3Flow Of The Day 12:00 - 1:00pm: 1:00 – 4:00pm: 4:00 - 5:30pm: Noon ConferenceFollow-upConsultationsProceduresPost op admissionsdidacticsSign-out Rounds with night team
4Day Shift Responsibilities Day-time Admissions:Should go to the team NOT on call that night, e.g. B-resident on call, A-team admitsTeams will be adjusted by fellow or attending to maintain equity in patient numbers and acuity between teamsBe flexibleWhen 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
5Patient Load Residents expected to carry 5-7 patients each Admissions above this number or chronic ICU patients will be covered by NPs
6Pre-rounding Weekday pre-rounding: Weekend pre-rounding: Residents expected to pre-round on all of their patientWeekend pre-rounding:3 pre-rounding individuals: post-call NF resident, Daytime resident, NP or ED ResidentIf high patient acuity, fellows can present patients or “discovery rounds” with attending if in-adequate time to pre-round
7Night Shift Responsibilities Every other night for 2 weeksGoal: Admit to your assigned team, but may be redistributedPresent new admissions on rounds; can shift between teams if requiredExpectation is that you stay through rounds, leave around noonNo continuity clinic before your night shiftsSignout at 4pm
8Resident Teaching Conferences PICU resident lectures:Monday / Thursday: 8 – 8:30amIn place of morning reportAt front desk in PICU
9Other Teaching Conferences DAYTIMECONFERENCELOCATIONTuesday7-8 amCVICU Conference2E PICU Conference room12-1PICU Fellows Conference2E PICU ConferenceThursdayPICU Conference: M&M, and others1-2PICU Weekly Sign OutWelcome to join any and all!
10Educational Resources PICU resident handbook with relevant PICU topics is available atHard copy is available in the resident call room.
11PICU chapters at http://peds. stanford Monitors in ICUVascular AccessCodesICP managementStatus EpilepticusSedationPediatric AirwayAirway ManagementMechanical VentilationARDSStatus AsthmaticusInotropesShockSepsisMeningococcus
12PICU chapters at http://peds. stanford CardiomyopathyLiver FailureAcute Renal FalilureFluids, Electrolytes, NutritionOncologyTransfusionsDKASubmersion InjuriesBrain DeathEnd of life issues
13PICU Tables at http://peds. stanford SedationInotropesShock
15Resident Role Receive sign out from overnight resident Pre-round on PICU patientsPresent patients at morning rounds beginning promptly at 8:30amDEVELOP 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
16Resident RoleBe actively involved in stabilization of acutely ill patientsEvaluate new admissions to the ICU and develop a management planPresent new admissions to the ICU fellow / attendingAttend evening rounds and transfer care of patients to overnight resident/fellowAttend teaching conferences conducted by the ICU attendings / fellows
17PICU NPs Julie Reed Kiersten Wells Acute care NP coursework UCSF Doctorate of Nursing Practice USF, in progressPICU RN several yearsKiersten WellsMember of LPCH SCAN team (Suspected Child Abuse & Neglect)Special focus in AdolescentSeveral years as cardiology PNP LPCH
18PICU NPs Integral member of team Work directly with Attending/fellow Provide ongoing continuity in PICU from week to weekHours available in PICU:Mon-Sat: 7:30am - 5:00pm; Some weekend flexibilityEnhance PICU flowBetween subspecialists and PICU teamBetween bedside RNs and PICU team—participate in daily discussion about patient dashboard
19PICU NPsAssist with admissions as needed throughout day for either teamParticipate in pre-rounding on weekdays/weekendReceive sign-out to assist with patient careFrom post-call fellowFrom pm clinic residentsMay 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,
20PICU NPsPICU NP: admits patients, based on fellow/attending decisions, typically to A team, but when resident in clinic may admit patients to B team as wellWeekends: Equal distribution of all patients between residents and NP
21Other Trainees in PICU Anesthesia fellows Emergency medicine residents Medical Students
22Anesthesia Fellows Present for half the blocks Primarily provide support for fellow level activities in the ICUWill not primarily follow patients
23ED Residents Will act as a day resident in the PICU on the B team May care for equal number of patients as pediatric residentsRounds 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
24Medical 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 patientsResident needs to write progress note
25PICU Evaluations for Pediatric Residents Group faculty evaluation completed on Med-HubVerbal feedback from attendings while on the rotation – Be sure to illicit feedback if not provided
26Notes The following need a full H&P: Trauma (even if went to OR first)TransportED admitsDirect admit from outsideThe following need an accept note:Post-op surgicalTransfer from floor/ rapid response
27NotesEach patient needs PICU daily progress note (unless admitted in early am)Significant events: codes/procedure/interventionRequire a note: confer with fellow who may do this noteTemplates exist for most proceduresInterim summary weekly on Thursday for any patient with LOS > 5d in PICU
28Notes Online PICU specific templates Systems-based note Indicate attending on your team and select “sign” not “review”Official legal documents, so use medical termsJustify level of ICU stay
29Transfers out of ICU Approval of the ICU Attending Transfer summary For non-surgical patients with >48hr ICU stayTransfer ordersSurgical patients: surgeons often write ordersConfirm transfer with surgical team and who will write transfer ordersSign patient out to ward resident
31Patient PresentationAsk attending re presentation preference: data first then plan, or data and plan by systemOn line PICU Progress Note availableCan be cumbersome, difficult to navigate during roundsIf presenting from COW – assure all information available – e.g. lab results, radiology studies, etc.
