General Critical Care Team

Welcome to the General Critical Care team at South Tees. We are a multidisciplinary team involved with the care of critically ill patients in several areas of the hospital. 

Our team comprises:

Clinical Director: Dr Michelle Carey 

Service Manager: Ellen Castling 

Matron Critical Care: Lesley Taylor

Consultants and senior doctors at the James Cook University Hospital:      

Dr Lesley Branch  Wellbeing Lead Dr Steve Chay  RRT Lead Dr Nicola Cree  Critical Care and Anaesthesia Dr Richard Cree  Critical Care and Anaesthesia Dr Alaa Dakak  Critical Care and Acute Medicine Dr Uwe Franke Critical Care and Anaesthesia, EPRR Lead, POCUS Dr Isabel Gonzalez  CCO Lead, SCI Lead, NoECCN Medical Lead Dr Jeremy Henning  Military ICM, Trauma

Dr Mark Howley  Military ICM, FICE Mentor Dr Tim Lowes  Military ICM, Trauma Dr Edel Macauley  Clinical Care & Research Fellow Dr Colin McAdam  Critical Care & Anaesthesia, FICE Mentor Dr Scott McGregor  PreHospital Medicine, Transfer Trainer Dr David McIntosh  Deputy Clinical Director, FICE Mentor Dr Diane Monkhouse  GHDU Lead, Medical Examiner Dr Jost Mullenheim  Critical Care and Anaesthesia

Dr Adrian Proffitt Military ICM, Critical Care and Acute Medicine Dr Caroline Smith  Critical Care and Anaesthesia Dr Alex Scott  FICE Mentor, CUSIC, Faculty Tutor Dr Michelle Shaw Critical Care and Anaesthesia Dr Emma Watson  Military ICM & Anaesthesia, Transfer Lead Dr Ali White  Critical Care and Anaesthesia Dr Steve Williams  FICE Mentor, Clinical Governance Lead Dr Judith Wright Deputy Clinical Director, Medical Examiner

Ward Managers Sue Mortimer GCC - Intensive Care Unit 2 Karen Banks GCC - Intensive Care Unit 3 Elaine Cater GCC - High Dependency Unit 4	Senior Educator Morag Tiernan Sue Mealing Julie Miller
Critical Care Senior Physiotherapy Team Phil Howard Heidi Williamson	Critical Care Ocupational Therapist Sharon Barker
Critical Care Dietitians Rachel Edson Siobhan Stewart Emma Watson	Critical Care Pharmacists Steve Lockwood Uzma Ali
Information analyst Martin Johnson (JCUH)

Office staff
Anne Foster (Office Manager)	Vicky Robinson (Secretary)
Clare   Butler (Secretary)	Jade Peacock (Secretary)
Hannah Ward (Secretary)
Julie Sweeney (Audit Clerk and VitalPAC Administrator)	Joanne Forbes (Ward Clerk)
Pippa Watson  (WardWatcher/Sepsis Administrator)	Julie Foy (Ward Clerk)
Lisa Causier (Ward clerk)	Hannah Loughran (Ward Clerk)
Samantha Conroy (Ward clerk)	Alison McDonald (Ward Clerk)
Christine Reynolds (Recepcionist)	Lynsey Thomas (Recepcionist)

The General Critical Care Network at JCUH is part of the regional North of England Critical Care Network.

We have 33 general critical care beds (Level 2&3) divided between Intensive Care Unit 2 and Intensive Care Unit 3 and General High Dependency Unit.

We also have input into the Spinal High Dependency Unit (L2, 4 beds) and the Neurosurgical High Dependency Unit (L2, 8 beds). There is a separate Cardiac Intensive Care Unit and Paediatric Intensive Care Unit. We take referrals from any area of the hospital. In your role within the critical care team you may be asked to provide care for a patient in any of these areas. 

We have several advanced critical care practitioners who undertook a 2-year training program to work as advanced practitioners within critical care. Their role includes patient assessment, practical procedures and drug prescribing. Their names are:

• Janet Pugh (Trainee rota manager)
• John Williams
  
• Helen Lal
  
• Karen Donnelly  (Trainee rota manager)
• Helen Bone
  
• Michael Trumper 
• Lydia Bussey

We have more than 200 members of nursing staff, a physiotherapy team led by Phil Howard and Heidi Williamson and dietetics team led by Rachel Edson.

We have a 24/7 Critical Care Outreach team at The James Cook University Hospital which will follow up all discharges from critical are and review referrals. Their bleep number is 7000. The Critical Care Outreach team at the Friarage covers 12 h a day / 7 days a week.

