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Presentation on theme: "WELCOME TO THE PICU."— Presentation transcript:


2 Flow Of The Day Pre-round Morning Report/ PICU Fellow Lecture (Mo/Th) Rounds (Except Fridays 9 am) Radiology Rounds Finish Rounds Work time/Didactics/First post-op admit Before 8am: 8:00 - 8:30am: 8:30 - 9:00am: 9:00 - 9:30am: 9: :00 am: 11: :00am:

3 Flow Of The Day 12:00 - 1:00pm: 1:00 – 4:00pm: 4:00 - 5:30pm:
Noon Conference Follow-up Consultations Procedures Post op admissions didactics Sign-out Rounds with night team

4 Day Shift Responsibilities
Day-time Admissions: Should go to the team NOT on call that night, e.g. B-resident on call, A-team admits Teams will be adjusted by fellow or attending to maintain equity in patient numbers and acuity between teams Be flexible When resident in clinic: All remaining team members, including residents from other team must help cover patients, e.g team B resident in clinic, team A will help NP cover

5 Patient Load Residents expected to carry 5-7 patients each
Admissions above this number or chronic ICU patients will be covered by NPs

6 Pre-rounding Weekday pre-rounding: Weekend pre-rounding:
Residents expected to pre-round on all of their patient Weekend pre-rounding: 3 pre-rounding individuals: post-call NF resident, Daytime resident, NP or ED Resident If high patient acuity, fellows can present patients or “discovery rounds” with attending if in-adequate time to pre-round

7 Night Shift Responsibilities
Every other night for 2 weeks Goal: Admit to your assigned team, but may be redistributed Present new admissions on rounds; can shift between teams if required Expectation is that you stay through rounds, leave around noon No continuity clinic before your night shifts Signout at 4pm

8 Resident Teaching Conferences
PICU resident lectures: Monday / Thursday: 8 – 8:30am In place of morning report At front desk in PICU

9 Other Teaching Conferences
DAY TIME CONFERENCE LOCATION Tuesday 7-8 am CVICU Conference 2E PICU Conference room 12-1 PICU Fellows Conference 2E PICU Conference Thursday PICU Conference: M&M, and others 1-2 PICU Weekly Sign Out Welcome to join any and all!

10 Educational Resources
PICU resident handbook with relevant PICU topics is available at Hard copy is available in the resident call room.

11 PICU chapters at http://peds. stanford
Monitors in ICU Vascular Access Codes ICP management Status Epilepticus Sedation Pediatric Airway Airway Management Mechanical Ventilation ARDS Status Asthmaticus Inotropes Shock Sepsis Meningococcus

12 PICU chapters at http://peds. stanford
Cardiomyopathy Liver Failure Acute Renal Falilure Fluids, Electrolytes, Nutrition Oncology Transfusions DKA Submersion Injuries Brain Death End of life issues

13 PICU Tables at http://peds. stanford
Sedation Inotropes Shock

14 Team Composition

15 Resident Role Receive sign out from overnight resident
Pre-round on PICU patients Present patients at morning rounds beginning promptly at 8:30am DEVELOP A PLAN & PRESENT IT (Your opportunity to be a doctor!!) After rounds carry out developed plan for each patient: e.g. call consults, follow up on radiologic studies, etc. Discuss any management changes of patients with the attending / fellow prior to carrying out changes

16 Resident Role Be actively involved in stabilization of acutely ill patients Evaluate new admissions to the ICU and develop a management plan Present new admissions to the ICU fellow / attending Attend evening rounds and transfer care of patients to overnight resident/fellow Attend teaching conferences conducted by the ICU attendings / fellows

17 PICU NPs Julie Reed Kiersten Wells Acute care NP coursework UCSF
Doctorate of Nursing Practice USF, in progress PICU RN several years Kiersten Wells Member of LPCH SCAN team (Suspected Child Abuse & Neglect) Special focus in Adolescent Several years as cardiology PNP LPCH

18 PICU NPs Integral member of team Work directly with Attending/fellow
Provide ongoing continuity in PICU from week to week Hours available in PICU: Mon-Sat: 7:30am - 5:00pm; Some weekend flexibility Enhance PICU flow Between subspecialists and PICU team Between bedside RNs and PICU team—participate in daily discussion about patient dashboard

19 PICU NPs Assist with admissions as needed throughout day for either team Participate in pre-rounding on weekdays/weekend Receive sign-out to assist with patient care From post-call fellow From pm clinic residents May perform procedures: based on unit need & as deemed appropriate by Attending/Fellow (i.e. new admit, the pt’s resident is post-call, etc.) Questions regarding PICU NPs? Contact Deb Franzon, Pager 23108,

20 PICU NPs PICU NP: admits patients, based on fellow/attending decisions, typically to A team, but when resident in clinic may admit patients to B team as well Weekends: Equal distribution of all patients between residents and NP

21 Other Trainees in PICU Anesthesia fellows Emergency medicine residents
Medical Students

22 Anesthesia Fellows Present for half the blocks
Primarily provide support for fellow level activities in the ICU Will not primarily follow patients

23 ED Residents Will act as a day resident in the PICU on the B team
May care for equal number of patients as pediatric residents Rounds one day on weekend (Sunday) Excused for Wednesday AM ED conferences: must pre-round & hand over notes to on call resident prior to leaving for education rounds

24 Medical Students Primarily 2 rotations in PICU
Critical care core clerkship – all patients followed by students on this rotation must be co-followed by residents (most students on this rotation) Sub-internship – these students can follow their own patients Resident needs to write progress note

