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Version: 1.0 FINAL
Date of next review: FINAL
Sunshine Coast University Hospital
Model of Care for Intensive Care Service
Version: 1.0 FINAL
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Version control
Version no Date Author/position Comments
0.01 28/04/2015 Chris Gardner/Principal Project Officer
Initial draft
0.02 15/05/2015 Helen Robson/TnT Co-ordinator and Chris Gardner
Further additions
0.03 18/05/2015 Jude Rhodes/Project Officer Editing and formatting changes
0.04 22/05/2015 Jude Rhodes Feedback from key stakeholders: • C Zantis • P Williams • J Jaspers • C Anstey • K McCleary
0.05 26/05/2015 Helen Robson, Chris Gardner and Jude Rhodes
Feedback from key stakeholders: • T Griggs • V Masurkar • M Terblanche
0.06 29/05/2015 Helen Robson Version 0.05 tracked changes accepted.
0.07 04/06/2015 Tess Atherton/Project Officer Editing
0.08 11/06/2015 Jude Rhodes Addition of Research component, section 7
0.09 16/06/2015 Jude Rhodes Incorporating feedback from V Masurkar, T Christensen, S Norman, M Terblanche, J Jaspers, T Griggs, M Ziegenfuss
0.10 30/06/2015 Tess Atherton Review
0.11 30/06/2015 Jude Rhodes Editing and formatting changes requested by J Hallas and Tess Atherton
0.12 09/07/2015 Helen Robson Updates after meeting with Gold Coast University Hospital on their model of care and lessons learnt.
0.13 14/07/2015 Helen Robson Tracked changes accepted for sign-off by clinical leads.
0.14 16/07/2015 Tess Atherton Reviewed Critical Care suite of documents
0.15 16/11/2015 Vikram Masurkar Updates after Clinical Challenge Panel Review.
1.0 FINAL 16/12/2015 Helen Robson Moved to final version – all changes accepted.
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Key definitions
Model of Care
The model of care details how a clinical or non-clinical service will be provided at a site, and how this service integrates with other health care providers within a network. The model of care informs the development of Service Unit Profiles, which prescribe in full detail the procedures and operational plans to operate the service at the site. The Model of Care links the operational detail of how a service is delivered (detailed in Service Unit Profiles) at each site to the higher-level principles of service delivery across the health service (stated in the Service Description).
Author: Chris Gardner / Helen Robson / Jude Rhodes
File Name: MoC_ICU.v1.0 FINAL
Endorsement Role Name Position Signature Date
Service Group Director Ratna Aseervatham Director, Surgical Services
Workstream 1 Lead Jodi Hallas Director Workstream 1, Service Strategy & Design
Clinical Lead / s Chris Anstey Director Intensive Care Unit
Mark Adcock Nursing Service Director Surgical Services
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Contents
Sunshine Coast University Hospital Model of Care 5
1. Service vision for Sunshine Coast University Hospital 5
2. Planned services on commencement of Sunshine Coast University Hospital 6
2.1 Service summary 8
2.2 Assumptions and constraints 8
3. Care delivery system 9
3.1 Referral and admission 11
3.2 Treatment 12
3.3 Discharge 13
3.4 Outreach 13
4. Supporting clinical services 14
5. The care delivery team 15
5.1 Medical 15
5.2 Nursing 16
5.3 Allied health 17
5.4 Pharmacy 18
5.5 Support staff 18
5.6 Mental health 18
6. Where care will be provided 19
7. Research and innovation 23
7.1 Research 23
7.2 Innovation 25
8. Risks identification 26
9. Evidence statement 26
10. Further reading and references 27
10.1 References 27
10.2 Further reading 27
11. Appendix A – consultation list 28
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Sunshine Coast University Hospital Model of Care
Please note: This Model of Care must be read in conjunction with the Service Description, Service Unit Profile and Clinical Transition Plan. It has been endorsed at a point in time however it is acknowledged that it will continue to evolve throughout the commissioning phase of the Sunshine Coast University Hospital (SCUH) in response to evidence based clinical and technological innovations and will be aligned to the annual business planning cycle.
1. Service vision for Sunshine Coast University Hospital
The Sunshine Coast Hospital and Health Service (SCHHS) will provide excellence and leadership in the health care of patients requiring intensive care services across the Sunshine Coast and the broader geographical catchment area.
The provision of high quality patient care for adults and paediatrics will be achieved through the Intensive Care Unit’s strong commitment to leadership, patient advocacy, collaboration, partnerships, innovation, education, training and research in an environment of openness, and respect.
This will be facilitated through a centralised ICU at the Sunshine Coast University Hospital (SCUH) providing critical care (medical and surgical) to the full spectrum of services available at the hospital.
In 2016, the SCUH adult ICU will provide a level 5 service and will increase its capability to provide a level 6 service by 2021/22 (as defined in the Clinical Service Capability Framework for Public and Licensed Private Health Facilities v3.2 (CSCF)1).
In 2016, the SCUH paediatric ICU will provide a level 4 service and will increase its capability to provide a level 5 service by 2026/27.
This development of services will complement the expansion of new sub-specialities to the health service i.e. neurosurgery and cardiothoracic surgery.
