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Orientation: February 2019

Join us for an intensive care department orientation day at Bendigo Health. Learn about our hospital, ICU unit, staff roles, and available services. Get a comprehensive overview of our facility and the healthcare we provide.

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Orientation: February 2019

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  1. Orientation: February 2019 Intensive Care Department

  2. Orientation day • Hospital Orientation – online package • ICU orientation • 1200-1300 – Bendigo IT summary & lunch • 1300-1315 – General orientation • 1315-1330 – ICU Liaison Service (Sarah Dyer) • 1330-1430 – M&M / Clinical Performance • 1430-1515 – General orientation • 1515-1530 – Research (Julie Smith) • 1530-1600 - SoT & Education (Tim Chimunda) • 1600-1630 – C6 ventilator overview (Jo Walter) • 1630-1700 – ICU & hospital walk around

  3. Bendigo Health Overview

  4. Bendigo Health • New Hospital opened January 2017 • Public Private Partnership (Exemplar/Spotless & Bendigo Health) • >3,300 staff • Catchment covers area 1/4 size of Victoria • Expanding regional health organisation • 678 bed acute service • >41,000 inpatients per annum • >45,000 emergency attendances per annum • > 1200 births each year • 372 inpatient unit beds • 72 same day acute beds • 60-bed rehabilitation unit • 6 (&) ICU equivalent funded beds (ICU/HDU/CCU) • 20 physical ICU bed space • 11 operating theatres (with Endoscopy/Bronchoscopy) • >10,000 surgical procedures performed annually

  5. Bendigo Health • Services NOT YET consistently available • 24/7 catheter laboratory • Open Monday to Thursday (4 days per week) • Interventional radiology • Vascular surgery • Paediatric surgery • PaediatricICU • Hematology • Neurosurgery • Cardiac surgery • Neurology • Rheumatology • ENT • Regional settings include: Mildura, Echuca, Swan Hill, Kyneton and Castlemaine

  6. Intensive Care Unit

  7. Unit Structure & Function • Clinical • ICU ward – “Inside” • Outreach (incl. telemedicine) – “Outside” • Professional Development • Teaching & Learning • Quality improvement • Clinical Governance • Research

  8. Intensive care Unit “Inside”

  9. Inpatient ICU Unit details • Combined ICU/HDU/CCU • 20 physical beds (6 ‘ICU equivalents’ funded) • 7 ventilators, 3 non-invasive ventilators • 4 transport Ventilators including one MRI friendly Ventilator • 3haemofilters • 1 IABP/Bronchoscope/transvenous pacing • Vascular access US • SonositeUS & Sparq • Echocardiography machine with TOE probe • Philips Sparq

  10. Inpatient ICU Unit details • Supported by a ‘public-private partnership’ (PPP) with Spotless who provide - • Patient transport support • Security & access • Communication systems • Cleaning and Environmental services • Food services • General facility maintenance

  11. Staff • 8 (9) Intensivists (4.3 FTE) • 5.5 FTE registrars and 4 FTE HMO • Medical students • Monash University & University of Melbourne • BMedSci x 2 • NUM– Darcy Bales • CNC – Jenni Tuena • ICU Nurse Educators • Undergraduate and postgraduate students • Liaison Nurses x 7 • Research nurse – Julie Smith • Data managers – Tracey Shard • ALS coordinator – Dani Dobie

  12. Staffing • 3 nursing shifts/day • Staffed: 8 nurses/shift supervised by ANUM • Day (each day): • 1 Consultant (0800 - 1800) • 1 registrar (0800 - 2030) • 1 HMO (0800 - 2030) • Outreach (Mon to Fri): • 1 Consultant (0900 - 1600) • 1 registrar (0800 - 2030) – Variable; this is effectively a partial leave cover position • Night (each day) • 1 registrar (2000 - 0830) • 1 HMO (2000 – 0530) • Clinical Support consultant (Mon to Fri) • 1 Consultant (0930-1500) • Covers administrative work, portfolio work & teaching

