RMH DAPM BULLETIN · Elective surgery has been curtailed this week and will be reviewed on an...
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RMH DAPM BULLETIN Vol.15 10.07.2020 • Latest COVID epidemiology • What’s New • What is likely to change over the next few weeks • Previous DAPM communication, education & training resources • Trusted COVID-19 Information Sources In Victoria 288 new cases overnight � What’s new? Dear Anaesthetic colleagues, It appears we may now be in the ‘second wave’ of the covid outbreak. The most recent recommendation now require that a surgical face mask is worn in all face to face patient interactions and where social distancing cannot be implemented. Essentially this means masks are to be worn at all times in the hospital. Please note this includes the cons office. Please continue with your meticulous hand hygiene. Elective surgery has been curtailed this week and will be reviewed on an ongoing basis. The need for preoperative covid testing of asymptomatic elective patients is being considered by the DHS. A definitive answer will be available next week. This is a stressful time for all of us and the need for care and kindness to each other is greater than ever. Daryl, Keat and I are available if there are any issues, or Alistair, Janette and Liz Leslie, our welfare officers. Please see the links at the end of the bulletin for further welfare resources and also in the Wellbeing section of the DAPM resource website https://anaesthetic-reference.com.au/news/ (password 6311) Take care, Liz Non-Clinical Time Unless required to be on-site for work related purposes such as training and education, working from home is recommended during your non-clinical time Meetings and Educational activities Recommend that all such activities are not done face-to-face Please join workplace as the latest RMH Covid-19 information and updates are available there.
Transcript of RMH DAPM BULLETIN · Elective surgery has been curtailed this week and will be reviewed on an...
RMH DAPM BULLETIN Vol.15 10.07.2020
• Latest COVID epidemiology • What’s New • What is likely to change over the next few weeks • Previous DAPM communication, education & training resources • Trusted COVID-19 Information Sources
In Victoria 288 new cases overnight ���
What’s new? Dear Anaesthetic colleagues, It appears we may now be in the ‘second wave’ of the covid outbreak. The most recent recommendation now require that a surgical face mask is worn in all face to face patient interactions and where social distancing cannot be implemented. Essentially this means masks are to be worn at all times in the hospital. Please note this includes the cons office. Please continue with your meticulous hand hygiene. Elective surgery has been curtailed this week and will be reviewed on an ongoing basis. The need for preoperative covid testing of asymptomatic elective patients is being considered by the DHS. A definitive answer will be available next week. This is a stressful time for all of us and the need for care and kindness to each other is greater than ever. Daryl, Keat and I are available if there are any issues, or Alistair, Janette and Liz Leslie, our welfare officers. Please see the links at the end of the bulletin for further welfare resources and also in the Wellbeing section of the DAPM resource website https://anaesthetic-reference.com.au/news/ (password 6311) Take care, Liz Non-Clinical Time Unless required to be on-site for work related purposes such as training and education, working from home is recommended during your non-clinical time Meetings and Educational activities Recommend that all such activities are not done face-to-face Please join workplace as the latest RMH Covid-19 information and updates are available there.
RMH DAPM BULLETIN Vol.15 10.07.2020
Some additional information for Covid-19 intubations in ED (Refresher) Prebriefing: - Note that their PPE may be slightly different. Use a face shield plus a hood if you like, but be aware the hood
may impair communication. - Induction drug dosing - important to discuss ahead of time. Only ketamine and 100mg of rocuronium is easily
available. Other drugs are possible to acquire but may take time. - Discussion about end point for bag mask ventilation and intubation: oxygen saturations may be an indication
for bag mask ventilation. Be aware that some ED team members may see this as an indication to intubate. - CICO and FONA: these are now terms that should be familiar to the ED team. Discuss who you expect to do
FONA and how the set up will occur, bear in mind this is slightly different to how the algorithm is in its current state where the airway operators swap places. Confirm the ED team leader is happy to do FONA if required, if not seek additional help.
- If you wish to have additional airway assistance, please contact an anaesthetic nurse as required. If you are unfamiliar with the equipment available, please make a time with the COVID team to come and look at the set up downstairs.
