Download Anaesthetics in Southampton

ACCS training in
University Hospital Southampton
An introductory guide to the rotations
through Acute Medicine, Intensive Care,
Anaesthetics and Emergency Medicine.
Acute Medicine in Southampton
Introduction
The ACCS acute medical block in Southampton comprises 6 months,
separated into two 3 months blocks. These will be spent in AMU and
respiratory medicine.
The intention is to expose trainees to a combination of acute and chronic
disease management which is necessary to fulfil the requirements of the
ACCS curriculum. The AMU block will enable trainees to obtain experience in
the initial management of medical and elderly care patients during the first few
days of their hospital stay. During the respiratory attachment, trainees will also
be involved in the initial management of respiratory patients in the AMU and
for the ongoing care of patients being managed by the respiratory team.
All trainees will be allocated an educational supervisor at the start of their 6
month block which will be one of the Acute Medicine consultants based on
AMU; this consultant will also act as clinical supervisor during the AMU block.
During the respiratory block one of the respiratory consultants will act as
Clinical Supervisor.
The Clinical Lead for the ACCS Acute Medicine programme in Southampton
is Dr Beata Brown; she will ensure you are allocated an educational
supervisor at the start of your attachment. Divisional induction is undertaken
at the start of your 6 month attachment and a local ‘mini-induction’ meeting
will be arranged at the time of changeover after 3 months. It is important that
you arrange to meet with your allocated educational supervisor as soon as
possible after starting your post and after the changeover. If you have any
concerns or questions about the posts please discuss these initially with your
educational supervisor or contact Dr Brown (ext 4716 or email:
[email protected]
The Acute Medical Unit
Introduction
During your medicine attachment you will undertake a 3 month block of time
working on the Acute Medical Unit (AMU). During this time you will be under
the supervision of the Acute Medical Consultants:
Dr Chris Roseveare
Dr Jas Dulay
Dr Beata Brown
Dr Mayank Patel
Dr Ben Chadwick
The consultants work a combination of early and late shifts, providing senior
cover on AMU between 08.00 and 21.00, Monday to Friday.
At weekends and overnight a larger number of consultants take part in an oncall rota, which also encompasses the morning Post Take ward round.
(PTWR)
Layout and operation of AMU
AMU is made up of 4 clinical areas:
Ambulatory Care (AMA) – 6 trolleys / 2 chairs
AMU1 (green) – 10 beds- mixed acute admissions bay
AMU 2 (purple) – 18 beds- male bay
AMU 3 (pink) – 18 beds- female bay
Most patients admitted as emergencies to the medical / elderly care ‘take’ will
start their in-patient stay in the AMU. GP referred patients are usually brought
directly to AMA, where they undergo immediate senior assessment (STAT),
when a decision is made on further investigation and need for admission.
Patients who self present to hospital or who are acutely unwell will be
assessed initially in the Emergency Department (ED) prior to referral to the
medical team.
Ambulatory Care (AMA) also functions as a trolley based area for daytime
assessment of patients where overnight stay is deemed un-necessary. This
area also encompasses the nurse-led DVT service and an area where
patients requiring once-daily IV antibiotics for cellulitis can be assessed on a
daily basis. AMA should close overnight (from 9pm).
When all beds are full it is sometimes necessary for AMA to be used overnight
for patients on beds.
Referral System
GP Referrals
If a General Practitioner deems that hospital admission to medicine / elderly
care is required he / she will contact the Admissions Dept (ADT). They bleep
the receiving Dr (bleep 9189) who will determine whether the patient requires
admission.
If the patient is accepted for admission, ADT then telephone the nurse coordinator on AMU to inform them of the admission.
Between 8am-9pm Mon-Fri the GP calls are usually answered by the acute
medicine consultant.
Overnight and at weekends the calls are taken by the on-call SpR.
Emergency Department Referrals
Patients are initially assessed by the ED Triage nurse and medical staff. If
medical / elderly care referral is deemed necessary, the ED Doctor will contact
the acute medicine SpR during weekdays or on-call SpR overnight and at
weekends.
The nurse in charge in the ED will inform ADT and liaise with the nurse coordinator on AMU.
The ‘Take’ Lists
When a patient is accepted for admission the accepting Dr will type their
name on the Take List.
The list comprises a table with columns indicating the source of referral,
whether they are to be seen by the medical / elderly care consultant, the
problem described by the referrer and the name of the junior doctor who has
assessed them. This list is kept on a daily basis on the computer in the
Multiprofessional Office on AMU. A new list should be created each day and is
stored under AMU-list icon.
Currently a new electronic, hospital wide, Doctors' Worklist is being developed
and soon will replace the current system.
Following referral of a patient to AMU…..
When a patient arrives on AMU the nurse co-ordinator will write their name on
the white board on the door of the Multiprofessional Room (MPR) along with
their destination bed. GP referred patients are initially assessed via STAT
system in AMA and wait there for junior clerking and a bed to be allocated or
directly discharged if admission is not needed
ED referred patients will be transferred to the AMU as soon as possible; if a
bed is not immediately available medical juniors may require to undertake
their initial assessment in the ED (see below), rather than waiting for transfer
to AMU.
The priority with which a patient needs to be seen is indicated by a number on
the board next to the patient’s name (1 is highest priority; 5 is lowest). Please
write your name on the board & the computer list to make it clear who has
seen the patient.
Senior Review of Medical / Elderly Care Patients on AMU
All patients admitted as part of the acute medical take are seen within 12
hours of admission by a consultant on a Post Take Ward Round (PTWR)
a) Patients aged <80 are the responsibility of the Acute Medicine
consultant of the day.
During weekdays the acute medical consultants operate a system of
continuous senior review; following initial assessment by a junior doctor
the acute medical consultant will review the patient and a clear
management plan will be documented on the ‘Post Take Ward Round’
page
Patients admitted overnight will be reviewed on the morning PTWR
(starting 8am) by the consultant who has been on-call the previous night;
in some cases this will be the acute medicine consultant for the following
day. (Consultant rota is displayed in the Multidisciplinary Office)
b) Patients aged >=80 are the responsibility of the on-call elderly care
consultant.
The elderly care consultant will usually arrive on the ward at around 4pm
and undertake a ward round of all patients seen before that time; wherever
possible the junior doctor who has clerked the patient should be available
to present the patient to the consultant.
Elderly care patients not clerked will be seen on the following morning
elderly care PTWR, which usually starts at 9am.
Speciality review of patients on AMU
Each morning a respiratory and gastroenterology team will come to AMU and
take over care of patients whose problem is deemed to be more appropriate
for their care.
Patients who are deemed to have a respiratory or GI problem should be
indicated in the ‘speciality’ column of the take list. The speciality team will
review these patients; if it’s deemed appropriate they will indicate in the notes
that they have taken over the care of the patient. Although the junior doctors
on AMU remain responsible for the day-to-day management of these patients,
daily senior review will be undertaken by the speciality team. Once transferred
off AMU the speciality team takes full responsibility for their care.
All patients should be admitted using the Medical Unit Admission Sheet. This
includes a page for the post-take consultant ward round. It is essential that
this part of the document be completed in its entirety, including differential
diagnosis, clear management plan, and documentation of x-ray and ECG
findings.
The estimated length of stay and proposed ward localisation area should be
documented in ALL cases; where possible, patients whose length of stay is
predicted to be <48 hours will remain within the AMU to ensure rapid
discharge.
Patients with a GI haemorrhage should be discussed with the on call
Endoscopist; emergency endoscopy is usually available before the start of the
morning list (8am-9am), between morning and afternoon lists (12.30-1.30) and
after the afternoon list. Patients admitted after 5pm should be discussed with
the on-call Endoscopist (available via switchboard) in time to be endoscoped
before 9am (e.g. before midnight or approx. 7am if the patient is
haemodynamically stable).
Patients referred following an episode of deliberate self-harm are usually seen
by the psychiatric crisis team in A&E. If admission is required for medical
reasons (e.g. cardiac monitoring, treatment with Parvolex, etc), or the patient
is too drowsy to be assessed in A&E the patient will be referred to the medical
team. A psychosocial assessment form should be completed by the admitting
medical team and faxed to the Department of Psychiatry (under 65 years of
age) or Moorgreen (over 65 years of age) as early as possible
Handover
Good patient care depends on adequate handover of all patients with active
medical problems. It is good practice to ensure that the following are clearly
indicated in the notes:
a)
b)
c)
d)
e)
Working diagnosis
The next proposed stage of medical management
The appropriateness of investigations
CPR/ITU/DNAR decisions
Information given to the patient
To assist handover there is
-
space at the end of the admission document
Weekend handover label
Weekend handover list/file on each ward
Formal daily handover meetings for Medicine and Elderly Care are conducted
Monday to Friday in WF11 Seminar Room on F Level West Wing starting at
08:30 hours. An SHO representative from D level and G level will attend the
meeting, and are then responsible for passing on the information to the
relevant inpatient team. There is a separate rota for handover meetings
issued by Zena Sadler in the Junior Doctor’s office X4734.
