ICU or IMCU Playbook

This resource is designed for units that need to quickly transition to an Intensive Care Unit (ICU) or Intermediate Care Unit (IMCU)

Section 1 is for the operational preparationSection 2 is for the unit preparationSection 3 is for the staff preparation

For all these sections, most of the resource documents are on the Advocate Aurora COVID page.

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ICU or IMCU

Operations

UnitStaff

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Leaders/Managers review these documentsN95 sterilization overview FAQPPE resource guideDuty to care: Leader toolEmployee Health exposure & response management resource guide

Determine with Site/Unit Leadership the following:❑ Is cohorting patients required?

o SBAR Cohorting Patients

❑ RT/RN Intervention Algorithmo Coordination between the RN and RT leadershipo Use the Algorithm to determine interventionso Use job aides for MDI/Nebulizer

❑ Are you using the Team Based Nursing approacho Coordinate shadowing experiences with the affiliated ICUo Get resources from the COVID 19 Info site:

• Nursing Resources Section>subsection Team Based Nursingo Email for questions: ASC-Surge-staff@aah.org

❑ Are you utilizing TNA model?o COVID Resources: Nursing Resources Section> Temporary Nursing Assistanto Email for questions: ASC-Surge-staff@aah.org

❑ Implement approved changes to Nursing Practices to improve efficiencieso Extended tubing guidelineso Family communication guidelineso AAH Pandemic Emergency Documentation Plan for Adults

❑ Consider a place to have a respite/ nap area that your team can useo Respite and nap room guidelines

Operation documents COVID site

This playbook is intended to help you jumpstart your transition to an ICU or IMCU. It is not intended to be a full accounting of all policies/procedures or need to know items located on the COVID19 info site or other AAH documents etc.

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Operations

Created by NEPD Created 12/16/2020 Sponsor: Jane Dus

Get Room Signage for your unit• Aerosolized treatment in progress sign• PPE signage: Airborne and contact precautions• PPE signage: Droplet and contact precautions (ED/hospital)

Facilitate Training • Use Staff resource page to get Team Members quickly up to speed on priority items• (See Staff section for specifics)

Daily Operations• Have ICU leadership and NPD/CNS do a walk through of unit• Coordinate with Lab to have lab work done before 6 AM and develop process to alert staff• Review alarm volume and how to manage on the unit• Review patient placement on unit based on physical layout and number of patients• Coordinate with ICU for mentoring and collaborating on transferring patients• Update any other disciplines that work with the unit (RT, PT, OT, Chaplain) • Coordinate with Bio Med, Central Supply, Facilities to get needed equipment /supplies (Unit section)

SIMULATION• Simulation team recommends a COVID Code simulation to minimize staff fears and improve comfort

level during these critical situations• Simulation team is also available to train staff on the increased acuity of patients.• Walk through process simulations to identify safety concerns related to conversion to a ICU or IMCU• For Wisconsin sites,

• Lynne Delfosse - Lynne.Delfosse@aah.org• For Illinois sites: email

• Kari Congenie- Kari.Congenie@aah.org• Lisa Plucinski- Lisa.Plucinski@aah.org

Alert Staff about change to an ICU or IMCU• Communicate to your team about the impending change in your unit. Consider

different methods based on how soon the information is need (i.e. happening now –next shift needs to know versus full staff communication)

• Send updates when the change is confirmed with the timeline

Operation documents COVID site

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OperationsThis playbook is intended to help you jumpstart your transition to an ICU or IMCU. It is not intended to be a full accounting of all policies/procedures or need to know items located on the COVID19 info site or other AAH documents etc.

Created by NEPD Created 12/16/2020 Sponsor: Jane Dus

Intervention in place on the unit Start Date

End Date

Signage for isolation/AGP in place

Team Based Nursing

Temporary Nursing Assistants

RT RN interventions

Virtual Visits and Vigils

Visitor Limitations

Labs Draw Times- ICU Draw Time

Alarms (address volume levels)

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Unit

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CleaningPlace Near Cleaning Supplies or Product needing cleaning Surface Disinfectant Substitution InfoPour Bottle Disinfectant Acute Site ProcessAir assist device cleaning guide with talking points

Emergency ResponsePrint and place near/on code cartsAdult bag mask filter informationPediatric bag mask filter informationAcute care adult emergent response (CPR) guidelines

