Critical Thinking in Critical Care

Rachel Kinney, CVT, VTS(ECC), discusses critical thinking in the hospital environment. Identifying potential patient needs, prioritizing competing tasks, and error avoidance are covered.

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The intensive care unit (ICU) is literally where life and death decisions are made. I have seen firsthand, over the past 12 years working in the ICU, how important critical thinking is to providing premier care with the best chance of survival to our patients. Critical thinking involves processing information in a manner to organize and clarify, raise efficiency, and recognize and avoid errors. I like to break this down into three easy steps that I can apply to the pets under my care: identify, prioritize, and prevent error.

The identify step is simply gaining an overall picture of the patient and their disease processes. Being aware of this information will allow you to provide the best care and anticipate any complications. This includes the signalment but goes beyond that; your patient’s anatomy, nursing care needs, predispositions, medical history, and current disease processes all give you valuable information about how to care for them.

Say your patient is an English Bulldog hospitalized for a potential foreign body. We all know that bulldogs can have problems breathing due to their atypical anatomy. So, why should we think about this when the dog is here for a possible foreign body? Vomiting and regurgitation are usually seen with foreign bodies, so this would lead me to be concerned about aspiration and the critical state it could put this patient in as a result. Then there’s the Labrador retriever on a ventilator post near drowning with stable vitals. He has a nasogastric tube and a urinary catheter in place and is on a CRI to keep him sedate. It can be easy to miss some of the nursing care required when working on a patient with so much going on. In these cases I will look over the patient from nose to tail to determine any extra care besides monitoring he will require. His eyes need to be lubricated, NG tube potentially aspirated and placement verified, range of motion of arms and legs, IV catheters checked for patency, recumbency changes, and urinary catheter care all at regular intervals. As critical thinking technicians, we are able to add these types of treatments to the orders without needing to be asked. This proactive approach will impress your veterinarian!

How about the Cavalier King Charles Spaniel that presents for a toxin ingestion requiring diuresis? Being aware of this breed’s predisposition to heart disease will enable close monitoring and quick intervention should any signs of heart failure be noted when receiving intravenous fluids. Knowing an animal’s medical history permits us to be prepared to address previous or known issues should they arise while in the hospital. Being conscious of preexisting conditions such as seizures, diabetes, hypoadrenocorticism and immune mediated diseases will allow for more detailed monitoring and swift response should symptoms arise.

Another important concept in identifying your patient is to understand his disease process. Being able to answer the question, “What is happening inside the body?” will give you better insight into the patient’s needs and what to expect down the road. Being prepared for complications that are known to arise with certain conditions will give them the best possible prognosis.

Now that you have identified your patient, you can use that information to prioritize your nursing care plan. You now have a better understanding of which patients are the most critical which allows you to formulate a plan of how best to keep up with their needs. This step becomes all the more important on those very busy days in the ICU with multiple unstable patients. You might have veterinarians coming to you with numerous orders for all of these patients, and it is up to you to determine the order the directives get done. Veterinarians rely upon us to complete their orders effectively and efficiently.

For instance, a DVM gives the following orders for the above referenced cases:

  • Start a Clinicare CRI via the NG tube on the Labrador on the ventilator
  • Discontinue the IV fluids and administer a dose of furosemide on the Cavalier with toxin ingestion
  • Administer an antiemetic to the bulldog with a potential foreign body

What do we do first? While it may be natural to want to tend to the Labrador (being the most incapacitated animal) first, we need to prioritize by which results need to occur first. While the Labrador may appear to be the most critical, he already has a protected airway and his vitals are stable and monitored closely via the ventilator and anesthetic monitoring equipment. Yes, it is going to be beneficial to get enteral nutrition started for him, but it will not affect his prognosis if the CRI is not started immediately. The orders for the Cavalier should be evidence that there is concern for heart failure, which can lead to rapid respiratory decompensation. Cessation of breathing and asystole are the two most imminent life-threatening issues to our patients. While administering an antiemetic to our bulldog patient may seem like the least important order, we have determined that he is at risk for aspiration pneumonia given his condition and anatomy. While his respiratory system is not currently compromised, any intervention that can be done to prevent continued vomiting and regurgitation would decrease his chances of developing this more dire condition. We are now able to prioritize that the orders for the Cavalier should be performed first, those of the bulldog second, and the Labrador’s third.

