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Step 2National Competency Framework for Adult Critical Care Nurses

Step 2 Competencies

Critical Care Networks- National Nurse Leads

STEP TWO COMPETENCIES PAGE 2

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Contents

All step 2 Competencies have been designed to provide you with further essential critical care skills which will require enhanced theoretical knowledge to underpin your practice. Some of the competency statements will be similar to those assessed in Step 1, but the level at which you are assessed will differ. You will now need to demonstrate application of your knowledge in practice and give a rationale for the care you deliver. You will still require the supervision and support of your Mentor, Lead Assessor and/or Practice Educator and you are advised to keep a record of any supportive evidence and reflective practice to assist you during progress and assessment reviews.

It is anticipated that these step 2 Competencies will form the next steps of your development, and will also form part of local academic programmes of education delivered at Level 6 or 7

Learning Contract Page 3

Step Two Competencies Respiratory System Page 4 Cardiovascular System Page 9 Renal System Page 11 Gastrointestinal System Page 14 Neurological System Page 16 End of Life Care Page 18 Inter & Intra Hospital Transfer Page 19 Rehabilitation 1 Professionalism Page 23 Leadership Page 23

Assessment and Development Records Page 24

Abbreviations Page 29

Bibliography Page 30

Acknowledgements Page 31


National Competency Framework for Adult Critical Care Nurses

Learning Contract

The following Learning Contract applies to the Individual Learner, Lead Assessor and Unit Manger and should be completed before embarking on this competency development programme. It will provide the foundations for:•Individual commitment to learning• Commitment to continuing supervision and support• Provision of time and opportunities to learn

LEARNERS RESPONSIBILITIES As a learner I intent to:• Take responsibility for my own development • Form a productive working relationship with mentors and assessors• Listen to colleagues, mentors and assessors advice and utilise coaching opportunities• Use constructive criticism positively to inform my learning • Meet with my Lead Assessor at least 3 monthly• Adopt a number of learning strategies to assist in my development• Put myself forward for learning opportunities as they arise • Undertake Step 2 competencies during a formal critical care educational programme• Use this competency development programme to inform my annual appraisal and development needs • Report lack of supervision or support directly to unit manager at the first opportunity

Signature ............................................................... Date: ...................................

LEAD ASSESSOR RESPONSIBILITIESAs a Lead Assessor I intend to:• Meet the standards of regulatory bodies (NMC, 2008)• Demonstrate ongoing professional development/competence within critical care• Promote a positive learning environment• Support the learner to expand their knowledge and understanding• Highlight learning opportunities• Set realist and achievable action plans• Complete assessments within the recommended timeframe• Bring to the attention of the HEI, Education Lead and/or Manager concerns related to the individual nurses learning and development • Plan a series of learning experiences that will meet the individuals defined learning needs• Prioritise work to accommodate support of learners within their practice roles• Provide feedback about the effectiveness of learning and assessment in practice

Signature ............................................................... Date: ...................................

CRITICAL CARE LEAD NURSE/MANAGERAs a critical care service provider I intend to:• Facilitate a minimum of 40% of learners’ clinical practice hours with their mentor/assessor and/or Practice Educator or delegated appropriate other• Provide and/or support clinical placements to facilitate the learners development and achievement of the core/essential competency requirements• Regulate and quality assure systems for mentorship and standardisation of assessment to ensure validity and transferability of the nurses’ competence

Signature ............................................................... Date: ...................................


Respiratory SystemThe following competency statements are about caring for the individual in the critical care environment who requires respiratory support, including monitoring, observation and respiratory care.

2.1 Anatomy & Physiology

You must be able to demonstrate through discussion application of your knowledge in relation to:

• The anatomy & physiology of the respiratory system to include: o Landmarks used in physical assessment including: • Lobes of the lung • Ribs/intercostal spaces o Neuromuscular control o Normal lung volumes and pressures o Physiological shunt o Physiological dead space

2.2 Enhanced Respiratory Assessment, Monitoring & Observation


A comprehensive physical assessment of the patient’s respiratory status including: • Normal parameters for respiratory observations, refer to Step 1.2• Neurological status • Communication ability • Auscultation, including recognition of normal and adventitious sounds • Percussion• CXR• ABG analysis o Indications for ABG analysis o Common causes of Acidosis and alkalosis • Common causes of airway obstruction • Actions you would take to restore respiratory function in response to observations including: o Oxygen therapy: • Indications and rationale for various methods of delivery o Humidification: • Indications and rational for various methods of humidification. • Advantages/disadvantages of each• Patient Positioning: o Effects of positioning on V/Q o Physiology underpinning Proning o Benefits and drawbacks of Prone positioning o Kinetic Therapy including the advantages and disadvantages • Indications for Bronchoscopy

You must be able to undertake the following in a safe and professional manner, giving rationale:

Accurately perform and correctly document a thorough and comprehensive respiratory assessment including:• Normal parameters for respiratory observations, refer to competency Step 1.2• EtCO2• Neurological assessment

Agreed Action PlanDate/Sign


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2.3 Non-Invasive and Invasive Ventilation


• Care and management of the patient requiring NIV o Principles of Non Invasive Ventilation (NIV) o The main types of NIV available in the clinical area o Patients who may benefit from NIV• Indication, advantages & disadvantages for intubation/invasive ventilation• The process of intubation: o Equipment required and rationale for its use o Drugs required, rationale for use and mode of action o Advantages and disadvantages of cricoid pressure• The likely causes for emergency re-intubation and discuss actions to minimise risks• Mechanical ventilation: o Normal parameters of ventilation o How ventilator settings can be manipulated to correct oxygen and/or carbon dioxide imbalances as per ABG’s results o Need for End tidal CO2 monitoring o Physiological and psychological effects of mechanical ventilation on the body• Significance of the ventilator care bundle• Secretions: o Indications for physiotherapy o Risks & benefits of physiotherapy o Recognise specific indicators for suctioning o Potential complications associated with suctioning and how to minimise/prevent these o Benefits and draw backs of sub-glottic suctioning

