Early Recognition and Rapid Administration of Acute Condition in

Intensive Care Unit: A Literature Review

Muhamad Ibnu Hasan

, Untung Sujianto

and Reni Sulung Utami

Students of Master Program in Nursing, Faculty of Medicine, Diponegoro University, Indonesia

Lecturer of Department of Nursing, Faculty of Medicine, Diponegoro University, Indonesia

Keywords: Early Recognition, Vital Sign Monitor, Rapid Administration, Direct Therapy, Intensive Care Unit.

Abstract: The observation program is an attempt to determine the deterioration of the patient's condition and has an

important role in improving patient safety. Critical care advantage patients whose near death through a

series of detailed observation actions with or without invasive and restorative treatment. Early recognition

and rapid administration is a prediction method for the successful treatment of acutely ill patients with a

high risk of death and decrease sepsis mortality. The aim of this review is to explore concept early

recognition and rapid administration method as the monitoring intervention in intensive care unit. This

article used integratif literature review through the search for published and gray literature in the following

databases: EBSCO (CINAHL & MEDLINE), Science Direct and PubMed. This review found 32

documents and selected 9 articles and 3 books literature for data extraction and analysis. Early recognition

and rapid administration method can be applied in intensive care unit. Vital Sign Direct Therapy (VSDT) is

considered to be suitable paper based protocol for early recognition and rapid administration method and

used goal directed therapy approach for the patient in intensive care unit. VSDT protocol consist of

monitoring and early intervention in danger sign in acute condition.

1 INTRODUCTION

Monitoring is basic intervention that is carried out

routinely and continuously in intensive care.

Monitoring is an effort to practice the forefront in an

effort to optimize hemodynamics, ventilation,

temperature, nutrition and metabolism in improving

the survival of patients in critical care rooms.

Monitoring also plays an important role in assessing

the effects of treatment, detecting procedural

complications and identifying early signs of clinical

damage (M. R & Payen, 2005; Moreno, Rhodes, &

Donchin, 2009).

Patients monitoring is carried out in detail with

or without accompanying invasive care efforts that

support the achievement of restorative care goals.

The purpose of restorative care is an attempt to

restore the physiological functions of critically ill

patients and if not achieved, patients can experience

a condition of organ failure which is the main cause

of patient death in critical care rooms (Aslakson et

al., 2012).

The knowledge insuficiency of monitoring

practice and delayed in treatment is a prone to errors

in carring process that can inhibit the benefits of

restorative care in critical care. The goals of

restorative care also constrained with the orientation

of health care provider which is more attention in

carring form oriented than patients oriented, lack of

access to support and standard decision according to

the patient's condition and lack of efficient global

facilities. The survey on critical care practices

indicate that the majority of ICU rooms have

limitations in acute resuscitation regulation

resources, especially in an effort to assess conditions

early and make decisions about giving immediate

treatment to patients (Bracco et al., 2001; Pronovost

et al., 2003).

The standard method to evaluate patient

condition early and decission of treatment rapidly

for critically ill patients are needed to overcome this

obstacle in critical care unit. Health care providers

must able perform clinical assessment to determine

patient's condition through monitoring, identified

patient clinical hazard conditions immediately and

give appropriate intervention for patients. (Benner P,

Tanner, & Chesla, 2009).

Acute patient had unstable condition and need

Hasan, M., Sujianto, U. and Utami, R.

Early Recognition and Rapid Administration of Acute Condition in Intensive Care Unit: A Literature Review.

DOI: 10.5220/0008201700670071

In Proceedings of the 1st International Conference of Indonesian National Nurses Association (ICINNA 2018), pages 67-71

ISBN: 978-989-758-406-0

continuous monitoring and treatment until get stable.

Patients with danger clinical conditions need to get

rapid action, include the efforts to consult with

another medical staff for the administration and

provide rescuciation management. Delayed efforts to

detect patient deterioration and the administration

will affect the final patient outcome. Therefore, the

effort need to improve monitoring as the clinical

assessment and immediately management of patients

with critical illness conditions in intensive care

(Kipnis et al., 2012).

2 AIMS

This paper is a literature review that explore concept

early recognition and rapid administration method as

the monitoring intervention in intensive care unit.

3 METHOD

Literatur review was chosen because it contain broad

integration of empirical and theoretical literature to

explore concept of certain phenomenon. An

extensive literature search was used in English,

conducted from 2010 to 2017 and following

databases Ebsco (CINAHL & MEDLINE), PubMed,

Spinger and text book literature. The included

studies used all range of study designs with

following keywords early recognition, rapid

administration, critical care, intensive care unit. The

combined database search was found 32 documents

and selected 9 final articles and 3 books literature for

data extraction and analysis. Most of the studies

excluded were not in adult patient and not full text.

