About Critical Care

Adult Critical Care services includes both High Dependency (sometimes called Level 2 care) and Intensive care (Level 3 care).  Critical Care is usually delivered in dedicated units within a hospital. The names can be confusing as they are often referred to as Intensive care (ICU), High Dependency (HDU) or Critical Care units but these are interchangeable names for the area of the hospital where the sickest patients are cared for.

Patients who require critical care are usually very ill and require close attention and monitoring. The very sickest of these will require advanced respiratory support or have two or more failing organ systems e.g. cardiac, respiratory, neurological that need supporting simultaneously. Most critical care units are equipped to deal with patients suffering from a wide range of different clinical conditions but some hospitals do have specialist units to deal with particular specialisms e.g. neurology, liver, oncology.

What to expect in Critical Care

It can be quite frightening coming to visit a loved one in Critical Care and it is natural to feel upset. The staff on the unit will be able to help you in understanding what all the different equipment around the bed is for. Most of the patients in Critical Care will be connected to a monitor and machines and have lines and drips of some sort. If an alarm does sound this does not always necessarily mean there is a problem and the nursing staff will deal with this and let you know what it is for, it might be something that needs doing e.g. changing one of the drug infusions in a syringe pump.  Usually, there is nothing to worry about and the staff will watch the patient very closely at all times.

​​For the first few days after admission to Critical Care many patients are kept asleep, ‘sedated’ with a mixture of sleep inducing and pain killing medications. This makes the life saving treatments, that are necessary in Critical Care, much more bearable for the patient, as well as allowing them to rest. Most patients do not usually remember this time although sedated patients may be able hear you even if they do not respond. The staff will talk to unconscious patients telling them what’s happening and it’s important that you do the same.

You might be asked to leave the bed side on occasions, this is usually because there are necessary medical  & nursing procedures that need to be done and these could upset you.

As patients start to get better, the sedatives that they are on to keep them tolerant of all the equipment is  reduced to allow patients to become a little bit more aware of their surroundings. This can be a frightening time for patients as they will not know what has happened to them and the after effects of the sedatives can take a while to come out of the patient’s system. Support from families and friends can be of great help at this time.

All Critical Care patients are different and some will get better much quicker than others who may need the support from the ventilator ‘breathing machine’ for a little longer. This slower recovery is often called ‘weaning’ and although the patient is getting better it can often be a slow process.  Support from families at this time can be hugely beneficial but it is important to remember that the patient may tire easily and become frustrated at their lack of progress and inability to communicate their concerns or feelings.

Visiting

Visiting hours are usually very flexible, but there may be times when visiting isn’t advised but the staff will normally let you know when this is. The number of people allowed around the person’s bed at any one time may also be limited to avoid overwhelming the patient. Sick patients need rest to aid their recovery so it is generally advised that visitors are kept to close family and friends.

To reduce the risk of spreading infection, you will  be asked to clean your hands when entering and leaving the unit and you may not be able to bring in certain things such as flowers. Please avoid visiting if you are ill yourself.

Staff will be on hand to help you in the first few days as seeing your family member in critical care for the first time can be upsetting. They may be drowsy and seem confused and they may also appear slightly swollen or have injuries such as bruises or wounds. They will usually have equipment attached to them, this is to help the staff monitor the patient’s vital signs and give medication to help them get better. There will be unfamiliar sounds and other noises so ask staff to explain what these are if you would like to know more

It might seems strange, particularly if your family member is sedated but it is important to talk to them and hold their hand if you want to. The reassurance of a familiar voice is usually comforting to patients.

Delirium

It is common for many patients who are critically ill to experience delirium. This is the name for an acute confusional state that many patients liken to being in a nightmare. This is a frightening time for patients as they are seeing, hearing and feeling things that don’t exist outside of their own minds. Families can often be very worried seeing their loved ones so distressed. A patient who has delirium may still recognise friends and family but they will not believe it when they are told that they are imagining these
frightening situations. Patients with delirium can find it very difficult to understand or remember
information – so even if they appear to understand what is happening, or may be joining in a conversation, they may not remember what has just been said to them.

Patients with delirium often cannot talk about what they think is happening to them. If they have a tracheostomy (where a tube has been put through a hole in the patient’s neck) they cannot talk normally and so it is difficult for them to tell the staff and their family what they think is happening.

