SSuun nnd ddeeerrrl lla aanndd RRRoooyyyaall ... · SSuun nnd ddeeerrrl lla aanndd RRRoooyyyaall...

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1 S S u u n n d d e e r r l l a a n n d d R R o o y y a a l l H H o o s s p p i i t t a a l l Integrated Critical Care Unit A survival guide for staff new to critical care Don’t Panic

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SSSuuunnndddeeerrrlllaaannnddd RRRoooyyyaaalll

HHHooossspppiiitttaaalll

Integrated

Critical Care Unit

A survival guide for staff

new to critical care –

Don’t Panic

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Contents Introduction

Philosophy of Care

Unit Layout

Useful Information

Unit personnel and the Multi-professional team

Ward-rounds

Communication

Daily routine

Laboratory investigations

Admissions, discharges and transfers

Relatives and visiting

Continuing education

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Introduction

Welcome to the Integrated Critical Care Unit!

We are an 18-bedded unit comprising of:

8 level 3 (ITU) beds and

10 level 2 (HDU) beds.

The configuration of the unit is one four bedded bay for level

3 patients, 4 single side-wards, 2 isolation / barrier nursing

rooms and two 4 bedded bays for level 2 patients. All the beds

are flexible however, and patients can be ventilated and

monitored in any area.

We hope that you will enjoy working in ICCU and that you will

gain a wide range of experience in different situations,

developing your skills in critical care.

As you develop in ICCU a series of objectives will provide

direction and challenge to your work, and aid you in your

professional development.

A preceptor / mentor will be assigned to you to guide your

progress through your orientation period, and provide support

and advice along the way as part of an ongoing relationship.

You will also have a team leader (a sister / charge nurse) to

oversee and direct your progress, guide you in your

professional development and assist you with any difficulties

you may experience.

Many of your nursing and medical colleagues have a great deal

of experience in critical care and are here to help you. Don’t

be afraid to ask if you have any queries!

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Philosophy of Care

The staff of the ICCU will provide a 24-hour service to

critically ill patients and their families or carers within

Sunderland Royal Hospital, striving to deliver the highest

possible standards of care based upon sound research and best

evidence.

We will show consideration for the individuality of each

patient, recognising and respecting his or her differing

physical, emotional spiritual and cultural needs. We will

maintain the patient’s dignity, privacy and confidentiality at all

times, whilst promoting maximum independence wherever

possible.

Each patient within the ICCU will have a named nurse,

responsible for the planning, co-ordination and delivery of care

within the multi-professional team.

We will offer support to relatives and carers, and endeavour to

keep them informed of any changes in condition or treatment.

We will encourage involvement in discussions relating to the

care of the patient, and participation in their care (where

appropriate).

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ICCU Unit Layout

Room 1-4 - Single side wards

Room 5 - 4 bedded bay (level 3)

Room 6 & 7 - Isolation / barrier nursing rooms

Room 8 & 9 - 4 bedded bays (level 2)

* * - Crash trolley / defibrillators

* *

* * - Other emergency trolleys

Room 5

*

*

Room 4

Room 3

Room 6

Room 2

Room 7

Sluice

Room 8

Room 1

Clean Utility * *

* *

Room 9

Office

Linen Storage

Visitors

Waiting

Area

Pay phone

Resource

room

Quiet room Storage area – disposables

Female/c

Beverage bay

Hand wash

area

Patient w/c

Staff lounge

Reception Domestic

store

Storage

Area – equipment

(workshop)

Waste

Disposal

Patient

access

Dr’s on call suite

Visitors

W/c

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Useful Information Shift Patterns

Early - 7.15am - 2.45pm

Late - 1.15pm - 8.45pm

Nights - 8.15pm - 7.45am

Off Duty

Off duty is usually prepared 2-3 weeks in advance. Self-

rostering is currently in operation. Students must work a

minimum of 2 shifts / week with their primary mentor.

Night Duty

Rotation to night duty is compulsory. All staff rotate

according to a roster that can be found at the nurses’ station.