Room set up: - Ergonomics can be challenging. Make sure prior to induction that you have set up the room the way you prefer
and you have easy access to your equipment - Additional staffing: three staff is guidance only, the process works with only three but sometimes the clinical
need requires additional support Staff allocation: - These intubations take at least 30 minutes or over an hour if the patient is unstable. Out of hours you will need
to make sure someone is available to cover emergencies as per usual as the staff member doing the intubation is unavailable for at least 30 minutes
- Please ensure that the consultant on call is aware after-hours and should attend to provide support - If the patient is stable enough for transfer to ICU for airway management, this should be the default pathway
as agreed by ED/Anaesthetics/ICU RMH ED COVID 19 Intubation checklist
Troubleshooting home access to the EMR
RMH DAPM BULLETIN Vol.15 10.07.2020
What is likely to change over the next few weeks There will likely be an increase in demand for Covid related support from ED and elsewhere and we will need to be flexible in the coming days and weeks Previous DAPM communication, education & training resources Some email communications might not have been received by everyone, please refer regularly to https://anaesthetic-reference.com.au/news/ for regular department updates (password 6311) http://www.anzca.edu.au/fellows/special-interest-groups/welfare-of-anaesthetists#resources Trusted COVID-19 Information Sources https://anaesthetic-reference.com.au/news/
http://covid19.intranet.mh.org.au/blog/
https://thermh.workplace.com/
RMH ED COVID-19 Intubation Checklist
RPP PPE - Don?t rush!Extra Pair of Gloves
Perform Buddy PPE Check
Allocate Roles & LabelLead Intubator
Airway AssistantMedical Team Leader
Runner
Team HuddleCase SynthesisGoals of Care?
Allergies?Comorbidities?
Other Considerations?
Drugs & DosesKetamine 0.5-2mg/kgRocuronium 1.5mg/kg
Metaraminol (0.5mg/mL)Extra Rocuronium
Morphine + Midazolam for sedationAdrenaline 1mg in 10ml
EquipmentStandard Kit?
Standard + Difficult Kits?
PPE and Team Preparation Prepare for Difficulty
Outside Room Airway Plan
- Plan A:Modified RSI with Video Laryngoscope and the most Senior Intubator
Use 30 second drillsDifficult or Failed Intubation
- Plan B/C:Tight 2 handed vice grip BVM & then LMA
Contact Anaesthetics on #6311
- Plan D:FONA - Scalpel, Finger, Bougie + Size 6 ETT
Do not ventilate during FONA attempt
PTOTURN ON NEGATIVE PRESSURE
RMH ED COVID-19 Intubation Checklist
Induction and Intubation
Inside Room Monitoring
ECG, BP, SpO2, EtCO2Kit DumpSuction
Remove facial hair
Bluey behind patient?s head
IV Access x2 & FlushGiving set
Drugs in room Optimise
Position +/- rampHemodynamics: early inotropes and limit fluids
Yellow binTurn off facemask O2 at wall outlet and
discard mask
VentilatorMode: PCV+
Resp Rate: 20/minI:E 1:1.5
Pcontrol: 10-15cmH2OPEEP: 10cmH2O
FiO2: 100%
Airway AssessmentChange plan?
Pre-oxygenation:BVM, tight seal, 2-hand grip 3 min
Avoid PPV but assist ventilation if Sats <80%
Induction & Paralysis(45 ? 60 sec)
Disconnect BVM above HME Filter
Intubate
Inflate cuffConnect HME Filter & EtCO2
Reconnect BVMEtCO2
Secure ETT
Connect ventilator via Safe Circuit Protocol
1. Paralysis2. Ventilator on Standby
3. Clamp ETT4. Break circuit above HME filter
5. Remove everything above ETT
6. Connect to ETT in following order
6a Inline suction6b HME filter
6c EtCO2 sensor
7. Connect ventilator circuit8. Unclamp ETT9. Start Ventilator
Post Intubation SedationNGT
Blade in TrayDispose of all consumables
Discard outer gloves
VentilationFiO2: Titrate to Sats >90%
PEEP &Pinsp: Titrate to TV 6ml/kg ideal body weight
If circuit break required follow Safe Circuit Protocol
Minimise cough using neuromuscular blockade
Exit room promptly
Meticulous PPE doffing with buddy
Debrief
HME Filter
EtCO2
To Patient
Circu
itSuction
From Ventilator
Post Intubation and Safety
Prepare Equipment
AA
TL
LITw i s t
& Lo ck
www.parkvilleEMR.org.au Last updated: 9 July 2020
Page 1 of 3 © 2018 Epic Systems Corporation. All rights reserved.
