Information petaining to critical care for the other hospitals will be added to this section. Meanwhile you can visit the following websites:
- Montreal General Hospital (see the MUHC website)
- Jewish General Hospital (JGH)
- Montreal Neurological Institute (MNI)
Critical Care Medicine at the RVH
The Intensive Care Unit of the Royal Victoria Hospital is a 25 bed unit caring for patients with critical illness. Of those 25 beds, 20 have full hemodynamic and ventilatory capabilities with the remainder (5) serving as step-down beds.
Given the size of the unit two medical teams, the Red and Silver, share the care of the 25 unit patients, each with an attending, a critical care fellow or a chief resident, and a variable number of residents. The attendings may round on either service. The residents, regardless of their core programs, may also be assigned to either service; their assignments being based on the provision of the widest possible clinical and academic exposure. For residents spending more than one month in the unit at one time, every effort will be made to divide their time equally between the two teams.
The Attending Staff is ultimately responsible for all patients under his/her care. As such, all final decisions concerning that care resides with him/her. While on service the Attending staff are intimately involved with the ongoing care of the patients and must be informed at all times, day or night, as noted below, of all significant changes in the status of those patients.
The Fellows or Chief Residents on both teams are responsible for the day-to-day activities of their respective teams. He/She should conduct all rounds and supervise the Junior residents. All procedures should be supervised by the Chief Resident unless it is clear that the Junior resident has had sufficient experience.
The Junior Residents are primarily responsible for the ongoing care of those patients assigned to them by the Chief Resident. He/She is responsible for the writing of daily progress notes and for the transfer notes. The resident should be completely familiar with the patients' present hospital course as well as all pertinent past medical history. On post call days, it is expected that the resident will leave following morning rounds. Because the Junior Residents are usually at different stages in their respective training programs, service responsibilities should be graduated in that the more senior residents should be prepared to help the more junior members. In this regard, it is suggested that the more senior residents be assigned the consultative role of assessing patients outside the ICU for admission to the Unit.
The call schedule is made in accordance with Article 12. As such, any specific requests must be made to the Director of the ICU (Dr. Peter Goldberg) at least two months in advance. Unless there are extenuating circumstances, vacation time will not be granted during the ICU rotation. Any subsequent changes in the call schedule must be made amongst the resident staff.
Nursing within the ICU is administered by the Head Nurse, (Ms. Jocelyn St. Laurent), by four assistant head nurses (AHN), and by a nurse-clinician teacher (Ms. Patricia Rose). During the weekdays, two AHN's are assigned to the unit to act as Charge Nurses (CN) while on evenings and night there is one. During weekends and holidays, an AHN is on-call while a senior staff nurse is assigned the role of CN. Bedside nursing assignments are made by the CN.
Effective July 1, 2003 the following structure for morning rounds is to be introduced.
Rounds will commence on both the Silver and Red services between 07:45 and 08:00 with the plan to finish bedside rounds at 09:30. On Wednesday, Service rounds will continue to be held at 08:30 to be preceded by approximately 45 minutes of bedside rounds.
Review of x-rays will take place between 09:30-10:00.
The following 30 minutes can be used for bedside rounds when necessary, writing of discharge orders, etc.
Morning lectures - lasting 45 minutes - and Friday rounds will run between 10:30 and 11:30.
Residents must review their patients prior to the start of morning rounds. For that to occur, residents should start their morning rounds at approximately 07:00 depending on their patient load. Patient assignment can be made either the evening before or in the morning. Failure of the residents to review their patients before bedside rounds will be grounds for an unsatisfactory grade for the ICU rotation.It is imperative that each patient be reviewed by the resident assigned to that patient before rounds so that appropriate clinical findings are noted, laboratory data is assimilated, and an appropriate diagnosis and therapeutic plan for the following twelve hours be decided upon by that resident.