2.2 Enhanced Respiratory Assessment, Monitoring & Observation continued


Accurately perform and correctly document a thorough and comprehensive respiratory assessment including:• Communication ability• Auscultation and percussion• Basic CXR interpretation• ABGs o Correctly interpret ABG for specific patients o Formulate a plan of care in response to ABG interpretation. o Modify therapy in response to ABG results• Provide appropriate intervention for patients experiencing airway problems: o Head tilt/chin lift/jaw thrust o Insertion of airway adjunct o Manual ventilation• Patient Positioning: o Care for a patient who is proned o Care for a patient undergoing Kinetic Therapy • Care for the patient who requires a bronchoscopy: o Physically & psychologically prepares the patient for the procedure as appropriate o Identify & assemble the equipment required for the procedure as appropriate o Assist medical staff during procedure o Monitor the patient’s condition throughout and seek assistance as required o Obtain & send samples for MC&S as required o Clean & dispose of used equipment



AchievedDate/Sign

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2.3 Non-Invasive and Invasive Ventilation continued


• Weaning and extubation:o Indicators for weaning (ICS guidelines)o Weaning strategies, advantages and disadvantages of nurse led weaningo Criteria for extubation/decannulation and potential complications associated with the processo Potential communication problems associated with an artificial airway and suggest methods to minimise/overcome theseo Preparation of the patient and equipmento Extubation procedure o Care of patient post extubation


• Manage the patient requiring Non-Invasive Ventilation:Correctly assemble NIV circuit(s)Correctly monitor the patient requiring NIVAdjusts therapy in response to changes in conditionCorrectly troubleshoots equipment alarms• Care for a patient during intubation: o Identify, assemble & check equipment required for intubation o Correctly anticipate and prepare drugs to be used during intubation o Provide assistance to medical staff during intubation o Correctly apply cricoid pressure as requested o Plan care according to the clinical needs of the patient• Manage the patient who requires invasive ventilation: o Accurately monitor & document ventilator observations, refer to competency Step 1.3 o Titrate ventilation therapy as directed o Adhere to the Ventilator Care bundle and support others to do so• Manage the patient who requires suctioning, refer to competency Step 1.3 o Pre-Oxygenate as appropriate o Monitor the patient throughout and respond to any deterioration in patient’s condition• Care for the weaning patient: o Appropriately monitor the weaning patient o Communicate effectively with the patient using communication aids o Adapt weaning strategies to individual patients o Monitor the patient for potential emotional, psychological & physiological issues related to weaning• Extubation: o Prepare the equipment o Prepare the patient physically and psychologically o Perform extubation procedure taking into account: • ABGs • Aspirate NG tube, stop Feed • Positioning • Pre-Oxygenate • Suction oro-pharynx , ETT • Deflate cuff & remove ETT • Apply oxygen/NIV o Monitor and observe patient post extubation• Support the patient during physiotherapy• Liaise with physiotherapist regarding appropriate treatment & care


AchievedDate/Sign


2.4 Enhanced Tracheostomy Care


• Rationale for: o Percutaneous tracheostomy o Surgical tracheostomy o Mini Tracheostomy o Changing inner-tube• Common types of tube used including: o Cuffed o Uncuffed o Adjustable flange o Fenestrated o Laryngectomy o Speaking valve • Potential hazards associated with tracheostomies: o During insertion o Following insertion • Physical and psychological effects of a tracheostomy • Rationale for performing a SALT assessment


• Assist with insertion of percutaneous tracheostomy: o Preparation of equipment o Patient care & observation pre/peri/post procedure• Monitor the patient for potential physical and psychological effects associated with tracheostomies and respond accordingly• Appropriately plan & deliver care in line with national/local guidelines• Assist with SALT assessment • Correctly identify when decannulation may be appropriate.• Appropriately monitor the patient for potential complications post decannulation

2.5 Enhanced Chest Drain Management


• Anatomy & Physiology related to chest drain insertion and the principals involved • Review indications for and potential complications of chest drain insertion, refer to competency Step 1.5 • Rationale for the monitoring and recording of: o Drainage o Swinging o Bubbling o Bottle changes o Dressings o Removal• Correct action to take if: o Drain blocks/falls out o There is an air leak o Bubbling stops o Underwater seal is lost o Tension pneumothorax develops• The rationale for the application of low thoracic suction to a chest drain o Indications for low thoracic suction o Correct suction pressures o Potential complications• Safe removal of chest drain including: o Indications o Procedure o Post removal care



AchievedDate/Sign

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2.5 Enhanced Chest Drain Management continued


• Prepare for and assist with chest drain insertion• Appropriately care for the patient during the insertion of chest drain• Manage the patient with a chest drain in situ• Undertake correct action if: o Drain blocks/falls out o There is an air leak o Bubbling stops o Underwater seal is lost o Tension pneumothorax develops• Effectively manage the drain and support others to do so: o Position of bottle o Appropriate/cautionary use of drain clamps o Dressings o Changing bottles/disposal o Monitoring drainage o Application of low suction• Assist with the safe removal of chest drain including: o Prepare patient o Prepare Equipment o Assist with the removal procedure o Care for the patient post removal of chest drain