  13. Coronary Care arrangements • Coronary Care Unit • Is a co-located unit in the ICU/HDU environment • ICU nurses are trained to care for both • Access to CCU is controlled by ICU ANUM/Cardiologist • Medical care is directed by Cardiology consultant and registrar • Medical registrar covers referrals and admissions after hours • Nurses directly contact cardiologist overnight for clinical issues – cardiologist may ask ICU registrar for help for time critical tasks. • Formats of Cardiology admission in ICU/CCU • Coronary Care admission • Single organ (primarily) Cardiology bed-card patient (consultant and registrar) • Cardiology control patient care, ICU not involved • ICU/CCU nursing staff care for patient • Escalation for deterioration through Cardiology departmentand referred to ICU if appropriate • Cardiology admission in ICU/HDU • Complex cardiology or multi-organ support needed outside of primary Cardiology problem • Any post op patients complicated by cardiac condition • ICU control care in collaboration with Cardiology (as per any other ICU admission) • ICU/CCU nursing staff care for patient

  14. Rostering • Consultant rostering • Found on FindMyShift (www.findmyshift.com) • Registrar Roster and Leave issues • Managed from the HMO office-Kath Creme • Migrated to FMS • Kronos • Tap-on, tap-off (TOTO) outside ICU tea-room • Can TOTO at other points in hospital • Cameron Knott is the clinical lead for rostering (icurosters@bendigohealth.org.au)

  15. Rostering – Find My Shift

  16. Staff communication • FindMyShift • Roster • Education • Meetings • Bendigo Health E-mail • we don’t use your personal email for hospital communication! • Bendigo ICU Hub • Bendigo ICU Website

  17. ICU Hub

  18. ICU Website • http://www.bendigohealthicu.org/

  19. Staff Welfare • We want you to be • Happy • Healthy • Thriving • Professional • Mentorship program available • Use the mentorship meeting tool to prepare for your meeting • Employee Assistance Program (EAP) • CICM and other colleges

  20. ICU attire • Smart clothing or scrubs • Respectful of a broad spectrum of a critically ill patient demographic • Nothing below the elbow (infection control) • Tie-free zone • Lanyard free zone • Self-care • Timely Lunch & Dinner…Time Management!

  21. Bed management • ICU bed management • ICU 1:1 (= 1 ICU equivalent or “package”) • HDU 1:2 (= 0.5 ICU equivalents or “package”) • CCU 1:2 • Coordinated through Consultant, ANUM and Bed Manager • Empty staffed beds reported to REACH each shift • Enables utilization of state-wide resources

  22. Information & Communication Technology • ICU is transitioning from paper to electronic medical record • Digital Medical Record (DMR) • Interim, ‘paper-lite’ system • Significant ongoing usability issues • Electronic Patient Record (EPR) • Will replace DMR, more sophisticated • Highly complex development process ongoing • September 2019?

  23. Daily routine • 0800 – 0830 Interprofessional handover round in Meeting Room • Consultant, Day & Night Registrars, day & Night HMOs • ANUMs, Bedside nurses, Allied health • 0830– 1100 • Bed Side Ward Round (Teaching opportunity) • After 1100 • Post Round work: Interventions/Chasing History, Investigations, correspondence/Family Meeting/Resus form updates • 1530-1630 Afternoon consultant handover round • Consultant, Day Registrars, day HMOs • ANUMs, Bedside nurses • Outreach team checks-in for ongoing issues

  24. Daily routine-2000-0800 • 2000: Night registrar & HMO hand over • 2100-2130: Night team interprofessional round • Night ANUMs, Registrars, HMOs, Bedside nurses • Depending on clinical acuity, night consultant may attend in person • If consultant not attending in person, there will be a night-time telephone round • 0100: • Night Hospital “Huddle” • Held in ED with Bed Manager, ED/Medical/ICU night teams • Goal is for peer support, load distribution and early detection of patients for discharge/deterioration

  25. Weekly schedules (also on FMS) • Monday: • Day registrar: M&M 1335-1430 • Micro Round 1430 • Tuesday • Medical Student Teaching 1100 • Outreach registrar: ICU Pre-admission clinic • Wednesday • Education 1200-1700 • Thursday • Outreach registrar: Trolley checks (Airway, PICC & Paediatric Emergency)

