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INTRODUCTION

KNOWLEDGE COMPETENCIES

  1. Discuss the importance of an interprofessional plan of care for optimizing clinical outcomes.

  2. Describe interventions for prevention of common complications in critically ill patients:

    • Venous thromboembolism

    • Infection

    • Sleep pattern disturbances

    • Pressure injury

    • Delirium

  3. Discuss interventions to maintain psychosocial integrity and minimize anxiety for the critically ill patient and family members.

  4. Describe interventions to promote family-centered care and patient and family education.

  5. Identify necessary equipment and personnel required to safely transport the critically ill patient within the hospital.

  6. Describe transfer-related complications and preventive measures to be taken before and during patient transport.

The achievement of optimal clinical outcomes in the critically ill patient requires a coordinated approach to care delivery by interprofessional team members. Experts in nutrition, respiratory therapy, physical therapy, social work, pharmacy, palliative medicine, critical care nursing and medicine, as well as other disciplines, work collaboratively to effectively and efficiently provide optimal care.

The following section provides an overview of interprofessional plans of care. In addition, this chapter discusses approaches to patient needs that are not diagnosis specific, but common to a majority of critically ill patients, such as sleep deprivation, pressure injury, and patient and family education. Additional discussion of these needs or problems is also presented in other chapters if related to specific disease management.

INTERPROFESSIONAL PLAN OF CARE

An interprofessional plan of care is a set of expectations for the major components of care a patient receives during hospitalization to manage a specific medical or surgical problem. Other types of plans include clinical pathways, protocols, and care maps. The interprofessional plan of care expands on the concept of a medical or nursing care plan and provides a comprehensive blueprint for patient care that includes the roles of multiple team members. The result is a diagnosis-specific plan of care that focuses the entire care team on expected patient outcomes.

The interprofessional plan of care outlines the tests, medications, care, and treatments needed to transition the patient to the next stage of care in a timely manner with all patient needs met. These plans have a variety of benefits to both patients and the hospital system:

  • Improved patient outcomes (eg, morbidity and mortality)

  • Increased quality of care

  • Continuity of care

  • Improved communication and collaboration between team members

  • Identification of hospital system problems

  • Coordination of necessary services

  • Prioritization of interventions

Teams of individuals who closely interact with a specific patient population develop interprofessional plans of care. The process of multiple disciplines communicating and collaborating around the needs of the patient benefits patients. Representatives of disciplines commonly involved in developing plans of care include providers, nurses, pharmacists, respiratory therapists, physical, occupational and speech therapists, social workers, and dietitians. The format for the interprofessional plans of care typically includes the following categories:

  • Patient goals (eg, pain control, activity level, absence of complications)

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