Over time, the ICU aims to become a paediatric accredited training facility under the College of Intensive Care Medicine of Australia and New Zealand (CICM).
The ICU will participate in clinical research projects–both industry sponsored and international collaborative research run by the Australian New Zealand Intensive Care Society Clinical Trials Group–across a wide spectrum of clinical questions with relevance for many Sunshine Coast residents.
The ICU will provide a national and international benchmark for the quality of care delivery by promoting and delivering evidence-based clinical practice.
Staff will be trained in the critical evaluation of medical literature and literacy in the research methods and in-situ simulation will continue as part of the regular education programs.
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2. Planned services on commencement of Sunshine Coast University Hospital
The following procedures/interventions are carried out in the SCUH ICU, at either the bedside or in the procedure room:
• intubation
• tracheostomy
• insertion of central venous and arterial catheters for cardiac and invasive monitoring
• cardio pulmonary resuscitation
• defibrillation
• all types of imaging (e.g. X-rays, echocardiography and trans-oesophageal and ultrasonography)
• 12 lead electrocardiography (ECG)
• doppler studies
• intermittent haemodialysis (by renal unit staff)
• continuous renal replacement therapy
• plasma exchange (by renal unit staff)
• intra-aortic balloon pump
• bronchoscopy
• use of advanced ventilation techniques (e.g. nitric oxide)
• chest drains
• electroencephalography
• telehealth support to Nambour General Hospital (NGH) and Gympie Health Service (GHS).
The Intensive Care Service is facilitated from a single centralised site at the SCUH. Other SCHHS sites (NGH, Caloundra Health Service (CHS), GHS and Maleny Soldiers Memorial Hospital (MSMH)) are supported by way of:
• an appropriate team, external to the SCUH, to facilitate retrieval/transfer of patients between hospital sites
• a consultative service providing support to deteriorating patients in acute medical and surgical wards and at SCUH
• a post intensive care unit follow-up (outreach service).
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The following table outlines the Intensive Care Services available across the SCHHS, including the CSCF service levels. Table 1: Intensive Care Services description and CSCF levels
Facility Patients CSCF level
Brief service description
SCUH Adult
5 Provides a CFCS level 5 adult Intensive Care Service.
Accommodates and manages patients with critical injury or illness, including major trauma.
Some specialty services are provided in Brisbane based on initial assessment and determination e.g. burns, initial management of spinal and brain injury.
Paediatrics
4 Provides a CSCF level 4 paediatric critical care service.
Provides dedicated specialist expertise and resources for the care and support of children and their families, using the skills of medical, nursing and allied health staff qualified and experienced in the management of critically ill children.
In collaboration with the SCUH Child and Adolescent Service, the ICU delivers critical care to children requiring ongoing care for short periods.
Children requiring complex care are referred to the Lady Cilento Children’s Hospital for care.
NGH, CHS, GHS, MSMH
Adults and paediatrics
N/A There are no ICUs at these facilities. Critically ill or critically injured patients will be initially supported in consultation with the intensivists at SCUH via telehealth2.
Patients requiring intensive care are transferred to the SCUH for treatment.
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2.1 Service summary
The following table is a summary of the Intensive Care Service at the SCUH:
Table 2: Intensive Care Services summary
Serv
ice
elem
ents
Primary health care prevention
Car
e se
tting
SCUH on campus
Ambulatory OPD consult SCUH and other facility
Ambulatory diagnostic State-wide–various offsite
Preadmission clinic Primary health care–onsite
Operating theatres Primary health care–offsite
Day stay Hospital in the Home
Multi stay < 36 hours Telehealth
Multi stay > 36 hours Oncology
Ongoing follow-up or referral on/back to GP
Other setting e.g. private bed/service
Rehabilitation
Transitional care
Oth
er Existing service
Outreach Expanding service
Critical care New service
Acc
ess
path
way
Emergency
Hou
rs o
f ser
vice
0900–1700
Outpatient 0700–2200
CYMHS On-call component
Chronic complex care After-hours access
Other Other hours (please nominate below)
2.2 Assumptions and constraints
The following outlines the assumptions and constraints regarding the Intensive Care Service at the SCUH:
Assumptions
• Patient safety is integral to the development of this model of care. • A paediatric ICU will be provided at the SCUH from opening and will include an
appropriately qualified and credentialed paediatric staff. • The ICU will provide personnel for a ‘Code Blue’ team and ‘pre-call’ response
(outreach). • An electronic clinical information system is in operation. • The ICU outreach will be fully funded.
Constraints
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• There is a lack of paediatric ICU qualified and credentialed nursing and medical staff state-wide.
• The need exists for a dedicated staffing resource including equipment. • The use of ICU staff to support ‘Code Blue’ and outreach teams may provide a
significant staffing burden as expansion occurs within the SCUH.
3. Care delivery system
Intensive care is a referral service that provides life support, expert medical and nursing care and complex treatment for adults and children with life threatening illnesses or injuries and children with multisystem failure and/or requiring ventilation.
The intensive care model integrates intensive care and high dependency patients ensuring safe de-escalation of care for high dependency patients.
Paediatric intensive care is integrated into the unit and is provided from designated beds, of which, numbers are flexed depending on the number of patient admissions.
