Lines of Responsibility
Availability
You are expected to be immediately available to the Unit when on duty. Please ensure that the ANUM knows where you are at all times.
Referrals to the Unit
Referrals will come directly to the registrar. The registrar (Outreach registrar when on duty) should assess all referrals, but may task the resident to assess the patient if there is an unstable situation in the Unit. All referrals must be discussed with the duty intensivist, regardless of the time of day.
All patients, except from theatre, referred to the Unit must be assessed within 30 minutes of the referral and discussed with the ANUM and the Duty Intensivist.
All referrals to ICU from theatre for unplanned surgery should be accepted (but still discuss with the ANUM and Duty Intensivist), unless one of the following situations occurs –
We request that the anaesthetists err on the side of caution when considering whether to put a CVC in. And if patients are critically ill, to put a CVC in with more rather than less lumens.
No patient may be admitted or refused admission (even if no beds are available) without the approval of the Duty Intensivist. ALL REFUSALS MUST BE ENTERED IN TO THE REFUSALS BOOK.
NB. Intensive Care is an acuity-based discipline. As such, a critically ill patient is our problem, whether we have beds or not. It may be appropriate for ICU staff to become involved in management of a patient outside the Unit in the event of a bed shortage.
Parent Unit Registrars must inform their Consultant of any patient who is referred or admitted to the Intensive Care Unit.
Elective Admissions
The vast majority of elective surgical admissions are seen in the ICU pre-admission clinic on a Tuesday afternoon. If a patient is accepted for ICU admission post-operatively, please document the following three things –
ICU patients
ICU functions as a closed Unit. This means that the Intensive Care Team is responsible for all patient management, although the patient remains under the bed-card of the Parent Unit. You provide all medical care for ICU patients, reporting directly to the Intensivist, and consulting where necessary with the Parent Unit. No treating team should prescribe drugs or fluids in the ICU charts. ICU is responsible for coordinating and integrating medical management.
The exceptions to this are for paediatric patients and the Acute Pain Service (APS), where we allow these teams to initiate or discontinue treatment as they require. They will notify you of their decision or recommendation, or involve you in decision making.
Coronary Care patients
CCU patients are admitted under a Cardiology bed card. During normal working hours these patients are managed by the Cardiology team. Out of hours the Medical Registrar admits Cardiology (including CCU) patients and must discuss admissions with the Cardiology consultant on-call. Once admitted to CCU, the ICU/CCU nursing staff will contact the Cardiology consultant on-call directly for advice and patient management. For time critical interventions the Cardiology consultant may ask for help from the ICU registrar.
Admission and Transfers
Please use template in G:\ICU\2) ICU Admission Transfer Summaries. Admission and Transfers must be completed electronically using the MS Word template and “copied and pasted” in to the DMR.
The Parent Unit should be notified that the patient is ready for the ward, as soon as the Intensivist has cleared the patient (usually after the morning ward round). We suggest that the Transfer Summary is started on admission of the patient to ICU, updated and edited daily. If there is a delay and the patient is discharged after hours, please notify the covering team and document this (who the covering doctor notified is) in DMR.
Use your discretion as to whether the Drug Chart should be re-written.
All patients who are discharged after 20:00 must be reviewed 2-4 hours after discharge by the ICU Registrar. Please also request a “Doctor Review” on Patient Flow, as a safety net once the patient has been discharged to the ward.
Resources
There is an electronic policy filing system known as PROMPT. Both PROMPT and UpToDate® are available on all hospital terminals. Please ensure that you understand how to access hospital policies using this system.
You are expected to be immediately available to the Unit when on duty. Please ensure that the ANUM knows where you are at all times.
Referrals to the Unit
Referrals will come directly to the registrar. The registrar (Outreach registrar when on duty) should assess all referrals, but may task the resident to assess the patient if there is an unstable situation in the Unit. All referrals must be discussed with the duty intensivist, regardless of the time of day.
