Critical and Emergency Care Nursing

Nurses working in critical care and emergency care settings deal with patients whose very survival often depends on the quality of care they receive. These nurses need high levels of skill and expertise, and the ability to think and act quickly in a crisis. They also need to be able to support patients’ families and friends in what are often highly distressing situations, while maintaining a focus on their patients’ best interests. This award is open to individual nurses or teams working in the NHS or independent sector who can demonstrate performance that has contributed to a significant improvement in the quality of patient care in emergency or critical care settings.

Calderdale and Huddersfield NHS Foundation Trust
BLOSM Service

The Calderdale and Huddersfield NHS Foundation Trust (CHFT) BLOSM Service has now been established for just under two years. We were fortunate enough to be a finalist for the 2023 Nursing Times Awards and have grown and developed as a service in the following 12 months. The service has been developed based in the six principles of trauma informed practice and has been developed by an experienced nursing team with a range of knowledge and experience. We have received funding from the West Yorkshire Violence Reduction Partnership alongside the West Yorkshire Health and Care Partnership to implement a trauma informed service which proactively identifies and engages with vulnerable people and offers timely and appropriate referrals into community services. The initial focus of our service has been our Youth Navigator pilot, introducing youth workers into our ED’s to identify and offer support to vulnerable young people attending ED who may be at risk of criminal exploitation, serious violence, and victims of knife crime, in the first year of our service going live we saw 737 engagements with young people. Over the last twelve months we have worked hard to expand the scope of our service to offer support to vulnerable people of all ages through the creation of new workstreams and through the development of strong networks with community providers. We have faced the challenges of being a new service without permanent funding in place which has meant we have had to work incredibly hard to prove the value and impact of our work to ensure funding into the next year. We hope to become a permanently funded service which can support vulnerable service users attending ED, improving outcomes for patients as well as reducing demand on emergency services and supporting our nursing and medical teams working within the Emergency Department.

Chelsea and Westminster Hospital NHS Foundation Trust
Little Journey – patient and relative app

The aim of the project was to introduce an interactive app for ICU patients and relatives at the Chelsea and Westminster and West Middlesex sites.

Dartford and Gravesham NHS Trust
Emergency department familiarisation visits

Health anxiety in adults with Learning Disabilities. People with learning disabilities frequently contend with a lifetime of adversity, inadequate social support and poor coping skills. These factors contribute to increased vulnerability to stressful life events which may trigger anxiety disorders. The Emergency Department (ED) is often perceived as a busy, chaotic and stressful environment and therefore we wanted to ensure that our most vulnerable patients had awareness of the environment in order to reduce stress and anxiety should they ever need care in the ED environment. To promote confidence in healthcare staff and services available. Staff need greater awareness of the needs of patients with learning disabilities requiring emergency care in order for them to be able to provide care without barriers. To breakdown barriers to accessing acute health services. To familiarise emergency care staff with the needs of support that people with LD might need in the ED. We contacted local community groups and explained to them the initiative to gauge the interest in touring the emergency care environment. The interest was there and we therefore engaged with local community groups. We needed to ensure that we were able to flex services in order to make reasonable adjustments that met with individuals needs should they be identified. This then allowed us to holistically support our patients. Our key priority was to ensure that participants felt empowered and confident to express their needs and wishes without judgement thus reducing stress and anxiety. Our aim for the future is to make this a rolling programme of work with the group that we have already work with and then to extend the programme out to other local community groups. Once established we hope to extend the work across the organisation including within elective services.

Guy's and St Thomas' NHS Foundation Trust
Developing a family liaison service in adult critical care

The Family Liaison Practitioner (FLP) role is part of an 18-month charity funded pilot project, involving the introduction of 2 full time FLPs within Critical Care. Family is used as an inclusive term, describing spouses, relatives, friends and anyone a person or patient considers important to them. Feedback from families of patients in Critical Care in the trust has highlighted poor communication as a cause for dissatisfaction, with lack of continuity of communication a particular issue. The majority of PALS interactions, formal complaints, and legal challenges cited communication as a factor. Feedback from Critical care staff in the trust shows lack of confidence with family communication, as well as anxiety and moral distress related to challenging communication. Incidents of violence and aggression towards staff in the department has increased, with a negative impact on staff wellbeing. The FLP role aimed to address these issues through providing enhanced communication for families, allowing families to advocate for patients and thus provide person-centred care. Through shared decision-making and collaborative communication built on trust, there was a desire to prevent breakdowns in communication and build a culture of positive communication. Process: • Engaging clinical teams from the outset • Embedding within the MDT and establishing processes • Networking with non-clinical teams • Advanced communication skills training • Establishing workflow and data collection processes Challenges: • Preventing duplication of existing roles • Manging workload to meet demand • Quantifying unmet need • Engaging staff who were uncertain of the role Future Plans: • Business case to seek funding for continuation of FLP role • Expand the team to meet demand • Secondment into the team to aid retention • Focus groups and engagement of service users to develop the service • Present and publish nationally Evidence 1 comprises an overview of FLP role development.