We are aware that every doctor has a different level of prior experience and knowledge. We do not expect you to always know what to do but you should always ask if you are unsure.

There are always plenty of people around during the daytime – middle grades, very experienced staff grades and consultants. Out of hours the ICU middle grade should be contacted on bleep 1005. If no-one is available or further advice is needed the 3rd call anaesthetist should be called on bleep 4598.

The unit is covered 24 hours a day, 7 days a week by a Consultant in Intensive Care. 

If you are UNSURE what to do, or about instructions you have been given, please ASK.

We hope you will learn lots, develop your clinical skills and most of all enjoy working with us.

Day to day work on the units

A daily handover from night shift resident +/- middle grade to daytime staff (resident, middle grade, ACCP and Consultant) occurs between 8.30 – 9.00hrs.

The ward round will then proceed to review each patient and make a plan for the day. Patients who are immunosuppressed should be seen first and those with contagious infections should be reviewed at the end of the round. A list of tasks for each patient will be generated. We encourage the use of the ward round jobs folder (available on each unit) rather than keeping your own list - this ensures that everyone is aware of all tasks and work is not duplicated or omitted. Tasks should be prioritised to ensure smooth running of the unit. 

On Monday, Wednesday and Friday afternoons, a microbiology round occurs on ICU with the Consultant Microbiologist. Please ensure all microbiology information is documented in the notes and drug chart and passed on at handover. 

We have introduced a standardised ‘panel’ of Web ice blood test requests for ICU admissions, basic daily set (stable patients) and extended daily set (unstable patients), any additional individual tests can be added as needed. These can be found in the collections menu (ICU collections) on Web ice requests. See Appendix 1 at the end of the document. 

The night shift handover occurs between 20.30 to 21.00hrs. Night shifts can be very variable. If the night shift is quiet this is an opportunity to ensure that all x-rays and results are reviewed / chased up, all documentation is up to date etc. You should ensure that you know each patients history and progress thoroughly for the morning handover. 

The GHDU opened in July 2012 and it is a very dynamic unit with a rapid turnover of patients. There is a daily bed-management meeting in the GHDU seminar room at 07:45 to organise elective admissions for that day. The middle grade doctor on nights is encouraged to attend (clinical work permitting) to inform of any changes overnight. 

The focus on the morning ward rounds should be to see the sick patients first followed by the patients highlighted for discharge. There will be a later surge in activity as the elective admissions arrive from theatre. This can often occur in the late evening. 

 

Documentation

Whilst the patient is in critical care they will have a set of ‘Pink’ Critical care notes. These are a different set of notes to the brown case notes and allow all information regarding the critical care stay to be easily accessed. It is vital that all documentation during the critical care stay is within these pink notes (especially notes from parent/visiting teams). The ward clerks photocopy the pink notes and transfer the copies to the hospital “brown” notes. 

There is an admission document included in every set of pink notes. It is vital that all necessary information is recorded in the admission documentation at the time of admission. If the patient requires intubation and ventilation it may be several days before the patient can communicate for further history. All sections of the admission document should be completed including the patients’ weight and height. If the patient is admitted from theatre, peri-operative information such as anaesthetic technique, blood loss, surgical difficulties etc should be recorded. There is space on the back page for a systems based management plan. Please be as thorough (and legible) as possible with all sections.

Sign, print name and GMC number and date all entries. 

A new daily sheet is completed by the night shift resident for each patient every day. This includes a summary of the admission, progress over the last 24 hours and a system’s based examination. Ward round and daily progress notes are then written on the back of this sheet. Continuation sheets are available when more space is required. Any blank space on the continuation sheet should be scored out when the next daily sheet is entered to ensure that records are chronological. Visiting teams should be directed to the correct place for documentation. 

There is ongoing audit of documentation. Your notes will be reviewed. Standards include: 

• Patients name and number on every page 
  
• All entries dated and timed ( 24 hour clock ) 
  
• The first entry that every Dr makes during the clinical episode has block capital name, role and GMC number 
  
• All entries signed, legible and in black or blue ink 
  
• Alterations are corrected appropriately ( single line cross out, dated and signed) 
  
• Records are kept chronologically 
  
• Clearly documented history and examination 
  
• Differential or definite diagnosis 
  
• Clear list of investigations and their urgency 
  
• Clear treatment plan and the treatment given 
  
• Evidence that the patient has been seen by a Consultant within 24 hours of admission 
  
• Record of any operation ( where appropriate) 
  
• Evidence of verbal or written information given to the patient and or their carer

All our most recent documentation documents can be found following this link

Medicine Kardex

We have a separate medicine kardex with a section for drug infusions for use while patients are within critical care.

