1. Orientation for PICU Fellows at UCSF BCH Mission Bay
July, 2019
Orientation for PICU Fellows at UCSF BCH Mission Bay

2. Introduction to the PICU at Mission Bay
Service Basics
Conference
CICU specific
Mock Codes
Research
Introduction to the PICU at Mission Bay

3. Where to find “stuff” Adminitrative Q => Kaitlin
“Don’t know” => Jana
Software orientation:
Duty hours, Evaluations, Procedure login: MyAccess-> Medhub
Schedule: Amion
PICU schedules, reading, ppt, policies: PICU wiki
HR related: MyAccess-> AtyourService
Myaccess-> Docusign
Epic-> Pagerbox

4. Service basics

5. Discharge Summary/Deceased
Sign-out times
Rapid Response
Procedures
Transport Calls
Discharge Summary/Deceased
Conferences
CICU specific

6. Service Basics Day fellow week is Monday – Friday
Night fellow: Starts week on Sunday and ends Saturday morning
After sign-out, log into the voalte phone (use your epic login credentials)

7. Service Basics- Team Structure
There are two teams during the weekday, each with a different attending, same fellow:
NP Team: attending, PICU day fellow, NP
Resident team: attending, PICU day fellow, and ~4 residents (pediatric and emergency medicine)
There is one team at night:
Attending, PICU night fellow, resident, NP
Service Basics- Team Structure

8. Service Basics- Day Rounds
7:45 AM NP rounds
8:30 AM Resident team rounds
It’s expected that you join both teams for rounds every day unless you are engaged in active patient care issues
NP rounds generally finish by 8:30AM. If NP rounds are running late, join the resident team rounds at 8:30
On Wednesdays, resident team rounds start at 9 AM and you skip NP team rounds.

9. Service Basics- Taking advantage of the NP attending
Urgent situations during resident rounds (rapid response team calls, transport calls, need for procedures, etc): staff with the NP attending

10. Service Basics- Night Rounds
Charge nurse, bedside nurse, resident, and NP will join, attending will NOT.
Rounds typically occur at midnight, led by the fellow.
Discuss active medical issues
Review the patient MAR (make sure medications are all appropriate, adjust sedation per CALM protocol)
Review lab frequency
Review (infectious) labs that are pending
Identify patients who require a spontaneous breathing trial (SBT)
Identify patients that can be ready for transfer out in the morning.
Goals of rounds:
Service Basics- Night Rounds

11. Service Basics: SBT Spontaneous Breathing Trials (SBT)
Every intubated patient should be assessed on a daily basis to determine extubation readiness
Creating a SBT plan is an important part of midnight rounds
Ie does the fellow need to be present, do feeds need to be held, does sedation need to be adjusted, etc

12. Service Basics: Signout
Most days, Day Fellow comes at 7 AM, Night Fellow comes at 5:30 PM
Exception = Wednesday
Day fellow should come in early and finish receiving signout before 7 AM so that everyone can get to the 7 AM conference on time
Night fellows are expected to return at 7 PM on Wednesdays (10 hours off after the 7-9 AM conference ends).
PICU Rounds should start immediately after conference ends (9:00AM)

13. Service Basics: Signout
Sunday covered by on-service night time fellow for the following week
Saturday fellow receives signout at 8AM from Friday night fellow
Sunday night fellow receives signout at 11 AM from Saturday fellow. The Saturday fellow must leave by 12 PM.
Saturday covered by off-service fellow (28 hr shift)
Service Basics: Signout

14. Notes Fellow writes following notes: Procedures RRT
Transport sheet form
Discharge Summary (usually nighttime fellow; only for medical admissions)
Death Summary
Transfer Summary for complex patients in CICU
For templates see:

15. Rapid Response Team (RRT): Policies and documentationz

16. Rapid Response Team (RRT) calls originate most frequently from the hospital floors or radiology
The PICU fellow is in charge of the RRT process
RRT calls come through your voalte phone from the Access Center
PICU Charge RN, RT, and PICU fellow are part of the Rapid Response Team
When an RRT is called, you have 20 minutes to go and assess the patient but should go as soon as you can.
Once you assess the patient, make sure to discuss the case and plan with your attending
You can escalate an RRT to a Code White at any time
RRT

17. RRT vs Code RRT*: PICU Fellow, PICU Charge RN, RN Supervisor, RT
CODE TEAM:  RRT PLUS CICU Charge RN, ICU Attending, Pharmacy, On-call Anesthesia Attending, Chaplain, Security
Code white – pediatric
Code blue – adult
Code pink- neonatal
ONLY the PICU team responds to code white calls outside of the ICU’s
*RRT in CTCU – same team members but CICU team.
RRT vs Code

18. Sometimes residents or other providers may come to the PICU to ask for management advice for floor patients
You can give general advice; however, if you leave the PICU to go see the patient on the floor, you must call an RRT (primary team can call or you can call yourself)
When in doubt and/or a patient sounds sick, call an RRT
RRT

19. For every RRT you are called to, you are responsible for:
The RRT Flowsheet
The RRT Note
These are essential for charting and tracking
RRT