  26. Ward rounds • Goals • Clinical examination • Review of nursing and allied health concerns • Development of integrated systems care plan for next 12 hours • Documentation • Communication of plan to patient, family, ICU and other teams • Enroll in clinical trials • Complete patient diary and “Get To Know Me” board • Determine discharge plans before 1000hrs PACEs (hospital-wide logistics meeting) meeting

  27. Ward rounds • Full thorough individual patient review after handover round • Chase down further history, correspondence, Investigations & source notes • Contact GPs and treating consultants, as needed • Write detailed contemporaneous notes • FAST HUGS ..MBSE • Issues list • Management plan • Feeding & fluid plan • Procedures & investigations (order, advocate and review) • Microbiology & antibiotics (Approval numbers, ID referrals) • Paper rounds • Update Rolling Handover (ROVER)

  28. Expectations • Doctor Availability in the ICU-24 hours per day • Professional approach • Call for help or advice anytime • Strict infection control • 5 moments of HH • Nothing below the elbows • CISCO phones & Pagers • Let someone know if you anticipate being ‘out of range’

  29. Patient reception • ED/Ward/Theatre/External-ARV • Aim is to have a single, contemporaneous multi-disciplinary handover at bedside • Not universal at present • ISBAR • Theatre-Surgical/Anaesthetic handover • Practice of medical telephone handover & bedside nursing handover

  30. Parent Unit • Encourage involvement in ICU care and family meetings • Seek advice from treating teams when they arrive in ICU • Encourage “Talk before you walk” behavior in treating teams • Actively ‘catch’ parent teams for updates • Bi-directional verbal and written communication • “CCMx” is not a recognised abbreviation • “How can we look after this patient better today?”” • CLOSED UNIT • Only ICU prescribes and administers therapies (to prevent patient safety problems) • Treating teams can requestfrom ICU • Report external teams physically prescribing to Consultant • Exceptions – • Acute Pain Service • Paediatrics

  31. ICU/HDU Referrals • Referral for elective bookings • Tuesday’s ICU pre-admission clinic – • Admission instructions • Suitable for ICU/HDU – cancel op if no ICU/HDU bed • Suitable for ICU/HDU – can proceed if no ICU/HDU bed, as lower risk • Do not require ICU/HDU • We avoid cancelling elective bookings as much as possible • If we may need to cancel, early discussion of bed availability b/w Bed manager, intensivist and parent unit pre-op. is required (even overnight!) • Refer all enquires from OR staff back to Bed manager

  32. ICU/HDU Referrals • Elective versus emergency referrals • Anyone: Consultant/Registrar/Resident can take the referral • Emergency or unplanned ICU/HDU referral • Intent is to take patients early and readily • Review referred patient within 30 mins • Early discussion of suitability for ICU (Intensivist) • Discussion of bed availability • Review with Parent unit • MET call is a NOT a referralmethod, yet may become a referral! • If services can’t be provided – external transport is required (ARV)

  33. Referrals • Refused ICU/HDU admission • May be due to – • ICU resource limitation • No available staffed beds • Too well for ICU • Too sick for ICU • Not appropriate for ICU admission • Needs to be approved by duty ICU consultant though discussion • Options may be - • Transfer to alterative hospital • Admission to another care location at BH • Must document in REFUSALS BOOK • Allows tracking of requests for ICU services • Followed up by ICU Liasion team • Enables future planning of service provision

  34. PICC referrals • Referral forms are available on PROMPT • Referrals are triaged through ICU Liaison Nurse (#47936) • Intensivist authorises insertion • TPN • Difficult access • Long term iv therapy • Inserted by • Radiology or • ICU • Oncology insert their patient’s PICC • CLABSI principles

  35. Procedures • Seek supervision actively • Work Place Competency (CICM website) • Consent • Supervision • Sterile technique • Number of goes! – Ask for help after the 2nd failure • Assess, report & manage complications • Documentation • Clinical note • Google form Procedure note

  36. Ultrasound • Clean it up after use! • SiteRite • Vascular Access • Stored in ICU, can leave ICU with ICU registrar • Can leave ICU only with authorization • Sparq • Vascular Access • Echocardiography • Not to leave ICU without permission • For ICU use only • FAST

