PROFILE OF LEARNING OPPORTUNITIES COMBINED CRITICAL CARE PLACEMENTS. Added to Practice Placements, Northumbria University Website July 12

Transcription

1 PROFILE OF LEARNING OPPORTUNITIES COMBINED CRITICAL CARE PLACEMENTS Added to Practice Placements, Northumbria University Website July 12 Rehabilitation Department Completion Date: March 2011 Review Date: March 2013

2 LEARNING ZONE Paediatric Regional Cardiac Unity General Surgeons Nursing Staff Specialist Surgeons Speech & Language Therapists Occupational Therapy Adult Critical Care Units CRITICAL CARE TEAM Transplant Gym Class Surgical Wards Social Workers Breast Clinic Clinical Nurse Specialists Transplant Unit Added to Practice Placements, Northumbria University Website July 12

3 TABLE OF CONTENTS Page No. Introduction 4 Staffing 5 Placement and Educators 6 Area profile Cardiothoracics 7&8 Critical Care RVI and Freeman 9 Surgical procedures 10 & 11 Physiotherapy intervention 12 Neuro ITU 13 Student teaching topics 14 Example of a typical placement 15 Additional learning outcomes 16 Recommended reading 17 Core skills 18 Management / organisation skills 19 Observational opportunities 20 Added to Practice Placements, Northumbria University Website July 12

4 4 INTRODUCTION Welcome to the Critical Care Team at the Newcastle upon Tyne Hospitals NHS Foundation Trust. The aim of this pack is to give you an introduction to our team and information about your placement. Location We are situated in the Rehabilitation Department at the RVI and the Freeman. Please report to the main physiotherapy reception on your first day. Working Patterns Working times - 08:00 a.m. - 16:15 p.m. Lunch time - 12:4 p.m. - 13:30 p.m. Uniform - see uniform policy Contact Numbers Hospital Switch Board Team Leader - Freeman RVI Band 7 Physiotherapist Cardio ICU Band 6 Physiotherapist Transplant Band 7 Physiotherapist Critical Care (FH) Band 7 Physiotherapist Critical Care (RVI) Band 7 Physiotherapist Neuro ICU Absence It is your responsibility to let your supervisor know as near to 8:00 a.m. if you are unable to attend for any reason.

5 5 STAFFING Freeman Team Leader Part time Cardiothoracics 2 x Band 7 Respiratory Rotational Physiotherapists 1 Band 7 Cardiothoracic Paediatric Physiotherapist 1 Band 6 Respiratory Physiotherapist 2 x Band 5 Physiotherapist Physiotherapy Assistant Critical Care 1 x Band 7 Respiratory Rotational Physiotherapists 1 x Band 6 Respiratory Rotational Physiotherapist 1 x Band 6 General Rotational Physiotherapist 3 x Band 5 Physiotherapists 2 x part time Physiotherapy Assistants 1 full time assistant RVI Team Leader Full Time RVI Critical Care 1 x Band 7 Respiratory Rotational Physiotherapist 1 x Band 6 Respiratory Rotational Physiotherapist 2 x Band 5 Physiotherapists 1 x Physiotherapy Assistant Neuro ICU * 1 x Band 7 Respiratory Rotational Physiotherapist

6 6 Placement and Educators You will be carrying out your placement on one of the following critical care specialty areas: - Critical Care RVI - Critical Care Freeman - Neuro ICU - Cardiothoracics Freeman (Including some Cardiothoracic Paediatric experience) This will be a mix of critical care and ward based experience. Clinical educators will be either a Band 6 or Band 7 Physiotherapist. Clinical educators and specialty area will be assigned on the first day of placement.

7 7 Physiotherapy Service CARDIOTHORACICS AREA PROFILE The Cardiothoracic team carries a busy and varied caseload. We are a regional cardiothoracic unit and one of 7 of the UK transplant units. The Freeman Hospital is the busiest transplant unit in the UK. Alongside Great Ormond Street, we offer children from all over the country a transplant service. Additionally, we are one of 3 ECMO centres for children, and have recently taken patients for adult ECMO for H1N1 patients. We offer a VAD (ventricular assist devices) service to adults. We are the only unit offering children a VAD service as a bridge to transplantation. Cardiothoracic is either a 2 nd or 3 rd year placement. There may also be an opportunity within the placement to gain some experience on the Cardiothoracic Paediatric Unit with the Paediatric Physiotherapist. This again would be a mix of PICU and ward based experience. WARDS COVERED WARDS 26 / CARDIAC CRITICAL CARE This is a 16 bedded regional cardiothoracic intensive care unit. The unit predominantly looks after patients following CABG, valve surgery, congenital heart defects, thoracic surgery and post op recovery following cardiopulmonary transplantation. The Freeman also offers a BIVAD/LVAD program; we are one of 2 units in the UK which offer this service. WARD 25A HDU This is a 6 bedded high dependency unit. It has an extremely fast turnover of patients. It receives patients from thoracic surgery, e.g. lobectomy, pneumonectomy. Patients will not be ventilated, although they may be supported with CPAP bellows and or inotropic support. WARD 25 This is a post operative surgical ward mix of cardiac and thoracic patients, it has 18 beds.