AchievedDate/Sign

2.6 Associated Pharmacology


• Commonly used medications for respiratory care, indications for use, mode of action and potential complications of:o Bronchodilators/Nebuliserso Steroidso Sedation/paralysing agentso Respiratory stimulantso Antibioticso Antihistamineso Mucolyticso Analgesiao Diuretics


• Safely prepare and administer medications used to support the respiratory system• Appropriately monitor the patient during administration of medicines• Titrate medication to achieve targets set by medical staff (e.g. sedation score to aid compliance to mechanical ventilation)


AchievedDate/Sign

2.7 Enhanced Cardiovascular Assessment, Monitoring & Observation


• Indications for haemodynamic monitoring in relation to the critically ill adult: o Invasive o Non-invasive• Determinants of the Normal Cardiac Cycle• Determinants of Cardiac Output o CO = HR (Autonomic control) xSV (Preload, afterload, contractility)• Determinants of Blood Pressure o BP= COxSVR• Determinants of Central Venous Pressure• Normal Cardiac Conduction Pathway• Effects of ventilation on the cardiovascular system• Recognise when advanced cardiac support is required to correct haemodynamic instability• Recognise referral criteria and how to refer to specialist centres


• Comprehensive cardiovascular assessment, recording findings, optimising treatment within prescribed limits and escalating problems to appropriate team members: o Pulse/ECG o Blood pressure with specific reference to MAP. o Temperature o Neurological status o Interpretation of arterial wave forms o Interpretation of Central venous pressure values and wave forms o Recognise the significance of a distended JVP o Renal function & urine output o Cardiac output measurements o Pulse oximetry o Fluid therapies o Capillary refill o Limb temperature o Biochemical markers o Skin turgor o Blood results




AchievedDate/Sign

Cardiovascular SystemThe following competency statements are about monitoring and caring for the individual in the critical care environment who is suffering from cardiovascular dysfunction.



2.8 Enhanced Fluid Management


• Fluid compartments within the body• Osmosis and diffusion in relation to fluid movement• Identify the clinical indications that necessitate fluid intervention• Identify key differences between colloids, crystalloids and blood products• Rationalise the choice of colloids, crystalloids and blood products in relation to the cardiac compromised patient.• Rationalise the choice of colloids, crystalloids and blood products in relation to the patient with cardiac disease


• Recognise altered fluid status (e.g. hypo/hypervolemia)• Recognise the requirement for fluid intervention• Correctly administer fluids according to local guidelines • Accurately record fluid balance according to local policy


AchievedDate/Sign



2.10 Enhanced Renal Assessment, Monitoring & Observation


• Methods of measuring and recording fluid output• Methods and techniques for monitoring the fluid status, balance and renal function of individuals in critical care at risk of renal deterioration: o Cardiovascular monitoring, refer to competency Step 2.7 o Recognition of Fluid depletion o Recognition of fluid overload o Maintenance of daily fluid balance charts o Patient weight o Urine output relative to weight o Renal blood profile o Creatinine clearance• Abnormalities related to renal failure and recognition, including therapy and interventions that can be used: o Nephrotoxic drugs o Drug dose adjustments in renal failure o Fluid overload


• Refer to patients past medical history and outline how this may affect renal function• Determine the monitoring needs for the individual at risk of deteriorating renal function• Demonstrate the ability to accurately measure and record fluid intake, output and balance and reports abnormalities• Review a patient’s arterial blood gasses and discuss their interpretation in relation to acid base balance and electrolytes in order to optimise therapy• Review a patient’s biochemistry and haematology results and discuss their interpretation in relation to AKI• Identify factors which may affect the assessment of renal function, for example blocked catheters and urinary retention• Evaluates the effectiveness of fluid replacement and drug therapy and adjusts care accordingly


AchievedDate/Sign

2.9 Anatomy & Physiology


• Renal System• Functions of the kidney• Production of urine• Elimination of electrolytes• Renal blood supply• Reasons for fluid redistribution in critical illness• Autoregulation and the hormones that affect fluid homeostasis - rennin angiotensin, Anti Diuretic Hormone (ADH), aldosterone• Causes of acute kidney injury (AKI)o Pre-renalo Intra-renalo Post renal


AchievedDate/Sign

Renal system The following competency statements are about monitoring and caring for the individual in the critical care environment who is suffering from cardiovascular dysfunction.


2.11 Continuous Renal Replacement Therapy


• Treatment choices available and the principals involved: o CVVHDF o CVVH o SLEDD o Haemodialysis o Peritoneal dialysis o Other


Assisting with line insertion:• Set up the appropriate equipment and consumables for line insertion• Maintain asepsis throughout the procedure in line with local policy• Establish the patient in the correct position for line insertion (depending on chosen site)• Document line insertion appropriately and in line with local policy• Outline a comprehensive monitoring and plan of care for the maintenance of the line• Ensure all relevant safety checks are performed prior to the use of the line• Heparin lock the line in accordance with local policy• Secure the line appropriately• Ensure all waste is disposed of in accordance with local guidelines

General care and maintenance:• Monitor the needs of the individual requiring this treatment therapy• Perform all base line blood profiles prior to treatment and offer explanations• Position the patient appropriately prior to treatment and offer rationale• Perform a limb perfusion assessment, if relevant• Record accurate fluid balance including running totals and accumulative balance• Establish an individualised plan of care for renal replacement therapy• Select the appropriate equipment and consumables for the chosen renal therapy• Safely assemble the chosen equipment and perform all relevant safety checks• Prime the circuit as per manufacturer’s recommendations and local policy• Select the prescribed treatment mode and set individualised prescribed treatment goals• Observe, monitor and conduct the following: o Access pressureso Return pressureso Trans membrane pressureo Filter checkso Blood chamber check, if appropriateo Gas chamber checks, if appropriateo Body temperature and appropriate adjustment of active warming /cooling (through replacement fluid or blood circuit)o Physiological parameterso Fluid balance assessmento Electrolyte balanceo Acid base balanceo Other, specific to own equipment used