Specimen Collection and Deisolation GuidancePrint and place near specimen collection materialsSpecimen collectionDeisolation and testing of previously COVID-19 positive (Acute care and ambulatory/outpatient settings)

Virtual Vigil Recommend Printing and placing in a binder near tablets for reference. Visitation guide should be printed in multiple copies to handout to family Device disinfection procedure for video visitationUsing virtual visitation guidanceVideo visitation guide for familyVideo visitation guide for care team

Resilience/Wellbeing Resource for Team MembersRecommend sending out on regular basis as a reminder and/or posting in a common areaResilience & well-being resource guideEmployee Assistance Program (EAP)Moral distress and COVID-19

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Print and post in areas where it makes sense as a just in time resource

Unit

Created by NEPD Created 12/16/2020 Sponsor: Jane Dus

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Unit This playbook is intended to help you jumpstart your transition to an ICU or IMCU. It is not intended to be a full accounting of all policies/procedures or need to know items located on the COVID 19 info site or other AAH documents etc.

Unit documents COVID site

Supply List to gather for your unit, work with Central Supply,

Bio Med, Pharmacy and Facilities:

Emergent Supplies

• Intubation equipment

• Rapid Sequence Intubation (RSI) Kits

• Additional code cart

• Emergency PPE/viral filter

• Additional Defibrillator

• Know where your nearest difficult airway kit is stored (ICU)

Unit Supplies

• Additional IV pumps and channels

• Additional PPE and respiratory equipment

Coordinate with Pharmacy

• Appropriate ICU/IMCU medications added to Pyxis

• Pharmacy support and rounding

Patient Room Supplies

• Individual patient monitors in each room

• Suction supplies and wall suction for each room (at least 2)

• Additional portable vitals carts (BP cuff/pulse ox/thermometers)

*All these items need to have a clearly assigned and easily acceptable

location in the unit and patient rooms

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Staff Preparation/Resources

Review these now (before 1st patient)

PPE/ Personal Protection

• Donning and Doffing PPE with N95 reuse• PPE Resource Guide• Personal Protection Tips• Performing N95 seal check

Look at these resources carefully to review PPE procedures prior to caring for patients.

Caring for Covid Patients

• COVID-19 Fast Facts for Nurses• Transporting Patients• Acute care adult emergent response (CPR) guidelines

Here are key items you need to know about the care of covid patients.

Review these within the first week

PPE/Personal Protection

• Mask Pressure Injury Prevention guidelines• Mask Injury Algorithm• Skin Care for Mask Wear

This information is more in-depth resources to prevent injury for long term use of PPE and PPE best practices

Caring for COVID Patients

• Adult Supplemental Oxygen• Oxygen therapy tip sheet• Adult high risk intubation• Pressure injury in COVID-19 patient nursing practice

alert• Proning materials in the proning section under Nursing

Resources Section on COVID 19 Info site

These references has more in-depth info on key points to know in taking care of this patient population

Space for instructions of announcement about switching?

These resources and much more can be found on the COVID19 Info Site. You can easily get to it through a link on the AAH Nursing Hub or simply CLICK HERE

Review when possible or when the need presents

Caring for COVID Patients

• Nursing Guidelines for Tracheotomy Care• V60 helmet RT job aid• Ventilator tip sheet• Ambulation of COVID-19 in hallway for medical evaluation• Medication guidelines for adult patients• Critical Care Onboarding for the Non-Critical Care Nurse• Critical Care Onboarding for the Non-ICU Nurses (VIDEO)

These resources and more may be found on the COVID19 info site. This sheet is only to highlight significant resources and not the entirety of what is available. 7

Staff

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Staff Preparation/ResourcesSpace for instructions of announcement about switching?

8

Staff

Nursing Care

Acute Care Readiness

• Acute Care Readiness Course SBAR• Fall prevention strategies• Handling medications in Patient Rooms• Glucometer instructions• Advanced Directives SBAR• Critical Care Onboarding for the Non-Critical Care

Nurse• Critical Care Onboarding for the Non-ICU Nurses

(VIDEO)• Nursing Guidelines for Tracheotomy Care• V60 helmet RT job aid• Ventilator tip sheet

Look at these resources carefully for information on how to care for the acute care patient

Other strategies • Patient belongings nursing practice alert Here are key items you need to know about the care of patients.

