Health Education England - North West: Postgraduate ...



F1 training in acute care:

Overview

• Tameside ITU is a 7 bedded mixed surgical and medical intensive care unit also providing surgical high dependency (and occasionally medical high dependency) care. It is usually staffed to 6 level 3 (ITU) and 2 level 2 (HDU) beds.

• Level 3 (ITU) care usually involves ventilation plus other organ support e.g. cardiovascular support, renal replacement therapy, sedation.

• Level 2 (HDU) care involves single organ support or monitoring e.g. non-invasive ventilation, CVS support alone. Due to the workload involved renal replacement therapy is classed as level 3 care currently.

• The case mix is varied and at any time often includes postoperative care (elective and emergency), sepsis, post cardiac arrest, pneumonia, respiratory failures, trauma, overdose, acute renal failure. You will see patients at all stages of their care form the initial stabilisation and diagnostics through to the weaning from CVS and respiratory support.

• The unit is staffed by highly skilled nursing staff who are very amenable to any questions you may have. The medical staff on the unit at any time include:

o Duty Consultant for week

o Duty Staff Grade for week

o F1 trainee (9 months out of 12)

o ST1/2 in Anaesthesia (intermittently allocated)

• Days commence with the handover round at 0830-0900 (depending on consultant). Patient daily plans are formed at this stage. Each patient is then seen in detail and the daily summaries are filled out. A second round is performed by some consultants later in the morning/ lunchtime, which usually involves some teaching.

Roles and responsibilities

• Attendance at ward round (s)

• Daily assessment of patients and completion of daily assessment forms (shared with middle grade and/or consultant)

• Assessment includes:

o Examination of CVS/RESP/GIT/CNS as appropriate

o Review of observation and infusion charts

o Review of hematology/biochemistry results

• Formulation of basic management plans with Staff Grade and/or consultant

• Ordering of investigations

• Review of investigations

• Initial assessment of ward patients referred for opinion (degree of supervision will depend upon your experience and the patient)

• Completion of discharge summaries

Weekly timetable

| |Mon |Teu |Wed |Thu |Fri |

|First Month(theatres) |0800-1700 |0800-1700 |0800-1700 |0800-1700 |0830-12:00 |

| | | | | | |

|Next 3 months(ITU) |08:30-17:00 |08:30-17:00 |08:30-17:00 |08:30-17:00 |8:30 – 12:00 |

Key staff working on ICU

Dr Anand Kulkarni, Director of Anaesthetics, Education Supervisor for F1

Dr Gonie Govenden, Consultant Anaesthesia

Dr Ross Kitson, ICM tutor/Director of ITU

Dr H Rehman, Consultant Anaesthesia

Dr Abdulla, Consultant Anaesthesia

Dr K Gourishankar, Consultant Anaesthesia

Dr T Mirza, Staff Grade ITU and Anaesthesia

Dr A Sidduqui, Staff Grade ITU and Anaesthesia

Dr M Ansari, Staff Grade ITU and Anaesthesia

Dr P Wendels, Staff Grade ITU and Anaesthesia

Dr Zaheer, Staff Grade ITU and Anaesthesia

Dr F Mrihel, Staff Grade ITU and Anaesthesia

Dr Q Sindhu, Staff Grade ITU and Anaesthesia

Dr Ali, Staff Grade ITU and Anaesthesia

Dr Soliman, Staff Grade ITU and Anaesthesia

Mrs Chris Greenhough., Matron Critical Care

Senior Sister Janice Murphy

Senior Sister Tracey Brandon

Charge Nurse Paul Cavanagh

Senior Sister Alix West

Ann Farrell, Outreach Matron.

Educational objectives for F1 trainees in ICM

There are three areas to focus your training in ICM during the three months.

• Procedures and practices: both to observe and in some cases perform.

• Educational topics/objectives: to guide your reading and to form the basis of discussions with the consultant/staff grade

• Audit and case report

• These forms are replicated for your daily usage so you may keep this document as a master copy.

Procedures and practices

• The following table contains a selection of procedures undertaken on the ITU

• In each case it is desirable for you to observe the procedure at least once on the unit during your three months

• If your exposure level on the unit is adequate and your supervisor satisfied of your understanding of the technique, risks and complications of the procedure it may be permissible for you to undertake some of these procedures under DIRECT supervision.

