JMS Orientation Manual - Alfred Intensive Care Unit

Transcription

Alfred ICU
&
Hyperbaric Medicine
Junior Medical Staff
Orientation Manual
Updated: Irma Bilgrami
July 2015
The Alfred Intensive Care Unit
-1-
Welcome to the Department of Intensive Care
&
Hyperbaric Medicine of The Alfred Hospital
The Alfred ICU is a large, complex, interesting and enjoyable place to work, and we are
confident that regardless of your background, seniority, and career aspirations, you will
find your time here extremely rewarding.
The Alfred is a quaternary level hospital providing state referral services in Heart and
Lung Transplantation, Heart failure including ECMO & ventricular assist devices, bone
marrow transplantation, HIV medicine, hyperbaric medicine, cystic fibrosis, haemophilia,
burns and trauma. It provides all adult tertiary teaching hospital services except for liver
transplantation, and obstetrics. There are no routine paediatric services however the
Alfred is the national paediatric lung transplant center – and we see a few children each
year.
In November 2008 the new 45 bed ICU was opened. This is a brand new state of the art
facility, which accommodates all critical care patients in the one unit. The unit is
geographically and demographically divided into three connected “pods” of 15 beds
each. The 4 pods are Cardiac, Trauma, Surgical and General; each one is staffed by a
separate team consisting of an ICU Consultant, a Fellow or Senior Registrar and a
Registrar or a senior RMO.
The Cardiac pod accommodates all post op cardiac surgical patents (elective,
emergency and transplants), cardiology patients (e.g. post cardiac arrest) and
extracorporeal supported patients (V-A ECMO & VADs (ventricular assist devices). The
Trauma pod accommodates all trauma and neurosurgical patients. The General and
Surgical pods accommodate pretty much everything else (e.g. haematology, burns, postop surgical, general medical etc.), including veno-venous ECMO support for respiratory
failure. All rooms are custom designed with specific air-flow and other facilities to
accommodate these particular patient groups.
The beds are made up of a variable mix of “ICU beds” (1:1 nurse patient ratio) and “HDU
beds” (1:2 nurse patient ratio). On average, there are now usually between 38-40
patients at any one time in the department, but depending on the ratio of ICU patients to
HDU patients or whether we have opened additional beds, this may vary between 35 to
45 patients. Whilst we always attempt to cohort patient groups i.e. trauma patients in the
Trauma pod and cardiothoracic patients in the cardiac pod, limited bed numbers and
patient load may occasionally mean that there is crossover of patient groups. We try to
minimize this and patient movement between pods is discouraged unless absolutely
necessary.
Staff within Intensive Care, include 19 full time ICU consultants, 2 fractional time ICU
consultants, 21 Senior Registrars/Fellows, 19 Registrars/SRMOs and in excess of 300
-2-
nurses. In addition to 10 EFT ward clerks and 6.8 EFT respiratory technicians, there are
allocated physiotherapists, dieticians, pharmacists, occupational therapists, speech
therapists, orthotists, social workers, orderlies and scores of support staff not directly
involved with patient care. It cannot be stressed enough that the secret to good intensive
care practice is teamwork and communication.
We hope you enjoy your time working in The Alfred Intensive Care Unit, and learn new
skills relating to the management of the critically ill patient. This manual is designed as a
reference for you to use during your term, as well as containing a lot of information that
will be of use when you start. Please take some time to peruse the manual in the lead
up to your commencement with us. If there are any questions regarding the information
within the manual, please contact the relevant consultant; if in doubt please direct
questions to Dr Irma Bilgrami.
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THE ALFRED ICU MISSION STATEMENT
Below, you will find The ICU Mission Statement. Please take note as we expect your
behaviour to also be guided by these principles –
As intensive care specialists, our primary responsibility is to provide safe, appropriate,
high quality care and comfort to all Alfred patients with any form of critical illness and to
support those that care for them.
•
Clinical care: Our aim is to provide best possible patient outcomes through
the practice of excellent, evidence-based, compassionate and consistent
team-oriented intensive care medicine. In every situation, the wishes of the
patient and the hopes of those around them will be balanced with the
likelihood of success and suffering. Our practice will include dignified endof-life care if treatment becomes futile.
•
Communication: To keep our patients and their relatives well informed.
To communicate effectively with our colleagues and other hospital staff.
•
Support: To build positive relationships within and outside our department.
To support our colleagues in our clinical and academic pursuits so that we
can attract, inspire, and nurture diverse and committed staff wishing to
continually improve their skills and knowledge.
•
Teaching: To facilitate critical care teaching of all intensive care and
hospital staff. We wish the Alfred to be the premier place for intensive care
training in Australia.
•
Research:
To maintain the Alfred Intensive Care as an international
Centre of Excellence in research. To encourage and support a broad
range of research activities.
To present regularly at critical care
conferences nationally and internationally.
•
Management: To deliver best practice, cost-effective, responsible intensive
care with wise management of human and material resources.
•
Quality Assurance: To continually improve our performance by regular
review of all aspects of service so that we change our strategies if required.
To set both long and short-term goals on an annual basis which we strive to
accomplish by working together.
•
Values: To apply the following values to all aspects of our work:
compassion, honesty, commitment, respect of personal beliefs and
differences. To remain open-minded to new ideas and approaches.
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Contents
STAFF MEMBERS........................................................................................................... 6
ICU CONSULTANTS ................................................................................................. 7
OTHER SPECIFIED ROLES ..................................................................................... 8
ICU RESOURCES ........................................................................................................... 9
MOBILE PHONES ................................................................................................... 10
INFORMATION TECHNOLOGY AND SUPPORT .................................................. 11
LIBRARY SERVICES .............................................................................................. 12
PROTOCOLS AND GUIDELINES .......................................................................... 13
PATIENT CARE PRACTICES ........................................................................................ 14
COMMUNICATION.................................................................................................. 15
DOCUMENTATION ................................................................................................. 15
HANDOVER ............................................................................................................ 16
WARD ROUNDS ..................................................................................................... 19
DATABASE (ICU Active) MAINTENANCE ............................................................ 19
PRESCRIBING in The Alfred ICU .......................................................................... 20
ADMISSIONS, DISCHARGES AND BED MANAGEMENT .................................... 21
INVASIVE PROCEDURES ...................................................................................... 27
TRANSPORT OF THE CRITICALLY ILL ................................................................ 32
INTENSIVE CARE RADIOLOGY ............................................................................ 33
INFECTION CONTROL IN ICU ............................................................................... 35
ICU OUTREACH ............................................................................................................. 37
MET (Medical emergency team) and Code Blue responses .............................. 38
Role of the External SR ......................................................................................... 38
Attendance at MET calls........................................................................................ 38
Escalation of care .................................................................................................. 39
NIV use during MET calls ...................................................................................... 40
Follow up and tracheostomy service ................................................................... 40
Referrals external to the Alfred ICU ..................................................................... 41
CRITICAL CARE ECHO AND ULTRASOUND ............................................................... 43
ORGAN AND TISSUE DONATION ................................................................................ 46
JMS ROLES AND RESPONSIBILITIES ......................................................................... 48
Senior Resident medical officers (SRMO) ........................................................... 51
Role of the overnight Registrar and SRMO ......................................................... 54
Senior ICU Registrars ............................................................................................ 55
ICU Fellows............................................................................................................. 56
After hours Clinical Lead: Role description ....................................................... 58
EDUCATION ................................................................................................................... 60
JMS SUPPORT............................................................................................................... 66
JMS ADMINISTRATION ................................................................................................. 70
RESEARCH AT ALFRED ICU ........................................................................................ 76
COURSES AT ALFRED ICU .......................................................................................... 84
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STAFF MEMBERS
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ICU CONSULTANTS
Director
Professor Carlos Scheinkestel, Department of Intensive Care & Hyperbaric Medicine
Deputy Directors
Professor Jamie Cooper, Head of ICU Research
Dr. Tim Leong, Head of Quality Improvement
Dr. Jason McClure, Head of General ICU
Dr. Deirdre Murphy, Head of Cardiothoracic ICU
Dr. Owen Roodenburg, Head of Trauma ICU
Full Time Intensivists
Dr. Irma Bilgrami
Dr. Lisen Hockings
Dr. Josh Ihle
Dr. Richard Lin
Dr. Steve McGloughlin
Dr. Vinodh Nanjayya
Dr Chris Nickson
Dr. Paul Nixon
Dr Lloyd Roberts
Associate Professor Vincent Pellegrino
Dr. Steve Philpot
Professor David Pilcher
Associate Professor Andrew Udy
Fractional Intensivists
Professor Stephen Bernard
Professor David Tuxen
Emeritus Intensivist
Associate Professor Bob Salamonsen
Honorary Intensivists
Professor Alistair Nichol
Hyperbaric Consultants
Dr. Andrew Fock, Head of Hyperbaric Medicine
Dr. Wei Ch’ng
Associate Professor Geoff Frawley
Dr. Ian Millar
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OTHER SPECIFIED ROLES
Supervisor of Training / Recruitment
Co- Supervisors of Training
Education Co-ordinators
Medical Student Supervisor
JMS Rostering
ECMO services
VAD services
Database / Bronchoscopy/lung transplants
MET service
Echo services
Medical Donation Specialists
ALS training
Infectious Diseases Consultant
Dr. Owen Roodenburg
Drs. Paul Nixon/Steve McGloughlin/
Irma Bilgrami
Drs. Irma Bilgrami/Vinodh Nanjayya/
Chris Nickson
AProf. Vincent Pellegrino
Dr. Vinodh Nanjayya
AProf. Vincent Pellegrino
Dr. Deirdre Murphy
Prof. Dr Dave Pilcher
Dr. Irma Bilgrami
Dr. Deirdre Murphy
Dr. Steve Philpot /Prof. Dave Pilcher/
Dr. Josh Ihle
Dr. Richard Lin
Dr. Alex Padiglione/
Dr. Steve McGloughlin
ICU NURSING
Nurse Manager
Quality CNM
Workforce and Education CNM
Nurse Manager Hyperbaric unit
Equipment
Sharon Hade
Wendy Grant
Emily Gowland
Amanda Burvill
Caroline Chong
ADMINISTRATIVE STAFF
ICU Administration
ICU Software Developer
Database Officers
Website
Donation Specialist Nurse Coordinator
Unit Book-keeper/Accounts
Conference & Event Coordinators
ICU Research Staff
Janine Dyer
Miguel De Sousa
Kathleen Collins/Tracy Burt/
Leena Maller
Leena Maller
Sharella D’Souza/Bridget O’Bree/
Jessica Amsden
Helen Zoumboulis/Jane Kempler
Cathy Oswald/ Leanne Stanczyk
Shirley Vallance/Phoebe McCracken/
Jasmin Board
-8-
ICU RESOURCES
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MOBILE PHONES
Mobile phones are available for work purposes for all the ICU areas and are carried by
the junior registrar for each of the areas. There are two phones for each position; one
should be on the charger in the Nurse Management Office whilst the other is in use.
When the battery runs out on the phone, it should be placed on the charger and
swapped with the charged phone. It is important to turn the phone off when placing on
the charger; calls will then automatically divert to the phone in use. Each phone has a
PIN number written on the back; you will be required to enter it when the phone is turned
on.
ICU Cardiac Team
(907) 63413
ICU General Team
(907) 63414
ICU Trauma Team
(907) 63403
ICU Surgical Team
(907) 60673
ICU Referral/Ward SR
(907) 62622
ICU Transport Registrar
(907) 63423
(Becomes internal night SR phone at 19h30)
ICU Liaison Nurse
(907) 66095
ICU Patient Access (Bed) Nurse
(907) 60716
ICU Research nurse
0419 770120 (pager 5310)
Please look after these mobile phones; ensure that when not in use they are plugged
into the chargers available in the Nursing Management office off trauma pod (next to lift
to ED).
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INFORMATION TECHNOLOGY AND SUPPORT
Via the bedside and desktop computers there is access to an extensive list of resources
that will be of assistance during your term.
The ICUNet is a local intranet, which will be your first port of call for information. It
contains all the updated (and a few very old) guidelines and protocols as well as links to
phone numbers and the educational resources of the Bayside Library services. It can be
accessed via the ICUNet icon on the dashboard of bedside computers (thin client
system) or by clicking on the desktop icon for non-bedside computers.
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LIBRARY SERVICES
The Bayside Health Library Services web site http://www.med.monash.edu.au/amrep/ is
a portal to an extensive list of journals and textbooks. Many, many current journals can
be accessed via the Ejournals link below. You will be given a password to access these.
The actual (Ian Potter) library is located on the ground floor, near AMREP if you need to
access older journals or need librarian assistance with searches.
Photocopying is available on the ward and in the ICU Consultant offices, which are
located on the third floor of the East Block building.
Textbooks for ICU are currently available in our library/study room, and in many cases
on the shared folder of the hard drive.
Power Chart Results and E-ordering
Power Chart is the hospital’s computerised ordering and results database that is
interfaced with electronic radiology allowing the clinician to access all relevant results of
ICU patients and perform all required ordering of tests. The hospital’s IT department
provides training and usernames and passwords for access.
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PROTOCOLS AND GUIDELINES
A large number of protocols exist to provide more uniform and consistently higher
standards of care. They are listed on the ICUnet site on the hospital network (desktop of
all ICU computers). There is also a link to these guidelines from the dashboard of
bedside computers. They can also be accessed via PROMPT on the hospital website.
