ORIENTATION 2016
Intensive Care Department
BENDIGO HEALTH
Overview
Bendigo Health
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>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
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Services for the Loddon Mallee region
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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
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Three main campuses in Bendigo
Regional settings include: Mildura, Echuca,
Swan Hill, Kyneton and Castlemaine
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$630 million to deliver a new Bendigo
hospital opens 23 January 2017
Bendigo Health
• Services NOT YET available
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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
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Clinical
Professional Development
Research
Telemedicine
INTENSIVE CARE UNIT
“Inside”
Inpatient ICU Unit details
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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
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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
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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 rounds
Stage
Purpose
Who
Time required
(minutes)
5 – 10
5 - 20
Outcomes
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2
Check-in
Business &
handover
Intensivist (s), ACN
Intensivist (s), ACN, ICU
medical staff, allied
health
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Management &
teaching
Intensivist, medical staff
(other staff able to
attend if they wish)
30 – 120
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Assessment of each patient
Construct management plan for day
Teaching
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Radiology review
5 - 15
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Check-out
Intensivist, medical staff,
physio
Intensivist, medical staff,
ACN
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Review all radiology
Teaching
Discussion and agreement on –
high priority tasks
timing of any procedures (eg.
tracheostomy)
incoming patients
bed access issues and any other issues of
concern
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All emergent issues resolved
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All patients ready for discharge identified
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Tasks identified needed to complete prior
to discharge
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Seek allied health input
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Intensivist handover
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Ward rounds
• ICU Detailed Paper Notes
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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 duties
Registrar
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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
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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
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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
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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…
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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
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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
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Shared care
May include PIPER consultation
Developing a program
Needs multi-disciplinary care
Infection control
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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
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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
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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
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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)
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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
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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
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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