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A CCrISP APPROACH TO THE DETERIORATING PATIENT
Mary Langcake FRACSDirector of TraumaSt George Hospital
CCrISP
• Care of the Critically Ill Surgical Patient• Developed in UK after Hillsborough Soccer
disaster• RACS administers under MOU
WHY
• We perform complex procedures on older sicker patients
• JMO’s need to deal with sick and often unfamiliar patients
WHOFACULTY• Multidisciplinary – surgeons, intensivists,
emergency physicians, anaesthetists• Must undertake CCrISP Instructors Course or
similar – Educator and fellow Instructors teach • Performance assessed by candidates and feedback
given to facilitate ongoing development as an educator with support from Committee as required
• Nurse co-ordinator – ED or ICU trained• Nurse observers – assist with scenarios,
proselytise about CCrISP
WHO
CANDIDATES• Pre 2008 - surgical trainees – 90% • From 2008 – surgical trainees - 20%
– Australia, New Zealand, Fiji, PNG
HOW?• Lectures• Demonstrations• Small group tutorials• MCQs• Role-playing with moulaged patients• All candidates assigned a mentor - guidance/feedback• Summative assessment
Objectives
Recognise the patient who needs simultaneous assessment and resuscitation
Employ a system of assessment – to prioritise and to prevent omissions
Be able to institute both immediate life‐saving measures and definitive management for the critically ill patient
Formulate daily management plans for surgical patients
Patients to be consideredRoutine pre‐operative patients
Risk factors – identify and control or improve
Emergency AdmissionsSevere acute problemsCo‐morbidity
Ward/HDU patientsSudden deteriorationFailing to progress/‘not right’At risk from surgery or disease processes
Immediate ManagementA B C D E
Full Patient AssessmentChart Review
History and Systematic ExamAvailable results
Decide and Plan
Stable Patient Unstable/Unsure
DailyManagement PlanDiagnosis RequiredSpecific Investigations
Definitive TreatmentMedicalSurgical
Radiological
Immediate management
Diagnose, Prioritise and TREATimmediate threats to life
AirwayBreathingCirculationDisability/Dysfunction of CNSExposure
End of Immediate ManagementImmediate steps undertaken to
preserve life
Ongoing monitoring established
Stable/improving vital signs?
Called for help
Moved to theatre or HDU/ICU
If at any time the patient’s condition deteriorates
You must go back to the start and
Re-assess ABCDE
Immediate ManagementA B C D E
Full Patient AssessmentChart Review
History and Systematic ExamAvailable results
Decide and Plan
Stable Patient Unstable/Unsure
Daily Management PlanDiagnosis RequiredSpecific Investigations
Definitive TreatmentMedicalSurgical
Radiological
CommunicationEnsure the patient is well‐informedCase note entry
Inform othersRecord plan against which you can check progressHelps you organise your thoughtsPre‐weekend summaries are very helpful
Nursing staffParameters, plan
Senior and other colleaguesRelatives
SUMMARYUnderstand need for simultaneous assessment and resuscitation
System of assessment reduces serious omissions
Institute a plan for definitive treatment
Reach a diagnosis to account for deterioration
Safe and selective investigations
Frequent clinical re‐assessment
Inform and involve your seniors appropriately
Consider level of care necessary at each stage
SUMMARY