ORIENTATION 2016

Intensive Care Department

BENDIGO HEALTH

Overview

Bendigo Health• >3,300 staff• Catchment covers area 1/4 size of Victoria• Expanding regional health organisation.• 678 bed acute service

• >41,000 inpatients per annum• >45,000 emergency attendances per annum• > 1200 births each year

• 60-bed rehabilitation unit• 8 intensive care unit • 5 operating theatres

• >10,000 surgical procedures performed annually

Bendigo Health• Services for the Loddon Mallee region

• Emergency and intensive care• General Medicine• General Surgery• General Paediatrics• Maternity & Women’s Health• Medical imaging• Pathology• Cardiology• Cancer services• Renal & dialysis• Endocrinology• Respiratory• Gastroenterology• Thoracic Surgery• ENT• Plastic Surgery• Urology• Rehabilitation• Community services• Residential aged care• Psychiatric care• Community dental• Hospice & palliative care

• Three main campuses in Bendigo

• Regional settings include: Mildura, Echuca, Swan Hill, Kyneton and Castlemaine

• $630 million to deliver a new Bendigo hospital opens 23 January 2017

Bendigo Health• Services NOT YET available

• 24/7 catheter laboratory• Interventional radiology• Vascular surgery• Neurosurgery• Cardiac surgery• Neurology• Rheumatology• Paediatric ICU

• Three main campuses in Bendigo• Regional settings include: Mildura, Echuca, Swan Hill, Kyneton and

Castlemaine

• $630 million to deliver a new Bendigo hospital opens 23 January 2017

INTENSIVE CARE UNIT

Unit Structure & Function

• Clinical• Professional Development• Research• Telemedicine

INTENSIVE CARE UNIT

“Inside”

Inpatient ICU Unit details

• Combined ICU/HDU/CCU• 11 physical beds (6 ICU equivalents funded)• 5 ventilators, 3 non-invasive ventilators• 2 haemofilters• 1 IABP/Bronchoscope/Pacing• Bronchoscope comes from OR so need to order• ECHO machine In ICU consultants office

Staff

• Intensivists x 6 • 5 registrars and 5 residents • NUM– Sue Tomlinson• CNC – Jenni Tuena• ICU Nurse Educators• Liaison Nurses x5• Research nurse – Julie Smith

Staffing

• 3 nursing shifts/day• Staffed: 8 nurses/shift• Day:

• 1 registrar (0800-2030) & 1 HMO (0800-2030)• Night

• 1 registrar (2000-0830) & 1 HMO (2000-0530)

Rostering

• Consultant rostering• Found on FindMyShift

• Roster and Leave issues • Kronos

Nursing ratios

• ICU 1:1• HDU 1:2• CCU 1:2

Daily routine• 0800: night to day hand over• 0830 consultant business round• 1600: afternoon consultant round• 2000: night registrar hand over• 2130: Night consultant round• 1230 & 1930 Paper rounds, Rolling Handover preparation

(ROVER)• Day tasks update/Drug and IV charts/Micro sheets

• Random Audits • Admission or Discharge summary/Notes/Documentations

Ward roundsStage Purpose Who Time required

(minutes)Outcomes

1 Check-in Intensivist (s), ACN 5 – 10 All emergent issues resolved2 Business &

handoverIntensivist (s), ACN, ICU medical staff, allied health

5 - 20 All patients ready for discharge identified Tasks identified needed to complete prior

to discharge Seek allied health input Intensivist handover

3 Management & teaching

Intensivist, medical staff (other staff able to attend if they wish)

30 – 120 Assessment of each patient Construct management plan for day Teaching

4 Radiology review Intensivist, medical staff, physio

5 - 15 Review all radiology Teaching

5 Check-out Intensivist, medical staff, ACN

5 Discussion and agreement on –o high priority taskso timing of any procedures (eg.

tracheostomy)o incoming patientso bed access issues and any other issues of

concern

Ward rounds• ICU Detailed Paper Notes

• FAST HUGS ..MBSE• Issues list• Management plan• Feeding & fluid plan

• Procedures & investigations• Microbiology & antibiotics• Paper rounds (Registrar checklist)• Patient Diary?• Research patient?

• SPICE/TRANSFUSE/Nebulised Heparin• ART123/ADRENAL

General dutiesRegistrar

• Responsible for implementation of plan• Delegation of tasks• Teaching of residents & students• Presentation (or Resident)

• Admission and Discharge summary (?Med Student)• Hand Over of CCU patients

• By CCU reg to ICU reg

ALL PATIENTS FULLY REVIEWED DAILY AND ONE FULL NOTE PER SHIFT

Expectation

• Doctor immediately available 24 hours per day• Professional• Strict infection control

• 5 moments of HH• Nothing below the elbows

• CISCO phones & Pagers

Patient reception

• Aim is to have a single, multi-disciplinary handover

• From Anaesthesia• Unusual practice of telephone handover

• From ED• From Ward• From Adult Retrieval/external transport

ICU specific Forms • Resuscitation • Palliative care• Drug Chart and IV form• Procedure Sticker• CVVHDF sticker• Consent-Trachy/Blood transfusion• Micro sheets • Tertiary Trauma Survey• Refusal forms• Tracheostomy Notes • VAE forms

Routine bloods & CXRs

• On admission: Full bloods, MRSA & VREswabs• Routine bloods: FBE, U&E, Ca-Pho-Mg• LFT, CRP as clinically indicated (1-2/week)• Coag as clinically warranted• Cultures- Blood, sputum, Urine, Antigen, PCR,