Liverpool Women's Hospital
Moving the early pregnancy assessment unit

The EPAU team care for women with complications in early pregnancy between 6 and 12 weeks.  Prior to Autumn 2023 we worked as a self-contained unit within the gynaecology emergency room. We worked out of two scan rooms within the back of the Emergency room and were a relatively an unknown resource.  With being based in only 2 rooms in GED we were very limited to what we could offer our patients, especially regarding management of miscarriage. As a team we felt frustration that we were not able to provide continuous care and would heavily rely on GED staff and doctors regarding consent and medical management of miscarriage.  The team felt lost and constrained by the lack of space within the GED. We felt that the EPAU should be a separate unit to enable us to grow and develop the service.  This was echoed by feedback from the people who have accessed our service who wanted more privacy and their own waiting area outside the busyness of the GED. Plans regarding an EPAU move commenced before 2021. This gave the team a boost generating excitement within the team for the further development of the service we offer. Sadly due to funding issues the plans for the move were rejected twice and we were forced back to the drawing board. In 2022 discussions began again regarding the move and following collaboration with senior nursing staff, senior medical staff and the Bedford team the EPAU moved officially in November 2023 and is now its own separate department, we are now able to offer miscarriage management and we have many future plans to improve our service by creating miscarriage management clinics, telephone clinics and to increase our scan service.

Portsmouth Hospitals University NHS Trust
MASST – Multi Agency Safeguarding and Support Team

A Safeguarding Adult Review (SAR) was published in 2023 following the death of x3 individuals, although all un related the link that brought them together was they were all experiencing homelessness or rough sleeping on the streets at the time of their deaths. Considerable learning was identified following the review, including a lack of robust oversight and accountability from the multiple professionals and agencies all involved with each individual. Another key theme was also the communication between agencies and sharing information. As safeguarding lead for the emergency department I was involved in the review as all three of the individuals had previously attended the department on multiple occasions. One finding of the review around communication and collaborative working between agencies made me think about how this could be improved when providing care and support for those patients experiencing homelessness. I brought together those agencies involved with supporting those patients experiencing homelessness and came up with the concept of MASST - Multi Agency Safeguarding and Support Team. We decided to all meet for an initial meeting and from there the team expanded to include external agencies such as housing support, hostels and the local council. We then started to meet fortnightly to discuss those patients that had come through the emergency department and ensure each agency was working together, communicating and sharing information to support that individual. Challenges included ensuring we had the correct agencies in place and regular attendance at the meetings. Positive outcomes to date include the support given and the key agencies being involved. Future plans include extending MASST meetings beyond the emergency department to the wider Trust for those patients that are admitted, supporting the discharge planning process as well.

Sandwell and West Birmingham Hospitals NHS Trust
Using oral ethanol to improve the emergency department management of patients who are severely alcohol dependent

Alcohol withdrawal is a potentially fatal condition and severe withdrawal is a challenging condition to manage, often requiring one to one observation. When a patient is experiencing delirium tremens, there is an associated risk to the individual, to staff and to fellow patients. Alcohol withdrawal management has not changed for decades. First line treatment is benzodiazepines, and for most patients this is an effective treatment. however for those who are very excessive drinkers (>30 units of alcohol per day) or those who are tolerant to benzodiazepines, this treatment is often ineffective. Severely dependent patients attending the emergency department in alcohol withdrawal often require large doses of benzodiazepines to stabilise their condition and the side effects of this treatment may result in admission. Instead at Sandwell and West Birmingham NHS Trust (SWB) we have introduced the use of oral ethanol (vodka) which quickly resolves withdrawal symptoms without side effects, enabling the patient to be safely discharged. This is innovative and we are the only team in the UK using this approach. The use of vodka is tightly controlled; it is a controlled drug, and the authorisation for this drug is only allowed by the nurse consultant, and clinical toxicologists. The use of vodka had to be agreed by the formulary and therapeutic group and in consultation with the senior ED nurses and medics. The effectiveness of this treatment has been audited and there was a significant reduction in the number of patients admitted into an inpatient bed and a significant reduction in alcohol withdrawal seizures between those who received oral ethanol and those who received the traditional benzodiazepine management. Patients who receive oral ethanol provided positive feedback with 96.2% saying they'd be happy to receive ethanol for future withdrawal management.

