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This chapter outlines the indications for admissions to the critical care unit (CrCU), and role of scoring systems to aid admission. The admission criteria should be based on need of the patient rather than bed availability. A number of steps could be taken if a critically ill patient presents in the absence of an available bed in the unit. The choice is often determined by the severity of illness, haemodynamic stability, ease of oxygenation, necessity of advanced interventions, time of the day and availability of medical staff. Patients who are deemed to have irreversible or severe organ system damage which is likely to prevent reasonable recovery should have treatment limits in place. All admitted patients should be handed over to one of the critical care doctors. A timely discharge from the CrCU is just as important as timely admission.
It is estimated that in excess of 10,000 critically ill or injured patients are transferred between hospitals each year in the UK. The optimal mode of transport selected for a patient transfer depends upon a number of factors. These include: the indication for, and urgency of, transfer; time to organize/mobilize transport; weather and traffic conditions; space; and cost. Current guidelines recommend that a minimum of two people accompany the transfer of a critically ill patient in addition to the staff required to operate the transport vehicle. The decision to transfer a critically ill patient is usually shared between the critical care consultants at the referring and receiving hospitals in collaboration with their consultant colleagues in the relevant specialities. Continuous monitoring of the ECG, SpO2 blood pressure and ETCO2 should be maintained throughout the transfer and recorded on the patient transfer sheet.
The initial assessment of the critically ill patient should begin with a brief, targeted history and an appraisal of the patient's vital signs to identify life threatening abnormalities that merit immediate attention. The goals of resuscitation are usually achieved by the use of supplemental oxygen, fluid or red blood cell transfusion, inotropic support or antibiotics as needed. Physiological Scoring Systems (PSS) developed from the recognition that critically ill patients, and in particular patients who suffered cardiac arrests, often had long periods of deterioration before the crisis or medical emergency occurred. Medical emergency teams (METs) and critical care outreach (CCO) teams aim to provide critical care skills rapidly to critically ill patients. Referrals to the critical care services may happen from any level, but the final decision to admit a patient to a critical care bed should be made by an experienced critical care physician.
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