ALERT™—a multiprofessional training course in the care of the acutely ill adult patient
Introduction
Some in-hospital cardiac arrests and deaths are avoidable [1], [2]. Often patients show signs of clinical deterioration for many hours, yet these go undetected or are poorly treated by ward staff. McQuillan et al. have shown that at least 50% of patients admitted to intensive care units (ICU) receive suboptimal care before ICU admission and that some ICU admissions might be unneccessary if ward care was better [3]. ICU and hospital death rates for those receiving suboptimal care prior to ICU admission are higher than for those who are well managed [3], [4], [5]. Suboptimal care is frequently related to poor management of simple aspects of acute care—those involving the patient's airway, breathing and circulation, oxygen therapy, fluid balance and monitoring. Other contributory factors include failures of organisation, a lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice, and poor communication. These factors often lead to complaints by patients or their families [6].
Although, the cause of substandard care is inevitably multifactorial, basic education in acute care and the preparation of staff for clinical practice may be important determinants [7]. Several excellent postgraduate courses teach adult basic and advanced resuscitation skills to a high level [8], [9], but they deal predominantly with the management of a patient in the period after a catastrophic event such as cardiac arrest or major trauma. With the main exception of the Care of Critically Ill Surgical Patient (CCrISP) Course [10] run by the Royal College of Surgeons of England, few training programmes teach a pre-emptive approach to critical illness, despite the recognition that ‘prevention is better than cure’.
The introduction of clinical governance in the UK [11], with its emphasis on audit, risk management and continuing education and training provided an additional impetus for the development of this type of course. Faced with clear evidence of substandard care in our hospital and an apparent relationship between quality of care and hospital outcome [3], we decided to develop a short course to instruct trainee doctors and junior ward nurses in the recognition of impending clinical deterioration, the management of simple disorders of disordered physiology and other aspects of the delivery of acute care. This course, Acute Life-threatening Events—Recognition and Treatment (ALERT™), has been run successfully in our hospital since the beginning of 2000 and is being implemented in a growing number of other UK centres. This paper descibes the rationale, the planning process, and the structure of ALERT™.
Section snippets
Development of the ALERT™ course
ALERT™ is a one-day multiprofessional course in the recognition and management of adult patients who have impending or established critical illness. It was developed using principles common to many advanced life support courses [12], [13], but particularly the CCrISP course [10], which is designed for trainee surgeons. Very early on, the course development group realised that releasing newly qualified doctors and nurses for more than one day at a time would be difficult. Consequently, ALERT™
Aims of the ALERT™ course
There were both educational and clinical aims to setting up the ALERT™ course. The primary educational aims included improved recognition of the course of critical illness and an increased understanding of basic clinical interventions that could stabilise the ‘at risk’ or deteriorating patient. The primary clinical aim was the elimination of potentially avoidable deaths, cardiac arrests and intensive care admissions. Table 2 identifies the specific objectives of the course.
