The Critical Care Clinical Nursing Research Unit was established in October 1998. It represented a collaborative venture by Sue Studdy (former Dean of School - Nursing and Midwifery, City University) and Jonathan Asbridge (Chief Nurse - Barts and the London NHS Trust, now acting Chief Executive). It is funded by the Special Trustees for five years. The innovation is led by Carol Ball, Research Fellow in Critical Care Nursing and Myrna Scott, Research Assistant in Critical Care Nursing.

At the time of the project's inception no other Critical Care Clinical Nursing Research Unit had been established in the UK. However, professorial appointments in Critical Care Nursing had been made in the USA and Australia and networks were established with Professor Sharon McKinley at the Royal North Shore Hospital in Sydney and Professor Kathy Dracup in the USA.

Initially, establishment of the Critical Care Clinical Nursing Research Unit was based on two developmental strategies. The first entailed ensuring that the research undertaken was inclusive. That is to say nursing staff felt involved in the development of a research within the intensive care units of the Barts and The London NHS Trust and that their interests were represented i.e a research culture evolved.  As a result of consultation with nursing staff, it was decided that research development was to be patient centred and focus on practice development at first. It was hoped that pertinent, practice based research questions would arise out of this strategy. The second strand of the development entailed increasing the credibility ot the Research Fellow, in research terms, through the attainment of a PhD. The rationale for this was that Carol would be able to attract funding when it became available.

Other projects suggested were the use of the prone position in the management ot the Adult Respiratory Distress Syndrome (ARDS), the effective management of pyrexia in sepsis and the safe and effective discharge of patients from the ICU. As a result of discussing practice issues, on team-awaydays, it became evident that communication between the ICUs across the Trust was not easy. A newsletter was commenced entitled 'On the Ball' (excuse the pun!) to inform nursing staff of practice development occurring on different sites. Practice development activity was collated and groups formed across sites to take the project forward. These topic areas included tracheostomy management, tissue viability, nutrition, management of ventricular drains, developing a sleep and rest policy and sedation scoring. It was also hoped the newsletter would aid communication between the various intensive care units concerning burgeoning research activity.

In order to release nursing staff to pursue the various issues outlined above and to ensure visibility of research staff in the clinical area it was agreed that nurses involved with identified research/practice development projects would be released from direct patient care on agreed shifts and replaced by Carol or Myrna. The researchers could then maintain their skills in the care of the critically ill and demonstrate a credible practice base.

Following on from this the research team was invited to be involved in an audit of trauma management within The Royal London Hospital. This involved auditing 30 consecutive trauma calls to the A & E department at the London over a 2 week, 24 hour on call period. The patients were audited from admission to discharge to determine the overall outcome of care.

Myrna has also developed an external link with the independent sector Heart Hospital, who are developing ICPs for cardiac surgical and cardiology adult and paediatric patients. Carol and Maree Barnett (Senior Nurse Cardiac Directorate), have also acted as the national co-ordinators of an international research project (approx. £4,000 funding achieved) which reviewed the reasons why patients delay accessing treatment when experiencing chest pain. Activity has also focused on increasing the profile of nursing in the care of the critically ill especially in relation to the development of government policy. To this end Carol has attended and continues to contribute to policy development within the Review of Adult Critical Care Nursing and the London Region Standing Committee - Critical Care.

Nursing staff have also been given the opportunity to access Research Groups, where the research process is discussed and applied to issues associated with the care of the critically ill. The innovation has been supported by consultant medical staff and the research team have been invited to participate in research bids made to the Medical Research Council. It is also hoped multidisciplinary research may occur in the future.

The effective management of pyrexia in sepsis was addressed through a retrospective, exploratory research study undertaken by Stephanie Dunleavy (Sister ICU The Royal London Hospital). This is now complete and will hopefully be published. The discharge of patients from intensive care has also been addressed, by Julie Whittiker (Staff Nurse ICU The London), through a small exploratory study. This has also now been completed and is the subject of publication (see below). The trauma audit is nearing completion and it is hoped data from this will be used to enhance the provision of current trauma services and result in publications.

An ICP package covering all care from the pre admission clinic to discharge for cardiac surgical patients at both Barts and The London Chest is to be launched in October. This package has resulted from close collaboration between practitioners and research team. In addition, The London Chest Hospital ICU launched their post operative ICP earlier this year after much hard work from Senior Sister Frances McGetrick.