• Finally many of these would be also suitable for your DOPS

|Procedure or practice |Date observed |signature |Date undertaken |signature |

|Arterial line insertion (radial) | | | | |

|Arterial line insertion (femoral) | | | | |

|Use of ultrasound to site CVC | | | | |

|CVC insertion | | | | |

|Hemocath insertion | | | | |

|Insertion of NG tube in ventilated patient | | | | |

|Endotracheal intubation | | | | |

|Percutaneous tracheostomy | | | | |

|Intercostal drain insertion | | | | |

|Set up of invasive monitoring transducer system| | | | |

|Bronchoscopy | | | | |

Educational topics/ objectives

• The following are a list of topics that are advisable for you to use to optimize your knowledge of critical care and guide you reading. Although it is not expected that you will cover all areas a concerted effort should be made to cover the majority of topics in your 3 months of ICM.

• Any of these can be used to facilitate a CBD.

• When the topic is covered get the assessor to sign the topic / competency

• Section 10 details common condition we see on ITU that may guide your background reading.

1. Patient assessment and outreach care

• Assessment of ABCDE in critically ill patient

• Identification of abnormal physiology

• Use of PARS scoring system

• Formulation of initial management plan for acutely unwell patient

• Appropriate investigations of critically ill adult patient

• ALS algorithm

• Principles of transporting & transferring patients

2. Interpretation of investigations

• Knowledge of abnormal hematology (FBC,COAG)

• Knowledge of abnormal biochemistry

o Sodium abnormalities

o Potassium abnormalities

o Renal dysfunction (see section XX)

• Knowledge of abnormal LFTs

• Interpretation of arterial blood gases

• ECG interpretation

o Common arrhythmias

o Patterns of infarction

o Heart blocks and bundle branch blocks

• CXR interpretation

o Collapse

o Consolidation

o Pneumothorax

o CVC line placement

o ARDS/pulmonary oedema

3. Cardiovascular management

• Principles of invasive monitoring

• Cardiac output monitoring (LidCO)

• Practical usage of vaso-active drugs

o Noradrenaline

o Adrenaline

o Dobutamine

o GTN

• Diagnosis of shock

• Management of shock

o Cardiogenic

o Septic

o Hypovolaemic

• Transfusion in the critically ill

• Haematology

o DIC

4. Respiratory management

• Indications and methods of tracheal intubation

• Indications for Percutaneous tracheostomy

• Basic airway management (performed in anaesthesia time)

• Non- invasive ventilation

o Indications & contra-indications

o Management

• Basic knowledge of ventilator modes

5. Nervous system

• Sedatives used on ITU

• Analgesia in the critically ill patient

• Analgesia in post-operative patients

• Assessment and management of delirium/confusion

• Management of status epilepticus

6. Renal system

• Causes and prevention of renal failure

• Indications for renal replacement therapy

• Modes of renal replacement therapy (basic knowledge)

• Pharmacology in renal failure

o Nephrotoxins

o Prescription principles

7. Metabolic care

• Nutrition in the critically ill

o Methods of feeding

o Basic nutritional regimes

o Complications of EN and PN.

• Glycaemic control on ITU

• Electrolyte disorders

o See section 2

o Re-feeding syndrome

• Stress ulceration

• Liver failure

o Basic principles acute vs. decompensated chronic

o Encephalopathy

o Variceal bleeding

8. Infection control/host defense

• Antimicrobials/ antibiotics used on ITU

• Principles of infection control

• Basic microbiology knowledge

o MRSA/MSSA

o C. difficile

o Pseudomonas

o Gram negative infections

o Nosocomial infections

▪ VAP

▪ CRBSI

• Management of sepsis

o Sepsis care bundles

o Source control

o CVS management

9. End of life care/ ethics

• DNAR and do not escalate orders

• Withdrawal of treatment

• Brain stem testing

• Principles of organ donation

• Decisions to accept / no accept patients for critical care

• Communication with families / breaking bad news

10. Conditions commonly treated on ITU

• Sepsis

o Severe sepsis

o Septic shock

• Post cardiac arrest

• Cardiogenic shock/ massive MI/ pulmonary oedema

• Massive PE

• Pneumonia

o Community acquired

o Healthcare –associated

• Exacerbation of COPD

• Asthma

• Acute respiratory distress syndrome

• Renal failure (either single organ or multi-organ)

• Post emergency surgery

o Visceral perforation

o Faecal peritonitis

o Ischemia of the bowel

• Overdose/ self poisoning

• Resources

• Tameside ITU guidelines: available in PDF form, on unit hard drives or in paper form in folder on nurses station. All systems covered.

