Mount Sinai ICU

1. Mount Sinai ICU

2. Mount Sinai ICU 16 bed medical-surgical ICU Closed 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

3. 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

4. Sources of consults / admissions MSH inpatients ACCESS OR/PACU emergency department PMH inpatients Criticall

5. 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

6. Admit decisions Assess patient, decide on ICU admission Discuss with fellow, attending, charge nurse if no resources available, speak to your attending staff Do not refuse admission without discussing with attending

7. 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

8. Admission orders - preprinted

9. Admission orders – Medication reconciliation

10. 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

11. 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 discharge Prior to discharge to Medicine: Assessed by Medical floor nurse Assessed by GIM housestaff

12. Discharges Dictate or web form: - discharges home - deaths - transfers to another hospital (eg. PMH) Deaths: - complete yellow M&M form - consider organ donation, autopsy

13. Discharge summary accessible via Powerchart Name, MSID, Family doctor, attending, admission and discharge dates all populated Dictation: web form

14. 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

15. 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

16. 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

17. Mount Sinai’s Critical Care Response Team 24/7 service: Nurse 24 hrs, fellow, attending ACCESS team

18. 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!

19. Daily rounds Resident summarizes problems Nursing report: head-to-toe RT: mechanical ventilation Pharmacist: medications Labs Management plan Checklists: CRBSI, VAP

20. Daily notes Daily note: “ICU Rounds”: Problem list New issues Plan Orders Check/confirm at the end Quality improvement checklists

21. 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

22. 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

23. Procedures central venous and arterial lines Ultrasound: lines, chest, echo PA catheters intubation Bronchoscopy Intraosseus line insertion Cardioversion Chest tube insertion

24. Procedures Simulation teaching Supervision: by fellow or attending Procedure notes: preprinted form Procedure logging: POWER

25. Procedures Backup for procedures: Fellow and Attending Don’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

26. 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!

27. 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

28. 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

29. 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)

30. 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) 2 3

31. CCM Resident/Fellow Teaching: Monday noon: responsible for resident teaching Thursday am: present fellow-specific teaching Evaluation on family meetings: twice per month

32. Resident Responsibilities in-house call about 1:4 look 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 – Friday Weekends usually 8:30 am

33. Resident Responsibilities Examine assigned patients, manage issues through the day when in doubt, ask, listen to the nurse! Code team leader: weekdays 8 – 5 only Post-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

34. 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

35. Infection Control Pseudomonas and Klebsiella oxytoca Recent increase in incidence Transmission from patients and basins Multidrug resistance Hand hygiene! Hand audits being done intermittently Daily allocation of “Hand hygiene monitor”

36. Infection Control

37. Hand Hygiene

38. 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

39. 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 services end of life discussions should always occur with the awareness/participation of referring services Involve our social worker

40. Research Opportunities interested residents should speak to individual staff and/or Geeta Mehta Many ongoing studies in the ICU Unit research coordinators may approach you about studies

41. Role of the Bedside Nurse system review on a daily basis co-ordinate communications co-ordinates family meetings reports to nurse in charge/nurse manager

42. Role of the RT airway management issues mechanical ventilation issues Bronchoscopy Art line/ PA line setup RT’s do one-on-one teaching on above:

43. Role of the Pharmacist ensures routine prevention strategies for DVT, PUD aware of important microbiologic data on each patient Dose adjustment, eg. Renal failure resource person for any other pharmacy related issue

44. Role of the Dietician recommends tube feeding and TPN formulas advises 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.)

45. 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 support available for staff support and debriefing (confidentiality observed) past or current religious affiliation not required for chaplaincy support

46. For further information See intranet site: http://info/intensivecare Accessible from MSH, TGH, TWH, PMH