Relacement Fluid:• Select the appropriate replacement fluid for an individual based on their physiological needs and blood profiles giving rationale for the chosen fluid, according to local guidelines/patient prescription


AchievedDate/Sign


2.11 Continuous Renal Replacement Therapy continued


Anticoagulation:• Prepare the chosen anticoagulation therapy in line with manufactures recommendations, NMC guidance and local policy• Safely administer anticoagulation therapy in line with NMC guidance and local policy • Establish monitoring plan for full blood count and coagulation blood profiles giving rationale•Conduct point of care testing as necessary and titrate anticoagulation therapy in response to results according to local guidelines

Trouble shooting:• Position the patient appropriately (depending on line site) to ensure adequate line patency and patient comfort• Perform basic troubleshooting to ensure continuation of therapyCare and Maintenance of Lines:• Undertake routine dressing changes, maintaining asepsis throughout procedure• Observe the line site and document findings appropriately• Heparin locks the line when not in use in line with local guidance



AchievedDate/Sign




• Fluid replacement therapy and indication for use: o IV o IV fluid and electrolyte replacement o Natural Colloid o Synthetic colloids o Crystalloid o Blood products• Commonly used medications in renal failure, indications, contraindications and the appropriate care of the patient during therapy: o Diuretics o Dextrose and insulin o Salbutamol, nebulised o Calcium o Calcium resonium o Sodium bicarbonate


• Evaluate the effectiveness of fluid replacement and drug therapy and adjusts care accordingly


AchievedDate/Sign

Gastrointestinal System The following competency statements are about the safe and effective care of the critically ill patient requiring support and management of gastrointestinal (including the Liver & Biliary system) dysfunction.

2.13 Enhanced Gastrointestinal Assessment & Management


• Surgical procedures and common reasons for intervention:o Hartmann’s procedureo Oesophagectomyo Colectomyo Toxic Megacolon or Colon• Acute GI conditions, signs, symptoms and common causes:o Pancreatitiso GI bleed o Oesophageal variceso Duodenal ulcers • Physiological changes associated with chronic liver disease and how a patient may present in critical care depending on the cause • Acute liver & biliary impairment, signs, symptoms and common causes specifying how a patient may present in critical care depending on the cause• Paralytic ileus – causes and effects• The process of bacterial translocation• Differing types of stomao Ileostomyo Colostomyo Ileal Conduit • Drain management associated with abdominal disorders• Risks of sepsis associated with GI disorders


• Refer to patients past medical history and outlines how this may affect gastrointestinal function• Determine the monitoring needs for the individual at risk of deterioration related to gastrointestinal function• Accurately measure and record nutritional intake and related observations • Report any abnormalities to appropriate MDT member• Correctly review a patient’s biochemistry and haematology results and interpretations the findings in relation to gastrointestinal function• Evaluate the effectiveness of therapeutic interventions and adjusts care accordingly • Alter nutritional regimes in line with MDT recommendations and local policy • Recognise the patient at risk of deteriorating from sepsis• Manage stomas/ drains in accordance with national and local policy and guidelines • Monitor and document stoma site appearance (such as colour, positioning, functioning) and escalates any concerns immediately




AchievedDate/Sign





• GI disorders:o Prokinetics & motilityo Laxativeso Antistimulantso Insulin/ hypoglycaemic agentso Probioticso Steroids o Anti diarrhea drugso Anti secretory drugs


• Safely prepare and administer medications used to support the gastrointestinal system• Titrate medication to achieve targets set (e.g. blood glucose control)


AchievedDate/Sign



Neurological System The following competency statement is about the assessment and management of the neurologically compromised patient in the general critical care environment.

2.15 Advanced Care and Management of the Neurologically Compromised Patient


• Intracranial and extracranial causes of neurological deterioration• The pathological causes of secondary brain injury and how these can be minimised or prevented• Specific pathological causes of deterioration following SAH, how these can be managed or prevented• Physiological measurements and observations that need to be recorded in relation to the monitoring and delivery of care to the neurologically compromised patient in a general ICU setting and advanced monitoring options which may be offered in a tertiary setting: o Importance of identifying clinical situations in which brain imaging would be required o How to detect specific complications such as disorders of sodium balance and diabetes insipidus and treatment options available o Importance of volume resuscitation and use of inotropes and vasoconstrictors in maintaining adequate MAP and CPP• Clinical situations where osmotic therapy is indicated o Importance of evaluating effects of: o Osmotic therapy o Inotrope support o Fluid resuscitation • Clinical situations in which therapeutic hypothermia would be used• Clinical situations in which a deep barbiturate coma would be induced• Clinical situation in which cerebral function monitoring / EEG would be used• Clinical situation in which an External Ventricular Drain (EVD) would be used to control ICP or treat hydrocephalus in SAH• Specific pharmacological strategies, rationale for their use, possible interactions and side effects• Specific blood gas parameters required and how these can be achieved through specific ventilation strategies• Advanced assessment for focal deficit: o Cranial nerve palsies and how each one reflects patho-physiological changes, specifically: o Gag and swallow reflex, facial weakness o Corneal reflex o Pupil, eye gaze and eye closure changes that may reflect focal pathology such as 3rd nerve palsy o Focal changes in limb power using the Oxford scale o Focal speech deficit:• Expressive and receptive dysphasia, aphasia and dysarthria• How neurological deficit could compromise patient safety in relation to: o Aspiration pneumonia o Eating and drinking o Corneal abrasion o Communication o Falls o Pressure sore development o VTE• Disorders of movement and how they may relate to anatomy o Specific safety risks to the patient with a movement disorder o Specific pharmacological treatment options for movement disorders