There is a formal handover on Medical HDU from 16:45 to 17:15 daily. This
involves the medical HDU team, and the evening on call team. Any patients
from the medical wards who require it can be handed over at this meeting.
There is also a formal handover from the evening on call team to the night
team from 21:00 until 21:30 in the F level seminar room WF11. Here jobs and
patients are handed over to the night team. Representatives from the
Hospital at Night team and Outreach are present at the meeting.
The weekend handover form in each patient’s notes must be completed on
Friday morning. Please state clearly the patient’s resuscitation status where
this has been discussed.
In addition a weekend handover list (green file) should be completed on each
ward, this should include any patient who needs clinical review or may be
suitable for discharge over the weekend. The cover team on a Saturday and
Sunday morning ward round will review these patients.
Discharge
All patients must have an estimated date of discharge (EDD) on admission
which will need to be continually monitored and updated if necessary. EDD
must be set for the date you think the patient will be medically fit. When the
patient is medically fit you will need to sign a section 5 form if they require any
further ongoing services.
Discharge summaries (HMR) are produced electronically on the e-docs
system. The discharge summary should be a full account of both the admitting
episode and any co-morbidities that the patient suffers from (e.g. diabetes),
whether or not they are directly related to the admission episode.
Patients are expected to go home before 11.00hrs on the day of discharge in
accordance with pre-11am trust targets. Therefore, ideally, all HMRs need to
be commenced on admission to the ward, updated regularly and completed
the day before discharge to ensure timely arrival of TTOs.
Junior Doctors Roles / Responsibilities while on AMU
The working arrangements on AMU are complex and subject to change on a
regular basis. On the first day of you AMU block you should make contact with
the AMU SpR / Acute medicine consultant who will give you a brief
introduction to the current working practice. If you are ever unsure about your
role please ASK any of the resident AMU medical staff.
Weekdays
A weekly rota is posted on the door of the multiprofessional office; this
indicates which area each junior doctor is allocated to on a daily basis.
Punctuality is extremely important – if you are likely to be late please bleep
the on-call SpR (9061) to inform them.
AMU 2 and AMU 3
During weekdays two junior doctors (one FY1 and one FY2 or SHO) are
allocated to each of AMU 2 and AMU 3. One of these juniors will be allocated
to work 8am-6pm; the other will work from 9am to 7pm. The 8am-6pm junior
should go to their respective area and join the morning PTWRs when they
enter their area. A handover folder is kept in each area in which the junior
should document jobs to be done following the PTWR.
Patients who are not seen as part of the morning PTWR will usually be seen
by the acute medicine consultant or SpR for the day. Once the morning
PTWR has been completed the junior doctors in this area should start to
review the remaining patients, maintaining a list of jobs to be done using the
handover folder.
Junior doctors allocated to the areas are responsible for ensuring that the jobs
relating to their patients are all completed.
When new patients arrive in the area they should be clerked in a timely
fashion by the team in each AMU (supported by the ‘take’ SHOs – see below).
Junior doctors should always be prepared to cross boundaries – if another
area is struggling due to junior doctor absence, patient dependency or the
need to undertake procedures requiring supervision. The 8am FY1 is also
responsible for the 2111 crash bleep and for dealing with any investigation
cards placed in the folder in the Multiprofessional Office.
AMU 1 and AMA
These areas are covered by FY2 and more senior grades doctors supported
by one of the Acute medicine SpRs.
Due to sickness or other leave it may be necessary for one of the AMU2 or 3
juniors to provide support to these areas during some weekdays.
Warfarin prescriptions for ambulatory patients with DVT need to be completed
between 5pm-7pm; the AMA junior will usually complete this before leaving;
on occasions it may be necessary for the on-call SHO to compete this.
‘TAKE TEAM’
TAKE SHO 1(CARDIAC ARREST BLEEP 2011) 1100-2100
Pick up bleep from 8am SHO and obtain handover of any patients waiting to
be seen. If no patients waiting to be seen, go to AMU 1 / AMA and support the
juniors in those areas.
You are responsible for ensuring that all patients are clerked in a timely
fashion – if patients referred by the ED are not moved to AMU immediately
due to lack of bed availability you should start assessing them in the ED.
Keep a close eye on the take list / patient list on the door of the
multiprofessional room. Present patients to the relevant consultant (medicine /
elderly care) once results are available.
Please ensure that you go to ED to see referrals as soon as possible, rather
than waiting for them to come to AMU. Once results of investigations are
back, patients can be reviewed promptly by the duty AMU consultant. GP
referrals are admitted via AMA STAT or straight to all areas of AMU and you
may need to visit each area to be aware of their admission. Please ensure
that any unwell patients/outstanding results/jobs or investigations are handed
over to the night team.
TAKE SHO 2 (BLEEP 2993) 1300-2200
10001
Pick up bleep from multiprofessional room. Contact Take SHO 1 on arrival
and start undertaking review of any new patients waiting to be seen. If no
patients waiting to be seen support team on AMU1 / AMA or any other area of
AMU which is under pressure.
As above, please ensure that you go to ED to see referrals as soon as
possible, rather than waiting for them to come to AMU. Please be available at
4pm to direct the EC consultant PTWR (mon-fri).
LATE SHIFT FY1 (CARDIAC ARREST BLEEP 2012 held 1700-2200) 13002200
On arrival bleep the take SpR 1 on 9061 and identify whether there are
patients waiting to be seen. If no patients waiting to be seen, support medical
staff on AMU / AMA.
Main role is to clerk acutely admitted patients anywhere in AMU, either from
ED or from GP referrals, then present to consultants when results are back. In
general FY1 should prioritise GP-referred patients, as ED referred patients will
usually have seen an SHO / SpR already.
The early shift F1 (0800 start) holds CARDIAC ARREST BLEEP 2012 from
0800 – 1700
THE AMU NIGHT TEAM (1 SpR, 1 SHO, 1 FY1)
SpR leads the team and takes referrals. SHO and F1 to clerk in new
admissions and review patients on AMU based on handover or nursing
requests. At 0730-0800, FY1 needs to ensure that post take list is up to date
with patient bed locations and printed off ready for 0800 Medical and 0830
E/C PTWR. Please also ensure that any patients not seen by previous
evening AMU consultant are listed as needing to be seen as part of 0800
PTWR. Accompany relevant consultant to present patients that you have
admitted then handover jobs etc to day shift Doctors working in appropriate
area of AMU.
WEEKEND WORKING ON AMU
The medical consultant undertakes a twice daily PTWR Saturday and Sunday
(0800 and 17.00). The elderly care consultant undertakes twice daily PTWR
on Saturday and a morning PTWR on Sunday (times variable but usually
08.30 and 16.30).
Weekend shifts – see attached
Annual and study leave
FY1 leave is incorporated in the rota and no additional leave is allocated.
FY2 & CMT leave allowance is 5 days study leave & 9 days annual leave in 4
months or 4 days study leave & 7 days annual leave in 3 months (1 day can
be carried over).
Only day shift can be taken as annual leave (any shift between 8am & 7pm).
All on-call shifts have to be swapped including nights - please ensure that any
swaps that alter day-time ward rota are clearly identified and covered (i.e. –
time off post nights)
Maximum 2 doctors off in one day. We aim for one doctor to be on annual
leave at any given time- but accept that occasionally 2 might be absent- i.e.
study leave or unforeseen circumstances. Please consult the screen planner
in the multidisciplinary office to plan your leave and submit all forms to Dr
Brown for signing.
Teaching
FY1 teaching programme facilitated by Dr Brian Flavin - Thursday pm
Foundation Years Acute Clinical teaching – Tuesday lunchtime
CMT clinical teaching- Thursday lunchtime
ACCS clinical teaching-Friday pm on AMU
Relevant timetables will be displayed in the multidisciplinary office on AMU
Enquiries:
Dr Beata Brown and Mary Pallot - AMU sec ext 4716
Respiratory Medicine
Respiratory consultants
Dr Anastasios Lekkas
Dr Anindo Banerjee
Dr Ben Marshall
Dr Katherine O Reilly
Dr Jane Wilkinson
Dr Rachel Limbrey
Dr Ramesh Kurukulaaratchy
Dr Simon Bourne
Dr David Land
Dr Tom Wilkinson
Dr Aye Aye Lwin
Cystic Fibrosis consultants
Dr Mary Carroll
Dr Thom Daniels
Dr Julia Nightingale
Respiratory trainees - general duties
Day to day management of inpatients:
Keep an up to date list of inpatients, diagnoses, investigations and ongoing
issues
Ensure that each patient is reviewed by a member of the team each day
Checking blood results daily and attending to abnormal results promptly
Organising routine investigations
Ensure that all sick patients are handed over to the night team. At weekends
the handover sheet and patient review folder must be completed
Liaising with discharge planning teams, completing HMR and ensuring that
outpatient appointments are organised
Respiratory trainees – specific duties
During your time with us we would expect you to gain experience in the
management of the following:
Management of COPD and asthma
Management of pneumonia and empyema
Investigation, treatment and diagnosis of lung cancer
Management of pleural effusion including malignant pleural effusions requiring
medical pleurodesis
Insertion of intrapleural chest drains and management of pneumothorax
Indications for starting non invasive ventilation
In patient management of TB and HIV related disease
The main Respiratory ward is D6. The senior sisters on this ward are Gina
Stanley and Charlotte Allen.