Delirium can show itself in two very different ways. The first is called hyperactive delirium and it will be very obvious that the patient is not themselves. They will be agitated and upset which is very distressing to see. The nursing staff will be trying to ensure the patient is safe and not pulling any lines out.

Hypo-active delirium is not as easy to spot as there is no sign that the patient is experiencing any frightening thoughts. Patients with these two types of delirium act very differently, they either don’t sleep at all or they sleep all the time; they are  restless or they remain absolutely still.

Family members can often help by holding the patient’s hand and reassuring them that they are in hospital and they are safe. You might need to tell them this more than once.  Let the nursing staff know whether your family member wears glasses or a hearing aid as this may help them to understand their surroundings better if they can see and hear staff talking to them.

Patient diaries can also be helpful for patients as it will provide a memory of what has been happening to them whilst they have been critically ill. Please ask a nurse if the unit encourages diaries for patients.

Patient diaries

Many patients who have been critically ill have found a patient diary useful for filling in ‘the gaps’ of their illness. These are commenced by staff working on the critical care unit, typically for patients who require advanced respiratory support and have been sedated already for 2 or 3 days. Some units only allow family members and visitors to write in them whilst other units invite members of the multidisciplinary team as well as families & visitors to write in them.

The diary provides a record of a patients’ stay in critical care which is written for the patient in terms that they can understand. It shows how the patient’s condition has changed during their illness, who has come to visit them and events that have been happening in the outside world whilst they have been ill.

Evidence shows that having a diary has meant that patients can make sense of some of the strange dreams that they may have experienced. It is much easier for them to see which of their memories were real and which were false

Critical Care Transfers

On rare occasions it may be necessary to transfer a patient from one critical care unit to another.  These can be unsettling for patients & families but there are specific reasons why these have to be done. These include:

• Moving to another hospital where other specialist care can be provided e.g. ECMO (extra corporeal membrane oxygenation)
• Returning to a hospital nearer to the patients home

The patient will normally be transferred with both medical and nursing support and staff on the unit will explain where your relative is going to and why.  When a patient is moved by ambulance to another hospital relatives will need to make their own travel arrangements to the new hospital.

Leaving Critical Care

When patients have recovered from their critical illness they will usually be discharged to a hospital ward to continue their recovery although occasionally they may be discharged directly home. Transfer back to the ward is a good thing as it means the patient no longer needs critical care. The transition to the general ward environment can be challenging for both the patient and family, particularly if the critical stay has been prolonged. Many patients and their relatives feel anxious at this time as they have become familiar with the environment and routine on the critical care unit and the staff are familiar. The Critical Care team will try and prepare patients and families for ‘stepping down’ and it is important to view the more normal atmosphere of the general ward as a significant step towards your relative’s recovery and rehabilitation.

The medical and nursing teams on the critical care unit will prepare a detailed handover for the staff on the ward so the ward staff will know everything that has happened to your relative.  It is not always possible but hospitals will try and transfer patients in the day time when there are more staff on the wards to help with settling patients in.

Rehabilitation

Many patients will leave critical care and resume their normal activities however the process of recovery can vary from patient to patient and some patients will find they need extra support to help them with their recovery from being critically ill. This may mean on going assessment by a team of specialists or attendance at a specialised programme of physical therapy to help maximise their recovery. The earlier this rehabilitation starts the better it is for the patient and the aim of the physiotherapist treatment is for this rehabilitation to commence whilst in the critical care unit and then to follow through to the ward and discharge home.

Patient data

All the critical care units in Greater Manchester submit data on patients who are admitted to them, to the Intensive Care National Audit & Research Centre (ICNARC). This is an organisation with a 25 year history of auditing adult critical care patient outcomes to identify the most effective ways of organising care and treating patients.

This national comparative audit, through the case mix programme (CMP), compares the outcomes of all patients admitted to critical care units in England, Wales and Northern Ireland. It ensures the submission of high quality information in the first instance and provides regular comparative reports to units to allow for local performance review with the ultimate aim of improving the quality of adult critical care.

Reports are regularly published on the ICNARC website, please click on the ICNARC link to access their website