1. Orientation: February 2018
Intensive Care Department

2. Orientation day Hospital Orientation – online package ICU orientation
Rostered day staff (1st day)
– Practical orientation of Bendigo Health
– Lunch in ICU (“getting to know you”)
– ICU Orientation
– Free-time for tying loose ends

3. Bendigo Health
Overview

4. Bendigo Health New Hospital opened January 2017 >3,300 staff
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
Neurosurgery
Cardiac surgery
Neurology
Rheumatology
Paediatric surgery
Paediatric ICU
ENT
Hematology
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
3 haemofilters
1 IABP/Bronchoscope/transvenous pacing
Vascular access US
Sonosite US & 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 7 Intensivists (4FTE) 5.5 FTE registrars and 4 FTE HMO
Medical students
Monash University & University of Melbourne
BMedSci x 2 (Zac and Rebecca)
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 ( )
1 registrar ( )
1 HMO ( )
Outreach (Mon to Fri):
1 Consultant ( )
1 registrar ( ) – Variable; this is effectively a partial leave cover position
Night (each day)
1 registrar ( )
1 HMO (2000 – ?0800)
Clinical Support consultant (Mon to Fri)
1 Consultant ( )
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
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 task ICU registrar as needed
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 nursing staff care for patient
Escalation for deterioration through Cardiology department, 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)

14. Rostering Consultant rostering Registrar Roster and Leave issues
Found on FindMyShift (
Registrar Roster and Leave issues
Managed from the HMO office-Isabelle Ivanov
Migrated to FMS
Kronos
Tap-on, tap-off (TOTO) outside ICU tea-room
Can TOTO at other points in hospital

15. Rostering – Find My Shift

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

17. ICU Hub

18. ICU Website

19. Staff Welfare We want you to be Mentorship program available
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

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
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:
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:
Midnight 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
Micro Round 1430
Tuesday
Medical Student Teaching 1100
Outreach registrar: ICU Pre-admission clinic
Wednesday
Education
Thursday
Outreach registrar: Trolley checks

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 request from 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 referral method, yet may become a referral!
If services can’t be provided – external transport is required (ARV)

33. Referrals Refused ICU/HDU admission Must document in REFUSALS BOOK
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 You may get referrals from outside ICU
Refer them all to the 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 Sparq Vascular Access
Stored in ICU, can leave ICU with ICU registrar
Can leave ICU only with authorization
Sparq
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, CRP as 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 Shared care with Paediatrics
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
~ Attendance 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
Document in CLIP audit and Google form
Ventilator Associated Events (VAEs)

42. Discharges 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 DonateLife Victoria

45. End-of-Life Care planned
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 CODE BLUE
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
1500 by Outreach Consultant
Enables remote management of patients
Any transfer is via ARV, with preference to come to Bendigo, if bed available

51. Outreach Registrar (x47538)
0830 – 2030 daily (if hours permit)
Reports to Outreach Consultant (0900 – 1700) OR ICU Consultant (days/nights)

52. Outreach Registrar (x47538)
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

53. Clinical support roles

54. Professional affiliations
Combined MU and UoM
Medical student program
LaTrobe
Undergraduate & Critical Care nursing
Physiotherapy
In-department
Year 3/MD2
Clinical placements
Weekly teaching of early clinical skills
Year 5
Pre-intern
May be asked to provide a performance review
Deteriorating patient simulation
CHERC program
Undergraduate
Clinical skills

55. Research Registrar projects Resident support Audit
Support available from Monash/LaTrobe academics and ICU consultants & research nurses
CICM projects
Resident support
Audit
Ongoing departmental audit
CICM Formal Project
ANZICS CTG - Julie Smith

56. Current CTG & industry Research Studies
PLUS
STAART-AKI
Nebulised heparin
SPICE 3
ART-123

57. Mortality & Morbidity Monday at 1330hrs 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

58. Supervisor of Training
Dr Tim Chimunda
Be proactive and book in!
The SoT will not chase you for your paperwork
Visit for CICM, ACEM, RACP, RACS, ANZCA paperwork
Visit for training advice
Tim does not do mentor meetings (to separate assessment and welfare roles)
Collates ongoing 360 degree feedback from team every 2 weeks.
Book in at the start, middle and end of your term
Preferably after your mentor meeting

59. Education Mandatory training
iLearn
Fire safety
Aseptic technique/Hand Hygiene
Blood safe
ALS
Open Disclosure training
System evolving in 2018 to new online system

60. Education & Training Wednesday afternoons
Clinical care covered by Consultants in this paid, protected teaching time
Based on themes
Focused on Part 1 exams in 2017
On FMS Hub link

61. Education & Training

62. 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

63. Student mentorship ePIA PBAF 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

64. Simulation Space

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