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13 December 2017

Inside CCU

Welcome to Inside CCU, an in-depth look at our Critical Care Unit.

The 12-bed Critical Care Unit, which includes one paediatric room, is one of the most intense departments in the hospital, with staff caring for critically ill and injured patients who require round-the-clock, often one-to-one care, as well as elective patients recovering from a surgical procedure.

Patients may need specialist treatment because one or more of their organs - for example their lungs or kidneys - are not functioning properly, and the Critical Care Unit is the combined areas of High Dependency Care and Intensive Care.

High Dependency Care patients require more care, monitoring and treatment that can be given on a general ward. One nurse cares to two patients in this instance.

Intensive Care patients need constant medical and nursing support to keep functioning, they may have more than one organ that isn’t working properly, and one nurse cares for one patient.

There are times when the unit is quieter than normal, with patients often on there for recuperation after an operation, before being transferred to a general ward.

However, given the unpredictable nature of life, staff can never second guess what is going to happen on a shift and, from a period of relative calm, the unit can become extremely busy with patients, for example, requiring intensive care following a traffic accident or a deterioration in their condition, the latter type which may well have been identified and reported to CCU by the Critical Care Outreach team.

In this feature we aim to take you around the unit, speaking to staff at all different levels, to try and capture what life is like on the unit at its busiest but, also, during more reflective periods.

Roz Yale, Lead nurse

Roz YaleRoz Yale is the lead nurse on the Critical Care Unit at Ipswich Hospital and spoke to us during a particularly challenging time.
The ward was full to capacity, in terms of patients, and operations, regrettably, were having to be cancelled.

Q. Hi Roz, could you explain what your role involves?
A. As lead nurse for Critical Care Services I lead several teams which include critical care, critical care outreach, the resuscitation team and the clinical support technician team.
In critical care my role is focused on quality and governance, on patient safety and also the nursing workforce, capacity and flow, managing the patients and staff on a day-to-day basis. It’s also about managing and making sure we are working within our budgets. For the outreach team, it’s about leading service development, as it is for the resuscitation team.

Q. How challenging is your role?
A. It is challenging at times, it’s very rewarding but it is challenging. For example, today is particularly challenging in Critical Care because we have got a high level of acuity and we are at maximum capacity for the numbers of patients we can take. It’s a challenge getting the right members of staff in to care for our patients.
I work very closely with consultants in critical care, the sister in charge and the operations team as well. I don’t make clinical decisions about the patients, that’s for the consultants to do, but I do support the workforce and try to help with hands-on care when I can.
The challenge over the last week has been the fact that we have been at maximum capacity in terms of the number of patients we can accommodate. We have had to cancel elective patients (those scheduled to come in for surgery) and that’s always very disappointing when we have to do that.
It’s challenging not having enough staff who are sufficiently skilled to care for the patients we have got. It’s not as simple as bringing in agency staff, the most important thing is having the right-skilled staff.

Q. What is the most rewarding part of your job?
A. The most rewarding part is obviously seeing the patients get better, improve and go to the wards. I also try and spend some time with families of the patients, and they are often very distressed perhaps to start with. To see them gain confidence in our staff is very rewarding.
Another rewarding part is being able to bring in new initiatives and seeing the service and practice develop, which is very important for me.
One of our most recent initiatives is the Critical Care Outreach follow-up clinic. It’s something that we have been wanting and needing for many years.
New NICE (National Institute for Health and Care Excellence) standards for the rehabilitation of patients in critical care have been released which indicate, and our evidence base suggests, that follow-up appointment for patients are really important in their journey and recovery. I am very pleased that we have been able to achieve that this year.
There are other initiatives in the pipeline too that we want to develop further and it will be very satisfying if they come off.