Action research associated with the monitoring of variances, in the cardiac integrated care pathway at Barts ICU, has led to practice innovation in the management of bleeding post operatively The process of change, in relation to the management of bleeding, was successfully presented by Trenna Boley and Sarah Cahill (Sisters ICU Barts) at the British Association of Critical Care Nursing (BA CCN) in September last year: Future work will focus on gaining consensus from the cardiac consultants in the management of bleeding and development of a nurse led treatment of bleeding protocoL

In addition, analysis of the variances identified the need for a weaning from ventilation algorithm to supplement existing extubation criteria. This work has been led and audited by Sister Lai Holden resulting in improvements in extubation times.

A third variance related to patient welfare. This is associated with the successful weaning of patients from long term ventilation ie. more than one day on a ventilation. Currently a review of patients' notes is being undertaken by Myrna Scott and Debbie Gaffey (Sister - ICU Barts) to ascertain the nature of problems encountered during the weaning process.

The ICP for spinal cord clearance, developed by Paul Ratcliffe (Charge Nurse ICU The Royal London) and supported by Myrna, is ready for implementation, but awaits certain changes to medical practice before moving forward. Evaluation of the spinal integrated care pathway will then take place. Variances will then be established and become the focus of future research.

The doctoral study undertaken by Carol has been the subject of various conference presentations. The RCN Research Forum, the International Council of Nurses and in December of this year it will form the basis of a review of advanced nursing practice, held under the auspices of the Intensive Care Society. The doctoral study has been submitted and defence of the thesis will hopefully take place in the near future. It is hoped that the model for advanced nursing practice in critical care, Legitimate Influence - the key to advanced nursing practice in critical care, produced as a result of Carol's thesis will be used to evaluate the new nurse consultant role in critical care. This will take the form of an Action Research project. Several nurse consultant appointments are in the process of being made within ELCHA specifically at Barts and The Royal London and the Homerton NHS Trusts. Carol has also been asked to participate in several other nurse consultant appointments, specifically helping with the presentation of regional bids, as a result of her research. It is also possible that the research activity, expected of nurse consultants, would result in some future collaborative research projects, publication and conference presentation.

Data collection for the international research project associated with delay in seeking treatment for chest pain is also complete. 150 patients were recruited from the East End of London. Analysis is now taking place and the research report is currently being written by Dr. Debra Moser and Professor Kathy Dracup, Dean of School (Nursing) UCSF USA. Publication is likely in June of next year. Carol and Maree have been invited to San Francisco to discuss further international collaboration on this topic

The Review of Adult Critical Care Nursing is now complete and the subject of scrutiny by the Chief Nurse for England and Wales. The London Regional Standing Committee for Critical Care Nursing has established a web site for critical care nurses which has several remits. The first is to provide a forum for practice development which will alert nurses to good practice initiatives and reduce replication. The web site will also provide access to an expert group who will provide guidance on the development of research proposals and dissertations. Carol has been invited to become a member of this expert group. The final aim is to develop some multi-centre research trials, using the network provided by registration at the web site.

The London Regional Standing Committee has also decided to review nursing workload and the need of critically ill patients for nursing (i.e. the 1:1 nurse:patient ratio). To achieve this the project currently addresses two issues. Firstly, the review of patient dependency and nursing workload scoring systems. Carol is to take the lead on this. The second strand of development, which may well form the second stage of the project, is to explore the work of critical care nurses from a qualitative perspective.

Teaching and learning associated with use of the prone position in ARDS has been instituted by Judith Adam (Sister ICU Barts) and Ita O'Connor (Sister ICU The Royal London Hospital). Judith has led the development of practice guidelines which will trigger consideration of the prone position and it is hoped that this will form a research protocol once the research question and aims have been decided. As a result of the forthcoming implementation of the clinical guidelines Hill Rom, (the manufacturers of the Respicair bed) have sponsored the placement of a Respicair bed in the Barts ICU for research purposes.

In June, Myrna and Paul Ratcliffe attended the RCN Critical Care Conference in Newcastle and presented a workshop on ICP development and implementation. Following this Myrna presented a paper on respiratory physiology and ventilation at the British Association of Recovery and Anaesthetic Nurses conference in Birmingham.

In September of this year, the Critical Care Nursing Research Unit was fortunate in having four papers accepted for presentation at the BACCN international conference, held in Edinburgh.

An individual presentation by Ann McGinley on the need for Trauma Nurse Co-ordinators. Ann has also been successful in being appointed as Nurse Consultant for the Patient at Risk Team.

Paul and Myrna presented a workshop on the development of ICPs for cardiac surgery and spinal cord clearance.

Myrna in conjunction with Richard Hatchett and Emma Gardner from the Heart Hospital presented a paper on the reality of implementing ICPs in the clinical area.

Judith and Carol presented the development of clinical guidelines in use of the prone position in ARDS.

A number of publications have also resulted from work undertaken within the Critical Care Clinical Nursing Research Unit, see end of this article.