ward bed. They duly documented her physiology, which as you can see is even worse. And a pressure of a in young, fit person is an absolute disaster. Pulse pressure's widened again. Very septic. Very vasodilated. Her GCS has decreased, more her temperatures got worse. FY2 repeats the bloods, quite a common thing to do, its in our comfort zone, we're sticking to our comfort zone. You ring a senior, excellent. Senior's busy, is this response adequate? The response in my opinion isn't adequate. Again, human factors here, very difficult for FY2 , but in our units I try to encourage them with the support of the nursing staff who've seen, of course have seen all this before, to ring the consultant, ring the urology consultant, and say I'm sorry to ring you, but this persons busy in the theatre, and this girl is really ill and needs a senior review. Can you, either come and review the patient, or can you come to theatre and take over for the Urology registrar and finish the procedure and they can come review the patient? Escalate the care. Empower people.
NEWS Response. You're probably all familiar with this, I won't go on about it too much. This is escalating. This girl's NEWS score is now eleven. This is very, very serious. Just to finish this episode off, this lady unfortunately ends up going to be ventilated on ICU. Had a cardiac arrest and aspirated minutes after transfer. She was right at the bottom of this slippery slope, and she could've been stopped so much earlier. She had to have CPR, she had to have a huge amount of organ support, respirtatory support, cardiovascular support, renal replacements. She actually survived, but against the odds. And it could have been prevented.
So why did it happen? Failure to recognise and act on deteriorating trends, to plan and communicate at several levels, failure to rescue the patient. Not recognising the deterioration and really documenting it quite carefully, to the point that she had a cardiac arrest.
So there's learning points here for the whole team. Not just for the medical team, but from the nursing team, from the systems team. If we used the algorithm, the outcome would've been completely different. We would've probably prevented the transfer at this point. And improved the outcome. I'm deferring now to my colleague Dave Yates, an intensivist. Dave what are your comments about this case? Because this was actually contributed by an intensivist elsewhere.
[David] Steve, I think what you described, with the, the going through the algorithm is the crucial bit isn't it? You've got a young girl here, using the example. The young girl is not stable for transfer, and by going through the CCrISP algorithm we've established that. Now, what we haven't done is said what treatments that young girl needs on an intensive care unit or a high dependency unit. And I don't think that's what CCrISP is necessarily all about. It's to introduce those treatments, but at the end of the day is expert treatment delivered in an intensive care unit. And I think what we want clinicians to do who are moving outside their comfort zone, is to recognise these patients, and to be able to flag them up to those that can deliver that extra level of care that's needed.
[Steve] That's a really important point, Dave, because I think the fear when people aren't familiar with CCrISP think they're trying to train pseudo-intensive care doctors; we're not. We're trying to train surgeons, or other doctors. The role for the surgeon beyond that is to make the care happen. Liaise with you guys, understand what you can offer, check the surgical wound from the appendicectomy, check if the Nephrostomy has fallen out; if you all start to support the person, with all the organ support we've described, that actually they get worse again, so we'll all get the, I'll organise in the interventional radiologist who will come and scan the patient again. Check the Nephrostomy not been displaced, check the why the sepsis isn't getting better. So it's that team work that's absolutely vital.
Okay, so why does communication matter? We've all seen communication go wrong, we've seen that in this example. Case note entry, really important. That's going to be so vital in these COVID times, we're going to have teams in unfamiliar environments. Vascular surgeon knowing how the open aneurysm or the van distal bypass should behave. But the nursing staff or the junior medical staff not knowing that, so being much more explicit about what we expect the recovery to be, what pitfalls to lookout for, how to assess the perfusion, who to call for help, what blood pressure parameters do you want through it, a patient who's had major vascular surgery. We've got to be much more clear about that. We're not very good at that, as doctors doing that. We've got to set the parameters and expectations, and communicate much more effectively. We're going to talk separately about SBAR communication, a really useful tool, across all specialties.
So is the stable patient different? No. They're not at all. The three stage assessment is still vital and this will improve your overall care. Stability is relative, of course. So for an experienced person, when I give this lecture normally, I say 'who is the most stable person in the hospital?' and unfortunately its the person in the morgue that's the most stable patient. So stability isn't always a good thing, stability of someone who is day one post major surgery can be okay, stability six days down the line, still not eating and drinking, still on a drip, still not opening their bowels, still not got out of bed, still got all the drains in, is a bad thing. So the checklist approach to the stable patient, as championed by CCrISP, I think is really important.
So things to talk about: routine investigations, bloods, but targeted bloods, writing up the fluids there and then, not just leaving it to a junior staff later, or someone on call to do. Look at drugs, that's increasingly different difficult to do in our Institution with electronic prescribing, but everyday looking at the drug charts. Are they on the correct drugs? Do we need to start drugs? Stop drugs? Do we need to look at the nephrotoxic drugs, for example. Are they getting their comorbid cardiac drugs, and immunosuppressant drugs, if they're appropriate. Why can't we get the drains out? Why can't we get the tubes out? Why can't we get a catheter out? Get a physio on board, physio is going to be stretched during these times. But we can give physio, we can encourage deep breathing, we can encourage mobilisation. And think about why can't we get this person in a lower level of care, why can't we get them home? Make progress.
So the summary is, using a system of assessment helps reduce omissions, and, as Ben talked about unforced errors. Every patient needs a plan for definitive treatment. Need to communicate that plan. And anticipate problems that might happen and who to call. Deteriorating patient, we've talked about that. Shocking case, really. They need physiological support and definitive treatment, so we need this whole team approach. Dave Yates and other colleagues in York are quite good at saying look they can keep supporting people on ICU, that's getting them better sometimes, we've needed a definitive treatment. And remember this system also applies to stable patients. So thank you very much for your time.