Q. Some people have the perception that working on CCU is less demanding than being on a regular ward. What is your view on that?
A. Critical care is a mystery for some staff groups and that’s because we are behind closed doors and people don’t often come to critical care.
Some students will have a placement here, but some students and registered nurses will never have the opportunity to come into critical care and don’t really understand what the service is that we offer, what patient care looks like in critical care or, from a staffing perspective, what it’s like to work in critical care.
There is a misconception that one nurse looks after one patient, therefore we might not be that busy.
However, because of the patients we have up here, because of the nature of their illness, they are closely monitored when they are with us. Some of our long-stay patients, when they then go to a ward, lose confidence during that transition and therefore, some of the staff discover those patients are quite needy and that creates a misconception.

Q. How much of your time is taken up by paperwork and issues around your budget?
A. Too much. I would like to do more patient care, I would like to be more hands-on and sometimes it is frustrating when other things get in the way of that.
I am trying to be more realistic about how I deliver hands-on care. Previously I have been putting six hours a week aside to be out on the shop floor, but that is probably more unrealistic due to meetings and other commitments I have. What I try and do is go in when can, when I have a space, and I can support the staff and team, then come away again.
To be a good leader and be credible, it’s really important to be out there and visible. This is important to the staff that I lead, and it’s important to myself.

Q. Do you ever get to reflect/evaluate or plan ahead?
For me there is not always enough head space and perhaps not enough time for reflection. On some days, one has to be a bit more reactive. At the moment my focus is around the patients. On other days I am a bit more on plan.
We are being warned that this winter could be a particularly harsh one in terms of stretching hospital resources. What are your thoughts?
From the Trust’s perspective, there is always a winter planning programme in place. From our perspective I have tried to improve our resilience, making sure that from a staffing perspective, I have filled as many maternity leave vacancies as I can, because that’s really important.
I have tried to improve our resilience by making sure we have sufficiently trained staff. We recently had a number of staff start on the unit. They are supernumerary at the moment, but will go into the numbers on critical care later in the month, and will be in place by December and over the winter period. Not carrying many substantive vacancies make us more resilient.

Q. How do you deal with death?
I don’t think you ever get over anyone dying.
Although you might remember your first patient that passes away, there are other patients that can have a significant impact on you, on an emotional level, and it does not matter how many years’ experience you have, that is always the case.
Sometimes patients you see in here are of a similar age to yourself and it does touch you for sure. It reminds you how fragile life can be at times.

Ward clerk, Alison Mulhearn

Alison MulhearnIf you have to visit CCU, and hopefully you won’t, you will be assured of a warm welcome from ward clerk, Alison, who spoke about her role a few weeks ago.

Alison has worked on CCU as a ward clerk for a relatively short space of time, having operated in the same role on the hospital’s Capel Ward for seven years, having originally arrived from Norwich and Norfolk Hospital.

“It can be stressful and you tend to pick up the vibes from staff working here as to how the department is,” said Alison.

“We can be full to capacity in terms of patients and I have a big list of (staff) telephone numbers to contact (to change their shift pattern or to do extra shifts) when that is the case.

“That does happen quite a lot and at the moment there are a lot (10 per cent) of nurses on maternity leave, while others will be on annual leave. There is also staff sickness to contend with.

“We all work together on here though and help each other out.

“Yesterday, being as busy as we were, I helped a healthcare assistant make a bed – I am not averse to doing that, although I draw the line at having to empty bedpans!

As well as keeping the department running smoothly, Alison also has to have an empathetic side.

“It’s about being a barrier for relatives,” explains, Alison, who works on a department where patients are in need of critical, often minute-by-minute care.

“I answer the video phone to them, allowing to come onto the department, then show them where the family room is, while I make sure the person they are coming to see is happy to have visitors.

“I make the relatives aware of the environment in which they are in – it’s the little things like making sure they know there is a pantry where they can go and make a hot drink or pour a cup of juice or water.

“My approach is, if one of my relatives was lying there in a bed, I would like them to be treated in the same way I treat our patients and the people that come to visit them.”

Critical Care patients’ diaries

Trust colleague with one of our patient diariesAs part of their rehabilitation, patients who receive treatment on Critical Care are offered a diary of their time there once they have left the unit.

The diaries are designed to fill in the gaps that patients may have as a result of being sedated for a period of time whilst on the unit and are filled in by the staff caring for them.