South Eastern Health and Social Care Trust
The benefit of a senior nurse on the post take ward round

Over the last few years we have realised the increasing pressure on the Emergency Department (ED), which leads to an increased pressure on staff and ultimately our patients. This The impact of this is leading to an increasing number of medical patients with the decision to admit, overcrowding and late flow from ED to substantive beds on wards. We wanted to use the skills of our senior nursing team in the Acute Medical Unit to improve early flow and ensure patients are spending less waiting in the Emergency Department - ensuring that the patients journey began promptly after the decision to admit to hospital. We wanted to make our team known in ED (Ulster Hospital, South East Trust) so the team had to get to know staff, a new environment and work place. The initial idea of this started back in 2020, just pre-covid, so there was a hold up in the project really starting off because we were unable to move around different areas of the hospital due to covid. We set the target of aiming for as much movement out of ED before 12pm, by discharging straight from the post take ward round (PTWR), transferring to our Sister hospitals Downe and Lagan Valley which do not have an ED open 24/7, and by setting up and increasing the use of our Acute Ambulatory hub - which is located in our AMU . The first idea started back in 2020, just before Covid happened. After Covid numbers in hospitals reduced and acute Covid care was at a minimum, we decided to implement this change and to try and start attending the Post Take Ward Round. Our Senior Nursing team created a pilot of what information was important to gather, and what our focus would be.

United Lincolnshire Hospitals NHS Trust
Reducing the flow of emergency surgical presentations to the emergency department

There was a need identified to reduce the flow of emergency surgical presentations to the Emergency Department (ED). The emergency General Surgical take was managed by a small on-call team who traditionally undertook emergency operations which consequently led to the delay of patient assessment in the ED setting. A trial was undertaken whereby fully ambulant stable patients, well enough to sit in a chair, could be assessed, diagnosed and managed under the appropriate speciality in a timely manner. A three month trial was undertaken in a designated area within the surgical admissions ward. This demonstrated that approximately 75% of patients could be safely managed as an outpatient without the need for admission. This improved both patient flow through ED , patient experience, and in addition to reduced bed occupancy. The success of the trial led to the development of a business case for a dedicated seven day a week assessment area which would Surgical Advanced Clinical Practitioner (SACP) led. Challenges we have faced include a need for nursing support staff which were not initially identified in the original business case. In addition, in times of increased bed pressures, the unit has been used as an escalation area. Future plans are to secure an establishment of nursing support staff to assist with venepuncture, cannulation, administration of medications, as well as an increase in the number of SACPs, with the aim of carrying out surgical procedures, running clinics and assisting in theatre.

University of Dundee
Scaling up ICU patient-led support groups across Scotland

ICU survivors experience high rates of anxiety, depression and Post-Traumatic Stress Disorder (PTSD); ~30%, ~30% and ~20%, respectively, however, there are few targeted therapeutic interventions or supportive services. Family members typically experience higher rates of anxiety, depression and PTSD, but their psychological support needs receive still less attention. Peer support has been available for UK ICU survivors and family members since ~2005, via a patient-led charity, ICUsteps. In Scotland, between ~2010 and 2015, however, there was only one nurse-led ICUsteps patient support groups (Dundee). My aim was to increase the availability and patient leadership of peer support across Scotland. In 2015, I secured philanthropic funding to establish an ICUsteps support group in Edinburgh, together with former ICU patients and ICU nurses. We co-created a culture of patient-centredness, such that meetings became entirely patient-led by 2018. Patient leadership became vital during the COVID-19 pandemic, as ICU nurses relinquished the provision of peer support. ICUsteps Edinburgh was one of the first and few UK patient support groups to offer online support, welcoming UK-wide and international patients. In 2023, I secured Scottish Government funding to scale-up peer support groups in Scotland. We developed bespoke training for ICU peer support together with a mental health organisation (Scottish Recovery Network), which was vital to overcome risk-aversity among ICU clinicians. We co-created posters and leaflets for each Scottish ICU, established three new groups and appointed a Network Co-ordinator to support collaboration, a national fund-raising campaign and to establish new groups. We are currently producing digital training resources, including patient stories on the benefits of peer support. We have actively engaged with mainstream media (newspapers and television pieces), the Scottish ICU community and Scottish Government. Future plans include securing research funding to examine the benefits of peer support, and the potential propagation of our model in Europe.