ICU or IMCU Playbook
This resource is designed for units that need to quickly transition to an Intensive Care Unit (ICU) or Intermediate Care Unit (IMCU)
Section 1 is for the operational preparationSection 2 is for the unit preparationSection 3 is for the staff preparation
For all these sections, most of the resource documents are on the Advocate Aurora COVID page.
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ICU or IMCU
Operations
UnitStaff
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
Leaders/Managers review these documentsN95 sterilization overview FAQPPE resource guideDuty to care: Leader toolEmployee Health exposure & response management resource guide
Determine with Site/Unit Leadership the following:❑ Is cohorting patients required?
o SBAR Cohorting Patients
❑ RT/RN Intervention Algorithmo Coordination between the RN and RT leadershipo Use the Algorithm to determine interventionso Use job aides for MDI/Nebulizer
❑ Are you using the Team Based Nursing approacho Coordinate shadowing experiences with the affiliated ICUo Get resources from the COVID 19 Info site:
• Nursing Resources Section>subsection Team Based Nursingo Email for questions: [email protected]
❑ Are you utilizing TNA model?o COVID Resources: Nursing Resources Section> Temporary Nursing Assistanto Email for questions: [email protected]
❑ Implement approved changes to Nursing Practices to improve efficiencieso Extended tubing guidelineso Family communication guidelineso AAH Pandemic Emergency Documentation Plan for Adults
❑ Consider a place to have a respite/ nap area that your team can useo Respite and nap room guidelines
Operation documents COVID site
This playbook is intended to help you jumpstart your transition to an ICU or IMCU. It is not intended to be a full accounting of all policies/procedures or need to know items located on the COVID19 info site or other AAH documents etc.
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Operations
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
Get Room Signage for your unit• Aerosolized treatment in progress sign• PPE signage: Airborne and contact precautions• PPE signage: Droplet and contact precautions (ED/hospital)
Facilitate Training • Use Staff resource page to get Team Members quickly up to speed on priority items• (See Staff section for specifics)
Daily Operations• Have ICU leadership and NPD/CNS do a walk through of unit• Coordinate with Lab to have lab work done before 6 AM and develop process to alert staff• Review alarm volume and how to manage on the unit• Review patient placement on unit based on physical layout and number of patients• Coordinate with ICU for mentoring and collaborating on transferring patients• Update any other disciplines that work with the unit (RT, PT, OT, Chaplain) • Coordinate with Bio Med, Central Supply, Facilities to get needed equipment /supplies (Unit section)
SIMULATION• Simulation team recommends a COVID Code simulation to minimize staff fears and improve comfort
level during these critical situations• Simulation team is also available to train staff on the increased acuity of patients.• Walk through process simulations to identify safety concerns related to conversion to a ICU or IMCU• For Wisconsin sites,
• Lynne Delfosse - [email protected]• For Illinois sites: email
• Kari Congenie- [email protected]• Lisa Plucinski- [email protected]
Alert Staff about change to an ICU or IMCU• Communicate to your team about the impending change in your unit. Consider
different methods based on how soon the information is need (i.e. happening now –next shift needs to know versus full staff communication)
• Send updates when the change is confirmed with the timeline
Operation documents COVID site
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OperationsThis playbook is intended to help you jumpstart your transition to an ICU or IMCU. It is not intended to be a full accounting of all policies/procedures or need to know items located on the COVID19 info site or other AAH documents etc.
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
Intervention in place on the unit Start Date
End Date
Signage for isolation/AGP in place
Team Based Nursing
Temporary Nursing Assistants
RT RN interventions
Virtual Visits and Vigils
Visitor Limitations
Labs Draw Times- ICU Draw Time
Alarms (address volume levels)
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Unit
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
CleaningPlace Near Cleaning Supplies or Product needing cleaning Surface Disinfectant Substitution InfoPour Bottle Disinfectant Acute Site ProcessAir assist device cleaning guide with talking points
Emergency ResponsePrint and place near/on code cartsAdult bag mask filter informationPediatric bag mask filter informationAcute care adult emergent response (CPR) guidelines
Specimen Collection and Deisolation GuidancePrint and place near specimen collection materialsSpecimen collectionDeisolation and testing of previously COVID-19 positive (Acute care and ambulatory/outpatient settings)
Virtual Vigil Recommend Printing and placing in a binder near tablets for reference. Visitation guide should be printed in multiple copies to handout to family Device disinfection procedure for video visitationUsing virtual visitation guidanceVideo visitation guide for familyVideo visitation guide for care team
Resilience/Wellbeing Resource for Team MembersRecommend sending out on regular basis as a reminder and/or posting in a common areaResilience & well-being resource guideEmployee Assistance Program (EAP)Moral distress and COVID-19
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Print and post in areas where it makes sense as a just in time resource
Unit
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
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Unit This playbook is intended to help you jumpstart your transition to an ICU or IMCU. It is not intended to be a full accounting of all policies/procedures or need to know items located on the COVID 19 info site or other AAH documents etc.