A detailed paediatric model of care will be developed by a paediatric intensivist, clinical nurse consultant / nurse manager and nurse educator after they are recruited to this role.
The unit provides invasive and non-invasive ventilator support, cardiac monitoring and renal support. It also provides care for trauma patients, specialised surgical procedures and a limited spinal and burns service (dependent on severity of injury as defined in the ICU admission criteria).
The following diagrams outline the patient flow for adults and children through the ICU which can be broken into four distinct stages: referral and admission, treatment, discharge, and outreach. Adults and children follow the same patient journey once admitted to the ICU. It is important to note that referrals for paediatric patients is different and is highlighted in the following sections.
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Diagram 1: Adult ICU patient journey
Diagram 2: Paediatric ICU patient journey
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3.1 Referral and admission
Patients are referred to the ICU from the Emergency Department, interventional suites (planned and unplanned), inpatient areas and from other hospitals. The admitting rights to the ICU are held by the admitting intensivist, using SCUH ICU defined admission criteria. These criteria are based on recommended state standards, ensuring all patients are assessed equally and without bias, thus upholding the principle of treating the right patient, in the right place and at the right time.
Emergency Department referrals
The ICU registrar identifies trauma patients admitted to the Emergency Department resuscitation zone when the ‘full response’ trauma page is activated.
The ICU registrar assesses the patient in the Emergency Department for admission to the ICU and escalates the referral to the admitting intensivist.
Other Emergency Department patients who may require an intensive care or high dependency bed are referred to the ICU admitting intensivist for review.
In instances where SCUH ICU is at capacity, a bed is organised in another facility after accessing the state-wide ICU bed availability database. ICU continues to provide clinical input while the patient is at SCUH.
Each pod is staffed to manage the inpatient load and to facilitate the increased transportation that has become an integral component of intensive care. Patients are most commonly transferred for ongoing treatment or investigations to either the Interventional Suite; the Clinical Investigations Unit; or the Medical Imaging Department.
For paediatric patients, the Paediatric Emergency Medicine (PEM) doctor may request advice on patient care from the paediatric intensivist whilst the patient is still in the Emergency Department.
Interventional Suite referrals
For patients undergoing complex surgery, the referral process to the ICU is triggered from the outpatients appointment where the decision to undergo surgery is made. If surgery is not complex and the patient has an elevated anaesthetic risk, the treating anaesthetist may collaborate with the ICU at the patient’s pre-anaesthetic evaluation appointment. (Refer to the Anaesthetics and Pain Management Model of Care for more detail.)
The referring doctor completes a scheduled ICU booking form and discusses the appropriateness of an ICU admission with the admitting consultant/registrar. Patients who deteriorate whilst under anaesthetic are referred for emergency post-procedure admission to the ICU.
Patients transferring from anaesthetic care are subject to the following points:
• In the case of ‘nurse only’ patient transfer from Post Anaesthetic Care Unit (PACU) to ICU the recovery nurse will transfer the patient.
• In the case where a medical escort is required for patient transfer from the operating room suite (ORS) to the ICU, a medical officer from the anaesthetic team will transfer the patient.
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ICU nursing or medical teams will be asked to assist in transferring patients if there are theatre staffing constraints that are likely to delay patient transfer from the PACU to the ICU, or if the transfer will cause delays to theatre cases. For instance:
• where the theatre list would need to be put on hold in order to allow an anaesthetist to escort the patient to ICU; or
• where theatre lists are being put on hold, as the PACU is full and unable to accept patients, causing there to be an acute need for available recovery nurses.
Appropriate medical and nursing handovers need to occur in all situations where there is a transfer of care.
For paediatrics, anaesthetists may request the paediatric intensivist to provide advice on patient care whilst the patient is in the recovery room.
Inpatient referrals Deteriorating inpatients may be referred to the admitting intensivist by the sub-speciality team e.g. general surgery, renal, paediatrics etc. Inpatients are reviewed by the intensive care medical team to determine clinical requirements and appropriateness to transfer care to the intensive care environment in consultation with the admitting intensivist. Alternatively, inpatients are identified through the early warning criteria recognition and response systems as a ‘pre-call’ and/or ‘Code Blue’.
While in the ICU, the primary care of the patient is the responsibility of the ICU medical team. The referring sub-speciality team, however, continues to play an important role in the ongoing care of the patient.
For children, the paediatric intensivist attends the paediatric ward round to support the early identification of patients that require intensive care.
Inter-hospital referrals Other facilities may refer patients who require intensive care that cannot be provided locally. These facilities are supported through telehealth until the patient is transferred by an appropriate retrieval team.
3.2 Treatment
The treatment pathway is the same for adults and paediatrics.
The multidisciplinary team, under the direction of the intensive care specialist, works collaboratively to deliver care to critically unwell patients. Inpatient specialist teams are encouraged to collaborate in the delivery of care. A daily multidisciplinary team handover ensures complex patient needs are assessed and planned for prior to review.