ALERT™ course material
A 70-page course handbook [16] is provided as preliminary reading for ALERT™ and covers all of the topics presented during the training day, together with additional supportive information. It is written in an easy-to-read and assimilate style, at a level that is appropriate for both newly qualified doctors and ward nurses. Considerable use has been made in the manual of tables, icons and key points. The text is divided into nine chapters (Table 3) that concentrate on the basic assessment,
Course structure
The one-day ALERT™ course consists of a combination of interactive seminars that use clinical vignettes on which to base discussion, and a series of role-play scenarios (Table 4). The topics covered during seminars complement the chapters in the course manual, whilst the scenarios permit the reinforcement of the patient assessment system and allow the practice of simple therapeutic manoeuvres in a simulated and safe environment. The patient assessment system consists of the following key stages
Discussion
ALERT™ is grounded in the principles of multiprofessional education and emphasises the benefits of interprofessional working [17] and clinical governance [11]. Although initially developed for newly qualified doctors and junior ward nurses, it is now apparent that medical students, student nurses, physiotherapists, resuscitation trainees, paramedics, consultants and healthcare support workers may all benefit from attending the course. The evidence that suboptimal care is not confined to our
Acknowledgements
The ALERT™ Course Development Group would like to acknowledge the financial support of the Hampshire and the Isle of Wight Education Consortium who assisted in the development costs of the course. We would also like to acknowledge the assistance of the following who have acted as trainers or administrators for the course in Portsmouth: Jane Carter, Sue Clarke, Sue Hall, Mike Hayward, Neil Hedger, Bryony Holding, John Knighton, Cassie Moore, Nicky Poplett, Matthew Quint, Paul Sadler, Suzie
Portuguese Abstract and Keywords
O curso de diagnóstico e tratamento de ocorrências agudas potencialmente fatais (ALERTTM) tem a duração de um dia, é multidisciplinar e foi primariamente concebido para fornecer a jovens médicos e enfermeiros, competências acrescidas na abordagem e tratamento iniciais de adultos em estado crı́tico. Muitos outros profissionais de saúde são destinatários potenciais. O ALERTTM assenta em princı́pios semelhantes a muitos outros cursos de suporte avançado de vida e
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Portuguese Abstract and Keywords
O curso de diagnóstico e tratamento de ocorrências agudas potencialmente fatais (ALERTTM) tem a duração de um dia, é multidisciplinar e foi primariamente concebido para fornecer a jovens médicos e enfermeiros, competências acrescidas na abordagem e tratamento iniciais de adultos em estado crı́tico. Muitos outros profissionais de saúde são destinatários potenciais. O ALERTTM assenta em princı́pios semelhantes a muitos outros cursos de suporte avançado de vida e incorpora aspectos de gestão clı́nica e interacção multidisciplinar e interprofissional. Inclui a leitura prévia dum apoio teórico, seminários interactivos, demonstrações práticas e simulação de cenários clı́nicos. Um aspecto particular deste curso é o de que os participantes mudam de papel durante a simulação dos cenários, o que é facilitador da entreajuda. Ao longo do curso os formandos são estimulados á reflexão sobre os actos praticados e á valorização de detalhes. O curso centra-se em problemas que freqüentemente levam os enfermeiros a solicitar apoio médico – ex: o doente cianosado ou hipotenso. Os aspectos comunicacionais são abordados durante seminários, nos cenários clı́nicos, mas igualmente durante uma sessão especı́fica onde se discutem três aspectos: Como dar más notı́cias; escrever no processo clı́nico e comunicação interdisciplinar/interprofissional.
Palavras chave: Educação; Tratamento de emergências; Formação.
Spanish Abstract and Keywords
El curso de Reconocimiento y Tratamiento de Eventos Agudos con Riesgo Vital (ALERTTM) es un curso multidisciplinario de un dı́a, originalmente diseñado para dar confianza y habilidad a médicos y enfermeras recién graduados, en el reconocimiento y manejo de pacientes adultos que presentan una enfermedad crı́tica inminente o establecida. ALERTTM puede ser también conveniente para muchos otros grupos de trabajadores de servicios de salud. ALERTTM fue desarrollado usando los principios comunes de muchos cursos de soporte vital avanzado e incorpora aspectos de manejo clı́nico, educación multidisciplinaria y trabajo interprofesional. Incorpora lectura precurso, seminarios informales e interactivos, demostraciones prácticas y actuación de roles en escenarios clı́nicos. Un aspecto moderno de ALERTTM es que los participantes intercambian roles durante los escenarios, facilitando ası́ la mutua comprensión. En todo momento durante el curso, los participantes son estimulados a reflexionar sobre sus acciones y poner especial atención a los detalles. El curso enfoca esos problemas que hacen que la enfermera de la sala llame al médico por ayuda, por ejemplo ‘el paciente azul’, ‘el paciente hipotenso’. Las destrezas de comunicación son cubiertas frecuentemente en el curso, durante escenarios y seminarios, pero también como sesión especı́fica que cubre tres aspectos—enfrentar malas noticias, registrar datos de pacientes y comunicación interpersonal/interprofesional.
Palabras clave: Educación; tratamiento de emergencia; entrenamiento
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