Standard 35: Critical Care

Why it matters. A critically ill patient can deteriorate in minutes. Continuous monitoring, with alarms set to the patient’s acuity, shows the change while there is still time to act.

Sample. Review monitoring records and alarm settings for 15 critical care patients across two shifts.

1. Each patient is monitored continuously at the level set for their condition.

Method. Check each record for continuous monitoring entries across the sampled shifts.

Evidence to show. Critical care monitoring and alarm settings (CRT-SOP-001).

Pass when. Every sampled patient has continuous monitoring recorded.

2. Alarm limits are set for each patient and recorded.

Method. Check each patient for the alarm limits recorded and the date set.

Evidence to show. Monitoring record (CRT-FRM-001).

Pass when. Every patient has individual alarm limits recorded.

3. Alarms are responded to and any alarm off is recorded with a reason.

Method. Check the alarm log for response times and any alarm switched off.

Evidence to show. Monitoring record (CRT-FRM-001).

Pass when. Every alarm is responded to and every alarm off has a reason.

Immediate fail (any one means the criterion is not met)

• A ventilated patient with alarms switched off and no monitoring record for a shift.

Why it matters. A critical care nurse cannot safely look after too many patients at once. A ratio matched to acuity keeps each patient within reach of skilled care.

Sample. Review staffing records for 10 shifts, including two nights and one weekend.

1. A defined nurse-to-patient ratio is set for each acuity level.

Method. Check the staffing policy for the ratio set for each acuity level.

Evidence to show. Staffing levels and skill mix (CLN-POL-001, existing, reused).

Pass when. The ratio is defined for each acuity level.

2. The ratio is met on each sampled shift, including nights and weekends.

Method. Check each shift against the ratio for the acuity on the shift.

Evidence to show. Daily staffing ratio register (CRT-REG-001).

Pass when. Every sampled shift meets the defined ratio.

3. Shortfalls are recorded and escalated.

Method. Check each shortfall for the escalation and the action taken.

Evidence to show. Staffing calculation record (CLN-FRM-001, existing, reused).

Pass when. Every shortfall is recorded and escalated.

Immediate fail (any one means the criterion is not met)

• A night shift with one nurse for four ventilated patients and no staffing record.

Why it matters. Patients in intensive care often show early warning signs hours before they arrest. A structured scoring system, with a rapid response route, catches them in time.

Sample. Review early warning scoring and rapid response records for 15 patients who reached a trigger score.

1. A structured early warning score is recorded at the set frequency.

Method. Check each patient record for scores at the set frequency.

Evidence to show. Vital signs and deterioration response (HOS-SOP-002, existing, reused).

Pass when. Every sampled patient has scores at the set frequency.

2. A trigger score brings a rapid response within the defined time.

Method. Check each trigger for the time to response.

Evidence to show. Rapid response and escalation (CRT-SOP-002).

Pass when. Every trigger has a response within the defined time.

3. Each response and escalation is recorded.

Method. Check each trigger record for the response, the clinician and the outcome.

Evidence to show. Observation and early warning chart (HOS-FRM-002, existing, reused).

Pass when. Every response is recorded with the clinician and outcome.

Immediate fail (any one means the criterion is not met)

• A trigger score reached and no one called for 90 minutes.

Why it matters. Deep sedation keeps a patient still but can cause delirium, and sedation left running too long prolongs ventilation. A protocol that sets the target and screens for delirium keeps the patient awake enough and safe.

Sample. Review sedation and delirium records for 15 patients who received sedation for more than 24 hours.

1. A written protocol sets the sedation level target for each patient.

Method. Check each record for the sedation target and the date set.

Evidence to show. Sedation and delirium management protocol (CRT-POL-001).

Pass when. Every sampled patient has a sedation target recorded.

2. Delirium is screened at the set interval.

Method. Check each record for delirium screening entries at the interval.

Evidence to show. Sedation and delirium screening chart (CRT-FRM-002).

Pass when. Every sampled patient is screened at the set interval.

3. Sedation is reviewed daily and minimised to the clinical need.

Method. Check the daily review entries and the level against the target.

Evidence to show. Sedation and delirium screening chart (CRT-FRM-002).

Pass when. Every sampled patient has a daily sedation review.