25 PICU Evaluations for Pediatric Residents
Group faculty evaluation completed on Med-Hub Verbal feedback from attendings while on the rotation – Be sure to illicit feedback if not provided

26 Notes The following need a full H&P:
Trauma (even if went to OR first) Transport ED admits Direct admit from outside The following need an accept note: Post-op surgical Transfer from floor/ rapid response

27 Notes Each patient needs PICU daily progress note (unless admitted in early am) Significant events: codes/procedure/intervention Require a note: confer with fellow who may do this note Templates exist for most procedures Interim summary weekly on Thursday for any patient with LOS > 5d in PICU

28 Notes Online PICU specific templates Systems-based note
Indicate attending on your team and select “sign” not “review” Official legal documents, so use medical terms Justify level of ICU stay

29 Transfers out of ICU Approval of the ICU Attending Transfer summary
For non-surgical patients with >48hr ICU stay Transfer orders Surgical patients: surgeons often write orders Confirm transfer with surgical team and who will write transfer orders Sign patient out to ward resident

30 Rounding & Presenting Patients

31 Patient Presentation Ask attending re presentation preference: data first then plan, or data and plan by system On line PICU Progress Note available Can be cumbersome, difficult to navigate during rounds If presenting from COW – assure all information available – e.g. lab results, radiology studies, etc.

32 Tips for Success on Rounds
Review films and know results Know results of studies completed over-night Be succinct during presentations Pertinent positives and negatives only DEVELOP A PLAN & PRESENT IT (Your opportunity to be a doctor!!)

33 Patient identification
Quick assessment: i.e. patient improving, worsening, or unchanged Major (not all) interval events Vitals: Tmax (time), HR SBP/DBP(MAP), RR, sats, CVP (vital sign ranges)

34 Physical exam: present exam appropriate for patient’s disease
Present meds within appropriate system as present: e.g. steroids for asthmatic in respiratory vs. steroids for liver transplant in GI May need to make specific sections for certain patients: e.g. Transplant, endocrine, orthopedics, etc.

35 Data & Plan to consider in each system
Respiratory: Data:CXR findings, mode of support - NC vs BiPAP vs ventilator, amount of support A/P: changes in pulmonary compliance and changes in respiratory support accordingly CV: Data: inotropic support, rhythm, echo results A/P: changes in hemodynamic status and need for changes in inotropic support Neuro: Data: sedation medications, imaging studies A/P: changes in neuro status, requirements for sedation

36 Data & Plan to consider in each system
FEN/GI: Data: I/O’s, nutritional source, calories per day, Labs, LFTs A/P: Changes in fluid status or liver functions, modifying nutritional support Renal: Data: Urine output, any renal replacement therapy, changes in BUN/Cr A/P: Changes in renal function or diuretics

37 Data & Plan to consider in each system
Heme: Data: labs, anti-coagulants A/P: changes in Hct, need for transfusion, coagulation status ID: Data: WBC, cultures, antibiotic levels A/P: changes in antibiotics, etc. Psycho-social: Family conferences or discussions with family

38 Completing patient presentation
One line overall assessment of patient condition List major plans for the day at the end Review orders Address Bedside RN concerns Address patient dashboard

39 PICU Quality and Safety
PICU Patient Safety Dashboard Real time clinical decision support Enhance patient safety and care coordination Multidisciplinary- pulls from documentation in EMR Bottom tab for each patient Review at conclusion of rounds for EACH patient

40 ✔ ✔ PICU Dashboard Tab Ensure Best Practices for ✔CABSI Prevention
✔Pressure Ulcer Prevention ✔VAP Prevention

41 Procedures PICU fellows are given priority for all procedures (particularly 1st year fellows) Prerequisite for CCM training Acute situations : fellow or attending NPs: at discretion of attending or for their own patients

42 Procedures Procedures residents should acquire some degree of comfort with while in the PICU Bag-mask ventilation Operating an anesthesia bag Placement of peripheral IVs Chest compression Familiarity with defibrillator

43 Bedside Nurses COMMUNICATION
Tell bedside nurse you are the resident caring for that patient Give them your pager #

44 Bedside Nurses Communicate all orders to the bedside nurse after written Minimizes confusion about orders Provides high level consistent patient care Improves patient safety Every nurse also has an Ascom phone if you can’t make it to bedside

45 Bedside Nurses Assure bedside RN present for rounds
Morning rounds: discuss orders for the day Evening rounds: discuss plan for the night Midnight rounds: discuss am labs, x-rays, etc.

46 Bedside Nurses The bedside RN = your eyes & ears to your patient
Provide “real time” clinical information If they know what you are looking for – they can tell you - Especially with sick patients **They can make you look good by keeping you updated on all pertinent info! **

47 Orders Do not write specific times for meds – allows RN to time them as possible for existing lines & to minimize line entry Only enter drug time if needs to be given at a specific time Do not time labs *** except for immunosupression drugs *** e.g. Prograf, CSA

48 Order Entry Qam labs in PICU are drawn at 4 or 5 am
Most routine labs and CXR require daily orders: CBC Coags Chemistries CXR Qam labs in PICU are drawn at 4 or 5 am TIP: Use PICU Daily Orderset during rounds!!

49 PICU specific Power - Plans
On Cerner PICU folder found under Power-plan folders

50 PICU specific Power - Plans
On Cerner Specific Power-plans available in PICU folder include: Fever work-up Trauma admit PICU Daily orders Respiratory failure DKA Hyperkalemia

51 Final Thoughts Take ownership of your patients Be present Be involved
Ask questions Suggestions on improving the rotation

52 Questions, concerns, thoughts on the rotation
Contact PICU rotation director - Dr. S. Kache at Pager:

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