Examples:














Basic and Advanced Cardiac Life Support guideline
Bayside Health Medical Emergency Response policy
ICU Admission/Discharge guideline
Consultant Notification policy
Spinal clearance protocol
Traumatic head injury management
Post cardiac surgical management
Airway management and Tracheostomy
Fluid resuscitation for major burns
Plasma exchange
Citrate anticoagulation for CVVHD
Central venous catheter guidelines
Withdrawal and withholding ICU support
Organ donation guidelines
These practices may differ from those you have encountered in other centers or
departments, so it is important that you make an effort to familiarize yourself with them
and refer to them from time to time. A lot of time and effort have gone into producing
these protocols and they represent the final consensus opinion of all units involved in the
patient care. There should not be any variation from these guidelines without good
reason and without ICU consultant direction.
The Alfred ICU has also created a Moodle on-line learning package that you will all be
granted access to (www.alfredicumoodle.org.au). There are a number of guidelines that
must be read prior to commencing your term in ICU. These can be found in the
‘mandatory guidelines in ICU’ section of the Moodle site.
There are associated questions with each of these mandatory guidelines, which you
need to pass. The ICU can tell which doctors have completed these and passed and
which have not.
Please note that you must pass these (as well as obtain your hand hygiene certificate)
prior to starting in the ICU
All our guidelines are also accessible through our external website in the “staff login”
area. Username and password are both “Alfred”
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PATIENT CARE PRACTICES
- 14 -
COMMUNICATION
Ultimate responsibility for ICU patient care lies with the ICU consultant on for that area of
the hospital. It is important that communication is always maintained with them.
Other units often review their patients whist in ICU and may make suggestions about
care. Never make changes to care without discussing it with the ICU consultant first.
Other units must never write on the drug charts of ICU patients or unilaterally change
management. The Alfred ICU is a strictly “closed” unit from a management point of view.
As such, only ICU staff are permitted to prescribe therapy for ICU patients. However,
parent units and others involved in the care of any one patient need to be kept informed
of changes to their patients, and should have significant input into patient care.
It is always important to notify other units and the ICU consultant when there are
unexpected deaths, admissions or significant changes in patient status or increases in
support requirements.
Please refer to the ICU “Consultant Notification” guideline
DOCUMENTATION
Medical documentation is important.
Medical notes
Notes must be written on every ward round and for any procedures/ special
events. They should also be written after any family meetings or discussions with
teams from outside ICU. They should clearly document any adverse events.
Notes must include
The date and time of review,
Timing of ward round
Name of the consultant
A brief synopsis of the findings, results and management plans.
Printed names (RMO) must appear with signatures after entry.
Records should only contain accurate statements of fact or clinical judgement.
They should not contain any other extraneous material. No abbreviations should
be used.
When you make a referral, ask a question or seek advice
To whom you spoke (name and position)
What time you spoke to them
What they said
- 15 -
HANDOVER
Proper handover of critically ill patients enables the timely, safe and effective transition of
direct clinical responsibility from one team to another. It is a highly valued skill that
contributes to high quality clinical care. All staff should maintain a patient problemfocused approach, and ensure their attendance, attention, thoroughness, and
professional language and conduct at all times. Distraction, noise and interruptions are
to be avoided and other work not central to the reception-handover process is delegated
to other staff wherever possible.
In some time critical circumstances, the handover may need to be initially truncated or
interrupted to perform essential interventions. Members of the team handing over
should remain present until the receiving team is satisfied that they have the appropriate
information to provide optimal care.
COMPONENT
C
Connect
O
Observe
L
Listen
D
Delegate
•
•
•
•
•
•
•
•
DETAILS
Prepare a safe environment
Connect Monitoring
Assess patient Safety
Meet Immediate Care Needs
Stop to Listen
Information Handover: ISBAR
Documents checked
Discuss questions, confirm information
Planned handovers of the patients in ICU between shifts is an important part of patient
care and ICU consultants are rostered on to attend the evening handover to ensure
adequacy of handover to the night team. Morning handover to the day team generally
occurs without the ICU consultant. The Night registrars do not remain for the morning
consultant ward round, so it is important that all ICU issues and Ward (outside ICU)
issues are handed over. The ICU bed state database, which incorporates a specific
handover sheet, must be up to date with each change of shift.
Please refer to the ICU “Handover of critically ill patients” guideline
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ICU Morning Hand-over
Time for the morning hand-over in ICU are as follows:
07:30 hrs- Cardiac pod
07:50 hrs- Trauma pod
08:10 hrs- General pod
08:30 hrs- Surgical pod
On the Tuesday and Thursday when the education sessions are on, hand-over should
occur prior to the commencement of the education sessions. The morning
education sessions are not protected teaching hours. Hence, the day shift JMS should
carry the phone and attend to any emergencies in the unit during these teaching
sessions.
Hand-over sheet:
ICU Active hand-over sheet is used for all the hand-overs in ICU. It is mandatory
to use these hand-over sheets for the hand-over. These hand-over sheets are in
ISBAR format.
There should not be any interruption during the medical or nursing hand-over,
unless there is an emergency. This is to ensure that all the relevant information
from the night shift is delivered to the morning staff.
Meeting with the pod ACN:
After the morning hand-over from the night JMS2, SR/Fellow in the pod meets
the ACN in the pod to discuss any issues and to communicate the sequence of
the consultant ward round. The pod ACN would then allocate the nursing breaks
according to this sequence. This would ensure that the bedside nurse is available
during the consultant ward round.
Order of reviewing of patients:
Patients would be reviewed in the following order.
1. Unstable;
2. Potential discharge;
3. New patient;
4. Rest of the unit.
Patients with two discharge boxes ticked will be reviewed at 6 AM by the night internal
SR/Fellow to assess if patient is still suitable for discharge. They will not be prioritized
during the morning round and will be seen as part of the rest of the unit, if they have not
been discharged in the interim.
Other critical handovers include - arrival of patients from theatre, emergency department,
or wards, and discharge of a patient from ICU, and occasionally when patients are
moved from one pod to another.
- 17 -
SUGGESTED FORMAT FOR HANDOVER OF CLINICAL INFORMATION
COMPONENT
I
S
B
A
R
DETAILS
• Presenter: Name, designation
Introduction
• Patient
• Emergency vs. elective
Situation
• Admission status
Explanation of the patient’s
• Surgery
surgical,
medical
and
• Anaesthesia
anaesthetic context
• Analgesia
• Routine vs. complicated
• Co-morbid illness
• Medications
Background
• Functional Status
• Treatment limits
• NOK discussions and notification
• Current access
• Airway assessment and management
• Ventilation
• Mechanical circulatory support: blood
loss,
transfusion
requirements,
anticoagulation requirements, peripheral
Assessment
circulation and access requirements
Presentation of the patient
• Venous access and invasive pressure
monitoring
• Current infusions
• Wounds
• Drains
• Pain management plan
• Surgeons documented post-op orders,
Recommendations and requests
preferences and plans
• Questions
- 18 -
WARD ROUNDS
1. Handover Round: The night staff will hand over to the daytime junior medical
team. These handovers are staggered; Cardiac Pod 07h30, Trauma Pod 07h50,
General Pod 08h10 and Surgical pod 08h30.
2. Morning Ward Round: The consultant-led ward round follows the handover
round. In addition to the medical staff, the ward round team generally includes
nurses, pharmacists, dieticians, physiotherapists, and students.
3. Afternoon Ward Round: A second, briefer consultant-led ward round will usually
occur at 16.30 hrs. The day should be planned so routine procedures are
completed before this time. X-rays and CT should be performed either before this
time or after 18:00 hrs. Decisions regarding which patients require an X-ray in the
morning and which patients can be discharged in the morning should be made on
this ward round.
4. Night Time Handover Ward Round: This commences at 19:30 hrs in Cardiac
ICU, then at 19: 50 hrs in Trauma ICU, then at General ICU at 20:10 hrs and
finally at 20:30 in the Surgical ICU. The handover is attended by the night
consultant and senior registrar and the handover is run by the day shift senior
registrar and registrar/SRMO for each pod handing over to the night junior
registrar for that pod.
DATABASE (ICU Active) MAINTENANCE
The ICU relies on ICU Active as the main database. It is an ICU specific web based
database. Among its many functions, the system allows staff to –
•
•
•
•
•
Track ICU in-patients and admission capacity and ICU length of stay
Identify patients due in to ICU and those ready to leave ICU
Identify patients currently out of ICU that require ICU follow-up or review
Provide patient summaries; “to do” lists and other patient details for staff
Log procedures performed in ICU
The medical staff, in conjunction with the database managers, must maintain this
database. Medical staff need to enter the clinical history, the procedures, some
admission information and aspects of the diagnosis. Senior registrars also need to enter
the details of all patients referred to ICU, whether accepted or not.
Printed handover sheets are compiled using ICU active. When using the printed reports
please be aware that there is confidential information contained with patient identifiers.
Please treat these confidential documents sensitively, manage them responsibly and do
not lose them. Please discard them in a shredding bin at the end of your shifts.
Detailed explanation of the system and instructions on its use are provided to all new
medical staff coming to ICU. All staff will need a password and username to access this
system external to the ICU and there is generic access for limited functions in ICU.
- 19 -
PRESCRIBING in The Alfred ICU
This information should be read in conjunction with the Alfred Health Medication
Management: Safe Prescribing guideline (available on Prompt). Prescribing practices
specific to the ICU include:
•
Only ICU staff (medical and pharmacy) write on ICU drug charts
•
Collaborative prescribing – communicate with the bedside nurse when changes
to medications are made. Following discussion with the bedside nurse, medical
staff may endorse times or box the administration boxes on the drug chart.
•
Generally prescribe medications using generic name except for oral opiates
available in multiple preparations (e.g. Endone, Oxycontin, or Ms Contin).
•
For oral liquid preparations, prescribe dose not volume.
•
Indication for each medication to be endorsed on drug chart.
•
PRN orders must indicate a frequency of administration (e.g. 2 hourly) and/or
maximum dose in 24 hours or target parameter (e.g. to keep K+>4).
•
Medications and fluids on ICU infusion should be prescribed daily before
midnight.
•
Renal replacement fluid charts to be rewritten only when exhausted
•
For chart re-writes:
o Drug charts should not be re-written on ward rounds
o Decisions for chart re-writes are made on morning ward rounds and must
be completed before end of the day
o Avoid distractions & interruptions while re-writing (eg. give phone to
someone else, sit down at desk)
o Use as an opportunity to review medications including orders withheld on
old chart or with specified stop dates
o New charts are to be used immediately – score out old charts with a
single line through each page and reconcile the new chart against the old
one to avoid omissions or inclusion of medications already finished.
o Transcribe the date therapy was originally prescribed not the date of rewrite
o When patients are “ready for discharge”, drug charts are only re-written if
less than 2 days remaining or >50% orders crossed out. Ensure prn IV
potassium, magnesium and opiate orders are ceased. Refer to
pharmacist for advice.
•
Regularly review and when appropriate restart usual medications which have
been withheld or not prescribed during the ICU admission. Refer to the
Pharmacist’s medication reconciliation form (MRF), which is attached to the drug
chart, for a list of the patient’s usual medications
•
The Reg/SRMO is responsible for entering antibiotic approvals into Guidance.
Clinical Pharmacists are available on the unit 7 days a week to assist and advise on
medication prescribing in the ICU. Each pod pharmacist attends weekday morning ward
rounds with the medical team.
Pager numbers for your ICU Pharmacists
Trauma ICU 4509 General ICU 5646
Cardiothoracic ICU 4216
- 20 -
Surgical ICU 5808
ADMISSIONS, DISCHARGES AND BED MANAGEMENT
ADMISSIONS
Emergency referrals for ICU admission will all come through the Senior Registrar
covering wards/referrals via the 62622 phone or via a MET or Code Blue call.
Remember to get the referring staff to initiate a MET call if the patient meets criteria.
Patients referred but not admitted to ICU constitute a “refusal”. Details of refusals need
to be entered into the ICU Active database. All refusals must go through the ICU
consultant on for admissions.
Referrals that come to the senior registrar on for wards from the pre-admission clinic, or
referrals that relate to patients being considered for ECMO, must be directed to the
consultant on for wards/referrals. Patients referred from Pre-admission Clinic must be
seen at that time.
In keeping with the principles of timely, quality care (TQC), all patients should be
admitted to ICU within 4 hours of referral.
Referrals from Emergency
Patients referred from E&TC for ICU admission are divided into two categories
1) Automatic Admission
Patients meeting the following criteria will be immediately referred to the ICU SR,
who must then organize a bed with the PAN prior to reviewing the patient
• All intubated patients, whose extubation is not imminent and for whom
palliation is not planned.
• All patients requiring vasoactive agents
2) ICU Review
Patients not meeting the above criteria are referred by E&TC within 60 min of arrival.
The ICU SR needs to review the patient within 60min of referral. ED referrals should
take priority over other commitments. The ward consultant can be called on to assist
with this process.
If on review of the patient, a further review is deemed necessary, this must be
facilitated within an hour and a decision about admitting the patient to ICU must be
made.
In addition to the 4 hour admission rule, patients requiring admission to the ICU from
E&TC need to be admitted within the day of arrival. To facilitate this, there will be a daily
RIAT (Rapid ICU Admission Team) round at 2200hrs. The RIAT consists of the ICU
consultant and SR and the E&TC consultant. The aim of the round is to identify any
patients that require admission and ensure it occurs prior to midnight.
- 21 -
Please see the “E&TC to ICU” admission guideline
Elective admissions from theatre
Elective admissions to ICU are usually determined the preceding day (Monday to Friday)
at the bed state meeting that occurs at 15:15 each weekday. At this meeting the order
and priority for the next day’s operations is established; it is attended by the ICU
consultant and Senior Registrar on for wards/referrals.