Accessing Epic from Home (2 Factor Authentication)
To ensure the security of Epic from outside the Melbourne Health Network, a number of strategies have been implemented to protect our patient’s records.
Before you can access Epic from home, you need to have set up Remote access with IT. You will need to have set up Duo Mobile 2-Factor Authentication (2FA) Security with MH IT services to access Epic from home. If you have not yet set this up either call 9342-8888 and hold for an operator (do not press 1 for EMR, as this is not an EMR issue), or email [email protected] with your Full Name, MH Username, & Mobile number. IT will be in contact about how to set up Duo Mobile Security, including how to download the mobile app to your phone.
1. Using the Link from within your online Learning Hub course, or navigating to https://epicprod.mh.org.au you will be presented with this login screen:
Enter your personal MH username and password & accept the Terms & Conditions
Take Note: To access this site, you will have needed to update your password to the new PassPhrase style password (13 character minimum, with 3 special characters (Capital, numerical, symbol), e.g. Love2work@RMH). You can Change your Password from your Webmail via Settings in the top right of your screen, or from any onsite work computer by pressing Ctrl+Alt+Del.
2. Next, you will be presented with this screen:
Enter the Passcode sent to your mobile phone
www.parkvilleEMR.org.au Last updated: 9 July 2020
Page 2 of 3 © 2018 Epic Systems Corporation. All rights reserved.
3. You may be presented with a screen asking to detect or download a Citrix Receiver. Allow download of Citrix Receiver/Workspace to occur, or select the button that says Already Installed if you have already installed Citrix onto your computer.
Mac Users: If accessing Epic using an Apple Mac computer, you will need to ensure you have downloaded a copy of Citrix Workspace onto your computer. You can download a copy of this from the link below https://www.citrix.com/en-au/downloads/workspace-app/mac/workspace-app-for-mac-latest.html
Windows Users: Most Windows computers already have Citrix Workspace/Receiver installed. Ensure you have the latest version installed on your computer by either searching for ‘Download Citrix Workspace for Windows’ or downloading the latest version from: https://www.citrix.com/en-au/downloads/workspace-app/windows/workspace-app-for-windows-latest.html
As always, when downloading any file from the Internet before opening ensure you scan the file for any viruses using your Anti-virus software.
4. You should now see the Citrix Storefront containing the Epic applications. If you do not see any Apps, ensure you are looking at the Apps screen, and not the Favorites screen. Open TRNPLY02 to practice using Epic or Train-ACE01 to complete your Refresher training.
You will now be able to Enter the TRAINING LOGIN from your Scenario or online course. If you cannot remember your training log on, you can find these at
https://connectingcareemr.phs.org.au/resources/training-playground-information/ This site will need to be accessed through an Internet Browser that you have opened via https://remotedocs.mh.org.au as the Connecting Care site is only available remotely or on site.
www.parkvilleEMR.org.au Last updated: 9 July 2020
Page 3 of 3 © 2018 Epic Systems Corporation. All rights reserved.
TROUBLESHOOTING:
If you receive an error warning when trying to log into this screen or an Invalid Username/Password error, despite having 2FA set up this is a known issue with Duo Mobile security, and MH IT services are working to rectify this.
