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Trainees’ Guide to the Anaesthetic Department, Freeman Hospital

Aug 2016 rotation Please read this guide as it contains important information about your rotation at the Freeman Hospital.

CONTENTS HOW TO FIND THE ANAESTHETICS DEPARTMENT (GENERAL SIDE) DEPARTMENTAL STAFF THINGS TO DO BEFORE YOU START OR ON YOUR INDUCTION DAY CAR PARKING ROTA, ANNUAL LEAVE & STUDY LEAVE E-RECORD AND E-PRESCRIBING STAFF HEALTH MEDICO-LEGAL POINTS

OPERATING THEATRES CHANGING ROOMS, LOCKERS, THEATRE DRESS CODE DUTIES OF ANAESTHETIC TRAINEES RUNNING OF THEATRES ANAESTHETICS MACHINES DRUGS ANAESTHETICS IN LOCATIONS AWAY FROM THEATRE SUITE ANAESTHETIC ASSISTANTS DRUGS SPECIFIC EQUIPMENT AND DEVICES OPERATING LISTS WARDS- what is where? START TIMES FOR THEATRE LISTS TRAINEE LISTS CHECKLISTS BOOKING OF ICU/HDU AND PACU BEDS

EMERGENCIES AND ON-CALL FIRST CALL DUTIES SECOND CALL DUTIES CRITICAL CARE ANAESTHETIST

CRITICAL CARE INDUCTION NOTES

INFECTION CONTROL TRUST POLICY MRSA POLICY

CARDIAC ARREST PROCEDURE

CRITICAL INCIDENTS / ADVERSE EVENTS / NEAR MISSES

DEPARTMENTAL GUIDELINES ACUTE PAIN SERVICE TRUST GUIDELINES

EDUCATION AND ASSESSMENT EDUCATIONAL SUPERVISORS WORKPLACE ASSESSMENTS TEACHING AUDIT AND JOURNAL CLUB ARCP FORMS/ASSESSMENT METHODS LIBRARY

Freeman Hospital Anaesthetics Dept. General Side Handbook2 MKW and NIH Aug 2010 updated VJA 2016 Freeman Hospital Anaesthetics Dept. General Side Handbook3 MKW and NIH Aug 2010 updated VJA 2016 Freeman Hospital 0191 2336161 Direct line to Anaesthetic Department 0191 2231059

Welcome to the Departments of Anaesthesia, Cardiothoracic Anaesthesia and Intensive Care at Freeman Hospital. We hope you’ll enjoy your stay here. This handbook hopefully provides some useful information to make you become more familiar with the department and the hospital. The list of contents at the top of the document is best used by placing mouse on line of interest and the doing a ctrl-left click. This will jump you to the relevant subsection. Throughout the document are links back to the ‘top’. Do the same on these and you get back to the index or ‘top of document’. There are other links as well. Links to pages on the Trust website will not always be accessible from outside the trust network.

HOW TO FIND THE ANAESTHETIC DEPARTMENT (GENERAL SIDE)

The anaesthetic department is on level 4 in the Institute of Transplantation. On entering via the Main Entrance (level 2), follow the signs to the Institute of transplantation and take either the stairs or lift to level 4. A Turn right at the top of the stairs and go through the first door. The second door is swipe card access only between 17:00 and 08:00– if your card has not been issued yet contact the secretaries on ext. 30159

DEPARTMENTAL STAFF

Directorate Administration Manager - Carol Baggaley (Tel No: 0191 2231059) Directorate Senior Medical Secretary - Linda Sime Directorate Secretary - Anne Smith

CONSULTANTS SPECIAL RESPONSIBILITIES

Dr. V.J. Addison College Tutor Acute Pain Management, Dr. H .J. Allen Associate Specialist Dr. I. Baxter Brachytherapy Dr. K. Beacham PAC Dr S. Burnside Liver transplantation Dr. G. Bedford Rotamaker Scoliosis Surgery, ENT Dr. A. Cain Rotamaker Liver Transplantation; Dr.. A.D. Chishti Clinical Director Liver Transplantation Dr. J. Cosgrove Anaesthesia & Intensive Care Dr. D. Cressey Anaesthesia & Intensive Care, Liver Transplantation Dr. J. Davison Anaesthesia and Intensive Care Dr. R. Diddee Liver transplantation Dr. M. Faulds Anaesthesia and Intensive Care Dr. M. Garner Locum Consultant Dr. M. Ghosh Locum consultant Dr. T. Haigh Locum consultant Dr. N.M. Heggie ENT, Paediatric Anaesthesia and Urology Dr. N. Hirschauer Education Coordinator Vascular and Orthopaedics, , Simulation Lead. Dr. J.J. Holland Acute Pain Management lead, Spinal Surgery Dr. H. Husaini Staff Grade Dr. M.S. Jones Acute Pain Management, Regional Dr. K. Kotur Anaesthesia ;Audit lead Dr J. McCheyne Pre-assessment and Vascular Dr. I. McCullagh Anaesthesia and Intensive Care Dr. G. McIntosh Urology Dr. I. Nesbitt Anaesthesia & Intensive Care Dr. S O’Neill TPD for ACCS Core Trainees Anaesthesia and Intensive Care

Freeman Hospital Anaesthetics Dept. General Side Handbook4 MKW and NIH Aug 2010 updated VJA 2016 Dr. J. Prentis Liver Transplantation Dr. D. Roberts Liver Transplantation Dr. J. Sainsbury Anaesthesia Dr. M. Sammut Orthopaedics Dr. S.A. Scully Vascular and Orthopaedics Audit Dr. R.D. Singh Regional Dr. J. Smith Anaesthesia Dr G. Timms Anaesthesia Dr. C. Snowden Liver Transplantation PAC lead Dr.H.Velasquez Staff Grade Dr. L. Waddilove Anaesthesia Dr. J. Walton Anaesthesia & Intensive Care Dr. M. Weaver Paediatric Anaesthesia, Training Program Director Dr. H. Wood Pre-assessment, ENT Dr. S. Wright Intensive Care and Research

Acute Pain Sisters Angela Knight Susan Breen Stewart Keenan Jenny Houston

OTHER PERMANENT MEMBERS OF STAFF Directorate Manager - Andrew Watson Deputy Directorate Manager - Joanne Greenup

Matron Central Operating - Alison Gray Senior Anaesthetic Sister - Sister Judith Hart Matron Integrated Critical Care - Sharon Thompson Integrated Critical Care Ward Clerk - Pauline Savage Integrated Critical Care Ward Clerk - Pamela Dunn

THINGS TO DO BEFORE YOU START OR ON YOUR INDUCTION DAY Trust online induction from the lead employer trust LET: the LET should have sent you this.

Departmental induction: This will take place on your first day. You will receive a timetable. If you cannot make it you must inform the secretaries. This induction is very important.

DECT PHONES Most trainees are now issued with their own DECT phone, which you collect on your first day from the secretary’s office. There are also separate DECT phones for the on-call teams (1st Call = 48914, 2nd Call = 48483 and I.T.U. = 48817). Please look after them and keep them charged. Whilst in Cardiothoracics you may be asked to surrender your phone as they will issue their own.

ID-BADGE You should get them on your first day, it is compulsory for all staff to wear them and it will give you access to most areas you’ll work in. Please do not wear lanyards.

CAR PARKING The main staff car park for the hospital is the multi-storey car park at the back of the hospital. You Freeman Hospital Anaesthetics Dept. General Side Handbook5 MKW and NIH Aug 2010 updated VJA 2016 have to apply for a car park permit. Unfortunately not everybody is issued with a permit, depending on where you live. The secretaries have some emergency on call permits for the yellow cardiothoracic car park, which can be collected the day before your on call and then delivered back to them. If these permits are lost you will be charged £450!!!! The car park at the front of the hospital is only for visitors (and very expensive!).

ROTA, ANNUAL LEAVE & STUDY LEAVE Please get requests in as early as possible Dr. Bedford and Dr Cain are in charge of the rotas. Application forms are available in the Trainees Room and in the Secretaries Office. There are two forms to be filled out, the official hospital A/L or S/L form and the departmental form no leave will be authorized unless you put a departmental leave form in and your leave card is also required when applying for annual leave. There are only two trainees allowed leave on each of the on-call tier allocation those working ITU allocation work on an eight week allocation and are allowed to take annual leave on week three and four of their rota. Leave is allocated on a first come first served basis. It should be taken pro rata within the rotation between hospitals. Once your leave is authorized it will appear in CLW if you are unsuccessful you will receive an e-mail from the secretaries. The rota is published in a web based format using a program called CLWrota. You can have a look at this from outside the Trust using this website, username and password. Please contact the Anaesthetic secretary for the password.

When you start you will have your own username and password. Note that these passwords are case-sensitive. If you have asked for leave and you think it has been accepted please make sure that it is on CLWRota. This is the final check and you must do it.

E-RECORD AND E-PRESCRIBING You will get a universal trust logon and in addition a special e-record logon password. There is a new e- system for certain aspects of patient care. These include e-prescribing and ordering. Operating lists are also published only through this system. Logon: this is by any terminal using your trust username and trust password. Click on the e-record’ icon. Next window has a number of icons. When you click on one of these you will be asked for your username (main trust username) and another password- the e-record password. Another way to logon will be with your photo ID pass which will be sorted for this after you start-hopefully on induction day.

Most useful to us are : powerchart, scheduling appointment book, and SNReportBuilder

Powerchart allows you to find patients, their laboratory results, tests ordered, radiology reports. You also use this to prescribe medications and to order tests.

SNReportBuilder : use this to find your operating lists scheduling appointment book: this gives an overview of all lists in theatre. Explorer allows you to find and print your theatre list

We will show you how to use it. It is not difficult but can be a little quirky. Overall it is very useful and powerful.