4 RESULT

4.1 Early Recognition in Intensive Care

Early detection is an attempt to find a disorder or

disease before developing into deteriorating

conditions. Efforts to early detection in intensive

nursing focus on the inability to identify earlier

deterioration in the condition of patients who might

benefit from the implementation of a series of

actions and strategies that continue to evolve to

improve treatment outcomes (Schultz, 2009).

Early detection of patient deterioration condition

is carried out immediately and requires accuracy in

assessing deterioration that occurs through patient

hemodynamic monitoring. Monitoring

hemodynamic conditions aims to provide factual

data in increasing the oxygenation needs of the body

tissues that are the furthest and effective in dealing

with hypoxia, shock and multiorgan failure. The

condition of vital organ hypoperfusion that lasts a

long time can cause multiple organ system

dysfunction, organ failure and end with death

(Rubenfeld, Aslin, & Rubinson, 2007; Pinsky &

Payen, 2005).

Hemodynamic changes in acute care settings

reflect the presence of cardiovascular insufficiency

conditions and response to an intervention. Early

monitoring of patients with unstable conditions is

carried out by assessing changes in vital signs and

specific organ perfusion markers such as capillary

filling speed (CRT) and urine output (Schultz,

2009).

The initial compensation that occurs in acute

care conditions is characterized by a mechanism for

increased breathing and heart rate with or without a

significant decrease in blood pressure and changes in

oxygen saturation as a sign of the initial decline in

the patient's condition. The effort of early detection

and management of the decline in the condition of

patients in acute conditions is carried out by

conducting an assessment of the Airway approach,

Breathing, Circulation, Disability, Exposure

(ABCDE) (Thim et al., 2015).

The ABCDE assesment is an approach for all

emergencies clinical condition to conduct immediate

assessment and management. This approach

improves treatment outcomes by focusing on life-

threatening clinical problems.

4.2 Early Administration in Intensive

Care

Early management is the provision of early

intervention carried out in medical emergencies

conducted by various regulatory techniques such as

the use of bundle methods and aggressive

resuscitation efforts based on goals direct therapy.

Goal-directed therapy (GDT) is a monitoring

technique to help guide fluid therapy, vasopressors,

inotropic and other treatments for patients in various

clinical settings. Goal-directed therapy uses

adjustments to heart activity which include preload,

afterload and contractility in an effort to balance

oxygen distribution with the body's oxygen needs

(Glew, 2009; Thompson-hill et al., 2009; O’Neal &

Shaw, 2015; Rivers et al., 2001).

The application of GDT significantly reduces the

duration of hospital stay and complications that arise

ICINNA 2018 - The 1st International Conference of Indonesian National Nurses Association

after treatment as a whole, especially kidney injury,

respiratory failure and wound infection. GDT was

originally developed in a critical care area to provide

care for surgical patients at high risk of shock, but

GDT has now been developed in the areas of

general, orthopedic, cardiothoracic and vascular

surgical treatments (Cecconi et al., 2013; Dunn,

Grocott, & Mythen, 2016).

4.3 Institutional Systems Improve

Earlier Recognition Rapid

Administration in Acute Resusitasi

Early recognition and rapid administration is an

effort to improve treatment success in patients with

acute conditions with a high risk of death. This

procedure is a key to the initial intervention that has

been carried out by referring to the target period of

the gold period as an achievement against safety

from life-threatening conditions. Efforts to

accelerate detection and treatment of patients have

been shown to increase outcomes for various acute

life-threatening emergency conditions, such as in

cases of acute myocardial infarction (MI), stroke,

shock or sepsis (Funk, Sebat and Kumar, 2009).

The strategy of aggressive early detection and

resuscitation is carried out to achieve a balance

between systemic oxygen delivery and demand for

oxygen to be a more definite profitable strategy.

This approach is also used in critical care areas as an

effort to increase the aggressiveness of care,

intervention and resuscitation by monitoring changes

in hemodynamic values. Indicators of hemodynamic

values and physiology will interact to obtain

performance and physiological estimates that can be

used as an effort to encourage early management

(Moser, 2014; Xu et al., 2016).

The application of early recognition and rapid

administration method in acute resuscitation critical

patient has been carried out with development

research program and produced several instruments

that can be used, the are checklist for early

recognition and treatment of acute Illness

(CERTAIN) dan vital sign direct therapy (VSDT).