All patients, except from theatre, referred to the Unit must be assessed within 30 minutes of the referral and discussed with the ANUM and the Duty Intensivist.
All referrals to ICU from theatre for unplanned surgery should be accepted (but still discuss with the ANUM and Duty Intensivist), unless one of the following situations occurs –
- There are no ICU beds. ICU will then assist in advising appropriate disposition (inter-hospital transfer or ward)
- There is suspicion that the patient actually may not require ICU admission. This is a rare occurrence and in this setting the Duty Consultant should assess the patient in recovery and discuss their opinion with the referring doctor or team (ie surgeon and / or anaesthetist).
We request that the anaesthetists err on the side of caution when considering whether to put a CVC in. And if patients are critically ill, to put a CVC in with more rather than less lumens.
No patient may be admitted or refused admission (even if no beds are available) without the approval of the Duty Intensivist. ALL REFUSALS MUST BE ENTERED IN TO THE REFUSALS BOOK.
NB. Intensive Care is an acuity-based discipline. As such, a critically ill patient is our problem, whether we have beds or not. It may be appropriate for ICU staff to become involved in management of a patient outside the Unit in the event of a bed shortage.
Parent Unit Registrars must inform their Consultant of any patient who is referred or admitted to the Intensive Care Unit.
Elective Admissions
The vast majority of elective surgical admissions are seen in the ICU pre-admission clinic on a Tuesday afternoon. If a patient is accepted for ICU admission post-operatively, please document the following three things –
- Whether patient is accepted for post-operative admission to ICU
- Your recommendation if there is no ICU bed. It will sometimes be safe (but not optimal) to proceed without an ICU bed. Often this is where cancelling the case would be the greater risk (for example, cancer surgery).
- The recommended resuscitation plan. Most patients are amenable to having discussion about what they would like to occur if there are significant and potentially life-limiting complications. Most, but not all, patients will be for full resuscitation. This should be discussed with the Outreach Intensivist in Clinic, acknowledging that a small minority of patients find this conversation overly threatening and anxiety providing. Use your discretion.
ICU patients
ICU functions as a closed Unit. This means that the Intensive Care Team is responsible for all patient management, although the patient remains under the bed-card of the Parent Unit. You provide all medical care for ICU patients, reporting directly to the Intensivist, and consulting where necessary with the Parent Unit. No treating team should prescribe drugs or fluids in the ICU charts. ICU is responsible for coordinating and integrating medical management.
The exceptions to this are for paediatric patients and the Acute Pain Service (APS), where we allow these teams to initiate or discontinue treatment as they require. They will notify you of their decision or recommendation, or involve you in decision making.
Coronary Care patients
CCU patients are admitted under a Cardiology bed card. During normal working hours these patients are managed by the Cardiology team. Out of hours the Medical Registrar admits Cardiology (including CCU) patients and must discuss admissions with the Cardiology consultant on-call. Once admitted to CCU, the ICU/CCU nursing staff will contact the Cardiology consultant on-call directly for advice and patient management. For time critical interventions the Cardiology consultant may ask for help from the ICU registrar.
Admission and Transfers
Please use template in G:\ICU\2) ICU Admission Transfer Summaries. Admission and Transfers must be completed electronically using the MS Word template and “copied and pasted” in to the DMR.
The Parent Unit should be notified that the patient is ready for the ward, as soon as the Intensivist has cleared the patient (usually after the morning ward round). We suggest that the Transfer Summary is started on admission of the patient to ICU, updated and edited daily. If there is a delay and the patient is discharged after hours, please notify the covering team and document this (who the covering doctor notified is) in DMR.
Use your discretion as to whether the Drug Chart should be re-written.
All patients who are discharged after 20:00 must be reviewed 2-4 hours after discharge by the ICU Registrar. Please also request a “Doctor Review” on Patient Flow, as a safety net once the patient has been discharged to the ward.
Resources
There is an electronic policy filing system known as PROMPT. Both PROMPT and UpToDate® are available on all hospital terminals. Please ensure that you understand how to access hospital policies using this system.