Patients referred from HDU are divided into two categories and will be discussed at the
bed meeting the preceding day
1) Automatic admissions
The following elective cases will be admitted directly to ICU from recovery. ICU
SR review is not needed and the Anaesthetist will phone the specific pod phone
to hand over the patient
o
o
o
o
o
Open Aortic Surgery (e.g. AAA)
Major Oesophageal Surgery (e.g. Ivor-Lewis)
Whipples Procedure
Hemi-hepatectomy
Radical Cystectomy & Ileal Conduit
2) Patients for review in recovery
All other patients will need to be reviewed in recovery by the external SR. The
anaesthetist will phone the SR to give a handover.
o
o
o
Recovery patients must be seen within one hour of handover. The SR
must deem the patient as ‘accepted’ ‘not for HDU’ or for 'further review’
and document in the notes.
Further review must occur within one hour and if patient not ward ready
should be admitted to HDU.
If patients are not for HDU this must be documented and handover back
to the parent unit must occur.
Please see the “Elective HDU admission” guideline
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DISCHARGES
In order to facilitate smooth transition of care to the wards, please note the following
steps in the discharge process
The ‘tick boxes’ on ICU Active
1. When the Consultant has authorized the patient for discharge, the first box
“Ready for Discharge” is ticked
This is the point that discharge preparation should commence. Summaries,
drug chart review, fluid chart review, ward obs chart all start after this box is
ticked
2. The second box “Ready to go” is ticked by the PAN nurse
This is when the discharge checklist has been completed. The patient is
ready to go to the ward within 4 hours
Once notified that a ward bed is available and allocated
 Refer the patient to Endocrine team (if required)
 Inform the home team
 Sign off on the discharge checklist
The time between ticking the two boxes should be kept to a minimum. If more
than 4 hours elapse, the row containing that patient will turn red on the home
screen in ICU active.
 All patients have a completed, thorough discharge summary prepared in ICU Active,
and an updated drug chart (and fluid orders) with no “ICU only” drugs or orders. For
discharges planned for the morning this must be completed by the night JR under
the SRs supervision
 The relevant unit registrar is contacted to notify them of the planned discharge, and
the patient is handed over to the parent unit, highlighting issues requiring ongoing
management
 All patients to be discharged on insulin are referred to the endocrine unit
 Patients with ongoing requirements for support (dialysis, non-invasive ventilation)
must be referred to the responsible team some time before anticipated discharge.
 Patients being discharged to the ward under their admitting surgical team with
severe medical problems should be referred to the medical unit of the day for
ongoing help with their management after discussion with the surgical team.
Please see the “ ICU Discharge” guideline
- 23 -
Delayed and after-hours discharges
Exit block of planned and prepared discharges means that these discharges may be
delayed to the subsequent days (with an attendant administrative and logistic burden on
the ICU) or to occur after-hours. After-hours discharges, whilst unavoidable, are
associated with increased risk of adverse events, and therefore, they will only occur
when the only way a new critically ill patient can be admitted is by discharging one 1:1 or
two 1:2 patients from the ICU. The following rules apply:
1. No patient is discharged after-hours without the express approval of the ICU
consultant
2. It will be the patients with both boxes ticked that will be discharged out of hours if
required.
3. The discharged patient is to have their support requirements reviewed and
checked: discharge summary, drug and fluid orders as above
4. Handover to the covering team is conducted, with a clear plan to notify the parent
team at the first available opportunity
5. The External SR is briefed and a plan formulated to monitor the patient’s
progress overnight, and given the opportunity to review the patient prior to
discharge to establish a clinical “baseline”:
Discharges to home
Where patients can be discharged home directly from ICU it is essential that the
following steps be taken:
•
•
The ICU consultant is made aware the patient is going home from ICU;
The primary bed card unit arranges all discharge (to home) details including
discharge summary, medications and outpatient appointments.
- 24 -
BED MANAGEMENT
Cancelling elective cases because of insufficient ICU beds on the day of surgery is
extremely rare; it must (can only) be done by the ICU Consultant on for wards/referrals
before 07:00 hrs. When too many ICU cases are scheduled for the following day, the
meeting will prioritise the patients and those with a low priority will be rescheduled.
The night senior registrar must contact the ICU Consultant on for wards no later than
06:30hrsto advise them of any changes or anticipated problems to the planned
admission profile for the day due to overnight admissions, deteriorating patients who
have progressed from 1:2 to 1:1 nursing ratios, or blocked discharges that influence
admitting capacity. Only the ICU consultant can cancel an elective case.
When there are no ICU beds available
When there are no critical care beds available in Melbourne, Adult Retrieval Victoria will
define a destination for a patient and proceed with the transfer of that patient, regardless
of the bed-state of the receiving Hospital’s ICU. This process was in 2010 extended to
acute neurosurgical patients. The Alfred ICU should comply with these Defined
Transfers.
Process for Providing an ICU Bed at The Alfred when an ICU Bed is not immediately
available
•
Initiate planned discharge of 2 stable HDU patients to create an ICU bed.
•
Change the category of 4 stable and appropriate HDU patients to that of
requiring 1:4 nursing to create an ICU bed.
•
Change the category of 2 stable and appropriate ICU patients to that of
HDU (i.e. requiring 1:2 nursing) to create an ICU bed.
•
Change the category of any stable and appropriate ICU patient to that of
HDU (i.e. requiring 1:2 nursing) and discharge 1 HDU patient to create an
ICU bed.
•
Seek to open an additional ICU bed, depending on physical bed space and
ICU nurse availability.
•
Cancel elective surgery that was to occupy a designated ICU bed
(according to the above elective surgical prioritisation) in order to create an
ICU bed for an emergency
- 25 -
The following three steps are recognised as options that should only be reluctantly
considered as they may pose potential additional risk to the ICU patient.
•
Initiate out of hours or early discharge of stable HDU/ICU patient(s) to
ward.
•
Seek to transfer the incoming patient to another hospital ICU; or if the
patient is unstable or has specific Alfred requirement (State Service), seek
transfer of another suitable (stable, non-state service) already in The
Alfred’s ICU.
•
Establish temporary ICU support in ED, Recovery Room, or ward until first
available ICU bed created through the above.
Protected Beds
Because of the high emergency load on The Alfred’s ICU, a protected bed policy has
been developed for cardiothoracic surgery to ensure the continued throughput of these
cases.
The ICU will maintain at least 7 beds for cardiothoracic patients (not including VAD,
transplant or thoracic surgical patients. Thus theoretically allowing for up to 13 cases
per week, depending on case complexity (2 on Monday, 3 on Tuesday, 2 on
Wednesday, 3 on Thursday and 3 on Friday).
Pod Swaps
“Pod swaps” are patient transfers between the different ICU medical teams and reflect
the need to redistribute workload, usually so that the patient can be paired with another
patient and nursed 1:2. “Pod swaps require consultant approval (never unreasonably
withheld), and handover between the ICU teams involved as above.
- 26 -
INVASIVE PROCEDURES
Registrars will perform the majority of procedures on the ward depending on level of
seniority, experience and training. Procedures must always be performed under
appropriate supervision.
For any doctor learning a technique, the first 5 attempts must be performed with an
experienced person (senior registrar or consultant) directly supervising and on hand to
assist. Records of procedures performed must be logged on the ICU Active database
(see ICU Resources) together with details of complications if any. This will at the end of
your time in ICU provide you with a log of all your procedures
Insertion of Central Venous Catheters
A CVC insertion is a potentially hazardous procedure.
Recent examples of
complications in the Alfred ICU include major air embolus, guide wire retention and
pneomothorax. It is thought that a team approach to CVC insertion offers the safest
approach to this procedure. This insertion team should be free from distractions and
focused solely on the task of the CVC insertion.
Any elective CVC insertion will follow a team approach where:
1. The Nurse and Dr. will decide on the appropriate CVC (3 or 5 lumen) and also
what complications may happen and how the risk can be minimized
2. The Nurse will observe the Dr’s approach to asepsis and will check this off on the
checklist (if done correctly). The Nurse will also wear a theatre cap and
mask. The Nurse is empowered to stop the Dr. from proceeding if the asepsis
approach is incomplete.
3. The Dr. will show the guide wire to the Nurse when it is removed from the patient.
4. This checklist is kept in sticker form in the CVC trolley.
5. The Nurse should fill in the sticker and place it in the patient’s chart. Any issues
with compliance should be referred to the ANUM and consultant.
If the CVC insertion is urgent (i.e. the patient is very unstable) this checklist may not be
able to be followed – in this case the checklist sticker should not ticked for asepsis and
the reason stated in the comments section. The CVC should be highlighted as inserted
under compromised circumstances and should be removed in 24 hours.
There will also be a laminated version of the checklist attached to the CVC trolley. This
will also contain information on equipment required, likely complications and some useful
tips on CVC insertion
- 27 -
- 28 -
Accreditation process for insertion of central lines.
a. If you have already inserted more than 5 subclavian, internal jugular and femoral
CVCs then you will only have to be accredited once for aseptic technique. Please
print out the insertion checklist and find a consultant or accredited SR to supervise
your insertion of a CVC (any site). If your supervisor is happy with your insertion
technique then get him/her to sign the checklist and give the form to Janine
Dyer. You will then be accredited.
b. If you have inserted less than 5 CVCs at each anatomical site then you will need to
be accredited for technique as well. This requires supervision of 5 examples at each
site (subclavian, internal jugular, femoral). Print out the checklist and get a
consultant, accredited SR or accredited line registrar to supervise you. Fill in each
form, get it signed and give to Janine Dyer.
Please see the CVC insertion guideline on ICU Net
- 29 -
- 30 -
Insertion of pulmonary artery catheters should be performed by senior registrars who
have completed accreditation or consultants only (unless specific permission is obtained
prior and adequate supervision exists).
Bronchoscopic equipment is readily available and easily deployed at the Alfred. This
should not lead to the situation where they are done frequently for trivial indications
(especially after hours). All non-emergent bronchoscopies should have prior consultant
approval. Please ensure that bronchoscopy is not performed via an oral ETT without a
bite block. The bronchoscope register must always be completed at the end of the
procedure, and these registers must be returned with the bronchoscope. It is essential to
be familiar with the equipment and safe performance of this procedure.
Percutaneous tracheostomies are only performed by consultants and registrars
training in ICU medicine (unless specific permission is obtained prior and adequate
supervision exists). Likewise, care of the “top end” which involves the maintenance of
adequate ventilation, provision of anaesthesia, control of the circulation and
bronchoscopy is a skill that must be acquired and requires adequate supervision. This
must not be performed by anyone other than experienced anaesthetic trained staff
capable of managing all the potential complications. The routine is for an ICU consultant
to supervise an SR to do the trache whilst a second ICU consultant supervises another
SR managing the airway. Two consultants must be present for the tracheostomy
insertion. Please see the tracheostomy guideline on ICUnet
Endotracheal intubation. A formal protocol concerning staffing at intubation in the
Alfred hospital exists (ICUnet), and the guideline can be accessed directly from the
dashboard of the bedside computers. Please see the intubation guideline on ICUnet
Intubations in intensive care may not be straight forward even in experienced hands, and
given the risks of anatomically and physiologically difficult airways in a complex and
unfamiliar environment, with a high performance requirement, ICU is not a suitable
environment to acquire the basic skills of airway management. Intubation training is
available in the operating theatre with anaesthetic consultant supervision on Friday
afternoons 1300-1730. Please see education section below.
ECMO (extracorporeal membrane oxygenation) services are provided by the Alfred ICU.
There are opportunities for advanced training in ECMO; Consultants perform ECMO
cannulations and initiate ECMO support. Each week an intensivist, typically the “wards”
consultant is rostered on for all referrals that involve ECMO or the possibility of ECMO
being required. All referrals for ECMO that come through to the Senior Registrar phone
should be passed on to the consultant directly. This service also considers ECMO
retrievals from other centers.
- 31 -
TRANSPORT OF THE CRITICALLY ILL
Intra-hospital Transports. Accredited Junior Registrars accompany ventilated patient
transports from the ICU for diagnostic investigations (e.g. CT/MRI) and remain with the
patient while they are out of the unit. When staffing numbers are down (e.g. sick leave);
or there are multiple transports at the same time; or the patient is unstable, Senior
Registrars and occasionally consultants will need to help out. It is necessary to notify the
consultant responsible when this is an issue.
Transfers for therapeutic procedures (e.g. angiography) are performed by the
anaesthetic department. They must be booked with the consultant in charge in the
anaesthetic department in the same way as for an operation.. This does not include
cardiac catheterization, which is the responsibility of ICU as per PAT guideline.
The anaesthetic department staff transport all patients from the ICU going to theatre.
The patient should be transferred using either an oxylog portable ventilator, or a PB840
ICU ventilator. Patients will not be “hand-bagged” to theatre. Please see the transport
guideline on ICU Net
Inter-hospital transports from the Alfred. All patients transferred out of the Alfred ICU
or ED to other hospitals that are intubated or critically ill must be accompanied by an
accredited Junior Registrar or Senior Registrar. It is extremely important that these
patients are fully assessed prior to transfer. Under no circumstances should a transfer
proceed if the stability of the patient is in question. Please direct any concerns to the
consultant responsible. The ICU consultant must be contacted for a final briefing prior to
departure.
Hyperbaric Medicine. ICU patients requiring hyperbaric oxygen therapy (HBOT) are
transported to and from the hyperbaric unit by the ICU team as with other intra-hospital
transports. For this patient group this is generally done by the ICU SR. Where the
hyperbaric registrar has suitable critical care training and experience, they may transport
the patient. Whilst the patient is in the hyperbaric chamber, the hyperbaric team (nurse,
registrar and consultant for hyperbaric services) will oversee the hyperbaric treatment.
However, the ICU registrar for the patient should remain in the hyperbaric department
until the patient is pressurized in case it precipitates changes in the ICU support. ICU
senior registrars can then leave the hyperbaric department, but should remain available
to promptly review the patient during the remainder of the treatment and should not
undertake elective procedures or transports during this time.
The care of all critically ill patients ultimately remains the clinical responsibility of ICU
anywhere in the hospital, even if they are receiving hyperbaric treatment.
