10 Things to Know about referring to ITU
Don't Ever Feel Guilty For Waking The Boss!
This blog was for 10 Things to Know with Dr Natalie Silvey, a fellow ICM reg. It is a pocket guide for those referring to intensive care for the first time.
The first time I called ITU I had such a hard time that it made me reluctant to call again. Now, as an ITU reg, I know that my referral was a bit pants. But at the time I was very junior, panicking, and unsure how to get help for my the sick patient in front of me.
I would never want anyone to be unable to get the help they need for a sick or deteriorating patient. So here are my top 10 tips on how to get help, and how to refer to critical care.
1. Tell us what you need
Start with what you need from us, and when.
- “Hello my name is Steph, I am the FY2 and I…
- ”Would like some advice on fluid balance.
- Would like an urgent review for my patient who may need admission.
- Need you to come to ward X immediately
2. Tell us what the problem is
Our primary role is organ support, and we tend to think in terms of problems rather than diagnoses.
• Is hypotensive despite 4L of fluids
• Has an AKI and refractory hyperkalaemia
• Is in T1RF and hypoxic on 15L NRB
3. Give us the numbers
Before you call (unless the patient is crashing in which case dial 2222 and we will come) it’s really helpful for us if you have the notes, the obs, the bloods and the gas in front of you. We will likely want the exact numbers in addition to the trend.
4. Give us the background, co-morbidities & escalation plan
We may ask you some odd Qs. How far can the patient walk? When did they last get out of the house? We are asking about their physiological reserve, whether ITU is in their best interests & what their wishes would be.
5. Have you called your boss?
ICM is a consultant led specialty. If we are admitting a patient it’s likely we will be calling our boss. So we may ask you to do the same. If your patient is sick enough for an ITU admission shouldn’t their consultant be aware?
6. But you don’t always have to refer across, to refer up
There may be times that your senior is in theatre, the med reg is in resus, and you find yourself on your own with a sickie. It is ALWAYS ok to call. Part of our job is outreach, and we will never mind giving advice.
7. Do you need to put out a crash call?
Still struggling to get help? Remember you can always dial 2222. This will get you the whole team. Find out who this is during the day and night. Sometimes it will be an intensivist, other times an outreach nurse or anaesthetist.
On that note it not always possible to attend every MET/crash call. It may be that we are stuck in theatre or that the patient in front of us is actually sicker. And we’re often not needed. If you do need us ASAP (i.e. an airway problem) consider putting out a fastbleep via 2222.
8. Still no luck?
This happens occasionally. It may be a horrendous night on the unit, or we are juggling multiple critically unwell patients. Or it might be the ITU reg is particularly difficult, they do exist. You may need to escalate to the ITU consultant
Usually, unless it’s an emergency this should be consultant to consultant. Never feel guilty about waking up the boss. Remember, you are advocating for your patient. Trust me, your consultant would always rather know.
9. Who else can you call?
There are lots of highly skilled clinicians who can bring critical care skills to the ward/ED who can support you. Find out who these are. Do you have a hospital a night service or night nurse practitioner? An outreach nurse or ACCP?
10. You CAN call us for a cannula
Ok, this is our pet peeve. But if no one else can get a line in it is ok to call us. Tips to get us on side:
• Have a go yourself
• Ask your senior to have a go
• Make sure the IV treatment needed is actually needed and needed now
This blog from LITFL is actually about referring patients from the ED but written by @precordialthump who is also an Intensivist, and I like it. Contains the @amalmattu rule of “be nice” and has some cracking advice for all specialties. https://lifeinthefastlane.com/referring-patients-from-the-emergency-department/
Again, this blog from @docib for @stemlyns is about referring patients from the ED but the advice is applicable to all specialities. http://stemlynsblog.org/making-a-referral-with-iain-beardsell-st-emlyns/
Lastly, my intensive care colleagues, I urge you to always be compassionate and kind. Remember the colleague on the end of the phone is calling you due to their overwhelming concern for the patient. Let’s break down the walls of critical care!