AchievedDate/Sign



2.15 Advanced Care and Management of the Neurologically Compromised Patient continued


• Monitor the effect of nursing activities on ICP if direct measurement is available• Calculate CPP if direct ICP monitoring is available• Pressure sore prevention and identify specific risks in relation to: o Therapeutic hypothermia o Inotrope use o Deep sedation• Plan and guide others in relation to nursing activity to maintain cerebral perfusion with respect to: o Normo-thermia (except when actively cooling or re-warming) o Head in neutral alignment and head up 30 degrees to maintain venous drainage o Optimising venous drainage by avoiding tight dressings/ETT tapes around the neck o Altering treatment goals to maintain physiological status in line with prescribed treatment plans o Titrating sedation and inotropes to maintain sedation score and CPP o Maintenance of blood gas parameters

Referring to recent evidence• Work within scope of practice, seeking advice or referring on to more senior multidisciplinary team members if the limit of knowledge is reached• Identify need for tertiary advice and seek it• Liaise with tertiary centre when a transfer for specialised treatment is indicated


AchievedDate/Sign



End of Life Care The following competency statement is about the withdrawal of treatment in the critical care environment.

2.16 Withholding or Withdrawing of Treatment


• Legal constraints, Mental Capacity Act (2005) and ethical practices on withdrawal or withholding of treatment • Procedures for forming and recording agreements on a patients withdrawal from treatment• Best practice procedures for early identification of potential organ donors (Donation After Circulatory Death – DCD) according to defined clinical triggers • Procedure for making a systematic and timely referral to Specialist Nurse – Organ Donation teams• Where appropriate procedures for returning to treatment after withdrawal• How to facilitate access to sources of support within the broader multi disciplinary team• Availability of care suitable for patients after withdrawal of treatment• Nature of post treatment care and means of easing the effects of the illness


• Establish with the multi disciplinary team that further treatment for the patient is futile and that, at some stage, active treatment should be withdrawn in the knowledge this will result in the patient’s death• Identify the patient’s preference for where care will be delivered after withdrawal from treatment• Review the End of Life care options suitable for the patient• Initiate a systematic timely referral to the Specialist Nurse- Organ Donation (SN-OD) for all potential organ and tissue donors as part of End of Life care, in line with local policy and guidelines • Involve the SN-OD and participate in the planning and conduct of a multi disciplinary team approach to families for consent/authorisation for organ and tissue donation according to best practice guidance• Agree with the patient, their family and colleagues a plan of care• Arrange resources for delivery of the plan, including liaison with MDT and appropriate support teams• Initiate care pathway to support end of life care• Evaluate the care pathway on a regular basis and adapt to patient need• Establish whether the patient wishes to change their original decision and, if they do, trigger a new plan of care• Initiate treatment algorithms to ease effects of illness: o Pain o Nausea o Agitation o Dyspnoea o Respiratory Tract Secretions


AchievedDate/Sign



Inter & Intra Hospital Transfer The following competency statement is about the effective coordination and management of inter or intra hospital transfers for critically ill patients, it includes those individuals who require emergency transport to a different location for investigation, treatment, intervention or ongoing care.

2.17 Assisting in the preparation and transfer of the critically ill


• Indications for transfer from critical care • Policies/procedure/guidelines related to the transport of the critically ill patient• Transfer process including the different considerations for clinical and non clinical transfer decisions• Methods, procedures and techniques for the portable monitoring and the types of equipment required during transfer• Monitoring techniques required and explain the necessity/appropriateness of each during transfer: o Continuous ECG o Arterial blood pressure Vs non invasive blood pressure o SpO2 o Continuous capnography with wave form analysis o CVP o Temperature o Intra cranial pressure• Emergency situations that may arise on transfer o Airway management o Alternative ventilation methods o Alternative monitoring techniques (non invasive methods) o Basic and advanced life support o Interpretation of vital signs o Alteration of treatment plans to maintain homeostasis o Titration of medications to optimise condition• Contents of the local emergency/transfer bag and identify the situations in which it may be required to be used the contents• Pharmacology requirements of the patient being transferred • Pre preparation considerations required for drug administration during transfer• Differing types of transport available and make recommendations for which is the most appropriate• Process for organising the appropriate transport• Process for preparing to transfer the critically ill patient• Process and sequence of communication required prior to, during and following transfer• Safe moving and handling of the individual and equipment being transferred• Documentation that needs to be completed for Inter & Intra Hospital transfers: o Transfer form o Vital signs observation chart o Nursing evaluation o Reporting of clinical incidents o Audit tool


AchievedDate/Sign



2.17 Assisting in the preparation and transfer of the critically ill continued

You must be able to undertake the following in a safe and professional manner, giving rationale, with the support of your mentor or assessor:

• Assists in the physiological optimisation/stabilisation of the patient prior to transfer• Assist in the preparation of equipment and resources: o Airway management o Portable ventilation o Suction equipment o CV support o Vital sign monitoring o Fluid therapy & pharmacological requirements o Infusion devices/syringe drivers o Transfer bag o Spinal board/transfer trolley o Warming blanket o Psychological support• Assist in the location, calibration and safely set up monitoring and transfer equipment including: o Alarm parameters o Prepare electromechanical devices o Supplementary gases o Transportation o Establishing optimum level of stability on portable equipment prior to transfer• Assist in and maintain the safety and continued treatment of the critically ill patient during transfer• Assist in the care for the family of the patient being transferred


AchievedDate/Sign



RehabilitationThe following competency statement is about factors contributing to the rehabilitation needs of the patient in a critical care environment, including those that have suffered a major trauma.