In the meantime, to enable you to continue your training follow the steps below as a workaround:
Open http://remotedocs.mh.org.au/
Connect using DuoMobile Security
Enter your MH User name and Password
Either select to have a Push Notification sent to your mobile, or enter a passcode found in your Duo Mobile app
Approve the request to log in, where you will be then taken to the Remote Work Resources page
Open the Access MH Virtual Desktop icon to VPN into RMH
You will now be able to open Internet Explorer and access https://epicprod.mh.org.au
If you have any issues or queries regarding your Melbourne Health IT account, or setting up remote access you can contact them via email on [email protected] or call 9342-8888. It’s also a good idea to register your mobile with IT via the intranet. This will allow you to send ‘reset’ to reset your password, or ‘unlock’ to unlock your locked account to (0427) 585-674
If you have any queries about this training tip sheet, please contact the Epic training team via email at [email protected]
www.parkvilleEMR.org.au Last updated: 9 July 2020
Page 1 of 3 © 2018 Epic Systems Corporation. All rights reserved.
Accessing Epic from Home (2 Factor Authentication)
To ensure the security of Epic from outside the Melbourne Health Network, a number of strategies have been implemented to protect our patient’s records.
Before you can access Epic from home, you need to have set up Remote access with IT. You will need to have set up Duo Mobile 2-Factor Authentication (2FA) Security with MH IT services to access Epic from home. If you have not yet set this up either call 9342-8888 and hold for an operator (do not press 1 for EMR, as this is not an EMR issue), or email [email protected] with your Full Name, MH Username, & Mobile number. IT will be in contact about how to set up Duo Mobile Security, including how to download the mobile app to your phone.
1. Using the Link from within your online Learning Hub course, or navigating to https://epicprod.mh.org.au you will be presented with this login screen:
Enter your personal MH username and password & accept the Terms & Conditions
Take Note: To access this site, you will have needed to update your password to the new PassPhrase style password (13 character minimum, with 3 special characters (Capital, numerical, symbol), e.g. Love2work@RMH). You can Change your Password from your Webmail via Settings in the top right of your screen, or from any onsite work computer by pressing Ctrl+Alt+Del.
2. Next, you will be presented with this screen:
Enter the Passcode sent to your mobile phone
www.parkvilleEMR.org.au Last updated: 9 July 2020
Page 2 of 3 © 2018 Epic Systems Corporation. All rights reserved.
3. You may be presented with a screen asking to detect or download a Citrix Receiver. Allow download of Citrix Receiver/Workspace to occur, or select the button that says Already Installed if you have already installed Citrix onto your computer.
Mac Users: If accessing Epic using an Apple Mac computer, you will need to ensure you have downloaded a copy of Citrix Workspace onto your computer. You can download a copy of this from the link below https://www.citrix.com/en-au/downloads/workspace-app/mac/workspace-app-for-mac-latest.html
Windows Users: Most Windows computers already have Citrix Workspace/Receiver installed. Ensure you have the latest version installed on your computer by either searching for ‘Download Citrix Workspace for Windows’ or downloading the latest version from: https://www.citrix.com/en-au/downloads/workspace-app/windows/workspace-app-for-windows-latest.html
As always, when downloading any file from the Internet before opening ensure you scan the file for any viruses using your Anti-virus software.
4. You should now see the Citrix Storefront containing the Epic applications. If you do not see any Apps, ensure you are looking at the Apps screen, and not the Favorites screen. Open TRNPLY02 to practice using Epic or Train-ACE01 to complete your Refresher training.
You will now be able to Enter the TRAINING LOGIN from your Scenario or online course. If you cannot remember your training log on, you can find these at
https://connectingcareemr.phs.org.au/resources/training-playground-information/ This site will need to be accessed through an Internet Browser that you have opened via https://remotedocs.mh.org.au as the Connecting Care site is only available remotely or on site.
www.parkvilleEMR.org.au Last updated: 9 July 2020
Page 3 of 3 © 2018 Epic Systems Corporation. All rights reserved.
TROUBLESHOOTING:
If you receive an error warning when trying to log into this screen or an Invalid Username/Password error, despite having 2FA set up this is a known issue with Duo Mobile security, and MH IT services are working to rectify this.
