Dayshifts
Carry out and document a thorough “daily review” of all patients, then accompany the consultant on the multi-disciplinary ward round. It is your responsibility to ensure that the written daily plan is carried out and that you know what the documented ‘Daily Goals’ of treatment are.
You should make yourself familiar with the unit protocols and in particular with certain procedures/process checklists that we use:
- Central line insertion bundle
- Daily Goals
- Transport checklist
- Intubation checklist
- CXR stickers
- Blood culture stickers
Nightshifts
- Ensure emergency drugs are available and stored in the bag in fridge
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- Checklist of drugs in Medications Section
- Check transport bag
- Replace equipment as necessary
- Check expiry dates on equipment
- Review all patients and write in notes – make sure you know what the documented daily goals of treatment are – you may be tested!!
Ideally referrals for admission to ICU should happen between the referring consultant and the consultant covering ICU. However, circumstances may arise where a junior doctor refers an acutely ill patient without discussion with or the knowledge of the referring consultant. In such a case the ICU trainee should go and assess the patient while the referring trainee contacts their consultant. Preferably the referring consultant will have seen the patient and, at the very least, the patient should have been discussed with the appropriate consultant before referral.
Every case referred will be assessed on an individual basis. The decision on whether to admit to ICU, or not, will be made by the consultant intensivist on call following discussion with the relevant parties. The consultants will make all major decisions on medical treatment, admission and discharge of patients.
Should a patient be admitted directly to ICU from A&E, the receiving junior physician or surgeon should be informed. Please ensure they are aware it is their responsibility to then inform the receiving consultant physician or surgeon of the presence of the patient in ICU. Document the “referring” consultant on every admission to facilitate discharge to parent team.
Should there be no beds available in Raigmore Hospital for a patient deemed appropriate for ICU care, the consultant on-call will locate an ICU bed elsewhere or, more likely, coordinate staffing to facilitate keeping the patient in Raigmore. If a decision is made to transfer a patient out of Raigmore it is the responsibility of the ICU medical staff to stabilise the patient and institute appropriate invasive monitoring for transfer.
The transfer should be discussed with the Intensivist for the receiving unit, and the appropriate Medical/Surgical consultant who will take responsibility for the patient in the receiving hospital should also be contacted by the referring Medical/Surgical team. A transfer letter should be typed, ideally by the referring team not the anaesthetist.
There is no national transfer service for critically ill patients between ICUs, therefore Raigmore medical staff must accompany these patients.
Notes:
A daily review sheet has recently been introduced. Some of the consultants prefer to use normal continuation sheets for documentation, especially with long-stay patients – to guide this there is a laminated template of a structured approach in each patient’s folder. There is a separate sheet for family discussion, although these may also be recorded in the main notes. Microbiology samples are recorded on a yellow sheet in each patient’s folder and results from all tests must be clearly documented.
Bloods:
A blood gas machine is available in ICU. Training will be arranged prior to your arrival. For those who cannot make this training, there are sessions every month which you can attend. Contact biochemistry to arrange training. Once trained you will be issued with a bar code, without which you cannot use the machine.
The morning bloods are taken by the nursing staff responsible for each individual patient, if the patent has an arterial line in place. The nurses are very supportive of junior medical staff and will take additional bloods outwith normal once a day testing, but this is still the doctor’s responsibility if nurses are busy.
Filing:
Filing of blood and investigations results is carried out by the ICU Ward Clerk, as part of her duties. However, it is the responsibility of the ICU Trainee to ensure that all results are reviewed and signed prior to filing. In the event of the clerkess being off, it remains the responsibility of the resident trainee to keep up to date with the filing.
Relatives:
The relatives of the patients in ICU are often under stress and an informative and sympathetic approach is vital. Usually the consultant will discuss a patient’s condition with the relatives, but the Trainee may on occasion be asked to speak with relatives. It is imperative that you know what has already been said and ask a nurse to witness what is discussed. A note should also be made in the patient’s medical notes of what has been discussed and with whom, as detailed above.
Discharges:
Patients will be discharged when, in the opinion of the ICU consultant, they no longer require intensive care. It is the responsibility of the ICU Trainee, to ensure that the Discharge Form is completed and clear instructions are given to the doctors taking over responsibility of the patient. If the patient is being discharged to a general ward, the ICU Trainee must liaise with the primary team and document the discussion. At the time of discharge a decision is made by the consultant intensivist whether the patient would be a candidate for readmission or not. This should be carefully documented.
Deaths:
All death certificates should be discussed with the ICU consultant before being issued. If there is any doubt as to the cause of death in a patient, or if a patient dies unexpectedly, the consultant intensivist should be consulted to see whether the Procurator Fiscal (PF) needs to be informed. There are also circumstances where the PF has to be informed e.g. suicides, assaults, death under medical care (F89), notifiable diseases etc. (Guidance notes pertaining to Death and the Procurator Fiscal can be found on the Raigmore intranet). The death certificate should not be issued in such cases until the case has been discussed with the PF.
If the PF is being informed, the family of the deceased should be told. The family can contact an undertaker, without a death certificate, but they must tell the undertaker that the case is being referred to the PF.
NHS Highland have recently moved to an on-line death certification system “Formstream” a link to which can be found in the Clinical Applications section of the Intranet. On issuing a death certificate, the trainee should ensure that a note as to the cause of death, as well as date and time of death is made in the patient’s notes. Normally a patient’s GP will be informed by the ward clerk, but please can you ensure that this has happened.
Organ donation should be considered for any patient for whom further treatment is considered futile. The Specialist Nurse Organ Donation (SNOD) is based in Aberdeen but happy to be contacted in any circumstances where organ donation may be possible.
Brain Stem Death:
The diagnosis of brain stem death requires the input of two consultants or one consultant and an experienced registrar. NHS Blood and transplant have published some very informative videos to guide medical staff through the testing process
The possibility of organ donation should be considered when the patient is diagnosed as brain stem dead. Provided that the patient meets all the necessary criteria and preconditions, the matter of organ donation should be discussed with the relatives, by the consultant, and the SNOD should be contacted. Information on organ donation can be found in the folder kept at the nurses’ station.
If there is the likelihood that the case will be referred to the PF, the possibility of organ transplantation will also need to be discussed with the PF.
Handover:
This should be comprehensive outlining the past medical history, current episode and significant events. Any plans for organ support would be clarified with the day teame.g. if the filter clots is it to continue? There should be a clear plan for ventilation overnight and goals of treatment. Fluid balance targets should be noted and the means to achieve ie CVVH with UF or frusemide or if fluid required which type is preferred.
Changing, starting or stopping antimicrobial treatment in ICU is a big deal and a consultant decision. Ensure that parameters for escalation are documented and the preferred agents already decided. Handover must also include any outliers that the ICU team have been involved with during the day. Escalation plans for patients both within and outwith the ICU should also be communicated.
Highland Critical Care 