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The Royal London Hospital

Adult Critical Care Unit

Trainee Survival Guide

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Welcome to

The Royal London Hospital Adult Critical Care Unit (ACCU)

TRAINEE SURVIVAL GUIDE

Click on a chapter to take you straight there

If on a trust computer the hyperlinks will take you to the relevant intranet page

Table of Contents GENERAL INFORMATION AND ORIENTATION ......................................................... 4

A Brief Guide to some of the ACCU Staff ................................................................. 5 The ACCU Consultants ............................................................................................. 6 ACCU Wireless / DECT Phone Numbers ................................................................. 7 Nursing Staff ............................................................................................................. 8 Trainees and Rotas ................................................................................................... 8 Sick Leave .................................................................................................................. 8 Post ............................................................................................................................ 8 Trust E-mail .............................................................................................................. 8 Appraisal and Assessment ....................................................................................... 9 Trust grade doctors NOT on a training program and revalidation ...................... 9 Clinical Governance ................................................................................................ 10 Audit and Research ................................................................................................ 13

INFECTION CONTROL ................................................................................................ 15 MRSA Policy ............................................................................................................ 16 Blood Cultures ........................................................................................................ 16 Antibiotics ............................................................................................................... 16 Antibiotic Guidelines .............................................................................................. 17 HIV Testing on ACCU .............................................................................................. 17 Central Venous Line Insertion ............................................................................... 17

THE DAY-TO-DAY RUNNING OF THE ACCU ............................................................ 19 Bleeps ...................................................................................................................... 19 The Trainee Rota (PLEASE READ THIS) ............................................................... 20 Locums .................................................................................................................... 22 The Daily Plan (Monday to Friday) ....................................................................... 24 Weekends ................................................................................................................ 25 Liaising with the consultant in charge .................................................................. 26 Help from Anaesthesia ........................................................................................... 26 Admissions .............................................................................................................. 26 Patients’ Notes ........................................................................................................ 27 Critical Care Transfer Summaries ......................................................................... 27 What to do when a patient dies on ACCU ............................................................. 29 Other Letters to GPs ............................................................................................... 30 Microbiology Ward Round .................................................................................... 30

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Emergency Buzzers on ACCU ................................................................................ 30 Imaging/Investigations.......................................................................................... 31 On Call Rooms ......................................................................................................... 32 Multi-function Device ............................................................................................. 32 Security ................................................................................................................... 32

PHARMACY ................................................................................................................. 33 Contacting a Pharmacist ........................................ Error! Bookmark not defined. Pharmacy Induction ............................................... Error! Bookmark not defined. Drug Charts ............................................................. Error! Bookmark not defined. Prescribing Issues .................................................. Error! Bookmark not defined. Links to Medicines Related Policies ...................... Error! Bookmark not defined. Antibiotics ............................................................... Error! Bookmark not defined. Vancomycin ............................................................. Error! Bookmark not defined. Emergency Drug Box .............................................................................................. 40

COMMON CLINICAL ENCOUNTERS ON THE ACCU ................................................. 41 Airway Emergencies on ACCU ............................................................................... 41 Major Head and Neck Surgery at the RLH ............................................................ 41 Renal Replacement Therapy (RRT) on ACCU ...................................................... 41 Possible Displaced / Blocked Tracheostomy? ..................................................... 42 Fasting for Theatre ................................................................................................. 43

CLINICAL SITUATIONS OUTSIDE THE ACCU ........................................................... 44 Airway Management Outside the ACCU ............................................................... 44 Grab Bags, Transfer Bags & Transfer Equipment ................................................ 45 Assistance Outside the ACCU ................................................................................. 45 Critical Care Outreach Team (CCOT) .................................................................... 45 CT Scanner .............................................................................................................. 46 MRI Scanner ............................................................................................................ 46 Interventional Radiology ....................................................................................... 46 Transfers to other ICUs (Clinical and Non-clinical) ............................................. 46

ORGAN SUPPORT IN AREAS OUTSIDE THE ACCU .................................................. 47 EQUIPMENT (courtesy of Richard Aldridge) ........................................................... 48 Transport equipment ................................................................................................. 50 Consumables & stores ................................................................................................ 50 Stock control ............................................................................................................... 50 MANAGEMENT ALGORITHMS AND THE ROLE OF THE ACCU TRAINEE .............. 51

Trauma Call ............................................................................................................. 51 Code Red Trauma Call ............................................................................................ 55

APPENDIX ................................................................................................................... 58 Red Transport Bag ................................................................................................. 58 Green Grab Bag ....................................................................................................... 59

This document is constantly evolving and all contributions / suggestions / corrections / additions etc. gratefully received, especially from trainees who have experienced the Royal London ACCU! Thanks. Chris Kirwan & Russ Hewson February 2016

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GENERAL INFORMATION AND ORIENTATION Welcome! The Royal London Hospital Adult Critical Care Unit is a 44-bedded mixed level 2/3 unit, with capacity for up to 22 level 3 and 22 level 2 patients. Level 3 Case-mix is varied, with approximately 30% surgical, 30% trauma and 40% medical patients. We admit ~1000 level 3 patients per year as well as ~2000 Level 2 patients – it’s busy!

The unit regularly uses ICP and other advanced neuro monitoring, proning and other advanced respiratory support, a variety of minimally invasive cardiac output monitors and we provide renal replacement therapy for ~10% of all admissions (twice the national average). Geographically, the unit consists of two 22 bedded wards (4E and 4F). Each 22 bedded area is sub-divided into 4x4 bedded areas and 6 side rooms (of which 4 side rooms are interconnected). There are 4 single, negative pressure side rooms. The 2 areas are called wards 4E (generally level 3) and 4F (generally level 2). Operationally, 3 teams run the ACCU, which are colour-coded. Team A (orange) beds 1 to 14. Team B (green) beds 31 to 44. Team C (blue) beds 15-30. Each team has a consultant and a senior nurse and a set of trainees. The overall patient mix of teams A&B will comprise up to a maximum of 22 level 3 beds and 6 level 2 beds. Though this can be flexed in special circumstances. Team C is Level 2 only (occasionally there have been Level 3 patients in this area though this is NOT routine and is a consultant / senior nurse only decision). At the weekends and overnight there are only two consultants covering, they take responsibility beds 1-22 and beds 23-44 each but the 3 nursing teams remain. The two 7 man trainee rotas will always be based within team A and B but are expected to assist the Team C trainees in emergencies. The 16 man rota is split across Teams A, B and C. At night there are 4 doctors from 22:00 until 08:00. Although it is nominally split so there are 3 covering Teams A&B and a 4th covering Team C you should all work together and help each other out when things are busy or if there is an emergency etc. In effect we are all one Critical Care Team. The first port of call from 22:00 until 08:00, for any query, is the ‘first on’ consultant.

Almost everything you need to know can be found on the ‘I-drive’. I:\surgery_&_anaes\ACCU

If you cannot access the ACCU folder, please check with Angela Vai x40345 in the administrators’ office that you are in the ‘_ACCU Trainees’ email group, if you are then contact Dr Russ Hewson

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A BRIEF GUIDE TO SOME OF THE ACCU STAFF CONSULTANTS Dr Marie Healy - Clinical Director for Division of Surgery

Dr Lynne Barrass Dr Nick Bunker Dr Julia Hadley Dr Russ Hewson Dr Dan Kennedy Dr Chris Kirwan Dr Andrew Leitch Dr Louise McWhirter:

Dr Ming Li Kong Dr Michael O'Dwyer* Professor Rupert Pearse* Dr John Prowle* Dr Peter Shirley Dr Mo Thavasothy Dr Vishi Verma Dr PJ Zolfaghari

*50:50 split between academic and clinical duties (:NB: Dr Louise McWhirter is currently on maternity leave) MATRONS Helen Hewitt Nicola Rudkin SENIOR PHYSIOTHERAPIST Jayne Manners Sally Kalsi PHARMACISTS Lauren Vanier Rory McKenna Susan Ramsay SENIOR TECHNICIAN Richard Aldridge DIETICIANS Evi Kyriakidou Lydia Hill

SENIOR WARD CLERK Sue Dorey SERVICE COORDINATOR Rajena Sampat ADMINISTRATORS Angela Vai Shafiul ‘Shaffy’ Hoque SPECIALIST NURSES IN ORGAN DONATION James Feely-Henderson Collette Day Hayley Heanes Michelle Tyler Lois Payne Bobbee Cotter

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THE ACCU CONSULTANTS

Dr Lynne Barrass Dr Nick Bunker Dr Julia Hadley Dr Marie Healy Dr Russ Hewson

Dr Daniel Kennedy Dr Chris Kirwan Dr Andrew Leitch Dr Louise

McWhirter

Dr Ming Li Kong

Dr Michael O’Dwyer Prof Rupert Pearse Dr John Prowle Dr Peter Shirley Dr Mo Thavasothy

Dr Vishi Verma

Dr PJ (Parjam)

Zolfaghari

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ACCU WIRELESS / DECT PHONE NUMBERS

45711 ACCU Consultant Team A

45712 ACCU Consultant Team B

45713 ACCU Consultant Team C

45714 ACCU HDU Trainee

45715 ACCU ICU Trainee (bleep 1113, 1480, 0814)

45717 Nurse in charge Team A

45716 Nurse in Charge Team B

45718 Nurse in Charge Team C

45643 Matron

45754 ACCU Bed Manager

To Bleep

81 – ‘Press Call button’ – bleep number – phone number

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THE ACCU IN GENERAL Nursing Staff Like all critical care units in London, recruiting and maintaining nurses is difficult. We have a lot of excellent nurses from all sorts of backgrounds both clinically and geographically and some are not only new to critical care but also new to London! You will find that the ICU nurses are extremely approachable and they will always be willing to help you and give advice. If you have any problems with the nursing staff please talk to the Band 7 in charge and, if necessary, the consultant on call or Matron if required. Trainees and Rotas There are 32 (sometimes more and sometimes less) trainees in 30 rota slots, working within the ACCU and you come from a variety of backgrounds. There are three rotas:

Two 7-person rotas based on 4E which are staffed with Anaesthesia / ICM trainees (who are airway trained i.e. >6/12 anaesthesia).

One 16 person rota based across 4E and 4F (which will also have some airway trained people who can equally well use their skills during their placement)

Dr Russ Hewson is the consultant with overall responsibility for the trainees and Dr Chris Kirwan is the consultant with responsibility for the trainee rota. There are some in depth rules covering the rota later on in this guide – PLEASE READ THEM Sick Leave If you are unable to come to work because of illness you must inform the ICU consultant in charge as early as you can (ext. 45711). Angela Vai and Shafiul Hoque (ACCU administrators) must also be informed about all sick leave. Extension 40345/6 or angela.vai@bartshealth.nhs.uk. or shafiul.hoque@bartshealth.nhs.uk Do not forget to let Angela and Shaffy know when you have returned to work. Post Post for the anaesthesia trainees may be sent to the Anaesthetics Department where you will have a post slot. Please label one of the pigeon holes in the 4E doctors’ office for post delivered to ACCU. Trainee payslips are also delivered to the 4E doctors’ office. Trust E-mail You should each obtain a Trust log-in (for computer access and e-mail). It is Trust policy that all employees regularly check their trust email. Important information is often sent by this route and therefore it is YOUR RESPONSIBILITY to check it regularly. We are no longer going to send information (i.e. rota, teaching

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timetables etc.) to personal email addresses. You can access the trust email from www.bltpn.bltnet.co.uk Alternatively, to sync your smart phone to the trust email system, which some of you may find easier, please follow the following steps:

Go to "settings" select "mail, contacts, calendars", Go to "add account", choose "Exchange" Put in your email and password (this will need to be updated when you

renew your login as and when your are asked to by the Trust computer systems)

Put "mobile.bartshealth.nhs.uk" in server box Put "live.trust.xblt.nhs.uk" in domain box Enter your username (not your email address) and password (as above).