There are 3 respiratory firms.
Team 1 is run by Dr Anindo Banerjee alternating with Dr Rachel Limbrey / Dr
Ben Marshall.
Team 2 is run by Dr Anastasios Lekkas alternating with Dr Simon Bourne or
Dr Kate O Reilly.
Team 3 is run by Dr Ramesh Kurukulaaratchy alternating with Dr Jane
Wilkinson. Each consultant is on the wards for 2 months at a time.
All three teams pick up new patients from AMU and D6 ward on a Monday
and Friday. The juniors generally come in early on these days to split the
patients up so each team has a similar number of patients. The take list on
AMU should allocate Respiratory patients on admission. Start on D6 to
allocate new patients there and then head down to AMU to pick up the new
ones there. The Consultants will join you there at 9am for the round.
Your patients will be spread across the hospital, particularly at busy times. D6
is the main Respiratory ward at present. The office in D6 has a list of the
outlying wards and each day the bed manager will leave lists on the desk of
outliers and which team should be seeing them. Generally they are on D2, D3,
D4, E2, E3, E4, E5, the Cardiology wards as well as the Princess Anne
Hospital! D5 has a list on the board and they will allocate patients to a
particular team. Some of your patients will therefore be General Medical
patients.
Each team also has a week where they pick up people coming out of HDU
and ITU. This rotates in turn, i.e. 1 in 3. Usually the only way you know who
these patients are is when you are rung by other Medical Teams or by the
ward nurses.
Team 1 also pick up some IDU patients because they look after the TB
patients.
Currently the doctors' worklist is being developed so that patients are
allocated to a team and will appear on your list so you know who and where
your patients are.
At present the weekly structure for each team is as below:
Team 1
Monday
Tuesday
Wednesday
Thursday
Friday
Full Consultant ward round with Dr Limbrey – pick up AMU and D6
patients first
Pick up AMU patients with Dr Marshall then SpR ward round
SHO ward round then meet with Dr Marshall to review patients in the
pm as required
SpR ward round
Full Consultant ward round with Dr Limbrey starting with AMU pick up
When Dr Banerjee is on (rotates monthly) he will do ward rounds with pick-up
on Mondays, Thursdays and Fridays (instead of Tuesdays).
Team 2
Monday
Tuesday
Wednesday
Thursday
Friday
Full Consultant ward round with pick up on AMU and D6 patients first
SpR or SHO ward round
SpR or SHO ward round
Pick up on AMU then ward round
Full Consultant ward round starting with AMU pick up
Unless Dr Banerjee on for Team 1 and then you swap your pick up day to
Tuesdays
Team 3
Monday
Tuesday
Wednesday
Thursday
Friday
Full Consultant ward round with pick up AMU and D6 patients first
SHO ward round
Pick-up on AMU then ward round
SpR ward round
Full Consultant ward round starting with AMU pick up
Professional responsibilities
You are responsible for ensuring the team has an organised and up to date
list of patients on the doctor’s worklist and that jobs for patients are completed
in a timely manner. This should be shared with the FY1 doctors and other
junior members of the team.
Teaching
Monday lunchtime teaching is at 1pm in the meeting room on D level (through
the double doors to the right of the lifts). This is usually junior led and you will
be expected to sign up for a session on the list in the room. You can present a
topic of your choice.
Each Consultant has their own time to discuss Radiology with the
Cardiothoracic Radiologists. They will let you know when these are. You need
to attend if one of your patients is being discussed but otherwise it is just a
good learning opportunity.
Wednesday lunchtime there is WeFit – Ground Round for the Hospital CMT
teaching on Thursday lunchtime. Thursday at 9am there is teaching on D
level. This is usually senior led.
Rotas and annual leave
This should be requested via Zena Sadler (junior doctors’ admin office) and is
usually straightforward if done in advance and if there are enough members of
the team around.
Additional information
If you want some time on HDU you would need to negotiate this with the HDU
SHO but the Registrars are often happy for you to attend clinics if the ward
isn’t too busy and your Consultant has approved this. The same would be true
for bronchoscopy lists and they can provide teaching on BIPAP if you ask
them.
If you need experience putting drains in, you may need to go to radiology as
some are put in down there with USS guidance.
The Respiratory centre is on D level and this is where you will find forms for
outpatient clinic referrals. The Respiratory and Asthma nurses are in the office
opposite. The Asthma nurse should be told about all asthma patients so she
can review them prior to discharge and assist with discharge and follow up.
The Respiratory nurses will often do the same for the COPD patients. They
will also arrange LTOT (you will need to do the ABG). The Respiratory centre
provides lots of assessments and facilities but you probably won’t get involved
in most of what they do.
If you need follow up in a TB clinic the ward clerk can book this on IDU (held
at RSH). The IDU nurses can arrange Mantoux testing for patients if you ask
them. Quantiferon gold testing needs to be ordered from the path lab (IDU
nurses will often go and get them) and the request needs to be accompanied
by an A4 form signed by a senior).
The Lung MDT is on a Thursday afternoon. To put a patient on the list contact
Amanda Durrant.
Bronschoscopies are booked through the Endoscopy centre on level E where
the lists are held. They are run on a Friday afternoon.
Intensive Care Medicine in Southampton
Introduction
Welcome to Critical Care. There are 2 main units – GICU and SHDU. GICU is
situated on level D and is divided in to 2 areas – GICU A and GICU B, with 21
beds, with a mixture of level 2 (HDU) and level 3 (ITU) patients. SHDU is on E
level and has 8 beds which are level 2 surgical / orthopaedic beds
Key members are as follows:
GICU Consultants
Dr Mike Celinski
Dr Becky Cusack
Dr Jonathan Fennell
Prof Mike Grocott
Dr Sanjay Gupta
Dr Max Jonas (Lead Consultant
Dr Julian Nixon
Dr Kathleen Nolan (ACCS Lead)
Dr Dom Richardson (Postgraduate tutor for ICM)
Dr Ben Skinner
Dr David Sparkes
Dr Suzie Tanser (TPD ICM)
Dr Tom Woodcock
SHDU Consultants
Dr Andrew Sansome
GICU consultants
Consultant pharmacist Mark Tomlin
Lead nurse (Matron) Amanda Barnes
Lead technician Alan Grimes
Physios Zoe, Rachel and colleagues
Ward clerks Vena and Alison
GICU Administrator Angela Richards Ext 6116
The ICM trainees come from a spectrum of base specialities and are at
different levels of their training. There are 4 ACCS trainees (6 month
attachment usually, but the trainees with EM as base speciality have the
opportunity to do 3 months Neuro and 3 months General ICU) There are
usually 3-4 anaesthetists (3 month attachment – usually ST1/2), medics
(respiratory and acute medicine SpRs) and surgeons. There will also be
FY1’s, FY2’s and medical students. There will be senior SpRs in Intensive
Care Medicine (final year of training). The senior nurses are all very
experienced and their opinion should always be taken seriously. Remember
that the nurses spend a whole shift with just one patient and therefore will
have intricate knowledge of them.
Trainee duties
The attachment will involve a full shift rota with long days (0800 – 2100), short
days (GICU 0800 – 1800, SHDU 0800 - 1600), twilights (1600 – 2400) and
nights (2000 – 0900). Each GICU unit is covered by a dedicated consultant for
a week at a time and SHDU is covered by a daily consultant. Nights are
covered by 1 ICU consultant for all units so someone is always available for
help and advice round the clock.
GICU rotas can be found at www.gicu.co.uk. Login GICU, password
adrenaline. You may swap shifts but please fill in a form confirming that you
have done so. No form = your responsibility for that shift. Short term sick
cover is built into your hours allowance and should be dealt with amongst
yourselves. Where sickness / unexpected absences are prolonged locum
arrangements will be agreed. SHDU rota is organised by Dr Andrew Sansome
and any swops etc should be agreed with him.