On morning rounds , the bedside nurse first gives his/her report, system by system. The residents then gives his/her report, system by system, from a medical perspective and his/her diagnoses and plan for the day. The Attending will use this forum to make appropriate teaching points. It is suggested that for purposes of continuity of care that each patient be assigned to a particular resident for the duration of the former's stay in the unit. Obviously, on post-call days, the care of those patients will have to be temporarily transferred to another resident. Following completion of bedside rounds, the x-rays are reviewed in C5-13.
For those patients, both on the Silver and Red services, for whom a morning discharge is most likely, transfer notes should be written by the on-call resident during the preceding evening-night.
Afternoon rounds must be, by definition, ad hoc. All Attendings are encouraged to finish rounds by 18:30.Evening rounds are usually done between 16:30 and 18:00. These are strictly work rounds in which therapeutic goals for the following twelve hours are set and potential problems identified for the on-call resident.
It is suggested that the on-call residents make brief rounds with the charge nurse prior to retiring to the on-call room. This assures the identification of therapeutic goals and may lessen the number of calls during the night.
In an attempt to keep the educational experience as wide as possible while at the same time avoiding overloading either of the two teams new patients are assigned to the team which is least busy. Exceptions to the rule are;all CVT patients should be admitted to the Silver team; and liver or pancreas transplant patients to the Red service. Other than these restrictions all other patients should be admitted to the team with the smallest anticipated clinical load. This is especially true during the hours of 18:00 - 08:00 when medical on-site coverage is thinnest. Regardless of the origins of the consult, a patient to be admitted to the Unit should be assigned to the least busy team, with the restrictions noted above. Therefore, if the resident of one team which is very busy and is consulted that resident should ask his/her colleague from the other team to accept that patient to his/her service.
All admissions to the Unit and all consults for which the patient is denied admission must be reviewed with the Senior on-call ( Chief resident or Attending ) within a reasonable period of time, regardless of time of day. Moreover, any significant interval changes in the status of patients within the unit must be similarly transmitted.
When a decision is made to accept a patient for admission the Charge Nurse must be informed; arrangements for the patient's actual admission and time thereof are the responsibility of the Charge Nurse.
There are usually two residents on in the ICU at any one time. Although they each have their individual services to cover they are requested to assure the smooth running of the unit. That means that if one of the services is particularly busy then the resident of the other service is requested to help out, whether that implies the placement of a line, etc. Furthermore, in an effort to equalize both the workload and teaching potential, both services should be equal in terms of number and acuity of patients. This implies that if a consult is received, regardless of who actually fields the call, a decision as to who should see the patient should then be made. These discussions should be hopefully resolved at the Junior level but if agreement cannot be reached then the Senior or Attendings should be consulted. The only caveats are our attempt to segregate all cardiac surgery patients on the Silver Service and Hepatic and Pancreas transplants on the Red. Also, if the patient has been recently - within the rotation period of the same Junior residents -discharged from the Unit, the patient should return to that service.
Also, if a patient has been seen in consultation by one of the services a second consult to the other service is not to be performed. If the requesting service is unhappy with the answer received from the initial consultation then the Attendings should resolve the impasse.
One of the banes of the Juniors is the seemingly continuous calls from the nurses during the night for such issues as potassium, etc. It is highly recommended that the Juniors make quick rounds with the Charge Nurse just before going to bed so that many of these issues can be resolved and so that he/she and the bedside nurse understand the therapeutic plan for the next 3-4 hours. The nurses will then be requested not to call save for what are judged to be critical issues for the next 3-4 hours at which point you will be recalled to the unit to resolve the minor issues that have arisen. We would very much like to monitor the number and nature of these calls. In the meantime, algorithms that can answer some of these minor issues will be instituted within the next 2 months.
By and large the Unit is self-contained in that it performs many procedures which heretofore had been performed by other services. These include tracheal intubations, central line placements, chest tube insertions, continuous Veno (arterial)-venous hemofiltration and dialysis, and cardiopulmonary resuscitation. If residents are not familiar with any of the above procedures they must make every effort to learn those skills during their rotation. In this regard, it is suggested that each resident maintain a log of the procedures performed for purposes of proof of training. Junior residents should be supervised during all procedures by a senior resident, fellow, or attending, who will be responsible for filling out a "Procedure Checksheet Evaluation Form."