Rotation usually takes the form of 2 weeks night duty followed

by 4-6 weeks days. However please see C.N. Duncan who will

try to accommodate you if you would like to do a longer stint of

nights. Students are also encouraged to work nights alongside

their mentor.

On Call

An on-call rota is in place to cover for staff shortages and

sickness. Once you have completed your introductory period if

you wish to participate in the on-call system place your name on

the rota (according to the guidelines for numbers of staff

required per shift.) The nurse in charge will advise you if you

are required to come out.

Enhanced Hours

Weekend, night duty, unsociable hours and bank holidays all

attract enhanced hour’s payments. These forms are to be

completed retrospectively on a monthly basis by the nurse in

charge. It is your responsibility to ensure that your enhanced

hours claims are checked at the end of the month and signed

for. If you do not check your claim we cannot ensure that

your enhance hours payments will be correct. If you have any

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queries about your enhanced hours claims, please see one of

the G-grades who will be happy to help. On-call claim forms

should also be completed monthly by you, and certified by the

nurse in charge.

Annual Leave

All annual leave is to be approved by C/N Todd. Holiday

request forms are available in a file at the nurses’ station.

Holidays are allocated on a ‘first come – first served basis’. As

there is a large number of staff working on the unit it is

advisable to get your requests in early to avoid disappointment!

Uniforms

Uniforms can be obtained from the sewing room, ext. 42182.

They are laundered in the hospital, and should not be worn to

or from work. Clean uniforms will be found in the staff

changing rooms situated on B-floor. Comfortable trainers may

be worn.

Lockers

Lockers are available in the staff changing room, which is only

accessible with a ‘swipe card’. It is advisable to lock away all

personal belongings. Handbag lockers are available on the unit

in the staff sitting room. Keys should not be taken home, and

lockers left empty at the end of your shift, as there are a

limited supply.

Equipment

When you first start you will be given a tour of the unit. Don’t

worry too much about remembering where things are kept – it

takes time! Try to familiarise yourself with the layout and

situation of the fire exits, emergency equipment etc.,

whenever you have a spare moment. To make things easier,

certain pieces of equipment that is needed in an emergency or

for an admission are stored together on trolleys.

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These are:

‘Crash’ trolleys with defibrillator (See plan of unit for

Arterial and central line trolley location of these items)

Chest drain trolley

PA catheter trolley

Tracheostomy trolley

Unit office

All CHS policy and procedure files are kept in here; you must

familiarise yourself with these.

Resource Room

This room is available for meetings, teaching sessions, private

study etc. If you wish to use the room please book it in

advance with the receptionists who keep a diary for this

purpose. A computer is available in here for general use, as

well as reference books, journals and CD’s. Please remember

that these items are for reference only, and should not be

taken off the unit. Please have some consideration for others

who may want to use them after you.

Patient Allocation

At the beginning of each shift the nurse in charge will allocate

patients to the nurses on duty. A named nurse system is in

operation on the unit, whereby F/E grade staff act as named

nurse and D grade staff as associate nurses. Usually, the

named nurse will be the nurse present on admission of the

patient. The named nurse will be responsible for the care of

the patient for the duration of their stay in ICCU, and when

possible will be allocated to their particular patient when on

duty. However, this may not always be possible due to skill mix,

holidays, staff shortages etc.

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Unit Personnel and the Multi-Professional team

Matron

Carole Gibson is based in the matrons’ office on B-floor, and

has professional responsibility for all nursing staff in the

Theatre Directorate. She can be contacted on Bleep 51384 to

advise on any professional issues.

Nurse Consultant

Lesley Durham has over 15 years of ‘hands on’ critical care

experience. Her role is to integrate policy, education, practice

development and research relative to the needs of the

critically ill, with the overall effect of improving the quality of

patient care. She is also responsible for the introduction of

the Critical Care Outreach Team (CCOT).

Practitioner-Lecturer

Debbie Cheetham also has over 10 years critical care

experience. She is responsible for the co-ordination and

facilitation of education and training within the unit, and the

delivery of critical care skills training to ward staff within the

trust. Her time is split working between Northumbria

University and CHS.