Trainees are expected to do daily clerking on “their” patients and ensure
necessary investigations and procedures get done. To enable you to access
patients’ results from the computer each trainee must be trained by a member
of the IT department and have their own password. The IT department can
be contacted on ext. 6000 to book a training session. Trainees will present
patients on Consultant rounds. Use the hours allocated diligently to get the
work done efficiently. It is recommended that you take different patients each
day to maximise your exposure to various critical illnesses. Remember that
you are all part of a team and you should work together to ensure that all the
tasks are done in a timely fashion.
Senior SpR duties
A senior SpR will usually be present. He/she should take a wider overview of
Intensive Care practice. Duties include supervising and assisting junior
trainees, seeing and advising on new referrals, keeping a check on the
progress of “outlying” critically ill patients, being aware of, and help with,
ongoing research projects.
A Consultant will see the patients every day.
One of the Sisters and Senior Staff nurses will be “in charge” on each shift;
make sure you know who is “in charge” and liaise closely over new
admissions or possible admissions.
ACCS Trainees
Four ACCS trainees do six months of ICM in Southampton. The trainees with
Emergency Medicine as their base speciality have the opportunity to do 3
months of general adult ICM (GICU) and 3 months of Neuro ICU (NICU). The
ACCS Educational Lead in GICU is Dr Kathleen Nolan and Dr Sarah Jones in
NICU. They will hold combined appraisals with you during your time on both
units.
It is expected that all ACCS trainees will achieve Basic Level Competencies
as outlined by the Faculty of Intensive Care Medicine. Trainees completing
more than 3 months of ICM are encouraged to complete some of the
Intermediate competencies also, though these may not contribute to
intermediate level competency assessments.
The following is a list of the documentation that you will need to complete
during your time on ICU. This is available on the ACCS website under
Intensive Care with links to the Faculty of Intensive Care Medicine
www.ficm.ac.uk
1. Educational Training Record (ETR). Part 2 this contains
a) Educational Agreement and Initial meeting
b) End of Attachment trainee assessment
c) Competency domains. These ICM speciality specific competencies are
designed to inform the Basic Level Training Competency Document (Part 3)
2. ICM logbook.
3. The Syllabus Part 3.
The composite competencies for Basic Level ICM are outlined here by
Domain, mapped to the relevant assessment tools and Good Medical
Practice. (Page 111-7) The Assessment Tools Key is available on page 1115.
4. Work Place Based Assessments (Use the paperwork on www.ficm.ac.uk)
You must complete a minimum of 13 WPBAs to include
3 Mini-Cex
6 DOPs
4 CBDs
Plus 1 MSF
5. Common Competencies: ACCS trainees must achieve at least level 2 in the
common competencies throughout the initial 2 years of ACCS training
6. Major Presentations: 2 x formative assessments (Mini-Cex or CBD) to be
completed within ICM, - ideally covering sepsis.
7. Practical procedures (See Intensive Care Home page of ACCS website)
This includes a list of WPBAs specific for ICM.
8. Structured Training Report
The exact paperwork for this has caused much confusion in the past.
Please ONLY complete the STR from Appendix 2 of the College of
Emergency Medicine website which is paper-based.
For Intensive Care this is on pages 126-129.
This form also has the 25 Core Competences which your clinical supervisor
can tick off to the level they think you have achieved (1 to 4).
By the end of your 2 year ACCS programme this needs to be more than 50%
to level 2.
By the end of your 3 year ACCS programme this needs to be all of them to
level 2.
PLEASE DO NOT USE THE FORM ON THE ePORTFOLIO AS IT DOES
NOT HAVE THESE CORE COMPETENCES ON IT!
This form should then be uploaded to your eportfolio and placed in your
personal library.
Wessex ACCS ARCP checklist (Updated March 2011)
GENERIC:
Registered with your base speciality College
CT1: Achieved 50% of the 25 Core competences to level 2 *
CT2: Achieved > 50% of the 25 Core competences to level 2
Y
Y
Y
INTENSIVE CARE MEDICINE
Ed supervisor completed and signed structured training report
Y
Completed a personal development plan for identified deficiencies Y
Achieved Basic Level competence in ICM
Y
Successfully completed a minimum of 13 WPBAs as follows:
3 Mini CEX
Y
4 CBDs
Y
6 DOPS
Y
Successfully completed at least 2 Major presentations
Y
Completed a satisfactory logbook of cases seen in ICM
Y
Cases documented in the logbook have an appropriate case-mix Y
No patient identifiable material in logbook
Y
Completed an audit and ideally closed the loop (not essential)
Y
Completed a patient safety project or some form of PS activity
Y
For CT1 trainees, attended a one day patient safety day
Y
Completed MSF with summary by the Ed Supervisor (> 11 replies) Y
EM/AM trainees to have successfully passed MCEM A/ MRCP 1 OR
demonstrate plan to sit/resit the exam
Y
Anaesthetic trainees consider when they will sit the Primary FRCA Y
In date for all appropriate Life Support courses
Y
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
Basic schedule for a working day
0800 Please start promptly at 0800 so that the person going off can hand over
and leave. Make sure bleeps are exchanged and are in working order.
Please do not leave bleeps unattended at the nursing station. Test calls
should be at 0730 each morning.
Handover At Handover, last night’s on-call trainees debrief their colleagues
and update them on the progress of each patient. If a patient has died during
the night, now is the time to inform the patient’s GP and admitting Team and,
when appropriate, the Coroner’s Officer. Please also complete a discharge
summary – this goes to the GP giving them vital information for family followup.
0900 Full examination and review of each patient allocated to you. You will
be expected to present the patient on the ward round.
1100 Main Round: Remember it is multidisciplinary. Admitting teams are
invited, and we get valuable input from nurses, physiotherapists, dieticians,
pathologists and pharmacists
1400 Time to follow up decisions from the round
1700 Short day workers hand over their patients to long day staff. Please
ensure that the handover sheet is updated. Night shift arrive for handover
Night Write up blood request forms: night nurses are often able to take bloods from
patients with vascular access next morning, helping us to get samples ready for
collection before 9am. The nurses may look up results for you but all results must be
acknowledged on the computer by a doctor. Check that bloods have been taken,
take any remaining samples yourself. NB, specimen containers must only be
labelled AFTER the specimen has been taken; relabeling invariably leads to
occasional errors. Identify the patients who will require CXR and sign the x-ray cards
prior to your handover to avoid interruption.
Handovers are an important part of patient care. Please be on time, your
colleagues have been working for 12 hours and want to go home!
Ensure that the information given is up to date – if you haven’t seen the
patient for 8 hours – say so!
Handover sheet: Confidentiality should be observed at all times with handover
sheets - they must not be left around and must be shredded after use. Please
avoid the use of inappropriate comments – you never know who may read
them!
Handovers need to be concise to ensure that they finish on time, however if
there are governance issues or things that you would prefer to discuss with a
consultant in private this is best done after the main handover.
Doctor’s Medical Administration Requirements for all Patients
Admissions
Patients in A&E must be seen by a member of the medical/surgical or trauma
admitting teams and “admitted” to the hospital before the patient is admitted to
ICU. All patients must have a named consultant who is a member of the
referring team.
SHDU patients are usually either booked elective surgical cases or discharges
from GICU. Other referrals should be discussed with the SHDU consultant or,
out of hours, with the GICU SpR/GICU consultant as it may be more suitable
for them to be admitted to GICU.
Discharging Patients
To either
The ward
Other hospitals
Home
Death
Patient discharges will only be made with the approval of an ICU Consultant,
and after discussion with the referring team. A ward transfer summary
including recommendations for continued care should be completed for all
patients being transferred to the ward. Ensure that only drugs and fluids that
are to be continued on the ward are prescribed on the prescription chart. If a
patient is DNAR, please ensure that this is clearly documented and the
referring team have filled in a red form. Where discharges occur out of hours,
you may need to do the red form yourself, to be reviewed by the team within
24 hours. If discharges are delayed, please ensure that the patient is reviewed
prior to discharge to check that they remain fit for discharge.
Please ensure discharge summaries are fully completed.
should be completed - 2 for ward and 1 with patient’s notes.
Three copies
Please ensure all parts of the discharge summary are completed including which
referring team has responsibility for the patient and to whom you have handed over
to.
Deaths
Death on the Unit must be reported to the Next of Kin and the referring team
immediately; ensure that either a Death Certificate is issued or the Coroner’s
Officer (Shirley Police Station) is informed. The coroner’s office is closed at
the weekends and so deaths at a weekend must be referred on Monday.
Please also inform the patient’s General Practitioner by telephone or fax and
fill in a cremation form for all patients. All patients who die also require a
discharge summary to be completed. This is sent to the GP as a letter and it is
vital that these are completed promptly. The death certificates and discharge
summaries should be reviewed by the supervising consultant prior to being
issued.