The diaries were originally introduced in Scandinavia back in the 1980s and have proved a useful addition to a person’s recovery since being brought into the UK, helping to prevent against Post-Traumatic Stress Disorder (PTSD) and Post Intensive Care Syndrome (PICS).

“Every emergency level 2 patient and all level three patients will have a diary and the nursing staff will write in them every day,” explains registered nurse, Harriet Bass.

“It does not matter how brief the diary entry is. They may include any significant events that may have happened or little things like what the weather was like that day.

“The patients are offered a chance to come and collect them and the diaries are good for filling the gaps.

“Patients that have been sedated for a long period of time, or have been delirious, or find it (their time on the unit) very difficult to remember, they can go back in and fill the blanks and that can stop them from developing such things as false memories and nightmares. It can help them with PTSD and Post Intensive Care Syndrome too.”

Studies have shown that the diaries give patients a link to the nurses, allowing them to understand the care and compassion they received from staff on the unit, which can give them a boost.

“If we miss any days we will write a diary entry from the notes and then bind it all together at the end with a summary explaining why they came to CCU, how long they stayed there and where they were discharged to. There is also a glossary at the back of the diary and information about support networks,” added Harriet.

“It can be really emotional for the patients going through their diaries but it does help them.”

Sadie plays an integral role

Sadie BanksHealthcare assistant Sadie Banks plays a crucial role in the Critical Care Unit team, allowing seriously ill patients to receive the kind of high dependency and intensive care they require.

One nurse will care for a maximum two high dependency patients at a time, while an intensive care nurse will look after just the one.

Physiotherapists, dietitians, radiographers and pharmacists are also regular visitors to a ward that has just 12 beds, plus one paediatric room.

Given those figures, there is a perception amongst some that working on CCU is easier than being on a normal ward.

However, the illnesses and injuries suffered by patients on the unit are so severe and, often, life-threatening that such intimate care and attention is crucial.

“The pace is different but it’s busy in a different way,” explains Sadie, who helps nurses maintain the best care possible by making sure they have everything they need for their patients.

“It’s not chaos, it’s nearly always calm and collected and if you do see people panicking up here you know it’s an emergency.

“Generally we are a cool-headed bunch but I think people believe we are laid back because it’s not as busy or chaotic as elsewhere.

“Yes, there are times when we are asked to go and work elsewhere in the Trust (because it is quiet on CCU), but then there have been shifts where we have really struggled because we are such a specialist area and we have struggled to find the staff with the right skills."

So what does Sadie’s role entail?

“We set up a lot of the equipment, we set up ventilators, the CPAP (Continuous positive airway pressure circuits), our role is to support the nurses because they remain by the patient bed spaces often and basically we make sure they have got everything they need for their patient,” she explains.

“We ensure a patient’s basic needs are met, such as brushing their hair for instance. Sometimes patients spend a bit longer on here than on the wards and it’s quite nice to get to know them and deliver really good care.

“We are in charge of making sure everywhere is stocked up, as well as helping out the nurses.

“We help roll patients for pressure area care. Our ventilated patients need three to four people to roll.”

She adds: “Sometimes, when you are trying to do something you’re meant to do in a day, it’s quite tricky to accomplish that without feeling like you are being pulled in all different directions."

From an emotional point-of-view, the job can be quite challenging.

“Especially if you have got to know someone and they have not done quite so well (their health may have deteriorated), or if things change with them from day to day, so it can be tricky sometimes," explains Sadie.

“Often it’s not what is happening to patients that upsets me, it is how their families react and you think to yourself how awful it must be to see a family member in that situation.

“That is quite often what gets me and it makes you appreciate your family and friends.

“We are all human and we have all got emotions. You can’t be expected to be a robot all the time and just come in and go home and not be affected by things.

“Generally, if something quite traumatic happens we will have debriefs and will all club together and support each other as much as we can."

The flip side of that is seeing a patient improve to the point where they are able to go home.

“Seeing the patients we care for improve is wonderful and we often get people coming back to visit the ward and they are always so thankful, as are their families.