Unit documents COVID site
Supply List to gather for your unit, work with Central Supply,
Bio Med, Pharmacy and Facilities:
Emergent Supplies
• Intubation equipment
• Rapid Sequence Intubation (RSI) Kits
• Additional code cart
• Emergency PPE/viral filter
• Additional Defibrillator
• Know where your nearest difficult airway kit is stored (ICU)
Unit Supplies
• Additional IV pumps and channels
• Additional PPE and respiratory equipment
Coordinate with Pharmacy
• Appropriate ICU/IMCU medications added to Pyxis
• Pharmacy support and rounding
Patient Room Supplies
• Individual patient monitors in each room
• Suction supplies and wall suction for each room (at least 2)
• Additional portable vitals carts (BP cuff/pulse ox/thermometers)
*All these items need to have a clearly assigned and easily acceptable
location in the unit and patient rooms
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
Staff Preparation/Resources
Review these now (before 1st patient)
PPE/ Personal Protection
• Donning and Doffing PPE with N95 reuse• PPE Resource Guide• Personal Protection Tips• Performing N95 seal check
Look at these resources carefully to review PPE procedures prior to caring for patients.
Caring for Covid Patients
• COVID-19 Fast Facts for Nurses• Transporting Patients• Acute care adult emergent response (CPR) guidelines
Here are key items you need to know about the care of covid patients.
Review these within the first week
PPE/Personal Protection
• Mask Pressure Injury Prevention guidelines• Mask Injury Algorithm• Skin Care for Mask Wear
This information is more in-depth resources to prevent injury for long term use of PPE and PPE best practices
Caring for COVID Patients
• Adult Supplemental Oxygen• Oxygen therapy tip sheet• Adult high risk intubation• Pressure injury in COVID-19 patient nursing practice
alert• Proning materials in the proning section under Nursing
Resources Section on COVID 19 Info site
These references has more in-depth info on key points to know in taking care of this patient population
Space for instructions of announcement about switching?
These resources and much more can be found on the COVID19 Info Site. You can easily get to it through a link on the AAH Nursing Hub or simply CLICK HERE
Review when possible or when the need presents
Caring for COVID Patients
• Nursing Guidelines for Tracheotomy Care• V60 helmet RT job aid• Ventilator tip sheet• Ambulation of COVID-19 in hallway for medical evaluation• Medication guidelines for adult patients• Critical Care Onboarding for the Non-Critical Care Nurse• Critical Care Onboarding for the Non-ICU Nurses (VIDEO)
These resources and more may be found on the COVID19 info site. This sheet is only to highlight significant resources and not the entirety of what is available. 7
Staff
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
Staff Preparation/ResourcesSpace for instructions of announcement about switching?
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Staff
Nursing Care
Acute Care Readiness
• Acute Care Readiness Course SBAR• Fall prevention strategies• Handling medications in Patient Rooms• Glucometer instructions• Advanced Directives SBAR• Critical Care Onboarding for the Non-Critical Care
Nurse• Critical Care Onboarding for the Non-ICU Nurses
(VIDEO)• Nursing Guidelines for Tracheotomy Care• V60 helmet RT job aid• Ventilator tip sheet
Look at these resources carefully for information on how to care for the acute care patient
Other strategies • Patient belongings nursing practice alert Here are key items you need to know about the care of patients.