Following the death of a patient
On completion of the night shift you need to refer all patients who have died
overnight to the Coroner by 9.00am.
The Trust guidelines are that the death certificate MUST be completed by
10am. (E.g. if patient dies at 1pm then this must be completed by 10am the
next day. If a patient dies during the night then this must be completed by
10am the same day). If this is not completed within the timescales then you
have breached the Trust guidelines and a report will be sent to Caroline
Marshall (Head of Department).
The Trust guidelines are that deceased discharge summaries MUST be
completed within 24hrs of death. If this is not completed within the timescales
then you have breached the Trust guidelines and a report will be sent to
Caroline Marshall (Head of Department).
All blood results MUST be acknowledged.
Certifying doctor is responsible for:
Informing Coroner
Completing death certificate and cremation form.
Informing GP between 9.00-1100am or
Handing over patient to a member of day staff
Day Staff Doctors:
Inform admitting team
Discharge summary
The patient must not be discharged from the handover summary sheets
(computer) until all 6 components are completed.
Critical Care Teaching / learning opportunities
GICU formal teaching takes place on a Tuesday afternoons – see enclosed
programme. Surgical critical care teaching takes place on Tuesday morning
from 0845 – 0945 in the anaesthetic seminar room on E level.
You may also attend your base speciality teaching – if you have any
difficulties with this please let Dr Dominic Richardson know.
Teaching takes place continually on ICU as there is always a consultant
present during the day. You should make the most of opportunities to
undertake practical procedures with support from your senior colleagues.
Grand rounds are held every Wednesday at 3pm where the clinical
management of patients on the unit is presented and discussed. This
provides you with the opportunity to present a case and also have it signed off
as a CBD.
M&M Meeting every month. Dates on website www.gicu.co.uk
Interprofessional learning. Weekly combined nursing and medical teaching
sessions on Thursdays or Fridays. See GICU website for details.
If you have a 3 month or greater attachment you should achieve the
appropriate competencies during that time. Please do not leave assessments
(CEX, CBD and DOPs) to the end as there may not be sufficient time to
complete them.
Everyone who is with us for 3 or more months will have a joining appraisal,
leaving appraisal and 360-degree appraisal. It is your responsibility to liaise
with your Clinical Supervisor to arrange these.
Infection Control
Infection control is taken very seriously and there are frequently spot audits on
hand hygiene etc. Please ensure that you have completed your mandatory
training and comply with it at all times. You should be ‘naked below the elbow’
at all times. This means no watches, long sleeves or jewellery of any kind
other than a wedding band. No rings with stones in are to be worn. Gloves
and aprons should be worn for all patient contact. This applies to all visiting
teams (who may need reminding!).
Please fill in the new trust cannulation forms for all cannulae.
Central line insertion requires the use of gown, gloves and aseptic technique.
Where lines have been put in, in potentially non-sterile environments, they
should be changed as soon as possible.
Arterial lines should be put in with a sterile technique. Sterile gloves should
always be worn. If a wire is being used a gown is mandatory.
Please ensure all line insertions are documented in the notes.
Antibiotic prescriptions should always be discussed with a consultant unless
standard postoperative drugs are used where the hospital policy should be
adhered to.
Saving Lives: Central Venous Catheter Care bundle
“Choose the right. catheter type”
•Single lumen (unless indicated otherwise
•Antimicrobial coated
“Select the appropriate insertion site”
•Subclavian
•Internal jugular
“Prep it right”
2% chlorhexidine in 70% isopropyl
Alcohol (ChloraPrep)
and allow to dry
.
CVC
INSERTION
ACTIONS
“Insert it right”
Correct PPE,
Hand hygiene,
Optimum Aseptic technique,
Safe disposal of sharps.
“Be bright, dress it right”
Always use a sterile,transparent,
semi-permeable dressing
“Document it right”
Document when it went in,
why it went in and who put it in,
Insertion site and catheter
type
The risk of infection reduces when all elements within the clinical process are performed
every time and for every patient.
The risk of infection increases when one or more elements of the procedure are
IPT June 2009
excluded or not performed.
“
.
Saving Lives: Central Venous Catheter Care bundle
“Don’t forget to rub or Scrub”
Use aseptic technique and swab
ports/hub with 2% chlorhexidine
in 70% isopropyl alcohol
prior to accessing the line
“Remember to inspect the
catheter site”
Regular inspection for signs of infection,
at least daily &
DOCUMENT
“Always check its dressed right”
An intact,dry,adherent transparent
dressing should be present
CVC
ONGOING CARE
ACTIONS
“Administration set
replacement :
time it right”
•Immediately following blood,blood products
•Following TPN-after 24hrs (72hrs if no lipid)
•Other fluid sets – after 72 hrs
“Hand hygiene – Get it right”
•Decontaminate hands before & after
each patient
•Use correct hand hygiene procedure
“No routine catheter replacement”
Do not routinely replace catheters as a
method to prevent catheter-related
infection.
The risk of infection reduces when all elements within the clinical process are performed
every time and for every patient.
The risk of infection increases when one or more elements of the procedure are
excluded or not performed.
IPT June 2009
ICU Empiric Antibiotic Guidelines
Antimicrobial therapy should not be started without clear clinical justification
and should always be discussed with a consultant.
Always culture prior to commencing antibiotics (exception CSF in suspected
meningitis)
If broad spectrum empiric antimicrobial therapy is initiated it should be
reviewed no later than 48 hours later and narrowed down where possible to
cover likely or proven pathogens
When starting antibiotics, clearly document the indication and how long is the
intended course
For all patients labelled as penicillin allergic, establish history and assess.
Those with minor penicillin allergy e.g. rash can be safely given
cephalosporins in most cases. In more severe penicillin allergy e.g. urticaria,
facial oedema or anaphylaxis take advice
In cases of allergy replace tazocin for ciprofloxacin, augmentin for cefuroxime
and for meropenem take microbiology advice. DO NOT start gentamicin
without consultant advice
The worsening of a patient’s condition may be secondary to the physiology of
sepsis and further antibiotic changes may not be necessary. Antibiotic
changes should only be made at consultant level.
Routine microbiological sampling will only include MRSA screening and
weekly urine samples for yeasts. (The latter will only be collected from day 7
unless clinically indicated and then weekly).
Gentamicin & vancomycin: please refer to protocol handbook
Requests for the initiation of antibiotic therapy from visiting teams MUST be
passed by the GICU consultant or microbiologist.
Guidance to trainees on when to contact a Consultant
The Intercollegiate Board recommends that each unit have a written set of
guidelines, protocols and policies to facilitate best medical practice. These
guidelines must include the specific circumstances under which a consultant
must be contacted. For Southampton General Intensive Care Unit these
include all of the following:
The unplanned referral of a patient for treatment. First stabilise the patient
and then discuss with the consultant the need for admission. Seek consultant
advice early if you need help to stabilise the patient or if there is concern
regarding the appropriateness of admission. Where possible, the referring
consultant should be involved in the decision.
Patients may only be discharged from ICU with the approval of the consultant,
the acceptance of the receiving team and the notification of Outreach.
Unexpected or unexplained change in an existing patient’s condition.
The necessity to undertake a complex technical procedure.
Request for inter-hospital transfer of a critically ill patient. Please discuss
all out of Trust referrals with a consultant before accepting them. It will also be
necessary to get the agreement of a medical or surgical team to accept the
patient (this also applies to patients admitted from the A&E department).
Major alterations in treatment policies.
Decisions concerning withholding or withdrawing
If patients are accepted from another hospital, or if they must be transferred
out to another hospital, ensure adequate arrangements have been made for
their safe transfer. Mobile Intensive Care facilities are available through the
Duty ICU technician. It is sometimes necessary to move a currently “stable”
patient to another ICU in order to accommodate a patient who is “too sick to
move” or who needs care only available on site. The nurse in charge helps
arrange and co-ordinate inter-hospital transfers of patients. Diplomatic
communication with the patient to be moved and his next of kin can help to
calm natural anxieties, though it must be acknowledged that transfer probably
poses a risk to speed of recovery or even to life.
All unplanned admissions or referrals to SHDU must be discussed with the
consultant or senior SpR.
Record keeping
On admission, notes should be made to include time of referral, when and
where first attended and time of ICU admission. Give a summary of baseline
health, events precipitating admission, clinical findings on admission,
differential diagnosis, planned investigations and planned management. Every
entry must be signed; if your signature is illegible, please also give your name
in block capitals! All entries must be dated and timed.
All acute clinical episodes and all procedures performed should be noted.
Daily progress notes should be made each morning, and results and
radiographs made ready for the Round. A brief note on decisions taken on
the Round should be added. Please also make a note of information given to
the patient and relatives when appropriate.