JMS must formally confirm the suitability of all patients for HBOT prior to their treatment
with the consultant responsible for their care and the hyperbaric team. Unstable or
deteriorating patients may not tolerate the physiological challenges of transport and
hyperbaric oxygen therapy, may deteriorate in the window between hyperbaric referral
and treatment and require review, and may simply have more pressing priorities for
immediate care.
Transfers represent a high-risk event for patients. Please let someone know if you do
not feel comfortable / adequately skilled to support patients during a transfer.
- 32 -
INTENSIVE CARE RADIOLOGY
Radiology is an important Department for the optimal management of ICU patients.
Mobile radiography is used on a regular basis to perform diagnostic X-rays so it is
imperative that efficient ICU and Radiography processes occur and that these are based
on an understanding of each Department’s requirements and work practices. Please
plan transport timings to try and ensure that patients requiring radiology outside ICU are
there on time.
In ICU, the default is for NO ROUTINE CXRs
 The resident should discuss who needs an early morning CXR with the
consultant on at the evening ward round each day, and then order all required
CXRs for the following morning.
 In an effort to reduce unnecessary radiation exposure, costs, and unnecessary
patient lifts/interventions the default position is not to order daily CXRs on all
patients.
 Radiographers will still automatically attend from 06:00 for the CXRs that have
been ordered. If less CXRs are ordered, it will be more likely that all X-rays will
be reviewable during the morning ward round.
CXRs can still be ordered as required throughout the day and night for any indications
that may arise. But please note CXRs are not routinely required following
(a) tracheostomy
(b) bronchoscopy
(c) recruitment maneuver
Post removal of ICCs
 Patients staying in ICU post removal of ICC: A chest x-ray can be done the next
morning
 Patients leaving for the ward: Please order the CXR whilst still in ICU
If it seems likely that a line will be changed or an ICC will be removed during the next 24
hours, it would seem appropriate not to order a morning CXR, but to wait until this event
occurs.
Reasons for performing CXRs to be specified on the request
1. On admission to the intensive care unit
2. Post-Tracheal intubation
3. Suspected pneumothorax (e.g., subcutaneous emphysema)
4. New central venous catheter (subclavian or internal jugular)
5. NG tube insertion
6. New other invasive devices
7. Deterioration in respiratory/cardiac function (including deterioration in oxygenation,
increasing airway pressures)
8. Looking for gas under diaphragm
9. Lung transplantation patients within 4 days of surgery
- 33 -
10. Otherwise at the discretion of the registrar/consultant
Teams of 2 radiographers work their way around the ICU taking the ordered X-rays.
They rely on the assistance of ICU nursing staff.
•
The night shift radiographers start in Cardiothoracic ICU (around 06.00 or so)
•
Then the day shift radiographers begin in Trauma ICU (after 08.00) and then move
to General ICU.
•
This process takes several hours, so X-rays will not always be available at the time
the ICU medical ward round visits each particular patient (especially General ICU).
•
Batches of roughly 4 X-rays are taken at a time. The plates are then taken to be
processed and images should be available on Powerchart within a further 10-15
minutes.
•
When a patient is unavailable for X-raying (due to clinical care or otherwise), the
radiographers will skip that patient and may come back at the end of the X-ray
ward round.
It is important to be aware of the following points with regards to other mobile X-rays:
•
After 16.00, the radiographers have a reduced staffing model, so it is important we
are aware of this in ordering mobile X-rays. An order at 16.15 that could have been
ordered at 15.00 may lead to significant but expected delays. Batching several Xrays late in the day (which might seem a good idea at the time) may not be as
convenient as ordering the X-ray as soon as the patient needs the X-ray.
•
If it is realised that an ICU patient needs one of these non-routine X-rays during the
morning X-ray ward round, the radiographers can be notified so that they can
attend this X-ray on that same round rather than coming back later.
Other Plain (non-mobile) X-rays
Several other types of X-rays are commonly ordered in ICU patients (cervical spine,
thoracic spine, lumbar spine, pelvis, limbs, etc.). These will usually require a transport to
the Radiology department.
All X-ray orders for ICU patients will be e-ordered by ICU medical staff. If a complex Xray request is e-ordered by Parent units (i.e. Trauma, Orthopaedics and Neurosurgery)
because the clinical rationale can be described better by the Parent unit medical staff,
the order for this X-ray and the justification for this X-ray must still be communicated to
the ICU medical staff. It is not appropriate for ICU patients to be having X-rays requiring
medical transports without an overall risk/benefit assessment.
- 34 -
INFECTION CONTROL IN ICU
The Alfred, primarily as a result of its unique patient load, has from time to time
developed significant problems with multi-resistant organisms (MBL gram negatives,
carbapenem-resistant Acinetobacter and MRSA have been notable problems). The
patients are often extremely ill and the last thing they need is an added infection from
poor hygiene practices so we are very keen to keep infection rates down. There are
rigorous preventive strategies in place, which will be discussed at the orientation
session; please contact Dr. Tim Leong or Dr. Steve McGloughlin if you have not received
orientation on this matter. It is essential you follow the current practice guidelines during
your time in ICU.
Previously there was a high rate of catheter related central line infections in our patients.
This high rate of CVC related infection has now been very successfully managed by
good education and strict adherence to the infection control policy. There is a line
insertion education and accreditation process for all HMOs and registrars and ID surveys
of all lines in situ in the ward.
It is essential that all unnecessary CVCs are removed as soon as they are no longer
required.
Finally, antibiotic prescribing is highly regulated and the current protocols updated each
year (see ICU net).
Hand Hygiene
There is a major focus on hand hygiene in the ICU using the WHO 5 moments of Hand
Hygiene. It should be obvious to everyone that hand hygiene in the ICU is extremely
important to minimise infection and patient cross-contamination. The simple adherence
to good hand hygiene practice is as important as any of the many complex life-saving
technologies we use in ICU.
With a huge effort from many ICU staff hand hygiene compliance is now tracking in the
70-80% range (2012/2013).
We need your help in the fight against nosocomial infection.
3 things to think about:
1. Remember to “WASH IN, WASH OUT”. Every time you enter and every time you
leave the cubicle you should perform hand hygiene.
2. LET’S AIM FOR 200% COMPLIANCE. This means 100% for personal hand
hygiene compliance and all of us remembering to remind others if they do not
comply with the 5 moments. Only by helping each other remember will we
achieve our goal.
3. JUST SAY THANK-YOU IF YOU ARE REMINDED ABOUT HAND HYGIENE.
Let’s not waste time arguing about it e.g. “but I didn’t touch anything….” Let’s
break down the barriers to reminding each other.
Our aim is to reduce the incidence of nosocomial infection in the ICU. This will decrease
patient morbidity and mortality.
It’s in your hands.
- 35 -
All staff must complete the hand hygiene education package and questions and hand in
the certificate obtained to Janine Dyer, prior to commencing work in the ICU.
- 36 -
ICU OUTREACH
- 37 -
MET (Medical emergency team) and Code Blue responses
The Alfred ICU SR heads the Alfred MET response. The ICU “external” senior registrar
and an ICU liaison nurse during the day or a member of the ICU nursing staff overnight,
attend every MET call; about 10% will require admission to ICU. Response time should
be within 5 minutes.
The Alfred MET service is provided on a 24-7 basis with the primary aim of preventing
unexpected deaths, cardiac arrests, or unexpected ICU admissions. Anyone can activate
a MET call, and criteria are widely published and promulgated throughout the hospital.
Role of the External SR
The ICU Senior Registrar is the leader of the MET team.
As well as coordinating the response, they are expected to ensure that there is adequate
follow up and a plan is in place. The ICU SR is responsible for the care of MET patients
until they are either admitted to ICU or are no longer unstable. If the patient is stable the
SR can hand over responsibility to the medical registrar and/or parent team. This
handover should be formally documented and communicated so that the chain of
command is clear.
There must be clear documentation of every MET call. The ICU SR can delegate this to
the parent team. The following must be specified in the notes: doctors present at MET,
problem, plan and person following up.
The ICU liaison nurse is an integral part of the MET service. The external SR must
maintain an open line of communication with the liaison nurse.
If the decision is to admit the patient to ICU the SR should formally handover the patient
to the relevant ICU medical staff. The “Due in/ Referrals” function should be used in
ICUactive to record the patient’s details, reason for ICU admission and any important
instructions e.g. heparin infusion to commence.
Attendance at MET calls
ICU medical attendance is mandatory at Met calls and Code Blues.
During the day, if the SR is unable to attend because of other work commitments, they
must contact the external ICU consultant ASAP, who can then attend.
Overnight, the Clinical lead may be called on by the external SR in order to facilitate
cover whilst multiple met calls/code blues are in process. If this occurs, the external SR
must get a handover from the Clinical Lead as soon as possible following the MET call,
The external SR remains responsible for the ongoing care of the MET patient.
Code Blue responses require immediate attendance – these are patients who meet
criteria for commencing Advanced Life Support. Alfred Health has ratified the 2010 ARC
guidelines for advanced life support.
- 38 -
Escalation of care
ICU consultant notification
The ICU consultant must be notified
Of all patients requiring admission to ICU
Of patients refused admission to ICU
If a patient has had a second MET call in a period of 72hrs. The
consultant must be notified before the end of the SR’s clinical shift.
Parent team notification
Please see The Consultation Notification Policy for the hospital
During the day, the consultant responsible for the patient should be notified of the
MET call. The SR does not have to make the call to the consultant personally;
the notification should come from the ward medical staff.
Overnight, the clinical lead must be notified. The decision to contact the home
team over night is at the discretion of the clinical lead. If not done so overnight,
the parent team must be notified in the morning.
The consultant responsible for the patient must be notified at all times of day or
night if
The patient has had multiple Met calls in 24hours
The patient has had a code blue
The patient is moved to a critical care area of the hospital (3CTC or ICU)
A change to patient resuscitation status requires consultant notification.
Alteration to the MET call criteria
The parent unit consultant must approve any alterations to MET call criteria at all
times.
Temporary alteration to the MET call criteria can be made by the external SR
whilst waiting for treatment to take effect. This is only if other observations remain
stable. For example, AF with a rapid ventricular rate and a stable blood pressure.
The SR is expected to specify the following on the CRP (the green form)
Criteria change
A defined time frame for the criteria change. This must not exceed 2hours
How frequently vital signs need to be measured during this time frame
Alteration to Clinical Review Criteria
During the day, the consultant responsible for the patient should be notified of
any changes made to the CRC. Overnight, the clinical lead should be notified.
- 39 -
NIV use during MET calls
The ICU external SR or the clinical lead can authorize the use of NIV during a MET. The
ICU liaison nurse or the Clinical operations manager will collect the NIV machine from
5E.
If NIV is commenced overnight, the AIR registrar needs to be informed in the morning.
This is the responsibility of the clinical lead. This can be delegated to the ICU SR on a
case-to-case basis
Notify – The AIR Registrar (0407524911) must receive morning handover
Indications – The indication for commencing NIV must be documented in the notes
Ventilator Settings – The machine settings must also be documented
The ongoing care of the patient remains the responsibility of the external ICU SR as
stated above.
Follow up and tracheostomy service
The ICU consultant and senior registrar on for wards will follow up all patients
discharged from ICU in conjunction with the ICU Liaison nurse. They will be seen daily
until ICU input is no longer required. The intention of this is to ensure that management
plans are continued on the ward after handover to the home team, and minimize or
prevent readmissions to ICU especially where discharges occur after hours.
Follow up details and interventions must be entered in brief into the ICU Active database
(see Job Descriptions) in the “follow up” section daily by the ICU senior registrar on for
wards. If required a patient can be added to the ICU Active follow-up database even if
they have not been admitted to ICU. When a patient no longer requires follow up, they
need to be removed/discharged from the follow up list.
Even after hours the external SR may be obliged or directed to conduct planned reviews
and follow up of patients of concern.
Patients with tracheostomies will be reviewed regularly until successful decannulation or
discharge.
- 40 -
Referrals external to the Alfred ICU
1) External SR requests referring doctor to
• speak to proposed Alfred parent unit
• Fill out ICU referral form (www.alfredicu.org.au) and fax it back
2) External SR
• Contacts parent unit to confirm above
• Notifies Admitting Officer- direct vs ED admit
• Notifies PAN (patient access nurse)
Any concerns regarding the timeliness, effectiveness, safety or cohesiveness of a MET
response must be reported to the ICU consultant responsible for the wards and also the
MET coordinator Dr. Irma Bilgrami. The “ICU MET Service guideline” document is
available for ICU registrars involved as MET responders, and outlines the expectations,
tasks and responsibilities of the MET service.
- 41 -
- 42 -
CRITICAL CARE ECHO AND
ULTRASOUND
- 43 -
Our department has a number of consultants with a special interest in echocardiography
and ultrasound and a full time echo fellow. The echo service is led by Deirdre Murphy
There is a weekly (Monday to Friday) roster for echocardiography and can be found on
the 3 week roster circulated by Janine. The ICU fellow or consultant rostered on for echo
should always be the first port of call for echo referrals.
Currently the consultants with an interest in echo include Josh Ihle, Tim Leong, Richard
Lin, Steve McGloughlin, Irma Bilgrami, Deirdre Murphy, Vinodh Nanjayya, Paul Nixon,
and Steve Philpot.
Weekend services by the echo consultants are provided according to availability and
rostering- please make these weekend referrals to ICU staff initially.
All echoes performed by trainees must be discussed with the consultant on for
echocardiography as well as the consultant on for the pod. If you do an echo overnight
please let the echo fellow know first thing in the am so that they can follow up your study
and decide if the patient requires a formal study.