Clinical management includes, but is not limited to, two bedside ward rounds per day conducted by the rostered intensive care specialist, junior medical staff, nursing staff and allied health staff2. Patients are continuously monitored outside of these bedside rounds and ongoing reviews and treatment (including management of orders) is carried out as required and according to the patients’ condition. Quality clinical handover at the bedside optimises the accurate transfer of information and responsibility3
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Clinical handovers will incorporate a standard template as per current practice. Every attempt will be made to minimise the number of clinical handovers by appropriate rostering. E.g. 12 hour registrar shifts as opposed to 8 hour shifts. Parent teams will continue to provide ongoing input into the management of their patients while they are in ICU.
As per the Australian College of Critical Care Nurses (ACCCN) guidelines, nurse to patients ratios are determined by patient acuity, patients requiring intensive care are nursed 1:1 or greater as necessary, high dependency patients are nursed 1:2, or as required4.
Due to the seriousness of ICU patient conditions, family and visitors are critical to the provision of care and advocacy of patients’ wishes. Family members play an important role in the psychological wellbeing of the patients. The intensive care team addresses the needs and concerns of the family members whilst in ICU through ongoing discussions and family meetings.
End of life care is an integral part of Intensive Care Medicine. End of life care will be managed on a case by case basis in a holistic manner incorporating the needs of the patient and their family.
Aboriginal and Torres Strait Islander patients and families have access to the liaison service to ensure the individual needs of the patients from culturally diverse backgrounds are met.
3.3 Discharge
Adults and paediatrics are discharged in the same manner.
Discharge planning from the ICU commences at admission. Patients are required to have a medical or surgical sub-speciality team throughout the intensive care admission.
Transfer of care is the responsibility of the admitting sub-specialty teams and delays to transfer of care cannot impact the discharge of ICU patients to the inpatient wards. Continuity of care is optimised through clinical handover to sub-speciality teams and inpatient units, based on internationally recognised standards for clinical handover as per the Australian Commission on Safety and Quality in Healthcare guidelines5.
On the day of discharge, patients are referred to the outreach team who follow patients for a defined period post intensive care.
3.4 Outreach
Outreach processes are the same for adults and paediatrics.
The outreach service is led by an ICU specialist and is dedicated to providing speciality teams and their patients with education, support and clinical expertise outside of the ICU. The objective is to enable the speciality teams, both medical and nursing, to provide the right care, for the right patient, at the right time.
With the use of considered criteria, the outreach service promotes safe, efficient and effective patient care by:
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• monitoring and assessing the progress of patients discharged from the ICU; and
• providing clinical support, educational support and resources to staff on inpatient wards.
This ensures the smooth transition of ICU patients into the appropriate care model, thereby preventing readmission to the ICU and supporting the development of ward based personnel.
The outreach service also provides a dedicated ICU resource to the following areas:
• ‘pre-call’ response
• ‘Code Blue’ response (medical emergency team)
• central venous catheter insertion service (including vascaths)
• tracheostomy (monitoring, education and changes)
• ward based simulation scenario training for medical emergencies
• outreach to other hospitals
• perioperative advanced decision-making multidisciplinary team
• post-ICU care follow-up clinic.
An outreach video consultation and conferencing service is provided for remote consultation and advice, including support to NGH, GHS and MSMH via telehealth from the ICU meeting room.
4. Supporting clinical services The following diagram outlines the clinical services that support the provision of the critical care service:
Diagram 3: Clinical support services
Emergency Department
→ Direct access by internal circulation for the transfer of patients by hot lift
Retrieval services
→ Direct access by hot lift and helipad for the transfer of patients
Interventional Suite
→ Direct access by restricted circulation for the transfer of patients (Operating Room Suite) Convenient access by restricted circulation for the transfer of staff and equipment (Endoscopy Suite, Clinical Investigations Unit)
Coronary Care Unit
→ Direct access by restricted circulation for the movement of patients and staff
Medical Imaging Department
→ Direct access by restricted circulation for the movement of patients
Pathology Laboratory
→ Direct access by priority/dedicated mechanical circulation for transportation of samples and blood
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Pharmacy Direct access by mechanical circulation for transportation of medications
Inpatient areas → Convenient access by restricted circulation for the transfer of patients
Birthing Service → Convenient access by restricted circulation for the transfer of patients
Renal Unit Convenient access by general circulation for the movement of staff and equipment
Biomedical Technology Services
→ Convenient access by restricted circulation for the movement of equipment and staff
Clinical services critical to the provision of intensive care include:
• Pharmacy: A dedicated Pharmacy Service will be available in the ICU with a pharmacist involved in all areas of a patient’s care from admission to discharge.
• Blood bank: Blood is readily accessible from pathology 24 hours a day via porter or Pneumatic Tube System (PTS).
• Pathology: The Intensive Care Service requires high frequency and urgency for pathology tests and blood products. Some pathology testing is undertaken within the ICU i.e. point of care testing either at the bedside or elsewhere within the ICU. However, the majority of samples will be transferred to pathology via a PTS.
• Equipment: Biomedical Technology Service (BTS) is responsible for testing, calibrating, maintaining and repair of medical equipment, particularly ventilators. Some work is carried out within the ICU, both at the bedside and within the dedicated respiratory workroom. The main BTS is collocated at the north end of ICU.
5. The care delivery team
The Intensive Care Service is comprised of medical, nursing and allied health professionals, as well as support staff.