Appraisal and Assessment All trainees who rotate to the RLH ACCU will be allocated a consultant as their educational supervisor. Dr Hewson will allocate supervisors but feel free to discuss problems, clinical or otherwise, with any of the consultants. You should arrange an appraisal date within two weeks of starting on the ACCU to set some educational objectives for your period on the unit. We will do an assessment at the end of each three / six month ICU module for each of you and this will be discussed with you and submitted for your ARCP/RITA. We welcome constructive feedback on the ICU module and you are encouraged to complete a feedback form (anonymously if you wish). We hope that this document helps you to familiarise yourself with the ICU. Let us know if there are other issues which you feel need to be addressed in this document. Trust grade doctors NOT on a training program and revalidation It is a statutory requirement to have annual appraisals that form part of your revalidation by the GMC (The ARCP counts for this). Doctors who are in an OOPE/R etc. and working on the ACCU will still be in an ARCP program so this paragraph does not apply to you. If you are not in a deanery training programme and not receiving an annual ARCP / RITA assessment then you have to undergo formal appraisal once a year. You can do this at the RLH through the Trust PReP system. If you are a Trust Doctor / Clinical Fellow, then this applies to you. - If you only have a 3 or 6 month contract and the period does not cover your

revalidation due date or when you are due your annual formal appraisal, you DO NOT need a PReP account (though one will be set up if your contract is extended). At the end of your job, please ask your educational supervisor to use a blank output form (ACCU folder / Trainees / Appraisal OUTPU form) to provide structure to a local assessment of your clinical work, which you could then take to your next employer to confirm your work has been reviewed in a fashion suitable for revalidation.

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- Early in your placement please contact the Medical Directors Office 020 7377 7329 (or email carla.martins@bartshealth.nhs.uk) to get registered on the PReP system if you need to. Make your educational supervisor aware, as they will have to conduct a formal appraisal with you when you finish the post. This is a joint responsibility between you and your supervisor. You risk not being revalidated if this is not completed.

Clinical Governance - Morbidity and Mortality (M+M) The unit has a rolling programme of clinical governance, which includes a mortality/morbidity meeting and a multi-disciplinary Governance group. Following a death a summary of the patients ACCU is drafted (this is the same

summary used for coroner’s referrals or cremation forms – see later). This is reviewed

the next available Monday and cases of concern/interest identified.

These cases are then allocated to trainees and a presentation of the case should be

prepared for the next Monday afternoon. This should involve relevant results, imaging

and data as appropriate. There is a critical care proforma available at

I:\surgery_&_anaes\ACCU\M&M The ICNARC office may be able to help with some of the fields and Angela or Shaffy will help with the notes. The discussion should involve the whole multi-disciplinary team and the outcome will be recorded. This may generate some action points that will be fed back into the ACCU Governance group. Any problems please email Dr Nick Bunker. - Incident Reporting and Serious Untoward Incidents (SUI) The Datix Incident Reporting system can be accessed via the Barts Health intranet homepage- third item on the “I want to” drop-down menu on the right hand side. They should be reported to Jo Tillman, the ACCU Matron. If you have been involved in an SUI, try and attend the SUI meeting (along with one of the ACCU consultants) it is a useful learning exercise. - NG Tubes Following some Never Events, the Trust has mandated that all doctors interpreting chest x-rays for confirmation of placement of NG Tubes should have been trained to do so. The training package and competency test can be accessed at http://bold.bartshealth.nhs.uk/ . You will need your assignment (payroll) number to create an account.

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Educational Opportunities

Time Meeting Venue

Monday 16:00

Morbidity and Mortality meeting (M&M)

ACCU Seminar Room (3&4)

Tuesday 08:00 to 08:30 (compulsory if on shift)

ACCU Teaching / Journal Club

4E Doctors Office

Tuesday 12:30 to 13:30

Medical Grand Round

Education Centre

Wednesday 08:15 to 09:00

Trauma Radiology Meeting

Clinical Radiology Meeting Room (1st Floor)

Thursday 08:00 to 08:30 (compulsory if on shift)

ACCU Teaching / Journal Club

4E Doctors Office

Thursday 12:30 to 13:30

Academic Trauma Meeting / M&M

ED Seminar Room (corridor leading from Resus)

- ACCU Teaching and Journal Club Every Tuesday and Thursday morning at 8am there is either a journal club led by a trainee or a teaching session led by a consultant, allied health professional or senior trainee. This is timetabled and therefore compulsory when on shift. The rota for this can be found on the I drive I:\surgery_&_anaes\ACCU\Medical Education Names are allocated to journal club sessions so you must check it to see when you are due to present. This folder also contains journal club guidelines and a selection of essential papers for you to choose from. Please make sure the paper has not already been done for the current trainee group. If you have another paper that is not in this folder, which you would prefer to present then feel free. Journal club discussion tends to be most beneficial and interesting if attendees have read the paper in advance so please let the consultant and your colleagues know which paper you plan to present. At least one of the consultants on for the week should be there to chair the session. - Trauma radiology meeting Excellent sessions run by a consultant radiologist, reviewing interesting trauma images from the preceding week. Obviously this clashes with handover. But it is

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often worth sending some trainees working standard days (and medical students)

- Trauma meeting Local and external speakers on trauma topics. Once a month M&M: review of all deceased trauma patients. - Critical Care Academic meeting Usually the last Monday of the month at 5 pm (in ACCU Seminar room 3/4). Publicised on a per-meeting basis. Other things you may wish to do for your own education: - ICU Follow-up Clinic - First Thursday of the month. Please contact Vishi Verma if interested. - Tracheostomy ward round - Tuesday lunchtime. - Anaesthetist, Max-fax, Physiotherapist, Speech Therapist. All patients in hospital with traches! If interested contact Dr Helen Drewery, consultant anaesthetist. - Critical Care Outreach Team (CCOT) - Join CCOT for a day or half a day (especially useful for junior trainees new to critical care)

- HEMS clinical governance days These occur monthly and are advertised by e-mail - Nursing day - very useful for those completely new to critical care. Arrange the day before with the nurse in charge in order to be allocated to work with an appropriate nurse and patient. ECHO TRAINING If you are interested in achieving FEEL / FICE accreditation, current mentors on the ACCU are Dr Lynne Barrass and Julia Hadley. Please speak with one of them.

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Audit and Research - Audit We participate in ICNARC, the National Intensive Care Audit database and almost all the consultants are continually involved in some sort of research, audit or data collection. Dr Julia Hadley has a list of audit projects being done or ones we need trainee help with for those of you who are interested. Please see her early in the rotation if you want to get involved – It’s probably a good idea to meet your educational supervisor first to make sure that an audit is an appropriate way to spend your time on the ACCU. If you have your own ideas for audit projects, all the better! Please discuss with Dr Hadley or your educational supervisor who can put you in touch with an appropriate member of the team. All audits must be registered with the Clinical Effectiveness Unit, via Dr Hadley. Further information about audit activity, results of recent audits and registration forms can be found at I:\surgery_&_anaes\ACCU\Audit\ACCU clinical audit program. - Research Professor Rupert Pearse, Drs Michael O’Dwyer and John Prowle all hold substantive academic positions within the Medical School. They have a number of PhD and MD students under their supervision and have a broad research portfolio but specialise in Peri-operative Medicine, Genetics in Critical Illness and AKI. If you are interested in discussing research and are considering trying to gain a higher degree at some point during your training they are happy to be contacted to offer help and advice. Many other consultants are also substantially involved in research (for example Drs Chris Kirwan holds an Honorary Senior Lectureship within the Medical School) so if you have any questions or an idea you want to talk through, ask around, there is likely to be someone who can help you! There are also a number of portfolio studies taking place on the unit and an active group of research nurses who you will notice wandering around the ACCU, screening patients and keeping you up to date with what projects are on the go. Please let them know if you think there is a patient who may be eligible for a study. There is a notice board in the 4E Doctors’ office detailing current research activity on the ACCU, which is updated daily by the research team reminding us of the studies we are recruiting for and our recruitment progress.

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- Projects, Presentations and Funding If you do a project, audit, data collection etc. whilst on the ACCU and this gets written up and accepted as an abstract somewhere then there are some funds that can support your travel and registration to that meeting. Applications are open to all members of the ACCU trainees (research and clinical) and assessed on their individual merit but preference will be given to those who do clinical work on the ACCU. There is an upper limit of £600 but we will gladly discuss all applications and can make exceptions. We appreciate that you may have left the unit by the time your data is presented but as long as the data was collected from the RLH ACCU you are eligible to apply. Please contact Chris Kirwan or Dan Kennedy if you feel you qualify!

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INFECTION CONTROL We continue to have outbreaks of hospital-acquired infection and previous audits have highlighted that infection control procedures need to be improved upon. Please ensure high standards are maintained at all times and challenge poor practice. If poor practice is witnessed staff will be issued with a warning notice. If standards do not then improve this could lead to disciplinary action. Infection control practices are regularly audited locally and Trust wide – Big Brother is watching so in the interests of reducing cross infection and to improve patient safety please note the following: - General practice

Alcohol hand gel must be used before and after any contact with the patient and the ACCU equipment at the patient’s bedside, including the notes and the 24 hour charts.

Use a disposable apron when you are attending to your patient or making any contact at the bed side.

Only use gloves if likely to have any contact with bodily fluids and always wash hands after using gloves.

When helping with a patient at another bedside, please use a clean apron from that bed area.

When a patient is suspected of having infectious diarrhoea you must wash your hands with soap and water after contact.

- Visiting Teams

Please restrict visiting teams to a maximum of three when they visit the patient bedside on the ACCU. All teams will have been informed of this and it is our job to enforce this and report staff who do not comply.

All staff (including visiting teams) must be ‘bare below the elbows’ when in the clinical setting. Please ensure that staff remove all watches and jewellery worn below the elbows and roll up sleeves prior to entering the clinical area.

- Policies and training

Ensure all new admissions to ACCU are screened for MRSA as per policy (see below) and that the MRSA protocol is started.

Ensure that the infection status of all patients is known and is part of the daily handover. It is your responsibility to know the infection status of patients on the Unit and act accordingly

Patients with infectious diarrhoea open pulmonary TB and certain other infections should ideally be isolated. If they are not isolated, please document why this decision has been made. Please liaise with the consultant in charge and the infection control team if unsure.

Always comply with ANNT (aseptic non touch technique) and ensure that others also comply.

Ensure lines and invasive devices are cared for and used according to

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Trust and Unit infection control guidelines. I:\surgery_&_anaes\ACCU\Policies and Guidelines

Maintain up to date infection control training – this is part of your mandatory training when you join the Trust.

MRSA Policy Please ensure you are familiar with the screening and eradication protocol which can be found in the Induction folder on the I drive I:\surgery_&_anaes\ACCU\Policies and Guidelines All our emergency admissions should be treated as ‘High Risk’ MRSA prophylaxis / treatment status as well as next review date should be completed daily on the pink Care Bundle forms. Please note that patients allergic to peanuts should NOT be prescribed naseptin – though this is not routinely used for prophylaxis Blood Cultures The contamination rate of blood cultures (BC) taken on the ACCU is very high with approximately 50% of all positive cultures being coagulase negative staphylococcus aureus. Blood cultures should be taken as per the Trust guidelines from a peripheral stab (http://bartshealthintranet/About-Us/Corporate-Directorates/Medical-Directorate/Infection-prevention-and-control/Index.aspx). If you also want to take BC from a central venous catheter then pair them with peripheral cultures and label them as such. Do not take BC from arterial lines except in exceptional circumstances. Antibiotics Repeated audits of antibiotic prescribing and administration reveal large gaps between the 2 events, up to 20 hours in one case! It is not acceptable to prescribe an antibiotic and then just walk away from the bed-space. You should:

Tell the nurse looking after the patient that you have prescribed it. Time subsequent doses at 6/8/12 (or whatever) hour intervals from the

first dose (i.e. 8 hourly drugs need not always be given at 06:00, 14:00, 22:00)

Tell the nurse it is important that it be administered as soon as possible (sometimes this may mean immediately).