Critical Care Echocardiography and Ultrasound education
During your time in the unit we will encourage you to learn the skills of performing critical
echocardiography and ultrasound. To this aim we have a weekly teaching meeting on
Tuesday afternoons, from 3pm to 5pm. This attracts a good attendance. For hands on
sessions to limit numbers so that you get a better experience we encourage only half the
group to come each week.
We aim to keep this at a very practical level with lots of hands on tutorials in order to give
you the best possible basic grounding in echocardiography. Ideally at the end of your
year (for SRs and yearlong JRs) you should be able to perform a level one echo study
and basic critical care US.
For senior registrars we stipulate that this session is mandatory. Certainly
echocardiography is becoming an increasingly necessary skill in the ICU (and a very
examinable topic!) For 12 month SRs the aim is to attain at least a basic level of
echocardiography by the end of the term. We encourage you to keep a log book of every
study performed. Each study performed should be recorded in the patient’s notes after
review by an ICU consultant. It is ideal if you can get your study reviewed by one of the
ICU echocardiographers at the time. Finally, every study that is performed (even if it is
very limited) should be recorded in the logbook attached to the echo machine.
You can apply for formal accreditation of your echo experience by ASUM. The CCPU
(see http://www.asum.com.au/newsite/Education.php?p=CCPU) is a formal qualification
to level one study status. In order to do this you will need to do 50 scans, an accredited
- 44 -
course (our TTE course is accredited for CCPU) and an online physics module. Please
come and speak to Deirdre Murphy/ Dr. Vinodh Nanjayya if you are interested.
Reporting
Our echoes are reported on a system called Syngodynamics. The reporting workstation
is located in the room adjacent to the meeting room on the first floor. This reporting
station (dual monitor set up) is only to be used for echo reporting.
Syngodynamics is loaded onto one computer at the workstations in each pod. It has a
blue icon. You all can log in with a generic log in
Username gaicugeneral
Password gaicugeneral
This will allow you to view all the department echoes and see reports including
preliminary ones.
Registrars with prior experience or certification in echo or those who gain significant
experience whilst working here will be given their own log in for Syngodynamics to
complete reports. These will still need to be verified by a consultant.
Equipment
There are four echocardiography capable machines “Ginger” is a state-of-art Phillips Epiq machine which can do 3D TOE, TTE and
general ultrasound.
 “Lily Allen” is a 3D capable Seimens SC2000 machine with TTE and TOE
capabilities. Lily Allen is only to be used by those who are accredited to use the
machine and the Syngodynamics system. Please contact Dr. Vinodh Nanjayya
for accreditation.
 Two of our 3 Sonosite machines have a sector scan for echocardiography and
are useful for rapid hemodynamic assessment studies.
The Sonosite machines are equipped also with small linear array transducers
and longer linear array transducers as well as curvilinear probes (suitable for
FAST and chest ultrasound).
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ORGAN AND TISSUE
DONATION
- 46 -
Patients who die in the Intensive Care Unit may be able to be organ and tissue donors.
Dying patients in the Emergency Department are also potential donors and these
patients must be referred to ICU to support the opportunity for donation. Donation can
occur after brain death or circulatory death.
Brain death is where there is irreversible loss of all functions of the brain as a result of
injury such as trauma, stroke or hypoxic brain injury. This is confirmed either clinically or
radiologically after the diagnosis of brain death, if there is consent for organ donation,
the ventilation and circulation of the patient is supported until organ retrieval.
Donation of organs after circulatory death (DCD) can take place when there is cessation
of the circulation following withdrawal of cardio-respiratory support.
Organ and tissue donation should be considered in any patient, in whom end of life care
is being initiated, including those in whom brain death is likely. All such patients must be
referred to the Donation Specialist Nursing Coordinator on pager 4040 (8am to 10pm,
Mon-Fri) or on phone number 93470408. The DSNC will perform a check of the
Australian Organ Donor Register prior to assisting staff in discussing donation with
patients’ families. Where there is consent to donation, the DSNC facilitates the donation
process.
For more information regarding the process of organ and tissue donation, please refer to
the following sources:
• Donation Specialist Nursing Coordinators: Sharella D’Souza, Bridget O’Bree,
Jess Amsden. The DSNCs can be contacted on Pager 4040 (8am – 10pm MonFri) or on 93470408 outside of these hours
• Medical Donation Specialists: Dr Steve Philpot, AProf Dave Pilcher and Dr Josh
Ihle. These consultants can be contacted via the hospital switchboard.
• Hospital guidelines: Organ Donation Overview; Donation after Brain Death,
Donation after Circulatory Death
• ANZICS Statement on Death and Organ Donation: available on intranet or
ANZICS website
• Donatelife website - www.donatelife.gov.au
- 47 -
JMS ROLES AND
RESPONSIBILITIES
- 48 -
CONSULTANT-LED CLINICAL CARE
Presently four daytime consultants are rostered during the day (Mon – Sunday); one for
each of the four ICU areas and one for the hospital wards/referrals. In addition there is a
night consultant (taking over from 5:30pm) who is responsible for all 4 areas overnight.
Beginning at 19:30 pm the night consultant will conduct the night handover ward round
with the night internal senior registrar and the pod registrar or SRMO and see all ICU
patients and referred patients waiting for ICU admission with the registrar/SRMO looking
after them. The night consultant remains in house and on duty until 8am.
It is essential that Senior Registrars and Fellows have good communication with the ICU
consultants on. Unlike many other units, the ICU consultants have a high clinical
presence during the day and are in-house overnight and expect to be fully briefed on
what is happening to their patients.
By definition, you will probably not have encountered some of the patient groups seen at
The Alfred as more than two thirds of bed days are filled with State Service patients.
Make sure you make the most of our incredible case-mix, and take every opportunity to
learn about their management.
Because of our unique case-mix, the ICU consultants have particular and diverse
expertise. We run a large number of courses throughout the year. The profits from these
courses, together with 15% of each consultant’s entitlement to private practice are
donated back to the department and allocated to research, education, projects and
equipment for the ICU.
The department is dependent on these monies to remain at the cutting edge.
It is therefore not possible to provide attendance at these courses for free, but Alfred
staff receive a 15% discount on the fees.
These currently include: BASIC, ALS, Bronchoscopy, Mechanical Ventilation, Ventilation
Waveforms, Echocardiography, TOE, Critical Care Ultrasound, Nutrition, ECMO
cannulation and workshops, ECMO symposium, Crisis Resource Management,
Infectious diseases, Consultant Intensivist Transitioning course and Haemodynamic
monitoring.
Lookout for the yellow ads. You will see them around the department, in the rumour file
and on the inside of the back cover of Critical Care and Resuscitation. (See pages 71-2)
All are great value and you are encouraged to attend and make the most of the available
expertise.
- 49 -
ALL JMS
All ICU doctors are expected to
1.
Arrive to work punctually (NB: commencement time varies between ICU pods and
for ICU SRs)
2.
Dress and behave in a professional manner
3.
Represent The Alfred in accordance with their employment contract
4.
Become familiar with clinical protocols and emergency procedures
5.
Communicate major changes in patient status to senior medical and nursing staff
6.
Maintain appropriate documentation in patient files and on ICU Active
7.
Participate actively in the education program
8.
Promptly complete any online education package required
9.
Observe all ICU rules and successfully perform on ICU key performance indicators
such as hand hygiene, procedural technique, CLABSI prevention etc.
10. Complete a BASIC course if they have not worked in ICU prior to starting in Alfred
ICU (Senior Registrars and Fellows are exempt from this requirement)
Expectations of each doctor reflect their experience and training.
The individual pay scale will be commensurate with their level of experience in line with
their other Alfred jobs for that contract year. They will not be expected to act above this
level without mutual agreement, and an explicitly altered contract.
Senior Registrars and Fellows are paid a fixed rolled up salary- calculated to include
average overtime and penalties. The following are guidelines for the responsibilities of
each position.
- 50 -
Senior Resident medical officers (SRMO)
HMO3 and above, usually Critical Care 3+ and BPT3+
Always answerable to or directly supervised by senior registrars or fellows, SRMOs
share responsibility for general patient management. SRMOs have the opportunity to
perform many of the procedures, transports and patient examinations in the ICU.
Transports often mean that these doctors are away for parts of the day. Ventilated
patients who need to leave the ICU to attend an investigation, (e.g. X-ray, CT or MRI) or
a procedure, (e.g. hyperbaric unit), must be accompanied by a SRMO, or more senior
doctor.
SRMOs who are interested may choose to learn and perform procedures under
supervision of the respective SR/fellow or consultant. Routine ICU care includes various
procedures such as Central venous lines, and arterial lines. These procedures may be
performed by SRMOs who are not registrars; however there are strict criteria for training
and accrediting that must be adhered to. These must not be undertaken without
supervision until completing the ICU accreditation for these procedures.
Further caveats include:
1. Only suitably trained registrars (not SRMOs) should perform non-emergent
intubation
2. Percutaneous tracheostomies (or the associated anaesthetic) are not to be
performed except by Consultants or Senior Registrars/Fellows under direct
supervision.
3. Airway procedures and central venous access on high-risk patients (e.g. severe
coagulopathy) should not be performed by SRMOs.
SRMO Administrative responsibilities include database entries (ICU Active) and
discharge summaries
For patients admitted during their shifts, SRMOs need to ensure that the ANZICS
diagnostic category and chronic health evaluation are entered onto the ICU ACTIVE
database at the time of patient admission. Clinical details and some admission
demographic data are required. Our data collectors will provide further orientation on this
process. The medical staff must complete all sections in yellow.
Discharge summaries (entered in ICU Active) are an extremely important form of
communication in the ICU. Even patients that die in the ICU require completion of the
discharge summary giving the details surrounding death clearly such that it can be
followed by someone not present at the time. Discharge summaries of deceased
patients (and patients that are readmitted to ICU) are reviewed at weekly consultant
mortality and readmission meetings and it is noted when there are insufficient details
included. The ICU Active discharge summary is an important link for the follow up team
and all active management issues should be listed.
Completion of the discharge
summary is the shared responsibility of the SRMO and HMO. In addition to a written
- 51 -
discharge summary, whenever a patient leaves the ICU for the ward, the primary treating
team should be notified by way of phone call to outline any specific ongoing issues.
SRMO Educational responsibilities
The SRMOs on day shifts are expected to prepare for and run the “labs and ‘lytes” data
interpretation section of the education meeting every Wednesday. This involves
selecting interesting radiology and laboratory results from 2 or 3 current inpatients and
producing a powerpoint presentation, the template for which is available on the ‘H’ drive
of the hospital’s computers. Each patient presented should have a brief synopsis of the
clinical issues followed by the relevant investigations; the session is interactive and
requires that you ask members of the audience to interpret investigations.
The
preparation for this session is not intended to be onerous, and it is regularly considered
the most enjoyable and useful aspect of the teaching program. The PowerPoint
presentations are subsequently saved on the shared drive of the computers as a useful
resource for those preparing for exams.
Summary:
SRMOs are
• Part of a team (usually with a HMO, SR/Fellow, and Consultant)
• Always answerable to a Senior Registrar or Fellow
• Never responsible for deciding admissions or discharges
• Not able to undertake procedures unless specifically trained and accredited
• Never on call
• Responsible for several clinical, administrative and educational duties
• Work approximately 50% of their time on days and
• Approximately 50% of their time night shifts without a HMO
(Still answer to an SR/Fellow)
- 52 -
Registrars (not including Senior Registrars and Fellows)
Usually ICU, Emergency, or Anaesthesia trainees
Registrars work as part of a team much like the SRMOs above.
However, being more experienced, and with more relevant training, they have greater
responsibilities than the SRMOs.
Along with the expectations of the SRMOs (above), Registrars have
1. responsibility for learning, being accredited, and performing routine ICU
procedures including Central venous catheters, arterial lines, Intercostal
catheters, dialysis vascular access catheters (vas caths)
2. expectations to be studying for or having completed a primary exam in College of
either Intensive Care, Emergency Medicine, or Anaesthesia (or equivalent)
3. Extra rostered role as the “lines/transport” registrar.
4. An expectation that they perform their responsibilities at a higher level than the
SRMOs
- 53 -
Role of the overnight Registrar and SRMO
1. They are expected to be on time for the evening Ward round. This starts at the
following times
 Cardiac pod: 7:30pm
 Trauma pod: 7:50 pm
 General pod: 8:10pm
 Surgical pod: 8:30 pm
2. For all patients in the pod
 After the evening ward round, they are required to assess and examine the
patients in their pod and write a brief summary in the notes
 They are expected to round on their patients every 2-3 hours, or more
frequently if required by the clinical state of the patient.
 They need to ensure all bloods and CXRs have been ordered for the morning
 They are expected to look up blood results at the end of your shift and inform
the internal SR of any results that need urgent attention
 It is their role to update ICU active at the end of their shift
 They have to liaise with the SR and will be always answerable to the SR or
fellow
3. New admissions
 They are required to do a thorough admission on all new patients. This
includes paperwork on admission but also ordering any tests for the next day
4. Potential discharges
 Patients with two boxes ticked: They are required to review these patients
with the SR at 6am to ensure they are still suitable for discharge
 Patients with one box ticked: It is expected that they will complete the
paperwork required for discharge.
5. Procedures
 They are not allowed to undertake procedures unless specifically trained and
accredited. The internal SR or fellow needs to be informed prior to any
procedure.
6. Communication and teamwork
This is the secret to good intensive care practice. Keep the communication
channels open
 They are expected to carry their phone at all times
 If they are doing a procedure, they need to inform and hand their phone to
the nurse in charge or the SR
 Prior to leaving the pod, they need to inform the nurse in charge
7. Breaks
 These will be coordinated by the internal SR. Two 30min breaks are
recommended
- 54 -
Senior ICU Registrars
There are 7 positions through which these registrars rotate – one for each pod during
day, an external day SR and 3 SRs at night: one internal to provide supervision and
support to the REGISTRAR OR SRMOs working in each of the three pods, and one
external to cover MET calls, trauma calls, referrals and ward follow up. A third
SR/Fellow is rostered to a hospital Clinical Leadership role overnight. Along with this, a
certificate course in Clinical Leadership is offered over the course of the year, to
complement the experience gained in the role.
