1. ORIENTATION 2016 Intensive Care Department

2. BENDIGO HEALTH Overview

3. 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 60-bed rehabilitation unit 8 intensive care unit 5 operating theatres >10,000 surgical procedures performed annually

4. Bendigo Health Services for the Loddon Mallee region Emergency and intensive care General Medicine General Surgery General Paediatrics Maternity & Women’s Health Medical imaging Pathology Cardiology Cancer services Renal & dialysis Endocrinology Respiratory Gastroenterology Thoracic Surgery ENT Plastic Surgery Urology Rehabilitation Community services Residential aged care Psychiatric care Community dental Hospice & palliative care Three main campuses in Bendigo Regional settings include: Mildura, Echuca, Swan Hill, Kyneton and Castlemaine $630 million to deliver a new Bendigo hospital opens 23 January 2017

5. Bendigo Health Services NOT YET available 24/7 catheter laboratory Interventional radiology Vascular surgery Neurosurgery Cardiac surgery Neurology Rheumatology Paediatric ICU Three main campuses in Bendigo Regional settings include: Mildura, Echuca, Swan Hill, Kyneton and Castlemaine $630 million to deliver a new Bendigo hospital opens 23 January 2017

6. INTENSIVE CARE UNIT

7. Unit Structure & Function Clinical Professional Development Research Telemedicine

8. INTENSIVE CARE UNIT “Inside”

9. Inpatient ICU Unit details Combined ICU/HDU/CCU 11 physical beds (6 ICU equivalents funded) 5 ventilators, 3 non-invasive ventilators 2 haemofilters 1 IABP/Bronchoscope/Pacing Bronchoscope comes from OR so need to order ECHO machine In ICU consultants office

10. Staff Intensivists x 6 5 registrars and 5 residents NUM– Sue Tomlinson CNC – Jenni Tuena ICU Nurse Educators Liaison Nurses x5 Research nurse – Julie Smith

11. Staffing 3 nursing shifts/day Staffed: 8 nurses/shift Day: 1 registrar (0800-2030) & 1 HMO (0800-2030) Night 1 registrar (2000-0830) & 1 HMO (2000-0530)

12. Rostering Consultant rostering Found on FindMyShift Roster and Leave issues Kronos

13. Nursing ratios ICU 1:1 HDU 1:2 CCU 1:2

14. Daily routine 0800: night to day hand over 0830 consultant business round 1600: afternoon consultant round 2000: night registrar hand over 2130: Night consultant round 1230 & 1930 Paper rounds, Rolling Handover preparation (ROVER) Day tasks update/Drug and IV charts/Micro sheets Random Audits Admission or Discharge summary/Notes/Documentations

15. Ward rounds StagePurposeWho Time required (minutes) Outcomes 1Check-inIntensivist (s), ACN5 – 10All emergent issues resolved 2 Business & handover Intensivist (s), ACN, ICU medical staff, allied health 5 - 20  All patients ready for discharge identified  Tasks identified needed to complete prior to discharge  Seek allied health input  Intensivist handover 3 Management & teaching Intensivist, medical staff (other staff able to attend if they wish) 30 – 120  Assessment of each patient  Construct management plan for day  Teaching 4Radiology review Intensivist, medical staff, physio 5 - 15  Review all radiology  Teaching 5Check-outIntensivist, medical staff, ACN 5  Discussion and agreement on – o high priority tasks o timing of any procedures (eg. tracheostomy) o incoming patients o bed access issues and any other issues of concern

16. Ward rounds ICU Detailed Paper Notes FAST HUGS..MBSE Issues list Management plan Feeding & fluid plan Procedures & investigations Microbiology & antibiotics Paper rounds (Registrar checklist) Patient Diary? Research patient? SPICE/TRANSFUSE/Nebulised Heparin ART123/ADRENAL

17. General duties Registrar Responsible for implementation of plan Delegation of tasks Teaching of residents & students Presentation (or Resident) Admission and Discharge summary (?Med Student) Hand Over of CCU patients By CCU reg to ICU reg ALL PATIENTS FULLY REVIEWED DAILY AND ONE FULL NOTE PER SHIFT

18. Expectation Doctor immediately available 24 hours per day Professional Strict infection control 5 moments of HH Nothing below the elbows CISCO phones & Pagers

19. Patient reception Aim is to have a single, multi-disciplinary handover From Anaesthesia Unusual practice of telephone handover From ED From Ward From Adult Retrieval/external transport

20. ICU specific Forms Resuscitation Palliative care Drug Chart and IV form Procedure Sticker CVVHDF sticker Consent-Trachy/Blood transfusion Micro sheets Tertiary Trauma Survey Refusal forms Tracheostomy Notes VAE forms

