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Department of Anaesthesia, Intensive Care, Bundaberg Base Hospital

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Department of Anaesthesia, Intensive Care, Bundaberg Base Hospital Department of Anaesthesia & Intensive Care Bundaberg Base Hospital INTENSIVE CARE HANDBOOK Name: Date: I have read and understood the duties Signature of Employee: and requirements of the position as described in this position description and agree to be employed under such conditions and the relevant award. I Signature of Supervisor: have read the orientation information and agree to the conditions listed therein. Review: Annually in January. Next update January 2012 1 Contents: 1. Introduction 2. Staffing 3. Departmental Overview 4. Rostering and Absences 5. Anaesthetics a. Senior Staff b. Trainees c. Education d. Quality Assurance 6. ICU a. ICU daily Business b. Policies for admission and discharge of patients c. Documentation and drug prescription d. Duties outside ICU (MET calls, ED referrals) 7. Communication in ICU 8. Pathology tests in ICU 9. Miscellaneous Clinical Topics 10. Resuscitation Guidelines 11. Patient Note/Handover Format in ICU 12. Orientation Objectives 2 1. Introduction This manual serves as an introduction to working in anaesthesia, intensive care, acute pain and peri-operative medicine at Bundaberg Base Hospital. All anaesthetic staff are required to familiarise themselves with the manual. New staff should approach existing staff members for any issues requiring further clarification. Welcome to the team, and we hope your time in the department is stimulating and rewarding. Bundaberg Base Hospital serves a growing population of about 90 000. The anaesthetic department provides a 24hr anaesthetic service for General Surgery, Orthopaedics, Obstetrics & Gynaecology, Urology, Endoscopy and Dental. The department gives over 4500 anaesthetics a year. The mixed Intensive Care / Coronary Care Unit has about 600 admissions a year. 2. Staffing Current senior staff members with departmental responsibilities: Dr Morné Terblanche Director of Anaesthesia/ICU Dr David Schapiro Staff Specialist (Pain management) Dr Anna-Louis Reyneke Staff Anaesthetist Dr Isaivanie Lingham Staff Anaesthetist Dr Joseph Tobias Staff Anaesthetist Dr Yaqoob Zia Staff Specialist Dr Vanessa Greig Staff Specialist (Labour anaesthesia) Dr Piotr Konopka Current Supervisor of Training Dr Sunil Singh Staff Anaesthetist/ Acting Director of ICU Other senior medical Staff with significant ICU involvement Dr Herman Whitmarr Visiting Consultant Cardiology Dr Andre Conradie Visiting Consultant Cardiology There are currently 5 training grade staff working in the unit Dr Widanagamage Epa Dr Sunanda Thilakarathne Dr Brian Chileshe Dr Jatinder Grewal Dr Kavitha Jayachakran 3 All Departmental information, guidelines, learning material can be found at: G:\Medical Services\Medical Staff\Anaesthesia Files All rosters can be viewed at: G:\Medical Services\SPECSEC\ROSTERS\Anaesthetics 3. Departmental Overview The department of anaesthesia & intensive care has six main areas of activity: 1. Intensive Care / Coronary Care Unit 2. ICU referrals and MET calls 3. Transfers/Retrieval 1. Intensive Care / Coronary Care Unit: Total: 8 Bed Spaces (6 staffed), (1 Paediatric, 1Isolation). Future planning for ICU Bundaberg includes accreditation for basic training. To work towards this achievement certain changes are necessary. Currently our unit has 7 day on-call roster for consultants. Fatigue management will include the on-call consultant for Anaesthetics The daily program looks as follows. 08:00 Handover round. This is a working round, concerned with management decisions. The patient’s progress is reviewed, and short and long term goals are identified together with a prospective timeline. Appropriate investigations are also planned for. Participants include the Duty Anaesthetist, Night PHO, day PHO, ICU consultant and nursing staff. This round should be concise and to the point. New patients may require more time. 10:00 Daily Tele-health ward rounds with RBWH consultant intensivist. This will allow clinicians on both sides to gather and evaluate outstanding special investigations, and to allow for a more comprehensive examination and assessment of the patient. 4 This round is registered for CME points and the department encourages participation. It is an important teaching opportunity. The PHOs do the presentation with input from ICU consultant for the week. As consultants are more involved in the daily care of patients, active participation should be encouraged. 