Serology etc• CXRs

• on admission, then as clinically warranted

Microbiology

• Pink forms• Actively chase results

Procedures

• Work Place Competency (CICM website)• Consent• Supervision• Sterile technique• Number of goes!• Documentation

• Clinical note• Google form Procedure note

Ultrasound

• SiteRite• Vascular Access

• Stored in ICU• Sparq

• Vascular Access• Echocardiography

• Stored in Sanjay’s office• Not to leave ICU• For ICU use only

PICC referrals

• You may get referrals from outside ICU • Refer them all to the ICU Liaison Nurse

(#7936)• Intensivist authorises insertion• Inserted by Radiology or ICU (you, with LN

nurse, in ward)• Oncology insert their patient’s PICC

Intubation

• Oxygenation, not airway plastic, is the goal…

• Is a TEAM game• Always “phone a friend”• Clear documentation in notes• Airway form being developed• Intubation checklist must be used – minimises

errors

Parent Unit• Encourage involvement• “Talk before you walk”

• Actively ‘catch’ parent teams for updates• Bi-directional verbal and written communication• “CCMx” is not a recognised abbreviation

• CLOSED UNIT• Only ICU prescribes and administers therapies• Treating teams can request from ICU

Referrals• Elective versus emergency• Consultant/Registrar/Resident• Emergency

• Review patient within 30 mins• Discussion of suitability for ICU (Intensivist)• Discussion of bed availability (ANUM – who D/W Bed Manager

always!)• Parent unit• MET call is a NOT a referral method, yet may become a referral!• REFUSALS BOOK

Referrals• Elective versus emergency• Consultant/Registrar/Resident• Elective• Most seen in ICU pre-admission clinic -

• Suitable for ICU – cancel op if no ICU bed• Suitable for ICU – proceed if no ICU bed• Do not require ICU

• Discussion of bed availability b/w Bed manager and parent unit pre-op.

• REFUSALS BOOK

Bed Management

• The arbiter of the bed state• We send people out through Adult Retrieval

Victoria if we can’t offer them a timely ICU bed

Paediatric ICU

• Shared care• May include PIPER consultation• Developing a program• Needs multi-disciplinary care

Infection control

• Hand hygiene• CLABSI• Full barrier protection for all lines, except ivs• Isolation procedures

Discharges

• Electronic summaries (notes & clerk)• Drug charts (rewritten as needed – common

sense)• Blood forms & radiology (for next 24 hours)• PARENT UNIT

• Contact and handover• After hours discharges – review within 4 hours

Deaths

• Consider organ and tissue donation• Document assessment• Inform treating team• Write ICU discharge summary

• Fax and call GP• Online Coronial or Births/Deaths/Marriages

certification

Organ and Tissue donation (OTD)• Can bring patients from ED for EOLC and family time• Consider organ and tissue donation in any EOLC

scenario• Donation after Brain Death (DBD)• Donation After Circulatory Death (DCD)• Tissue donation• Corneal/whole eye donation

• OTD can occur when patient is coronial referral• Call Organ and Tissue donation nurse early

INTENSIVE CARE OUTREACH

“Outside”

Outreach & Outpatient activities

• Medical emergency team (MET)• Code Blue team• Outreach round – TPN, PICCs• ICU Liaison nursing• ICU pre-admission clinic• ICU Follow-up clinic• Weekday telemedicine to Echuca HDU

MET & CODE Blue• Team (only 1 ICU doctor to attend - Registrar)

• ICU and Med Reg; CCRN and ward Nurse• Respond within 5 mins• Assessment• Management• MET sticker• >= 2 MET consultant review• Policy in Prompt

• CODE blue• Immediate response• Prompt for policy • Senior Docs from ICU/ED/Anaethetics/CCRN

Telemedicine

• Weekday telemedicine consultation with Echuca HDU

• 1500hrs• Enables remote management of patients• A bridge to HDU in Echuca

NON-CLINICAL

Research

• Registrar projects• Resident support• Audit

• Ongoing departmental audit• Formal Project related

• ANZICS CTG - Julie Smith

Mortality & Morbidity• Wednesdays at 1335hrs on overhead projector• Team meeting and discussion• Patients presented:• Deaths in the unit & post ICU discharge• Readmissions• Morbidities

• CLABSI, VAPs, accidental CVC removal, failed extubation etc

• Day registrar presents• types updates as needed• Format on G: drive

Education

• Mandatory training• iLearn

• Fire safety• Aseptic technique/Hand Hygiene• Blood safe• ALS• Open Disclosure training

Education & Training

• C6 accreditation for ICU in CICM• Rotating RACP, ACEM, ANZCA trainees• Supervisor of Training – Emma Broadfield• Exam preparation• Mentors• Pastoral Care

Education & Training• Wednesday afternoons

• ICU grand rounds and presentations (Registrar/Consultant)• Based on themes• On FMS Hub link

• Other specialty teaching• Audit• Mentorship• Echo• Daily Presentations at bedside• On-line Information• Intranet access to journals, Up to date, Crit-IQ, PROMPT• BASIC course 2 per year• Critical Airway course

ICU attire• Smart clothing or scrubs• Respectful of a broad spectrum of a critically ill patient

demographic • Nothing below the elbow• Tie-free zone• Lanyard free zone• Radiology Monitors are to review Radiology not for

Internet Browsing!• Timely Lunch…Time Management!

Any questions?

Time for a tour