“Getting that interaction at such a level, seeing people get better, seeing them progress day by day is lovely.”

Rehab is key to recovery

CCU colleagues discussing rehabilitationIt’s a Wednesday afternoon and three members of staff are huddled together, deep in conversation.

Lead nurse Roz Yale, physio Vicky Jeffrey and critical care outreach nurse Nikki Benmore are about to go on their weekly rehabilitation round, assessing the current status of the patients and discussing rehabilitation goals for the forthcoming days.

CCU cares for patients with a whole host of serious, complex and often life-threatening illnesses and injuries and, as a result, means they can be confined to a bed for days, often weeks.

According to NHS Improvement 65% of patients admitted to hospital are 65 or older and a person over 80 who spends 10 days in a hospital bed will lose 10% of muscle mass. This could be the difference between going home and going to a home.

“The rehabilitation of patients is important in CCU as many get very weak within the first 12-24 hours of their arrival,” explains Roz.

“Patients lose muscle mass and it is very difficult to get back to where they were. They may also suffer from a lack of sleep, side-effects of drugs that are commonly used in Critical Care, and other symptoms such as delirium, nightmares and hallucinations. For some patients they go on to develop Post-Traumatic Stress Disorder (PTSD) as a result of their episode of critical illness.”

National Institute for Health and Care Excellence (NICE) guidelines on rehabilitation for patients in critical care were recently updated and the hospital is working towards improving compliance with these.

“We are working towards becoming fully compliant with the NICE standards for Rehabilitation and part of this includes reviewing patients on a weekly rehab ward round who have been on the unit for more than four days and are requiring input from more than one professional group,” adds Vicky.

“That means getting together with professionals such as dietitians and speech and language to ensure we have input by the multi-disciplinary team. We lack psychology services which are vital to supporting the patients through their recovery, but we are active in maintaining patient diaries which are really helpful in filling in the any gaps in time or memory that the patient may have experienced.”    

She continues added: “There has been a massive drive towards early rehabilitation as this is essential to prevent the many physical and psychological impairments that are associated with an admission to critical care including reduced muscle strength, respiratory problems, delirium, anxiety and depression.

“Rehabilitation starts as soon as the patient is awake enough to participate. We give an exercise programme to those who are not medically stable enough to get out of bed and aim to get people in to a chair at the earliest opportunity, even while they are still ventilated. ”

The presence of an occupational therapist will hopefully become more commonplace in future too.

“We also want to explore the role of the Occupational Therapist on the unit and how they can impact on the patient’s recovery,” adds Vicky.

“There is growing interest across the country in the role of the OT in CCU and in the future this may include assessing cognitive function, helping to prevent patients from developing some of the psychological problems associated with being on CCU such as anxiety, hallucinations and delirium and exploring patients ability to join in with PADLs (personal activities of daily living).”

Roz added: “Being on CCU does impact a patient negatively. They may not be able to sleep, they will lose strength and find it difficult to eat. Without the ability to do these things the fittest amongst us would struggle.

“Because of that a patient can become more depressed and doesn’t want to eat that can be a sign of PTSD so that’s why it’s so important to carry out an early rehabilitation assessment.”

The end goal is to ensure the patient is fit enough to be able to move to a ward to continue their rehabilitation where they may find it difficult to adapt, given they will no longer require round-the-clock, one-to-one care.

“Once they are deemed fit enough to go onto a ward we explained who we are and bridge that gap between CCU and the ward they are going on,” explains Nikki.

“The longer the period of time a patient is on a ward after leaving CCU, the more time the Outreach team will spend with that patient.”

Charge nurse – Ed Barnes

Ed BarnesThe only predictable aspect of charge nurse Ed Barnes’ role is its unpredictability.

With 17 years’ experience in the role, Ed boasts vast experience working on CCU but, even now, can never second guess from one day to the next.

"You have to be very clever at times, you have to juggle a lot of balls and the job is very unpredictable," said Ed, who spent a brief period of his career working as a nurse on a cruise ship headed for such far flung destinations as North Africa and the Caribbean.

