Caring for critically ill patients has its own set of unique challenges, according to Courtney Waxman, MS, CVT, RVT, VTS (ECC), an instructional technologist at Purdue University’s Veterinary Nursing Program. During a lecture at the Fetch dvm360® virtual conference last week, Waxman discussed patient care strategies and provided suggestions for managing professional and personal stressors technicians may encounter in small animal intensive care units and critical care services.
Checklists and care bundles
An important area of focus is on strategies to provide consistent, high-quality patient care in a setting that is often very busy, with critical patients whose care crosses over many shift changes. Waxman stressed the value of checklists and care bundles, which can prevent lapses in recall of important but perhaps less prominent details and provide a less labor-intensive way to capture all facets of a particular standard of care. Checklists and care bundles also create a culture of accountability, provide consistency, establish patient care standards, improve patient care quality, and reduce morbidity and mortality.
One example of a widely used checklist is Kirby’s Rule of 20, which is a suggested list of 20 parameters for daily assessment of critically ill patients. Similarly, care bundles can provide a standardized approach to patient care related to a particular disease or procedure to prevent common oversights. Examples include all treatments (major or minor) associated with urinary catheter care or ventilator care.
The value of care bundles is illustrated by 2 nationally recognized care bundles: the RECOVER Initiative, which is an evidence-based care bundle providing guidelines for veterinary cardiopulmonary resuscitation (CPR),1 and the Surviving Sepsis Campaign, which is a human adult and pediatric care bundle to provide reduced morbidity and mortality for patients with sepsis.2
Maintaining the medical record
One aspect of critical care nursing that is not necessarily unique, but is very important and has strong legal implications, is maintaining the patient medical record. Waxman emphasized the importance of accurate and thorough charting. When charting, it is important to report the facts as events happen, she said, rather than waiting until the end of shift when memory and fatigue may preclude accuracy and completeness. It is also important to avoid adding opinions or using unprofessional language, as the medical record is a legal document and may be requested by owners, veterinarians, or legal and regulatory entities.
Biosecurity
Given the critical and often fragile nature of these patients, biosecurity practices are also of great importance as patients may be infectious or immunocompromised. Waxman directed the audience to the American Animal Hospital Association’s 2018 biosecurity consensus statement, which details protocols for those sites that need guidance.3 Necessary routine practices include wearing gloves for all patient care, changing gloves between patients, and frequent hand washing. Where appropriate, personal protective equipment may be required of the nursing staff or any visiting owners, and in some cases, owner visits may need to be minimized.
Shift transitions
An additional area of importance is the transition between nursing shifts. Waxman presented some startling data from human medicine. In a study of nurses, information retention from verbal rounds was only 26%. This rate improved to approximately 31% to 58% when written notes were taken in addition to verbal rounds. However, where a preformatted rounding form was used, the retention rate jumped to 96% to 100%.4 It is worth noting that for patients undergoing long hospital stays, the loss of information during verbal rounds can be compounded over multiple shifts and multiple days, potentially translating to patient care mistakes or omissions. Waxman likened this to a real-life game of “telephone,” which may be amusing as a children’s game but is far from ideal in a critical care setting.
Another strategy to standardize rounds and improve information transfer is to overlap shifts to allow for a dedicated rounds time during each shift change. The amount of time needed should be estimated as 1 to 3 minutes per patient for rounds associated with each shift change, and 5 to 10 minutes per patient for more detailed daily rounds that involve the entire interdisciplinary care team. Rounds are most effective when conducted cage-side to better visualize the status of each patient while discussing the case details.
In addition to rounds, each technician should do a walkthrough at the start of their shift to familiarize themselves with cases and review patient orders and treatment sheets. Talk to the clinician on the case about the patient care plan for that day. When performing patient care, attend to the most critical patients first. Additional tasks that are not specific to an individual patient are to check fluid pump programming for each patient, verify alarm parameters for each monitoring device, check all intravenous catheters, and ensure at the beginning of each shift that the CPR area and resuscitation supplies are stocked and ready for emergency use.
Stress and self-care
In addition to medical strategies, Waxman addressed the important professional and personal stressors that exist in the critical care setting. These stressors are not necessarily unique to veterinary medicine or critical care, but are very common in the veterinary critical care setting. Burnout, compassion fatigue, decision fatigue, and imposter syndrome are the 4 types of emotional tolls that affect veterinary professionals working in these environments.
Although there are similarities across these 4 conditions, they are not alike. Burnout is a physical or mental collapse that results from overwork or stress in one’s work or personal environment. This is slightly different than compassion fatigue, which is a traumatic stress disorder that occurs in caregiving environments as a result of emotional challenges. Although symptoms may overlap, there are some differences, and the causes of burnout and compassion fatigue are different.
Decision fatigue is another condition that occurs in the critical care environment. After making decision after decision, eventually the quality of decisions can deteriorate over time as if the decision-maker’s ability is getting “worn out.” One strategy to offset this fatigue is to minimize decisions in situations that you are able to control, and to reduce the stress of decision-making.
Finally, imposter syndrome is characterized by feelings of inadequacy despite evidence of competence and success. Imposter syndrome is common in the veterinary community, affecting both veterinarians and technicians. Strategies to combat imposter syndrome include focusing on successes, focusing on the value provided by your work, and avoiding the tendency to compare yourself with others. Ultimately, although there are differences between the signs associated with these 4 emotional conditions, the underlying theme is to focus on physical, mental, and emotional elements self-care.
Rebecca A. Packer, DVM, MS, DACVIM (Neurology/Neurosurgery), is an associate professor at Colorado State University College of Veterinary Medicine and Biomedical Sciences in Fort Collins. She is active in clinical and didactic training of veterinary students and residents and has developed a comparative neuro-oncology research program at Colorado State University.
References
- Fletcher DJ, Boller M, Brainard BM, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines. J Vet Emerg Crit Care. 2012;22(S1):S102–S131 doi:10.1111/j.1476-4431.2012.00757.x
- Levy, M.M., Evans, L.E. & Rhodes, A. The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Med. 44(6):925–928 (2018). doi:10.1007/s00134-018-5085-0
- Stull JW, Bjorvik E, Bub J, Dvorak G, Petersen C, Troyer HL. 2018 AAHA Infection Control, Prevention, and Biosecurity Guidelines. J Am Anim Hosp Assoc. 2018;54(6):297-326. doi: 0.5326/JAAHA-MS-6903
- Starmer AJ, Spector ND, Srivastava R. Changes in medical errors after implementation of a handoff program.N Engl J Med. 2014;371:1803-1812. doi: 10.1056/NEJMsa1405556
