Transcript WELCOME TO THE PICU

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 - 12:00pm:
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: Noon Conference
1:00 - 4:30pm: Follow-up
consultations/procedures/postop admissions/didactics
4:30 - 5:30pm:
Sign-out Rounds with night team
Resident Teaching Conferences
PICU resident lectures:
• Monday / Thursday
• 8 – 8:30am
• In place of morning report
• At front desk in PICU
Other Teaching Conferences
Tuesday
12-1
PICU Fellows
Conference
2E PICU
Conference
Thursday
12-1
PICU Conference:
M&M, Journal
Club, Fellows
research
2E PICU
Conference
Educational Resources
• PICU resident handbook with relevant PICU
topics is available at
http://peds.stanford.edu/Rotations/picu/picu_re
c_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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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
2 Teams in PICU
Team A
Team B
Attending
Attending
Fellow
Fellow
Second year pediatric resident
Third year pediatric resident
+/- NP
ED resident
Resident Role
• Receive sign out from overnight resident
• Pre-round on PICU patients
• Present patients at morning rounds beginning
promptly at 8:30am
• 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
• Attend teaching conferences conducted by the
ICU attendings / fellows
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 5th resident in the PICU
• May care for equal number of patients as
pediatric residents
• Rounds one day on weekend
• 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
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Online
PICU specific templates
Systems-based note
Indicate attending on your team and select
“sign” not “review”
TIPS for PICU Notes
• These are the official legal medical record
• They support level of care provided
• Therefore:
– Avoid colloquials or not universally understood
abbreviations
– Use words to support ICU care—
• instead of dehydration—mild tachycardia but stable,
CR monitor
• Try: dehydration with tachycardia, compensated
shock in ICU for continuous hemodynamic
monitoring
ICU Transfers Requirements
• Approval of the ICU Attending
• Transfer summary
– If going to a resident team, usually non-surgical
and ICU stay >48h
• Transfer orders
– Surgical patients: surgeons often write orders
– Always clarify with surgeon if OK to transfer
& WHO will write transfer order
• Sign patient out to ward resident
Rounding & Presenting Patients
Flow of Rounds
• 8:30 Typically BMT, Liver, Renal
Transplant
• Followed by:
– Sick/high acuity
– Transfers
– Remainder
• Neurosurgeons round on their patients
between 7:30-8:30 usually
Tips for Success on Rounds
• See CXR if available before rounds
start…ETT high/low, new findings that
can’t wait for rounds to start?
• Any special drains in place? JP, Chest tube,
EVD…know how much output total & per
shift
• Any pending studies completed from prior
day? EEG, MRI, US, ECHO, cultures
….know the result
• Patient identification
• Quick assessment: i.e. patient improving,
worsening, or unchanged
• Major (not all) interval events
• Vitals: Tmax (time) , vital sign ranges,
including CVP, ICP if applicable
Completing patient presentation
• Be succinct; try not to present same data
more than once
• One line overall assessment of patient
condition
• Review orders
• Address patient dashboard
• Engage Bedside RN in rounds!!
Procedures
• PICU fellows are given priority for all
procedures (particularly 1st year fellows)
– Prerequisite for CCM training
• Acute situations : fellow or attending
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/Defibrillator familiarity
• Code cart familiarity
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
• 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
• To minimize line entry RNs like to have
flexibility to time meds
– UNLESS You want drug given at a specific
time
– Qday ordered at 8pm won’t happen until 8 am
next day
• RNs may batch labs to minimize line entry
*** 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
• In 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
Admitting Trauma Patients
• ANY TRAUMA patient—admit as follows:
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LOCATION: 2E/PICU
Ward Attending: select PICU Attdg
Service: Select Trauma (even if head trauma)
Sub-specialty attending: Select Trauma or
Neurosurgery Attending
• If head trauma or NAT: Peds
surgery/trauma must be notified to do
tertiary survey
• Trauma H&P in Epic, co-write admit orders
Order Entry Reminders
• Extubation: Requires an extubation order
– Don’t just D/C vent order
– Other important orders are linked to extubation
• Blood product orders
– Still require a call slip
– Inform patient’s RN that products ordered
• ACE(airway clearance evaluation) vs CPT
– Allows some autonomy to RT to develop plan
for best mode of therapy
Discharges
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Patient safety dashboard useful tool!
Prescription paper available from USA
Loads into one printer and special tray
Select the PICU prescription printer for all
D/C scripts
– Rx_picu_fntdsk
PICU Quality and Safety
• PICU Handoff
Initiative for ALL OR
Handoffs
– One Message, One
Time
– Role cards utilized
– IPASS tool for handoff
comes with 45 min call
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
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Ensure Best
Practices for
✔CABSI
Prevention
✔Pressure
Ulcer
Prevention
✔VAP
Prevention
Discharge Planning
Catheter Associated Bloodstream Infections
Ventilator Associated Pneumonia
Patient Safety
COWS
• Be sure to sign off
• Don’t leave patient information exposed
• Plug them back in (a dying cow is not
pretty)
• !! No cow tipping !!!
PICU Etiquette
• Please speak in quiet voices, particularly
around main nurses station
• We follow HUSH in the PICU
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. Courtenay Barlow at
[email protected]
Pager: 23492