Now, there will be times when more than one patient is in need of immediate medical intervention to save his life. Being able to delegate tasks to achieve your goals is an invaluable skill to have in animal medicine. Even if you are not the one physically providing the care to your patient, taking the initiative to ensure urgent needs are being met as quickly as possible grants the best prognosis and demonstrates your responsibility to your patients.

This brings me to the final step I use for critical thinking on the job: preventing errors. This is a huge concern in any medical field and should never be taken lightly. Believe me I know how easy it can be to fall into the habit of just going through the motions. This happens when we can become complacent and forget the incredible responsibility we have as caretakers. We become what I think of as “treatment monkeys.” Our motions become automatic and we perform treatments on the pet’s record without thinking about what it is we are really doing. This is when mistakes most often happen. I will assume that all of us have made some sort of medical mistake, big or small, during our careers given the human component. Well, remember that rush of dread and panic that courses through your body the moment you realize you have made a mistake? I sure do. And I want to do anything I can to avoid that feeling. By remaining cognizant of the responsibility we have and our client’s trust in us, we can greatly decrease the number and severity of medical mistakes in our clinic.

There are two methods that I have found easy to integrate into your work routine that can help achieve the goal of avoiding errors. The first is triple checking. I learned a method in tech school that I have never forgotten and apply every day. It is so simple and easy once you get the hang of it. Every single time you pick up any medication to administer, there should be three times you verify the drug and concentration: first, when you pick up the bottle; second, as you draw the drug up into a syringe or take pills out; and finally when you are putting the bottle back on the shelf. I also apply this method to IV fluids as incorrect fluid type, rate, and additives can go unnoticed if not frequently checked.

verify the drug and concentration 1 verify the drug and concentration 2 verify the drug and concentration 3

The second method is equally easy: ask questions! You don’t understand exactly how the veterinarian wants a procedure done? Don’t know what that word means? What does that medication do? Ask. Does that dose seem really high? Are the post-op orders different from the surgeon’s requests? Ask, ask, ask! So easy, right? I think this step is skipped often because it can be intimidating to ask questions if you think you will be judged for not knowing the answers. While it can be a humbling experience to not know something, this is how we as technicians continue to learn and gain confidence on the job. That feeling of embarrassment of not knowing something does not hurt anyone (other than your pride), while following orders that you do not understand or that don’t make sense could lead to errors.

Unfortunately medical mistakes will never be completely eradicated, with us being human and all. But mistakes can be greatly reduced and made less life threatening by being detail oriented. When we apply critical thinking to our work, we progress our knowledge and confidence in our role as a patient advocate. And ultimately provide greater service to our patients and clients.

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Karen Holmes's picture

Thank you! Thank you!! THANK YOU!!! One of the best articles I've read so far. As a vet nurse (Aussie version of Vet Tech) with previous experience in emergency and critical care I completely agree with everything you've written.

I am now a trainer of student vet nurses and this article wonderfully expresses the importance of pre-empting patient needs, questioning when uncertain and continually assessing what you are doing.... sometimes my students need to hear this from someone other than me! This article is most definitely going on my favourites list :)

Christina Meyer's picture

Thank you so much for this! As a recently employed ICU tech...this advice is so important to me.

Valwynn Williams's picture

Another awesome article by @Dove contributors! I love to build protocols and strategies for myself to rely on when I'm dead tired and/or crazy busy. Thanks for this. Also, I like to remind myself of the responsibility I carry for my patients and that "the buck stops here" with me :-)