21. Routine bloods & CXRs On admission: Full bloods, MRSA & VREswabs Routine bloods: FBE, U&E, Ca-Pho-Mg LFT, CRP as clinically indicated (1-2/week) Coag as clinically warranted Cultures- Blood, sputum, Urine, Antigen, PCR, Serology etc CXRs on admission, then as clinically warranted

22. Microbiology Pink forms Actively chase results

23. Procedures Work Place Competency (CICM website) Consent Supervision Sterile technique Number of goes! Documentation Clinical note Google form Procedure note

24. Ultrasound SiteRite Vascular Access Stored in ICU Sparq Vascular Access Echocardiography Stored in Sanjay’s office Not to leave ICU For ICU use only

25. PICC referrals You may get referrals from outside ICU Refer them all to the ICU Liaison Nurse (#7936) Intensivist authorises insertion Inserted by Radiology or ICU (you, with LN nurse, in ward) Oncology insert their patient’s PICC

26. Intubation Oxygenation, not airway plastic, is the goal… Is a TEAM game Always “phone a friend” Clear documentation in notes Airway form being developed Intubation checklist must be used – minimises errors

27. Parent Unit Encourage involvement “Talk before you walk” Actively ‘catch’ parent teams for updates Bi-directional verbal and written communication “CCMx” is not a recognised abbreviation CLOSED UNIT Only ICU prescribes and administers therapies Treating teams can request from ICU

28. Referrals Elective versus emergency Consultant/Registrar/Resident Emergency Review patient within 30 mins Discussion of suitability for ICU (Intensivist) Discussion of bed availability (ANUM – who D/W Bed Manager always!) Parent unit MET call is a NOT a referral method, yet may become a referral! REFUSALS BOOK

29. Referrals Elective versus emergency Consultant/Registrar/Resident Elective Most seen in ICU pre-admission clinic - Suitable for ICU – cancel op if no ICU bed Suitable for ICU – proceed if no ICU bed Do not require ICU Discussion of bed availability b/w Bed manager and parent unit pre-op. REFUSALS BOOK

30. Bed Management The arbiter of the bed state We send people out through Adult Retrieval Victoria if we can’t offer them a timely ICU bed

31. Paediatric ICU Shared care May include PIPER consultation Developing a program Needs multi-disciplinary care

32. Infection control Hand hygiene CLABSI Full barrier protection for all lines, except ivs Isolation procedures

33. Discharges Electronic summaries (notes & clerk) Drug charts (rewritten as needed – common sense) Blood forms & radiology (for next 24 hours) PARENT UNIT Contact and handover After hours discharges – review within 4 hours

34. Deaths Consider organ and tissue donation Document assessment Inform treating team Write ICU discharge summary Fax and call GP Online Coronial or Births/Deaths/Marriages certification

35. 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 coronial referral Call Organ and Tissue donation nurse early

36. INTENSIVE CARE OUTREACH “Outside”

37. Outreach & Outpatient activities Medical emergency team (MET) Code Blue team Outreach round – TPN, PICCs ICU Liaison nursing ICU pre-admission clinic ICU Follow-up clinic Weekday telemedicine to Echuca HDU

38. MET & CODE Blue Team (only 1 ICU doctor to attend - Registrar) ICU and Med Reg; CCRN and ward Nurse Respond within 5 mins Assessment Management MET sticker >= 2 MET consultant review Policy in Prompt CODE blue Immediate response Prompt for policy Senior Docs from ICU/ED/Anaethetics/CCRN

40. Telemedicine Weekday telemedicine consultation with Echuca HDU 1500hrs Enables remote management of patients A bridge to HDU in Echuca

41. NON-CLINICAL

42. Research Registrar projects Resident support Audit Ongoing departmental audit Formal Project related ANZICS CTG - Julie Smith

43. Mortality & Morbidity Wednesdays at 1335hrs on overhead projector Team meeting and discussion Patients presented: Deaths in the unit & post ICU discharge Readmissions Morbidities CLABSI, VAPs, accidental CVC removal, failed extubation etc Day registrar presents types updates as needed Format on G: drive

44. Education Mandatory training iLearn Fire safety Aseptic technique/Hand Hygiene Blood safe ALS Open Disclosure training

45. Education & Training C6 accreditation for ICU in CICM Rotating RACP, ACEM, ANZCA trainees Supervisor of Training – Emma Broadfield Exam preparation Mentors Pastoral Care

46. Education & Training Wednesday afternoons ICU grand rounds and presentations (Registrar/Consultant) Based on themes On FMS Hub link Other specialty teaching Audit Mentorship Echo Daily Presentations at bedside On-line Information Intranet access to journals, Up to date, Crit-IQ, PROMPT BASIC course 2 per year Critical Airway course

47. ICU attire Smart clothing or scrubs Respectful of a broad spectrum of a critically ill patient demographic Nothing below the elbow Tie-free zone Lanyard free zone Radiology Monitors are to review Radiology not for Internet Browsing! Timely Lunch…Time Management!

48. Any questions? Time for a tour