They are advanced trainees in intensive care medicine.
They are expected to have successfully completed a primary exam for the CICM (or
equivalent), and have at least 6, but preferably 12 months Anaesthesia experience and
training. They may have already completed their Fellowship exam. They are usually in
their final year of training or after.
Each SR is allocated a consultant mentor for feedback, support and development.
Each SR is also expected to provide mentoring and support to more junior medical staff.
Special SR duties: meeting attendance
• The Trauma ICU SR attends the multidisciplinary Trauma X-ray meeting every
Monday and Thursday at 07.30 in the ED Seminar room on the ground floor.
• The Cardiac ICU SR attends the Transplant meeting every Friday at 0730 in the
cardiology seminar room in the Alfred Heart Centre on the 3rd floor.
Hospital (external) Ward Senior Registrar (Day 07.30-20.00) (Night 19.30 – 08.00):
These Senior Registrars are responsible for:
1. ICU Follow-ups and review of tracheostomy patients. This is done as a ward
round with the ICU consultant (on for wards) and the ICU nurse liaison staff.
2. ICU referrals. This responsibility includes monitoring bed state and bed demand.
This involves liaising with all of the ICU areas as well as the Patient Access
Nurse (PAN Ext 60716), and managing any patients awaiting admission to the
ICU under consultant direction and supervision. ICU charts should be
commenced whether in recovery or ED and clear instructions for the nursing staff
written in the relevant areas. Even though these patients are not physically in ICU
they should be reviewed at normal ward round times with the external ICU
consultant.
3. Cardiac arrests (code blues) and MET calls
4. Data base maintenance. They are responsible for maintaining the ICU Active
database at the start and end of each shift by adding all ICU or HDU referrals
and refusals, potential discharges and patients follow up.
5. Daily (weekday) 15:15 elective admission planning meeting in the ICU.
- 55 -
ICU (Internal) Night Senior Registrar 19.30 –7:30:
This job involves overseeing the care of all ICU inpatients and supervising the Registrars
or SRMOs on for all the areas. The shift starts with attendance at the night handover
ward round.
SR educational responsibilities
Senior Registrars have protected teaching time on Tuesday and Wednesday
afternoons. They are expected to attend the Journal Club during their week on clinical
service to contribute to the discussion of classic and current ICU research.
Attendance is also expected at echo teaching and bronchoscopy teaching when rostered
on for day shifts.
All SRs are encouraged to attend the weekly consultant meeting in the ICU seminar
room on Thursday afternoon when workload permits (this is not protected time). This
session is used to review morbidity and mortality, quality assurance and clinical issues,
as well as administrative aspects of the consultant role. It is expected that those SRs
who have passed their fellowship exam will attend these meetings when they are
rostered on, if clinical workload permits.
SRs are also integral to the research endeavours of the unit. They are strongly
encouraged to be involved in a research project during the year. There are ample
opportunities to complete the formal project aspect of CICM training. SRs are also
expected to identify patients who may be eligible for enrolment into a trial. In some
cases, we also depend upon the SRs to prescribe or initiate treatment in accordance
with trial methodology.
ICU Fellows
Fellows in the Alfred Intensive Care are senior CICM or equivalent trainees, recognised
for having completed their fellowship exam, and have completed their minimum training
time for the CICM (or equivalent).
They must have at least 12 months Anaesthesia experience.
Their role and roster is the same as the SRs (see above), but includes a higher
expectation of non-clinical and administrative responsibilities. This reflects that they are
not studying for a fellowship exam, and their level of training and experience. It is
expected that they will be involved in elements of teaching, research, protocol and
guideline writing/revision, and departmental management.
They answer directly to the rostered ICU consultant.
- 56 -
Hyperbaric Medicine Cover over the week-ends:
Hyperbaric registrar works from Monday to Friday and covers hyperbaric chamber for
both elective and emergency treatments during weekdays.
During weekends ICU external SR/Fellow provides cover for the hyperbaric chamber.
The hyperbaric registrar finishes duty at 3:00 PM on Friday and hands-over to the
external SR/Fellow. From that time till Monday morning 08:00 AM, ICU external
SRs/Fellows take all the outside referrals for the hyperbaric chamber. After taking the
referral, external SR/Fellow contacts the consultant on-call for the hyperbaric chamber
who would advise further about patient management.
The consultant on-call for the hyperbaric chamber can be contacted via the Switch
board. If the referred patient requires hyperbaric treatment, the consultant on-call would
advise on the things to be organized.
If a patient admitted in ICU needs hyperbaric treatment over the week-end, the patient
would be accompanied by the Transport registrar or registrar/SRMO working in the pod
in which the patient is admitted. These sessions will be supervised by the consultant oncall for the hyperbaric chamber.
The external SR/Fellow is responsible for any MET calls or emergencies in the
hyperbaric chamber both during weekdays and week-ends.
- 57 -
After hours Clinical Lead: Role description
This is a night (hours 20:30-0830) and weekend hospital leadership position, staffed by
Senior Registrars rotating from ICU.
They are required to display independent leadership and communication with the
afterhours medical staff in the hospital, as well as liaising directly with individual unit on
call staff, if further escalation is required they will be supported by the ICU consultant.
The role requires that they take responsibility for a team of hospital ward medical staff
comprising the after hours medical and surgical residents and registrars. The emphasis
is on quality patient care: progressing a patient’s care not simply managing
deteriorations. They are responsible for providing a motivated successful team
environment for all after hour’s staff, in particular the medical staff. They will be required
to develop a sustainable new team structure, as this is a new position, with a newly
structured roster. As such, some non-clinical and non-technical skills will be necessaryas this is a significant change from previous years, and from other hospitals. It is
expected that the role will evolve significantly as the new team leads the Hospital at night
with the new structure. The Clinical Lead will be instrumental in developing and leading
further changes.
Feedback on the structure and function of the team will be actively sought, and can be
directed to Owen Roodenburg for this particular role.
They will liaise closely with the nursing leadership team including the clinical operations
manager and the coordinator.
Tasks include:
At the start of each shift the Clinical lead will orientate themselves to the current hospital
state, including available beds, available monitored beds, admissions waiting, tasks
registered to be undertaken on task management system, and know which medical staff
are rostered. They will review the previous night and previous weeks performance.
This will provide the basis for team handover when the night staff begins their shift.
The Clinical lead will:
• Have the responsibility and authority to manage and lead the after hours team
• All residents, medical registrars, and surgical registrars will take direction when
required from the Clinical lead. This will at times include being tasked to
undertake admissions, inpatient reviews, and procedures when they are
considered best positioned to provide the care for that patient.
• Coordinate and lead handovers, at start of and during the night and weekends.
• Actively promote and model a healthy positive attitude towards collegial
collaboration , including coordinating break periods.
• Provide education, supervision and clinical support across medical and surgical
specialties.
- 58 -
•
•
•
•
•
•
•
•
Offer immediate feedback on each and EVERY patient requiring escalation (MET
and Clinical Review Criteria reviews). Specifically, whenever a patient clinical
review is performed for a notified Clinical Review Criteria, a resident (or at times
a registrar) will be required to both assess and manage that patient, but also to
report that assessment and plan to the Clinical lead.
Determine (and be involved when required) when escalation outside of the
hospital is required (on call specialty registrars/consultants).
Focus on whole of hospital bed management, patient care progression, quality
and safety.
Determine and oversee Cardiology bed admissions, and contact cardiology when
required for advice or intervention.
Manage monitored beds after hours
Determine NIV usage for ward patients overnight, and inform the AIR Registrar
via the on call phone at 7.30am. If NIV is commenced on weekends, informs the
AIR registrar ASAP and manage the patient until the time patient is seen by the
registrar.
Be available to assist all staff including MET team/external ICU SR as a clinical
leader.
Monitor workload allocation including admissions, clinical reviews, and individual
patient care requirements, and redistribute workload to achieve the greatest
efficiency advantage to the hospital.
Reporting structure:
Although they will assume the most senior in hospital responsibility for the hospital after
hours, they will report directly to relevant specialty unit on call registrars/consultants
about both clinical and non-clinical issues.
However, as an ICU Senior Registrar, the ICU consultant is expected to be involved
when any further escalation is required. Ultimately they are accountable to the Intensive
Care and Hyperbaric Director.
- 59 -
EDUCATION
- 60 -
Co-ordinators: Drs Vinodh Nanjayya, Chris Nickson and Irma Bilgrami
The Alfred runs a multi-faceted, dedicated training program led by consultants. If you
are rostered on, it is expected that you will attend all of these sessions. You are of
course welcome to attend if you are not rostered on.
Please note that if you swap shifts, the teaching responsibilities will also be transferred
to the replacement person. If you have organised a roster swap please make sure that
you have passed on teaching responsibilities (if any) to the person you have swapped
with.
Time
Monday
07300830
Tuesday
Wednesday
Thursday
Journal Club
FCICM exam
practice**
Airway /
Bronchoscopy
teaching
Friday
10001100
Medical Student
Teaching
11001200
12001300
In-situ
simulation*
In-situ
simulation*
fffgf
13001400
Senior Registrar
Teaching (13pm)
14001500
Critical Care
Echo/
Ultrasound
Teaching (35pm)
15001600
JMS/ Registrar
Teaching
cbcbcb
In-situ
simulation*
* In-situ simulation sessions are dependent on staff, equipment and room availability.
The session on Wednesday is for junior medical staff attending Wednesday teaching
who are not rostered on to a clinical shift.
** Not protected teaching time
- 61 -
BASIC
The Basic Assessment & Support in Intensive Care (basic │ victoria) course is run at
the start of each 3 month term in the ICU (i.e. 4 times a year). It is aimed specifically at
junior registrars and residents who have little or no prior exposure to ICU medicine. It is
also open to external candidates (fees apply). Attendance is compulsory for all new-toICU staff and ICU covers all costs for those rotating to ICU.
It is a two day course run specifically by the Alfred ICU team. The topics covered relate
very much to everyday ICU Medicine;
•
•
•
•
•
•
Ventilation (well covered)
Transport of the critically ill
ABG interpretation for ICU
Advanced Life Support
Central line insertion
Many more topics
The purpose is to educate all new-to-ICU staff prior to starting their clinical rotation in
ICU and should take away some of the initial anxiety some people may experience prior
to starting in a very different working environment.
Since the course has started it has received exceptionally positive feedback and has
helped to improve the overall experience of an ICU term for the candidates.
Course material is mailed to all candidates in the weeks prior and includes a hard copy
course book and also a DVD. The course itself changes on a regular basis based on
feedback from candidates. There is a combination of lectures and practical skills
stations.
Dr Irma Bilgrami is the consultant responsible for the administration and running of the
course. There is also a post-course assessment including an MCQ. It is mandatory that
the assessment is passed prior to commencing clinical duties in ICU.
The Journal Club
 Every Tuesday morning in the ICU seminar room from 07.30 – 08.30.
 2 papers are presented by junior medical staff, as per roster provided at start of the
term
 The articles are distributed by email to all registrars two weeks prior
 Summaries of the critical appraisals and discussions are published on the
INTENSIVE website (see http://intensiveblog.com/category/journal-club/).
 Breakfast is provided at these meetings, and it is compulsory for those rostered on.
- 62 -
Echo and critical care US Teaching: Co-ordinated by Dr Vinodh Nanjayya
 Tuesday afternoons, from 3.00-5.00 pm
 It is a structured training program run over 12 months. The program covers
transthoracic echocardiography, lung/pleural ultrasound, vascular ultrasound and
focused abdominal scans.
 These sessions include didactic lectures, hands on bedside practice as well as the
state of art HeartWorks simulator
 You are encouraged to perform and record bedside echocardiographic studies for
review and discussion at these sessions.
Airway and Bronchoscopy Teaching: Co-ordinated by Prof Dave Pilcher
Thursday morning from 07.30-08.30.
These sessions cover all aspects of
 Bronchoscopy in the critically ill patient, including equipment, patient set-up, and
bronchoscopic procedures including BAL, retrieval of foreign bodies and transbronchial biopsy.
 Airway management of the critically ill
 Basics of mechanical ventilation
Wednesday Lunchtime Teaching
 From 13.00 to 15.00 each Wed, in the ICU seminar room, there is departmental
teaching for all JMS.
 This is protected training time and the consultant on duty should take the ward phone
for that period.
 Lunch is provided, courtesy of industry sponsorship.
These sessions are themed according to topics from the ICU curriculum and consist of
1)
Team-based interactive quizzes; these are usually led by the Senior Registrar
championing the topic.
2)
Teaching sessions run by either an ICU consultant or an invited speaker from
departments outside the ICU. These include lectures, active learning
sessions, interactive discussions and simulation-based learning.
3)
Labs and Lytes; Each JR working day shifts presents an interactive 10 minute
presentation of laboratory results, radiology or any other results of interest
from 1 or 2 patients in their pod. The JR presenting should ask the audience
for interpretation of results and facilitate discussion. The presentation is then
published on the INTENSIVE website (see http://intensiveblog.com/labslytes/)
- 63 -
Tuesday Afternoon Teaching – for SRs
This is protected teaching time for senior registrars only, and runs from 1300 -1500h in
the ICU meeting room (unless otherwise advised). Other junior medical staff are
welcome to attend if they are not on clinical duties.