STAFF HEALTH All Anaesthetists should have Hepatitis B Vaccination and if you have not undergone this we would advise you to attend Staff Health as soon as possible in order to arrange that this be done. Freeman Hospital Anaesthetics Dept. General Side Handbook6 MKW and NIH Aug 2010 updated VJA 2016 IF YOU ARE SICK If you are sick and cannot come to work please phone in and let us know. Phone the secretaries before 8am. They will pass the message on to the rota maker and consultants in theatre. They will ask you a few questions-this is Trust policy and it applies to everyone. If you are off work sick for over five days you must get a sick note from your GP. Ensure you inform the Lead Employer Trust (LET) on Tel No: 0191 275 4757

CARE FOR THE CARER'S - COUNSELLING SERVICES All of us have periods when things do not go well or professional duties are particularly worrying. You are encouraged to discuss any such worries with any of the Consultant staff - we are keen to help, but can only do so if we know there is a problem. If you prefer to talk to someone outside the department, the Hospital Chaplain may be able to help (ext 26168, bleep 3277). A counselling service, staffed by hospital staff volunteers, has recently been established. Please contact Administration for further details. Many Consultants in the department and throughout the Trust are trained mentors and are very happy to be approached in this regard.

MEDICO-LEGAL POINTS We would encourage you join a Defence Society (MPS or MDU). To rely on hospital indemnity alone is not in your own best interests. Any event or situation which may involve medico-legal action should be brought to the attention of the duty Consultant and the Clinical Director immediately.

You are encouraged to discuss as fully as possible any problems which occur in clinical practice with patients and their relatives. Factual objective information and expressions of sympathy are wholly appropriate. However, it is not appropriate to discuss fault or blame. As in all clinical work, it is essential that you make accurate, legible, contemporaneous notes and seek immediate Consultant help – you should not deal with these situations on your own. If you have to go to the Coroner’s Court please let us know-a number of us have been there and we can help out and support you.

OPERATING THEATRES

CHANGING ROOMS Theatre changing rooms are locked and you need your swipe card I.D. Badge to get in. Please do not leave any valuables in your lockers.

LOCKERS Lockers are available in Central Operating changing rooms these are allocated by Rebecca on induction day. You will need to give a £5 deposit for a locker key -returnable once the key is handed in at the end of your attachment. If you need theatre clogs you can either use your own or there are some in each theatre which are sent for washing at the end of each day. Please do not leave valuables in the lockers.

THEATRE GOWNS If you have to leave the theatre suite to see patients etc, you should wear a green gown tied around the waist over your theatre greens. Gowns should be available at the entrance to each holding bay. Similarly if you come into theatre from ICCU in blues you need to put on a green gown tied around the waist. Outdoor clothes and shoes must not be worn in theatres. Freeman Hospital Anaesthetics Dept. General Side Handbook7 MKW and NIH Aug 2010 updated VJA 2016 DUTIES OF ANAESTHETIC TRAINEES a) Operating Theatres duties and training, including pre and post operative Assessment and acute pain management. b) Intensive Care duties and training. Second call should attend ITU evening ward round c) On-Call commitments in Anaesthesia and Intensive Care d) Attendance and participation in teaching sessions, departmental audit meetings and journal clubs. e) Audit f) Work as a team and help each other out. If you are quiet check with all other on call personnel to see if you can work together to lighten the workload.

First call weekends : on Friday you attend the pain round a.m then join the consultant in theatre 15. On Saturday you are expected to join the pain sister on the pain round so you are familiar with all patients with epidurals. If theatres are quiet please check to see if ITU/outreach or the second call anaesthetist need any help.

Second call weekends: Attend ward round in ITU at 8.30 am. Assist on ITU ward round unless there is a case in theatre of educational benefit.

RUNNING OF THEATRES The Central Operating Department consists of 20 Operating Theatres with attached Anaesthetic Rooms and 3 Recovery Units – one for general patients one for ENT patients and one for Institute of transplantation theatres.

Theatres 1, 2 & Endourology Theatre Urology Theatre 3 & 4 General Surgery / Vascular Surgery Theatres 5, 18, 19 Renal / Liver Transplantation / Hepatobiliary Surgery Theatres 6, 7, 8 & 20 Orthopaedics Theatre 9 ,17 Imaging Theatre / General Surgery / Vascular Surgery Theatre 15 Emergency Theatre (daytime and out of hours). Theatre 16 Urology Theatres 10, 11, 12 & 14 ENT (Theatre 12 Emergency ENT Theatre out of hours).

The layout of the Anaesthetic rooms in the Central Operating Suite is in general identical.

All theatres have now Draeger Primus anaesthetic machines. The only exception is theatre 5 and 18, which have a Draeger Zeus machine. Please make yourself familiar with the machines and all other equipment. Do not use the Zeus unless you have been shown how. The default machine in theatre 5 for trainees is the Primus, not the Zeus. This is departmental policy.

FOLDERS IN ANAESTHETIC ROOMS Each theatre has a yellow/green folder in the anaesthetic room with the AAGBI emergency guidelines in. There is a crisis management book in each anaesthetic room. There is a desktop filing drawer stocked with all relevant forms you may need –PCA/VIP/NG/CVO/Art Freeman Hospital Anaesthetics Dept. General Side Handbook8 MKW and NIH Aug 2010 updated VJA 2016 line/WHO forms. There are airway alert forms in envelopes in each anaesthetic room. So if you have a patient with a grade III laryngoscopy or more please fill one of these forms out and discuss with a consultant and the patient after the operation. Critical incidents are now filled out via the DATIX system on the computer.

DRUGS Suxamethonium and atropine are not drawn up as a routine. Please ask for these if you want them on standby for a specific case. Make sure you are aware of the dilution used. Less commonly used drugs will vary from one theatre to another according to the specialty involved. Drugs which are not available in a particular theatre will be available from the central theatre drug store or from the Intensive Care Unit. Sevoflurane: this is very expensive but also very useful. Please do not waste it. Do not use it for maintainance unless there is a specific indication. We have desflurane available for specific cases (elderly and obese patients).

Intralipid for treating local anaesthetic toxicity: treatment packs are in the main central anaesthetic drug cupboard between theatres 4 and 5

Suggammadex : this is in the main central anaesthetic drug cupboard between theatres 4 and 5

Malignant Hyperpyrexia pack: This is in the main central anaesthetic drug cupboard. The only item missing from this pack is insulin kept in theatre 9’s fridge.

ANAESTHETICS IN LOCATIONS AWAY FROM THEATRE Occasionally anaesthetics are also given for endoscopies, interventional radiology, lithotripsy, MRI and CT. Interventional radiological procedures like embolisations, stents, TIPSS etc are done in the interventional radiology suite opposite theatre (as well as vertebroplasties.) Both X-Ray and Lithotripsy are on Level 2, X-Ray being almost directly beneath the Cystoscopy Unit and Lithotripsy is at the end of the corridor leading from the Main Entrance. Neither of the latter 2 areas was originally designed for administration of General Anaesthesia. Nitrous Oxide is by cylinder only in Lithotripsy. All anaesthetic machines and appropriate drugs and equipment need to be brought to areas outside Central Operating so please liaise with the Anaesthetic Nurse /ODA in Charge to ensure that this is provided. There is now a trolley with all the relevant drugs and equipment available, which is usually in the theatre corridor. Completion of the anaesthetic machine check is especially vital prior to starting an anaesthetic in these circumstances. The MRI unit should get a MRI compatible Draeger Fabius machine soon.

You must always be accompanied the entire time by an experienced Anaesthetic Nurse or ODA when you are working in any of these locations. Please ask one of the permanent members of staff to show you around both of these sites before you go to give anaesthetics there. The routine monitoring available in both X-Ray and Lithotripsy consists of Pulse Oximetry, Non-Invasive Blood Pressure and ECG.

ANAESTHETIC ASSISTANTS We have dedicated Anaesthetic Nurses or O.D.A.s within our Theatres and under no circumstances should you undertake an anaesthetic without having a skilled assistant. Always ask senior staff for advice if in doubt. Student Nurses and trainee O.D.A.s are not permitted to work as anaesthetic assistants without being supervised.

Freeman Hospital Anaesthetics Dept. General Side Handbook9 MKW and NIH Aug 2010 updated VJA 2016 SPECIFIC EQUIPMENT AND DEVICES There is an ABG machine in theatre 15 anaesthetic room, the general recovery area and in the Institute of transplantation Haemocue and BM machines are in theatre 15 Rapid transfusion and cell saver equipment. Make yourself familiar, where the blood fridge in theatre is (between theatre 9 and ENT coffee room and in the I.O.T) For more information on our equipment go to the trust website on the intranet. Try this link: \\nuth-fnas01\dept33\Anaesthesia Medical Devices\Start.html

MEDICAL DEVICES RESOURCE WEBSITE: What is it? It's basically a website that displays the vast majority of the medical devices you are likely to encounter in your practice, along with resources that might help you use them safely, such as operating manuals, quick guides etc. Most people find it useful. Unavoidably it will always be a work in progress. Please feel free to email feedback to the site administrator Dr Mario Sammut.

How do you find it?

These are the two quickest ways. Start from the Trust Intranet Home Page and use the A - Z directory. Under A find Anaesthetics Department Freeman and then click on the Education Tab on the left. Scroll down to Resources and click on Medical Devices in Theatre & Critical Care. Under L find Learning Zone and then hover over the Clinical Education tab at the top and select Medical Devices Freeman Anaesthesia.

OPERATING LISTS The Department covers lists entirely at the Freeman Hospital and all Operating Lists should be available on e-record. We will show you how to view these on the induction day. You will also find them in the relevant theatre and holding bay. If all else fails please phone the secretary for the relevant consultant surgeon.