2.18 Contributing Factors to Rehabilitation Needs & Patient Dairies


• Reasons why the following specific health conditions may cause ongoing rehabilitation needs in the critically ill: o Critical illness and patterns of recovery o Trauma and patterns of recovery o Cardiac disease and patterns of recovery o Renal disease and patterns of recovery o Acute brain injury and patterns of recovery o Spinal injuries and patterns of recovery o Stroke and patterns of recovery• Commonly seen critical care conditions that may increase the risk of a patient requiring rehabilitation and outline the reason this may occur: o Multi organ failure/sepsis o Multiple trauma o Multiple co-morbidities o Artificial airway for more than 48 hours o Tracheostomy o Major surgery/amputation o Neurological conditions o Prolonged sedation o Neuropathy/loss of pre admission function o Loss of muscle mass o Cognitive impairment o Intrusive memories o Sleep deprivation o Post traumatic stress disorder o Delirium o Anxiety o Depression• Diversity issues and how they may impact on the patients rehabilitation needs: o Age o Culture o Religion o Language o Sexuality o Identity• Benefits of patient diaries in the recovery from critical illness: o Explanation for loss of time o Providing information for a period of their life for which they may not have a memory of o Accepting and understanding their own emotions o Accepting and understanding the emotions of their family• The legal and ethical considerations for patient diaries: o Use of photographs o Confidentiality o Consent issues o Relatives vs Staff diary entries o Level of information written • Right phase in the critical care patients recovery to introduce the diary of their critical care stay


AchievedDate/Sign



2.18 Contributing Factors to Rehabilitation Needs & Patient Dairies continued


• Resources available for recovering critical care patients: o Step down follow up visits o Ongoing rehabilitation goals o Intensive rehabilitation clinics o Follow up clinics o Local patient and relative information o ICU Steps o Other support groups


• Where used instigate a patient diary on admission and ensure it is kept up to date• Use appropriate language and style of writing in line with local policy or guidance• Anticipate factors contributing to extended rehabilitation needs• Make swift referrals to appropriate multi disciplinary team members• Facilitate access to appropriate follow up care and services• Offer support and reassurance to the patient and their family during the rehabilitation process


AchievedDate/Sign



2.19 Enhancing Professionalism


• NMC code of conduct: Standards of conduct, performance and ethics for nurses and midwives (2008)


• Demonstrate self-awareness of own strengths and limitations • Demonstrate effective inter-professional relationships that facilitate meeting the needs of patients and families• Demonstrate an ability to be a motivated self-directed learner• Demonstrate safe and effective written, verbal, telephone and electronic communication strategies• Demonstrate safe effective work/life balance strategies

ProfessionalismThe following competency statement is about maintaining professionalism in critical care nursing practice.


AchievedDate/Sign

2.20 Improving Critical Care Services


• Ensuring patient safety• Identify where critical care practice can be improved


• Identify actual or potential risks or incidents• Instigate immediate response to safe guard patient/s• Report adverse or potential risks through internal clinical incident reporting system• Assess to incident and provide immediate feedback to shift leader• Identify and report any equipment failures in line with local policy• Contribute to safety meetings• Promote a safety culture, sharing lesions learnt• Undertake audit to benchmark critical care practice, refer to competency Step 1.50• Review any feedback or suggestions for improvement from patients• Question existing practice to challenge present performance/culture• Assist in change led by more experienced clinical staff • Assist with projects in your unit to improve services

LeadershipThe following competency statements are about developing leadership styles and skills throughout your professional development in critical care.


AchievedDate/Sign

STEP 2 Competencies - Tracker Sheets

The following table allows the tracking of Step 2 Competencies and should be completed by Mentors, Lead Assessors or Practice Educators (or equivalent) as the individual achieves each competency statement. This provides an easy and clear system to review and/or audit progress.

Competency Statement Date Achieved Mentor/Assessor SignatureRespiratory System 2.1 Anatomy & Physiology 2.2 Enhanced Respiratory Assessment, Monitoring & Observation 2.3 Non-Invasive and Invasive Ventilation2.4 Enhanced Tracheostomy Care2.5 Enhanced Chest Drain Management2.6 Associated Pharmacology Cardiovascular System 2.7 Enhanced Cardiovascular Assessment, Monitoring & Observation 2.8 Enhanced Fluid Management Renal System 2.9 Advanced Anatomy & Physiology 2.10 Enhanced Renal Assessment Monitoring & Observation2.11 Continuous Renal Replacement Therapy2.12 Associated Pharmacology Gastrointestinal System 2.13 Enhanced Gastrointestinal Assessment & Management 2.14 Associated Pharmacology Neurological System 2.15 Advanced Care and management of the Neurologically Compromised Patient End of Life Care 2.16 Witholding or Withdrawing of Treatment Inter & Intra Hospital transfer 2.17 Assisting in the preparation and transfer of the critically ill Rehabilitation 2.18 Contributing Factors to Rehabilitation Needs & Patient Diaries

Professionalism 2.19 Enhancing Professionalism Leadership 2.20 Improving Critical Care Services


Assessment & Development Plan Records




Photocopy

if

Required

Ongoing Assessment & Development Plan

Date | | | (Please add date to the Assessment Record Summary)

This meeting between Learner and Lead Assessor is to identify the progress made by the nurse in achieving competence in practice against those competencies identified in the initial and/or previous meetings. It is here further objectives will be set. Ongoing assessments should take place at least every 3 months. If the learner requires additional support a further action plan can be completed.

