Orientation February 2020 Intensive Care Department Orientation day

Orientation: February 2020 Intensive Care Department

Orientation day • • • 07: 30 – 09: 30 Hospital Orientation 10: 00 – 10: 30 Bendigo IT summary/overview (Emma Broadfield) 10: 30 – 11: 30 General Orientation (Emma Broadfield) 11: 30 – 11: 45 Education (Vijay Palaniswamy) 11: 45 – 12: 30 ICU & hospital walk around 12: 30 – 13: 15 Lunch 13: 15 – 13: 30 ICU Liaison Service (Jude Downie) 13: 35 – 14: 30 M&M 14: 30 – 14: 45 Research (Julie Smith) 14: 45 – 15: 00 Questions

Bendigo Health

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 & >45, 000 emergency attendances per annum • 372 inpatient unit beds • 60 -bed rehabilitation unit • 6 ICU equivalent funded beds (ICU/HDU/CCU) • 20 physical ICU bed space • 11 operating theatres (with Endoscopy/Bronchoscopy)

Bendigo Health • Services NOT YET consistently available • 24/7 catheter laboratory • Interventional radiology • Vascular surgery • Paediatric ICU • Hematology • Neurosurgery • Cardiac surgery • Neurology • Rheumatology • ENT

Intensive Care Unit

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

Inpatient ICU Unit details • Combined ICU/HDU/CCU • • • 20 physical beds (6 ‘ICU equivalents’ funded) 7 ventilators 4 transport Ventilators (1 MRI compatible ventilator) 3 haemofilters 1 IABP/Bronchoscope/transvenous pacing Vascular access US • Sonosite US & Sparq • Echocardiography machine with TOE probe • Philips Sparq

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

Staff • 8 Intensivists (4. 3 FTE) • 6 registrars & 4 HMOs • Medical students • Monash University & University of Melbourne • BMed. Sci x 2 • NUM: Darcy Bales & CNC: Jenni Tuena • ICU Nurse Educators • Undergraduate and postgraduate students • Liaison Nurses x 7 • Research nurse – Julie Smith

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 • 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

Rostering • Consultant rostering • Found on Find. My. Shift (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)

Staff communication • Find. My. Shift • • • Roster Education Meetings • Bendigo Health E-mail • we don’t use your personal email for hospital communication! • Bendigo hub • Bendigo ICU Website

ICU Hub

ICU Website

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

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!

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

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 • May 2020

Daily routine • 0800 – 0830: Interprofessional handover • 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 • 1530 -1630: Afternoon consultant handover round • Consultant, Day Registrars, day HMOs • ANUMs, Bedside nurses • Outreach team checks-in for ongoing issues

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

Night huddle questions • • How busy are you? Do you have any patients of concern? Do you need help? Are you able to offer any help?

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 1345 Wednesday • Education 1200 -1700 Thursday • Outreach registrar: Trolley checks (Airway, PICC & Paediatric Emergency)

Ward rounds • Goals • • Clinical examination Review of nursing and allied health concerns Development of integrated 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 1000 hrs PACEs (hospital-wide logistics meeting) meeting

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)

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’

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

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 • CLOSED UNIT • Only ICU prescribes and administers therapies (to prevent patient safety problems) • Treating teams can request from ICU • Report external teams physically prescribing to Consultant • Exception – Acute Pain Service

Referrals • Referral for elective bookings • Tuesday’s ICU pre-admission clinic • Emergency referrals • • • 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 referral method • If services can’t be provided, external transport is required (ARV)

Referrals • Refused ICU admission • May be due to – • ICU resource limitation • Too well for ICU • Not appropriate for ICU admission • Needs to be approved by duty ICU consultant • Must document in REFUSALS BOOK • Allows tracking of requests for ICU services • Followed up by ICU Liasion team • Enables future planning of service provision

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

Procedures • • Seek supervision actively DOPS / Work Place Competency Supervision Sterile technique Number of goes! – Ask for help after the 2 nd failure Assess, report & manage complications Documentation • Clinical note & sticker

Ultrasound • Clean it up after use! • Site. Rite • 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

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

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

Paediatric HDU • • • May include PIPER Developing 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

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

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

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 Donate. Life. Victoria 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

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 Donate. Life Victoria

Organ and Tissue Donation 1. Was this patient considered for organ and tissue donation? 2. Were they referred to Donate Life Victoria? 3. What was their AODR 1 status? 4. Was the family informed of donation potential? 5. Donation outcome? • 1 Australian Organ Donor Registry

Intensive care outreach “Outside”

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 • Telemedicine to Echuca HDU (consultant led)

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 Dual coordination: Nurse – algorithm, Doctor – team leader PROMPT for policy senior Medical team from ICU/Anaesthetics/CCRN

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

Outreach Registrar (x 47538) • 0830 – 2030 daily (if hours permit) • Reports to Outreach Consultant (0900 – 1700) OR ICU Consultant (days/nights)

Outreach Registrar (x 47538) • • • Covers METs and Code Blue on wards Manages PICC insertions Assists in after-hours workload Assists in Quality Improvement Attend Pre-admission Clinic Attends Quality Improvement meetings • • • Code Blue, Trauma & MET committees Trolley checks Medical student teaching

Clinical support roles

Professional affiliations Medical student program • In-department • Year 3/MD 2 • Clinical placements • Weekly teaching of early clinical skills • Year 5 • Clinical placements • Pre-intern • May be asked to provide a performance review Undergraduate & Critical Care nursing & Physiotherapy • CHERC program • Undergraduate • Clinical skills

Research • Registrar projects • Allocation to ICU portfolios • Support available from Monash/La. Trobe academics and ICU consultants & research nurses • CICM projects • Resident support • Audit • Ongoing departmental audits • ANZICS CTG - Julie Smith

Current CTG & industry Research Studies • • • PLUS STAART-AKI SPICE 3 ART-123 Balance REMAP

Mortality & Morbidity • Monday at 1335 hrs in meeting room • Inter-professional team meeting and discussion • Prepared and presented by ICU registrar • Wednesday to Wednesday census period • Data obtained from Data Manager & Director • Day registrar presents • types updates as needed • Template format on G: drive • Patients presented: • Deaths in the unit & post ICU discharge • Readmissions • Morbidities • CLABSI, VAPs, accidental CVC removal, failed extubation etc

Supervisor of Training • Dr Emma Broadfield • Be proactive and book in! • • • The So. T will not chase you for your paperwork Collates ongoing feedback from team every 2 weeks. Book in at the start, middle and end of your term • • • Start – to identify training needs, expectations Middle – appraisal End – assessment & paperwork

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

Education & Training • Wednesday afternoons • Clinical care covered by Consultants in this paid, protected teaching time • Based on themes • Focused on Part 1 exams • On FMS Hub link • Registrars and Crit Care HMOs affiliated to consultant for support with portfolio

Student mentorship • Teach them internship skills • “hidden curriculum” • • Death certification Coronial requests Recovery and disease trajectories Advanced Care Planning Goals of Care or Limitation of Treatment forms MET behaviours – “while you are waiting. . . ” Team behaviours (encourage engagement in simulation) Types of organ support in ICU

Student mentorship • e. PIA • Electronic Pre-Intern Assessments • Registrars and consultants • Part of formal pre-intern assessments • PBAF • Professional Behaviours Assessment forms • Contact J. Fletcher or Lee Cassells if student behavior concerns

Simulation Space

Education & Training • Daily Presentations at bedside • Intranet access to journals, Up to date, Crit-IQ, PROMPT • BASIC course • Registrar driven clinical and viva exam practice

Questions?