CERTAIN is a web-based decision support tool

that displays relevant clinical information and is

filled with evidence-based knowledge of the best

clinical practice, organized according to a systematic

review of end-user data requirements and ergonomic

workflows. The CERTAIN application on mobile

devices was also developed with HTML-5 as a

complementary part of availability and ease of use

CERTAIN (Vukoja, 2015).

CERTAIN consists of two modules namely the

ELITE module (stabilizing the patient's condition

that threatens an emergency during admission /

resuscitation) and the CERTAIN round module (to

help provide routine maintenance every day

recommended). The CERTAIN module is regulated

by considering how experts incorporate information

into decision making models of clinical conditions.

Assessment of this application begins with an effort

to read each element from top to bottom which

contains primary assessment (ABCDE) and

secondary surveys and readings from left to right

which contain the basic elements of determining

clinical conditions for a list of patient problems,

availability of interventions on the central panel

status and proposed treatment and intervention

(Vukoja, 2015).

VSDT is one of the regulation strategies for

directed therapy through a series of efforts to

monitor changes in the condition of the patient's

vital signs which include airway, breathing and

circulating accompanied by procedures for

emergency conditions or hazard conditions that

occur based on paper records. VSDT is modified

from an EWS (early warning system) instrument by

considering the limited time and availability of

health resources (Baker, 2009).

The VSDT protocol is based on the limited time

and availability of appropriate health resources

provided by health workers, some of the activities

that can be carried out by nurses without a doctor's

direct presence, can be modified by the treating

physician, not as a substitute for doctors and clinical

assessment and openness is advanced therapy. The

parameters of a single danger sign are sorted from

several composite scores to create simplicity and

efforts to activate the early and specific governance

directions to be given. If a danger sign is found from

one of the parameters, the exclusion protocol

observations of vital signs are carried out more

frequently, ie every 30 minutes and given acute

acute resuscitation management for patients (Schell

et al., 2015).

5 DISCUSSION

Critical care provides restorative care to patients

with critically ill conditions through a series of

observation and management measures that are not

obtained in the usual care room. The success of

restorative efforts is able to restore the function of

organs as they should, but failure can lead to the

emergence of death.

Early Recognition and Rapid Administration of Acute Condition in Intensive Care Unit: A Literature Review

The main cause of death in intensive care is the

presence of acute and refractory multiple organ

dysfunction syndrome, central nervous system

failure and heart failure. Acute and refractory

multiple organ dysfunction (MODS) syndrome is a

developmental condition that has the potential to

disturb the physiological body but is reversible,

involving two or more organ systems due to

worsening physiological conditions (Ramírez,

2013).

MODS management is carried out with several

non-specific treatments in an effort to resolution and

prevent worsening conditions. Important events that

often appear before the occurrence of MODS is the

emergence of hypocirculation or shock conditions

that can often be predicted to occur within the first

24 hours of receipt. This condition is an important

concern, because early detection and the provision

of adequate initial resuscitation measures are the

main therapeutic focus that can improve the patient's

prognosis (Mizock, 2009; Khwannimit, 2008).

Implementation of patient management through

early recognition and rapid administration approach

in intensive care unit according to the principles of

MODS management which is the main cause of

death in critical patients. MODS occurs clearly

within 24-48 hours after a threat of physiological

conditions. The classic sequence of organ

dysfunction usually begins with the discovery of

signs of respiratory dysfunction and followed by

liver or gastrointestinal system dysfunction, kidneys

and other organs (Mohan, Harikrishna and Kumar,

2014).

Acute respiratory distress syndrome (ARDS) is

an early manifestation of the emergence of

respiratory system involvement in the condition of

MODS. The involvement of the digestive system is

characterized by an increase in transaminase liver

enzymes, hyperbilirubinemia and synthetic

dysfunction with an increase in international

normalized ration (INR) that develops into severe

liver failure or mild hyperbilirubinemia with or

without cholestasis. Acute kidney injury is classified

according to the RIFLE category.

Cardiovascular dysfunction is characterized by a

vascular condition that experiences systemic and

hypermetabolic inflammation. A decrease in the

Glasgow coma scale indicates neurological

dysfunction. Endocrine dysfunction is characterized

by dysfunction of the hypothalamic-pituitary axis,

impaired glucose and protein metabolism

(Venkataraman and Kellum, 2007).

6 CONCLUSION

Early recognition and rapid administration can be

applied in the intensive care unit. Vital Sign Direct

Therapy (VSDT) is considered as paper-based

protocol that is suitable for early recognition and fast

administration methods using goal-directed therapy

approach for patients in the intensive care unit. The

VSDT protocol consists of monitoring and optional

initial intervention in danger signs in acute

conditions.

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Early Recognition and Rapid Administration of Acute Condition in Intensive Care Unit: A Literature Review