8 8 WARD 30 This is a 30 bedded post operative ward, mainly patients who have undergone CABG, valve and thoracic surgery. WARD 27A This is the regional transplant unit. It has 5 cubicles. Pre-transplant patients are nursed on Ward 29 or Ward 27 and will be assessed by their physiotherapist. PICU This is a 9 bedded regional cardiothoracic paediatric intensive care unit. The unit predominantly looks after babies born with a cardiac abnormality. Toddlers and adolescents having further corrective surgery will be looked after here. Children undergoing cardio-pulmonary transplantation, or an artificial support e.g. BIVAD; LVAD will be cared for here. Any neonates, babies, infants or young children requiring ECMO will be supported here. WARD 23 This is an 12 bedded regional cardiothoracic surgical ward plus 6 bedded HDU, looking after children from birth to 18. It provides an assessment service to children from the midlands to Aberdeen, northern and southern Ireland that may require cardio-pulmonary transplantation consideration. CONDITIONS TO BE TREATED INCLUDE: - Post operative CABG MVR / TVR /AVR Maize procedure Ross procedure Aortic Root repairs Congenital heart defects Cardiac transplant Lung transplant - singe - double Heart lung transplant Cardiac tumours Lobectomy Pneumonectomy Empyema drainage / decortication Pleurectomy Pleurodesis Video-assisted lung biopsy Pneumothorax surgery Children born with cardiac defects that require immediate surgery

9 9 CRITICAL CARE RVI On this placement you will have the experience working both in the ITU / HDU setting, and on the surgical wards. The unit covers a mix of post operative upper GI, and colorectal surgery, a mix of medical problems, and burns and plastics. AREAS COVERED: ITU HDU Ward 36 Ward 46 Ward 44 Ward beds 6 beds - Upper GI. 20 beds plus 4 special care beds. - Types of surgery: oesophagectomies and gastrectomies. Lower GI surgery. - Types of surgery; anterior resection, hemicolectomy, panproctocoloectomy and Hartman s. mostly breast cancer, with some colorectal cases. - Types of surgery; Mastectomy and wide local excision. Infectious diseases. - Patients are in isolation. - This is a mix of medical patients, HIV/AIDS, TB and any other infectious diseases. CRITICAL CARE FREEMAN On this placement you will have the experience working both in the ITU / HDU setting, and on the surgical wards. AREAS COVERED ITU/HDU - 17 bedded unit. - On this unit you will see a mix of the following: o Renal medicine and surgery including transplant. o Hepato-biliary including transplant. o Orthopaedics. o Vascular surgery including amputation. o Lower GI surgery. o Haematology. Ward 2&3 - Urology - surgeries including; radical cystectomy, nephrectomy, ureterectomy, TURP. - Also seen is elderly mobility. Ward 5 - Lower GI. Surgeries include; colectomies, hemicolectomy and Whipples. Ward 6A - Renal transplant. Wards 6 - general surgery and vascular Ward 8 - vascular surgery including amputees and bypass grafting. Ward 10 - ENT. - Surgeries include; laryngectomy, radical neck dissection, parodidectomy and surgeries including forearm flaps. Ward 12/HDU - Liver surgery, medicine and liver transplant.