Consultants

On ICCU we have a team of both Consultant Anaesthetists /

Intensivists who share responsibility for the unit on a rota

basis. The consultants attached to the unit are:

Dr. J. (John) Green - Anaesthetist

(Clinical Director)

Dr. A. (Andy) Morrison - Anaesthetist

(Lead Clinician ICCU)

Dr. A. (Tony) Taylor - Anaesthetist

Dr. H. (Bhaskar) Bhaskar - Anaesthetist

Dr. P. (Phil) Cudworth - Anaesthetist

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Dr. A (Alistair) Roy - Anaesthetist

Dr. G. (Gary) Lear - Anaesthetist

Dr. P (Paul) McAndrew - Anaesthetist

Critical Care Co-ordinators

On each shift there is a sister or charge nurse, responsible for

the co-ordination of the unit. They also act as team leaders

for a designated group of nursing staff and health care

assistants.

Sisters – Chris Tippins, Sue Cockburn, Eileen Lawton,

Michelle Smithson.

Charge Nurses - Ian Todd, Chris Welsh, Rob Duncan.

Nurses

All other nurses in ICCU are at D, E or F grade, with usually 1

bedside nurse for each level 3 (intensive care) patient, and 1

nurse for 2 patients who are classified as level 2 (high

dependency).

Health Care Assistants are an essential part of the ICCU team

and assist with the smooth running of the unit. Among their

many duties they help with the cleaning and testing of

equipment, take specimens to the lab and collect blood

products, assist with patient care and help with the resetting

of bed areas once patients have been discharged from ICCU.

However, this is not solely the responsibility of the HCA’s – it

is part of the nurses role to ensure equipment is cleaned and

bed-spaces are correctly reset ready for the next admission.

Administrative Assistants (Receptionists) are again an

essential part of the ICCU team. They are based in the

reception area, which is manned from 8.30 am unit 8.30 p.m.,

and are the first point of contact for visitors to ICCU. They

greet relatives and other visitors to the unit, and direct

telephone enquiries to the appropriate areas. As well as this

admin assistants are responsible for all aspects of clerical

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work, including input of admission data into the computer, filing

and care of patient notes, and the ordering of stationary and

other stores.

Physiotherapists

Physio’s generally visit the unit 3 times per day to perform

chest physio and limb exercises on ICCU patients. On-call

physio’s can be bleeped via switchboard out of working hours,

and extra visits may be pre-booked through the patients

allocated physiotherapist.

Dietician

It is vital to ensure our patients are adequately nourished, and

it is our aim to commence nutritional support (either enteral or

parenteral) as soon as possible after admission to ICCU. Th

unit has a feeding policy in situ with a protocol based on up to

date research guidelines. The dietician visits the unit on a

regular basis (usually daily) and to assess the nutritional

requirements of the patients. She can also be contacted via

bleep if necessary.

Pharmacist

The pharmacist usually visits the unit on a daily basis to assess

drug regimes and offer advice. A pharmacy technician also

visits the unit daily to order stock drugs, enteral feeds and

I/V fluids etc.

The nurse in charge orders urgent, non-stock and controlled

drugs on a daily basis, usually.

Chaplains

Chaplains are available for people of all denominations, and are

pleased to visit patients and relatives on the unit. They can be

contacted via switchboard or bleep system as required. The

chapel is also available to be used by visitors and staff as a

place of peace and tranquillity.

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Ward Rounds

Ward rounds take place on a daily basis at 0900hrs. The team

usually consists of:

ICCU consultant

Registrar / SHO on –call

Nurse in charge

Microbiologist

The pharmacist and dietician also join in when available.

The nurse looking after each patient should also be present

during the ward round. Major decisions regarding the

treatment and care of the patient are usually made at this

time, and it is the nurse’s responsibility to ensure that any

changes are implemented and documented accordingly, and

passed on to other members of staff during the handover.

Numerous ‘mini-rounds’ may also take place during the day; it is

up to the bedside nurse to keep the nurse in charge informed

of any changes.