It is acceptable to use the ward kardex for elective overnight admission’s to HDU however all other patients will require a separate ICU kardex. Please ensure all drugs are prescribed generically, are legible and are signed and dated. If you are prescribing (or transcribing) antibiotics please ensure the actual start date is documented as well as the indication eg: organism x in sputum. It is also helpful to indicate the proposed length of the course when it has been determined. If you are unsure about a drug you are asked to prescribe please ask / check. 

You will notice that the ICU Kardex is already pre-printed with some of the commonly used drugs. Please ensure that you complete the prescription, sign and date it. 

Handover sheets 

A ward round jobs book is kept on each unit to reduce the need for you to keep your own jobs list.

If you do feel the need to have your own list or handover sheet, please ensure it does not contain identifiable patient details and that it is disposed of in a confidential waste bin or shredder.

The trust regards lost handover sheets as a major breech in patient confidentiality and will take disciplinary action accordingly. 

Rota

Janet Pugh and Karen Donnelly, are in charge of the junior rota. Please see rota guidelines and discuss any rota issues with her. Similarly, the middle grade rota is coordinated by a senior ICM trainee supervised by Dr Alaa Dakak. 

There is usually a resident doctor or ACCP in each ICU and 2 on HDU with a middle grade on each unit and 4 Consultants during the daytime. At night there is 1 resident on each unit, 1 middle grade to cover all 3 units and a Consultant on-call. 

Instructions on how to view the Critical Care Junior Doctors Rota on the Intranet 

Please note that there is an electronic rota, including an app, in development. We will let you know as soon as it is ready and how to access it.

Sickness

Please contact the ICU office as soon as you recognise that you will be too ill to work. If this is out of office hours please contact the on-call Consultant. You should also inform the person who holds your sickness record card. If you are sick for longer than 7 days you will require a sick note from your Doctor.

Uniforms

You should wear a clean uniform for each shift and change if it becomes visibly soiled. Scrub suits are available should you wish to wear them. They can be purchased from Anne, Clare or Jade and cost £15 per set. They are then yours to keep. If you choose not to wear a scrub suit the trust uniform policy must be complied with – see below.

The trust operates a bare below the elbow policy.

ALL staff in any clinical area are expected to adhere to this. All jewellery apart from plain wedding bands should be removed.

Uniforms and work wear  when providing patient care
GOOD PRACTICE	WHY
Dress in a manner which is likely to inspire public confidence	People may use general appearance as a proxy measure of competence
Wearing short sleeved shirts and blouses Avoid wearing white coats	Cuffs become heavily contaminated and more likely to come into contact with patients
Change into and out of uniform at work	Patients confidence in NHS may be undermined
Wear clear identifiers  ( Name badge)	Patients wish to know who is caring for them
Change immediately if uniform or clothes become visibly soiled or contaminated	Visible soiling might be an infection risk and is likely to affect patient confidence
Tie hair back off the collar	Patients prefer to be treated by nurses/ midwives with short or tidy hair and a neat appearance
Keep finger nails short and clean	Long and or dirty nails can present a poor appearance and long nails are harder to keep clean
Change into a clean uniform at the start of each shift	Maintains professional appearance
Wear soft-soled, closed toe shoes	Closed toe shoes offer protection against spills. Soft soles reduce noise, which can disturb patients rest.
BAD PRACTICE	WHY
Wearing uniform to go shopping or similar activities in public	Patients confidence in the NHS may be undermined
Wearing false nails for direct patient care	False nails harbour micro-organisms and can reduce compliance with hand hygiene
Wear hand or wrist jewellery/wristwatch (a plain wedding ring may be acceptable)	Hand/wrist jewellery can harbour micro-organisms and can reduce compliance with hand hygiene
Wearing numerous badges or other adornments	One or two badges may be acceptable, too many looks unprofessional and may cause injury when moving patients
Wear neck ties ( other than bow-ties) in any care activity which involves patient contact	Ties are rarely laundered but worn daily. They have been shown to be colonized by pathogens
Carry pens/scissors etc in outside breast pockets	May cause injury when moving patients.
Wearing uniform sloppily e.g. wearing cardigans when providing direct patient care or wearing uniform dress without tights/stockings	Patients expect staff to have a neat appearance.
Wearing excessive jewellery, including necklaces, visible piercing and multiple earrings. Where earrings are worn, they should be plain studs.	Excessive jewellery looks unprofessional and may be hazardous

DoH, Uniforms and Workwear. An evidence base for developing local policy, September 2007

Morbidity and Mortality meetings 

We hold weekly M&M meetings to review all patients who have died on our units and discuss any incidents or morbidity issues.