10 10 Surgical Procedures & Post-Op Physiotherapy Upper GI Surgery: Oesophagectomy: Indicated for oesophageal cancer to remove the tumour, taking away part of the oesophagus and sometimes part of the stomach, bringing the remaining stomach up into the chest where it s connected to healthy part of the upper oesophagus. There are two incisions, a laparotomy, to access the stomach, and a thoracotomy, through which the lung is deflated and a rib broken to allow access to the oesophagus. Post-op patients are nursed in ITU / HDU for the first day or two, although some may go straight to Special Care unit on Ward 36. Drips & Drains: NG Tube to remove excess gastric fluids & prevent vomiting; Chest Drains (Apical & Basal) to re-inflate lung & allow drainage of fluid from plural cavity; PCA or PCE; IVT; PEG tube to allow feeding directly into the small bowel. Fluids are strictly controlled with patients nil by mouth for the first 48hrs, then if the surgeon is happy, slowly progressive amounts are commenced starting with 25mls per hour. Eating is not allowed for 5 7 days until a barium swallow proves there is no anastomotic leak, and then patients commence a limited diet of initially soft foods. Length of stay is generally 2 3 weeks, but is often considerably longer if complications arise. Important considerations: positive pressure (NIV, CPAP, IPPB) & deep NP suction are contraindicated without surgeons consent due to risk of damage to the anastomosis. Gastrectomy: Performed for stomach cancer, removing all or part of the stomach. Nissen Fundoplication: Indicated for gastroesophageal reflux and hiatus hernia. The gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. Often performed laparascopically. Lower GI Surgery: Cholystectomy: Removal of the gallbladder, normally performed laparascopically. Colostomy: Connecting a part of the colon onto the anterior abdominal wall, leaving the patient with an opening on the abdomen called a stoma. Can be permanent (due to removal of lower part of colon, e.g. due to cancer) or temporary (to rest part of the lower bowel that s been operated on). Ileostomy: a stoma that has been constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin. It s necessary where disease or injury has rendered the large intestine incapable of safely

11 11 processing intestinal waste, or can be used temporarily to allow the entire lower colon to rest. Anterior Resection: Removal of the upper part of the rectum reconnecting to remaining colon, for rectal cancer. A temporary loop ileostomy is made to allow the colon to heal. Hemicolectomy: Removal of half the colon (left or right) with subsequent joining of the remaining portions of the intestine. Hartmann s Procedure: Excision of the upper rectum and sigmoid colon. The rectum is oversewn and a colostomy formed. This can be later reversed once the operated bowel has recovered. ERCP (Endoscopic Retrograde Cholangiopancreatography): Investigation to examine the pancreatic and common bile ducts, performed via oral endoscopy. Proctocolectomy: Removal of rectum and colon. Panproctocolectomy: Removal of the entire rectum, anus and colon. The terminal ilieum is brought to the surface to form a permanent ileostomy. Performed for ulcerative colitis. Sigmoid Colectomy: Removal of the sigmoid colon and anastomosis of descending colon to rectosigmoid. Whipples: Removal of the distal half of the stomach, the gall bladder, the distal portion of the common bile duct, the head of the pancreas, duodenum, proximal jejunum, and regional lymph nodes. Reconstruction consists of attaching the pancreas to the jejunum and attaching the common bile duct to the jejunum) to allow digestive juices and bile to flow into the gastrointestinal tract and attaching the stomach to the jejunum to allow food to pass through..ectomy: excision or removal of e.g. appendicectomy.plasty: creation or reconstruction of e.g. angioplasty.ostomy: creation of permanent opening e.g. colostomy.otomy: cutting into / incision e.g. laparotomy

12 12 Physiotherapy Intervention Pre-Operative: Assessment: A respiratory assessment to identify existing problems Treatment: Teach ACBT Advice: Explanation of the effects of anaesthetic and surgery, the benefits of breathing exercises and early mobilisation, and the importance of adequate analgesia. Post-Operative: Chest Assessment Teach ACBT, supported cough and FET Ensure sufficient analgesia, discuss with pain management team as appropriate Ensure patients have effective cough and can clear secretions independently Early mobilisation, sitting out in chair initially, then progressing distance walked till patient mobilising independently, and finally if appropriate a stair assessment. Ensure CVS stability and no motor block from epidural. Care with Chest Drains keeping below level of chest.

13 13 NEURO ITU RVI 10 bedded ITU with a mixture of neurology, neurosurgery and trauma. On this placement you may have an opportunity to link in with the surgical team at the RVI. CONDITIONS SEEN - Traumatic Brain Injury. - Sub Arachnoid Haemorrhage - Sub-dural haematoma - Neurosurgery - Neuromedicine including Guillain Barre, Multiple Sclerosis and Motor Neuron Disease. - Medical respiratory failure. Experiences will include: - management of the critically ill neurological patient, secondary to traumatic brain injury including; management of ICP s and cooling. - The student will also be involved in the early rehabilitation of these patients alongside the Band 7 physiotherapist.