• the competency based initiative from the ESICM

• From the intensivists in Pennsylvania a really good introduction to ITU (although slightly American):

• A more detailed resource with interesting essay and guidance that may help with your projects

• On line journal with some useful papers and reviews

• Lots of gorey pictures and discussions about trauma critical care plus fun moulages

• A good basic resource from the ITU chaps in Hong Kong

• Books that our trainees have found useful include Churchills Pocketbook of Intensive Care (2004) Bodenham, Bellamy, Whitely and The Oxford Handbook of Critical Care (2006) Singer, Webb. Feel free to buy these then you can always sell them on to your successor if you didn’t want to keep it!!

Educational record for Dr

F1 trainee Acute Care rotation (ICM phase)

Dates:

From

to

Educational supervisor:

Sheet 1: practical procedures to observe / perform

Remember some may also be suitable for a DOPS.

|Procedure or practice |Date observed |signature |Date undertaken |signature |

|Arterial line insertion (radial) | | | | |

|Arterial line insertion (femoral) | | | | |

|Use of ultrasound to site CVC | | | | |

|CVC insertion | | | | |

|Hemocath insertion | | | | |

|Insertion of NG tube in ventilated patient | | | | |

|Endotracheal intubation | | | | |

|Percutaneous tracheostomy | | | | |

|Intercostal drain insertion | | | | |

|Set up of invasive monitoring transducer system| | | | |

|Bronchoscopy | | | | |

Educational topics/ objectives

• The following are a list of topics that are advisable for you to use to optimize your knowledge of critical care and guide you reading. Although it is not expected that you will cover all areas a concerted effort should be made to cover the majority of topics in your 3 months of ICM.

• Any of these can be used to facilitate a CBD.

• When the topic is covered get the assessor to sign the topic / competency

1. Patient assessment and outreach care

• Assessment of ABCDE in critically ill patient

• Identification of abnormal physiology

• Use of PARS scoring system

• Formulation of initial management plan for acutely

unwell patient

• Appropriate investigations of critically ill adult patient

• ALS algorithm

• Principles of transporting & transferring patients

2. Interpretation of investigations

• Knowledge of abnormal hematology (FBC,COAG)

• Knowledge of abnormal biochemistry

o Sodium abnormalities

o Potassium abnormalities

o Renal dysfunction (see section 6)

• Knowledge of abnormal LFTs

• Interpretation of arterial blood gases

• ECG interpretation

o Common arrhythmias

o Patterns of infarction

o Heart blocks and bundle branch blocks

• CXR interpretation

o Collapse

o Consolidation

o Pneumothorax

o CVC line placement

o ARDS/pulmonary oedema

3. Cardiovascular management

• Principles of invasive monitoring

• Cardiac output monitoring (LidCO)

• Practical usage of vaso-active drugs

o Noradrenaline

o Adrenaline

o Dobutamine

o GTN

• Diagnosis of shock

• Management of shock

o Cardiogenic

o Septic

o Hypovolaemic

• Transfusion in the critically ill

• Haematology

o DIC

4. Respiratory management

• Indications and methods of tracheal intubation

• Indications for Percutaneous tracheostomy

• Basic airway management (performed in anaesthesia time)

• Non- invasive ventilation

o Indications & contra-indications

o Management

• Basic knowledge of ventilator modes

5. Nervous system

• Sedatives used on ITU

• Analgesia in the critically ill patient

• Analgesia in post-operative patients

• Assessment and management of delirium/confusion

• Management of status epilepticus

6. Renal system

• Causes and prevention of renal failure

• Indications for renal replacement therapy

• Modes of renal replacement therapy (basic knowledge)

• Pharmacology in renal failure

o Nephrotoxins

o Prescription principles

7. Metabolic care

• Nutrition in the critically ill

o Methods of feeding

o Basic nutritional regimes

o Complications of EN and PN.

• Glycaemic control on ITU

• Electrolyte disorders

o See section 2

o Re-feeding syndrome

• Stress ulceration

• Liver failure

o Basic principles acute vs. decompensated chronic

o Encephalopathy

o Variceal bleeding

8. Infection control/host defense

• Antimicrobials/ antibiotics used on ITU

• Principles of infection control

• Basic microbiology knowledge

o MRSA/MSSA

o C. difficile

o Pseudomonas

o Gram negative infections

o Nosocomial infections

▪ VAP

▪ CRBSI

• Management of sepsis

o Sepsis care bundles

o Source control

o CVS management

9. End of life care/ ethics

• DNAR and do not escalate orders

• Withdrawal of treatment

• Brain stem testing

• Principles of organ donation

• Decisions to accept / no accept patients for critical care

• Communication with families / breaking bad news

Date of appraisal:

Appraiser:

Comments:

Dr Ross Kitson, ICM Tutor

Dr Anand Kulkarni, Director of Anaesthetics; Education Supervisor for Foundation trainee F1

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