"Literally the whole activity workload can change in minutes. You may have five patients on the unit and then, within an hour, you have got nine – that’s how it goes.

"It’s a bit like A&E, it’s almost all or nothing at times but generally its very busy most of the time."

Ed has many responsibilities as charge nurse and, on a day-to-day basis, manages the unit and its flow, ensures patient safety and manages staffing levels.

"The demand for beds can be higher than the number we have," he explained.

"I have to work in conjunction with the consultants and we go through the process of assessing the patients and their needs to see whether they require a bed and, if they don’t, try and free up capacity for those that do."

Ed is speaking in the middle of a shift where the unit is at full capacity.

“We are busy today and we haven’t been able to accommodate all the patients that we need to get in, so difficult decisions have to be made in terms of elective (pre-booked operation patients) and whether we have enough capacity for emergency cases.

"We do get our elective cases in usually, but the nature of our environment unpredictable and our workload is determined by the demand on the beds."

A harsh winter has been predicted meaning Ed and his team may well be stretched to their limit in terms of bed capacity.

"We are generally busier in winter to be honest and certainly, our activity has picked up in the last month or so. Christmas can be very busy but it’s difficult to predict,” he explained.

"Our elective activity probably reduces but the emergency activity, I suspect, increases having worked over many Christmas and New Year periods.

"Generally we try and manage within the department, we have to because we don’t have a consistent level of workflow – it fluctuates – it’s not like working in an elective unit where we have a predicted activity level."

Not only is the workflow unpredictable from day-to-day, so is the nature of the symptoms suffered by patients that use the unit.

"Most of what we do is quite shocking and that’s because we work in a  unique environment,” he continued.

"It’s rare I get shocked but we do have some very tragic cases, we deal with a huge age spectrum, and there is a lot of emotion involved.

"I am able to switch off most of the time but there are challenges within my role that make it difficult on occasions.

 "From a management perspective you need to know your staff, their skillset and use the resources in the best way possible and this is demanding."

Have you signed up to be an organ donor?

Death is never an easy subject to broach, but out of incredible sadness and heartache can come some happy endings.

On average, three people a day will die waiting for a potentially life-saving transplant but there is always hope while ever people are prepared to donate their organs.

There are living donors who - by offering a kidney, lobe of a lung, portion of the liver, pancreas, or intestine - provide their loved one or friend an alternative to waiting on the national transplant waiting list for an organ from a deceased donor.

Those that have deceased will have expressed their wish to be placed on that list prior to their death and it’s the job of specialist nurse, Claire Burbridge, to co-ordinate a transplant going forwards.

“Organ donation forms part of end-of-life care and hopefully fulfills some wishes the donor may have made during their lifetime if they put themselves on the organ donation register or had the conversation with their loved ones,” said Claire, who audits all the deaths in the emergency department and CCU, ensuring that everyone that should have been referred has.

“We know that on average three people will die every day while waiting for an organ transplant so the more people that have the organ donation conversation with their loved ones, the more likely their family members will then know what that person would have wanted and it then becomes a much easier decision for them when we broach the subject.

“It can bring comfort to the family knowing a part of their loved one is living on elsewhere and knowing, that in some circumstances, some good has come out of a real tragic situation.

“But it can be tough to talk about too. The first part of the conversation will be to clarify what the family understands and whether or not they are at that point where they are ready to think about the next steps because that is the most important thing.

“If they are not ready to accept that their loved one is going to die, then it’s too soon for us to breach the subject of donation.”

Claire works in a team of 20, covering 12 regions including Essex, Cambridgeshire, Bedfordshire, Hertfordshire and, of course, Suffolk.

There is a clear framework in place to make the role work from a practical point-of-view, but it is also vital that staff have the appropriate people skills and empathetic side too.

“We deal with everything from the first referral about a potential organ donor right through to the theatre process and organs leaving the theatre,” she added.

“We are dealing with families who are receiving the news that their family member isn’t going to survive their illness or injury, so we work with them to get them to accept that.