The handover sheets should be updated at the end of every shift. Any
complications including ventilator associated pneumonia should be
documented on the sheets.
Please remember to document:
All ICU referrals (audit form).
All line insertions
Results of all x-rays
All critical incidents should be recorded in specific critical incident forms,
which are found in the filing cabinet near the nursing station. They should also
be fully documented in the notes.
The Royal College of Anaesthetists regards ongoing outcome audit based on
admission severity of illness as a basic professional activity and an essential
part of training. On this ICU audit staff with special training and responsibility
for audit collates and record the necessary data, including the APACHE II
score, for inclusion in a national database (ICNARC – see later). Please help
them by keeping clearly written records and ensuring pathology results are
obtained and recorded. You should take the time to familiarise yourself with
the scoring systems, as a working knowledge of these may be expected of
you by your examiners.
Visiting Consultants
When a Consultant visits please welcome him/her and present relevant details
of the case. If changes in therapy are requested prescribe them yourself (we
do not allow even Consultants to change patient therapy without informing
you). Be polite and diplomatic and avoid arguments! If you are unhappy
about proposed changes, contact your own Consultant. Please enter a brief
“seen by” note in the patient’s record.
Initial Drug prescribing in ICU
1.1
Sedation
Short term:
Propofol 1% 0 – 30ml/hr
Fentanyl 50 g/ml 0 – 4ml/hr
Long term or cardiovascularly unstable:
Midazolam 50mg/50mls N saline 1 – 10mg/hr
Morphine
50mg/50mls N saline 1 – 10mg/hr
or
Fentanyl
50 g/ml
0 – 4ml/hr if renal impairment
Inotropes / vasopressors
Noradrenaline
Dobutamine
Adrenaline
Dopamine
Vasopressin
8mg / 100 mls 5% dextrose
500mg / 100mls 5% dextrose
10 mg / 100mls 5% dextrose
200mg / 50mls 5% dextrose
40 iu / 40mls 5% dextrose 0 – 4ml/hr
Postop analgesia
PCA
Morphine 100mg / 50mls N Saline, 1mg bolus
Epidural
OR
0.125% bupivicaine
0.15% bupivicaine + 2g/ml fentanyl 0–15ml/hr
Others
All patients should be prescribed:
IV ranitidine 50 mg tds (bd in renal failure)
sc heparin 5000iu bd or mechanical compression device
PO / PR paracetamol 1g qds prn
prn potassium
Via CVP
1g / 30mls over 1 hr
Peripheral 3g / litre
PO / NG
Sando K 1 – 3 tabs
Insulin 50iu/50mls as sliding scale
Maintenance fluids
Dextrose saline / N saline as appropriate
If significant hyperchloraemic acidosis, dextrose 5% 1 litre + 150mls 8.4%
sodium bicarbonate may be used as the maintenance fluid
Daily Patient Review
20 things to consider before the ward round!
1.
2.
3.
4.
5.
Time spent on ICU.
Admission diagnosis and premorbid state.
Current physiological problems
Airway
Ventilation ARDSnet?, TV, RR, FiO2, PEEP
Target PaO2, PaCO2
Weaning protocol
Is the patient head up?
Is a chest x-ray required?
6. Circulation Inotropes
Cardiac output measurement?
Target MAP, CVP, fluid balance, urine output
Do they need b-blockade?
Are they receiving their usual cardiac medication?
7. Renal
Is the urine output adequate?
Renal function improving?
If on haemodialysis what is the target fluid balance, are they
adequately anticoagulated?
8. Nutrition
NG nutrition established?
What is the target calorie intake and is this being achieved?
Bowel regime established?
9. Blood glucose
Is blood glucose elevated, has insulin been prescribed, does
the prescription need altering?
10. Sedation / analgesia – appropriate?
11. Prophylaxis DVT and peptic ulcer prophylaxis prescribed?
12. Infection
Cultures taken – results so far
Antibiotics – when started / blind or directed
Are antibiotic levels needed?
Clinical evidence of infection?
Can any lines / catheters be removed?
Have steroids been considered?
Are they suitable for research study inclusion?
13. Routine bloods reviewed?
14. Medications reviewed?
15. Is the referring team up to date?
16. Has the family been updated?
17. Any special investigations needed?
18. Are the medical notes up to date?
19. Is the patient ready for discharge?
20. Plan for next 24 hours.
Sepsis screening
1.Is the patient’s history suggestive of a new infection?
a. Pneumonia/ empyema
b. UTI
c. Acute abdominal infection
d. Meningitis
e. Skin/soft tissue inflammation f. Bone/joint infection
g. Wound infection
h. Catheter or device infection
i. Endocarditis
2. Are any two of following signs & symptoms of infection both
present and new to the patient?
a. Hyperthermia > 38.3 °C
b. Hypothermia < 36 °C
c. Chills with rigors
d.Tachycardia > 90 bpm
e. Tachypnoea > 20 bpm
f. SBP < 90 or MAP < 65
g. Headache with stiff neck
If the answer is yes to either question 1 or 2, follow sepsis
protocols.
Severe Sepsis
Are there any new organ dysfunctions present?
1.
Acutely altered mental status
2.
SBP < 90 or MAP < 65 mmHg
3.
SpO2 < 90% on room air or on supplemental O2
Creatinine > 180 mmol/L or urine output < 0.5 ml/kg/hour
for > 2 hours
4.
Bilirubin > 35 mmol/L
5.
Platelet count < 100,000
6.
Lactate > 2 mmol/L
If the answer is yes, severe sepsis is likely. Follow severe
sepsis protocols and aim for the following physiological
targets:
Central venous pressure: 8–12 mm Hg
Mean arterial pressure  65 mm Hg
Urine output  0.5 ml/kg/hr
Central venous [ScvO2] saturation  65%
Sepsis – the first 6 hours
Is sepsis likely?
If YES:
1. Take blood cultures x 2
2. Take bloods for FBC, U&E, LFT, clotting
3. Give broad spectrum antibiotics within 1 hour
Is this severe sepsis?
If YES 6 hour targets to be achieved:
Central venous pressure: 8–12 mm Hg
Mean arterial pressure  65 mm Hg
Urine output  0.5 ml/kg/hr
Central venous [ScvO2] saturation  65%
Is SBP < 90 mmHg or MAP < 65 mmHg?
If YES:
Give 20 – 40 ml/kg fluid challenge
If BP remains inadequate
1. Insert CVP line – aim CVP 8 – 12 mmHg
2. If SBP still < 90 or MAP < 65mmHg
3. Start noradrenaline (4mg / 50 mls) 2 – 20 ml/hr
Is lactate > 4
If YES:
1. Insert CVP line
2. Measure central venous saturation
If central venous saturation <65% and CVP / BP targets achieved:
1. Start dobutamine infusion
2. Consider transfusion if HCT < 30%
All patients should be managed in level 2 or 3 area
ICNARC DATA COLLECTION
ICNARC (Intensive Care National Audit and Research Centre) was
established by the Intensive Care Society in January 1994. Through the
information collected it is aiming to provide answers to:
The effects of ICU
The current level of provision
Monitoring the overall impact of ICU’s
ICNARC aims to assemble, maintain and develop a national observational
database of case mix and outcome information on patients treated within
ICU’s, in collaboration with the participating units in the UK. Its strength lies in
the very strict definitions by which data are collected and entered, enabling
accurate comparisons to be made between units.
Reports are published every six months and supply data on:
* Demographic information
* Unit outcomes
* Past medical history
* Hospital outcome
* Length of stay
* Patient throughput
* Bed occupancy
* Severity of illness
*Case mix adjusted mortality
In the reports data is given for the unit and then compared with other units,
whilst confidentiality is maintained.
Our unit has collected data for the ICNARC case mix programme from 1985
and reports for General ICU can be found in the Audit and Research office.
The data collected includes whether a patient admitted to the Unit has been
continually managed by a member of the ICU medical staff prior to that
admission. For example, if the ICU doctor is caring for a patient in A&E whilst
awaiting a bed on ICU this information should be documented clearly in the
notes. The time from which the patient was continuously managed by a
member of the ICU medical team up until their admission to ICU should be
recorded as this may have resource implications and may also introduce leadtime bias.
Other information which is necessary but often not documented is the presedation GCS and the time at which a decision was made to withdraw
treatment (NOT the time at which treatment was withdrawn). Please try to
ensure that these are documented. The ICU audit team collate the Critical
Care Minimum Data Set (CCMDS) for all adult critical care beds across the
trust (74 in all). This is important work as in the future, payment by results will
be introduced which will determine the income of the units based on their
actual dependency levels.
SHARPS AND CONTAMINATION INCIDENTS
Q. What is a needlestick / contamination injury?
A. a) Any injury which breaks the skin and is caused by a sharp object that
may have been contaminated with blood or body fluids
or
b) Any splash of blood or body fluid on non-intact skin, (e.g. cuts, eczema) or
mucous membranes (e.g. into eyes or mouth).