REVIEW OF COMPETENCIES ACHIEVED

ON TARGET: YES NO

IF NOT WHICH COMPETENCIES HAVE YET TO BE MET

REASONS FOR NOT ACHIEVING

SPECIFIC OBJECTIVES TO ACHIEVE COMPETENCE

KEY AREAS & ADDITIONAL COMPETENCIES TO BE ACHIEVED BEFORE NEXT MEETING

Learners Signature: ……………………………………………

Lead Assessors / Practice Educators Signature: ……………………………

NEXT AGREED MEETING DATE: | | |

Photocopy

if

Required

Additional Action Planning

Date | | |

This document is to be completed as required to set SMART objectives for the learner who requires additional support to achieve certain competencies (these will have been identified during the 3 monthly Ongoing Assessment & Development plan).

AREAS FOR FURTHER ACTION PLANNING



NEXT AGREED MEETING DATE: | | |





Photocopy

if

Required

Final Competency Assessment


This meeting is to identify that all the competencies within (please circle) Step 1/ 2/ 3 have been achieved and that the nurse is considered a safe competent practitioner

COMPETENCY STATEMENT:The nurse has been assessed against the competencies within this document and measured against the definition of competence below by critical care colleague, mentors and assessors and is considered a competent safe practitioner within the critical care environment.

“The combination of skills, knowledge and attitudes, values and technical abilities that underpin safe and effective critical care nursing care and interventions”.

As part of quality assurance the nurse is expected to maintain a portfolio of practice as part of NMC regulations to support ongoing competence and declare any training development needs to their line manger or appropriated other. Competency will be reviewed annually as part of staff personal development plans. Where necessary objectives will be set to further develop any emerging competency required to work safely within the critical care environment.

LEAD ASSESSORS COMMENTS

LEARNERS COMMENTS



Photocopy

if

Required

Annual Competency Review


This record is a statement between the nurse who has completed Step1, 2 & 3 competencies successfully and their Assessor/Practice Educator and/or Appraiser. It should be used and reviewed alongside local appraisal systems annually to ensure that the nurse continues to demonstrate themselves as a safe competent critical care practitioner.

OVERALL COMPETENCY MAINTAINED YES NO

IF NOT WHICH COMPETENCIES REQUIRE FURTHER DEVELOPMENT

SPECIFIC OBJECTIVES TO ACHIEVE COMPETENCE

FURTHER COMMENTS

Signature: ……………………………………………

Lead Assessors / Practice Educators Signature: …………………..................…………





ABG Arterial Blood Gas

AKI Acute Kidney Injury

ALI Acute Lung Injury

ANTT Aseptic Non Touch Technique

ARDS Acute Respiratory Distress Syndrome

BACCN British Association of critical Care Nurses

BLS Basic Life Support

BP Blood Pressure

BTS British Thoracic Society

CAM Confusion Assessment Method

CC3N Critical Care Networks National Nurse Lead Group

CCMDS Critical Care Minimum Data Set

CMS Capacity Management System

CO2 Carbon Dioxide

COPD Chronic Obstructive Pulmonary Disease

COSHH Control of Substances Hazardous to Health

CPAP Continuous Positive Airway Pressure

CPP Cerebral Perfusion Pressure

CSF Cerebrospinal Fluid

CT Computerised Tomography

CV Central Venous

CVP Central Venous Pressure

CVVH Continuous Veno Venous Haemofiltration

CVVHDF Continuous Veno Venous Haemodiafiltration

ECG Electrocardiograph

ET Endotracheal

EtCO2 End Tidal Carbon Dioxide

ETT Endotracheal Tube

EWS Early Warning Score

GCS Glasgow Coma Scale

GI Gastrointestinal

HEI Higher Educational Institute

HME Heat Moisture Exchange

HR Heart Rate

ICNARC Intensive Care National Audit & Research Centre

ICP Intracranial Pressure

ICS Intensive Care Society

ILS Intermediate Life Support

IPC Infection Prevention & Control

IRV Inverse Ration Ventilation

IV Intravenous

KSF Knowledge & Skills Framework

MAP Mean Arterial Pressure

MDT Multidisciplinary Team

MRSA Methicillin-resistant Staphylococcus Aureus

MUST Malnutrition Universal Screen Tool

NG Nasogastric

NHS National Health Service

NICE National Institute of Clinical Excellence

NIV Non Invasive Ventilation

NMC Nursing & Midwifery Council

NPSA National Patient Safety Agency

PPE Personal Protective Equipment

RCN Royal College of Nursing

RRT Renal Replacement Therapy

SAH Subarachnoid Haemorrhage

SLEDD Sustained Low-Efficiency Dialysis

SPO2 Saturated Oxygen

SR Sinus Rhythm

SVR Systemic Vascular Resistance

SVT Sinus Ventricular Tachycardia

TMP Trans Membrane Pressure

VAP Ventilator Associated Pneumonia

V/Q Ventilation Perfusion Ratio

VTE Venous Thromboembolism Risk Assessment

Abbreviations

Brain Trauma Foundation (2007) Guidelines for the management of traumatic brain injury. Journal of Neuro Trauma. 24 (1) pp S- 59 S - 64. p 17-23. p 47-74.