“Then, at an appropriate time, we will broach the subject of organ donation, if the deceased patient ever made a wish known to be an organ donor. We then complete the whole process which can take at least 12 hours.”

Up to and including March 31 this year there were 6,389 people on a waiting list for transplants, including 175 children, while in the last financial year more 3,500 transplants from deceased donors were made, including 2,159 kidney transplants.

“It depends on the age of the donor and their past history in terms of what can be donated,” said Claire.

“We don’t deal with the recipients ourselves but we will write to the families if they want us to, about a month later, if they want to find out more about the recipient of one of their relative’s organs.”

Claire spends her time between Ipswich, West Suffolk and Colchester hospitals and constantly liaises with staff and families throughout. She also has to do on-call shifts.

“I really love my job and they are a really supportive team (on CCU) at Ipswich,” said Claire.

“But we are here for the staff too because some of the families they deal with can really struggle, so it can be emotionally draining for them too.”

'I'd be lying if I said I could turn off every time I left work'

There is a misconception amongst healthcare professionals that working on CCU is far less demanding than operating on a normal ward. As per the Intensive Care standards, one nurse cares for a maximum of two high dependency patients or one intensive care patient at any time, compared to eight to ten patients typically on a hospital ward. The role of a CCU nurse can be more stressful than most, given the critical and complex nature of a patient’s illness or injury.

Felicity Chapman is the education sister on CCU and she regularly witnesses how working on CCU, in such an intense environment, can affect a member of staff. “We have been very busy over the last couple of months but that said, over the last year there has not been any periods of less activity.”

“Depending on how sick the patient is there will be one nurse to one patient or a maximum of two patients for one nurse. If you are working on a one-to-one basis, then those patients often cannot maintain their own airway so if they are on a ventilator and anything becomes loose or disconnected, the patient won’t be able to fix it themselves. There are some shifts which are less challenging, but the care doesn’t change.”

Felicity’s colleague, Duncan Burbery, who is a charge nurse on the unit, agrees: “One-to-one care means that the patient actually requires one person there all the time.

“There is always something going on and you can actually go through a shift from the beginning to the end and never actually stop. It can be physically and mentally draining, sometimes far more mentally because you have got to concentrate for 12 hours constantly and you can come away feeling absolutely exhausted. The demands of looking after that one critically ill patient are immeasurable really, it can be very consuming and you are often supporting the patient’s family and relatives as well as part of that care.” And they appreciate it, even if things get fraught at times.

“It’s comforting for the family to know they have the same nurse but there are times when the patient can be challenging and act out of character and in those instances, we will make sure the same nurse does not go back to that particular patient.”

Given the serious nature of the department and the types of illnesses and injuries that occur, there can be a lot of anguish experienced by both families and staff.

Duncan said: “I don’t think you ever get used to it (death), you learn to deal with it better at the time and I think you learn how to handle situations with that experience.

“It doesn’t get any easier, you become more capable as you learn and get more experienced but, because every situation is different, certain things may touch you personally, if what a patient is going through reminds you of what a family member went through for instance.

“You have to have that level of empathy as sometimes you will see a patient at the very worst point in their life. It can be hard sometimes but every situation is different and the challenges are different.”

He added: “One of the hardest things is when we have children as patients, especially young children, because we are not as familiar with them and don’t look after them every day.

“Children and babies can change so rapidly and we try and stabilise them in order to transfer them out to a paediatric intensive care unit and that can be quite a challenging experience.

“On the other side, you can get a good feeling knowing that you have helped that patient, and seeing that small child going off is quite a fulfilling part of your role.

Felicity added: “As a critical care nurse you have to be, to an extent, calm and composed on the surface and you deal with what you have been presented with, but I would be lying if I said I could turn off entirely every time I left work to go home.”

Felicity’s role as education sister involves managing and delivering mandatory and non-mandatory training, datix reporting, working clinically, supporting pre-registration students, and mentoring and supporting all CCU staff undertaking educational courses.

Duncan’s role as charge nurse and clinical informatics involves developing and problem solving the clinical information system (the chart & notes system in CCU), and training staff in its use, working clinically, data analysis, CCU equipment & stores management and recently health & safety.

