Specialties in ICU

ECMO is the common abbreviation for extracorporeal membrane oxygenation, also known as ECLS (extracorporeal life support). ECMO is a highly specialized technique, which is managed by a group of intensive care specialists and ECMO-trained nurses. Colloquially ECMO may be referred to as an artificial heart & lung machine.

The JHH ICU has provided ECMO care since 2012 and now provides this form of support to more than 10 patients per year. The hospital is registered with the international Extracorporeal Life Support Organization (ELSO) and is renowned in the hunter area for its experience in using ECMO for either cardiac (VA) or respiratory (VV) supports.

A unique character of JHH ICU ECMO program is it's managed by specialized intensive care team. The management, selection of cases, veno-venous & veno-arterial cannulation, priming of circuit, daily management and transport to diagnostic areas are conducted by the specialised ICU team. The ICU maintains a close consultative relationship with the JHH surgical and perfusion services which support the ECMO program.

The ECMO service supports cardiac interventions in Cath Lab such as high risk multivessel interventions and post cardiac arrest cardiogenic shock. The ICU ECMO service provides support to the cardio-thoracic surgical team by managing central VA ECMO support in post cardiac surgery patients.

JHH ICU runs a comprehensive education program based on theoretical and simulation knowledge covering all aspects of ECMO in the adult patient. The ECMO program undergoes regular audit as well as review with other ECMO centres across the state to ensure the highest level of care is maintained for our patients.

The John Hunter Hospital is one of 7 Adult Major Trauma Centres and one of only 3 Paediatric Major Trauma Centres in NSW. As such, the John Hunter Hospital's Adult Intensive Care Unit (ICU) and Paediatric Intensive Care Unit (PICU) play a very important role in providing critical care services to severely injured patients of a population of close to 1 million people within the Hunter and New England regions.

Critically injured patients can arrived from anywhere in the area to the JHH ICU and PICU transferred by either the Pre-hospital or Inter-hospital Hunter Retrieval Teams. Once at John Hunter Hospital patients are able to receive elective or emergency surgery in neurosurgery, cardiothoracic, orthopaedics, plastics, paediatrics, as well as interventional radiology services.

There are also close to 1,700 trauma presentations to the emergency department to which the ICU responds as part of the Trauma Call Team. In 2018 there were more than 1,350 adult trauma hospital admissions, and 203 paediatric trauma hospital admissions. There were 226 adult admissions to ICU (more than 1 every other day) of severely injured patients, evidenced by an average Injury Severity Score (ISS) of 23 and average APACHE 3 score of 52. There were also 30 severely injured paediatric admissions to PICU with and average ISS of 20.

Senior and junior ICU medical staff get the chance to work in a multidisciplinary environment when looking after severely injured patients. ICU trainees have the opportunity to be exposed to all aspects of trauma care including retrieval medicine, emergency management and resuscitation, operative and post-operative care, and rehabilitation services. There are state-of-the-art radiology, haematology and transfusion, and pathology services available at all times. Research and education are cornerstones of the service we provide due to the world-leading researchers who work at John Hunter Hospital, the hospital's and ICU's continuous involvement in clinical trials, and the close ties with the University of Newcastle and the Hunter Medical Research Institute. The combination of all of the above makes John Hunter Hospital a leading centre in trauma and a great place for ICU trainees to develop.

The John Hunter ICU provides collaborative tertiary ICU support to all our surgical specialties including:

• General Surgery including Upper GI, Hepatobiliary, Colorectal & Endocrine Surgery
• Vascular Surgery
• Neurosurgery
• Orthopaedic Surgery
• Trauma Surgery
• Cardiothoracic Surgery
• High risk obstetrics/maternal-fetal medicine
• Renal Transplant Surgery
• Plastic Surgery
• Ear Nose and Throat Surgery
• Oral, Maxillary and Facial Surgery
• Head and Neck Surgery