EPIC and charting

EPIC • Surge Inpatient Nurse Self-Paced 100 Workbook• Surge Inpatient Nurse Self-Paced 200 Workbook• Surge Inpatient Nurse Self-Paced Course Details• COVID-19 Tip Sheets • EPIC Emergency Documentation for Adults

Consider printing out these resources for staff, be present to mentor staff and consider having a “phone a friend” resource if needed until staff comfortable

These resources and much more can be found on the COVID19 Info Site. You can easily get to it through a link on the AAH Nursing Hub or simply CLICK HERE

Created by NEPD Created 12/16/2020 Sponsor: Jane Dus

Tele-ICU Information

SheetB

en

efi

ts o

f Te

le-I

CU

Monitoring

Collaboration and Support

Orders/Assistance

Educational/Mentoring

Quality Assurance and Improvement

Data Reporting for Outcomes and Metrics

24/7 presence

Staffed by at least 1

physician at all times

Provide needed

support to the

bedside

Have a minimum of

5 years of critical

care experience

Average assignment:

45-50 patients

Support both

physician and RN

roles

Assist in data

collection necessary

for reporting

PHYSICIANS NURSESHEALTH CARE

ASSISTANTS(HCAs)

Acute Issues Tele-ICU Can Address

“First look” at all new admissions (seen

within 30 minutes)

Ventilator issues

Arrhythmias, especially atrial fibrillation

with rapid ventricular response

Hypotension

Electrolyte abnormalities

Physician presence at medical alert/

medical response, RRT transfer, or

before on-site Physician arrival

Adjustment of sedation

Need for GI prophylaxis

Ventilator liberation assistance

Antibiotic stewardship

Glucose management

Review/ interpret x-rays

and EKGs

Created by NEPD Created 12/16/2020 Sponsor: Jane Dus

→ Usually this type of call is transferred directly to the doctor.

→ Messages may be taken only if the doctor covering is already on the telephone with another call. Messages will go to the other physician in that case.

→ Nurse at the site should be told to expect orders or call back within 30 minutes

→ A message should be done for almost all of these.

→ Nurse at the site should be told to expect orders or call back within 15 minutes

Tele- ICU Information Sheet

Tele-ICU MonitoringTele-ICU becomes an integral part of the critical care team upon the

patient’s arrival to the unit.

Monitoring includes real time assessments – same access as what the

bedside sees and views: Vital Signs, labs, EMR, X-ray, etc.

Monitoring for subtle changes in patient condition utilizing sophisticated

software: eCare Manager providing alerts and trending for proactive

management and prevention of adverse outcomes.

Response to emergent and urgent situations by Tele-ICU Intensivist

and eRN

• Medical Alert/Medical Response

• In response to patient condition as warrants

Emergent Urgent Routine

Emergent Triaging of Phone Calls

Immediate response or action needed Response or action needed soon Information is not time sensitive but needs to be communicated to the teamExamples (include but not limited

to):• Acute change in v/s; acute

change in mental status,• Acute change in respiratory

status, Increase in O2 requirements

• Acute mental status change• Hypotension• Hypoxia/Hypercarbia• Pre-code situation• Very abnormal key labs in

physiologically unstable patient (e.g. pH < 7.20 on ABG; Hbg <7)

Examples (include but not limited to):• Abnormal labs in a

physiologically stable patient (e.g. k+, Mag Gluc, Hbg)

• Time sensitive order renewals

• Another physician is calling• Results of any previously

ordered tests by eICU• HTN; Low urine output• PRN meds for safety issue

Examples (include but not limited to):• Abnormal labs; just

reporting or FYI• Treatments and Tests

completed• Medication renewals that

are not time sensitive• PRN Medications• X-ray checks for tube

position or placement

When to call for help!

Created by NEPD Created 12/16/2020 Sponsor: Jane Dus

Staff Preparation/Resources

Medical Alert: Code TeamAdult Care: Adult CPR Emergent Response Guidelines

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Staff

Consider creating a document like this that has how

to call for help at your facility and place it in the unit

(thank you ASLMC for sharing)

Created by NEPD Created 12/16/2020 Sponsor: Jane Dus

Created by AAH Respiratory Care Council Created 12/10/2020 Sponsor:

Staff Educational ResourcesEducational resources have been developed to support providers, nursing, and respiratory therapy in the management of HFNC for COVID patients.