If it does need to be given straight away, ascertain whether or not this feasible

(the antibiotic may or may not be standard stock) Check back in half an hour to see if the antibiotic has been given. If not, find out why and what is being done about it.

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Some of these problems will be solved by ePrescribing as the paperless ACCU is rolled out across the unit, but you should still check!

Antibiotic Guidelines The Barts Health Antibiotic guidelines have now been published on the ‘microguide’ app

For apple OS: 1) Go to app store 2) Search and download microguide

(from horizon strategic partners limited)

3) Select Barts Health NHS Trust 4) Click continue 5) Download adult antimicrobial guide

For android OS: 1) Go to Play Store 2) Search and download microguide

(from horizon strategic partners limited)

3) Select Barts Health NHS Trust 4) Click continue 5) Download adult antimicrobial guide

For those who haven’t got smartphone, please use the link below http://microguide.horizonsp.co.uk/viewer/barts/adult HIV Testing on ACCU In accordance with national guidelines, because the prevalence of HIV in Tower Hamlets is >0.2%, all emergency admissions are routinely tested for HIV. Detailed information about this process can be found at I:\surgery_&_anaes\ACCU\Policies and Guidelines Central Venous Line Insertion All central venous (CV) lines need to be inserted with strict adherence to our local ICU policy which is modified from the Trust guidelines and available on the I drive in the ACCU folder. I:\surgery_&_anaes\ACCU\Policies and Guidelines At induction you will be asked to document your current competence and knowledge of safe line insertion technique. If you do not feel confident inserting lines independently please let the senior ICU trainees and your educational supervisor know as we can help train you. In summary, when you place a central venous catheter you must use full aseptic technique including gown, gloves and a mask and clean with 2% chlorhexidine / 70% alcohol solution (not 0.5% chlorhexidine). It must be documented, either by filling out and placing in the notes the sticker usually found inside the line insertion pack or by writing directly into the notes. Following insertion of all CVCs:

Confirm venous placement by transducing the line to confirm a venous pressures and/or waveform.

When venous placement is confirmed, the line can be used with immediate effect.

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A chest X-ray is NOT needed following insertion of uncomplicated right internal jugular CVCs under ultrasound. DO a chest X-ray after insertion of:

Subclavian vein CVCs (higher risk of pneumothorax); Complicated internal jugular CVC insertion (multiple passes, small veins,

multiple previous CVCs / vascaths / tunnelled HD catheters); Left internal jugular vascaths (ensure that the line is not tenting the SVC) Remove old lines within 30 minutes of insertion and confirmation of new

line.

Access for CRRT

There is a myriad of data which supports confirms that the correct placement of CV access for CRRT improves filter life span (including from this unit). Please ensure you use the correct length line and aim to get the tip of the CV line in (at) the right atrium / lower SVC for lines placed in the IJ or (in the rare occasion you used it) the SC vein. All femoral lines should be the longest line available.

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THE DAY-TO-DAY RUNNING OF THE ACCU

Bleeps There are three bleeps available for use each day on the ICU, two of which must be carried by the airway trained trainees. All bleeps MUST be answered promptly If any of the bleeps are malfunctioning you must take them to Switchboard (behind the security desk at Stepney Way entrance) and rectify any faults as soon as possible. Bleep 1113 should be held by the C day on the 1113 rota, and be handed over to the equivalent doctor on call at night. This is the only bleep which receives both cardiac arrest and trauma calls, and all emergency and fast bleeps to other parts of the hospital. It also tends to receive ward referrals etc. and generally coordinates calls from other teams, CT scan arrangements etc. It must be carried at all times and answered promptly. Please ensure that it remains charged at all times. Bleep 1480 also receives all cardiac arrest and trauma calls but not fast bleeps or emergency bleeps. This should be carried by the Team B C day The first runner should carry 0814. This doctor will be the first responder to trauma and arrest calls. If multiple emergencies are happening at once (2 x trauma teams needed etc.) the Team A C day (i.e. coordinator) will allocate the next trainee to attend. At night there are four other anaesthetic trainees in the hospital. The senior SpR on-call carries bleep 1220. You should always liaise with your colleagues each evening as you may need them to give you a hand, particularly in an emergency or if you are very busy. The paediatric SpR carries bleep 1061, the obstetric and acute pain SpR carries bleep 1326 and the anaesthetic SHO carries 0028. Please do not hesitate to contact one of your colleagues if the consultant is not immediately available in an emergency.

ALL ADMISSIONS ARE TO BE DISCUSSED WITH THE FIRST ON CALL ACCU CONSULTANT

AT LEAST ONE AIRWAY TRAINED DOCTOR (Anaesthesia or ICM) MUST REMAIN ON 4E AT ALL TIMES

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The Trainee Rota (PLEASE READ THIS)

There are some specific rules and responsibilities associated with the trainee

rotas. The shifts are as follows

S 08:00 – 17:30 C 08:00 – 21:00

N 20:00 – 09:00 L 14:00 – 22:00

There are 3 rotas: 2x7 person rota’s which are differentiated as the 1113 rota and second

airway rota which are based primarily on ‘ICU’ which are beds 1-14 & 31-44 (i.e. level 2/3 beds)

1x16 person rota which is split across the ICU and HDU (beds 15-30 i.e. level 2 beds only) o This is NOT a 3rd rota as such and will contain senior and junior trainees o This rota will contain some airway-trained people (anaesthetics and ICM).

They can be runners, attend trauma calls etc. Use their skills appropriately!

o We encourage the C day on 4E to volunteer to coordinate the B side when they are rostered there to gain experience in leadership and critical care management – this role should not be assumed to the 2nd airway C day

Minimum Rota Requirements From each of the two 7 man rotas, there must always be S, C, N shift every

week day and a 1 x C and N shift at the weekend The 16 man rota must always provide 2xC and a N for the HDU and 2xS, a C

and an N to the ICU every weekeday. Over the weekend it provides, 2C and 1N for the HDU and 1C and 1N for the ICU

There must be 2 L days across the unit, one for Team C (HDU) and one between Teams A+B. This can be cross covered but the Team A+B L MUST be airway trained. This flexibility is to allow L days to be taken off as leave.

Rota Administration Only trust emails will be used to contact you – if you do receive

correspondence on your personal email, this is fortunate but is NOT a guaranteed method of communication

There will be a rota co-ordinator (one of the trainees) for the 2x7 man rotas and a separate one for the 16 man rota – find out who they are!

There is never a final version as things may / always change but, once your annual leave has been approved by the rota co-ordinator by email then you can be assured that this time is off.

You do your own swaps and email the rota coordinator with solutions, which they will then update the rota accordingly – you do not have editing rights on the rota – it is password protected!

o The rota coordinator does not do swaps for you If you have an exam and it is proving difficult to get the time off - email the

rota coordinator and Dr Kirwan together and we can make a plan

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DO NOT copy in Dr Kirwan (or any of the administrators) for routine swaps and leave requests – it wastes space in our inbox! You do not need to fill in extra leave forms, your rota coordinator will keep a tally of the leave you have taken – be honest

You are band 1A and this is a legal, EWTD compliant rota - we have checked it many times so you don't need to, but we do regular diary card monitoring exercises which we expect you to fill in honestly; You may leave late (e.g. you are stuck in CT scan or resus etc.), which you must mention (unless it is of your own accord for educational reasons e.g. to observe a specific procedure). You also may leave early, commonly after handover at 8:00 or 20:00. This leeway is built into the system so we also would expect you to record it. Because of the out of hour’s commitment these rotas will never be down-banded, that is until our health secretary decrees it…..

They are rolling rotas so some may do the odd S, C, L or N more than others; it’s the way it is.

The trainees on the 7 man rotas must support the HDU fellows, especially overnight – you are part of one big ACCU family!

You can swap between the two 7 man rotas, but you cannot swap a C or N with the 16 man rota and vice versa – this is to do with the allocation of airway trained staff (in exceptional circumstances this is possible if the person is airway trained, but it must be discussed with Dr Kirwan).

If you are on the 1113 rota, you’re expected to carry this bleep when you are on a C day and coordinate the work (usually senior ICM trainee or senior anaesthetic trainee) and lead the A side – see below

Bank Holidays

If you work on a bank holiday for 4 hours you are entitled to ½ a day in lieu If you work on a bank holiday for more than 8 hours, you are entitled to a

‘day in lieu’. o Please email the rota coordinator when you are using an ‘in lieu day’.

You can take the ‘in lieu’ days prior to working a bank holiday to ensure you take all the leave you are entitled to as leave requests often become congested.

If you fail to book all your leave by the time you finish the post, there will NOT be any compensation or ‘payback’ for the days you did not take as there is more than enough opportunity for everyone to have all their leave during the period they are with us.

Carrying Leave over from another job

As this is a new job for all who rotate into it, you can only have ¼ of your allocation in 3 months if that is your placement and ½ of it in 6 months. You cannot carry over leave into this job or from this job into another job.

Fixed Annual Leave

Some (but not all) annual leave is already built into all three rotas, o 7 man rota’s

There is one A/L day incorporated into the 7 week rolling pattern.

o 16 Man rota

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There are 5 A/L days incorporated into the 16 week rolling pattern.

Study Leave

We hope you are sensible about organising your study leave and try to be flexible.

There needs to be a good reason i.e. course, conference, defending their thesis etc. – however, only one course / conference per placement

o Exceptions to this can be discussed with Dr Kirwan if you are presenting / teaching at a course / conference but do not assume it will be okay.

You can have 1 day for revision for an exam as long as the rota is otherwise staffed to minimum standard

You are expected to come to work on their ARCP day but can leave early or arrive late or go and come back depending on the time

Dr Kirwan is happy to discuss exceptional circumstances which are proving difficult to swap

The rota coordinators are given additional study leave to facilitate organising the rota

Christmas Rota (when applicable) There will be a separate rota for the two weeks covering the festive period

and we will endeavour to have this available by the first week of November DO NOT book any leave / flights over Christmas prior to this unless it has

been approved by Dr Kirwan - which he will do for exceptional circumstances, after discussion, and if it is possible. He appreciates the need to book long haul flights well in advance.

Locums and iPOINT We often have locum slots available so there is opportunity to earn some

extra cash! Please ensure you are registered with the Trust Bank through iPoint. The ACCU administrators’ office can help you with this if you did not do this

during Trust induction. NB: Please inform Angela Vai and Shaffy Hoque (administrators) once you have registered with iPoint.