17:00 Business round, to review all old patients and monitor progress of patients and act on results of special investigations received. Also reassess goals and review newly admitted patients. Outstanding special investigations should be followed up during the afternoon. During the afternoon round outstanding results should be identified and problems assessed. The Consultant and PHO should formulate a clear plan for each patient for the evening which should be handed over to the night PHO. Re-evaluation of the patient, with a review of the goals identified earlier in the day, and re-assessment of the patient. 19:30 Handover to the night PHO. A clear plan should be available with problem areas highlighted. If there are any uncertainties it should be cleared with the consultant on call. Referrals, admissions and Consultations New admissions and referrals are always to be discussed with the on-call consultant. Ideally the initial consultation should be at a consultant level. We appreciate that this may not be always available but a consultant should be involved at the earliest opportunity. Patients admitted via the emergency department should always be seen by at least a PHO from the appropriate discipline. There must always be an admitting discipline and unit who takes responsibility of the discharged patient. For example: A patient presenting with pneumonia should be seen by the on-call medical team. Sometimes due to the patient’s condition assessment in DEM my not be possible. Under these circumstanced the on-call team must come and see the patient within a reasonable time frame. When the patient is fit for discharge he/she will be discharged to that team so it is of the utmost importance that they are aware of the patient from admission. The admitting unit must review the patient at least once daily and document their review and advice. ICU welcome daily ward rounds from other disciplines and will actively seek advice. Ultimately orders and change in management will be the responsibility of the ICU team. This should limit confusion, omissions and other errors. Management of complicated patients Decision making in ICU will normally be in consultation with Brisbane. Decision making will take the Clinical Service Capability Framework into consideration. All decision making will ultimately be in the best interest of the patient and rest with the Consultant on-call. The final decision to transfer or not, is the 5 responsibility of the consultant on-call. If RBWH is not able to accept the patient another unit should be approached. If no bed can be identified the Clinical Coordinator should be asked to help. If a patient can’t be transferred for whatever reasons this should be clearly documented. Death in ICU Mortality is unavoidable in ICU. To ensure an appropriate level of care all deaths will be reviewed by the Director and presented at the Critical Care Service forum on a monthly basis. Where appropriate an HEAPS analysis will be completed with the help of the Clinical Governance Unit. If there is uncertainty about whether a death is reportable to the coroner or not, an A1 form should be completed. The Coroner will respond in a timely manner. If the Coroner does not deem the case reportable the unit will be informed and a death certificate can be issued. If the death is reportable no death certificate can be issued. The police will be notified by the coroner and they will visit the unit. It is very important to note that the police can only remove the patient’s file when cleared by records. Records will scan the file and make it available to the police. Remember that your statement must be factual. Don’t include your opinion. You may be asked for that later! Inform someone that is more important then you. An email will do. Managers hate surprises. If appropriate PRIME the incident immediately. The unit is classified as a Level 1 facility. This means the unit is capable of providing immediate resuscitation and short term cardio-respiratory support for critically ill patients. It also has a major role in the monitoring and prevention of complications in “at risk” medical and surgical patients. Deteriorating patients and patients with multi-system involvement should be discussed with the Royal Brisbane (RBWH) Senior Intensivist as soon as possible (Tel: 3636 5946 direct number 24/7). Transport for retrievals to Brisbane is organised through Queensland Clinical Coordination (QCC) in Brisbane (speed dial 6133). Currently our Unit participate in a Video business round with a RBWH Intensivist every morning where all patients are presented. Funding has allowed RBWH to allocate an Intensivist and secretarial support for this service. This service has lead to better communication with RBWH as well us better appreciation for the particular organisational, infrastructure and staffing difficulties experienced by our institution. Consequently transfer of patients is easier to facilitate. The unit is well equipped: with standard invasive and non-invasive monitoring equipment, 1 cardiac output monitors namely ‘Vigileo’, 3 ‘BIPAP Vision’ non-invasive ventilators and, 3 Nellcor Puritan Bennett 840 ventilators and one Sonosite
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