In the meantime, to enable you to continue your training follow the steps below as a workaround:
Open http://remotedocs.mh.org.au/
Connect using DuoMobile Security
Enter your MH User name and Password
Either select to have a Push Notification sent to your mobile, or enter a passcode found in your Duo Mobile app
Approve the request to log in, where you will be then taken to the Remote Work Resources page
Open the Access MH Virtual Desktop icon to VPN into RMH
You will now be able to open Internet Explorer and access https://epicprod.mh.org.au
If you have any issues or queries regarding your Melbourne Health IT account, or setting up remote access you can contact them via email on [email protected] or call 9342-8888. It’s also a good idea to register your mobile with IT via the intranet. This will allow you to send ‘reset’ to reset your password, or ‘unlock’ to unlock your locked account to (0427) 585-674
If you have any queries about this training tip sheet, please contact the Epic training team via email at [email protected]
RMH ED COVID-19 Intubation Checklist
RPP PPE - Don?t rush!Extra Pair of Gloves
Perform Buddy PPE Check
Allocate Roles & LabelLead Intubator
Airway AssistantMedical Team Leader
Runner
Team HuddleCase SynthesisGoals of Care?
Allergies?Comorbidities?
Other Considerations?
Drugs & DosesKetamine 0.5-2mg/kgRocuronium 1.5mg/kg
Metaraminol (0.5mg/mL)Extra Rocuronium
Morphine + Midazolam for sedationAdrenaline 1mg in 10ml
EquipmentStandard Kit?
Standard + Difficult Kits?
PPE and Team Preparation Prepare for Difficulty
Outside Room Airway Plan
- Plan A:Modified RSI with Video Laryngoscope and the most Senior Intubator
Use 30 second drillsDifficult or Failed Intubation
- Plan B/C:Tight 2 handed vice grip BVM & then LMA
Contact Anaesthetics on #6311
- Plan D:FONA - Scalpel, Finger, Bougie + Size 6 ETT
Do not ventilate during FONA attempt
PTOTURN ON NEGATIVE PRESSURE
RMH ED COVID-19 Intubation Checklist
Induction and Intubation
Inside Room Monitoring
ECG, BP, SpO2, EtCO2Kit DumpSuction
Remove facial hair
Bluey behind patient?s head
IV Access x2 & FlushGiving set
Drugs in room Optimise
Position +/- rampHemodynamics: early inotropes and limit fluids
Yellow binTurn off facemask O2 at wall outlet and
discard mask
VentilatorMode: PCV+
Resp Rate: 20/minI:E 1:1.5
Pcontrol: 10-15cmH2OPEEP: 10cmH2O
FiO2: 100%
Airway AssessmentChange plan?
Pre-oxygenation:BVM, tight seal, 2-hand grip 3 min
Avoid PPV but assist ventilation if Sats <80%
Induction & Paralysis(45 ? 60 sec)
Disconnect BVM above HME Filter
Intubate
Inflate cuffConnect HME Filter & EtCO2
Reconnect BVMEtCO2
Secure ETT
Connect ventilator via Safe Circuit Protocol
1. Paralysis2. Ventilator on Standby
3. Clamp ETT4. Break circuit above HME filter
5. Remove everything above ETT
6. Connect to ETT in following order
6a Inline suction6b HME filter
6c EtCO2 sensor
7. Connect ventilator circuit8. Unclamp ETT9. Start Ventilator
Post Intubation SedationNGT
Blade in TrayDispose of all consumables
Discard outer gloves
VentilationFiO2: Titrate to Sats >90%
PEEP &Pinsp: Titrate to TV 6ml/kg ideal body weight
If circuit break required follow Safe Circuit Protocol
Minimise cough using neuromuscular blockade
Exit room promptly
Meticulous PPE doffing with buddy
Debrief
HME Filter
EtCO2
To Patient
Circu
itSuction
From Ventilator
Post Intubation and Safety
Prepare Equipment
AA
TL
LITw i s t
& Lo ck
