WELCOME TO THE PICU

Report
WELCOME TO THE PICU
Flow Of The Day
Before 8am:
8:00 - 8:30am:
8:30 - 9:00am:
9:00 - 9:30am:
9:30 - 11:00 am:
11:00 - 12:00am:
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
Flow Of The Day
12:00 - 1:00pm:
1:00 – 4:00pm:
Noon Conference
Follow-up
• Consultations
• Procedures
• Post op admissions
• didactics
4:00 - 5:30pm:
Sign-out Rounds with
night team
Day Shift Responsibilities
Day-time Admissions:
When resident in clinic:
• Should go to the team • All remaining team
NOT on call that
members, including
night, e.g. B-resident
residents from other
on call, A-team admits
team must help cover
patients, e.g team B
• Teams will be adjusted
resident in clinic, team
by fellow or attending
A will help NP cover
to maintain equity in
patient numbers and
acuity between teams
• Be flexible
Patient Load
• Residents expected to carry 5-7 patients
each
• Admissions above this number or chronic
ICU patients will be covered by NPs
Pre-rounding
• Weekday 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
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
Resident Teaching Conferences
PICU resident lectures:
• Monday / Thursday: 8 – 8:30am
• In place of morning report
• At front desk in PICU
Other Teaching Conferences
DAY
TIME
CONFERENCE
LOCATION
Tuesday
7-8 am
CVICU
Conference
2E PICU
Conference room
Tuesday
12-1
PICU Fellows
Conference
2E PICU
Conference
Thursday
12-1
PICU Conference:
M&M, and others
2E PICU
Conference
Thursday
1-2
PICU Weekly Sign 2E PICU
Out
Conference
Welcome to join any and all!
Educational Resources
• PICU resident handbook with relevant PICU
topics is available at
http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
Hard copy is available in the resident call
room.
PICU chapters at
http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
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Monitors in ICU
Vascular Access
Codes
ICP management
Status Epilepticus
Sedation
Pediatric Airway
Airway Management
• Mechanical
Ventilation
• ARDS
• Status Asthmaticus
• Inotropes
• Shock
• Sepsis
• Meningococcus
PICU chapters at
http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
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•
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•
Cardiomyopathy
Liver Failure
Acute Renal Falilure
Fluids, Electrolytes,
Nutrition
• Oncology
• Transfusions
• DKA
• Submersion Injuries
• Brain Death
• End of life issues
PICU Tables at
http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
• Sedation
• Inotropes
• Shock
Team Composition
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
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
PICU NPs
• Julie Reed
– 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
PICU NPs
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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
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, [email protected]
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
Other Trainees in PICU
• Anesthesia fellows
• Emergency medicine residents
• Medical Students
Anesthesia Fellows
• Present for half the blocks
• Primarily provide support for fellow level
activities in the ICU
• Will not primarily follow patients
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
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
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
Notes
• The following need a full H&P:
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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
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
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
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
Rounding & Presenting Patients
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.
Tips for Success on Rounds
• Review films and know results
• Know results of studies completed overnight
• Be succinct during presentations
– Pertinent positives and negatives only
• DEVELOP A PLAN & PRESENT IT
(Your opportunity to be a doctor!!)
• 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)
• 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.
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
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
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
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
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
PICU Dashboard Tab
✔
✔
Ensure Best
Practices for
✔CABSI
Prevention
✔Pressure
Ulcer
Prevention
✔VAP
Prevention
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
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
Bedside Nurses
COMMUNICATION
COMMUNICATION
COMMUNICATION
– Tell bedside nurse you are the resident caring
for that patient
– Give them your pager #
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
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.
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! **
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
Order Entry
• Most routine labs and CXR require daily orders:
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CBC
Coags
Chemistries
CXR
• Qam labs in PICU are drawn at 4 or 5 am
• TIP: Use PICU Daily Orderset during rounds!!
PICU specific
Power - Plans
• On Cerner
• PICU folder found
under Power-plan
folders
PICU specific
Power - Plans
• On Cerner
• Specific Powerplans available in
PICU folder
include:
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Fever work-up
Trauma admit
PICU Daily orders
Respiratory failure
DKA
Hyperkalemia
Final Thoughts
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Take ownership of your patients
Be present
Be involved
Ask questions
Suggestions on improving the rotation
Questions, concerns, thoughts on the rotation
Contact PICU rotation director Dr. S. Kache at
[email protected]
723-5495
Pager: 13483

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