5.1 Medical
The SCUH ICU is an intensivist-led multidisciplinary team service. It is expected that all registered medical specialists in the ICU are Fellows of the College of Intensive Care Medicine of Australia and New Zealand (CICM). As the peak professional organisation for critical care medicine in Australia and New Zealand, the CICM has a significant interest in ensuring the highest standards of medical care for patients are maintained.
The SCUH ICU is accredited by the CICM as a training facility and provides health care training and education to a variety of medical, nursing and allied health staff. The ICU staffing mix allows the provision of specialised intensive care and the delivery of education and training.
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In CICM accredited facilities, ICU intensivists oversee the training of junior medical staff comprising of advanced trainees, basic trainees and registrars from other disciplines. Intensivists are trained under and are Fellows of the CICM.
At least one intensivist must be exclusively rostered to the pod at all times. During normal working hours this intensivist must be predominantly present in the unit or pod, and at all times, be able to proceed immediately to it. In addition to the attending intensivist, at least one registered medical practitioner, with an appropriate level of experience, must be exclusively rostered and predominantly present in the unit or pod of 8-15 patients at all times.
Duties outside of the ICU, such as outreach and medical emergency teams must be staffed by personnel additional to those required for managing patients within the ICU, and must not compromise care of patients within the ICU6.
A paediatric intensivist oversees the management of critically unwell children and training of the attending intensive care physicians. The paediatric intensivist also manages a team of dual specialists including: paediatric ICU consultants, paediatricians, anaesthetists and medical staff from emergency, and adult ICU.
5.2 Nursing
ICU nursing staff comprise of a nursing manager, clinical nurse consultants, nurse educators, clinical nurses, clinical coaches, research coordinators and organ and tissue clinical nurse consultants.
At least one designated nursing manager is required per ICU who is formally recognised as the unit nurse leader7.
The ACCCN recommends there must be a designated critical care qualified senior nurse per shift who is supernumerary. The team leader is supported by an ACCESS nurse(s) who provides assistance, coordination, contingency, education, supervision and support. The ACCESS Nurse is also the best resource for minimising delays to emergency admissions8.
Clinical nurse consultants are clinical experts who manage long-term patients, transfers to wards (ICU patient flow), clinical management support for nursing staff on day-to-day clinical issues, maintain clinical standards, quality activities, patient safety review and analysis of incidents, nursing review rounds, material and equipment management support for the nurse unit manager.
Nurse educators and clinical coaches are vital resources in the ICU, playing a key role in the transition of nurses into intensive care to postgraduate critical care nursing, ongoing up-skilling and professional development, and multidisciplinary simulation based training.
Nurse educators play a key role in maintaining quality patient care through the development of nursing staff. Staff development includes:
• assessing staff learning needs
• reviewing and developing educational resources
• reviewing the curriculum and program
• developing training activities and competency-based assessments.
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Nurse educators are responsible for the management of the transition program participants and post graduate critical care students; undergraduate student placements; and direct entry graduate nurse program.
Clinical coaches are vital to maintaining safe practice standards through induction and orientation, clinical skill development, safe practice, and preceptee/preceptor support at the point of care.
Organ and tissue donation, and transplantation clinical nurse consultants promote and enhance the fundamental role of the critical care nurse within the health professional team for optimal organ and tissue donation and transplantation outcomes.
A senior paediatric nursing staff member oversees the nursing management of critically unwell children and training of all nursing staff involved in the care of paediatrics. There is also a paediatric specific nurse educator that is shared with other paediatric specific areas within SCUH including the Women’s and Families Service, Post Anaesthetic Care Unit and the Emergency Department.
5.3 Allied health
Allied health team members include social workers, physiotherapists, dieticians, occupational therapists, speech pathologists and diversional therapists.
Social workers take a lead role in addressing the needs and concerns of the family members in the ICU as well as assessing the ongoing psychosocial needs of the critically ill patient.
Physiotherapists assess patients’ respiratory, cardiovascular, neurological, and musculoskeletal systems to formulate treatment plans. They focus primarily on the respiratory management of intubated patients and exercise rehabilitation of recovering patients.
Dieticians provide a key role by:
• assessing patients’ nutritional needs
• guiding decisions about appropriate nutrition therapy
• monitoring fluid and electrolyte status
• initiation of specialised enteral and parenteral products
• adjusting the nutrition care plan to the specific disease state and changes in the patient’s clinical condition.
Occupational therapists play a key role in the cognitive assessment and management of patients, activities of daily living and functional assessment and customised splint provision.
Speech pathologists provide assessment and intervention of swallow and communication on referral for tracheostomy patients and extubations.
Diversional therapists support long term ICU patients.
For paediatrics, the allied health support is a collaboration of expertise of both adult ICU and paediatric allied health staff.
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5.4 Pharmacy
The ICU pharmacist monitors the drugs that are prescribed for interactions and appropriateness and ensure prescribing guidelines are adhered to. Reducing error and harm from medicines through safe and quality use is an important element of intensive care medicine and assists in achieving patient safety and quality standards.
The role of the pharmacist includes:
• Handover – handovers from emergency pharmacist, or other ward pharmacist, if applicable.
• Admission – obtains an accurate medication history and develops a medication action plan for the patient; liaises with treating team; and is part of ward rounds.
