Mount Sinai ICU

Mount Sinai ICU

16 bed medical-surgical ICUClosed administration

• countersign orders from outside services

• notify referring services about all significant changes in their patients’ condition and in the event of a death of their patient

Attending Staff:

• Tom Stewart (Physician in Chief)

• Niall Ferguson (Director, Critical Care)

• Stephen Lapinsky(Site Director & Education)

• Geeta Mehta (Research Director)

• Mike Christian (I.D./Military medicine)

• Eddy Fan

• Christie Lee

• Michael Detsky

Sources of consults / admissions

MSH inpatientsACCESSOR/PACUemergency departmentPMH inpatientsCriticall

Daily schedule

7:45 sign over 8:00 allocate patients 8:00 - 8:30 discharges, see patients 8:30 – 9:00 rounds 12:00 teaching (post call residents

welcome!)

Afternoon : see patients, procedures Bullet rounds Tuesday 1pm: multidisciplinary

Admit decisions

Assess patient, decide on ICU admissionDiscuss with fellow, attending, charge

nurseif no resources available, speak to your

attending staff Do not refuse admission without

discussing with attending

Admit decisions If the unit is full:

• this is the attending and NUA’s responsibility• Obligation to open 2 additional beds

Options:• Transfer a stable patient to the floor/SDU• Open beds in PACU or CCU. • Criticall to another hospital

We do not take responsibility for patients outside the unit except:• Patients transferred from ICU to PACU• ICU patients bedspaced in CCU

Admission orders - preprinted

Admission orders – Medication reconciliation

Electronic order entry

ICU limited involvement in POE

ICU will only do Transfer orders online:• Checkbox Transfer orderset• Medication & fluids order entry• Education & support

New admissions: check electronic orders, eg. post-op orders

Discharge decision

make this decision as early as possible, preferably the night before

communicate this to the nurse in charge Communicate with receiving service on

the day of dischargePrior to discharge to Medicine:

• Assessed by Medical floor nurse• Assessed by GIM housestaff

Discharges

Dictate or web form:- discharges home- deaths- transfers to

another hospital (eg. PMH)

Deaths: - complete yellow M&M form

- consider organ donation, autopsy

Discharge summary accessible via Powerchart

Name, MSID, Family doctor, attending, admission and discharge dates all populated

Dictation: web form

Discharge medications:• Confirm complete:

• ICU flow sheet• ICU Cardex• Pharmacist admission notes

• Check with pharmacist/nurse if unsure

Do not erase patient from signout• Change room number to “ACCESS”

Discharges

New requirement to inform Trillium Gift of Life Inform charge nurse for who will make contact TGOL will communicate with family if necessary For:

• Deaths• Impending deaths• Withdrawal of life-support

Further education to follow

Deaths and Impending deaths

Provincial requirement to increase capacity by 15% before transferring out via Criticall:• = 2 additional beds• Usually to be located in the CCU (16N), or PACU • Managed by ICU medical and nursing staff• Need to be clear under whose care patients are• Keep on signout: eg. number “18 Bedspace

CCU7”

Additional surge will take over remainder of CCU beds -> 8 beds in total

ICU Surge Plan

Mount Sinai’s Critical Care Response Team• 24/7 service: Nurse 24 hrs, fellow, attending

ACCESS team

Education sessions

Day 1: “Intensive Care University”• Full day teaching, simulation

teaching daily at noon – see schedule attending rounds or mortality rounds on

Tuesday noon multidisciplinary teaching (RT, pharmacy,

nutrition, research) on Friday noon Simulation & practical sessions Post-call residents are welcome!

Daily rounds

Resident summarizes problemsNursing report: head-to-toeRT: mechanical ventilationPharmacist: medicationsLabsManagement planChecklists: CRBSI, VAP

Daily notes

Daily note:• “ICU Rounds”:• Problem list• New issues• Plan

Orders• Check/confirm at the end• Quality improvement

checklists

Quality Improvement data collection

Central line infections• Procedure checklist/note in central line insertion

package• Daily data collection for CLI

Ventilator associated pneumonia• Checklist in nurses binder, reviewed by RT on

rounds• Ventilated > CXR changes > check chart (WBC,

sputum, etc)

Data is publicly reported

Procedures – Procedure Note

Central line insertion kit contains drapes, cleaning material, gowns and Procedure Note/Checklist

To be completed by nurse and physician White copy into chart (Progress notes section) Yellow copy into tray at Ward Clerks desk Acts as checklist, note and for QI data

collection Trial note: feedback is appreciated

Procedures

central venous and arterial linesUltrasound: lines, chest, echoPA catheters intubationBronchoscopy Intraosseus line insertionCardioversionChest tube insertion

Procedures

Simulation teachingSupervision: by fellow or

attendingProcedure notes: preprinted formProcedure logging: POWER

Procedures

Backup for procedures: Fellow and AttendingDon’t call anesthesia for routine intubations

• They are very busy and it is not their responsibility

• RT’s can intubate or support you• Anesthesia will be a backup if you have a

problem• Make sure fellow/staff are involved

Procedures

Wastage of supplies:• Most supplies taken into a room cannot be

reused, even if not opened• Only take into room what you are about to use• This is a Patient safety and Economic issue!