20. Procedures in the picu z

21. Procedures in the PICU
In general, the PICU fellows should do all procedures (central lines, intubations, arterial lines, peripheral IVs, etc)
If you are busy and feel very comfortable with a procedure, you can offer the procedure to an NP or resident after talking to your attending
Please let your attending/program director know if other providers are “taking away” procedures from you- this should not be happening

22. Peripheral IVs in the PICU
It is important to become comfortable with placing peripheral IVs in children
When an IV is needed, PICU nursing has been asked to contact the PICU fellow first (instead of the vascular access team) in order to give fellows opportunities to develop this skill set
Please make every effort to take advantage of this opportunity!
Peripheral IVs in the PICU

23. Procedural Supervision
Discuss the level of supervision needed for the procedure with your attending prior to initiating the procedure
Review what medications will be used for sedation/analgesia with your attending
Remember to use the sedation navigator for procedural sedation
This is under the procedure tab in the left hand toolbar in the patient’s chart
Procedural Supervision

24. Transport calls z

25. The Access center (x31611) will call your voalte with a transfer request.
Grab the Transport sheet (located behind PICU charge nurse desk)
Typically, the access center will give you age, chief complaint, and MRN (if known UCSF patient) before speaking with the referring provider
It’s helpful to go through the transport sheet systematically (get HPI, vitals, labs, etc). Try to be complete but concise
Decide on the mode of transport: depends on how stable patient is, distance, weather, availability of transport, traffic.
Ask transport team to call you once at the bedside or Follow-up with the outside physician to get updates on patient- especially if too sick
Give recommendations to transport team for transfer
Transport Calls
Always discuss with attending but usually PICU MB does not accept:
No trauma-> goes to CHO PICU
No psych patients

26. Transport Calls- Bridging in Others
When taking a transport call for the first time, it’s helpful to either find your attending to take the call with you in person or ask the access center to bridge in your attending so they can listen along with you
Do NOT delay in formally accepting a sick patient (so that the transport process can proceed). 
Discussions such as further history, advice from consultants, etc can occur in parallel. 
Whenever in doubt, ask your attending.

27. Transport Calls- Bridging in Others
There are circumstances when it’s required or helpful to have subspecialists bridged into the transport call
Code Stroke: If a code stroke is activated, the pediatric neurovascular team needs to be on the initial call. The access center workflow is to bridge in the neurology team, and then others (eg Neuroradiology, Interventional Radiology, etc) as directed by ICU and Neurology.””
Subspecialty patients: if patients are being transferred for subspeciality care (ie peds neurosurgical management, 2nd opinion for seizure disorder, etc)- it’s helpful to have the subspecialist in on the initial call
If you would like to have a subspecialist bridged in on the transport call, just ask the Access Center to page the appropriate team
Transport Calls- Bridging in Others

28. PICU M&M z

29. PICU M&M
Please remember to keep track of your RRTs, morbidities, and mortalities while on service
The M&M fellow will you at the beginning of the month asking for cases.
It is your responsibility to the M&M fellow back with cases
The M&M fellow will help you create your M&M presentation (especially in the beginning of your first year)
Template is here:
Please, follow the timeline for M&M presentation

30. Conferences z

31. Conference
We have weekly didactic conference every Wednesday from 7-11 AM.
On service fellows (BCH San Francisco and Oakland) attend conference from 7-9 AM.
Board Review and Bedside teaching (9-11AM) occurs for off service fellows
Be on time!  = 7:00 am NOT 7:05am :)  

32. Mandatory Conferences
Every Wednesday Morning
(7-9 AM if on service; if on elective/research, 7-11 AM)
PICU Research Conference
(monthly- 2nd week of the month)
RTC-PCCM
(quarterly)
All PICU Mock Codes
(Usually 3rd week of the month)
Fellows College
(see wiki for dates)
Mandatory Conferences

33. CICU specific z

34. Saturday/Sunday day is covered by an off-service fellow (two 10 hr shifts), as is Saturday night (15 hr shift)
Sunday night is covered by the on-service night time fellow for the week starting at 5 PM
Saturday AM: Weekend fellow receives signout at 7:30 AM by Friday night fellow
Night fellow presents on sickest patients and leaves by 9 AM.
Night fellow should gather numbers for weekend day fellow so they can present patients after 9 AM
Weekend call:
Have the cardiology fellow bridged in on transport calls, especially in patients well known to the heart center
Some calls may come in through cardiology, but for any patient that comes to the CICU the ICU fellow should take over as MCP
Transport:
CICU specific

35. Mock Codes PICU CICU PICU CHO Sign-up at:
Code+Schedule

36. Research
Clinical: Sandrijn, Mindy, Shan, Martina (Statistics), Sarah,..
Basic: Jeff, Erika, Tom..
Translational: Matt, Patrick..
Funding resources:
Wiki
Pivot
Mentors:
-SOC mentors, clinial, career, …
RTC-PCCM conference
PICU Research Conference:

37. Sick calls/Call switch/Vacation/Conferences
Find coverage for clinical work, as well as if you are M&M fellow/ teaching fellow
Look-up conferences a year in advance and make sure you include them in your “time-off” requests for next academic year 
Sick calls/Call switch/Vacation/Conferences

38. Welcome!! 