WARDS The Surgical Wards are as follows:

Wards 1, 2, 3 Urology Ward 4 Day Treatment Centre - Day Case Surgery and Day of Surgery Admission Wards 5, 6, 7, 8, General Surgery, Vascular Surgery Wards 10 Adult ENT Ward 11 Paediatric ENT (open weekdays only) Ward 12 Liver Surgery Wards 19, 20 Orthopaedics NCCT 32,33,34 Contains oncology, renal medicine, haematology and radiotherapy unit Ward 37 ICCU Ward 38 Transplantation ward

START TIMES In general, most lists start at 8.30 am, Vascular Surgery and ENT lists begin at 9.00 am so please check

Freeman Hospital Anaesthetics Dept. General Side Handbook10 MKW and NIH Aug 2010 updated VJA 2016 your list start time. Many ENT patients arrive on the day of the surgery and this is soon to be extended to other lists so please allow yourself time to see the patients prior to the operating starting time. Afternoon operating starts at 1.30 pm unless stated otherwise.

TRAINEE LISTS Trainees will have both teaching and solo lists, the ratio of which will depend on your seniority. Trainees will be expected to see all patients pre-operatively for all lists. This is usually best achieved by liaising with the Consultant concerned if you are having a teaching list before visiting patients. We have produced guidelines for pre-operative investigation and these are included in the list of departmental guidelines. If you are going to be absent for a teaching list for any reason, please inform either the Consultant or the Anaesthetic Secretaries. If you are doing an unsupervised list you will have a named consultant in brackets next to your name on the rota. This will be your supervising consultant. So if you have any queries or require any advice or help with a patient, please liaise with that particular person. Otherwise everybody is happy to help. If you think that a patient should be cancelled please discuss the decision with your supervising consultant. If your list finishes early please reallocate yourself to another theatre or offer others breaks.

Private patients are paying for the services of a Consultant Anaesthetist. If a private patient is unexpectedly listed on one of your operating lists, you must bring this to the attention of the Anaesthetic Secretary or one of the Consultant staff in order that a Consultant can be made available for that patient.

CHECKLISTS Before a list starts there must be a meeting in theatre with all staff involved present. Everyone must introduce themselves and then discuss the cases to be done. This is very important. Each patient gets checked in at main reception and again by the anaesthetic nurse/ODA. When the patient arrives in the anaesthetic room you must also make sure, that the patient understands what operation they are undergoing, that the consent form and the list show the same operation and that the consent form is signed. If there is a specific site of surgery involved, e.g. limb operation, the site should be marked and agree with the consent form. Once you’ve checked that the site is correct, you then also have to sign the checklist. Please go through the anaesthetic part of the WHO checklist before induction of anaesthesia as this is now completed electronically on Surginet

If you are doing a block where side is relevant please make a final check (pre needle check) before proceeding.

Once you are in theatre with your patient please use and facilitate the WHO checklist that is now mandatory. This provides an important final check before the start of surgery.

BOOKING OF ICU/HDU/PACU BEDS These should have been made in advance, but it is always useful to check. There is an admission book on the nursing station in ICU, and it will appear electronically on e-record . If you think your patient require any of the above, discuss with your list mentor and the relevant ICU Consultant. They will let you know on the morning of surgery if there is a bed available. If you have an unplanned admission to ICI/HDU or PACU, please discuss this with the ICU consultant of the day. Please read the PACU policy by following the link (PACU Policy) Freeman Hospital Anaesthetics Dept. General Side Handbook11 MKW and NIH Aug 2010 updated VJA 2016 EMERGENCIES AND ON-CALL ON-CALL TEAM There is no Casualty at Freeman Hospital but emergencies are admitted here throughout the 24 hours to the Emergency Admission Suite or from within the hospital from other specialities. In life threatening situations for example ruptured aortic aneurysm and patients with compromised airway you will be called urgently to the Admission Suite to help with the assessment and / or resuscitation of these patients. Many Vascular patients may also come to theatre directly from the Admission Suite and so you will be called to pre-assess the patients there, so please familiarise yourself with the set up and equipment held there as soon after your arrival in the department as possible.

Many of the emergency cases that do come to theatre are complex and you may often require senior assistance. The emergency theatre 15 is usually covered by a designated anaesthetic consultant during the day. He/she is responsible for the overall management of the Anaesthetic service and should be informed of any staffing problems occurring on that day and of any problems with surgical or nursing colleagues. After 5pm the on-call consultant takes over. Emergencies are booked through theatre 15.

Freeman Hospital Anaesthetics Dept. General Side Handbook12 MKW and NIH Aug 2010 updated VJA 2016 FIRST ON-CALL ANAESTHETIST Theatre handover times are 8.00 am until 8.30am and 19.30 to 20.00 hours pm. Handover in theatres takes place in the general theatre coffee room. All the anaesthetic charts of patients waiting to be anaesthetised are taken to the coffee room (stay in theatre with your patient if you are busy here) and all patients are talked through with emphasis on co-morbidities, investigations awaited and any concerns. Please call the duty consultant to release you from clinical duties and allow an interruption free handover if needed.

Critical Care handover times are 8.30 to 09.00 am and 20.30 to 21.00 hours pm.

During the day the first on call phone is carried by the Consultant Anaesthetist covering theatre 15. The first on call trainee on long day midweek is allocated to an all-day teaching list and is marked in italics on the rota. He/she may be withdrawn from the list if required to help out with seeing preop patients or assist with emergencies.

Between 4.30 and 5 pm the 1st Call will get a handover from the Acute Pain Team and is expected to take over the first on call phone from theatre 15 and liaise with the 2nd Call +/- Consultant on call as to what emergency work is to be done. All emergency cases tend to be referred via the first on call. Please see them as soon as possible so that pre-optimisation can start early and not delay surgery. You must see patients scheduled for theatre even if they will not be operated on until after your shift. At night you are expected to see all cases which are booked for the following day and make sure they are ready for surgery e.g. that all required blood tests, X-match and investigations have been done.

You must ask for advice or help before anaesthetising patients outside your normal expertise, children, or seriously ill patients. There is plenty of support as we all know that a lot of patients here are very complex and often very ill. You should review patients on the PACU at night.

If the nightshift 1st Call has no theatre cases, no preops and there are no pain patient issues to be dealt with, go to critical care and help out there.

The first on call phone and any emergency cases get handed over to the night person at 19.30 and then to the Emergency Consultant at 8 the next day. At weekends it is handed over to the incoming 1st Call. On Saturday morning there is usually a member of the Pain Team working until 13.00 hours but they will hand over promptly at that time. First call is expected to join the pain nurse on their ward round . Please keep the first call phone charged.

At nights and weekends the 1st Call is also responsible for changing the infusion bags for any patients with epidurals and supervising the patients with acute pain needs .

SECOND ON CALL ANAESTHETIST For the second on call the same changeover times apply as for the 1st on call: 8 – 8.30 and 19.30 – 20.00. Please take over the 2nd on call phone in the morning. On weekdays you will be scheduled for a teaching list all day. In the afternoon you may work either with the Consultant on for Theatre 15 or stay with your list from the morning. It depends where you are needed and where the most interesting work is being done. If there is no Consultant, please either enlist assistance from the 1st Call or the Consultant on call after 5 pm when you need it.

Occasionally you might get withdrawn from your list in the morning to help out with emergencies or transfers on ICU, if there is no other anaesthetist available. Freeman Hospital Anaesthetics Dept. General Side Handbook13 MKW and NIH Aug 2010 updated VJA 2016 Out of hours your responsibilities extend to the HDU/CCU/PACU and Outreach. You will also get asked for help from your junior colleagues from CCU or to review patients by the outreach team, which now runs 24 hrs a day, 7 days a week.

We ask you to do a formal ward round on Critical Care at night somewhere between 01.00-03.00 with the Critical Care resident and senior nurse to ensure all patients conditions and treatment plans are updated and revised.

You are also responsible for the PACU at night. Please familiarise yourself with the patients on PACU at the end of the day and review them at 6.30 am in view of getting them ready for discharge to the ward. They have to leave recovery in the morning before handover to ensure the prompt start of the running of theatres. If there are not fit enough to go back to the ward in the morning and need further treatment on HDU, please discuss with the oncoming ICU Consultant as soon as possible, so arrangements for transfer can be made early. Please discuss all ASA 4/5 patients with the Consultant on call, as well as all admissions to Critical Care.

You are pivotal to the organisation and efficient running of emergency work in peri-operative care and critical care and will work closely with 1st Call and the Consultant on call.

CRITICAL CARE ANAESTHETIST The Critical Care trainee works a full shift with the handover times being 08.30 to 09.00 am and Outside normal working hours, the Consultant on-call is responsible for the Critical Care Unit. Care must always, however, involve the referring Physician or Surgeon.

There is a quiet room available for rest for the Critical Care resident and 1st Call / 2nd Call on the Unit. A set of protocols and guidelines for trainees on the Critical Care Unit is available within the Unit. No patient should be admitted or discharged from the Critical Care Unit without Consultant authorisation. The Critical Care Unit trainee holds the cardiac arrest bleep, but if this trainee is not an anaesthetist, 1st Call will be called to attend also.

Freeman Hospital Anaesthetics Dept. General Side Handbook14 MKW and NIH Aug 2010 updated VJA 2016 INFECTION CONTROL-TRUST POLICY Hand hygiene is vitally important and saves lives! Please use these guidelines. .

Hand hygiene. Wash your hands or use alcohol gel for decontamination  Before patient contact,  Before an aseptic procedure,  After patient contact,  After body fluid exposure  After contact with patient surroundings. The last point means that we have to clean our hand after touching any object or furniture in the patient’s immediate surroundings even if the patient is not touched (such as trolley, beds etc.) We don’t do well on that score. All wrist watches and jewellery (particularly stoned rings) should be removed before hand decontamination. Cuts and abrasions must be covered with waterproof dressings. Please refer to the WHO guidelines attached. Gloves are single-use items and should be removed and discarded immediately afterwards.