EPIC and charting
EPIC • Surge Inpatient Nurse Self-Paced 100 Workbook• Surge Inpatient Nurse Self-Paced 200 Workbook• Surge Inpatient Nurse Self-Paced Course Details• COVID-19 Tip Sheets • EPIC Emergency Documentation for Adults
Consider printing out these resources for staff, be present to mentor staff and consider having a “phone a friend” resource if needed until staff comfortable
These resources and much more can be found on the COVID19 Info Site. You can easily get to it through a link on the AAH Nursing Hub or simply CLICK HERE
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
Tele-ICU Information
SheetB
en
efi
ts o
f Te
le-I
CU
Monitoring
Collaboration and Support
Orders/Assistance
Educational/Mentoring
Quality Assurance and Improvement
Data Reporting for Outcomes and Metrics
24/7 presence
Staffed by at least 1
physician at all times
Provide needed
support to the
bedside
Have a minimum of
5 years of critical
care experience
Average assignment:
45-50 patients
Support both
physician and RN
roles
Assist in data
collection necessary
for reporting
PHYSICIANS NURSESHEALTH CARE
ASSISTANTS(HCAs)
Acute Issues Tele-ICU Can Address
“First look” at all new admissions (seen
within 30 minutes)
Ventilator issues
Arrhythmias, especially atrial fibrillation
with rapid ventricular response
Hypotension
Electrolyte abnormalities
Physician presence at medical alert/
medical response, RRT transfer, or
before on-site Physician arrival
Adjustment of sedation
Need for GI prophylaxis
Ventilator liberation assistance
Antibiotic stewardship
Glucose management
Review/ interpret x-rays
and EKGs
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
→ Usually this type of call is transferred directly to the doctor.
→ Messages may be taken only if the doctor covering is already on the telephone with another call. Messages will go to the other physician in that case.
→ Nurse at the site should be told to expect orders or call back within 30 minutes
→ A message should be done for almost all of these.
→ Nurse at the site should be told to expect orders or call back within 15 minutes
Tele- ICU Information Sheet
Tele-ICU MonitoringTele-ICU becomes an integral part of the critical care team upon the
patient’s arrival to the unit.
Monitoring includes real time assessments – same access as what the
bedside sees and views: Vital Signs, labs, EMR, X-ray, etc.
Monitoring for subtle changes in patient condition utilizing sophisticated
software: eCare Manager providing alerts and trending for proactive
management and prevention of adverse outcomes.
Response to emergent and urgent situations by Tele-ICU Intensivist
and eRN
• Medical Alert/Medical Response
• In response to patient condition as warrants
Emergent Urgent Routine
Emergent Triaging of Phone Calls
Immediate response or action needed Response or action needed soon Information is not time sensitive but needs to be communicated to the teamExamples (include but not limited
to):• Acute change in v/s; acute
change in mental status,• Acute change in respiratory
status, Increase in O2 requirements
• Acute mental status change• Hypotension• Hypoxia/Hypercarbia• Pre-code situation• Very abnormal key labs in
physiologically unstable patient (e.g. pH < 7.20 on ABG; Hbg <7)
Examples (include but not limited to):• Abnormal labs in a
physiologically stable patient (e.g. k+, Mag Gluc, Hbg)
• Time sensitive order renewals
• Another physician is calling• Results of any previously
ordered tests by eICU• HTN; Low urine output• PRN meds for safety issue
Examples (include but not limited to):• Abnormal labs; just
reporting or FYI• Treatments and Tests
completed• Medication renewals that
are not time sensitive• PRN Medications• X-ray checks for tube
position or placement
When to call for help!
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
Staff Preparation/Resources
Medical Alert: Code TeamAdult Care: Adult CPR Emergent Response Guidelines
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Staff
Consider creating a document like this that has how
to call for help at your facility and place it in the unit
(thank you ASLMC for sharing)
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
Created by AAH Respiratory Care Council Created 12/10/2020 Sponsor:
Staff Educational ResourcesEducational resources have been developed to support providers, nursing, and respiratory therapy in the management of HFNC for COVID patients.