• Assessment – ensures the appropriate use of medicines for treatment plan and , appropriate dosing in the patient (renal impairment), therapeutic drug monitoring, interactions, IV compatibilities, advice on routes of administration, liaising with treating team and being part of ward rounds.
• Observations – undertakes ongoing daily assessments and medication counselling; monitors adverse drug reactions; and documents.
Discharge – works with treating team to ensure all chartered medications are appropriate for the ward and all ICU specific medicines are ceased – or a plan is in place for their use, and handovers to ward pharmacist.
5.5 Support staff
ICU support staff include:
• Equipment officer – responsible for auditing and managing equipment and equipment specific consumables.
• Administration staff –dedicated to and situated within the ICU. They provide administrative support to the business functions of the unit, including records and data management, admission and discharge of patients, filing, general reception duties, and support to the senior directors within the department.
• Operational staff – comprise of ward persons to assist with direct patient care, cleaners and support workers to ensure logistical support.
• Data manager – responsible for education and support of the clinical information system. This includes software upgrades, development and uploading of charts/forms, development of reports, run reports, audits of data integrity, customising CIS to the unit and regular maintenance.
• Student numbers – include medical, nursing and allied health students reflect the need to provide clinical placement opportunities to accommodate the increasing number of students entering the training system in the ICU.
5.6 Mental health
The ICU is supported by the Consultation Liaison Psychiatry (CLP) service. The CLP clinical nurse consultant is available Monday to Friday for psychiatric reviews/referrals. Referrals are faxed to the CLP on admission and as clinically indicated.
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6. Where care will be provided The ICU is located on the eastern side of level 2 in the main hospital building, and is co-located with the Coronary Care Unit. The following diagram is a floor plan of the ICU:
Diagram 4: Floor plan of ICU
The ICU is positioned to provide a pleasant experience for patients and visitors, taking advantage of climate and scenic views, particularly for patients accessing the outdoor spaces.
The interventional suite (comprising the Extended Day Surgery Unit, operating room suite, endoscopy, procedural laboratories and Clinical Investigations Unit) is located on the western side of the second floor and is linked to the ICU via the restricted corridor for the transfer of patients and equipment.
The acute dialysis unit and biomedical technology services are located on the second floor. There is direct access to the hot lifts which provide direct access from the helipad, the Emergency Department and to the Medical Imaging Department.
The procedure room can be utilised for intensive care procedures for patients cared for elsewhere within the hospital or the community, and require access to ICU equipment and staff. The procedure room is also designed to be used for opportunistic and planned simulation based learning when not being used as a patient procedure area. The nurse educator and clinical coaches, in collaboration with the ICU consultant team, facilitate simulation based learning to address clinical risk, improve clinical communication and team work skills.
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There are two open air balconies (two beds per balcony) which have fully equipped ICU beds. These beds are used for long-term patients to rehumanise them after long periods in the ICU and also for terminally ill patients who are in the last stages of life, thus providing some privacy for relatives.
The accommodation within the ICU is configured to facilitate efficient and effective patient care. There are four, 10 bedded pods, and each pod has its own clinical services and can function independently. Pod 2 can be completely isolated as required e.g. during a pandemic emergency. Office and educational spaces are contained within the bounds of the ICU staff who are not directly involved in patient care but provide an important support function in the case of patient deterioration. As such, ICU office accommodation is located in close proximity to patient areas to facilitate this support.
A number of bedspaces are dedicated for the use of paediatrics and are supported by paediatric trained staff.
The waiting room is the primary location for family and visitors. There are several relatives rooms located around the ICU, provide dedicated areas for private discussions, rest and family meetings away from the bedside.
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The following diagram outlines the designated areas within the ICU:
Diagram 5: designated areas
The single room environment provides patients with the optimal environment for recovery. Single rooms have the benefits of improving sleep and minimising confusion, reducing noise, allowing conscious patients to have entertainment, and providing privacy for the patient and for family visits9. Isolation bedrooms and ensuites accommodate the needs of highly dependent patients, additional staff and equipment. Rooms are self-sufficient to minimise potential cross infection.
The intention is for all patients to remain in the same room for the duration of their admission in the ICU; however most of the equipment is mobile in case patients are required to be moved to another bedspace or pod. This reduces the requirement for cleaning and ensures beds become available sooner.
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All patient rooms are capable of providing sufficient intensive care for all patients, including bariatric patients. Ceiling mounted pendants and patient hoists are included in the design to minimise the impact clinical equipment has on the floor space.
Diagram 6: ICU patient room plan
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7. Research and innovation
7.1 Research
The ICU is a busy training unit with a commitment to growing its research activity.
The principal goals of the ICU research unit include:
• providing an environment capable of designing, conducting, and participating in local, national and international research
• facilitating and promoting investigator-initiated, collaborative clinical research
• advancing the SCUH Critical Care Group as the lead site for national and internationally conducted studies
• providing a teaching environment advancing the education and understanding of research methods
• promoting excellence in intensive care research that focuses on improving ICU patient care at the SCUH.
The SCUH ICU is well placed to contribute to research projects across a wide spectrum of clinical questions with relevance for many Sunshine Coast residents building on its research experience.