Patients with MRSA and C Diff: On entering the infected area, all staff should  Wash their hands with soap and water (not alcohol gel)  Put on disposable apron and clean gloves for protection.  When leaving the infected area, discard the apron and gloves in a yellow or orange bag.  Wash hands with soap and water (not alcohol gel).

Peripheral venous cannula insertion:  Wash hand and use gloves for protection.  Clean the insertion site with 2% Chlorhexidine Gluconate spray and allow to dry.  Complete the peripheral venous cannula record.  This applies to all lines inserted in the wards, theater and ITU. The only patients exempted are those having day case procedures.  All cannula ports must be cleaned with 2% chlorhexidine before and after giving iv fluids or injections.

All giving sets should be changed  Immediately after giving blood and blood products  24hrs after giving TPN (if it contains lipids)  After 72hrs for all infusions.

Theatre : Gowns should not be worn from Theatre to theatre or from ITU to Theatre. Gowns should be bare below the elbow unless they are sterile

Freeman Hospital Anaesthetics Dept. General Side Handbook15 MKW and NIH Aug 2010 updated VJA 2016 MRSA PROTOCOL SUMMARY Firstly there are two people involved in deciding infection control policy at the Trust: Dr Price (DIPC) and Prof Gould (unofficially). Dr Price heads the infection control group but Kate is very active in deciding policies, protocols and guidelines. The info below came directly from Kate.

The full guideline can be found at: http://intranet/Policies/InfectionControl/ControlofMRSA30thMarch09.pdf

The current policy pertaining to screening of elective surgical cases is: 1) All appropriate cases are swabbed in PAC (exceptions are non high risk children, OBs, day case dentals and endoscopy)

2) Any positive cases are referred via the infection control nursing team to the surgical consultant in charge of that patient’s care

3) The surgical consultant can decide on 1 of 2 approaches: a) bring the patient as an inpatient for eradication therapy b) organize eradication therapy as an outpatient usually via the GP (Eradication is via chloR hex mouthwash, body wash and toothpaste and mupirocin spray and should be done as close as possible to admission to prevent recolonisation).

4) As the patient will not get tested again (unless brought in for treatment) until they are admitted the patient remains MRSA positive on paper regardless of whether they have had eradication therapy or not.

5) All patients are tested again on hospital admission

6) A patient is only considered MRSA negative once they have had 3 negative swabs (there are specific conditions under which these have to be taken; they’re on the intranet)

To summarise the above for our purposes: All patients MRSA positive in PAC are to be considered positive on admission for surgery regardless of whether they’ve had eradication or not. The only caveat to this is if they have been readmitted between PAC and surgery and had 3 negative swabs.

All MRSA positive patients need to be barrier nursed on ICCU and therefore count as level 3 (ICU) in terms of bedstate.

MRSA positive patients can be admitted to PACU but only if they are the ONLY patient in PACU. This is for staffing reasons. They will be barrier nursed in recovery.

As far as re testing is concerned as we have a search and destroy policy for MRSA in the Trust all patients being moved within the hospital are retested on arriving at their new destination (ie: ward to ICCU, ICCU to ward, etc). WE NEED TO KNOW AS SOON AS YOU ARE AWARE (preferably pre admission in our admission book). If you can’t find the status in the notes any screening results are on eRecord.

Although very occasionally on ICCU we move patients with 2 negatives out of cubicles this is not Trust policy and is only done when we have no choice and after consultation with micro.

Freeman Hospital Anaesthetics Dept. General Side Handbook16 MKW and NIH Aug 2010 updated VJA 2016 In terms of antibiosis for MRSA positive patients:

AVOID all cephalosporins (esp cefuroxime) Only 4 commonly prescribed antibiotics are effective against the bug: Teicoplanin (drug of choice for surgical prphylaxis) Linezolid (effective but also an MAOI so not good for theatre) Vancomycin (should only be used on renal wards under senior micro guidance due to risk of VRE and renal damage) Daptomycin (only commonly used in ICU, expensive with side effects). Gentamicin can also be effective and has some good gram negative cover.

You do not necessarily need to speak to micro should you get a patient who is MRSA positive as teicoplanin is the drug of choice (with or without gent and metronidazole) (John Walton 2010)

CARDIAC ARREST PROCEDURE A cardiac arrest call is initiated by ringing Switchboard on 2222. A test cardiac arrest call is made at 10.00 a.m. every day. Cardiac Arrest team members are:- Critical Care Anaesthetist Second on call anaesthetist R.M.O. House Office on take for the Wards C.C.U. S.H.O. C.C.U. Nursing Officer Portering Manager/Charge Porter General Surgery Nursing Officer Liver Transplant Sister Mrs Patterson (Nursing Support Officer) Defibrillators are located behind the lifts on every level. Please ensure that you are fully conversant with the usage of these machines. Each ward has an arrest box/trolley. There is a defib in each recovery room. Pacing defib: one of the critical defibrillators has this function.

AIRWAY ALERT An airway alert is initiated by ringing 2222 and stating airway alert. A test airway alert call is made each day. When an airway alert call is made make sure your anaesthetic nurse or yourself takes the red airway bag from theatre 15 to the call as this has all essential airway management equipment.

CRITICAL INCIDENTS / ADVERSE EVENTS / NEAR MISSES These events hopefully will not occur very often, but they will happen to us all at some times in our careers. We fully subscribe to a ‘no blame’ culture and would urge every member of the anaesthetic department to be confident to complete the Trust Incident Form. This is now a computerised form found on the Trust Intranet via the DATIX system. For anything but the most minor event, please discuss it with a Consultant and they will decide on any further action which needs to be taken, and can give you support at the time. Please make sure you know these. At present we also ask you to fill in a paper form which is used by the education fellow in monthly teachings and M&M meetings

Freeman Hospital Anaesthetics Dept. General Side Handbook17 MKW and NIH Aug 2010 updated VJA 2016 Freeman Hospital Anaesthetics Dept. General Side Handbook18 MKW and NIH Aug 2010 updated VJA 2016 DEPARTMENTAL GUIDELINES IN THIS SECTION: Theatre emergency protocols Fasting times for adults and children Day surgery Anaesthetic machine check Children and parental presence Practice of anaesthesia recovery room care and handover Surgery the pill and HRT The diabetic patient Acute pain service Difficult airway Stop before you block

Theatre emergency Protocols All anaesthetic rooms have yellow/green folders containing written guidelines for most anaesthetic emergencies: Anaphylaxis;adult and paediatric cardiac arrest ;MH; LA toxicity;failed intubation

PRE-OPERATIVE FASTING These guidelines follow AAGBI recommendations which are based on the American Society of Anaesthesiologists (ASA) guidelines.

Guideline:

 6 hours for solid food, carbonated drinks, infant formula, or other milk

 4 hours for breast milk

 2 hours for carbohydrate rich drinks used for enhanced recovery programmes (e.g. Polycal liquid)

 2 hours for clear non-particulate and non-carbonated fluids. Tea /coffee with a small amount of milk

There is no need to cancel if the patient has been chewing gum or sucking boiled sweets immediately prior to surgery. It is an anaesthetic decision as to whether a patient is adequately fasted.

Oral premedication can be taken prior to surgery as prescribed by the anaesthetist.

The elderly, sick patients, children, those who have had bowel preparation and breast feeding mothers may require intravenous fluids prior to surgery.

Adults and children having emergency surgery after trauma may have delayed gastric emptying, The guidelines above should be followed for non life or limb threatening conditions but an empty stomach cannot be guaranteed.

Freeman Hospital Anaesthetics Dept. General Side Handbook19 MKW and NIH Aug 2010 updated VJA 2016 DAY SURGERY We do not have a dedicated day unit at Freeman, but a substantial amount of day surgery is undertaken. Day case paediatric patients are admitted to Ward 11 (E.N.T.) and 17 (Orthopaedic). Adults are admitted to Ward 4, but when this is full may be admitted on a day stay basis to any of the in-patient surgical wards. Endourology Theatre lists have a mixture of day cases and in-patient for endoscopic work, which may be complex in nature. All other day surgery patients are treated on the routine lists in Central Operating. Whenever possible, day patients should be scheduled before in- patients to allow adequate time for recovery.

We are currently modifying our screening and checking procedure for day patients. Surgeons are asked to follow written guidelines on patient selection and to ask all patients to complete a health questionnaire and undergo B.P. and Urinalysis check in Outpatients. The questionnaire should be retained in the notes and updated by Ward 4 staff on the day of admission. This should avoid the need for clerking of day patients by the Surgical House Officers. The system is at present being introduced in general surgery and certain E.N.T. Clinics. Selection guidelines and questionnaires are appended. Day cases should not be cancelled without discussion with a Consultant Anaesthetist, though usually this will be a formality.

ANAESTHETIC MACHINE CHECKING PROCEDURES Each machine has a checklist attached to it to guide you.

PONV PROTOCOL There is a PONV protocol that anaesthetists should follow regarding the use of antiemetic agents regularly and on a PRN basis. A copy of this is in each anaesthetic room.

EMERGENCY PROTOCOLS In all anaesthetic rooms there is a yellow/green folder (next to the drug fridge usually) with copies of all emergency protocols. Please make yourself familiar with this as soon as possible after arrival in the department. There are also crisis management books in each anaesthetic room.