  37. ICU specific Forms • Resuscitation (MR85) – electronic – every one gets one • Palliative care • Drug Chart and IV form • Procedure Sticker • CVVHDF sticker • Consent-Tracheostomy/Blood transfusion • Microbiolgy sheets • Tertiary Trauma Survey • Refusal forms (in folder) • Tracheostomy Notes • VAE forms • CLIP forms (Oct – Dec) • Google procedure logs

  38. Routine bloods & CXRs • On admission: Full bloods, MRSA & VRE swabs • Routine bloods: FBE, U&E, Ca-Pho-Mg • LFT, CRPas clinically indicated (1-2/week) • Coagulation as clinically warranted • Cultures- Blood, sputum, Urine, Antigen, PCR, Serology etc • CXRs (performed at 0500hrs onwards, if in am) • on admission, then as clinically warranted

  39. Microbiology • Pink forms • Actively chase results • Now (mostly) off-site  you will need to be vigilant about delayed or inaccurate results • = ESCALATE

  40. Paediatric HDU • May include PIPER (neonatal/paediatric retrieval service) TC/VC consultation at RCH • Developing an HDU program • Needs multi-disciplinary care • Short-term Paediatric ICU capability only • Attendance at Paediatric MET/Codes • ICU medical staff are not required at Neonatal Codes

  41. Infection control • Hand hygiene • Central Line Associated Blood Stream Infections • CLABSI rates monitored by VICNISS system • Full barrier protection for all lines, except i.v.cannulae • Isolation procedures • Annual CLIP audit

  42. Transfers • Electronic summaries in the DMR notes • Drug charts (paper) • rewritten as needed (common sense) • Remove ICU related drugs (K, Mg, PO4 “APP”) • Blood forms & radiology (for next 24 hours) • PARENT UNIT • Contact and handover • After hours discharges – review on ward within 4 hours

  43. Deaths • Consideration of potential for organ and tissue donation is a normal part of every EOLC • Ask for help in any EOLC process • Will need to contact DonateLifeVictoria for medical suitability for each case • Document death assessment • Inform treating team of death • Write ICU discharge summary • Fax GP (each time) and call GP (in hours) • Online Coronial or Births/Deaths/Marriages certification

  44. Organ and Tissue donation (OTD) • Can bring patients from ED for EOLC and family time • Consider organ and tissue donation in any EOLC scenario • Donation after Brain Death (DBD) • Donation After Circulatory Death (DCD) • Tissue donation • Corneal/whole eye donation • OTD can occur when patient is a coronial referral • Call Organ and Tissue donation nurse early through DonateLifeVictoria

  45. GIVE trigger • GCS ≤ 5 • Intubated and/or • Ventilated • End-of-Life Care planned • Includes cessation of life sustaining therapy

  46. Organ and Tissue Donation • Was this patient considered for organ and tissue donation? • Were they referred to Donate Life Victoria? • What was their AODR1 status? • Was the family informed of donation potential? • Donation outcome? • 1 Australian Organ Donor Registry

  47. Intensive care outreach “Outside”

  48. Outreach & Outpatient activities • ICU Outreach • Follow-up ICU patients • Follow-up METs • Follow-up refused patients • TPN • Vascular access (CVCs, PICCs) • ICU deteriorating patient services • Medical emergency team (MET) • Code Blue team • ICU Clinics • ICU pre-admission clinic • ICU Follow-up clinic • Telemedicine to Echuca HDU • Developing Perioperative Medicine

  49. MET & CODE Blue • Medical Emergency Team • only 1 ICU doctor to attend - Registrar • ICU and Med Reg; CCRN and ward Nurse • Respond within 5 mins • Assessment of ABC; resuscitation status • Management (if critically ill) • MET sticker • ≥ 2 MET: consultant review • Policy in Prompt • CODE BLUE • Ensure your ALS updated last 12 months • Immediate response • PROMPT for policy • senior Medical team from ICU/Anaesthetics/CCRN

  50. Telemedicine • Telemedicine consultation with Echuca HDU • 1300 by Outreach Consultant • Enables remote management of patients • Any transfer is via ARV, with preference to come to Bendigo, if bed available

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