In relation to tracheal intubations, this skill is critically important. Arrangements will be made, when requested or otherwise indicated, with the Anaesthesia Department so that these skills can be learnt early within the rotation. The Respiratory Therapists will demonstrate endotracheal intubation using a teaching mannequin at the start of each rotation.
Also it should be noted that sterile procedures must be followed in all cases of the instrumentation of a sterile cavity. That is masks, sterile gowns, and sterile gloves must be used for all central line placements - their de novo insertion as well as their change over a wire - and for chest tube insertion. For arterial line placements, a mask and sterile gloves must be worn.
Although the Unit is self-contained it should not be insular. That is, consultations are encouraged form all subspecialties for the educational objectives of both the subspecialty residents and of the ICU residents. In this regard, only orders signed by the ICU residents will be carried out by the nurses. Other services may make suggestions but those suggestions must be countersigned by the ICU residents. This is done so as to coordinate and optimize the care of the patient.
All central lines must be placed under strict guidelines as provided by the CDC. This includes the wearing of a sterile gown, sterile gloves, and mask. Nurses have been requested to remind residents of these guidelines and to call the Charge Nurse or Attending if those guidelines continue to be ignored.
Arterial lines, when a short angiocath is to be inserted, can be placed with the operator wearing a mask and sterile gloves. Any procedure requiring the use of a guidewire, e.g. femoral arterial cannulation, should be performed in strictly sterile conditions as described above.
Residents are requested to write a note after every procedure including central and arterial line placement, intubation, etc.
Verbal orders should be kept to a minimum. They shall be accepted but a confirmatory written order should be made within a reasonable period of time.
This applies particularly to Ventilator orders. If a written order does not appear in the chart then the respiratory therapist has been instructed to place the patient back on the last ventilatory mode and parameters for which there is a written order.
In terms of ventilator management, Juniors are requested not to adjust the ventilators at any time. If a patient is having respiratory difficulty, you should have the nurse and respiratory therapist called while you remove the patient from the ventilator and bag the patient with 100%O2 .
Seniors and Attendings should adjust the ventilators only if they are familiar with the workings of the ventilator model in question. Several mishaps have occurred given the variety of new generation ventilators that we have received over the past few years. Regardless, please promptly inform the therapist, who is in the unit at all times, of the changes and write the appropriate orders.
All X-Rays are kept either on the viewer in C5-13 according to patient bed number or in the filing cart. All X-Rays should be kept in either of these two places.
Allied medical and non-medical services
The Dietetics Department maintains a very strong and crucial role within the ICU. It is our present practise to start nutrition quite early on in the patient's ICU course, preferably by the enteral route. Ms. Michele Port assesses each patient and participates actively in morning rounds.
Total Parenteral Nutrition is also ordered by the medical team and administered by Pharmacy in consultation with Dietetics.
A Medical Ethicist will usually attend morning rounds at least once every week or two weeks.Dr. Eugene Bereza is available at all times however to discuss ethical issues that may arise around the care of the critically ill. He will be chairing the “Ethics Rounds” that will be held every three-four months.
There are two full-time Pharmacists between the hours of 07:00 and 18:00. They routinely monitor drug levels when appropriate and have, as their responsibility, the task of suggesting equal but less costly drug therapies.
A Physiotherapist is assigned to the ICU during weekdays and weekend days.
The Respiratory Therapy service performs many functions relating to the ventilatory management of the ICU patients. These tasks include the measurement of respiratory system mechanics, the assessment of central respiratory drive, the measurement of endotracheal tube resistance, the performance of metabolic studies and the adjustment of ventilator settings. In regards to the latter, all orders for ventilator changes must be written and signed in the order sheet and all changes on the ventilator, save for those done in urgent situations, must be performed by the Respiratory Therapists.
Approximately once per month, a meeting of the nursing and allied medical and non-medical staff working in the Intensive Care Unit will be chaired by the Medical Director to review and coordinate activities within the Unit.