CHILDREN AND PARENTAL PRESENCE In general, a single parent usually will accompany a child to the anaesthetic room. Only occasionally this may not be appropriate. Ward staff appreciate that the presence of a parent is at the discretion of the anaesthetist and is NOT a right and inform parents accordingly. Please involve a senior anaesthetist if parents or ward staff are concerned over your decision to deny them access to the anaesthetic room.

PRACTICE OF ANAESTHESIA All patients must have pulse Oximetry, E.C.G. and Non-invasive Blood Pressure and Capnography in the anaesthetic room and continued into theatre as an absolute minimum. The only possible exception to this non-invasive blood pressure measurement in a child having elective surgery, but this must be used as soon as the child is asleep and prior to leaving the anaesthetic room to go to theatre. If you use muscle relaxant you must use a nerve stimulator.

An in-dwelling cannula should be inserted in every patient.

The anaesthetist must remain with his patient at all times unless dealing with a crisis, for example a call in extreme is to recovery. But your first responsibility is to the patient that you are anaesthetising and they must be safe at all times.

Freeman Hospital Anaesthetics Dept. General Side Handbook20 MKW and NIH Aug 2010 updated VJA 2016 An anaesthetic chart must be filled in for every patient. Names of Patient, Surgeon and Anaesthetist and date of operation must be legible.

The anaesthetic record is a legal document and must be completed in full, including I.V. site, drugs and dosages, monitoring, IV therapy and cardio-respiratory parameters. Any regional procedures must be documented fully and the position of the patient noted.

RECOVERY ROOM CARE Each recovery room space has a trolley and there is a resuscitation bag on the wall. Before taking a patient to recovery please request permission to do so by Theatre intercom to ensure that there is a bed space available. The patient must be escorted from theatre by the anaesthetist and appropriate hand over instructions given to a trained recovery nurse regarding position, fluids, analgesia and oxygen therapy. For elderly patients (>70) or those having major surgery, the nurse sending for patients will request transfer from the ward on the patients own bed and the patient can then recover on this. All other patients recover on tilting trolleys. All patients receive 02 by mask or nasal cannulae unless specifically countermanded by the anaesthetist. Observations of oxygenation, cardio-respiratory signs, conscious level and pain control are made and recorded on the reverse side of the anaesthetic sheet. Level of sensory block is recorded when appropriate. Requests for any additional monitoring or treatment should be recorded on the back of the anaesthetic sheet. After spinal or epidural anaesthesia, you should state the level of block at which you are happy for the patient to be discharged from Recovery. You must also give explicit instructions for care on the ward until the block has worn off completely.

Adults having had minor, uneventful surgery and anaesthesia may have their I.V. cannula removed, but any patients in whom nausea and vomiting occur or in whom post-operative bleeding is a risk should retain their cannulae in situ. This particularly applies to children. (Ensure, however, that cannulae are well secured and bandaged so that the hub cannot cause damage if the child rubs his eyes, for example). Instructions must be given to ward staff on when to remove the cannula.All cannula must be flushed with saline prior to leaving theatre.

Our recovery rooms are extremely busy and experienced recovery nurses will undertake to discharge stable, comfortable patients to the ward without specific reference to the anaesthetist. You must specifically state your wish to review the patient before discharge if you wish to review your patient before they go back to the ward. Patients having major surgery or in whom there have been peri- operative problems should always be discussed with (and reviewed by) the anaesthetist before the recovery nurse undertakes to discharge them to the Ward. All anaesthetists are expected to review their patients post-operatively - this is fundamental to both patient care and your own education and professional development. If you are leaving patients in recovery and going home you must hand patients over to the on-call team.

SURGERY AND THE CONTRACEPTIVE PILL

MAJOR SURGERY Stop pill at least 4 weeks before surgery (Progesterone only pill excepted - there is no increased risk of D.V.T. in association with non-oestrogen O.C.P., so treatment may continue as normal). For emergency surgery in patients taking the oestrogen O.C.P., subcutaneous heparin and T.E.D., stockings MUST be used.

MINOR SURGERY Freeman Hospital Anaesthetics Dept. General Side Handbook21 MKW and NIH Aug 2010 updated VJA 2016 There is no need to stop the O.C.P., or take special precautions before minor surgery (other than to the legs) when rapid post-op mobilisation is anticipated.

Freeman Hospital Anaesthetics Dept. General Side Handbook22 MKW and NIH Aug 2010 updated VJA 2016 HORMONE REPLACEMENT THERAPY Despite the advice in the B.N.F. that patients on H.R.T. should be managed in the same way as those taking O.C.P., there is no evidence that H.R.T. is associated with increased risk of peri-operative thrombo-embolism.

H.R.T. employs a natural oestrogen, delivered in low dosage (particularly when administered via a dermal patch). A recent editorial argued against the need for discontinuation of H.R.T. before major surgery.

H.R.T. is not an indication for postponement of elective surgery and special precautions are only necessary when the patient has other risk factors for thrombo-embolism (previous history, type of surgery etc).

SURGERY IN THE DIABETIC PATIENT Peri-operative management of diabetes is supervised by the Physicians. A nominated Physician is on- call for this on a weekly basis.

The Ward staff will inform the diabetic team of the patients admission and they will prescribe either a G.I.K. (for all insulin dependent diabetics and for patients on oral hypoglycaemics in whom major surgery is proposed) or provide instructions on omission of oral hypoglycaemics and frequency of B.M. monitoring.

For patients with diabetes well controlled on diet alone, involvement of the diabetic team may well be minimal but monitoring of peri-operative B.M. remains essential. G.KI.. infusions will be started on the Ward by the House Surgeon before the patient comes to theatre.

ACUTE PAIN SERVICE see also: http://intranet/AcutePain/

Here is some background information on the role of our Acute Pain Service and more specific information about the analgesic techniques you are likely to encounter in this hospital. If you feel that the information could be usefully amended or expanded, please pass on your suggestions to any of the Pain Team.

Acute Pain Service staff

The Pain Team at Freeman Hospital consists of Consultant Anaesthetists and Nursing Sisters: Consultant Anaesthetists: General side: Jenny Holland (Lead Anaesthetist for the Pain Service), Vicki Addison and Martin Jones. Cardio side: Sameena Ahmed

Pain Nurses: Susan Breen, Angela Knight, Stewart Keenan and Jenny Houston

The Acute Pain Service conducts daily pain rounds commencing at 9am in Recovery. General Side and NCCC - Dr’s Holland, Jones and Addison each attend weekly pain rounds Cardio – Dr Ahmed, Dr Samuel and Dr Powell cover a weekly pain round. All Consultants are available for teaching advice and help.

Acute Pain Service information

Freeman Hospital Anaesthetics Dept. General Side Handbook23 MKW and NIH Aug 2010 updated VJA 2016 All up to date Acute Pain Service Guidelines can be found on the trusts intranet site. Please refer to them if you are unsure about any aspect of pain management

Freeman Hospital Anaesthetics Dept. General Side Handbook24 MKW and NIH Aug 2010 updated VJA 2016 Acute Pain Service routine

Acute Pain Service 1st Call Anaesthetist Cardio Fellow (Ward 1-20, NCCC & (Wards 23-30 & PICU) ICCU) Ward 1-20, Mon – Fri 08.00-17.30 Mon – Fri 17.30-08.00 Thurs 09.00-12.00 NCCC & ICCU rostered pain round Sat 08.00-14.00 Fri 09.00-12.00 rostered pain round

Sat 09.00-12.00 pain round

Sun & Bank Holidays 24 hour cover Wards 23-30 & Mon – Fri 08.00-17.30 Mon – Fri 17.30-08.00 PICU Sat, Sun & Bank Holidays 24 hour cover

NB Ward 38 – renal / pancreas patients covered by 1st call Anaesthetist General side; cardio- thoracic patients covered by cardio Fellow

We review all patients using Intrathecal and Epidural infusion analgesia (EIA) twice a day and see patients with Nerve Catheters once a day. The majority of patients will be post-operative, but we also take referrals from ward staff for patients with acute non-operative pain e.g. critical limb ischaemia, acute pancreatitis. Paediatric patients with Epidurals must be reviewed by the on call every night. Adult Epidurals / Intrathecals / Nerve Catheters can be reviewed by telephone to ensure there are no problems. When reviewing the patients you must carry out and document a full set of Epidural observations for each patient. Information leaflets are available in pre-admission clinic, all surgical wards, the hospital intranet and the APS data base. We encourage you to issue these during your pre-op visit out and document a full set of epidural observations for each patient. Ward staff are instructed to contact 1st call for acute pain problems out of hours.

Epidural infusion analgesia (EIA)

Please ensure that you reserve EIA for patients undergoing significant upper abdominal/chest surgery, major pelvic surgery, or in whom medical conditions warrant regional rather than opiate analgesia e.g. severe COAD. You should discuss any such patients with one of the Consultant staff pre-operatively. Most surgical wards will accept patients with EIA. Our routine mixture for EIA is 0.1% bupivacaine with 5-40 mg Diamorphine per 500ml delivered via dedicated yellow Smiths CADD pump. One filter should be used and secured between 2 dressings. Analgesia should be maintained with 0.1% bupivacaine and routine top ups of stronger must not be used on the wards. EIA must be prescribed on the dedicated yellow prescription forms. The infusion bags can only be changed by the Acute pain service or an Anaesthetist.

Approximate guide for programme rates:

Freeman Hospital Anaesthetics Dept. General Side Handbook25 MKW and NIH Aug 2010 updated VJA 2016 Lumbar L3/4-L1/T12 bolus - 6mls background - 6mls Mid thoracic T12 - T10 bolus - 5mls background - 5mls Thoracic T9 - T 7/6 bolus - 4mls background - 4mls

EIA should be continued until the patients’ use has declined and he/she can convert to oral analgesia. The exit site must be inspected daily for signs of infection and to ensure that the IV3000 dressing remains intact; if any disconnection occurs in the epidural line between patient and filter then the epidural must be removed as contamination of the catheter is inevitable. Ward staff do not routinely discontinue EIA without reference to the Pain Service or 1st on-call Anaesthetist.

