History

Royal Prince Alfred Hospital (RPAH) was opened on September 25th 1882 at a cost of approximately £90 000 with a capacity of 146 beds. With the acceptance of 14 medical students in 1884 it became the first teaching hospital in New South Wales.
Since these early days RPAH has undergone substantial changes. In the 1940's extensions such as: King George V Memorial Hospital (Mothers & Babies), and the Institute of Cardiology was established. An extension of the Cardiology Institute saw Page Chest Pavilion being built in 1957. Further progression embracing new technologies to support medical research and the growing needs of the community were the Cancer Detection clinic and the Institute of Dermatology built in 1959 and more recently the Renal Unit built in 1961.

The development of the General Intensive Care Unit began in the 1950's subsequent to the poliomyelitis epidemic. This introduced a wider use of mechanical ventilation. In RPAH these patients were grouped together in an isolation area known as the Tetanus Ward.
Then in 1975, a more formalised Intensive Care Unit (ICU) was implemented which saw a larger expansion to 9 beds, relocated in the Albert Pavillion (A7). Some eight years later, another move was necessary with the expansion to 12 beds located in the Edinburgh Building, known as E6ICU.
2002 saw the opening and development of the 'Intensive Care Service Hot Floor', with the capacity to ventilate 54 patients.

The Intensive Care Service (ICS) is a level 6 tertiary referral and trauma centre, under the Respiratory & Critical Care Services within the Sydney South West Area Health Service. It is the national liver transplant unit where over 900 transplants have been completed since 1986 of which approximately 25% are children. The success rate is currently 90% survival for the first 12 months. The ICS has retained its specialties with a General ICU/HDU (GICU/HDU), Cardiothoracic ICU (CSIC), and Neurosurgical ICU (NSIC). A dedicated team of medical, nursing and allied health specialists provide both acute and long-term care management. The annual patient admission to the ICS is approximately 3300-3500 patients with occupancy calculated at 100%. Approximately 50% of the admissions are referred from other health care facilities within New South Wales. The average patient length of stay is 3 days with an average age of 61 years.

A diverse casemix of patients provides a very challenging environment for both nursing and medical staff. These challenges include the care of complex medical and surgical cases, under such disciplines as Respiratory, Cardiology, Neurology, Nephrology and Gastroentorology. The expertise of our nursing staff in these clinical areas and in the technological aspects of the unit allows for the delivery of complex clinical management. This is facilitated by a nursing structure comprised of 3 Clinical Nurse Educators, a Clinical Nurse Consultant, 3 Nurse Unit Managers, a Nurse Manager, a Clinical Information System Officer, a Research Coordinator, Clinical Nurse Specialists and various Allied Health Services.

Education for Intensive Care Service staff is a high priority as evidenced by the multiple programs, daily inservices and workshops to meet all learning levels of the nursing continuum. A comprehensive orientation program is modified to support individual needs. An Inducotory Program provides a supportive environment for the novice nurse. This incorporates the professional development learning tool 'Clinical Ladders', workshops, and allocated study leave providing direction and education towards safe clinical practice. For the more experienced nurse there is a self-directive 'Clinical Ladder' program. This provides the foundation for competent team leadership in view of attaining Clinical Nurse Specialist status. Further educational opportunities are available through workshops such as: Team Leadership, Preceptorship, Continuous Renal Replacement Therapy, Intra Aortic Balloon Pump, Advanced Haemodynamic Monitoring, Neuro, Mechanical Ventilation (Essentials and Advanced), Advanced Life Support and Pacing. Registered Nurses are also encouraged to obtain post graduate qualification through the UTS/SSWAHS Graduate Certificate in Critical Care Nursing / University of Sydney / College of Nursing.

A prominent part of our quality improvement program is the Clinical Performance Indicator Project. The monitoring of specific Intensive Care Indicators (outside of those recommended by the ACHS) was introduced to the unit in 1999. These Indicators identify or 'flag' potential and/or actual problems which may be either clinical or resource based. Indicators provide an evidence base from which we are able to assess our standard of care and then instigate change where necessary in order to continue improving our service. We are currently benchmarking against our own previous data in order to measure trends in our clinical performance. Current Clinical Indicators that we record are - patient entry & exit blocks, the prevalence and incidence of pressure ulcers, the use of mechanical restraints, unplanned extubations and newly acquired MRSA. We also monitor the compliance of checking the intubation trolley, glucometers, defibrillators and cardiac arrest trolley on a daily basis. The Research Coordinator in conjunction with medical and nursing staff participate in international, national and local research trials and surveys. Initial and ongoing education is provided to nursing staff by the Research Coordinator, as informed participation is essential. The data collected is partly reliant on ongoing nursing patient assessments and observations. Furthermore involvement in research has been seen to enhance nursing interest in patient care and patient outcomes through the generation of discussion.

A Clinical Information System (CIS) has been in place since 1985. The initial CIS used in the GICU was the Hewlet Packard Patient Data Management System (HPPDMS) and was first introduced in 1985. In February 1999 HPPDMS was replaced with CareVue, which was primarily a digital flowsheet used to record physiological data, to prescribe and chart medications and fluids and as an electronic health record comprising all of the patients notes. CareVue was in turn replaced with a more robust CIS, Philips IntelliVue Clinical Information Portfolio (ICIP) across the entire ICS on the 11th November 2008, after an initial migration testing period in the CSIC from the 2nd September 2008.

A CIS is most importantly a database where all patient information is stored. It is intended that this information will be used to create reports which will be valuable research and quality improvement tools. The ICS management structure provides nursing staff with many professional development opportunities. This is achieved by the introduction of 24 hour Clinical Nurse Educators on a 12 month rotational basis. In addition the 'Assistance, Coordination, Contingency, Supervision and Support' (ACCESS) Nurse position provides further nursing support to employees in each unit. The ACCESS Nurse position is a rotational role for Registered Nurses who are seeking managerial experience.

These ACCESS Nurse and CNE positions strengthen the foundations and further provide senior nurses with the opportunity to develop and consolidate their education management skills. Over the 22 years since RPAH opened its doors to the public the hospital and staff have been at the forefront of innovative changes and development. Today with a $250 million upgrade, RPAH remains consistent with its history of providing extensive and diverse facilities to meet the needs of the people it cares for.

If you would like to be a part of the Intensive Care Service,
the first 'Hotfloor' Adult Intensive Care Unit in the Southern Hemisphere, please contact:

Nurse Manager:
Mr Adam Reid
Phone: +61 2 9515 5307
Email: adam.reid@sswahs.nsw.gov.au

Compiled and written by:
Frankie Hopkins, ACNC
Brett Abbenbroek, NM
Chanelle Innes, CNC
Melissa Wulff, NUM
Revised by Suzy Dimovski A/CNC March 07
Revised by Chris Wise CIS/Telehealth Support Officer May 09