Q. How do I report a needle stick / contamination injury (NSI)?
A. Ring the NSI Hotline on 6353 at any time and follow the instructions
Q. Why do I need to visit Occupational health after a needle stick/
contamination injury?
A. We offer appropriate advice and treatment following risk assessment of the
injury. We will help to collect information about the source of contamination
and will document the incident.
Even if you have had a full course of Hepatitis B and know that you are
protected, you must still be seen so that we can check your immunity and
advice about booster doses.
Q. What information do I need to bring with me to Occupational Health
or A&E?
A. If the source is known, the patient’s name, date of birth and ward. Any
other information about the patient and/or equipment involved to assist in the
assessment of risk is helpful.
Q. Will I contract Hepatitis B/C or HIV?
A. The risk of catching Hepatitis B following a needle stick involving blood
infected with the virus is between 5 and 30%. For Hepatitis C, the risk of
infection from a needle stick with infected blood is around 3%. The chances
of catching HIV after an HIV positive needle stick are very low - only 0.03% (3
infections per 1000 injuries).
These risks will vary according to the injury and the patient involved, so it is
very important that Occupational Health or A&E assesses all incidents
properly.
Q. What blood tests will be taken?
A. From you: At the time of injury, blood will be taken to test for Hepatitis B
antibodies. The sample will also be stored. We recommend that more blood
is taken 3 months after the injury, again for storage. Blood is stored
indefinitely to help you prove the origin of infection, should you become
infected with any blood borne viruses from the injury.
From the patient: With the patient’s consent, blood will be taken to see if they
are infected with Hepatitis B or C.
Q. What happens if I have a NSI and have not had a course of Hepatitis
B?
A. Depending on the type of injury that you’ve had, it may mean that we have
to give you an accelerated course of Hepatitis B. If the injury is considered
high risk, we may need to give you an injection of immunoglobulin
Q. What happens if the patient involved is infected with HIV?
A. In the event of high-risk exposure to HIV infected blood or body fluids;
three anti-HIV drugs may be prescribed by an expert (as listed in the Policy for
Management of Sharps and Contamination Incidents). These drugs should
ideally be started within 1 hour of injury. The drugs are available in
Occupational Health or A&E.
Q. Who do I need to inform when I have a needle stick injury?
A. At the time of injury you need to inform your Manager and ring the NSI
Hotline on 6353. If you are seen in A&E out of hours, the Occupational
Health Dept. need to be informed about the injury, so that we can check you
have had the appropriate follow-up and document the injury in your records.
OUTREACH
Firstly welcome to Outreach. As the nursing half of Outreach, we just wanted
to stress that we aim to bother you as little as possible. We will always utilise
the patient’s own team first and only refer you the patient after the registrar is
involved. The only exceptions to this are airway and respiratory emergencies
when we would call you and the registrar concurrently. Remember our role
includes assisting you with patient care outside ICU, so if you need assistance
with a transfer from resus. to scanner, an extra pair of hands stabilising a
patient post arrest or support while you sort out a patient directly referred to
you on the ward give us a call.
We follow up all GICU discharges, therefore if you have a specific concern tell
us and we will ensure that it is addressed on the ward.
Regards, the Outreach Nurses
The Outreach Service guide for Doctors in Intensive Care.
Outreach in Southampton commenced in November 2000; it’s
aims were and still are to identify patients who require critical
care early, facilitate prompt admission, support those patients
discharged from the unit and identify those inappropriate for
ICU admission early. As a doctor on GICU you are
immediately part of the Outreach Service.
1
Your role within Outreach
1. Timely review of patients identified on the ward
as requiring critical care support.
2. Liaison with the ICU consultant re. admission.
3. Informing the Outreach nurse of specific problems
related to patients being discharged.
4. Liaison with the Outreach nurse re. patients referred
to you directly but who do not require ICU admission
especially If these patients need support on the ward.
3
The Outreach Nurse’s role
1. To inform you of any patient who requires your input on the
ward. Ensuring that the patient’s team are fully involved and the
referral is appropriate.
2. To follow up all GICU discharges.
3. To assist with the stabilization and transfer of patients being
admitted to ICU.
4. To review patients on the wards, identified by you as requiring
increased support.
2
Outreach Contacts.
The bleep is always 9191.
The Outreach office is extension 3444.
Anaesthetics in Southampton
Introduction
The Shackleton Department of Anaesthesia provides service and training in
Southampton General Hospital, Princess Anne Hospital and the Treatment
Centre at the Royal South Hants Hospital. It is the largest medical specialty in
UHS with 89 consultants and 45 trainees but you will find it very friendly and
supportive.
Anaesthesia is provided for all general hospital surgical specialties as well as
for the majority of tertiary specialist services. Whilst you will mainly work in the
general areas of practice you will have direct exposure to some of the more
complex work and many opportunities for education in sub specialty areas.
Induction and Administration
On your first day you will have to attend the Trust’s all day induction session
unless you are already based at UHS, in which case you will attend the
educational programme in the anaesthetic department. On your second
morning you will attend the induction session for all new trainees in
anaesthesia which is run by the College Tutors in our department. You may
also care to meet Melanie and Annie our departmental administrators and
Louise our secretary. They administer all issues related to leave booking and
publish the rotas on a fortnightly basis via email.
We have a departmental handbook available and this can be found on the
hospital intranet via
http://staffnet/Departments/DivisionA/Criticalcareandtheatres/Anaestheticdepa
rtment/Training.aspx
Those ACCS trainees whose base specialty is Anaesthesia must register with
the Royal College of Anaesthetists as soon as possible.
Dr Patrick Butler is the tutor for ACCS anaesthetists in Southampton and with
the College Tutors advises on education, supervision and training for novice
anaesthetists. With the administrators he organises theatre sessions for
ACCS trainees and decides on the award of their initial competency
certificates with their educational supervisors. He is supported in these tasks
by Dr Andrew Cowan.
Training Programme
For at least your first 3 months you will only administer anaesthetics under the
direct supervision of a Consultant or Associate Specialist anaesthetist. Only
when you have been assessed as competent after this period of training will
you be allowed to anaesthetise patients without direct supervision by a
Consultant. Even at this point you are only qualified to anaesthetise patients
of ASA Grade 1 or 2 without direct supervision and you will be expected to
discuss case management with a more experienced anaesthetist before you
embark on any anaesthetic. You must ensure at all times that you have
unimpeded access to a consultant for advice or assistance.
You must keep an anaesthetic case logbook which must be started on day
one of your clinical work and may be paper or computer based. The College
website can provide the latter.
There are a variety of versions of the training programme to be found on
anaesthetic and ACCS websites. From February 2012 all Wessex ACCS
trainees in anaesthesia will follow the Wessex deanery guide to the basis of
anaesthetic practice. This is found at
http://www.wessexdeanery.nhs.uk/docs/Wessex%20IAC%20%20CT1%20Bas
is%20%2012-09-11.doc
Initially you will work towards obtaining the Initial Assessment of Competency
(IAC) which requires 3 months of training and completion of specific WPBAs
plus satisfactory feedback from consultants and successful list assessments.
Successful completion of the assessments themselves does not guarantee
progression but they are taken into consideration when determining whether
trainees have achieved the minimum clinical learning outcome. The decision
to award the IAC and to undertake solo lists is made by Dr Butler in
discussion with your educational supervisor and other consultants. Within the
6 months the following units of training must be completed satisfactorily:
1. Preoperative assessment
2. Premedication
3. Induction of general anaesthesia
4. Intra-operative care
5. Postoperative and recovery room care
6. Management of respiratory and cardiac arrest
7. Control of infection
8. Introduction to anaesthesia for emergency surgery
Trainees with anaesthesia as a base specialty are expected to have achieved
all the minimum clinical learning outcomes detailed in this section and obtain
the IAC before progressing to the remainder of basic level training (BLT) at
CT2/3 level. The same level of performance and attainment at 6 months is
expected of non anaesthesia ACCS trainees to satisfy ARCP.
Only a Consultant or Associate Specialist may sign off competency paperwork
that contributes to the minimum required for IAC and ARCP purposes but you
are encouraged to make use of all training opportunities when working with
senior trainees and you may ask them to assess your competence in a formal
manner. There are excellent e-learning opportunities available too and we can
direct you to them. When you start in the department we will ask you to keep a
record of all attempts and successes at tracheal intubation, laryngeal mask
insertion, rapid sequence intubation and subarachnoid block on a chart
supplied. These will be regularly reviewed to view progress at these basic
skills.