Borthwick, M, Bourne, R, Craig, M, Egan, A and Oxley, J (2006) Detection, prevention and treatment of delirium in critically ill patient. United kingdom Clinical Pharmacy association.

Department of Health (1996) Guidelines on admission to and discharge from intensive care and high dependency units. DoH, London

Department of Health (2005) Mental Capacity Act 2005 Code of Practice London: DH Available online at: http://www.legislation.gov.uk/ukpga/2005/9/contents

Department of Health (2008) End of Life Care Strategy; promoting high quality care for all adults at the end of life. London: DH.

Department of Health (2009) Reference guide to consent for examination or treatment (2nd edition) London: DH

Department of Health (2008).Clean, safe care: Reducing infections and saving lives. Gateway ref: 9278

Department of Health (2010) High Impact Intervention: Renal haemodialysis. DOH guideline.

EPUAP (2009) European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel

Intensive Care Society (2004) Guidelines for Adult Organ and Tissue Donation Prepared on behalf of the Intensive Care Society by the Society’s Working Group on Organ and Tissue Donation

Intensive Care Society (2009) Standards and recommendations for the provision of renal replacement therapy on the intensive care unit in the united kingdom. ICS guideline

Intensive Care Society (2011) Guidelines for the transport of critically ill adults. Standards and Guidelines

National Institute for Clinical Excellence (2007) Head Injury: Triage, Assessment and Early Management of Head Injury in Children, Infants and Adults. www.nice.org.uk/CG056

NCEPOD (2009) Adding Insult to injury: a review of the care of patients who dies in hospital with a primary diagnosis of acute kidney injury (acute renal failure. NICE publication

NHS Confederation (2012): The NHS handbook: The essential guide to the new NHS. Available at www.nhsconfed.org

Tortora G. J. and Derrickson B., H. (2011) Principles of Anatomy and Physiology, International Student Version (13th Edition). John Wiley & sons, inc. New York.

UK Code of Practice for the diagnosis of brain stem death; including guidelines for the identification and management of potential organs and tissue donors. Working Party established through the Royal College of Physicians on behalf of the Academy of Medical Royal Colleges (1998)

Bibliography





This framework has been developed in partnership with a wide range of stakeholders from practice and academia within the critical care community across England, Wales and Northern Ireland. Thanks are extended to all contributors specifically the following:

Chair Critical Care National Competency Working Group:

Melanie Kynaston Cheshire & Mersey Critical Care Network, Mid Cheshire NHS foundation Trust

Members of the Critical Care National Competency Working Group:

Alison East on behalf of Herts and Beds Critical Care Network

Alison Eddleston University of Central Lancashire

Amelda Blignaut Independent Health Sector

Andrea Berry Lead Nurse Greater Manchester Critical Care Network, Chair CC3N

Andrea Baldwin Director & Lead Nurse Lancaster & South Cumbria Critical Care Network

Angela Himsworth Lead Nurse The Midlands Critical Care Networks

Ann Price BACCN Representative & Senior Lecturer Canterbury Christ Church University

Anne Miles Critical Care Unit Manager Wye Valley NHS Trust, Herefordshire

Caroline Wood on behalf of Mid Trent Critical Care Network, United Lincolnshire Hospital NHS Trust

Chris Hill Royal Free Hospital King’s College London

Debora Cheetham Practitioner/Lecturer North of England Critical Care Network, City Hospitals Sunderland NHS Trust

Diane Eady on behalf of Mid Trent Critical Care Network, United Lincolnshire Hospitals NHS Trust

Gemma Ellis Wales

Helen Jones The Walton Neuroscience Centre

Joanna Gallimore Professional Development Nurse, University Hospitals Birmingham NHS Foundation Trust

Julie Platten Nurse Educator North of England Critical Care Network, Queen Elizabeth Gateshead

Karen Donnelly Nurse Educator North of England Critical Care Network, James Cook University Hospital

Kerry Pennington-Haigh Critical Care Sister St Helens & Knowsley NHS Trust

Linda Bower Kent & Medway Critical Care Network

Lesley Durham NOrF Representative, Director & Lead Nurse North of England Critical Care Network

Lisa Billington Senior Critical Care Sister, Mid Cheshire NHS Foundation Trust

Lorna Johnson NOrF Representative & West Yorkshire Critical Care Network

Lorraine Burgess ICS Representative & Senior Lecturer John Moores University

Lorraine Marsons Birmingham City University

Maria Kisiel Birmingham City University

Mary Jordan Workforce Development Lead Cheshire & Mersey Critical Care Network

Mary McQuillan Clinical Nurse Educator Tunbridge Wells Hospital

Neville Rumsby Practice Educator Liverpool Heart & Chest Hospital

Christie Peggy South Devon Healthcare NHS Foundation Trust

Sarah Clarke Director & Lead Nurse Cheshire & Mersey Critical Care Network

Sheila Kinoulty Northern Ireland

Stella Evison Education & Development Practitioner Central Manchester Foundation Trust

Acknowledgements

Critical Care Networks-National Nurse Leads (CC3N) 2013

All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and patents Act 1988.

Neither the Critical Care Networks-National Nurse Leads (CC3N) nor the authors accept any responsibility for any loss or damage arising from actions or decisions based on the information contained in this publication. Ultimate responsibility for the treatment of patients and interpretation of the published materials lies with the Registered Nurse.

This document has been produced with support from these organisations and is available through their websites.

www.baccn.org.uk

www.icusteps.org.uk www.norf.org.uk

www.ics.ac.uk

www.rcn.org.uk

www.independenthealthcare.org.uk

www.cc3n.org.uk

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