Educational Resources located on COVID site
High flow oxygen adult High Flow Oxygen AdultROX IndexAdult Supplemental OxygenV60 Helmet Job Aid
COVID website education for staff to get familiar with the HFNC system for patients
Device specific education
Airvo Education https://www.youtube.com/watch?v=uGZ8GGYxLhs
Staff education for use of these devices
Optiflow Education https://www.fphcare.com/us/hospital/adult-respiratory/optiflow/mechanisms-of-action/
Vapotherm Education https://academy.vapotherm.com/
Additional Resources and education
https://www.sccm.org/COVID19RapidResources/Resources/High-flow-nasal-cannula-(HFNC)-use-in-COVID-19-res
Experience of HFNC in SARS
Demonstration of HFNC Machines used at AAH • Optiflow• Airvo
Education
These resources and much more can be found on the COVID19 Info Site. You can easily get to it through a link on the AAH Nursing Hub or simply CLICK HERE
High Flow Nasal Cannula Guidebook(Adult Patients)
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https://www.youtube.com/watch?v=gSVI6fFu6DM&feature=youtu.be
Created by AAH Respiratory Care Council Created 12/10/2020 Sponsor:
Monitoring
Safety Measures
✓Cohort similar patient population to help with maintaining staff familiarity and education.
✓Consideration of step-down unit to support intermediate care needed.
✓Create algorithm for ideal management of patients to determine when moving to ICU setting would be most appropriate.
✓Create patient monitoring guidelines.
✓HFNC is considered an AGP procedure based on AAH guidelines. Follow AGP guidelines.
✓KEEP DOOR CLOSED AT ALL TIMES
✓Consider lower patient to nursing ratio to allow for proper monitoring
✓Consider lower RT to Patient ratio for high flow utilization.
Patient monitoring
If available, the following are recommended patient monitoring
✓Continuous Pulse oximetry
✓Telemetry monitoring
✓Consider Tele-ICU monitoring cart.
✓Monitoring patient's respiratory status:
❖SPo2 Saturation trend.
❖Respiratory rate
❖Working of breathing
❖Level of Consciousness
✓Monitor patient ROX index. Watch for trend of decreasing ROX score (indication of impending failure).
✓May need to consider placement of non-rebreathing mask over HFNC to achieve targeted SpO2
When adding HFNC as intervention to your unit, consider the following safety measures and patient monitoring. Work with your RT team and Nursing leadership to put in place.
Monitoring and Safety COVID site
High Flow Nasal Cannula Guidebook(Adult Patients)
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Staff Preparation/ResourcesSpace for instructions of announcement about switching?
Respiratory Care Maintenance of COVID PatientsAdult COVID 19 Positive or PUI: Respiratory Management
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Staff
Nursing Care
Respiratory Care Maintenance of COVID Patients
Adult COVID 19 Positive or PUI: Respiratory Management Look at these resources carefully for information on maintain the respiratory status of COVID positive/PUI Patient
Proning: • Manual Proning How-To Video• Proning with a Lift How-To Video• Manual Prone Position in the non-intubated patient• Proning Patient Information• Proning Tracking Sheet
Look at these resources carefully for information on Proning both intubated and non-intubated patients
Alarm Monitoring & Management
Alarm awareness is very important. It is EVERYONE’S responsibility to respond to alarms. Work with unit and leadership to tailor alarms to reduce nuisance alarms while following policy and guidelines. Always address alarms and escalate response as warranted. You jeopardize patient safety if you ignore alarms.
Operations should have addressed monitor volumes for alarms in this unit.
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
Staff Preparation/Resources
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Staff Resource List for Team Members
Team Based Nursing ApproachThis team based nursing approach allows RNs to use their highest level skills to provide a piece of patient care to a collaborative team model to provide safe and effective care for our patients. This means non-ICU RNs will provide standard care within their scope under the delegation and
supervision of an ICU RN.
*Thank you for sharing resources Aurora West Allis Medical Center!
Topics Resources
Reassignment orientation for non-ICU RN to critical care
Reassignment orientation for non-ICU RN to critical care
Critical care onboarding for non-ICU nurses: Presentation
Critical care onboarding for non-ICU nurses: Video
Reassignment orientation for RN to Adult Care
Reassignment orientation: RN to adult team nursing
Team Based Nursing Team ICU delegation toolkit
Team med surg delegation toolkit
Team-based nursing PowerPoint
Unit Communication Sheet *AWAMC
Unit Information TIP Sheet
Created by NEPD Created 12/16/2020 Sponsor: Jane Dus
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