Vascular / Orthopaedic Patients We do not routinely offer joint replacement or bypass graft patients Epidurals. However, if your patient is respiratory compromised and has a cardiovascular history then EIA is appropriate – Please inform the Acute Pain Service in this event and confirm with ward staff that staffing levels are sufficient to monitor these patients adequately.

Intrathecal If, on inserting an Epidural an inadvertent dural puncture occurs, we recommend threading the catheter and running an Intrathecal – use the dedicated green Intrathecal prescription chart. We also occasionally use Intrathecals for palliative care or chronic pain patients.

Patients with an Epidural / Intrathecal infusion remain the ultimate responsibility of the initiating Anaesthetist

Patient Controlled Analgesia IVAC PCAM pumps are used and pharmacy supply morphine vials 50 mgs / 50 ml s. If Morphine is contra-indicated then Fentanyl (neat 50mcg per ml) may be used. Standard settings for a Fentanyl PCA are 10-25 mcg PCA bolus and 0-25mcg background. Background infusions are only used if the patient is on long term strong opioids or in exceptional circumstances - discuss with Consultant Anaesthetist / Acute Pain Sister

It is the responsibility of the Anaesthetist to prescribe the drug and dose on the appropriate PCA chart. All syringes are drawn up and checked by the Anaesthetist and the Anaesthetic nurse / ODP. It is the legal responsibility of the person preparing these solutions to programme the PCA pump and connect it to the patient. Please ensure a non-return valve is included in the IV line.

The ward nurses are not qualified to programme pumps or administer loading doses. Most ward staff are sufficiently familiar with PCA management that they are able to decide when the patient can reasonably be weaned from the technique. Weak opiates are prescribed for any patients whose PCA is discontinued (please see PCA discontinuation guidelines).

Local Anaesthetic techniques Local anaesthetic infusions all run via a dedicated grey Smiths CADD –solis Nerve Catheter pump using Bupivacaine 0.1%. The infusion bags can only be changed by The Acute Pain Service or an Anaesthetist.

Paravertebral infusions are routinely used for cardio-thoracic patients post-operatively. The standard prescription is a continuous infusion running at 12-15mls per hour. Nerve Catheters are also used for Orthopaedic and Vascular patients – a continuous infusions usually runs at around 5ml per hour, alternatively local anaesthetic top ups can be given but must

Freeman Hospital Anaesthetics Dept. General Side Handbook26 MKW and NIH Aug 2010 updated VJA 2016 be administered in the Recovery area of Theatres by the Consultants, Acute Pain Sisters or the on- call Anaesthetist.

Wound infusions are used following knee replacement – running at 5mls per hour with a nurse activated bolus of 20mls ever 4 hours – and are removed after 24 hours.

Wards that accept: PCA / Nerve 1, 2, 3, 5, 6, 8, 10, 12, 19, 20, 23, 25, 25a, 26, 30, 32, 33, 35, 38 ICCU Catheters / Wound and PICU Infusion Epidural 2, 3, 5, 6, 8, 12, 19, 20, 23, 25, 25a, 26, 38, ICCU and PICU.

Before removing a PCA / Epidural / Nerve Catheter / Wound infusion pump from the theatre equipment store the pump log must be completed.

Multimodal Analgesia All post-operative patients are routinely prescribed: 1. Paracetamol 1g QDS (caution in liver patients / patients with deranged LFTs) 2. PRN anti-emetics (follow anti-emetic guideline) 3. NSAID's if not contra-indicated (short duration and prescribe PPI) Patients should not routinely be prescribed anti-depressants / sedatives / weak opiates / strong opiates with PCA / EIA / Intrathecal, unless the patient has been taking the drug long term. If patient is on opioids prior to surgery please follow APS guidelines.

Chronic pain patients You will also encounter occasional chronic pain patients with a long history of opiate use and / or abuse. If you are planning PCA or EIA in a patient with a history of chronic opiate use, please discuss the management with a member of the Pain Service prior to commencing the infusion.

Entonox Entonox analgesia is available for patient use on Wards under the supervision of the Acute Pain Service. Some Ward staff have been trained to administer entonox. You can gain access to entonox via the Acute Pain Service.

Cardio-thoracic Paediatrics PICU patients will generally have an infusion of morphine in the immediate post-operative period, whether ventilated or not. Occasionally, the theatre team will bring a patient to PICU with a morphine PCA that has been set up in theatres. The theatre team may also consider prescribing other post operative analgesics or anti-emetics, though the PICU team are usually happy to do this. Paracetamol is typically given in a dose no greater than 60 mg/kg/24 hours. NSAIDs are not routinely used but, if not contra-indicated, are prescribed in conservative doses. A typical morphine prescription for a child will be (the patients weight in mg of morphine), made up to 50mls total volume, with 0.9% Saline / 5% Dextrose. The infusion may be programmed as a PCA, NCA, background infusion or combination thereof. The maximum dose of morphine is 50 mg in 50 ml. A typical PCA prescription for an opiate-naïve adolescent would be a 1ml bolus and a 5 minute lockout. If a patient is to be discharged from PICU but requires a morphine PCA this should be prescribed by a consultant and the solution will be prepared and the pump programmed by the consultant or Freeman Hospital Anaesthetics Dept. General Side Handbook27 MKW and NIH Aug 2010 updated VJA 2016 acute pain sister prior to discharge. It will almost invariably be a bolus/lockout programme with no background infusion.

Initial troubleshooting should be referred to the Cardiac on call Anaesthetist, simple problems can be dealt with by that person. On PICU, particularly at night, the resident doctor on the unit will troubleshoot pain problems but may need advice.

If there are to be any significant changes to a prescription, or if problems are complex or difficult to resolve, a Consultant Paediatric Cardiothoracic Anaesthetist should be contacted by telephone for advice at an early opportunity. They may either give telephone advice or choose to see the patient. Changes to PCA or Epidural/paravertebral prescriptions should not be made without the knowledge and approval of a Consultant Paediatric Cardiothoracic Anaesthetist.

CADD SOLIS epidural pump training IVAC PCAM pump training

Please familiarize yourselves with the epidural and PCA pumps prior to use. All necessary information is on the medical devices website. Training will be available at induction and the pain sisters are available for advice during working hours and Saturday mornings

DIFFICULT AIRWAY Please be aware of predictors of difficulty of both intubation AND bag mask ventilation and think ahead- PLAN FOR FAILURE. Get help as soon as you realize you might have a problem. Be aware of difficult airway society guidelines relating to failed intubation be aware of ‘can’t intubate, can’t ventilate action plan’ These DAS links are very useful

http://www.das.uk.com/files/ddl-Jul04-A4.pdf http://www.das.uk.com/files/rsi-Jul04-A4.pdf http://www.das.uk.com/files/cvci-Jul04-A4.pdf http://www.das.uk.com/files/simple-Jul04-A4.pdf

Airway equipment :

There are 4 difficult airway trolleys in the theatre suite, one in the institute of transplantation theatres one in ENT, one outside of theatre 15 and one in endourology. The Difficult airway trolleys are red and contain extra LMAs, intubating LMAs, cook airway exchange catheters, a Manujet for needle cricoithyroidotomy and jet ventilation, a Cook-Melker needle and surgical cricothyroidotomy pack. It also has wires for use with the fibrescopes

Freeman Hospital Anaesthetics Dept. General Side Handbook28 MKW and NIH Aug 2010 updated VJA 2016 Airway Trolley • Endourology • Theatre 15 • Theatre 11 • IOT Corridor

Manujet/ Cricothyroidotomy Kit  On Each Airway Trolley  Theatre 12 Anaesthetic Room

Glidescope  Endo-urology Corridor  Outside Main Recovery  Theatre 12 Anaes Room  RIOT (shared with ITU and IOT)

Fibre Optic Scopes  Theatre 15 Prep Room. Code access. ODP needs to retrieve.

Freeman Hospital Anaesthetics Dept. General Side Handbook29 MKW and NIH Aug 2010 updated VJA 2016 Glidescope We have an adult glidescope. Please learn to use this under our supervision. It is not a device to be used first time in an emergency.

Cardiothoracic theatres has a paediatric glidescope.

Fibrescopes We have a variety of fibrescopes. They are kept in the endoscopy area in the cardiothoracic block.

Airway alert forms If you have dealt with a difficult airway please fill in a set of ‘airway alert’ forms. They are usually in large brown envelopes in the anaesthetic rooms labeled ‘airway alert forms. If you are unsure ask a consultant or Dr Weaver. There are enough forms and letters for the notes, patient, GP and one for the department. We keep a record of these. There are also enough envelopes for all the required forms. Dr Weaver administers this project.

STOP BEFORE YOU BLOCK If you intend to perform a local anaesthetic block please follow WHO checklist procedures to confirm you block the correct limb. You will not be handed your block needle by your anaesthetic assistant until the correct checks have been made.

TRUST GUIDELINES All trust guidelines are easily accessed via the trust intranet. The following must be looked at so you are aware of the procedure at Freeman

1.Code of practice for needlestick injuries (NUTH) 2.Consent to examination and treatment policy incorporating the mental health capacity act 2005 (NUTH) 3.Blood sampling acceptance and rejection policy

EDUCATION AND ASSESSMENT The entire department will be involved in your teaching and training in one way or another. In addition remember that your trainee colleagues are a great resource. Vicki Addison is the College Tutor, Varma Mritumjay is training programme director and based at the RVI Karen Beacham and Joe Cosgrove are College Examiners Nicola Hirschauer and the education fellow organize the teaching program. The medical student teaching is organised by Dr Karuna Kotur and Dr Sam Burnside . You will be expected to help deliver this teaching. Every other Consultant is also involved in teaching and training.