The ICU research unit participates in the collaborative research studies which not only allows the development and analysis of new treatments but also provides a national and international benchmark for the quality of care delivery. It has a proven track record in clinical research including both industry sponsored and international collaborative research run by the Australia New Zealand Intensive Care Society Clinical trials Group (ANZICS-CTG). The ICU also works with the George Institute, and The University of Queensland (UQ), and is developing a growing association with the University of the Sunshine Coast (USC).
The unit currently has four major research streams in which investigator driven research is developing:
• aetiology of renal failure, identification of biomarkers and development of new therapies in collaboration with industry partners
• renal replacement therapy, anticoagulation, electrolytes and acid base balance
• shock resuscitation, microcirculation and metabolism with a focus on resuscitation strategies and phase of illness in collaboration with the Critical Care Research Group at The Prince Charles Hospital and the Bloomsbury Institute of intensive Care Medicine, University College London
• medical emergency teams.
Professional roles The pivotal role of research coordinator in managing the conduct of clinical trials in ICUs has gained increased recognition over the last decade. The research coordinator position is a condition of accreditation of ICUs for specialist training by the College of Intensive Care Medicine. The role of the research coordinator is complex and broad and includes managing many aspects of individual study conduct including ethics and regulatory approval, recruiting and consenting patients and data collection.
Future perspectives
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As the hospital and ICU grows, the research unit aims to develop its research activity and track record. The unit aims of growing into a professorial unit with a national and international presence and with the ability to attract and employ the best senior medical trainees in a fellowship capacity.
Research activity will increase the already very active role within the ANZICS-CTG in terms of collaborative studies. In addition there will be a shift in the primary focus to the development of a higher output from novel investigator driven studies. This will involve applying for local, regional and national competitive grants and close partnership with the new university partner and existing collaborations and the support of clinical staff in research higher degrees (PhD/MPhil).
Once the paediatric ICU and level 6 surgical services become functional, SCUH ICU will be able to provide all mandatory modules that are required for FCICM advanced training.
Hybrid (paediatrics and adult) training opportunities are available to nursing and allied health staff.
ICU education aligns to the Practice Development Model including inter-professional interdepartmental education using a values based decision making model, enabling nursing, medical and allied health to collaboratively explore learning opportunities across disciplines.
Hybrid training opportunities to ensure nursing staff are appropriately skilled in the care of paediatrics should include:
• Resus for Kids
• Recognising and Managing the Deteriorating Paediatric Patient (RMDPP)
• Paediatric Advanced Life Support
• Interdepartmental Paediatric Rotation to DEM Paediatric Pod/Paediatric Ward/ Paediatric Perioperative
• Education Practice in Queensland (EPiQ) Acute Paediatric Module
• EPiQ Paediatric Intensive Care Module
• Paediatric Regional Rotational Program to the Lady Cilento Children’s Hospital (LCCH) Paediatric ICU
• Simulation based learning opportunities with the Paediatric Ward and DEM
Allied Health have commenced a program of training to prepare for the paediatric component and increased complexity of adult specialties (including cardio-thoracic surgery and neurosurgery) of the critical care treatment provision at SCUH. This has involved an in-depth Allied Health in service program, competency assessment program of complex skills, and simulation-based training program for Allied Health from Senior Therapists with previous experience at Tertiary Level facilities that cover all of the proposed new specialties at SCUH.
The SLiPAH (Simulated Learning in Paediatrics for Allied Health) program has been utilised and links established with Lady Cilento Paediatric Teams to up-skill in preparation for, and to complement the future paediatric ICU service within Allied Health.
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7.2 Innovation
In-situ simulation The ICU actively embeds in-situ simulation into the education program as a contemporary educational modality. A state of the art high fidelity in-situ simulation facility exists within the ICU. In-situ simulation provides an opportunity to conduct simulation in the normal work environment on a regular basis enabling development of technical and non-technical skills. These skills enable staff to respond promptly and appropriately to a variety of clinical events leading to improved quality of patient care.
In-situ simulation, as a teaching methodology, provides improved educational opportunities for ICU staff with a specific focus on communication, teamwork, crisis resource management and debriefing. It allows for both planned and opportunist learning ranging from part task and clinical skills training in isolation, to high fidelity, immersive and complex interdisciplinary scenarios.
The ICU in-situ simulation model consists of an ICU consultant and a nurse educator who develop, review and evaluate all scenarios and teaching sessions, equipment maintenance, data management and reporting. The ICU clinical coach acts as the simulation coordinator.
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8. Risks identification The majority of ICU patients are referred as emergency admissions at any time and in the expected approximate proportions as:
• emergency admissions – 38%
• inpatient areas including operating room suite – 50%
• inter hospital transfers – 12%.
The following table outlines the potential risks associated with delivering the Intensive Care Service and the proposed mitigating actions:
Table 3: Intensive Care Service risks and mitigating actions
Risks Mitigation strategy
Patients are admitted as booked admissions, however surgery can only progress if appropriately resourced beds are available on the day of surgery.
Ensure ICU beds are appropriately resourced to allow optimal flow into the unit, thereby minimising bottlenecking in the Emergency Department and maintaining flow of patients through the operating rooms
Restriction of patient flow inhibits the ICU’s ability to discharge patients to wards. This results in bed block in the ICU and prevents critically ill patients from being admitted to the ICU.
