A CCrISP APPROACH TO THE
DETERIORATING PATIENT
Mary Langcake FRACS
Director of Trauma
St 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
WHAT
• Teaches:
“Prompt, simple actions save lives
AND prevent complications”
WHO
FACULTY
• 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?
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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 considered
‹
Routine pre‐operative patients
‹
Risk factors – identify and control or improve
Emergency Admissions
Severe acute problems
Co‐morbidity
‹
Ward/HDU patients
Sudden deterioration
Failing to progress/‘not right’
At risk from surgery or disease processes
Immediate Management
A B C D E
Full Patient Assessment
Chart Review
History and Systematic Exam
Available results
Decide and Plan
Stable Patient
Unstable/Unsure
Diagnosis Required
Daily Management Plan
Specific Investigations
Definitive Treatment
Medical
Surgical
Radiological
Immediate management
‹ Diagnose, Prioritise and TREAT
immediate threats to life
Airway
Breathing
Circulation
Disability/Dysfunction of CNS
Exposure
End of Immediate Management
‹ Immediate steps undertaken to preserve life
‹ Ongoing monitoring established ‹ Stable/improving vital signs?
‹ Called for help
‹ Moved to theatre or HDU/ICU
Not the end , just the beginning!
Now ..find the real source of the problem!
If at any time
the patient’s condition deteriorates
You must go back to the start
and
Re-assess ABCDE
Immediate Management
A B C D E
Full Patient Assessment
Chart Review
History and Systematic Exam
Available results
Decide and Plan
Stable Patient
Unstable/Unsure
Diagnosis Required
Daily Management Plan
Specific Investigations
Definitive Treatment
Medical
Surgical
Radiological
Communication
Ensure the patient is well‐informed
‹ Case note entry
‹
Inform others
Record plan against which you can check progress
Helps you organise your thoughts
Pre‐ weekend summaries are very helpful
‹
Nursing staff
Parameters, plan
Senior and other colleagues
‹ Relatives
‹
SUMMARY
Understand 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
SUMMARY
Safe and selective investigations Frequent clinical re‐assessment Inform and involve your seniors appropriately
Consider level of care necessary at each stage
CURRICULUM REVIEW
• CCrISP Committee in final stages of review
with plans to pilot the Australasian 3rd
edition early 2010
• Aims to keep the Course relevant and fresh