CCM Resident/Fellow

first line of consultation for the resident when in doubt, consult with the attending back up call 1:3, may need to do 1 – 3 in-house

calls Teaching: fellow teaching, track formal rounds Quality improvement: checklist,

SaferHealthcareNow M & M rounds

M & M rounds

last Tuesday of the month review monthly stats: Patrick Cheng present all deaths briefly categorise all deaths 1 – 5 for categories 4 and 5, detailed review,

may go on to Quality of Care Committee present autopsies if available

CCM Resident/Fellow

Fellow 1:• Runs rounds, Co-ordinates team

Fellow 2:• Support: transfers, discharges, procedures,

resuscitation, nursing issues during rounds• Quality improvement• ACCESS (if no fellow 3)

Fellow 3:• ACCESS team• Quality improvement

(Fellow 4: Research, reading, QI)

CCM Resident/Fellow

In house call• Additional call rooms on 7

• Or contact on call medical resident or Chief Medical Resident

Door password:(1+4)23

CCM Resident/Fellow

Teaching:

• Monday noon: responsible for resident teaching

• Thursday am: present fellow-specific teaching

• Evaluation on family meetings: twice per month

Resident Responsibilities

in-house call about 1:4look after all patient care after hours,

including consults• do not leave the unit unattended if

there is an unstable situation ongoing inside the unit

hand-over at 7:45 Monday – FridayWeekends usually 8:30 am

Resident Responsibilities

Examine assigned patients, manage issues through the day

when in doubt, ask, listen to the nurse!Code team leader: weekdays 8 – 5 onlyPost-call morning:

• order CXR for each patient where indicated• Order ECG for patients where indicated

write transfer orders and a transfer note for each patient being considered for transfer

Infection Control

Consider MRSA & VRE precautions:• Hospital transfers• U.S. hospitals

Influenza precautions (in season) for:• Febrile respiratory illness requiring ICU• Fever & ARDS NYD• Droplet precautions + N95, no negative

pressure

Infection Control will assess and advise

Infection Control

Pseudomonas and Klebsiella oxytoca• Recent increase in incidence• Transmission from patients and basins• Multidrug resistance

Hand hygiene!Hand audits being done intermittentlyDaily allocation of “Hand hygiene

monitor”

Infection Control

Hand Hygiene

Antibiotic Stewardship Program

Dr. Andrew Morris - ID Physician Dr. Sandra Nelson - ID Pharmacist

Optimize antibiotic utilization Meet Mon, Wed, Fri after rounds: 10 min Recommendations:

• Improve patient care• Education• Cost savings

Family contacts

daily contact is the standard Initial meeting within 48 hr of admission

(standardized format)ensure that consistent communication,

especially with regards to outside servicesend of life discussions should always occur

with the awareness/participation of referring services

Involve our social worker

Research Opportunities

interested residents should speak to individual staff and/or Geeta Mehta

Many ongoing studies in the ICUUnit research coordinators may

approach you about studies

Role of the Bedside Nurse

system review on a daily basisco-ordinate communicationsco-ordinates family meetingsreports to nurse in charge/nurse

manager

Role of the RT

airway management issuesmechanical ventilation issuesBronchoscopyArt line/ PA line setupRT’s do one-on-one teaching on

above:

Role of the Pharmacist

ensures routine prevention strategies for DVT, PUD

aware of important microbiologic data on each patient

Dose adjustment, eg. Renal failureresource person for any other

pharmacy related issue

Role of the Dietician

recommends tube feeding and TPN formulasadvises management for tube feeding

complications (e.g. diarrhea, high gastric residuals)

ensures appropriate diet and supplement orders

adjusts nutrition care based on swallowing assessments (e.g. appropriate p.o. initiation, modified diet education, calorie counts etc.)

Role of Chaplaincy

provides emotional and spiritual support to patient and family during ICU stay

available to attend family meetings, treatment decisions

provides/facilitates religious care end of life care and bereavement supportavailable for staff support and debriefing

(confidentiality observed)past or current religious affiliation

not required for chaplaincy support

For further information

See intranet site:

http://info/intensivecare

Accessible from MSH, TGH, TWH, PMH