EDUCATIONAL SUPERVISION You will be assigned an educational supervisor (ES). You must get in touch with your ES as soon as

Freeman Hospital Anaesthetics Dept. General Side Handbook30 MKW and NIH Aug 2010 updated VJA 2016 you can to arrange your first meeting. You should send him/her a copy of your changeover form. Fill out as much of the initial form as possible prior to your meeting. You then need to organize follow-up meeting for midterm and end of term. Please meet with your educational supervisor more often than this and keep him/her up to date.

Workplace assessments Some of your work in theatre/critical care will be part of modules and some will not. All of it will be useful. Think ahead and plan to get your assessments done. Discuss this with your educational supervisor. Make the most of opportunities.

Teaching You should be timetabled to attend the Simulation Centre at least once during your 6 months.

New starters will have weekly teaching initially the programme will be circulated on your arrival at Freeman and if a new starter you are expected to attend.

We teach a lot of medical students and you may be asked to help provide delivering these sessions.

There is monthly teaching prior to or after audit.

The RVI offers teaching sessions every Wednesday afternoon which you are welcome to attend. Please ensure you negotiate your attendance with either the rotamaker or the consultant you are doubled up with.

Exams practice When exams are coming up we will try and arrange viva and OSCE practice for you.

Audit and journal club The department has monthly audit meeting which usually includes a journal club. You will be assigned to one of these journal clubs along with 2 other trainees. When your turn comes get in touch with the consultant organizing the audit so that you can select your articles/topic. If you have an audit from another hospital and you would like to present it here please let us know. Audits are important for your portfolio and can be fun so do get involved. Make sure you come to audit when you can.

ARCP forms The ARCP process occurs each year. The forms are involved and it is easy to get them wrong. You must start sorting it out well in advance of the deadline. Make sure you alert your educational supervisor to this.

Assessment We will send assessment forms out to all consultants. The results will be fed back to you by the College Tutor or your ES.

Multisource feedback Please feel free to arrange one of these. Let your educational supervisor know about it. E-portfolio MSFs take at least 1 month before you receive any results back so if this is required for an ARCP Freeman Hospital Anaesthetics Dept. General Side Handbook31 MKW and NIH Aug 2010 updated VJA 2016 make sure you allow enough time

Freeman Hospital Anaesthetics Dept. General Side Handbook32 MKW and NIH Aug 2010 updated VJA 2016 LIBRARY http://intranet/library/default.asp The Library is in the Postgraduate Centre on Level 1. You’ll find the majority of Anaesthetic textbooks and relevant Journals there. If they don’t have what you need, ask and they might be able to order it for you. The ext is 31325

Opening times: Mo – Wed 9am – 6pm Thu – Fri 9am – 5pm

SECRETARIAL SUPPORT AND COMPUTING FACILITIES The Secretaries Office has all appropriate forms for travel expenses, study leave, annual leave, family planning claims. There are computers beside the beverage bay, which can be used. There are also computers in most operating theatres. IT will provide computer access codes at the Trust induction. You will then have a Trust email account. Please check this frequently. Do not use the computers in the secretaries’ office without their explicit permission.

CATERING, HOSPITAL SHOP, HOPPER, BANK

CATERING During the week there a dinner lady comes to main theatre coffee room/kitchen. She sells sandwiches and some warm food like soup or jacket potatoes from 11.30 – 13.30. You’ll have to try and get there early; otherwise all the nice food is gone!

The hospital Dining Room is on Level 1 and is open from 7.15am until 7.30pm. Breakfast 7.15am – 11am Lunch 11.30am – 2pm Dinner 3.15pm – 7pm There is a new Coffee Shop which is open Monday - Friday 9.00am - 5.00pm and nightly 11.00pm - 1.30am which offers a range of food. Vending machines are available in the main dining room at night and throughout the 24 hours in Central Operating staff room. These contain some hot meals as well as snacks. Microwave ovens are sited in the main dining room, central ops staff room and in the I.T.U. Kitchen. Reasonable take-aways are available locally from Church Road (fish & chips, Pizzas, Indian and Chinese) and Newton Road (Indian, Chinese and fish and chips).

Freeman Hospital Anaesthetics Dept. General Side Handbook33 MKW and NIH Aug 2010 updated VJA 2016 HOSPITAL SHOPS There are hospital shops on level 2, one near front main entrance,the other at the entrance to NCCC. Both sell sandwiches, drinks, sweets, papers etc. They are open from 8am - 7.45pm Mo – Fri and 8am – 7pm Sat and Sun.

You will be served in the hospital restaurant or shops if dressed in “CCU Blues”, but not in “Theatre Greens” by order of the Trust Control of Infection Team, and this rule is non negotiable for all of us.

BANKING The HSBC Bank situated in the Main Concourse, is open on Tuesdays and Thursdays from 10.30am - 2.30pm. There are Post Offices on Church Road and Heaton Road. Stamps are available in the Hospital shop. A post box is at main reception near the main entrance.

LAUNDRY There is a laundry facility available at the Uniform Issue Bar on Level 1. It is open from 7am – 3pm.

Freeman Hospital 0191 2336161 Direct line to Anaesthetic Department 2231059

Policy for admission, responsibility and discharge for Freeman PACU.

Updated 15.02.2010 Dr D Cressey

1. PACU commenced elective activity on March 5th 2007

2. PACU is an Adult service only.

3. Currently patients with known MRSA or Clostridium difficile infection will only be admitted to PACU if they can be admitted as the sole PACU patient due to the restrictions that strict barrier nursing entails.

4. Up to two elective patient beds per weekday will usually be accommodated at any one time, plus a single emergency bed for recovery of emergency surgical patients.There are also 4 PACU plus beds located on ICCU. Staffing mix / experience will limit any expansion of this at present. There may be specific times where a third member of nursing staff will be present whilst being mentored in their starting weeks in Recovery. These members of nursing staff will be considered supernumerary and must not be identified as a reason to ask PACU to take additional patients above and beyond the capacity as stated above.

5. Assistance from other members of the night team will be available when required.

6. Initially bookings will be via the ward clerks on the ICCU – along with the other critical care admissions they will be recorded on the standard daily booking form. It is essential that surgeons/ anaesthetists confirm if a patient is suitable for PACU. o These patients will ultimately be identified by preadmission clinic

7. Written criteria for patient selection have been provided in a separate document. Freeman Hospital Anaesthetics Dept. General Side Handbook34 MKW and NIH Aug 2010 updated VJA 2016 8. Day to day running;

i. Elective cases will be prioritised by the consultant on for ICCU, along with other elective critical care bookings. Recovery and reception will be notified before 08.30 am on the day of surgery which patients are going to PACU that day.

ii. Clinical appropriateness is the final arbiter. PACU will only work if patients are guaranteed prompt discharge the following day. Pressures to cope with waiting time targets in medically unfit patients must not affect these clinical decisions.

iii. If during the day it becomes apparent that clinical priorities have changed on the basis of either better than expected physiological condition or unexpected difficulties arising for different patients then the patients selected for PACU care may be altered. The responsibility for changing which patient occupies a PACU bed rests with the Critical Care Consultant or the On-call anaesthetic consultant out of hours. The most efficient use of this precious resource requires a significant degree of flexible working.

iv. Admissions will have Recovery documentation as outlined:

 ICCU observation and fluid balance charts changing to ward charts as soon as the decision to discharge is made.

 Both Ward Kardex (green) or e-record prescribing can be used in PACU

 No ICCU medical admission sheet

 ICCU short stay nursing care plan.

 Modified ICCU discharge chart.

v. A modified ICCU discharge chart with physiological scoring / checklist for CXR review, blood results etc must be completed pre-discharge.

vi. Bloods will be sent by the recovery staff as requested by the anaesthetist supervising the case on arrival in PACU. The default request will be for FBC, U+E and ABG (if arterial access in situ). An ECG will also be done for all patients unless specified as not necessary.

vii. The on call anaesthetic team will be primarily responsible for patients in PACU. The surgical team must be available to review specific surgical issues. viii. First point of call will be to the 1st call anaesthetist, as is currently the case in Recovery. If they are not available then the 2nd call anaesthetists will be contacted.

ix. The on-call surgical specialty registrar must be aware of any patient in PACU and will provide appropriate surgical advice/ review and assist with patient management if the anaesthetic junior staff are otherwise busy.

x. Additional cover will be available from the Consultant surgeon on call for the relevant specialty. Freeman Hospital Anaesthetics Dept. General Side Handbook35 MKW and NIH Aug 2010 updated VJA 2016 xi. The H@N team will not usually be involved in the care of these patients whilst they are in PACU.

xii. Ultimate responsibility for patients in PACU (along with admission and discharge rights) will belong to the on call consultant anaesthetist. xiii. Admission / discharge timing. It is not mandatory (unless otherwise stated by the responsible anaesthetist) for patients electively admitted to PACU during the day to stay overnight. If reviewed by the appropriate anaesthetic staff and deemed fit for discharge to the ward then after the necessary documentation the patient should be discharged on the day of surgery before 22.00hrs (even if this means PACU being empty; the staff can be gainfully employed in other duties). Between the hours of 22.00hrs and 07.00hrs NICE and NPSA guidelines 2007 recommend that patients are not discharged to the ward from Critical care areas (PACU included) unless circumstances are extreme and that it would constitute a critical incident if discharge occurred. In these circumstances an appropriate form would need to be completed and the patient reviewed the following morning by the Outreach team on the ward. Planned discharge time for overnight stays on PACU is between 07.30 and 08.00am. xiv. Physiological scoring for PACU patients as per the MEWS system should be performed a minimum of 3 times for patients staying overnight. This includes a mandatory record at around 6am prior to 2nd call review.

xv. Between 06.30 and 07.00 am the anaesthetic second call or if necessary the first call should review any patient in PACU. They should do a physical assessment and chart review, record it on the medical record and state whether the patient is fit for discharge to the ward. xvi. If the second call does not think the patient fit for ward discharge then they must inform the nurse in charge of ITU of a potential need for an HDU bed. They must then also pass this information to the anaesthetist coming on to start in emergency theatre that day. xvii. Any patients not discharged by 8am will be reviewed by the consultant on call for emergency theatre at 08:00 – 08:15. If the patient is not likely to be fit for discharge within 30 mins then the emergency theatre consultant should contact the Critical Care Consultant immediately so they are aware of the need for this patients’ HDU admission before giving the go ahead to that days’ elective surgery patients.