As ICCU patients will come from or go to other wards they also

have a consultant for the speciality they are admitted under

e.g. Surgery, medicine etc. who will visit regularly and liase with

the ICCU doctors.

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Communication

HISS System

City Hospitals Sunderland uses the HISS computer system.

Patient admissions, care plans, evaluations, lab requests and

results are contained on the system. Your mentor / preceptor

will identify any training needs and organise appropriate

sessions.

A MOX system of messaging exists. Please remember to read

your messages on a regular basis, as important information is

often disseminated this way.

E-mails

The e-mail facility on the Computers is by far the quickest and

easiest way to communicate with other members of staff. A

message can be sent to all members of staff via this system.

Please remember to read your messages on a regular basis, as

important information is often disseminated this way.

Notice boards

Are situated in the staff sitting room and by the nurses’

station. Off duty, information regarding study days, and any

changes to the unit are posted here.

Handover

At the commencement of each shift staff receive a brief

handover for the patients in the area they are working in,

followed by a more detailed report for their allocated patient.

A series of safety checks are completed by both nurses, which

includes ventilator settings, alarm parameters and drug

infusions.

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Daily Routine

0715 - Changeover of staff, handover and safety checks.

Bed-spaces should damp dusted and restocked.

8000 - Blood specimens taken as required and sent to labs.

0900 - Ward round

Changes implemented as required

1000 - Physiotherapy

Individual patient care

1315 - Changeover of staff, safety checks as 0715.

Individual patient care and hygiene needs.

1400 - Physiotherapy.

1530 Physiotherapy

1800 - Individual patient care and hygiene needs.

TPN changed daily.

2015 - Changeover of staff, safety checks as 0715.

2200 - Individual patient care and hygiene needs met.

0000 - Enteral feed discontinued.

0200 - Individual patient care and hygiene needs met.

0600 - Individual patient care and hygiene needs met.

Enteral feeding recommenced.

Ventilatory weaning commenced and sedation

stopped if appropriate.

This is intended as a guideline only, and is adapted to the

requirements of the patient as appropriate. Every effort is

made to ensure that all patients receive holistic, individualised

care, usually prescribed by the named nurse.

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Laboratory Investigations

Investigations are carried out routinely on a daily basis, or as

required for the individual patient.

Bloods sent daily are:

FBC (purple bottle, marked as urgent)

U&E, albumin, glucose (green bottle, marked as urgent)

LFT’s (green bottle, non-urgent)

Coagulation (blue bottle, marked as urgent)

Abg’s (heparinised syringe, analysed on unit)

Other requested investigations:

Bone profile (Monday, Wednesday, Friday)

Sputum C&S (Monday, Wednesday, Friday)

Cardiac enzymes (green bottle, non-urgent on patients with

known/suspected M.I.)

Therapeutic drug levels (e.g. Vancomycin, Theophylline,

Digoxin, usually gold-topped bottle.)

CRP/PCT (On patients suspected to be septic. Gold top

bottle, given directly to microbiologist, and returned to unit

for PCT analysis)

Other common investigations:

Sputum - C+S, Gram Stain

Urine – C+S, Electrolytes and Osmolarity

Blood – C+S

Swabs – C+S, MRSA

Line Tips – C+S

Specimens are sent to the lab via the pneumatic chute system.

This operates at the following times:

8am – 8pm Routine and Urgent specimens

8pm – 8am Urgent specimens only

All urgent specimens outside of normal hours (8am-8pm),

antibiotic assays and urgent microbiology samples should be

telephoned to the relevant department prior to despatch.

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Admissions, Discharges and Transfers

Admissions

Although many admissions to ICCU are emergencies, via

theatre, from wards, A&E or from other hospitals, patients

who are admitted to ICCU are may also be planned surgical

patients who come from theatre requiring close monitoring

(usually level 2) and sometimes ventilation (level 3). The

patient’s consultant should make admission referrals to the

ICCU consultant. A diary for booking of elective admissions is

kept at the nurses’ station.