Immediate fail (any one means the criterion is not met)

• A patient held on deep sedation with no daily sedation review.

Why it matters. Families of patients in intensive care are often frightened and cut off. Regular, understandable updates and a clear policy on presence reduce distress and help the team work with them.

Sample. Review family communication records for 15 critical care patients and the presence policy applied.

1. Family receive a regular update on the patient’s condition.

Method. Check each record for family update entries at the set frequency.

Evidence to show. Family communication and presence (CRT-SOP-003).

Pass when. Every sampled family has regular updates recorded.

2. Updates are understandable and the family can ask questions.

Method. Check each update record for the explanation and the questions recorded.

Evidence to show. Family update record (CRT-FRM-003).

Pass when. Every update records an explanation and any questions.

3. The family presence policy is applied and any restriction is recorded with a reason.

Method. Check each restriction for the reason and the review.

Evidence to show. Family update record (CRT-FRM-003).

Pass when. Every restriction has a reason and a review recorded.

Immediate fail (any one means the criterion is not met)

• A family denied information for days with no presence policy applied.

Why it matters. Decisions to stop life-sustaining treatment are among the hardest in medicine. A written protocol, with the patient or family and the team, makes the decision careful and respectful.

Sample. Review end-of-life and withdrawal decision records for 10 patients in the last 12 months.

1. A written protocol governs each decision to withdraw life-sustaining treatment.

Method. Check the protocol for the decision steps and the approvals.

Evidence to show. End-of-life decisions and withdrawal of life-sustaining treatment (CRT-POL-002).

Pass when. The protocol covers every decision step.

2. Each decision is documented with the clinicians and the family involved.

Method. Check each decision record for the clinicians and the family involvement.

Evidence to show. Withdrawal of treatment decision record (CRT-FRM-004).

Pass when. Every decision names the clinicians and the family involved.

3. Comfort and symptom control are planned at withdrawal.

Method. Check each decision record for the comfort plan.

Evidence to show. Care of the dying patient (HSP-SOP-003, existing, reused).

Pass when. Every withdrawal has a comfort plan recorded.

Immediate fail (any one means the criterion is not met)

• Life support withdrawn with no documented decision and no family discussion.

Why it matters. Most deaths on a ward were preceded by hours of warning signs. A score that is recorded but leads to no response protects no one.

Sample. Review vital sign frequency and deterioration response for 15 inpatients who deteriorated in the last 3 months.

1. Vital signs are recorded at the set frequency for each inpatient.

Method. Check each inpatient record for vital signs at the frequency set for their score.

Evidence to show. Vital signs and deterioration response (HOS-SOP-002, existing, reused).

Pass when. Every inpatient has vital signs at the set frequency.

2. The frequency increases when the early warning score rises.

Method. Check each rising score for the increase in frequency.

Evidence to show. Observation and early warning chart (HOS-FRM-002, existing, reused).

Pass when. Every rising score is followed by an increased frequency.

3. The deterioration is recognised and acted on within the set time.

Method. Check each deterioration for the recognition and action time.

Evidence to show. Rapid response and escalation (CRT-SOP-002).

Pass when. Every deterioration is acted on within the set time.

Immediate fail (any one means the criterion is not met)

• A deteriorating inpatient with vital signs recorded twice a day and no early warning score.

Why it matters. The last days of life need a clear plan, comfort measures and a dignified environment. Without a plan, care becomes improvised and the patient suffers.

Sample. Review care plans and records for 10 patients who died in critical care in the last 6 months.

1. A defined care plan is in place for each dying patient.

Method. Check each record for the care plan dated before death.

Evidence to show. Dying care plan record (HSP-FRM-005, existing, reused).

Pass when. Every sampled patient has a care plan before death.

2. Pain and symptoms are assessed and controlled.

Method. Check each record for symptom assessments and the control given.

Evidence to show. Symptom assessment and control (HSP-POL-001, existing, reused).

Pass when. Every sampled patient has symptom control recorded.

3. Family present are supported and their presence is recorded.

Method. Check each record for family support entries.

Evidence to show. Family and carer support (HSP-SOP-001, existing, reused).

Pass when. Every record shows family support recorded.

Immediate fail (any one means the criterion is not met)

• A dying patient left in pain with no comfort plan and family not allowed to stay.