Utilise a discharge protocol to minimise discharges after 18:00 hours.
Implement patient flow to support a robust ICU discharge process that targets an occupancy rate of less than 70% as directed by the state wide health service strategy for intensive care services10.
9. Evidence statement
The development of the Model of Care (MoC) documents is an ongoing process which has been refined and adapted by way of consultation with the clinical communities of the SCHHS as well as the broader Queensland Health community. The MoC documents represent the work to date and are a reflection of current thinking person centred care, supporting clinical excellence and best practice in health care delivery. While the documents are designed to inform the Transition and Transformation towards the SCUH, it is expected that the MoC documents will continue to evolve as practice changes and improves. The development of the MoC documents has been informed by:
• current practice within the existing services within the SCHHS • best practice informed by contemporary evidence • observation of a service elsewhere in Queensland, nationally or internationally.
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10. Further reading and references
10.1 References 1 Queensland Health 2014, Clinical Services Capability Framework for Public and Licensed Private Health Facilities v3.2, Queensland Government Department of Health, Brisbane 2 Telehealth can be defined as consultation by videoconference, telephone, etc 3 Australian Council on Healthcare Standards, http://www.achs.org.au/search/?q=national%20standards 4 Australian College of Critical Care Nurses (ACCCN), ‘ICU staffing position statement 2003 on intensive care nursing staffing’, retrieved April 2015, https://www.acccn.com.au/documents/item/20 5 Australian Commission on Safety and Quality in Healthcare, Clinical Handover Standard 6, http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/NSQHS-Standards-Fact-Sheet-Standard-6.pdf 6 College of Intensive Care Medicine of Australia and New Zealand, ‘Minimum standards for Intensive Care Units’, policy document IC-3(2014), retrieved 28 April 2015, http://cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC-3-Minimum-Standards-for-Intensive-Care-Units-Seeking-Accreditation.pdf 7 Australian College of Critical Care Nurses (ACCN), ‘ACCCN ICU staffing position statement 2003 on intensive care nursing staffing’, retrieved April 2015, https://www.acccn.com.au/documents/item/20 8 Australian College of Critical Care Nurses (ACCN), ‘ACCCN ICU staffing position statement 2003 on intensive care nursing staffing’, retrieved April 2015, https://www.acccn.com.au/documents/item/20 9 Health Management.org, ‘ESICM 2014: ICU Design – Open Wards or Single Rooms?, retrieved April 2015, https://healthmanagement.org/s/esicm-2014-icu-design-open-wards-or-single-rooms 10 Queensland Health [2013], ‘Adult intensive care services statewide health service strategy 2013, retrieved May 2015, http://www.health.qld.gov.au/hsp/docs/ics_strategy_final.pdf 10.2 Further reading Sunshine Coast Hospital and Health Service 2012, Annexure 3B – Functional Design Brief to the Project Deed, Nambour.
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11. Appendix A – consultation list
Key stakeholders involved in planning
Planning leads
Kerrie Hayes Executive Sponsor for Service Group Sunshine Coast Hospital and Health Service
Dr Ratna Aseervatham Service Group Director Sunshine Coast Hospital and Health Service
Dr Chris Anstey
Mark Adcock
Director Intensive Care Unit
Nursing Service Director Surgical Services
Nambour General Hospital
Sunshine Coast Hospital and Health Service
Key stakeholders
Dr Vikram Masurkar Deputy Director ICU Nambour General Hospital
Dr Vicki Campbell Staff Intensivist ICU Nambour General Hospital
Dr Gerard Joyce Staff Intensivist ICU Nambour General Hospital
Dr John Moore Staff Intensivist ICU Nambour General Hospital
Dr Morne Terblanche Director Anaesthetics Nambour General Hospital
Dr Tanya Kelly Acting Director Anaesthetics Nambour General Hospital
Dr Michael Putt Respiratory Physician ICU Nambour General Hospital
Dr Stephen Priestley District Director
Emergency Medicine
Nambour General Hospital
Ted Christensen Nurse Unit Manager ICU Nambour General Hospital
Sandra Norman Clinical Nurse Consultant ICU Nambour General Hospital
Jenny Jaspers Nurse Educator ICU Nambour General Hospital
Tania Griggs Nurse Educator ICU Nambour General Hospital
Carol Pound Nursing Director
Perioperative and Critical Care Services
Nambour General Hospital
Kay Friend Acting Nursing Director
Perioperative and Critical Care Services
Nambour General Hospital
Louise Skinner Pharmacist Nambour General Hospital
Paul Williams Pharmacist Nambour General Hospital
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Kate McCleary Physiotherapist Nambour General Hospital
Nola Powell Social Worker Nambour General Hospital
Robert Walton Clinical Psychologist Nambour General Hospital
David Ward Director Medical Imaging Nambour General Hospital
Murray Koltermann Assistant Director Medical Imaging Nambour General Hospital
Carol Trevor Manager Safety and Quality
Transformation and Transition Program Workstream members
Melissa Ceccato
John Penney
Education and Research
Sally John
Diane Jeays
Workforce
Russell Searle
Eric Lie
ICT
Margaret Hoekstra Governance
Graham Reeks Consumer Engagement
Caroline Zantis Health Service Planner
