Question 3

College answer

Syllabus topic/section:

2.2.1 Communication and collaboration in ICU: Handover and referrals

Discussion: 

Most candidates did reasonably on part a), but many were let down by part b). Some candidates did better in part b), but very few candidates performed well in both sections of this question. Candidates that scored less well in part a) simply listed targets without any detail or rationale for those chosen, or they over focused on a single aspect eg how to intubate. Good answers had structure (usually by system) and included specific management aspects and targets that related back to ICP control. Good answers also included an awareness of the regional location and the limitations this posed on ICP monitoring. Several candidates did not mention broader trauma issues like C spine management as part of their answer. Candidates that scored less well in part b) tended to limit the answer to repetition of the management outlined in part a) for the handover, but didn’t include the location, personnel or non-technical features required for a safe handover. Answers that scored higher marks in part b) included communication for safety (the accurate and careful exchange of information between clinicians) and used a formalised or non-formalised structure to aid this (for example ISBAR, MIST or AMPLE).

Discussion

It is telling that the examiners had chosen to label this SAQ with the "handover and referrals" syllabus item. Consider: six marks are in brain injury, but this generic question on neuroprotective strategies cannot possibly be a good discriminator, as everyone should be able to answer it with enough content to achieve near-100% pass marks at this stage in their training. 

a) Management of the patient is basically a reiteration of the BTF guidelines (mostly the prehospital sections), and consists of:

A - intubate the patient

- if impossible (i.e. nobody there knows how), introduce an airway device and await a skilled operator

B - maintain SpO2 > 90% and PaCO₂

C - maintain normotension, but if there are features of raised ICP, aim for a higher MAP (80 or 90)

- Avoid cerebral venous hypertension; care not to tighten ETT tapes and ties

- loosen C-spine collar and sandbag the neck and head while awaiting a formal CT report for the neck

- Elevate head of bed 30-45^o

D - sedation and analgesia to prevent ICP rises

- serial reexamination of pupils to detect herniation

- if ICP increase is suspected, give mannitol or hypertonic saline as rescue therapy

- detect and treat seizures

E - avoid causing hyponatremia or hyperglycaemia; rewarm the patient to normothermia

F - avoid albumin infusion

demand

b) Principles of a safe and effective clinical handover:

The best way to answer this would probably be to borrow from something like "Communicating for Safety". Note that the SAQ has specifically asked for the "principles", not "the specific information you think might be relevant to ask for". The principles of handover are:

• Leadership: there needs to be a nominated handover facilitator to lead the process
• Handover participants: members of the multidisciplinary team
• Handover time: all agree on the timing
  • Must remain interruption free
  • If an emergency is taking place, prioritise stability;
  • once the emergency is resolved, a "hands off" handover is recommended so nobody is distracted
• Handover place -  bedside, vs. "paper round" huddle, or even remote tele-handover
• Handover process where the details are exchanged in some structured format. eg. ISBAR:
  • Identification of the teams
  • Situation
  • Background
  • Assessment details
  • Recommended course of action
• Documentation of the receiving team / delivering team and that the receivers have taken over care