14 14 Examples of Student Teaching: Critical Care & Surgery RVI, Freeman and Cardiothoracics. Topic CPAP, NIV, IPPB Respiratory Ax (specific to each site) Ventilation V/Q, Sepsis Auscultation Tracheostomies Chest X-rays ARDS Suction Renal Failure MHI ABGs Case Scenarios Monitoring on ITU Weaning ITU Drugs Proning Critical Illness Polyneuropathy Site specific teaching i.e. neuro, cardiothoracics.

15 15 An example of a typical placement. Day Monday Tuesday Wednesday Thursday Friday Activity Introduction to team and tour of the department. Health and safety etc Introduction to workbook to direct learning. Spend time working alongside members of the team to orientate yourself. Shadow critical care nurse. Observe assessment and treatments. Participate when appropriate. Discuss and agree objectives of the placement. Start to expand patient caseload. Assist with rehab patients. Caseload will increase further. You will attend inservice training each week. Continue to increase your own caseload. A chance to sit down with supervisor and review progress through week. Week 2 Continuation of your own caseload, with an opportunity to observe relevant procedures i.e. tracheostomy, bronchoscopy and to visit theatre if you wish. Week 3 Visiting tutor may come out and visit at this point. Continue to progress through the workbook. Weeks 4 / 5 &6 Your caseload should have reached the level that was outlined in your appraisal, and you will be working toward your final assessment. There will be the opportunity to observe any relevant procedures that you have not yet seen. At some point through the course of the placement you will have the opportunity to spend time with then Occupational Therapist and the Speech and Language Therapist. Your half way assessment will be completed at the end of either your 2 nd or 3 rd weeks, dependent on the length of you placement.

16 16 ADDITIONAL LEARNING OPPORTUNITIES Visit specific assessment laboratories for various tests. Work with nursing staff on adult critical care. Observe surgery. Observe lung function testing. Observe Bruce protocol treadmill test exercise testing Spend time working with patients in the physiotherapy gym. Spend time with other members of the MDT e.g. SALT, OT.

17 17 Recommended pre-placement reading: Any university lectures covering respiratory care; assessment and treatment Surgical conditions Pryor and Webber (2004) Physiotherapy for respiratory and cardiac problems. Churchill Livingstone Harder. B (2003) Emergency Physiotherapy: On Call Survival Guide. Churchill Livingstone. Whilst on placement we will do lots of specific teaching alongside the surgical team. We will provide you with a work book which together we will complete. Use full web links

18 18 CORE SKILLS Learning objectives Resource / Personnel Communication verbal and non-verbal with members of the team. Physiotherapists, Consultants, OT, SALT, Administration staff. To work as part of a team working together with other members. Physiotherapists, Consultants, Medical Staff, Administration staff. To develop effective organisational skills and caseload management. Clinical educator, physiotherapists. To develop skills of empathy, sensitivity, assertiveness with patients and carers. Physiotherapists. To assess cardiothoracic patients postoperatively, identifying problem lists And treatment plants. Physiotherapist, Clinical Specialists, Reasoning sessions. To put into practice knowledge of anatomy, physiology and pathology learnt in college. Educator, College tutors, other Physiotherapists or students. Use of internet, and computer for x-ray interpretation. Physiotherapists, Administration staff. Medical terminology. Medical dictionary, internet Management of patients with acute pain. Pain team, physiotherapists. Using equipment e.g. stethoscope to Aid assessment. In-service Physiotherapists observation Use of adjuncts to physical-therapy E.g. Bird Ventilator. In-service Physiotherapists observation Clinical reasoning. Supervision Clinical reasoning sessions Skills of group work and management of gym sessions. Physiotherapists combined working sessions

19 19 MANAGEMENT / ORGANISATION SKILLS Learning objectives Resource / Personnel Prioritising caseload / time management. Physiotherapist / educator. Management of own clinical caseload including assessment / treatment. Carry own caseload independent of educator but with regular supervision. To assess patients and plan appropriate management necessary. Liaise with community physiotherapist, OT, other physiotherapists.

20 20 OBSERVATIONAL OPPORTUNITIES Learning objectives Physiotherapy assessments. Physiotherapy treatments. Theatre visits. Angiography studies. Gym sessions Observe complex patients being treated. Observe procedures such as tracheostomy, bronchoscopy. Observe OT / Speech Therapist Attend specific patient education classes. Resource / Personnel Observe physiotherapists doing assessments / treatments. Surgeon. Cardiology laboratories. Senior physiotherapists. Senior physiotherapists. Surgeon. OT / SALTS Physiotherapist / Nurse.

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