These sessions are consultant led. However, post fellowship SRs are expected to
actively participate and teach at these sessions. These sessions are aimed at challenges
SRs will face as they transition into a consultant role. They include sessions on
communication skills, and simulation. A significant part of the program includes teaching
on leadership & mentoring and ECMO. By the end of the year, participants may be
eligible for the following certificates
Alfred ICU certificate in Leadership and Mentoring
A program for the ICU Fellows and SRs, run with the help of organisational
psychologists. This program, over 7 sessions, addresses issues such as conflict
management, team work, leadership and learning to negotiate- skills essential to
have but rarely taught before embarking on a consultant role. Participants must
attend 5 sessions to be eligible for the certificate.
Alfred ICU ECMO Accreditation Certificate
The certificate requirements include attending 4 training sessions during SR
teaching. These include both theory, hands on training and simulation. In addition
to this, participants must complete the 2 day ECMO training course.
ICU-IS-SIM In Situ Simulation Programme
Immersive simulation scenarios run on Monday and Friday at 12.00 noon in the
department. This is a medical and nursing collaborative. Up to 3 junior medical staff and
3 ICU nurses, working on the floor are invited to take part. This will be guided by the
clinical work load and staff availability. Scenarios are designed to reflect situations
encountered in daily ICU practice. An additional session is run at 3pm on Wednesday for
junior medical staff attending the Wednesday teaching session who are not rostered on
a clinical shift that day.
Intensive Care Fellowship Exam Preparation
These sessions provide practice for the written exam. A mock exam is held every
Wednesday at 07.30 – 08.30, followed by a discussion of the answers led by an ICU
consultant. They are not protected teaching time and are held for registrars not rostered
to clinical shilfts. Practice sessions for the clinical exam can be arranged with ICU
consultants directly and additional sessions are provided closer to the clinical exam.
Education website
INTENSIVE (http://intensiveblog.com) is a website that serves as a journal and resource
guide for The Alfred ICU. Appropriate content created by consultants and trainees is
published on the website to assist in knowledge translation, facilitate revision and allow
those who are unable to attend formal sessions to have access to the presented content.
- 64 -
Anaesthetic skills training sessions
The anaesthetic sessions are predominately aimed at the SRMOs and JRs who
have little or no previous airway experience.
 First priority for attendance is for anyone that does not have a rostered work
commitment on the day. This is at your own discretion, in your own time and is
not paid. These are the only people who should be booking in advance.
 Second priority is anyone who is rostered to do a transport shift on the Friday and
has some spare time.
 Third priority is those who are rostered on, provided you make arrangements to
be available to return to clinical work immediately should you be required, remain
contactable, and on the day have approval granted by your consultant for a
vacancy confirmed by the ICU secretary Ms Janine Dyer (ext 63036) who
administers the session allocations: workload often prohibits this.
Places are limited to 2 - 3 people per session. Due to rostering limitations within the
Anaesthetic Department, sessions other than a Friday afternoon cannot be
accommodated. Once you are confirmed for a session, you need to be changed into
scrubs and report to Louvella, Dept. of Anaesthesia, 1st floor, Main Ward Block by
13.00 The Consultant in Charge for the day will allocate you to a theatre
for the afternoon session which commences at 13.30. You should use the 30 minutes
prior to theatre starting to assess the patients on the list and liaise with the
Consultant with whom you will be working.
It is really important that if your circumstances change and you are no longer able to
attend a session for which you have registered, you must let Janine Dyer know.
Wednesday pm Primary examination teaching – for JRs/SRMOs
These sessions are run by the anaesthetics department in collaboration with the ICU
department. They run from February to November, in the Robert Orton seminar room in
the anaesthetics department. They cover the syllabus for the anaesthetics primary
examination, which is similar in many respects to the CICM primary syllabus. This is not
protected teaching time; however, you should make arrangements with your
SR/consultant if clinical workload allows so that you can attend as many of these
sessions as possible. These sessions run from 3 – 5pm on Wednesday afternoons,
unless otherwise advised.
It goes without saying that the success of the training program is dependent upon the
input from all of the junior medical staff. Whilst the consultant group are heavily involved
and interested in the education program, we rely on you all to support it. We hope that
the program meets the needs of all of our trainees; the program is continuously reviewed
and modified. We strongly encourage feedback from you in order to help the program
evolve. Please let Vinodh Nanjayya or Irma Bilgrami or Chris Nickson know if you feel
that there are aspects of the program that could be improved.
- 65 -
JMS SUPPORT
- 66 -
Supervisor of training (SOT)
The supervisor of training is Dr Owen Roodenburg. He will meet with you early during
your term, and conduct regular In-Training Assessments with you. If you have any
enquiries about your training requirements, please direct them to Owen as soon as they
are recognised.
Steve McGloughlin, Paul Nixon and Irma Bilgrami will assist Owen with the SOT tasks
for CICM
Chris Nickson is the ACEM SOT and Steve Philpot, the ANZCA SOT.
Mentoring in ICU
The ICU environment can be busy and stressful. To help with issues relating to work,
training and other stresses, a mentorship program is run at the Alfred ICU.
You will be assigned a mentor at the start of your rotation. This will be a consultant for
the senior registrars and fellows, and a fellow/senior registrar for the more junior doctors.
Please contact your mentor within the first weeks of your rotation to arrange to meet with
them.
A mentor and leadership program is also run for the Fellows/Senior registrars to help
them provide ongoing help and support for the junior doctors.
Each mentor/mentee team is expected to meet a few times.
Registrar & Fellow Assessments
Each week, when the consultants finish, an on-line assessment is completed for the
SR/Fellow for that week. In this way we have continuous assessments and can pick up
any issues of concern early.
Once a month all the other JMS are assessed
We attempt to in this way be able to provide intervention and guidance throughout your
time here, rather than waiting till the end of your time with us.
- 67 -
NASA Survey & Consultant Performance Review
At the end of your time in ICU, you will be asked to complete a short survey on your
experience here. We take your feedback seriously and act on it. Please assist us by
completing this. This will be e-mailed to you.
We also perform a 3600 performance review of all the consultants in the Department
yearly. The brief on line questionnaire is sent to all the other ICU consultants, about 100
external consultants, the nursing leadership team and all JMS.
We will appreciate it if you assist us by also completing this. It is only once a year,
towards the end of the year and helps us to continuously improve.
- 68 -
Trainee Goals: 2015
(Prompts for Trainee-Mentor meetings)
Intensive Care Training
Trainee:
Mentor:
Meeting dates: Feb-April
May-July
Aug-Oct
Nov-Feb
……………
……………
……………
……………
Background/Previous/current skills & experience:
Reason for working at Alfred ICU:
Career goals:
Goals for 2015 in Alfred ICU:
CICM requirements (e.g. Primary exam/ADAPT/Project/Medicine/Anaesth/final exam)
Other training program requirement (ANZCA/ACEM/RACP/RACetc.tc)
Research
Technical skills
Leadership/ responsibilities- (NON CLINICAL ROLE/REPONSIBILITY)
What do you need to achieve goals?
To do before next meeting? (E.g. get proposal/plan for audit/project done)
- 69 -
JMS ADMINISTRATION
- 70 -
JMS ROSTERING
The ICU JMS roster coordinator is Dr Vinodh Nanjayya. Following commencement of
employment at the Alfred, all correspondence regarding rosters will be sent to you at
your Alfred email address, in accordance with hospital policy.
If you have any concerns at any time during your appointment please do not hesitate to
bring it to our attention immediately
The roster template
The roster template is the minimum staff will be required to work in ICU.
1. Additional shifts may be rostered over and above the template minimum
2. Amended and updated rosters can be issued with not more than 7 days’ notice
3. These late changes are typically to cover unplanned junior medical staff leave
and absences, often for illness, significant personal or family difficulties
4. Unless a staff member has approved leave for the period concerned, they are
considered available to be rostered and expected to work.
5. Please ensure you have leave or swaps arranged to meet your important
personal commitments as non-rostered times may change.
6. It is the responsibility of each junior medical staff member to check every
published roster for changes that may affect them.
7. Please also be aware of the education roster; any education commitments must
be included in any shift swaps.
The Hyperbaric rotation
There is a dedicated hyperbaric registrar in the first half of the year. When the hyperbaric
registrar goes on leave, registrars on 12 month appointments to ICU will be seconded to
the hyperbaric unit to cover the hyperbaric unit. . They may not take leave during these
rotations. Please see Dr Tim Leong or Dr Nanjayya with any queries.
- 71 -
Timecards
ICU now is on Kronos, an electronic online rostering system. You will not be required to
submit any paper timesheet. At the end of the pay period, the timecards will be signed
off electronically from Kronos.
1. You will be able to view your shifts online via Kronos. Please refer to the
“Employee Cheat Sheet” below for a “how to” guide. Also, there is an e-learning
tool on the intranet site under “Kronos Training and Resource Centre”
2. All leave will be directly entered and approved in Kronos; therefore a paper leave
form is not required.
- 72 -
3. Employees who work additional shifts in locations outside ICU must e-mail Dr.
Nanjayya of their shift details, including date, time, Cost Centre and nature of
shift (e.g. on-call). When sending this confirmation e-mail to Dr. Nanjayya, please
include the manager of the other location and ask them to confirm your shifts with
Dr. Nanjayya by e-mail. Also, you will be required to enter the details of the
additional shifts onto Kronos, so that it can be approved on Kronos. Failure to do
this will result in non-payment for these shifts.
Further information regarding Kronos is available on the Alfred Health Intranet site.
Pay slips are posted in your alphabetical mail boxes located behind ICU main reception.
Leave allocation
Those with 12 month appointments (Fellows, SRs and Registrars) have an entitlement of
5 weeks annual leave (AL), 1 week of conference leave (CL), and 1 week paternity leave
(PL). The AMA HMO certified agreement 2002 makes provision for 8 days examination
leave (with 2 weeks’ notice) for fellowship examination.
1. There is only a limited number of staff that may take leave at any time: 2 JMS3
and 1 JMS2: leave vacancies are allocated on a first come basis.
2. Registrars may not take leave during any rotation to the hyperbaric unit, but may
swap hyperbaric rotations with other registrars.
3. AL preferences for the whole year will be sought on appointment and must be
submitted no later than 2 weeks following commencement. In ICU, annual leave
is rostered on a Monday to Sunday basis i.e. by calendar week. Whilst we will try
to allocate everyone his or her first preference, unfortunately this isn’t always
possible. In the absence of submitting preferences successfully, ICU will allocate
you leave at a time that cover is available. You may accept this leave or swap it
with a colleague. The rules regarding swaps are detailed below.
4. Conference registration details need to be provided in addition to the leave form
for CL to be approved. The deadline for CL submission for the year is 31 March.
Requests after this deadline may not be considered.
5. Please advise if you intend to apply for exam leave.
ED registrars on 6-month rotations
1. By interdepartmental agreement E&TC and ICU split the entitlement for the AL
and CL equally. In practice this provides for 2 weeks AL for one 6 month rotator
and 3 weeks AL for the other 6 months, and one of each pair of ED registrars
takes CL in the 6 month period in ICU.
2. The exception to this is if both trainees have a specialty training commitment
(e.g. presentation of a formal project at a conference) at the same time.
- 73 -
Other Staff (Registrars and SRMOs) on 3-month appointments are not permitted to take
annual leave during their ICU terms.
Roster and timesheet FAQs
Can I swap?
Yes. Just please follow these guidelines. All swaps need to be approved in advance by
Dr. Nanjayya. Just complete a roster swap form, available from Medical Services or the
ICU Secretary, get it signed and then hand in to the ICU Secretary. This form supports
your insurance cover in the event of accident or injury when travelling to work. Even if
you have swapped the shifts, on the timecard only the original rostered hours will be
displayed and you will be paid for your original rostered shifts.
Remember
• “Like-for-like”:
SR/Fellow with SR/Fellow and registrar/SRMO with
registrar/SRMO.
• “Week-for-week”: this is the preferred mode of swapping, and will readily be
approved
• “Day-for-day”: these are not our preference, but will be looked at favorably if they
are for major personal/family commitments or professional development
activities.
What if you are sick?
1. Call the ward to which you are rostered immediately and speak to the medical
staff there to let them know you won’t be in.
2. Then email/’phone Janine Dyer, ICU Admin Manager, at the next convenient time
in business hours. Don’t forget the need to provide medical certificates for
absences of more than a single day.
I needed to stay to do something urgent. Can I be paid un-rostered overtime?
It would have to be very uncommon situation for junior medical staff to be unable to
handover to anyone and so be prevented from finishing work on time. Un-rostered
overtime must have consultant approval, and this must be relayed to the rostering
consultant immediately. Also, un-rostered overtime needs to be entered into the Kronos.
The guidelines for that are provided with the attached KRONOS “Employee Cheat
Sheet”.For a full description of the relevant policy please see “Approval Process for
Payment of ALL Un-rostered Overtime for all Junior Medical Staff” available on the
intranet.
I did an inter-hospital transfer and didn’t finish on time, or was on call after hours. How
does that get paid? This would obviously constitute a valid reason for un-rostered
overtime, and would obviously meet with consultant approval. Claim the time up to the
time you returned to the hospital. Remember to take a cab docket for the return journey.
- 74 -
Also, enter this into Kronos. The guidelines for that are provided with the attached
KRONOS “Employee Cheat Sheet”.
Training time
There are 2 hours of formal teaching time per week. In addition, there are a minimum of
40 minutes teaching time during the usual 3.5-4.5 hours/day of consultant supervised
ward rounds, X-ray sessions and procedure supervision that fulfil the remaining 3 hours
of teaching time per week. There is also mortality and morbidity review, a review of
unplanned readmissions to ICU, a journal club as well as numerous Intensivist-led
teaching sessions throughout the year that registrars preparing for fellowship exams
should attend. ICU consultants are ready, willing and able to provide exam preparation
for candidates sitting the: CICM; RACP; RACS; ANZCA and ACEM exams. There is
also considerable time and effort provided by Intensivists to assist registrars with
presentations for the ASM of ANZICS, and preparing manuscripts for publication. For the
registrars on week off attendance at formal teaching session on Wednesday is
compulsory. 4 hours of teaching will be provided to them on that day. There will be no
other payments for teaching time provided in ICU.