Protected teaching
There is a formal anaesthetic teaching programme held in protected time
organised by Dr Butler and delivered mainly by him and Dr Andy Cowan. You
will find the timetable on the notice board in the coffee room. It is quite flexible
so that we can fit it around trainees’ leave to ensure good attendance and
therefore the dates may evolve during the 6 months. It tends to be front
loaded to the early months to enable you to discuss the basic skills and
knowledge as soon as possible in your attachment. Whilst sessions are
overseen by consultants you will be expected to read around all the subjects
in advance and each present a topic that has been allocated to you either by
the consultant or by one of you emerging/elected as a coordinator for the
group. Other formal teaching takes place at a variety of departmental
meetings or in the simulator suite. You will have at least one simulator training
session for rapid sequence induction and critical incident management in your
6 months.
There are opportunities for informal, practical teaching on every theatre list.
Please take every opportunity to ask questions and get teaching from your
consultants / registrars as well as completing workplace based assessments
as often as you are able. It is imperative that you turn up on time for each
teaching list and see the patients beforehand. This is not only courteous to the
patient and consultant, but more importantly is integral to your training in
anaesthesia in pre-operative assessment, equipment and drug checking and
formulating anaesthetic care plans. The more actively involved in the patients’
care you are, the more you will gain in terms of learning and enjoyment.
Initially it is often a good idea to contact the consultant a day in advance to
agree which patients need seeing, to discuss what teaching opportunities
there are and whether you want to undertake any formal training
assessments.
There is also a formal educational department-wide programme for the rolling
half day theatre closures, morning breakfast meetings and a variety of
morbidity / audit / other educational meetings which are published and
distributed.
Appraisal and Supervision
During your anaesthetics attachment you will be allocated an Educational
(Clinical) Supervisor (ES) within anaesthetics, irrespective of your base
specialty. You must meet with your anaesthetic ES within 2 weeks of the
beginning of your post to formulate a “learning agreement”. At this meeting it
is recommended that you arrange firm dates to meet again in months 3 and 6
so that leave for either party does not cause the dates to slip backwards. At
the month 3 meeting you should have completed all paperwork for the initial
assessment of competency as well as at least 3 list assessments. If you think
that you are not going to meet this deadline you must alert Dr Butler well in
advance. In month 6 you will have a formal appraisal when you will receive
feedback about your anaesthetic knowledge, skills and attitudes as judged by
consultants. You must bring all relevant paperwork. This will include your
anaesthetic case logbook, completed workplace based assessments, your
portfolio and any details of audits, projects, exams or courses undertaken
during your placement. This information is essential for your ES to be able to
complete your ARCP report accurately.
Duty hours
The normal work day in anaesthesia is 8 am to 6 pm and initially you will work
Monday to Friday at these times. The 6 months is divided into 6 week blocks
for duty hour purposes. In the first block you may take 3 days off (zero days)
to keep your duty hours EWTD compliant. These are separate from and in
addition to your annual leave allowance (q.v.). In the second 6 weeks you will
do mainly daytime duties but add in 5 late shifts which run from 12:30 to 22:30
on Mondays to Fridays. You take 3 zero days again. From week 13 onwards
you will work 4 late shifts and one weekend per 6 weeks. The weekend shift is
a late session on Friday, Saturday and Sunday. In each 6 week block you
may take 2 zero days plus the Monday and Tuesday after weekend sessions.
The responsibility for selecting which late and weekend sessions you work
and which zero days you take is yours alone. You must self roster and put in
leave requests in the ACCS diary in the office 6 weeks in advance.
Annual and study leave
Annual leave is 15 days in the 6 months and may not be carried over. It must
be booked with the Administrators or Secretary 6 weeks in advance. Study
leave is 15 days in the 6 months. Half of this is internal and is accounted for
by the departmental teaching programme and simulator training. Half is
reserved for external study days (regional/national meetings/courses) which
you may take with ES and college tutor approval. No leave can be brought
forward from a previous job or carried over. Study leave may be taken only for
courses supporting exams in your base specialty, ACCS regional/national
meetings and attendance at one life support course (ALS/ATLS/
APLS/EPLS etc). The department does not support the use of study leave for
private study prior to exams.
Advance leave bookings and any other queries
If you have any questions regarding your rotation to the Shackleton
Department or if you want to book any leave in advance of your start date in
Southampton please contact [email protected]. or
[email protected].
Emergency Medicine in Southampton
When you start
Currently we run an induction program for the 1st two weeks of your post,
combined with online education modules. This follows immediately on from
the hospital induction program. Scrubs are to be worn when clinical and these
are available from the department secretaries.
Rota
This is a rolling shift rota with built in leave. Usual shifts are 8-18, 10-20, 1222, 18-03/05 and 2200-0815. Choose the “line” of the rota that best suits your
leave requirements. Dr Smethurst will co-ordinate the rota.
Educational supervisor
Jude Reay and Sarah Robinson supervise all the ACCS CT1 and 2 trainees
whilst Steve Halford supervises the CT3s.
Education
There is a weekly education session on Thursday afternoon for SHOs and
additional 2 hour blocks of self-study are included in the rota to enable elearning to take place.
For trainees the most important people in the department are
Laura West: Rotas.
Chris Penniston: Consultant secretary and Registrar rota. Talk to Chris about
Police statements.
Carole Collins: lead receptionist. This lady is the key to unlocking IT stuff and
can authorise most things in the department.
Sarah Charters: Consultant nurse leading the management of vulnerable
adults, drug and alcohol dependence.
There are 14 consultants, and they each have different backgrounds, skill
bases, personalities and management styles
Diana Hulbert: Lead consultant. Lead for psych / O&G / vulnerable adults
John Heyworth: Recently stepped down as the Head of the College. Lead for
complaints. Co-lead CDU.
Mike Clancy: College President, ex-dean (responsible for the Oxford
handbook and the college curriculum!). Co-lead resus. Lead critical care.
Julia Harris: Link with the Deanery (head of Wessex School EM), the ARCP
guru. Lead for neurosurgery / infection control.
Steve Halford: Paediatric EM specialist, takes on the CT3s as educational
supervisor. Co-lead paediatrics. Haematology lead.
Nick Maskery: Trauma guru and member of the Basics team. Co-lead
resuscitation. Governance lead. Majax lead.
Brian Flavin: leading the foundation years training. Co-lead research. Lead
cardiac, cardiothoracic and vascular surgery.
Adel Aziz (Associate Specialist): Works with the police and is the link for
alternative routes to a CCT. Co-lead minors. Orthopaedics lead.
Sarah Robinson: College tutor. Lead for toxicology, alcohol and drugs.
Specialty medicine link. Minors co-lead. Flexible training lead.
Iain Beardsell: Symphony genius. Majors co-lead. Organises SHO induction
and teaching. Co-lead research. VTE lead
Jude Reay: Lead for child protection/ paediatrics. Co-lead M&M. Guidelines.
Middle grade education
Sanjay Ramamoorthy: Education guru. Majors co-lead. AMU lead.
Michael Kuiber: Audit lead. Runs middle grade rota. Surgery/ ENT/ Max fax/
urology lead. Ultrasound lead.
Marianne Smethurst: Writes the SHO rota, get your requests in early! Co-lead
CDU. Lead radiology and oncology
The Consultants provide shop floor presence on 7 days a week from 8am to
midnight. There will always be a Clinician of the Day (COD) available and for
most of the day there will be one Consultant running resus and another in
majors. Lots of supervision and opportunities for shop floor education and
completion of WPBAs!
Departmental layout
Within the department, there are 6 distinct areas:
1. At the door, just inside the ambulance bays, there is an area of Rapid
Assessment and Treatment (RAT)
2. Resus, is currently a 3-4 bed area (dependent on necessity)
3. Majors consists of 4 major bays, 2 side rooms and 10 smaller bays. In
most cases a patient in the smaller bays will have had bloods, cannula,
ECG and some have X-rays requested. It remains your responsibility to
ensure that patient’s veins are cannulated - for the nurses this is an
extended role and depends on the skill base of the nursing staff
4. Paediatrics has one side room and 4 other treatment bays. The place
can sometimes get a little snug and the need may arise for creative
management of space.
5. Clinical decision units.
These areas are for adults so no-one under 18 goes there. It is split
into 1 (usually female) and 2 (usually male) they are well serviced by
an excellent and often overlooked OPOST and social services team
who, if given ample warning, can avoid a lot of social admissions.
6. Minors, although in name only at times! There are usually 2 Emergency
Nurse Practitioners (ENPs) who are the font of knowledge when it
comes to minor injuries.
The department has a dedicated Radiology suite, on extension 4021 or via
the tannoy 103 on the bench in majors; they will perform portable X-rays in
resus.
Southampton is now a major trauma centre with a helipad, so there are plenty
of opportunities to be involved in the care of multiply injured patients.
We will soon have access to a dedicated CT scanner to minimise transfer
distance and time.