Educational Resources located on COVID site

High flow oxygen adult High Flow Oxygen AdultROX IndexAdult Supplemental OxygenV60 Helmet Job Aid

COVID website education for staff to get familiar with the HFNC system for patients

Device specific education

Airvo Education https://www.youtube.com/watch?v=uGZ8GGYxLhs

Staff education for use of these devices

Optiflow Education https://www.fphcare.com/us/hospital/adult-respiratory/optiflow/mechanisms-of-action/

Vapotherm Education https://academy.vapotherm.com/

Additional Resources and education

https://www.sccm.org/COVID19RapidResources/Resources/High-flow-nasal-cannula-(HFNC)-use-in-COVID-19-res

Experience of HFNC in SARS

Demonstration of HFNC Machines used at AAH • Optiflow• Airvo

Education

These resources and much more can be found on the COVID19 Info Site. You can easily get to it through a link on the AAH Nursing Hub or simply CLICK HERE

High Flow Nasal Cannula Guidebook(Adult Patients)

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https://www.youtube.com/watch?v=gSVI6fFu6DM&feature=youtu.be

Created by AAH Respiratory Care Council Created 12/10/2020 Sponsor:

Monitoring

Safety Measures

✓Cohort similar patient population to help with maintaining staff familiarity and education.

✓Consideration of step-down unit to support intermediate care needed.

✓Create algorithm for ideal management of patients to determine when moving to ICU setting would be most appropriate.

✓Create patient monitoring guidelines.

✓HFNC is considered an AGP procedure based on AAH guidelines. Follow AGP guidelines.

✓KEEP DOOR CLOSED AT ALL TIMES

✓Consider lower patient to nursing ratio to allow for proper monitoring

✓Consider lower RT to Patient ratio for high flow utilization.

Patient monitoring

If available, the following are recommended patient monitoring

✓Continuous Pulse oximetry

✓Telemetry monitoring

✓Consider Tele-ICU monitoring cart.

✓Monitoring patient's respiratory status:

❖SPo2 Saturation trend.

❖Respiratory rate

❖Working of breathing

❖Level of Consciousness

✓Monitor patient ROX index. Watch for trend of decreasing ROX score (indication of impending failure).

✓May need to consider placement of non-rebreathing mask over HFNC to achieve targeted SpO2

When adding HFNC as intervention to your unit, consider the following safety measures and patient monitoring. Work with your RT team and Nursing leadership to put in place.

Monitoring and Safety COVID site

High Flow Nasal Cannula Guidebook(Adult Patients)

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Staff Preparation/ResourcesSpace for instructions of announcement about switching?

Respiratory Care Maintenance of COVID PatientsAdult COVID 19 Positive or PUI: Respiratory Management

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Staff

Nursing Care

Respiratory Care Maintenance of COVID Patients

Adult COVID 19 Positive or PUI: Respiratory Management Look at these resources carefully for information on maintain the respiratory status of COVID positive/PUI Patient

Proning: • Manual Proning How-To Video• Proning with a Lift How-To Video• Manual Prone Position in the non-intubated patient• Proning Patient Information• Proning Tracking Sheet

Look at these resources carefully for information on Proning both intubated and non-intubated patients

Alarm Monitoring & Management

Alarm awareness is very important. It is EVERYONE’S responsibility to respond to alarms. Work with unit and leadership to tailor alarms to reduce nuisance alarms while following policy and guidelines. Always address alarms and escalate response as warranted. You jeopardize patient safety if you ignore alarms.

Operations should have addressed monitor volumes for alarms in this unit.

Created by NEPD Created 12/16/2020 Sponsor: Jane Dus

Staff Preparation/Resources

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Staff Resource List for Team Members

Team Based Nursing ApproachThis team based nursing approach allows RNs to use their highest level skills to provide a piece of patient care to a collaborative team model to provide safe and effective care for our patients. This means non-ICU RNs will provide standard care within their scope under the delegation and

supervision of an ICU RN.

*Thank you for sharing resources Aurora West Allis Medical Center!

Topics Resources

Reassignment orientation for non-ICU RN to critical care

Reassignment orientation for non-ICU RN to critical care

Critical care onboarding for non-ICU nurses: Presentation

Critical care onboarding for non-ICU nurses: Video

Reassignment orientation for RN to Adult Care

Reassignment orientation: RN to adult team nursing

Team Based Nursing Team ICU delegation toolkit

Team med surg delegation toolkit

Team-based nursing PowerPoint

Unit Communication Sheet *AWAMC

Unit Information TIP Sheet

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