We can only offer locums to current employees through iPoint – it is an efficient system and pays weekly

Once registered it is possible to remain on the system after your contract has finished (you need to tell them) and you can return to other locum opportunities if you wish

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Trainee Deployment / Responsibilities on ACCU

ACCU

One C-day trainee on 4E and CARRIES BLEEP 1113 – this should be the C day from the 1113 rota and thus should allow for continuity

o Stays on ACCU o “Attaches” themselves to team A consultant o Fields all referrals o Acts as coordinator for the day, deploying colleagues and ensuring

the consultant is kept informed o Would usually be the same person Monday to Wednesday and

Thursday to Sunday

Weekend cover on ACCU: o All trainees for 4E and 4F to meet in doctors’ office on 4E o Work load to be shared across the unit and agreed at morning

hand over

ED

Deployment to ED calls: o General trauma: ST3 and above o Code red: ST5 and above or Consultant o ED Consultant requests help: ST5 and above or Consultant

Outside the ACCU

Supervising colleagues (both ACCU and non ACCU) in ‘remote locations’: o Can only be done under exceptional circumstances o ACCU Consultant needs to be informed and has to agree that this is

appropriate o Clear lines of responsibility and communication to be agreed prior

to the procedure o Check lists, where available, need to be followed

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The Daily Plan (Monday to Friday)

Time Activity

08:00

Handover 4E doctor’s office - start with the ‘MORNING DRILL’ laminated sheet - split into team A+B - C day trainee should be allocated to each side - hand over each side at the same time with your consultant 4F doctor’s office - Team C handover with consultant Tuesdays and Thursdays Teaching will take place before handover for Teams A,B and C

09:00

Trainees begin clerking patients - all patients are to be examined fully

10:00 – 13:00

Consultant ward round

14:00 L trainees arrive – one reports to each team (A,B & C) 17:30

Day consultants hand over to night consultants S day trainees go home

18:00

Evening consultant ward round - a C day trainee should accompany each consultant

20:00

C day trainees hand over to the night trainees

The ICU nurses take routine bloods at approximately 04:00 and the results should be reviewed as soon as they are available (approximately 9am) and management adjusted accordingly. - Day Shift (C and S) One of the C day trainees takes responsibility for co-ordinating the morning handover and carries the 1113 bleep and should be on side A. There should be another C day trainee on side B. The S day trainees should split themselves across the teams bearing in mind the usefulness of continuity. - Late Shift (L) The main role on the L shift is to support the day and night teams. You will find yourself doing a lot of the scans / transfers and be expected to clerk in the patients who arrive late in the day allowing the C day and night trainees to handover in peace (well that is the theory).

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- Night Shift (N) After hand over you will probably find the consultants are still around - unlike other units this is normal practice so don't be put off by it! You should liaise with the consultants before they try and go home and ensure you know who to call should you need to. You should aim to start your night round before 23:00 with the nurse in charge on your side. Tasks to be completed before morning handover:

Order the x-rays Complete/update patient handover document and print them out for

incoming day staff Add any outliers to the white board (i.e. patients you have seen that need

to be flagged up for re-review etc.) Familiarise yourself with all patients and present all new patients, paying

attention to presenting complaint, history of presenting complaint, PMH, differential diagnosis etc.

Nights are often a good time to look through CRS and update any results/print out EEG/CT/MRI reports to file in the patient notes

- Communication and rest periods

Ensure the 1113 and 45715 phones are being carried by the senior registrar

Ensure the 45714 phone is being carried by the HDU registrar Ensure that the nurses in charge of each team know how to contact their

respective registrars If you leave the unit, ensure the nurses and the senior registrar knows

how to get hold of you If you go for some rest during a quiet period in an on call room, please

give the extension number of the room to the nurse in charge of the team you are covering and the in charge registrar, sometimes the phone reception can be intermittent

All HDU admissions overnight should come through the senior ICU trainee on 4E. The trainee covering HDU overnight can go and review patients on the ward who may be suitable for HDU admission but this has to be discussed with the 1113 holder on ICU to ensure adequate cover. Weekends There are only two consultants at the weekend and they join the 4E handover so 4F can hand over by themselves. Often one consultant will start and bed 1 and the other at bed 23 and the trainees can cross over at bed 15 and 31 - though this doesn’t always work / happen. The aim is to close the 4 elective surgical beds on Saturday afternoon and re-open them again in time for elective post-operative admissions on Monday.

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Liaising with the consultant in charge Consultants are always available to be called if you have a question or are concerned about a patient, at any time of the day or night. If you do not feel that you can call someone or if you feel you have been treated unfairly when you phoned a consultant please tell someone (e.g. educational supervisor / the clinical lead) so the problem can be solved quickly. You must liaise with the consultant in charge regarding all admissions to the ACCU. Please discuss with the consultant if you have any queries about patient management regarding patients on the ACCU, those you have been asked to see on the wards or in the Emergency Department, especially if you do not think someone is appropriate for critical care because it would be futile. We would prefer that you speak to us rather than take responsibilities / decisions which you feel unsure about Out of hours, you may want to liaise with the other trainees on-call (particularly the senior trainee on 4E if you are covering HDU). Help from Anaesthesia The senior anaesthetic trainee carries bleep 1220. This is particularly important if you are called out of the ICU for prolonged periods, e.g. attending a trauma call. You may need one of the anaesthetic trainees to stay with a patient in ED whilst you return to the ICU The anaesthetic department should take over the patient as soon as it has been decided that they are being transferred to theatre or interventional radiology (IR) - ICU trainees are NOT to transfer patients to theatre or IR (or stay with them during a procedure). Admissions We have >1100 level 3 admissions per annum and we have > 95% bed occupancy, therefore the ICU tends to be full most of the time and there is a lot of pressure on the beds. All admissions must be accepted via the consultant in charge of the ICU for that day and should be coordinated through the person holding bleep 1113. The senior nurse in charge must also be informed as they will update you on the bed status and also help to discharge patients to the ward to facilitate emergency admissions. All admissions to ACCU should also involve a senior member of the referring team, ideally consultant. During the day HDU referrals should go through the ACCU Team C Consultant or trainee, however, overnight all referrals/admissions come through the senior ICU trainee. Please ensure that all admissions are discussed with the ICU consultant on call overnight. If you feel ICU/HDU admission is not in the patient’s best interests then this should also be discussed with the ICU consultant on call. There is an electronic booking system for elective admissions to ACCU, both ICU and HDU but bed availability needs to be re-confirmed with ACCU staff on the

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day of surgery. The consultant and the nurse in charge normally co-ordinate this via the ACCU bed manager. All ACCU patients are also under the care of at least one other consultant physician or surgeon. Transfers from other hospitals must be accepted by a medical or surgical team prior to accepting the transfer. Trauma transfers from other hospitals should usually be admitted via the ED so that they can have a repeat trauma call particularly if the injury is recent. Patients’ Notes There is a specific admission form and a separate daily sheet which are universal across the ACCU. Please write an update and management plan for each patient in their notes each morning. In addition all procedures must be documented as well as emergency treatment carried out during the day. All significant microbiological findings and antimicrobial therapy must be clearly documented in the notes (use yellow microbiology and VAP form- see details below). The pink care bundles should also be completed and reviewed on the ward round- often the nurse in charge will assist with this. All communication with other teams and with family members must also be documented. A discharge summary must be written prior to all discharges from the ACCU. Similarly, a brief summary should be sent to the GP for any patients who die on the ACCU. Critical Care Transfer Summaries Critical Care summaries have to be done for every patient who leaves the ICU / HDU These are done on CRS (the same system where you find blood results) Critical Care summaries have to be done for every patient who leaves the ICU / HDU These are done on CRS (the same system where you find blood results)

1. Log on to CRS using your own card and open the patient’s Powerchart.

2. Click on + Add in the documentation line on the left hand side menu.

3. Select ICU Transfer Summary as the document type.

4. Click on the ‘Precompleted’ tab below.

5. Select the first template in the list, ‘ACCU Transfer Summary’.

6. Write the summary. If you wish to add to it later (e.g. starting the summary before discharge), click on Save. See step 13. If you have finished the summary and the patient is leaving, go to step 7.

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7. Click on Sign. This starts the spellcheck. Please use this if you can’t spell. You may need to click on Sign again afterwards.

8. In the ‘Sign note’ box, ensure the ‘Request endorsement’ check box is ticked. Please ensure the date and time are current – if not, click on the ‘Current Date’ button. Don’t tick the ‘Print final document’ box.

9. Search for the consultant in the Endorser field; select ‘Sign’ in the Type field. The correct consultant is the daytime consultant responsible for the bit of the unit the patient is in.

10. Click OK.

11. The document can be opened and printed as any other document can; this copy can go in the notes with the patient.

12. (If you need to modify the document before printing it but after signing it, highlight the document in the documentation view, click on ‘Modify’ and then select ‘Correct’. You will click on ‘Sign’ again to accept your changes.) Ideally you won’t need to do this – the preferred option is to save and review (as in steps 6 and 13).

TO CONTINUE A PREVIOUSLY STARTED SUMMARY

13. To add to a previously started summary, click on + Add in the documentation line on the left hand side menu, select the ‘Existing’ tab and select the already started summary in the list. Go to step 6.

The consultant will then receive a message to review the summary.

Please ensure the summary is allocated to the appropriate Team A, B or C consultant, which MAY NOT be the consultant covering overnight when the patient is admitted or discharged

Organ Donation RLH is one of the busiest hospitals in the UK for organ donation and this forms an important part of our workload. We have a team of Specialist Nurses in Organ Donation (SNODs – listed above) who are based at The Royal London and are supported by 2 Clinical Leads – Dr Kennedy and Dr Verma. In accordance with NICE Clinical Guideline 135, Organ Donation should be considered a normal part of End-of-Life care for patients on the ACCU. Any patients who have a medical plan for withdrawal of treatment or who meet criteria for brain stem testing should be referred to SNODs. Forms for brain stem testing and donor optimization are available on ACCU. For even more information please see following links: http://www.odt.nhs.uk/pdf/timely-identification-and-referral-potential-donors.pdf http://www.odt.nhs.uk/pdf/family_approach_best_practice_guide.pdf http://www.odt.nhs.uk/pdf/donor_optimisation_guideline.pdf

To Contact the specialist nurses please phone ext 40336 (RLH) or email _ACCUSNODS@bartsandthelondon.nhs.uk For urgent referrals please contact 24 hour pager 07659100103

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What to do when a patient dies on ACCU 1. Certify the patient as soon as is appropriate

2. Write a summary of the death

Include – Name, DOB, DOD, MRN

Summary of stay in no more than 500 words

Save under the appropriate week in

\\LNASV3\Directorates$\surgery_&_anaes\ACCU\Critical Care

Summaries\Deceased patients

Save as Surname, Forename

3. Complete a discharge summary on CRS

a. Enter the patient’s record on CRS

b. Go to Ad Hoc on top bar

c. Select discharge from the list on the left of the screen

d. Select in-patient discharge summary

There are now 4 pages

i. Discharge Info I – copy and paste from the summary above. Make it clear that the patient has died

ii. Discharge Info II – Select finalised and select Gp in the bottom box and it will be sent direct to Gp practice.

iii. Diagnosis – should auto-populate iv. TTA – Select Not applicable

4. Does the death need to be referred to the coroner?

The following is a guide to which patients require referral to the coroner. If in doubt refer.

Death was violent, suspicious or unnatural (i.e. all traumas)

Cause of death is unknown

Death related to self-neglect or neglect by others

Suicide

Any death in custody

Death is related to an accident

Death during surgery or before recovery from anaesthesia

If any of these criteria are met then a coroners referral form

(\\LNASV3\Directorates$\surgery_&_anaes\ACCU\Critical Care

Summaries\Deceased patients) needs to be completed. You should copy and paste the

summary of care into this document and ensure the hypothesized cause of death is

completed.

This should be sent to bereavement at mailto:bereavement@bartshealth.nhs.uk

5. If not complete an MCCD and a cremation form

MCCD book is kept in the CD cupboard. Once complete it should be attached to the notes and left for the ward clerk to take to the bereavement office.

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A cremation form (Form 4) (http://bartshealthintranet/About-Us/CAGs/Clinical-Support-Services/Pathology/Documents/Cremation-form-4.pdf) should also be completed it can always be removed later if not necessary

Other Letters to GPs The ward clerk, Sue, prints off standard letters to GPs for every patient admitted to ICU and every patient who dies on ICU. These letters will be left in the trainee pigeon-hole in the doctors’ office on 4E. These should be completed with basic information, signed and returned to the ward clerks’ post-tray at the reception desk on 4E to be posted to the GPs. At present this may result in duplication of letters to GPs regarding deceased patients whilst we are getting the ‘Summaries for Deceased Patients’ letters firmly established. Microbiology Ward Round There is a yellow microbiology / VAP surveillance sheet in every patient’s notes. The first side should be completed every day for every patient as part of your daily assessment and reviewed on the ward round. The reverse side should be completed if ventilator-associated pneumonia (VAP) or ventilator-associated tracheitis (VAT) is suspected or being treated and should be completed for the next 7 days. In the early afternoon a consultant microbiologist will do a ward round (Monday to Friday) - one of the doctors (preferably the “coordinator”) must attend this round and document results and a management plan for patients on the yellow microbiology sheet. Please provide all relevant clinical information including history, medical background, WCC, CRP, temp and patient progress in order to aid rationalisation of antimicrobial therapy. You MUST document the micro ward round on the microbiology sheet in the column labelled ‘latest micro’ EVERY day, even if it to write ‘no change’. If possible two trainees should go on the round, one to write on the drug chart and one to write in the medical records. Some of the microbiologists move very fast! Carry some spare blank micro forms for patients whose notes are missing a micro form. Emergency Buzzers on ACCU The emergency call buzzers on ACCU pose a couple of particular challenges: When the buzzer is activated in a patient area it can be very difficult to hear in other clinical areas (although it can be easily heard in the doctors’ office). There are light units in the ceiling which will flash and lead you to the appropriate bay if you follow the trail of lights but it’s not always that easy to tell where the emergency is! There is a control panel at each of the nursing stations which can be consulted- the area with the emergency should be flashing red.

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Imaging/Investigations Ensure appropriate and accurate clinical details are written on all imaging requests. Failure to do so may result in refusal, inappropriate imaging or inappropriate reporting. - CT/MRI Scans should first be discussed with the relevant radiologist (in hours there is a body radiologist and a separate neuro radiologist. Out of hours it’s one on call radiologist) to enable protocoling. After that a call to the relevant scanner should be made to coordinate a time slot. Keep the holder of 1113 informed so staff can be allocated sensibly. There is a portable CT head scanner that is sometimes used on the ACCU in order to avoid transfer to the scanning room. Please talk to the consultants about it. Its use is largely determined by the availability of a radiographer. We are allocated a (close to) daily MRI slot (usually around 2pm), use it wisely and think about who made need an MRI at hand over in the morning as this requires planning! - Scans with Contrast It is preferable to have a 18G or larger venflon to administer contrast. This may not be possible in ICU patients so there is provision for the use the pressure injector through a CVC line. This is NOT TO BE ROUTINE as it is off licence carrying an albeit <1% risk of line rupture, according to the manufacturer. The policy that Radiology has approved requires any critical care patient to have written consent to use a CVC with the pressure injector and this is either a normal or form 4 consent form depending on capacity. An ST3 or above from ACCU must sign it prior to going to CT, and the radiologist will countersign it when in CT. The official policy is in the same place as all the others. If the radiologist refuses, call their consultant (at any time of the day) - Ultrasound A radiology trainee is usually made available for critical care scanning at lunchtime / later afternoon so get requests in as early as possible (on CRS) in the morning in order to ensure they are processed and conducted. If there are lots of requests on any one day, prioritise them for the radiologist! It is helpful to give the radiologist a heads up by phone on the US requests for the day, especially if scans are urgent (41012/41011/41013). - Duty radiologist For CT/MRI/Fluoroscopy and x-ray clinical radiology queries, protocolling and discussion (at The Royal London site only)- contact the duty radiologist on DECT phone on 45709 / 45710 For all Ultrasound, Interventional Radiology, Paediatrics and Nuclear Medicine queries - contact the extension numbers below. Ultrasound – ext. 41011/3

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Paediatrics – ext. 40984/5 Interventional Radiology – doctor: ext. 40112/3; nurse coordinator: 40105 Nuclear Medicine – ext. 55767 or 55883 - Echocardiograms This is now ordered through the CRS system in the same way as if you were ordering a blood test. - EEG and other Electrophysiology Requested on CRS. Results on EPR, as above. Usually helps to call down to the department to give them a heads up On Call Rooms There are two on call rooms for use by trainees (one for 4E and one for 4F). DO NOT LOSE THE KEYS! They are very expensive to replace. If you use the room at night, please call housekeeping to have the room cleaned (you have to leave the room unlocked for it to be cleaned). Multi-function Device MFDs can be used to print, scan, fax and copy. Instructions can be found in the ACCU folder at: I:\surgery_&_anaes\ACCU\Equipment Instructions

Security Don’t leave valuables lying around, even in the doctors’ office on ICU. There have been thefts. If you would like a locker in the changing room, ask Angela Vai, one of our administrators and bring your own padlock.

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PHARMACY Contacting a Pharmacist

Pharmacy Induction A talk for ACCU doctors can be found here: I:\surgery_&_anaes\ACCU\ACCU Trainees\Induction\Pharmacy Introduction for ACCU Drs.ppt This contains useful medicines related information. A brief summary of the important policies can be found below. Drug Charts o ACCU drug charts should be used for all patients o Please ensure drug charts are re-written in a timely manner during the

dayshift – there’s nothing worse than having to do them overnight. o Always complete the allergies section accurately (including detailing the

nature of the allergic reaction, if known)

o Print the name of the medication and do not use commercial names (e.g. Augmentin / Tazocin)

o Print your name next to your signature o Always double check and sign the “allergies checked” box for every drug

prescribed o For ease, the drug charts have pre-printed sections but signatures and start

dates are still required

Monday – Friday 9am -5pm

Saturday & Sunday 10.30 – 4pm

Out of hours

ACCU ward pharmacists (Susan, Lauren, Rory)

Weekend pharmacy team

On Call Pharmacist

Bleeps: 4E (1193) 4F (1667) Extension: 60135

Extension: 42323

Via switch

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Prescribing Issues A table of routine prescriptions on ACCU can be found in the policies and guidelines folder at: I:\surgery_&_anaes\ACCU\Policies and Guidelines\Medicines This covers MRSA prophylaxis, thromboprophylaxis, eye protection, GI protection, mouthcare and Arterial/CVC flush.

Drug Dose Route Frequency Comments Chlorhexidine body wipes

Topical OD MRSA prevention protocol

Corsodyl dental gel (chlorhexidine)

Topical QDS VAP prevention, mouth care protocol.

Lacrilube Topical eyes QDS If sedated/low GCS

Ranitidine

or Lanzoprazole

or Pantoprazole

50mg IV TDS Until absorbing full feed.

30mg NG OD If admitted on it / high risk for

GI bleed. 40mg IV OD

NaCl 0.9% flush bag 500mls for arterial & CVC flush. - On continuous IV infusion

page. Consider: TEDS Flotrons Tinzaparin

Weight based s/c

OD

If not contra-indicated. Reduce dose in renal

impairment or less than 50kg Increase dose if >109kg

Links to Medicines Related Policies

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IV guide

1 – from the intranet home page

2

36

Electrolytes Electrolyte administration on ACCU is different to that on the general wards This policy is currently under review but can be found here: http://rl1vmsps02/BHFileshare/Shared%20Documents/All%20Trust/Pharmacy%20Intranet/BLT/Critical%20Care/Electrolyte%20Administration.pdf

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Low Molecular Weight Heparin o Thromboprophylaxis and treatment – Tinzaparin (innohep®)

Tinzaparin thromboprophylaxis in standard patients

< 50kg 51-109kg 110-149kg ≥150kg

3500 units

od 4500 units od 7000unit od

9000 units

od

o ACS – FONDAPARINUX See separate guidance

Prokinetics o If a patient is not absorbing their feed prescribe metoclopramide 10mg IV

tds (reduced to 5mg IV tds if less than 50kg). o Prescriptions should be regularly reviewed and stopped as soon as possible

with a 5 day maximum in routine cases. http://rl1vmsps02/BHFileshare/Shared%20Documents/All%20Trust/Pharmacy%20Intranet/BLT/Surgery%20and%20anaesthetics/Prokinetics.doc

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Antibiotics

MICROGUIDE - See infection control section When prescribing antibiotics in penicillin allergy please refer to the traffic light poster:

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Renal doses for antibiotics o This pharmacy guide can be used as a starting point when

prescribing in renal impairment

http://rl1vmsps02/BHFileshare/Shared%20Documents/All%20Trust/Pharmacy%20Intranet/BLT/Antimicrobial/Dosing%20in%20renal%20impairment.doc Vancomycin Continuous vancomycin infusions are used on ACCU Key points:

Continuous infusions are not suitable for end stage renal patients who are normally on PD/HD unless they are receiving CVVH/HDF (intermittent dosing should be used in ESRD)

Ensure allergies are checked before prescribing All patients require a loading dose unless they have received intermittent

vancomycin preadmission In cases of previous vancomycin use, a level must be done before

prescribing the loading dose for the infusion (if they level is in range no loading dose is required)

The loading dose is prescribed on the stat side and the continuous infusion is prescribed on the infusion page.

Bolus dose is 25mg/kg (max of 2g). There is one standard concentration and a standard starting rate for the continuous infusion. The first level will be sent after 12 hours and the rate adjusted accordingly.

Daily vancomycin levels are done and the infusion rate is altered accordingly (target concentration range – 15-20mg/L)

Current policy: Access via medusa on the intranet

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Emergency Drug Box

There are THREE silver-lidded Tupperware boxes in the pharmacy fridge on ACCU for use in EMERGENCY AIRWAY SITUATIONS. These boxes MUST NOT be used for routine airway management on ACCU The boxes contain propofol, etomidate, suxamethonium, rocuronium, atropine and metaraminol along with pre-labelled syringes and drawing-up needles. The drugs should not be drawn up until needed for clinical use. The task of checking that the boxes are stocked sealed and up to date should be allocated to a specific trainee during the morning drill (usually the first runner) and this task should be performed immediately after handover. Restocking the drug box after use is the responsibility of the DOCTOR using the drugs and should be completed as soon as possible after the emergency is resolved so that the drugs are immediately available if there is another airway emergency.

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COMMON CLINICAL ENCOUNTERS ON THE ACCU Airway Emergencies on ACCU

Retrieve an emergency drug box from the pharmacy fridge.

The standard airway trolley and difficult intubation trolley are kept opposite the reception desks on 4E and 4F.

The algorithm for management of a blocked / displaced tracheostomy is found in the ACCU policies and guidelines folder at I:\surgery_&_anaes\ACCU\Policies and Guidelines\Respiratory Major Head and Neck Surgery at the RLH This speciality has recently moved to RLH from SBH. The particular issues with these patients are observation and management of any reconstructive flaps as well as potential airway problems. Of note patients who have had a laryngectomy have an ‘end stoma’ and their airway CANNOT be managed via the oral or nasal route. Patients undergoing flap surgery should have a Flap Monitoring Chart. You are advised to familiarise your self with the ‘Flap monitoring chart’ (I:\surgery_&_anaes\ACCU\ACCU Documentation) and the ‘Displaced / blocked tracheostomy management’ algorithm as above. Renal Replacement Therapy (RRT) on ACCU There are two modes we routinely use when providing renal replacement therapy on the ACCU, CVVHF and CVVHDF. There are comprehensive guidelines for RRT and vas-cath insertion available in the ACCU folder. Please ensure you put the correct line in the correct vein. I:\surgery_&_anaes\ACCU\Policies and Guidelines We cannot provide RRT in the HDU beds but you should consider if the patient can be transferred to the Renal HDU (discuss with Team C consultant). The dose is 25mL/kg/hr of either replacement fluid in HF or effluent (in a 50:50 split for dialysis and filtration) in HDF. There are special circumstances (e.g. severe metabolic acidosis and oligo/anuric rhabdomyolysis) where the dose for HF may be increased to 35 or 60mL/kg/min - this is a consultant only decision. The machine does not allow pre-dilution in HDF. We support heparin Flolan and citrate as anticoagulation.

PLEASE TAKE TIME TO FAMILIARISE YOURSELF WITH THE EQUIPMENT ON THE DIFFICULT INTUBATION TOLLEY BEFORE YOU NEED TO USE IT

IN AN EMERGENCY!

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Possible Displaced / Blocked Tracheostomy?

If tracheostomy definitely displaced or if patient deteriorating and unable to ventilate

If in doubt

YES

If in doubt and pt stable

YES

Call for help—bed space alarm and call Dr’s (bleep 1113/1480 initially) 100% Oxygen via face mask and tracheostomy

Check the capnograph (ETCO2) – If not on; put it on via HME filter

Call for difficult airway trolley

Attach Water’s Circuit / Ambubag to tracheostomy (with capnograph)

WILL A SUCTION CATHETER PASS? MAXIMUM 2 CAREFUL MANUAL VENTILATIONS Allow 5s for capnograph trace to appear Is there a good capnograph trace and is ventilation easy?

PROBLEM WITH TRACHEOSTOMY TUBE BLOCKED? Replace inner tube HERNIATED CUFF? Deflate and reinflate cuff DISPLACED? Bronchoscopy if time and skill allow DEFLATE CUFF; VENTILATE VIA FACE MASK with TRACHEOSTOMY TUBE COVERED OR CAPPED CALL FOR MORE HELP—

Bleep 1220, THEATRE ODP and/or MAX-FAC

REMOVE TRACHEOSTOMY TUBE Cover tracheostomy site Ventilate using face mask and 100% oxygen Consider LMA

REINTUBATE ORALLY when personnel available

Other cause likely- Consider

Pneumothorax

Bronchospasm

Equipment failure Assess breathing and circulation. ALS algorithms if necessary

Single attempt at bronchoscopy via tracheostomy (senior help): Look for tracheal rings

and trachea Consider

advancing/reinsertion of tracheostomy over bronchoscope (extreme care if tracheostomy <7 days old)

If still problematic Contact maxillo-facial

surgeons Consider RSI and oral

reintubation

NO

SURGICAL EMPHYSEMA/SWELLING IN NECK? If so, extreme caution with further ventilation

If successful reintubation doesn’t allow easy ventilation consider:

Tracheal obstruction – secretions, blood, foreign body, bronchoscopy +/- lavage

Tracheal false passage – Maxillo-facial surgeons +/- reintubation with manual guidance

Pneumothorax – bilateral thoracostomies if in doubt

Signs of a potential tracheostomy problem: 1. Change in ETCO2 trace 2. Hypoxia, CVS instability, failure to achieve set pressure/ventilation 3. Patient talking despite tracheostomy cuff inflated 4. Audible cuff leak despite appropriate cuff pressures (22-28 cmH2O)

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Fasting for Theatre Intubated or tracheotomised patients on ACCU do not necessarily need to be fasted prior to going to the operating theatre. The policy can be found in the ACCU folder I:\surgery_&_anaes\ACCU\Policies and Guidelines\Operational Guidance

This also forms an appendix to the Trust Nil by Mouth policy.

To avoid confusion with the anaesthetist, please call them and discuss the reasoning behind your decision.

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CLINICAL SITUATIONS OUTSIDE THE ACCU The intensive care trainees cover all cardiac arrest and trauma calls in the hospital. On the Royal London site there are currently about 300 cardiac arrest calls and more than 2000 trauma calls per annum. Trainees may therefore spend quite a lot of time out of the ACCU. You may organise between yourselves in the morning who is going to cover these calls. However the person on the Coordinating trainee on the long day should try to stay on the unit if possible. There is a separate section below regarding the role of the anaesthetist at trauma calls – you must read this read and discuss with Dr Healy if you have any questions regarding this. At least one airway-trained doctor (anaesthetic trainee or suitable ICM trainee) should be present on 4E at all times. It may therefore be necessary to enlist anaesthetic assistance via 1220 if multiple trauma calls coincide, especially out of hours. If you are leaving the unit overnight (e.g. to attend a trauma call or review a ward referral), inform the other trainees (and nurse in charge, if possible) where you will be. Airway Management Outside the ACCU Due to the complexity of polytrauma patients locally and the frequency of difficult airways, all non-anaesthetic ICM trainees should undergo a formal assessment of airway management skills with one of the consultants at the beginning of their attachment prior to attending trauma calls. If you subsequently attend a trauma call with a particularly difficult airway (eg facial trauma / burns) you should get assistance from a senior anaesthetist (e.g. 1220). If you would like to get some advanced airway practice (e.g. video-laryngoscopes, intubating LMA, Airtraq etc.) in the controlled environment of the operating theatre please contact Dr Julia Hadley. Junior anaesthetic trainees (CT1/2) should not attend trauma calls without support from a senior trainee.

Rapid Sequence Induction Checklist In the ED, attached to every airway trolley, there is a Rapid Sequence Induction Checklist. This checklist has been produced following near misses and incidences of poor airway management around the RSI of critically ill patients outside the ACCU.

o It is a talk and respond checklist and o It must be gone through before between the doctor in charge of the

airway and their assistant at every RSI. o Record the completion of the checklist in the documentation of the

induction

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Grab Bags, Transfer Bags & Transfer Equipment There are RED transfer bags which accompany patients whenever they leave the ACCU (e.g. to theatre, radiology, inter-hospital transfers). There are GREEN grab bags which trainees take with them when attending emergencies OFF the ACCU (e.g. cardiac arrests, emergency ward referrals). There is no need to take a grab bag when attending A&E resus. Both bags contain equipment and a limited selection of drugs (the contents lists should be attached to bags if you wish to see what they contain). Of note, since the drugs are non-refrigerated, the only muscle relaxant is vecuronium so you may wish to take suxamethonium or rocuronium from the fridge if you think you are likely to intubate the patient. The RED bags are restocked by the technicians / HCSW on ACCU. The GREEN bags are restocked by the trauma ODP so please bleep 1494 and let them know if you have broken the seal and used anything from the GREEN bags. Contents of each bag can be found in the appendix. Please take care of the portable transfer equipment (ventilators and monitors), positioning and handling them carefully to avoid dropping / falling off the bed! If accidents do occur, please inform the technical team immediately. Do not return broken equipment to the store room! Wall-mounted monitors are not to be removed to accompany patients. Portable monitors must be used. We aim to introduce routine use of a transporter gantry which attaches to the bed and carries all equipment securely in the next few months. Please use this if offered it by the technologist. Document all trips off the ACCU in the notes (e.g. CT, MRI etc.), even if only to state that the transfer was uneventful.

Assistance Outside the ACCU The trauma ODP (bleep 1494) attends trauma calls and cardiac arrests. If you need assistance with an unstable patient on the wards or non-trauma patients in A&E Resus (e.g. intubation) you can bleep them and ask for assistance if they are not busy elsewhere. Another source of potential support when managing unstable patients on the wards is the Critical Care Outreach Team. ODP or CCOT can help you with equipment, monitoring, technical support etc. Critical Care Outreach Team (CCOT) CCOT comprises of a senior critical care nurses (bleeps 1294, 1680 and 1681) and a senior physio (1205). They see MANY referrals (approximately 1200 primary referrals per year) and all patients who step-down from ACCU (1700 per year). They may come to you for advice, patient review or to refer patients for escalation to ACCU. Please respond to these requests promptly, involving the ACCU consultant where necessary. Discussion with a senior member of the referring team is also required.

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The CCOT physio or the tracheostomy team may ask you to perform trache changes on the ward: this is routine for the first change of a tracheostomy tube. CT Scanner - Trauma Calls/ED Patients: These patients are scanned in the ED scanner, which is directly adjacent to resus. - ACCU / Ward Patients In hours in-patients are generally scanned in the scanners on the 1st floor in the radiology department. It is not entirely unusual to have to wait 5-10mins for a porter post scan, in which case you can park the patient and yourself in the CT / MRI anaesthetic room which has wall oxygen to plug into. Out of hours (generally after 17:00), most scans take place in the ED scanner as described above. MRI Scanner You are likely to be off the unit for a long time! Take lots of spare drugs for patient – sedation, paralysis, vasoactive agents, lots of ivi extension tubing (at least 3 per set) and make sure the patient safety form is filled in. Take the minimum iv infusions e.g. bolus muscle relaxants instead of ivi Consider a line + flush for such boluses (you will always remember this after the scan has started) The equipment down there is interesting… NIBP only, intermittent ECG trace, SpO2 (v useful pleth trace), fairly standard anaesthetic machine and ventilator but check it before you start transferring, EtCO2 (invaluable) Interventional Radiology For trips to interventional radiology, it has been agreed with the anaesthetic department that when ACCU patients go to IR for DIAGNOSTIC procedures, the ACCU medical and nursing staff should accompany the patient. If the patient is going for an interventional procedure (e.g. coiling of aneurysm following SAH, insertion of drains) anaesthetic cover will be provided by the emergency theatre anaesthetist and ODP. Transfers to other ICUs (Clinical and Non-clinical) The ICU consultant must be informed about ALL patients transferred to other ICUs from the Royal London Hospital. Patients may be transferred from theatres, A+E or other areas and the ICU team will usually be involved although anaesthetic trainees will sometimes do the transfers, especially out of hours and they should inform the consultant anaesthetist on call. Full documentation is mandatory to record all monitoring, vital signs and other clinical data for the duration of the transfer. You must use one of the Trust transfer forms. Copies can be found in the Team A sisters’ office on the ICU.

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Organ Support in Areas Outside the ACCU - Renal HDU A 6-bed unit on the 9th floor, which can provide one additional organ support (in addition to dialysis) i.e. low dose vasopressors (Noradrenaline <0.2 mcg/kg/min), CPAP. They do not provide CVVH(D)F or BiPAP. - Neuro-monitored bay An 8-bed unit on 12E, which can provide tracheostomy care and CPAP - NIV Unit The respiratory ward (13E) has 4 BiPAP beds but the number can vary. As the London Chest Hospital does not take acute admissions, ACCU will take emergency (i.e. ED) admissions as per the normal referral route. Many wards can take patients with tracheostomies (but patients in side room or those with single lumen tracheostomy tubes) will require a ‘special’. - Obstetric HDU A 4-bed unit, which also serves as obstetric theatre recovery has recently opened on level 6, on the link between the South and Central towers (directly over the canteen). No organ support is provided here, simply closer monitoring of sick obstetric patients. You may be asked to review a patient here. - Recovery Occasionally elective surgical patients who are due to come to HDU and have been given a bed have to wait in recovery for a space to be cleared in our HDU. These patients, once they have been recovered from their anaesthesia, become ACCU / HDU (i.e. OUR) patients! A kind anaesthetist may help you out, but they need to be seen and clerked by us and placed on the whiteboard in the 4F doctors office. Usually the wait is brief but, previous trainees have found it very useful to go to recovery and start clerking them in, sorting out the drug chart etc in anticipation of their imminent arrival. If an elective patient requiring level 2 care is operated on in the knowledge that there is no HDU bed and then ends up in recovery, this is the responsibility of the anaesthetic team, NOT you! If you are called to see them, please call the HDU consultant (45713) or the first on consultant (45711) out of normal working hours.

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EQUIPMENT (courtesy of Richard Aldridge) We have a lot of basic and not-so-basic equipment on ACCU, which our technologists mostly look after. You will be shown the most important equipment and how to use it on the day of your induction. If you have not attended this, please contact Dr Andrew Leitch (Consultant equipment lead). - The Tech Team There is a team of 8 and Richard Aldridge is the lead technologist. In addition there is Nurur, Vlad, Olly, Mohammed, Raleigh, Serhiy and Michael. They provide an 8 am – 8 pm service, 7 days a week, and carry bleep 1430. There will usually be 2 techs on over a weekend and three most week days. The techs can be expected to:

Get scopes ready for use when requested Take away dirty scopes for decontamination Perform Lidco calibration Set up Brainz monitoring Set up renal filters Set up Nitric Oxide Set up all ventilator and NIV circuits Perform PCT assay on request Perform ECG on request Perform Rotem coagulation test on request. Attend patient transfers to CT, MRI, IR when requested.

Of the more esoteric equipment you may not have come across elsewhere, keep an eye out for inhaled Nitric Oxide, the oscillators, the Brainz monitor (amplitude integrated EEG), A Lung CO2 removal. You are responsible for the equipment you use. It is all ridiculously expensive to buy and repair (e.g. a typical transport monitor repair can costs ₤1,000!). Please look after it and handle it carefully. Think of the Oxylog as your brand new car for instance (it costs about as much) – you wouldn’t drop it or scrunch it into walls. If you do have an accident, please come clean and tell the technologists so they can arrange any necessary repairs / identify recurring problems. Please also let them know about any kit that looks like it’s going to have a problem soon. (loose covers, screws, wires, connectors, cracked cases, displays etc) - Ultrasound machines There is one Sonosite Nanomax, a Siemens X300 and a GE Vivid S5. For US-guided line placement the Sonosite should be used, reserving the more high-tech and EXPENSIVE Siemens and GE machines for echo and ultrasound studies. Please get training in the use of the Siemens ultrasound machine before using it as we have had recurrent breakdowns resulting from misuse leading to the

49

machine being out of service for prolonged periods. There is a laminated guided attached to the machine. You must clean the machine and probes before and AFTER use and the machines should be left plugged in at all times when not in use. Probes must NOT be cleaned with alcohol-based cleaning products as this damages them. If there is any risk of contamination with body fluids, the probes must be covered with a sheath, whether or not the probe is being used for a sterile ultrasound-guided procedure. The probes must not become contaminated with body fluids as they are very difficult to fully decontaminate and this can lead to transmission of infection. Please ensure when you have finished using the machines, that the probe cables are not dragging on the floor where they can be run over and damaged. A new probe for these machines will be in the region of £5000 - Bronchoscopes: We have two 4.9 mm diameter scopes

all that is necessary for percutaneous tracheostomies) and one larger 5.9 mm diameter scope (ideal for diagnostic / therapeutic bronchoscopies).

This scope should be used through a minimum size 7.5 ETT, ideally upsize it pre-procedure if you can. (Note that the larger scope is now obsolete, and should only be used as a last resort. We are hoping to get another small one.

We also have a small emergency fibroscope, which is kept in the FOB. This requires special cleaning if used, so should only be used if there is nothing else available.

Clean bronchoscopes are kept in the drying cabinet on 4E. If you need a scope, please ask the techs to remove it from the cabinet for you – they will know how to log the scope out of the cabinet and what tracking paperwork needs to be done. It will come in its tray, in a clear plastic bag, on the video stack. Please only request a scope if you are about to use it, not hours before. It can only remain sterile outside the cabinet for a limited time. Once removed it will have to go to endcoscopy for cleaning, even if its not been used, thus taking it out of service for several hours. Please handle the scopes very carefully. Do not force them through a catheter mount into the ETT or provoke a flexion/extension injury! Pay particular attention to the location of the bronchoscope during percutaneous tracheostomies to avoid a needle-stick injury to it. After use:

replace the protective waterproof cap securely over the electrical connections

suck 500 mL of sterile water through the suction channel place the scope back into the tray and cover it with the red bag supplied

50

fill in the scope cleaning form which will have come with it and attach it to the outside of the bag – THIS MUST BE DONE SO WE CAN TRACE THE SCOPE TO THE PATIENT

place the scope in its tray in the dirty scopes trolley in the blood gas room; in hours, let the techs know you have finished

DO NOT RETURN SCOPES TO THE DRYING CABINET (even if not used) DO NOT THROW ANY ATTACHMENTS AWAY – if in doubt, leave them

in the tray with the scope We also have disposable Ambu scopes and the mobile screen kept in the FOB. Please consider using these (particularly for percutaneous tracheostomies), especially at weekends when there is less decontamination provision. Disposable scopes are £200 each!

Transport equipment The ACCU has three sets of transport equipment comprising an Oxylog 3000 ventilator, GE FM patient monitor, Portable suction, red bag with drugs, tubes etc and drip pole for pumps. Please beware of the limitations of how many patients can be transferred at any one time. There are frequently requests to provide more equipment than the unit has available.

Consumables & stores Both 4E (ITU) and 4F (HDU) have comprehensive storerooms, which should have stocks of the items you are most likely to need. There is an alphabetical list just inside the door, which will guide you to which cabinet (CAB) and which drawer (DR) the items you are looking for. Please note that most of the IV related products are listed with an IV prefix on the list. The storerooms are organised into zones to try and keep related products together: Blue labels are airway, Red labels IV / cardiac, Green labels dressings. Black & White labels is everything else! There are some specialist airway products and a few other seldom used products that are only kept in the 4E store, but in general there is duplication of stock in both store rooms.

Stock control In general you should not need to worry about the everyday items running out as they will be topped up automatically. There are however a number of items that are not frequently used, and are thus also not checked regularly for the stock levels. If you are finding issues with the stock of items running out, please let either Rajena Sampat (unit coordinator) or Richard Aldridge know. If you would like to introduce new products into the stores, then please speak with Richard initially.

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MANAGEMENT ALGORITHMS AND THE ROLE OF THE ACCU TRAINEE Trauma Call There are over 2000 trauma calls per year at The Royal London Hospital. After a trauma call is declared a team comprising of the following personnel will be group called to the Emergency Department. Team members include:

Team Leader (ED Consultant or SpR)

ACCU SpR (Anaesthetist or senior ICM trainee)

ODP General surgical SpR or SHO

Orthopaedic SpR or SHO Neurosurgical SHO – scribe ED Nurse 1 ED Nurse 2 Radiologist Radiographer

All trauma calls must be attended promptly by one of the Senior ICM or anaesthetic SpRs. All of the following anaesthetic bleeps receive trauma calls. Bleep 1113 Bleep 1480 Bleep 1220 Bleep 0814 Bleep 1119 The ACCU SpR may occasionally be asked to attend paediatric trauma calls if the paediatric anaesthetic SpR and the senior SpR (bleep 1220) are busy. You should handover to the paediatric anaesthetic SpR (bleep 1061) as soon as they are free.

Role of the ACCU doctor: assess breathing and provide ventilatory support as necessary

o Approximately 30% of patients will already be intubated and ventilated.

in conjunction with the team leader assess circulation and co-ordinate fluid, blood and blood product replacement as necessary

Gain large bore peripheral or central venous access as required establish intra-arterial blood pressure and central venous pressure

monitoring as required provide anaesthesia and analgesia as required co-ordinate patient transfer in conjunction with team leader ensure that spinal immobilisation is maintained

If, at any point, you are unsure or feel you need help CALL AN ACCU CONSULTANT

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inform scribe of all therapeutic interventions undertaken and encourage documentation of vital signs, blood results and other relevant information

discuss need for critical care post resuscitation and advise accordingly If the patient is awake

Take an AMPLE history o Allergies; Medications; PMH; Last ate; Events Leading to…

ensure that cervical spine immobilisation is maintained during intubation in all trauma patients at risk of cervical spine injury.

o You may remove the cervical hard collar to allow adequate mouth opening but a suitable assistant must apply manual in-line immobilisation. A second assistant will be required to maintain cricoid pressure if this is required

If the patient is anaesthetised

Administer 100% oxygen on 10 litres/min via the Bains circuit and ventilate manually until you have quickly examined the chest.

Then place the patient onto the ventilator after checking the oxygen concentration, inspiratory and expiratory times and the flow rate per second.

A ventilator alarm should be used. Please check peak pressures regularly. After attaching all appropriate monitoring, including end-tidal CO2 you should consider instituting some form of anaesthesia. There may be volatile agents available if you require. Immobilisation Most patients will arrive in a cervical collar taped to sandbags. You will usually be asked to assist with a log roll onto a scoop so that the patient can be moved from the vacumat. You will then have to log roll the patient off the scoop to allow for x-rays etc. to be taken. It is the responsibility of the anaesthetist to co-ordinate this move unless you are administering life saving intervention. Venous Access If the patient is hypotensive or severely shocked you should insert a large bore 8 French trauma line via a Seldinger technique into a central vein before the situation gets critical. Internal jugular access is not usually possible as a cervical collar will often be in place and the spine must be maintained in alignment. If using a subclavian line, place this on the side of the chest injury if it is likely that the patient will need a chest drain on that side as this may prevent the development of the bilateral pneumothorax. Beware if a major vascular injury is suspected at this site. The femoral route should be avoided in those with suspected severe pelvic trauma. You should discuss fluid replacement with the team leader and advise or co-ordinate this as you see fit. Please bear in mind the team leader may be a very

53

experienced consultant or a relatively junior SpR so use your discretion accordingly. Beyond the initial assessment After initial evaluation and resuscitation you must co-ordinate fluid resuscitation. We usually start with crystalloid resuscitation but type O blood may be administered in an emergency in a severely shocked patient. However group specific blood is usually available within 10 minutes of the sample being taken and this should be used instead of type O blood as soon as this is available. You must co-ordinate the fluid resuscitation in conjunction with the team leader, ODP and Nurse 1 as indicated. All fluids should be warmed; the level 1 rapid infusion device may be used in unstable patients. Please beware as very large volumes of fluid can be given very quickly. If there is a suspected head injury it is wise to assess the ABCs followed by a mini neurological examination, paying particularly attention to pupillary size and reaction. In addition you must review the arterial blood gas results and maintain the PaCO2 in the normal range, that is approximately 4 .5 – 5.0kPa. You will need quite a high minute volume to prevent the re-breathing of CO2 and you must pay particular attention to this. Change tight ET tube ties to a secure tape if severe head injury suspected/confirmed. In adults you should aim to maintain the mean blood pressure at 80-90mmHg until significant head injury is excluded. In patients with haemorrhagic shock who are likely to have a head injury it is best to aim for a MAP of 70mmHg until haemorrhage has been controlled, as over resuscitation may exacerbate bleeding. Insert a temperature probe and take measures to maintain normothermia. This includes the warming of all fluids and using a Bair hugger as soon as it is available. Trauma patients normally spend 40 - 60 minutes in the resuscitation area prior to transfer for further investigations, surgery or intensive care. All patients will have a routine chest x-ray and pelvic x-ray and frequently abdominal, pelvic, limited focused cardiac and chest ultrasound (extended FAST scan). When the FAST scan is being done you should ask the radiologist to rule out pericardial collection in who are shocked or if there is any possibility of cardiac tamponade. Most patients will go on to have extensive CT imaging, including head, spine, chest, abdo and pelvis, where appropriate. A preliminary report will be provided by radiologists as soon as possible with a more detailed report available subsequently on PACS and CRS Please pay particular attention to the results of these investigations as this will save a lot of time and effort on the Intensive Care Unit at a later stage. Please encourage the appropriate personnel to document all results in the patient’s notes. Following completion of the primary survey the orthopaedic SpR will usually complete a secondary survey if the patient is stable. Otherwise the patient may be sent for urgent scanning or surgery and this will need to be

54

completed at a later stage. Where possible patients should be stabilised prior to transfer to the CT scanner or other diagnostic areas within the radiology department. You must liaise with the Team Leader and advise accordingly depending on the status of the patient. However, the team leader’s decision may be to transfer an unstable patient to CT scan. If this is the case, the patient should be accompanied by the FULL TRAUMA team with resuscitation ongoing. If in any doubt call the consultant. The scribe will usually document vital signs, drugs and fluids administered, urine output and initial results while the patient is still in the ED resuscitation room. However, you must liaise with the ED nurse accompanying the patient to the CT scanner to continue this process. You must ensure a full record is available. Prior to the transfer of the patient to the CT scanner etc. you must secure all lines and tubes and commence a propofol infusion, maintain analgesia and fluid resuscitation and change the patient over to a portable ventilator. The patient should be placed on a scoop prior to transfer. Alternately a “patient slide” can be used. You may use the portable ventilator while the patient is in the CT scanner. Please ensure that the patient is stable prior to initiating scanning and that all lines, tubes etc are safely positioned. You must place the Propac monitor and the ventilator in a position that can be viewed from the control room in the CT scanner while the scan is being performed. You may interrupt the scanning process at any stage if there is a problem with the patient. Please pay attention to all investigations performed and the results as they become available. To avoid delays please liaise with the Intensive Care Unit at an early stage if it is obvious that the patient will need an intensive care bed. If it is likely that the patient will need to go to the operating theatre please liaise with your colleague on bleep 1220 to plan this process well in advance. YOU MUST ENSURE THAT ALL APPROPRIATE INFORMATION IS FULLY DOCUMENTED IN THE TRAUMA BOOKLET. The anaesthetic section must be completed and the vital signs must be recorded in all unconscious patients. Please use the observation chart as your anaesthetic record. (Start an anaesthetic chart if the patient goes to theatre). Please read the BLT guidelines for all of the following:

Clearance of the Spine in the unconscious patient Management of severe head injury (RLH ICU guidelines) Massive transfusion guidelines/ use of Activated Factor VIIa

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Code Red Trauma Call Only a senior member of the Trauma Team who has undergone induction training can trigger CODE RED TRAUMA Tranexamic acid Tranexamic acid is an antifibrinolytic agent that inhibits activation of plasminogen to plasmin; a bolus of Tranexamic acid (1g, iv over 10 min) should be started within 3 hours of injury followed by continuous infusion (1g, iv) over 8 hours Blood Transfusion – Emergency Group O Stock Group O Neg (use in females) and O Pos (use in males) blood available in blood track fridge for CODE RED use MUST INFORM Blood Bank when units used so that stocks can be replaced Switch from Group O to patient’s group as soon as possible CODE RED PACK A contains: 4units FFP. CODE RED PACK B contains: 4units FFP; 1 pool Platelets; and 1 pool cryoprecipitate. Fresh Frozen Plasma FFP needs defrosting before issue – this takes around 30mins (allow time for transit) Each dose should contain ~15ml/kg of FFP – around 4units for average adult Cryoprecipitate Cryoprecipitate needs defrosting before issue – this takes around 30mins (plus allow for time transit) Do not put cryo in fridge after defrosting since can precipitate Each dose should contain 2 pools cryoprecipitate for average adult Platelets Stored at ambient temperature DO NOT REFRIGERATE Since platelets have short shelf life of 5 days only the blood bank has limited supplies of platelets and has to order additional units from the Blood centre as needed. Laboratory testing Must request fibrinogen as well as coagulation screen and Full Blood count for all patients with massive haemorrhage Repeat testing of Coagulation screen including fibrinogen and platelet count needed after transfusion of components to guide further replacement. Recombinant FVIIa: Discuss with Haemophilia Registrar (Bleep 1155 or via switchboard on call) regarding use of rFVIIa in patient who continues to bleed despite replacement therapy with FFP, platelets and cryoprecipitate.

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MAJOR INCIDENT PLAN ACTION CARD

ADULT CRITICAL CARE UNIT (ACCU- WARDS 4E/4F) ROYAL LONDON HOSPITAL

ACCU REGISTRAR (1113)

INCIDENT DECLARED When major incident declared ensure that and duty ACCU 1st-on consultant and on-site junior ACCU medical staff (Bleeps 1480/0814/1427/0816) have been informed. If possible try and obtain a Situation Report (SITREP) from the MI Control room or the emergency department before discussing with the consultant. In the event that the duty ACCU 1st or 2nd on consultants cannot be contacted due to phone lines not working, then work through the consultant list until an ACCU consultant has been notified.

I. Liaise with the ACCU Nurse in charge (bleep 1387) of at RLH to identify patients that can be discharged / stepped down within the ACCU or to the ward / transferred

II. Liaise with 1220 (anaesthesia coordinator) to establish theatre capacity

and the potential numbers of patients attending the resuscitation room. III. If out of hours ensure HAN are facilitating the setting up of a satellite

ACCU; in the first instance an 8 bedded level 2 area in the 4th floor theatres recovery.

IV. Liaise with the duty PICU registrar for issues related to paediatric

patients (Bleep 0956)

V. Ensure that ACCU junior medical staff continue with routine work and that patients already admitted are having on-going medical care. Ensure discharge summaries are prepared for all step downs / transfers.

VI. In the event of a trauma call that requires your attendance ensure that

the ACCU fellow or other suitable trainee is in charge of coordination relating to the incident pending senior help.

VII. Identify those junior medical staff due on duty on the next shift and try

and foresee any travel difficulties and forewarn if necessary.

VIII. There will be a difference between a MI declared during working hours and one declared out-of-hours. Your role initially will be coordination. There is often a time-lag between declaration of a MI and patients attending.

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MAJOR INCIDENT PLAN ACTION CARD

ADULT CRITICAL CARE UNIT (ACCU- WARDS 4E/4F) ROYAL LONDON HOSPITAL

ACCU TRAINEE MEDICAL STAFF (not 1113)

The initial phase of any response will be to ensure appropriate on-going care for current ACCU patients and to prepare for any further MI related patients. There may be a significant time lag between the incident being declared and the ACCU receiving patients.

INCIDENT DECLARED When major incident declared and if you are on duty ensure that you report to 1113 and make them aware that you know the incident has been declared.

I. If out of hours or you are off duty attend the RLH ACCU and proceed immediately to meeting rooms 3/4 (in ward 4E) to await further instructions.

II. Ensure you have you Trust ID and your mobile phone (with charger)

when attending the hospital. III. Be prepared to be stood down depending on the nature of the incident

and the need to maintain staffing over the following days.

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APPENDIX Red Transport Bag

LEFT HAND POCKET (open) RIGHT HAND POCKET (open)

Non-sterile gloves (assorted) ECG electrodes (2 packets) 1x Tuff cut scissors

1x Laerdal mask BACK POCKET (open)

1x Stethoscope Sterile gloves (assorted; sizes 5.5 to 9) 1x Eye protectors 5x Pack of 5 10cm x 10cm swabs 1x Pen Torch

FRONT POCKET (sealed)

3x Guedel airway; 1 each of size 2, 3 & 4 Nasopharyngeal airways size 6, 7 & 8

2x Laryngoscope handles (disposable) 1x 10ml syringe 2x Macintosh Laryngoscope blades; 1 each of MAC 3 & MAC 4 1x intubating bougie 1x intubating stylet 1x Magill’s forceps 1x Yankauer suction 1x Catheter mount and HME filter 5x KY jelly 1x ETT tape & foam 1x Mini D-Fend & CO2 tubing 30x Tracheal suction catheters; 10 each of size 8,10 & 12

MAIN SECTION (sealed)

1x AMBU Bag with size 5 face mask 2x Face masks; 1 each of sizes 3 and 4 7x ET tubes; 1 each of size 6.0, 6.5, 7.0, 7.5, 8.0, 8.5 & 9.0 3x Laryngeal Mask Airways; 1 each of size 3, 4 & 5 1x non-rebreath face mask and O2 tubing Giving sets Clear bag (currently specimen bag) 2x blood giving sets 6x syringes; 2 each of 5ml, 10ml & 20ml

2x crystalloid giving sets 5x 21G hypodermic needles 2x volumetric pump giving sets 4x 10ml ampoules 0.9% NaCl 4x 10ml ampoules sterile water Burgundy drug pouch

Clear bag (within infusion pack) 1x Adrenaline 1 in 1,000 minijet (1ml) 6x Venflons; 2 each of 16G, 18G & 20G 4x Adrenaline 1 in 10,000 minijet

(10ml) 2x 20G Insyte arterial lines 1x Amiodarone 30mg/ml minijet 1x Leader Cath 20G 8cm arterial line 2x Atropine sulphate 1mg/5ml minijet 5x small Tegaderm iv advanced dressings

1x Diazemuls injection 5mg/ml (2ml)

3x large Tegaderm iv advanced dressings

1x Ephedrine injection 30 mg/ml (1ml)

5x large bioclusives (IV 3000 1-hand) 1x Glyceryltrinitrate spray 400mcg/spray

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Green Grab Bag Front compartment of main bag 2x Face Masks; 1 each of sizes 3 & 4 2x Laryngoscope handles 2x Laryngoscope Blades; 1 each of Macintosh sizes 3 & 4 1x Blue Frova intubating catheter 1x face mask with oxygen tubing and reservoir bag 6x tracheal suction catheters; 2 each of sizes 12, 14 and 16 2x Yankauer suction 1x Suction tubing 3x Laryngeal mask airways; 1 each of size 3, 4 & 5 1x 20ml syringe 1x HME Filter & catheter mount 1x Blue drug pouch – contents as red bag Side Pocket 1 (Ventilation) 1x Water’s circuit 1x Ambu Bag with size 5 face mask

Side Pocket 2 (Fluid) 1x 1000ml bag Plasma-Lyte 148 1x 500ml bag 0.9% saline 1x 500ml pressure bag 1x blood giving set 1x extension line 1x 3-way tap

Red intubation pouch (flat on top of bag) 5x ET Tubes; 1 each of sizes 6.5, 7.0, 7.5, 8.0 & 8.5 3x Guedel airways; 1 each of sizes 2, 3 and 4 2x Nasopharyngeal airways; 1 each of sizes 6.0 and 7.0 2x KY Jelly sachets 1x Portex CO2 clip 1x ETT tie 1x 10ml syringe 1x Magill’s forceps Red arterial line bag (rear compartment of main bag) 4x Arterial cannulae; 2 each of sizes 20G Insyte and Vygon leadercath 20G 8cm 1x Arterial transducer set 2x Tegaderm dressings 2x Sani-Cloth 2% chlorhexidine wipes 2x packs Gauze Blue i.v. bag (rear compartment of main bag) 5x Venflons (Introcan Safety winged); 1 each of sizes 14G, 16G, 18G, 20G and 22G 4x iv dressings (BD Veca-C) 4x Sani-Cloth 2% chlorhexidine wipes

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GOOD LUCK

ASK FOR HELP IF YOU ARE WORRIED

BELIEVE NOTHING,

TRUST NO ONE, GIVE OXYGEN

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