Almost 30 years in the same role. What's the secret?

Richard Howard-Griffin has been a consultant in intensive care for almost 30 years, having started in Ipswich in 1989.

So what’s the secret to his longevity on such a demanding unit?

“I can pretty much switch off straight away when I go home, that’s definitely important and why I am still doing the job” he says.

“When I am on call, although I am thinking about the patients, provided I have a treatment plan in place for each patient and things are going well, I am generally happy and I won’t be dreading the next phone call.

“I can pretty much relax between the issues I have to deal with and that is important, otherwise you will be on edge all the time.” However, being able to focus on a life outside the critical care unit can be challenging at times.

There will be patients on the unit that are on an upward curve in terms of their recovery from critical illness, while others will need a period of recuperation to recover from an elective operation.

There will be some patients that require intense, round-the-clock, one-to-one nursing care. “These patients are the sickest in the hospital and they need to be subject to the very detailed analysis and investigations we carry out,” continues Richard, who oversees a department that takes in patients admitted from Accident and Emergency, theatres, acute medical wards and elective (planned) surgery and the very sickest paediatric patients for resuscitation and stabilisation prior to transfer to a specialised paediatric intensive care unit,

“It can take several hours to discuss every person’s condition and the key is attention to detail, as you are managing some patients hour by hour, minute by minute.

“The more chronic patients do not require such close monitoring, but we are constantly re-evaluating patients to move them off the unit as quickly as we can.”

A typical day for Richard will start at 8am with a multi-disciplinary team meeting in the department’s seminar room.

That will see the trainee doctor who has been on-call overnight, relay the latest clinical information about each patient with all their clinical physiology parameters and investigation data on screen, allowing discussion among senior medical and nursing staff to review their plans for each patient.

Elective surgical patients are then taken into consideration. The number of beds occupied , their nursing dependency and the number of nursing staff available determine whether or not pre-booked elective procedures can go ahead.

The Critical Care Outreach Team are also present at the meeting, highlighting patients at risk of requiring critical care that need to be reviewed immediately on the ward or kept an eye on for the moment.

After liaising with the bedside nurse regarding treatment plans, provided there are no emergency patients to deal with, practical procedures such as invasive lines and bedside tracheostomies can take place. At 11am the bedside ward wound will see a detailed review of each patient’s clinical and laboratory data and X-rays, drug treatment and feeding plans. Treatment plans can then be modified accordingly.

Richard’s role then is to ensure the smooth running of all aspects of the unit, with another ward round scheduled for late afternoon to ensure all the plans are on track.

His day tends to finish at around 6pm, from when he will then be on-call and ready at the end of a telephone to give advice or come in if required.

“We have a lot of resources here, there are a lot of doctors and nurses, but we are often dealing with the sickest patients and they demand a lot of input,” he explains.

“The most frustrating thing is sometimes not having enough beds to admit the patients you want to admit or, vice-versa, when you find the unit acting as a depository for patients who we know are well enough to go to the ward but are sitting here because the hospital are using that as a source for an extra bed.

“Getting the right patients in here is quite challenging sometimes but I enjoy the multi-tasking aspect of managing quite a lot of things at the same time.”

Because the condition of a patient on the unit is usually quite severe, the ability to be able to call upon a whole host of different teams, such as dietitians, pharmacists, physiotherapists is crucial but can create the impression to outsiders looking in that such a wealth of resource makes working on CCU easier.

“To some extent I would go along with that,” explains Richard.

“The nurses have instant backup from medical teams and that doesn’t happen on a general ward quite as easily, but undoubtedly you might say the sickest patients need a lot of expert nursing input and that can be quite stressful at times.

“Sometimes the sickest patients present some very awkward problems and can demand a lot of nursing care. Some patients are unnecessarily held here because there is no room on the wards. However, I accept that being a nurse on a general medical or surgical ward can see them rushed off their feet due to number of patients, which creates pressure on staff in a different way.”

“On the one hand I would say we do live in an ivory tower, but we need too sometimes."