The John Hunter ICU provides tertiary medical ICU to the Hunter, New England and Mid North Coast regions. Supported by world class medical specialist teams, the ICU provides care for patients with:

• Severe respiratory failure including advanced ventilatory techniques and ECMO
• Severe heart failure & patients requiring coronary reperfusion
• Severe infections
• Renal failure
• Endocrine abnormalities
• Neurological Disorders including clot retrieval for acute ischaemic strokes and coiling of aneurysms
• General Medical disorders

The Paediatric Intensive Care Unit (PICU) at JHH, is a tertiary 8 bed intensive care serving a teaching paediatric hospital, the Hunter New England Area as well as the State of New South Wales. It cares for critically ill children with medical or surgical conditions including trauma.

The current PICU was built in 2017 as a brand new entity with state of the art facilities, patient rooms as well as a focus on facilities for parents to promote family centred care. The current PICU is funded for 4 beds but has physical capacity for 8 beds with plans for expansion into the future.

The unit admits approximately 400-500 critically ill children annually. Our admission rate continues to raise as the PICU expands. Most sub-specialities are represented including trauma, neurosurgery, ENT, respiratory and oncology. The hospital is a major trauma centre for the region. Academically the hospital is associated with the University of Newcastle.

The PICU also provides a PICU outreach service for support for critically unwell children on the ward and in the emergency department.  The PICU team also supports the Hunter Retrieval service and the Newborn Emergency Transport Service (NETS) for the transport of critically unwell children in the region.

Staff

The PICU is staffed by dedicated paediatric intensive care specialists who are invested in teaching, training and growing the PICU service for Hunter New England area. There is currently one junior medical officer (registrar level) rostered at any one time. Registrars complete 6 month rotations in the PICU.

The unit is also staffed by intensive care nurses who have done specific training in paediatric critical care. The management of the patients is supported by a multi-disciplinary team with close relationships and input from the speciality paediatric teams from the John Hunter Children's hospital.

Benefits of training as a junior medical officer

The PICU rotation is a fantastic learning experience. The term allows you to become proficient in the recognition and management of the deteriorating child, common paediatric conditions as well as to have exposure and opportunity to develop procedural skills such as vascular access and advanced airway support.

Currently our registrars rotate from the adult intensive care unit and the term counts as paediatric ICU experience with the College of Intensive Care Medicine.  As the junior medical officer you get the opportunity to work 1:1 with a staff specialist on all your shifts.  As a result there is a great amount of formal and informal education in PICU. In addition there is a paediatric intensive care specific training program which involves scheduled one to one teaching sessions with you and a PICU Consultant. You are also able to attend all the teaching sessions being held through the adult intensive care unit.

John Hunter Hospital performs approximately 400 elective and emergency cardiac surgical operations per year. This includes off-pump coronary bypass surgery, minimally invasive valvular surgery, aortic surgery and transcatheter aortic valve implantation (TAVI).

All post-operative patients are admitted to the intensive care and managed in collaboration with the cardiac surgical team. The intensive care unit conducts two Cardiac Advanced Life Support (CALS) courses per year at the John Hunter Hospital, as well as regular multidisciplinary in-unit Cardiac ICU teaching for our medical and nursing staff.

The care and management of critically ill patients with acute neurological injuries have been getting more focus recently and special interest groups have formed both locally and nationally. Both our ICU and PICU support strong programs within neurology, interventional neuroradiology and neurosurgery incl. spinal surgery. We particularly admit many patients with TBI, subarachnoid haemorrhage and post out-of-hospital cardiac arrest.

In addition to standard neuromonitoring with intracranial pressure monitoring, our unit is now capable of offering multimodal neuromonitoring with continuous EEG, NIRS, Transcranial Doppler and pupillometry.

Within the next couple of years, we are also hoping to provide brain tissue oxygen monitoring for patients with severe TBI. However, this technology may initially be introduced through a national randomised control trial. Many of our enthusiastic intensivists have shown great support for local projects and research within neurocritical care.