Admission

UK Patient admissions 2009

Reasons for admission to intensive care

Some patients are best cared for in intensive care immediately following their operation whereas other patients will return directly to the ward from the theatre recovery area but if a problem occurs their consultant may admit them to the intensive care unit.

Intensive care units can offer a higher level of monitoring and treatment than on an ordinary ward. Staffing levels are much higher (there are more nurses, doctors, physiotherapists and assistants per patient) and there is specialist equipment that is only available in this area. Senior staff are closely involved in the hour by hour management of patients by the bedside and all staff are especially trained to care for the most unwell patients.

 
Planned admissions

There are some operations where patients are best managed in intensive care immediately afterwards in almost all cases, whereas there are other operations after which patients would normally return straight to the ward from the theatre recovery area, but a particular patient might have other problems or illnesses that mean their doctors believe a period of observation or treatment in intensive care will make a difference to their recovery.

The theatre staff will liaise with the intensive care unit throughout the operation and towards the end of the operation they will send for the bed. There are different practises in different hospitals but either the theatre anaesthetists and nurses will bring the patient to intensive care or the intensive care staff will go to the operating theatres and collect the patient.

The patient may still be asleep and ventilated on the breathing machine or they may have been woken up. The staff will use special transfer monitors to carefully observe the patient throughout the journey and portable infusion pumps to keep giving essential medicines.

There will be a thorough handover of all the important past history of the patient, the reasons for the operation and the events that have taken place during the operation as well as the details of the operation itself. The surgeons will usually visit the patient in intensive care a short time later.

Sometimes operations are cancelled because of a lack of intensive care beds. Most intensive care units in Britain run at, or near, full capacity all the time. One of the very important jobs of the medical and nursing team on the intensive care unit is trying to work out each day who is able to return to the ward and which planned operations can go ahead. If your operation is cancelled, remember that the doctors and nurses are putting your safety first and it is likely that they had to admit an emergency patient despite trying to keep a bed for you.

Many hospitals now have other options for patients following these planned operations, such as extended recovery areas, specialist ward areas or "fast track" systems. These have been created to reduce the need for intensive care beds thereby reducing the number of cancelled operations and is an attempt to stop planned surgery and emergency admissions from needing the same resources.

 
 
Emergency admissions

If a patient is admitted to the hospital with an acute illness they will be seen by the emergency department team or by one of the general medical, surgical or specialist teams. If the doctors or nurses looking after the patient think that the patient needs a higher level of monitoring or specialist treatment then they contact the intensive care team who will come and see the patient.

Usually the intensive care staff will have been involved in the care of the patient in the emergency department or on the ward in the hospital. Patients frequently require a period of stabilisation before it is safe to move them to the intensive care unit. Sometimes it may be necessary to perform emergency investigations in the X-ray department before the patient goes to intensive care.

The intensive care team and the admitting team will often reassess the patient together and discuss the further management with the patient, their family or next of kin and sometimes their GP. The intensive care team will advise both on further things that can be done on the ward and whether going to intensive care is going to help the patient. Not all patients will benefit from being taken to intensive care, sometimes the intensive care team will advise that there is nothing else that can be done for a patient and they will help the admitting team make sure the patient is comfortable and given a dignified death. If the team feel the patient will benefit from intensive care and will survive what may be a long and difficult illness then they will admit the patient to the ICU. The most senior doctors and nurses make these decisions with as much involvement from the patient as is possible.

It can take an hour or more to stabilise a very unwell patient enough to safely transfer them in lifts and through corridors to the intensive care unit, during this time the patient will be receiving the same care that they will on intensive care but provided by the ICU staff on the ordinary ward. Sometimes the intensive care unit is full and a patient who is improving and who can safely leave intensive care will need to be transferred to the ward before there is space to move a new patient into. Again, the team will provide intensive care treatments on the ward until the bed is available. Even more rarely there is no possibility of a patient being transferred from intensive care and the new patient (or sometimes an existing intensive care patient) has to be transferred to another hospital that does have an intensive care bed.

 
 
Once on the unit

Following admission to the ICU, it can take a further hour or more to make the patient comfortable in their new environment. The staff may have to put more monitoring equipment on the patient, this can include inserting extra drips and special "central lines" (long drips that are usually placed in the large veins in the neck or top of the leg).

There may be emergency treatments that must be established, such as putting the patient to sleep and inserting a breathing tube into their windpipe and stabilising them on the ventilator. Sometimes kidney dialysis must be started urgently.

The nurses will put the patient onto clean sheets and check for pressure areas. Special beds are used in intensive care to prevent development of pressure sores. Some patients require even more specialist beds. Sometimes someone will come out to relatives while this is happening to get more details about next of kin, and contact telephone numbers for family as well as giving families information about visiting, car parking, whether there is a facility for you to stay near the unit, especially if it is a specialist unit a long way from home.

The first few hours on intensive care are often a very unstable time and a patient's condition can change minute to minute. The doctors and nurses will usually explain if they think this is likely. Frequently one of the team will sit down at this stage and summarise what has happened so far and what they are expecting in the next few hours. Don't be afraid to ask questions and to ask to speak to the doctors, but please understand if they are not available immediately, particularly at night when staffing levels are usually lower and the doctors may be needed in other areas of the hospital.

The patient population in the critical care unit is mixed and varies across units. A patient waking up after an operation may experience a strong sense of security as they were advised of, and prepared for, their admission. However, an emergency patient's perceptions of their surroundings, as they wake up, will be clouded as they awake from sedation and depending on how aware they were of what was happening during admission. It has been reported that, as sedation wears off and the illness lessens, patients may experience anxiety and depression. In critical illness, anxiety, depression and panic attacks are common. The patients in the critical care unit are physically and emotionally dependent on the staff looking after them and the provision of information, security and emotional support is important to help patients cope.