Meetings are held between 1-2pm on either Tuesday / Wednesday or Thursday lunchtime. Everyone is welcome to attend (bring your lunch!) and they are a valuable learning tool.

If you wish to participate in the meetings by presenting a case please contact Dr Lukasz Badek. 

Radiology Meetings 

A radiology meeting is held every Monday except Bank Holidays in the GHDU seminar room from 13:00.

Dr Jeremy Dean reviews images on request.

This is an informal meeting with good educational value. Please bring the health care records with you and document all relevant discussion. 

Trauma patients 

If you are the resident doctor on night shift caring for any new major trauma patient on your unit, please email the trauma team (stees.majortrauma.team@nhs.net) before 07.30 with the pertinent details of the case to allow Trauma and ED teams to review images and plan management in their morning meeting in ward 33 seminar room.

The trauma team will then attend ICU at the end of the meeting around 09:00.

It is really only pertinent details of the patient and does not need to be a full history.

For example:

Mr XYZ, ICU 3 bed X 

D1234567 28 yo male, RTA 

Open # tib fib : operative plan and timing? 

Liver lac - conservative mx (need to check any restrictions in rolling etc?) 

Complex facial fractures: op plan and timing? 

Any ICU issues e.g CVS instability, sepsis, ARDS 

There is a Major Trauma patient MDT form to allow all specialties to document issues.

This should come with the patient from ED but there are copies available on all the units. 

Please note the presence of a Major Haemorrhage Trolley in ED. This contains all the kit you should require to deal with a patient with major haemorrhage e.g PPE, haemostatic agents, Large bore access. Please ask the ED team for this or ask to see it to familiarise yourselves with it if required. 

Case conferences 

We frequently hold multi-disciplinary case conferences to discuss challenging or long stay patients, often after or as part of the weekly M+M meeting.

You are welcome and encouraged to attend a conference about any patient you have been involved with and may be asked to present a summary of the case to start the meeting. 

Patient diaries

Patient diaries are a useful way for patients to understand what has happened to them during their critical illness.

It is a written (sometimes photographic) contemporaneous record of their critical care stay that they can take away with them.

All members of the multi-disciplinary team are encouraged to participate on the patients’ behalf. Please discuss with a senior member of the Medical or Nursing team.

Patients have asked in several ocassions at the ICU follow up clinic for doctors to write on the diaries. 

Computers

You can use any of the computers on the units however please be aware that they are required for clinical use such as requesting investigations and viewing x-rays. If you want to check emails or complete non-clinical work then computers in the ICU and GHDU seminar rooms are available.

If all computers are in use and you are free to do non-clinical work there is a cluster of computers in the Rodney Cove-Smith library. You will need to obtain a personal login for computer use within the trust.

Computers on wheels are available on each unit. Please ensure they are plugged in after the ward round as they have limited battery life. 

Catering facilities

The coffee room on the critical care units is always fully stocked with tea, coffee, milk, cold water, squash, bread (with toaster), butter and a selection of jams / spreads. £5 per month should be paid to the secretaries.

There are two large fridges to store any packed lunch and two microwaves for all staff use. Please label your food with your name and the date on the stickers provided. Any unlabelled food will be thrown away.

Please keep the coffee room clean and tidy at all times. 

There are a variety of food suppliers within the main hospital: canteen, WRVS, Costa, Marks and Spencer and WH Smiths.

After 10pm there are NO catering facilities within the hospital. There is a trolley service to each ward. This usually arrives at ICU around 10.30pm. 

Rest and general wellbeing 

There is a Junior Doctor’s office on the main ICU corridor for the use by all junior medical staff. It contains a bed to allow you to get some rest if your shift is quiet. There are also en-suite bathroom facilities. It is for use by all members of the junior medical team so please try to keep it tidy. 

It is essential that you have adequate time for meal breaks. Because much of work is emergency driven it is difficult to predict timing of breaks. It is essential that you work as a team to ensure that everyone has the opportunity to eat/drink with safe provision of clinical cover. 

If you feel too tired to drive at the end of your shift, it is really important that you take rest before you attempt to drive. The residents’ room should be available. Feel free to put a note on the door requesting not to be disturbed. If you are struggling to find a place to rest, please seek help from the duty consultant. 

If you need a break off the unit, please let inform the sister in charge of your contact details before you leave.