32Tips for Success on Rounds Review films and know resultsKnow results of studies completed over-nightBe succinct during presentationsPertinent positives and negatives onlyDEVELOP A PLAN & PRESENT IT (Your opportunity to be a doctor!!)
34Physical 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 GIMay need to make specific sections for certain patients: e.g. Transplant, endocrine, orthopedics, etc.
35Data & Plan to consider in each system Respiratory:Data:CXR findings, mode of support - NC vs BiPAP vs ventilator, amount of supportA/P: changes in pulmonary compliance and changes in respiratory support accordinglyCV:Data: inotropic support, rhythm, echo resultsA/P: changes in hemodynamic status and need for changes in inotropic supportNeuro:Data: sedation medications, imaging studiesA/P: changes in neuro status, requirements for sedation
36Data & Plan to consider in each system FEN/GI:Data: I/O’s, nutritional source, calories per day, Labs, LFTsA/P: Changes in fluid status or liver functions, modifying nutritional supportRenal:Data: Urine output, any renal replacement therapy, changes in BUN/CrA/P: Changes in renal function or diuretics
37Data & Plan to consider in each system Heme:Data: labs, anti-coagulantsA/P: changes in Hct, need for transfusion, coagulation statusID:Data: WBC, cultures, antibiotic levelsA/P: changes in antibiotics, etc.Psycho-social:Family conferences or discussions with family
38Completing patient presentation One line overall assessment of patient conditionList major plans for the day at the endReview ordersAddress Bedside RN concernsAddress patient dashboard
39PICU Quality and Safety PICU Patient Safety DashboardReal time clinical decision supportEnhance patient safety and care coordinationMultidisciplinary- pulls from documentation in EMRBottom tab for each patientReview at conclusion of rounds for EACH patient
40✔ ✔ PICU Dashboard Tab Ensure Best Practices for ✔CABSI Prevention ✔Pressure Ulcer Prevention✔VAP Prevention✔✔
41ProceduresPICU fellows are given priority for all procedures (particularly 1st year fellows)Prerequisite for CCM trainingAcute situations : fellow or attendingNPs: at discretion of attending or for their own patients
42ProceduresProcedures residents should acquire some degree of comfort with while in the PICUBag-mask ventilationOperating an anesthesia bagPlacement of peripheral IVsChest compressionFamiliarity with defibrillator
43Bedside Nurses COMMUNICATION Tell bedside nurse you are the resident caring for that patientGive them your pager #
44Bedside NursesCommunicate all orders to the bedside nurse after writtenMinimizes confusion about ordersProvides high level consistent patient careImproves patient safetyEvery nurse also has an Ascom phone if you can’t make it to bedside
45Bedside Nurses Assure bedside RN present for rounds Morning rounds: discuss orders for the dayEvening rounds: discuss plan for the nightMidnight rounds: discuss am labs, x-rays, etc.
46Bedside Nurses The bedside RN = your eyes & ears to your patient Provide “real time” clinical informationIf 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! **
47OrdersDo not write specific times for meds – allows RN to time them as possible for existing lines & to minimize line entryOnly enter drug time if needs to be given at a specific timeDo not time labs*** except for immunosupression drugs ***e.g. Prograf, CSA
48Order Entry Qam labs in PICU are drawn at 4 or 5 am Most routine labs and CXR require daily orders:CBCCoagsChemistriesCXRQam labs in PICU are drawn at 4 or 5 amTIP: Use PICU Daily Orderset during rounds!!
49PICU specific Power - Plans On CernerPICU folder found under Power-plan folders
50PICU specific Power - Plans On CernerSpecific Power-plans available in PICU folder include:Fever work-upTrauma admitPICU Daily ordersRespiratory failureDKAHyperkalemia
51Final Thoughts Take ownership of your patients Be present Be involved Ask questionsSuggestions on improving the rotation
52Questions, concerns, thoughts on the rotation Contact PICU rotation director -Dr. S. Kache atPager: