HMO responsibilities: admissions & discharges, daily reviews, MET calls

Admissions / Discharge summaries:
  • Currently we are completing discharge summaries on a Word document on G drive (CCU à Clinical à ICU Admissions & Discharges) and uploading “Part C – Discharge Summary” onto DMR when discharged. This is because when patients leave hospital the home team does the main discharge summary to the GP which should include the ICU relevant information
  • There is a set layout, just fill in the gaps as you go
  • There is a generic admission and discharge summary which you can start/update and save under the patient’s name in ‘DMR Current Admissions’ folder
  • The admission summary is a pro-forma for the admission note that is copied into DMR on admission to ICU
  • There is a big emphasis on handover, you should be making sure you have a verbal handover to the treating intern or HMO (or cover if after hours), maybe even to the registrar if complicated. Ensure to document the name/designation of who took handover
  • Try and write blood slips/ fluid orders etc. for the next day
  • Please try to update the discharge summary every shift if possible, especially if discharge from ICU is probable in the next 1-2 days. This means that the person taking over from you is not rushed to do it if the patient suddenly has a bed on the ward. Rushing to write a discharge summary for a complex patient who has 100 pages of notes and you have never met before can be very frustrating so helping each other out to keep the documents updated throughout a patient’s admission is extremely helpful.
 
Daily Reviews:
  • A large portion of the workload. Every patient is reviewed thoroughly by a resident or registrar every day. This involves – talking to the patient, examining the patient, reviewing their investigation results, reviewing all their paperwork, checking plans are completed.
  • It is often done by the night team as their ward round
  • Use this time to review allied health inputs etc and to check that necessary forms are completed.
  • Something that is worth paying attention to that you may not be familiar with if this is your first ICU term – MR85 forms (aka NFR forms) should be done for all patients in ICU as soon as possible. Check this on your daily review and discuss with your registrar and consultant.
  • Several of the long-stay patients have Patient Diaries, documents written in by medical, nursing, allied health staff as well as family. Doctors aren’t so good at writing in these, so try and make it part of your daily review.
  • You can also screen patients for delirium using the CAM-ICU tool – get the registrar to show you the tool on the ICU observation chart. It’s unbelievably easy.
 
MET calls:
  • Monday to Friday there is an “outreach” registrar (approx. 0800 - 1630) who will attend MET calls with an allocated nurse
  • On the weekend there is not an outreach registrar and there is just the one registrar who will go to METs - unless they are busy, then it will be your job. If you don’t know Bendigo hospital, don’t worry, you will always be going with an ICU nurse
  • MET Team= ICU nurse, ICU registrar (or HMO), medical registrar, and home team registrar (or resident/intern)
  • If you attend a MET call your role is to assess and manage any critical illness (ABCD) and whether the patient needs a higher level of care (ICU, CCU, theatre etc), and also to act as a conduit to ICU- a MET call counts as an ICU referral if the home team / medical registrar asks for an ICU / HDU bed during the MET. If this occurs you will generally call your registrar and have them come and review, however it may be appropriate to call the consultant directly. It is important to note that the medical registrar is essentially the leader of the MET call, and your role is to provide support and assess ABCs.
  • Also note that if a patient has more than one MET call during 24 hours, it must be escalated to a home team consultantby the parent team (ie NOT your job) as mortality in multiple MET call patients is approx. 20%, double ICU mortality and approx. 10x ward patient mortality.
 
ICU Beds:
  • Only Consultants can say yes or no to an ICU bed, so never confirm a response one way or another – we do not have the authority to do so
  • The bed state in ICU is often fluid – patients can be sent to the ward if clinically necessary – so in general do not say that we are ‘full’ as people may transfer patients to Melbourne etc. when it could be avoided.
  • Just check with your registrar/Consultant who will talk to the ANUM regarding bed state if needed
  • There are also planned post op admissions for patients who were referred for a bed prior to their surgery and seen in clinic – you can find these in the ‘ICU Referrals’ folder and often it can be useful if you have a moment to start their admission before they arrive (as often they will arrive after surgery at 6-7pm when you are busy preparing for handover)

Outreach:
  • Outreach registrar and consultant also work closely with Liason ICU nurse team
  • Daily review of patient’s who have had MET calls the previous day and patient’s who were refused from ICU admission or discharged from ICU and patient’s on TPN
  • There is a folder for all MET calls and also for all ICU Refusals
  • Also take PICC referrals and do PICC insertion
  • As well as attending the MET calls the outreach registrar will also see and assess all of the ICU referrals and attend the Tuesday afternoon pre-op clinic and Echuca tele-health consultations
     
Research
  • ICU is a very active place for research and we are always running a number of formal research projects
  • Research coordinator is Julie
  • Be aware of what projects are running and eligibility criteria
  • If you think a patient is eligible then speak up and have a go at enrolling the patient yourself (review the consent process beforehand and discuss with registrar) –sometimes we are rewarded with chocolates for research enrolment