Pre-operative visits

For those planned surgical admissions, whenever possible we

arrange for a nurse from the unit to visit the patient on their

ward prior to theatre. This allows us to give them and their

families’ information regarding their stay in ICCU, hopefully

alleviating some of their anxiety.

Transfers

We occasionally transfer patients to other hospitals within the

critical care ‘network’ of other hospitals within the region.

This is usually done if the patient requires specialist care from

another unit e.g. Cardio-thoracic, neuro-surgery and burns. A

qualified nurse and anaesthetist will accompany the patient.

Transfers

When patients are ready to leave the unit, they then go the

ward of their speciality consultant. Beds can be arranged by

bleeping the bed manager on-call. It is also important that the

appropriate medical team and ward staff are informed of the

patient’s readiness to transfer to ensure continuity of care. A

patient transfer documented should be completed for all

patients transferred from ICCU and a discharge summary

completed by the medical staff for level 3 patients who are

transferred.

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Relatives and visiting

The staff of ICCU aim to provide a supportive environment for

the relatives of ICCU patients. We endeavour to ensure that

close relatives are provided with adequate information,

emotional support and help to better equip them to deal with

events or traumas they may encounter in ICCU.

Visiting Times

A flexible, open-visiting policy is in place in ICCU for immediate

relatives of patients. However due to the nature of the unit a

period of ‘protected patient care time’ must be maintained

between 0800hrs and 1130hrs to allow for ward rounds etc.

Visitors are encouraged to visit between 2pm and 8pm, which

will enable them to spend quality time with their relatives.

Several short visits are advised to allow the patient to have

important rest periods. It is also necessary to stress the

importance of removing outdoor coats and hand-washing prior

to visiting patients on the unit, and reminding visitors that we

are not able to accept fresh flowers for the patients due to

the infection risks.

Facilities are available for the comfort of visitors such as a

sitting room with television and drinks machine, payphone as

well as a quiet room for interviews. We are also able to

arrange overnight accommodation in the ‘Woodford Williams’

patient hotel for visitors who do not live locally or who are

required to be close at hand in the case of an emergency.

Children

Visiting by children under the age of 11 years is allowed at the

discretion of the nurse in charge. Parents must be reminded

that children visiting the unit should be supervised at all times

for their own and other patients’ safety.

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Continuing Education

Induction Programme

During your first weeks on the unit you will be given a clinical

competency programme. This will give you aims and objectives

to help you to develop your knowledge and skills in critical care.

Here on ICCU we are committed to providing learning

opportunities for our staff to aid with their professional

development and deliver the highest possible standard of

patient care.

There are opportunities for in-service training both within the

unit and City Hospitals Sunderland with both formal and

informal teaching sessions. Allocated places for study days

and courses such as Foundations in Critical Care, Adult Critical

Care Module and PP126/7 are also available.

Requests for places on courses and study days should be

identified through appraisal with your team leader and

negotiated with the practitioner / lecturer who will advise you

of relevant forms to complete etc.

Mandatory Study sessions

It is compulsory to attend annual fire, manual handling and CPR

updates. It is your responsibility to ensure that you attend

these sessions. Dates are clearly displayed on notice boards.

Many of the sessions are actually performed on the unit, so you

have no excuses!

Remember!

In accordance with NMC requirements for PREP it is your

responsibility to ensure that you undertake a minimum of 5

days study relevant to your area of clinical practice every 3

years in order to demonstrate professional development.

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Sister Tippins also requires to see your NMC PIN number when

you start on the unit and each time you re-register.

Preceptorship co-ordinator

Sue Cooper facilitates induction into the trust and induction

programmes. She can be contacted on Ext. 42578 (afternoons

only) to offer help and advice for newly qualified staff and

staff new to City Hospitals Sunderland.

We hope this booklet proves useful to you in the coming weeks

as you settle into ICCU. Please do not hesitate to ask any

member of staff if you have any queries, no matter how small

or trivial they may seem, we are only too happy to help.

Most of all, enjoy your time in ICCU, and don’t panic!

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Created by M.Smithson

Updated May 2005