the alfred intensive care unit - 1 - alfred icu & hyperbaric

The Alfred Intensive Care Unit - 1 -

Alfred ICU &

Hyperbaric Medicine Junior Medical Staff Orientation Manual

Updated: Irma Bilgrami July 2015


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, post-op 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


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.


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 end-of-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.


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


STAFF MEMBERS


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


OTHER SPECIFIED ROLES Supervisor of Training / Recruitment Dr. Owen Roodenburg Co- Supervisors of Training Drs. Paul Nixon/Steve McGloughlin/

Irma Bilgrami Education Co-ordinators Drs. Irma Bilgrami/Vinodh Nanjayya/ Chris Nickson Medical Student Supervisor AProf. Vincent Pellegrino JMS Rostering Dr. Vinodh Nanjayya ECMO services AProf. Vincent Pellegrino VAD services Dr. Deirdre Murphy Database / Bronchoscopy/lung transplants Prof. Dr Dave Pilcher MET service Dr. Irma Bilgrami Echo services Dr. Deirdre Murphy Medical Donation Specialists Dr. Steve Philpot /Prof. Dave Pilcher/ Dr. Josh Ihle ALS training Dr. Richard Lin Infectious Diseases Consultant Dr. Alex Padiglione/ Dr. Steve McGloughlin ICU NURSING Nurse Manager Sharon Hade Quality CNM Wendy Grant Workforce and Education CNM Emily Gowland Nurse Manager Hyperbaric unit Amanda Burvill Equipment Caroline Chong

ADMINISTRATIVE STAFF

ICU Administration Janine Dyer ICU Software Developer Miguel De Sousa Database Officers Kathleen Collins/Tracy Burt/ Leena Maller Website Leena Maller Donation Specialist Nurse Coordinator Sharella D’Souza/Bridget O’Bree/ Jessica Amsden Unit Book-keeper/Accounts Helen Zoumboulis/Jane Kempler Conference & Event Coordinators Cathy Oswald/ Leanne Stanczyk ICU Research Staff Shirley Vallance/Phoebe McCracken/ Jasmin Board


ICU RESOURCES


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).


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.


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.


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”

http://www.alfredicumoodle.org.au/


PATIENT CARE PRACTICES


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


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 problem-focused 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 DETAILS

C Connect • Prepare a safe environment • Connect Monitoring

O Observe • Assess patient Safety • Meet Immediate Care Needs

L Listen • Stop to Listen • Information Handover: ISBAR

D Delegate • 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


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.


SUGGESTED FORMAT FOR HANDOVER OF CLINICAL INFORMATION COMPONENT DETAILS

I Introduction • Presenter: Name, designation • Patient

S

Situation Explanation of the patient’s surgical, medical and anaesthetic context

• Emergency vs. elective • Admission status • Surgery • Anaesthesia • Analgesia • Routine vs. complicated

B Background

• Co-morbid illness • Medications • Functional Status • Treatment limits • NOK discussions and notification

A Assessment Presentation of the patient

• Current access • Airway assessment and management • Ventilation • Mechanical circulatory support: blood

loss, transfusion requirements, anticoagulation requirements, peripheral circulation and access requirements

• Venous access and invasive pressure monitoring

• Current infusions • Wounds • Drains • Pain management plan

R Recommendations and requests • Surgeons documented post-op orders,

preferences and plans • Questions


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.


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 re-write

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 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.


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 Open Aortic Surgery (e.g. AAA) o Major Oesophageal Surgery (e.g. Ivor-Lewis) o Whipples Procedure o Hemi-hepatectomy o 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 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.

o Further review must occur within one hour and if patient not ward ready should be admitted to HDU.

o 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


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


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.


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


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.


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


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


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.


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.


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


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 X-rays 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 X-ray 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.


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.


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.


ICU OUTREACH


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.


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.


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.


Referrals external to the Alfred ICU

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.

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)

http://www.alfredicu.org.au/


CRITICAL CARE ECHO AND ULTRASOUND


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


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).


ORGAN AND TISSUE DONATION


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 Mon-Fri) 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


JMS ROLES AND RESPONSIBILITIES


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.


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.


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


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)


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


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


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.


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.


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 on-call 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.


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 necessary- as 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.


• 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.


EDUCATION


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 Tuesday Wednesday Thursday Friday

0730-0830

Journal Club FCICM exam practice**

Airway / Bronchoscopy teaching

1000-1100

1100-1200

Medical Student Teaching

1200-1300

In-situ simulation*

In-situ simulation*

1300-1400

Senior Registrar Teaching (1-3pm)

JMS/ Registrar Teaching

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1400-1500

Critical Care Echo/ Ultrasound Teaching (3-5pm)

1500-1600

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


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-to-ICU 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.

http://intensiveblog.com/category/journal-club/


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 trans-bronchial 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/labs-lytes/)


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.

http://intensiveblog.com/


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.


JMS SUPPORT


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.


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.


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)


JMS ADMINISTRATION


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.


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.


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.


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.


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.


RESEARCH AT ALFRED ICU


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 sub-investigators 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.


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


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


• 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 co-ordinator 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.


• 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


• 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

The POLAR Study: Instructions for using the Meditherm

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 radio-opaque.

• 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.


COURSES AT ALFRED ICU


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.