9. Emergency surgical patients or elective surgical patients with an unanticipated need for PACU overnight may be admitted to the 2 PACU beds if capacity is available and they meet the standard PACU criteria in particular the suitability for discharge by 8am. (Temporary admission to an available PACU bed or the emergency bed until ICCU bed availability is urgently arranged may be considered for patients needing higher or more prolonged level of care provided there is capacity to take these patients on a 1 nurse 1 patient ratio).

10. Elective surgical cases requiring a predictable prolonged stay in recovery by reason of the operative procedure (duration, invasiveness, specific concerns re post-operative bleeding or airway or flap observations) need separate consideration. If they are likely to need recovery significantly beyond the 20.00hrs cut off for day staff shift then they will impact Freeman Hospital Anaesthetics Dept. General Side Handbook36 MKW and NIH Aug 2010 updated VJA 2016 on PACU and emergency recovery facilities. As such they should be considered as requiring PACU care and should be processed and allocated (or deferred in the absence of a bed) by the consultant in ITU. This group will be assessed in the same way as other patient groups using the recovery discharge score to determine suitability for return to the wards. Ongoing need for other surgical assessments such as flap observations should be provided on the wards once recovery discharge criteria are met. The policy of specialing patients (ie post cystectomy or post-op major neck dissection) should continue as at present as deemed appropriate by each specialty.

11. No more than 4 patients can be cared for on PACU at any one time. If a non-electively- booked-PACU-suitable patient needs prolonged post-op close observation during the evening or overnight and both PACU beds are occupied then they can be cared for in the “Emergency Recovery” bed as the third patient in recovery. However that precludes recovery staff from taking any further patients. As such any patients having emergency surgery overnight will have to be recovered by the emergency theatre staff as occurred prior to the 24 hour recovery system being introduced. This third patient should be treated as a Recovery patient and would be eligible for discharge to the ward during the night once they meet recovery discharge criteria. (As opposed to formal PACU patients who must not be discharged between 22.00 hrs and 07.00 hrs as per NICE and NPSA recommendations 2007).

12. At weekends recovery staffing levels during the day are limited such that elective PACU admissions during working hours are likely to cause unacceptable pressures on the recovery service. If planned PACU admissions are to be considered during the day then extra staffing up to 21.00hrs would need to be arranged to facilitate this.

13. During the evening and overnight at weekends the staffing levels for PACU are the same as during the week and so cases could be admitted to PACU using the same criteria as for weekdays.

14. If a Private Patient is being considered for PACU care at the weekend they MUST meet the Standard PACU criteria and extra staff will need to be arranged to cover the day shift through to 21.00hrs. These patients should be booked with as much notice as possible at the latest by Friday 9am prior to the weekend and cannot be started without confirmation that extra recovery staff are available as above. Responsibility for their care remains with the Consultant Anaesthetist doing the case who must be immediately contactable for the duration of their stay in PACU.

Revised 15.02.10 DMC

CRITICAL CARE INDUCTION INFORMATION FROM DR CRESSEY

Orientation to Freeman Hospital Critical Care Unit Tour of the unit incl storage, coffee room and office areas Bedside orientation i.e. what is where, how the pendant works etc Chart review (+ where they’re all kept and how the notes are arranged.) Talk with Pauline/ Jean about discharge summaries/death certificates etc

Daily routine in ICU 0830-0900 sit down ward round night person then leaves (hours requirement) walk round. Lasts to 0930-1200! Freeman Hospital Anaesthetics Dept. General Side Handbook37 MKW and NIH Aug 2010 updated VJA 2016 Coffee, microbiology, jobs plan.

Layout of ICU: 17 ICCU beds including 4 PACU plus beds. Staffed and funded for; 9 level 3 and 6 level 2 beds or any combination where 1 ITU (level3) bed can be swapped for 2 HDU (level2 beds): eg 8ITU & 8HDU or 10ITU & 4 HDU or 7 ITU and 10 HDU

Booking cases for ICU/HDU: Booking in book- ensure routine cases are written in the book- generally surgical team does this via our ward clerks. Emergency cases- phone ITU consultant/ consultant on call

Ward rounds and handovers: Aim for handover round 17.00-18.00 weekdays. Useful if second call can attend. ) Evening handover 2030-2100) write in notes @ time Night cover 2nd call round 2-3am – important review stage – check medication etc Sunday wardrounds 0900)

Transferring patients: Priorities identified on ward rounds. Try not to transfer outside hospital. Repatriation to home hospital ideal then Cardiac or RVI generally next port of call, then NGH. Inform/ discuss with consultant on call about transfers. Live bed state on NICBIS database.

Second Call Duties: Usually list during day Occasionally HDU Emergency cover at night inc ICU cover- single junior at night currently, (may change to 2) First cover ITU may not have any anaesthetic experience. 12HDU Accept from ward 29 (they are not automatically a Cardiac ITU case though some are)

Calling consultants: When admitting patients must discuss with consultant (ideally they should be assessed first- to avoid admitting those who will not benefit from ITU) Transferring patients out of unit Anything you’re not sure about

Resident shifts: On call shifts Early- 0830-1730 0800-1800 Long- 0830-2100 0800-2000 Twilight- 1630-2300 1930-0830 Night- 2030-0900

Training: See Dr O’Neill Audit: See Dr Wright Guidelines: See Dr Walton Publications: See IDN/JFC/ JW/ S’ON/ SW

Record keeping: Daily charts: to be filled in on ward round by day shift doctors Freeman Hospital Anaesthetics Dept. General Side Handbook38 MKW and NIH Aug 2010 updated VJA 2016 Results charts: to be filled in by night doctor prior to ward round (often assisted by day starting shift) Notes to be filled in for all ward rounds (3 times per day)

Theatre case admissions: Priority check ABC Must get handover from accompanying anaesthetist or recovery staff if level 2 Check surgical/anaesthetic notes for post-op instructions Check plans for anticoagulation if appropriate especially thromboprophylaxis – needs a written entry in notes if this is to be omitted Write up usual medications on purple Kardex – discontinue all e-record drugs until ICCU becomes active with erecord (e-record prescribing on ICCU should begin 6th Sept 2010)

Computer. We need an active e-mail address for each trainee. Trainees must check e-mail at least 2x/wk Security of hospital computer data, log off PACS, results APEX

Guidelines folders: Big Blue folders @ ITU bed space Short cut icon main computer desktop Can be very useful as a quick revision tool

Discharges: Brief letter to ward clerk for typing – this will be reviewed and signed by the consultant who has seen the patient prior to discharge (you have been warned!) Hand written form into notes at current notes “page” Phone the receiving team, if no contact made keep trying and record the attempts in the pre- discharge notes. If at weekend then call on-call receiving team AND e-mail home team consultant to say where and when the patient has gone

Resuscitation Know your defib, Pick up and run bag.

Overnight plan: Division of tasks – 1st call anaesthetist is expected to join ICCU once theatre and pain work has been completed. 2nd call runs the team – please ensure equitable rest time.

Outreach: Cover available 07.30-19.00 by outreach sisters May call 2nd on to review patients. If not busy, the ITU doctor may assist but priority is always to the unit

Specimens Chute: Specimens. Do not send blood culture bottles or other breakables MUST STILL RING LABS FOR URGENT SPECIMENS Blood cultures at weekend: need to inform microbiology so samples can be plated out, and ring porter to take specimen to lab.

Doctors Room Shared room on call bed opposite the staff room.: Office space during the day, available for rest periods for trainee over night, pull down bed. Must be left tidy after use. May also used for teaching sessions during the day. The quiet room for discussions with relatives has a Parker Knoll chair and can be a quiet rest place overnight for 2nd call.

Freeman Hospital Anaesthetics Dept. General Side Handbook39 MKW and NIH Aug 2010 updated VJA 2016 Nursing Staff. Senior nurses have many years’ experience with our casemix. They essentially keep the unit working and are very good at helping with problems.

Teaching. We hope to run regular (weekly) teaching sessions for trainees. These are trainee led with consultant/advanced trainee supervision. Attendance is expected even on days not rostered on duty (You are rostered for 45hrs/week work, but paid for 48, and historically, attendance by trainees has been poor)

Rest during night shifts on ICCU from ajk Jan 2011

First and second calls should run the overnight team and ensure that each of the medical staff get a reasonable break if possible. 1. There is also an on call room on ITU opposite the coffee room for all to share. 2. At all times there should be a visible doctor on the unit so the nurses can access medical advice 3. Please tidy up after yourself / clear the sheets + return the bed to its position – unfortunately we don’t have domestic capacity to do this and it shouldn’t be left to the nurses or admin staff on the unit. This is the most likely potential reason for having the bed withdrawn I’m afraid – so for your future colleagues’ benefit please tidy up.

Miscellaneous: ODM CVVH Ultrasound

Freeman Hospital Anaesthetics Dept. General Side Handbook40 MKW and NIH Aug 2010 updated VJA 2016

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