Training Time only applies to registrars in a training scheme i.e. pay classification HM24
and above, with a 43 hour week.
- 75 -
RESEARCH AT ALFRED ICU
- 76 -
The Alfred ICU is a national leader in critical care research with many major journal
publications and projects spanning most areas of this diverse specialty. Areas of
research and publication include traumatic brain injury, nutrition, blood transfusion, acute
lung injury and ARDS, chest trauma, sepsis, and ECMO. Trainees are encouraged to
participate in our research program, and all trainees will have the opportunity to fulfill the
CICM formal project requirement during a term here.
The ICU research group is led by Professor Jamie Cooper, who is also the Monash
University Director of the Australian and New Zealand Intensive Care Research Centre
(ANZIC-RC), and immediate past Chair of the Australian and New Zealand Intensive
Care Society Clinical Trials Group (ANZICS-CTG). He holds an NHMRC senior
practitioner fellowship. There is a large team of ICU consultants actively involved in
research, including Prof David Pilcher, who holds a Monash University research
practitioner fellowship. The research group is supported by a clinical research manager
(Shirley Vallance), and two research co-coordinators (Jasmin Board and Phoebe
McCracken).
The research group works very closely with the Australian and New Zealand Intensive
Care Research Centre (ANZIC RC) at the Monash University Department of
Epidemiology and Preventive Medicine (DEPM), and also with the Australian and New
Zealand Intensive Care Clinical Trials Group (ANZICS CTG). As a registrar, you are
encouraged to take advantage of the many opportunities that will facilitate involvement in
the high quality research that is undertaken. You will be encouraged to act as subinvestigators on studies that interest you and will be supported in projects you wish to
conduct yourself. The Alfred also provides many forums for presenting research, where
formal projects and other research can be shared in a collaborative forum to which all
other Victorian ICU trainees are invited.
Below is a summary of the major trials currently being conducted in the Alfred ICU. You
may be approached to consider your patients eligibility for one of these trials. All
protocols, inclusion and exclusion criteria are available on ICU Net. The research
coordinators are always available to answer any questions and carry a 24 hour pager
(5310) and mobile phone (0419 770 120). They are also available through the
switchboard, ask for ICU Research.
Senior registrars play an integral role in the studies that actively recruit after hours, such
as the POLAR and PHARLAP studies. As a senior registrar you will be asked to identify
and screen for these patients. Additionally, you may be required to consent the patient,
randomize and follow the protocol, in the case of the PHARLAP and HELP-ECMO
studies. The external registrar will also be expected to alert research staff of the
admission of patients with a severe traumatic brain injury. Training will be given by the
Research staff and an appendix at the back of this manual provides full details on these
two trials.
- 77 -
The protocols and details of all of these studies are found on the intranet. Go to ICU Net
> ICU Research or search for ICU research from the home page.
Please contact the research manager for advice on ethics submissions, data collection
or any research related enquiry. The research team is a resource for any registrars who
would like to pursue their own research in their area of interest. Advice and assistance
will be given to support small project grant applications (up to value of $10,000).
Trainees are encouraged to attend the monthly research meetings.
CURRENT STUDIES
EOLIA
A multi-center randomised trial to test the early use of ECMO compared to standard care
in ICU patients with severe ARDS.
EPO – TBI
A multi-centre randomised trial testing erythropoietin in ICU patients with severe
traumatic brain injury in order to improve long term cognitive and functional outcome.
HELP-ECMO
A randomized pilot study that aims to determine the feasibility and safety of
administrating prophylactic anti coagulation in critically ill patients on ECMO when there
is no indication for full systemic anticoagulation.
MM-MRI
A project that will develop high specificity outcome prediction models using multi-modal
MRI, for ICU patients in severe coma, in the early phase after traumatic brain injury.
PHARLAP
A multi-centre randomised controlled trial of an open lung strategy including permissive
hyercapnia, alveolar recruitment and low airway pressure in patients with ARDS.
POLAR – see appendix 5
A multi-centre randomised trial of very early, sustained, moderate hypothermia (33°C) in
patients with severe traumatic brain injury, in order to improve long term neurological
outcome.
SUPPLEMENTAL PN
A multi-centre randomised pilot study to determine if the use of supplemental parenteral
nutrition in ICU patients improves hospital length of stay, survival, and health-related
quality of life.
TRANSFUSE
- 78 -
A multi-centre randomized phase 2 trial of the effect of standard issue red blood cell
units on mortality compared to freshest available red blood cell units in ICU patients.
TEAM
A pilot randomized controlled trial of early mobilization in critically ill patients to improve
functional recovery and quality of life.
CHEER
A controlled trial of refractory out of hospital cardiac arrest treated with mechanical CPR,
hypothermia, ECMO and early reperfusion.
The PATCH study
A multi-centre randomised, placebo-controlled and blinded trial of pre-hospital treatment
with tranexamic acid for severely injured patients at risk of acute traumatic coagulopathy.
APPENDIX FIVE: POLAR STUDY INFORMATION
POLAR (The Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury) is a
prospective randomised controlled multi-centre trial of early and sustained prophylactic
hypothermia in 500 patients with severe TBI.
The primary outcome measure is the proportion of favorable neurological outcomes
(Glasgow Outcome Score Extended: GOSE 5 to 8) at six months following injury.
Secondary outcome measures include quality of life, mortality and incidence of adverse
events.
Inclusion Criteria
• Blunt trauma with clinical diagnosis of severe TBI and GCS <9
• Estimated age ≥ 18 and < 60 years of age
• The patient is intubated or intubation is imminent
Exclusion Criteria
• Clinical diagnosis of drug or alcohol intoxication as predominant cause of coma
• Randomisation unable to be performed within 3 hrs of estimated time of injury
• Estimated transport time to study hospital >2.5hrs
• Able to be intubated without drugs
• Systolic BP <90mmHg
• Heart rate > 120bpm
• Cardiac arrest at scene or in transit
• GCS=3 + un-reactive pupils
• Penetrating neck/torso injury
• Known or obvious pregnancy
• Receiving hospital is not a study site
• Evidence of current anti-coagulant treatment
- 79 -
•
Known to be carer dependent due to a pre-existing neurological condition
External Senior Registrar Responsibilities
Overnight, the external SR must notify ICU research of a potential POLAR patient ASAP
following the patient’s arrival in ED. Randomisation must occur within 3 hrs of primary
injury. Patients may arrive in ED already enrolled in the POLAR study by Ambulance
Victoria (AV). Enrolled patients will have a blue (hypothermia) or green (normothermia)
wrist band to alert staff of their enrolment into the POLAR study (see example below).
ICU research coordinators should still be notified as a secondary eligibility and safety
assessment will be completed in ED. Information on POLAR can be found on the
intranet, and also in the cupboard outside resus 3 in ED.
For patients already randomised by the ambulance:
•
•
•
If the ambulance crew have already randomised pre-hospital, ensure wrist
band are attached and document enrolment in the history. Alert the ICU
research coordinator regardless of treatment allocation.
Patients randomised to standard care will be treated as per usual clinical
practice and maintained at normothermia.
For patients randomised to cooling please contact the on-call research coordinator to discuss management of the patient. All patients in the cooling arm
will be assessed for clinically significant bleeding or high risk of bleeding.
Patients will be maintained at 35 degrees using leg and chest wraps until it is
deemed safe to cool to 33 degrees (usually following theatre and once coags
have been checked in ICU). If the patient is bleeding or is at high risk of
bleeding, their temperature will be held at 35 - 37°C (temperature based on
clinical decision) and the patient will commence cooling when bleeding risk has
resolved. Patients may be given cold saline to maintain temperature of 35
degrees prior to applying cold wraps.
Eligible patients not already randomised by the ambulance
•
•
•
•
•
Severe TBI patients may arrive in the ED who has not been randomised into
POLAR by AV.
Randomisation must occur within 3 hrs of injury. You may need to check the
time of injury/accident with AV if it is not clear from the patient notes.
Alert the Research Co-ordinator ASAP and they will direct you over the
telephone.
They will want to know: age, mechanism, time of injury, what are the pupils
doing, best GCS prior to sedation and intubation, other injuries, any clinically
significant bleeding, temperature on arrival to ED, and has the patient been CT
scanned?
As a courtesy inform all attending units that the patient will be randomised into
the POLAR study.
- 80 -
•
•
•
•
•
•
If the co-ordinator is unable to attend or in cases where randomization must
occur imminently, you will randomise the patient by opening the next
sequential envelope which will reveal the treatment allocation. The research
coordinator will go through the inclusion and exclusion criteria with you and tell
you where to find the randomization envelopes. Please make sure this is
documented in the history. Just write “this patient is in the POLAR study,
randomised on date ___/___/___
@
__:__hrs. Study number___.”
Remember to document the treatment allocation.
Consent is deferred and has been approved by ethics. When the family arrives
in ED they are generally too distressed to take in a lot of study information.
The research staff will obtain consent to continue at a more appropriate time.
Those randomised to normothermia will be kept at 36.5 - 37.5deg and
managed as per standard care.
Patients randomised to hypothermia will commence the cooling protocol
immediately. Reduce the patient’s covering to a light sheet and give 1L cold
N/Saline which is kept in the ED drug room fridge. The patient may receive up
to 2L cold saline depending on amount of fluid given pre-hospital. If the
patient’s temperature is < 35 degrees, it is not necessary to give the cold
saline following randomization. Ask the ED nurse to insert a temperature
monitoring IDC, this is the most accurate way of monitoring the patient’s
temperature while cold.
If the patient needs to go to theatre for evacuation of a mass lesion and/or
insertion of EVD/ICP monitor, their temperature will be held at 35°C in OR and
cooling to 33°C will be commenced as soon as the risk of bleeding has
resolved and the surgical team is happy for further cooling. The meditherm
cooling machine can go with the patient to OR but, depending on the patients
temperature, often this is not necessary. Let the anaesthetist know to keep the
patient lightly covered and that you would like the temp not more than 35°C.
If the patient has no requirement for OR, the chest wrap and leggings should
be applied ASAP and cooling to 33°C commenced. Refer to cooling guidelines.
The ICU PAN will be able to help you locate the cooling machine and manage
the cooling wraps.
What about patients who have been randomised and they have a normal CT and are
drug/alcohol affected?
•
These patients will have active cooling withheld until they can be clinically
assessed. Whilst waiting for drugs/alcohol to be cleared, keep sedated and at
35°C. When appropriate, decrease sedation and assess. (If the patient shivers
significantly during clinical assessment they may be warmed to 36°C).
•
Patients will be withdrawn from the protocol if they
- localise or obey
- do not require ICU admission
- if in the opinion of the treating physician they do not have a severe TBI
- 81 -
•
If the patient’s motor score is withdrawal (or worse) they should be re-sedated,
the surface cooling vests/wraps applied and will continue in the “cooling arm”.
The single most important thing to remember is to notify the Research Coordinator of an
enrolled or potential patient. They will guide you through the rest. Page 5310
using the Meditherm
The POLAR Study: Instructions for
If the patient has been randomised to the cooling arm:
•
•
•
•
•
•
•
•
•
If temp ≥ 35° and patient already intubated infuse 1L cold saline (kept in ED
fridge) as quick as can be administered. If patient arrives not intubated give 2L
cold saline (discuss with ED consultant).
Wrap the chest wrap and leggings around the patient. (If you are in a hurry, the
chest wrap alone will suffice as it is in 60% contact with body and is still
effective). It fastens with Velcro so allows for quick and easy access and is radioopaque.
Turn the power on (front of machine), set the temperature for 33ºC (keep your
finger in the down arrow) and set the machine for automatic mode, rapid cooling
(rabbit mode). Monitor core temperature. Plug the end of the patients’ temp probe
into the machine temp probe. Bladder temp is ideal but oesophageal will suffice.
Automatic mode uses the patient temperature to drive therapy. Feedback is
constant.
Avoid shivering as it increases metabolic rate and 02 consumption. If shivering is
a problem despite sedation consider a non – depolarising neuromuscular
blocking agent (e.g. cisatracurium).
Avoid HYPOTENSION that may occur due to cold water diuresis. Target MAP
80mmHg if no ICP monitor. Target CPP > 60mm Hg if ICP in situ.
Increase MAP with crystalloids (avoid albumin). If MAP does not respond to fluid
challenge administer inotropes (clinicians choice).
Watch for hypokalaemia which is common during cooling - monitor electrolytes
frequently
If the patient is going to the operating room, leave chest wraps and leggings on.
The Medi-Therm lll can go with the patient to OR.
Any questions, please page ICU Research who are always available pg 5310.
- 82 -
- 83 -
COURSES AT ALFRED ICU
- 84 -
The ICU runs more than 30 courses per annum. The profits from these courses, together
with 15% of each consultant’s entitlement to private practice are donated back to the
department and allocated to research, education, projects and equipment for the ICU.
The department is dependent on these monies to remain at the cutting edge.
It is therefore not possible to provide attendance at these courses for free, but Alfred
staff receive a 15% discount on the fees.
Look-out for the yellow ads. You will see them around the department, in the rumour file
and on the inside of the back cover of Critical Care and Resuscitation.
These currently include: BASIC, ALS, Bronchoscopy, Mechanical Ventilation, Ventilation
Waveforms, Echocardiography, TOE, Critical Care Ultrasound, Nutrition, ECMO
cannulation and workshops, ECMO symposium, Crisis Resource Management,
Infectious diseases, Consultant Intensivist Transitioning course and Haemodynamic
monitoring.
All are great value and you are encouraged to attend and make the most of the available
expertise.
- 85 -

JMS Orientation Manual - Alfred Intensive Care Unit

Transcription

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