Module overview - Phases of care (I & II) - PACT

Skills and techniques / Basic clinical examinationModule overview - Phases of care (I & II)Phase I - The primary survey: ensuring safe careContext of careLimit the boundaries of the problem,and structure an initial approach.◆ Site of care◆ Main clinical featuresPhysiology firstAssess: . . . . . . . . . . . . . . . . . . Act to correct main problems:◆ Airway . . . . . . . . . . . . . . . . . . . Clear airway◆ Breathing . . . . . . . . . . . . . . . O 2 and support breathing◆ Circulation . . . . . . . . . . . . . . IV access and fluids◆ Conscious level◆ Drug therapy◆ Excretion – urine output, drains◆ Fluids – input, route and type◆ General features – temperature, colour, oedemaReview response◆ To initial actions◆ Trends in vital signs – better or worse?Primary surveyUndertaken in the first few minutesof patient contact or reviewUnderlying principle:Physiological safety first:deliver adequate O 2 to cellsMindset:I must try to correct abnormal physiologyand quantify the severity of the problemTo do:◆ Think of the context◆ Assess◆ Act◆ Review◆ Call for help!Phase II - The secondary survey: identifying the underlying problemHistory◆ Focus on current acute history◆ Background health: co-morbid diseases◆ Drug history, allergies, interactions and compliance◆ Social circumstances, psychosocial independence◆ Collateral history and chart reviewExamination◆ Systems approach◆ Preliminary diagnostic hypotheses◆ Consider investigations requiredLaboratory tests◆ Arterial or venous blood gases (ABGs)◆ Standard routine tests◆ Targeted investigationsPatient-related procedures◆ Monitoring – information gathering◆ Therapeutic proceduresSecondary surveyWhile continuing iterative reviewof physiological safetyUnderlying principle:Identify the cause(s) of the problemMindset:I must seek additional information to explainpossible causes for abnormal physiologyTo do:◆ Obtain a preliminary history◆ Examine the patient again◆ Initiate targeted investigations◆ Form a diagnosis◆ Consider chronic diseases, drugs, social factors◆ Begin definitive treatmentEUROPEAN SOCIETY OF INTENSIVE CARE MEDICINE

Skills and techniques / Basic clinical examinationModule overview - Phases of care (III & IV)Phase III - The tertiary survey: integration; turning data into effective actionMaking a diagnosis◆ Managing data◆ Linking clinical and laboratory information◆ Revising probabilitiesTreatment: planning,monitoring andreviewing responses◆ Problem-oriented analysis◆ Causation◆ Therapeutic goals◆ Preventative measures◆ Site of care◆ Patient-centred outcomes◆ Assessment of severity of illnessand physiological reserveTertiary surveyWhile continuing iterative review of physiological safetyUnderlying principle:Plan the right treatment for this patientMindset:I must provide safe and effective treatment in accordancewith patient’s known or presumed wishesTo do:◆ Re-check the findings from the secondary survey◆ Single or multiple organ problem?◆ Choose safest environment for care delivery◆ Evaluate patient response to treatment◆ Obtain more detailed history using various sourcesPhase IV - Continuing care: systems managementTeamwork◆ General principles◆ Communication skills◆ Managing dissent and conflictDocumentation◆ Record keeping◆ Electronic methods of information managementContinuing careUnderlying principle:Safe care requires coordinated input from many peopleworking effectively togetherMindset:I must work with all members of the multidisciplinary teamto avoid gaps, discontinuities and conflictsTo do:◆ Team management◆ Communication – a two-way process◆ Support, empower team members througheffective information◆ Clear treatment plan◆ Clear documentationEUROPEAN SOCIETY OF INTENSIVE CARE MEDICINE