Page 53 - ACCCN's Critical Care Nursing

30 S C O P E O F C R I T I C A L C A R E

TABLE 2.6 Key points when documenting an incident in a patient’s file notes 21

Question Explanation
Where did the incident occur? For example, bedside, toilet, drug room
Were there any pre-event circumstances of significance? For example, short-staffed, no written protocol
Who witnessed the event? Including staff, patient, visitors
What was done to minimise negative effects? For example, extra staff brought to assist, slip wiped up, sign placed on front
of patient chart warning of reaction/sensitivity etc
Who in authority was notified of the incident? Involving a senior, experienced manager/authority should help expedite
immediate and effective action.
Who informed the victim of the event? What was the victim Clear, concise and non-judgmental explanations to victim or representative
told? What was the response? are necessary as soon as possible, preferably from a credible authority
(manager/director).
What follow-up support, counselling and revision occurred? This is important for both victim and perpetrator; ascertain when counselling
occurred and who provided it.
What review systems were commenced to limit recurrence Magistrates and coroners in particular want to know what system changes
of the event? have occurred to limit the recurrence of the event.

respect, and may help to resolve anger and frustration as coordinate the activity without actually demonstrat-
well as to educate all concerned in how such events can ing or implementing their decisions)
be prevented in the future, a right for which many con- ● peer support programs and training of peers, which
sumer advocates are now lobbying. 76 can be informal, where colleagues debrief others who
have had traumatic or confronting experiences (e.g. a
The process of root cause analysis (RCA) can assist the
team to explore in detail the sequence of events and difficult resuscitation, an aggressive or violent attack
system failures that precipitated an incident and help to or a major personal trauma such as a personal family
inform future system reforms to minimise harm. An RCA tragedy); however, there is growing evidence of the
is a generic method of ‘drilling down’ to identify hospital value of a more formalised system of peer support,
system deficiencies that may not immediately be appar- where staff volunteer to make themselves available for
ent, and that may have contributed to the occurrence of training and to provide assistance and a listening ear
a ‘sentinel event’. The general characteristics of an RCA to a colleague in need. In more complex cases, peers
are that it: 77 may suggest that the staff member seek professional
counselling but can still make themselves available as
● focuses on systems and processes, not individual peer support if desired by the affected staff member.
performance
● includes a review of the relevant literature MEASURES OF NURSING WORKLOAD
● examines the event extensively for underlying contrib-
uting causes OR ACTIVITY
● enables procedure and system modifications. Several workload measures 79–86 have been developed in
an attempt to capture the complexity and diversity of
CONTINGENCY PLANS AND REHEARSAL critical care nursing practice (see Table 2.7 for common
In addition to written policies and protocols, and as well instruments). Some hospitals use an electronic care plan
as having well-educated clinical staff, it is always advis- with activity timings to calculate nursing time and work-
able to have back-up systems in place, especially for major load. An Australian instrument, the critical care patient
83
and rare events that may require rapid management and dependency tool (CCPDT), was developed to measure
coordinated responses. Ryan and MacLochlainn suggest nursing costs in the ICU and is still used in some units
87
the following: 78 to document workload, although no further validation
studies have been published since the original research
● a senior manager rostered on call and accessible for in 1993. The most common instruments used in clinical
advice 24/7 practice and research are variants of the therapeutic inter-
● training of managers (not just clinicians) to know vention scoring system (TISS) and the Nursing Activity
how to respond to crises and incidents Scale (NAS) (see Tables 2.7 and 2.8).
● current and easy-to-find policies and protocols, with
specific information for a manager
● rehearsal of major and rare but foreseeable events, THERAPEUTIC INTERVENTION
such as power outage, external disaster and mass casu- SCORING SYSTEM
88
alty influx, and unit evacuation (these can be per- The therapeutic intervention scoring system (TISS) was
formed as simulated events or ‘tabletop’ exercises, initially developed to measure severity of illness and
where people describe how they would respond and related therapeutic activities, but has been widely used as