Transcript Slides - UCSF Department of Anesthesia and

Intensive Care Unit
Welcome & Orientation
UCSF Moffitt & Long Hospitals
Rotation Learning Goals
• To learn to care for critically
• To improve on techniques
ill patients
• To understand
management of respiratory
failure with mechanical
ventilation
• To develop a better
appreciation of
cardiopulmonary
physiology
• To understand indications
for different modalities of
hemodynamic monitoring
to place invasive monitors
• Understand the
pharmacodynamics and
pharmacokinetics of
sedatives
• Learn the communication
skills required in the role of
the critical care consultant
• Develop a multidisciplinary
treatment plan for critically
ill patients
Learning Goals
Have a fun and educational month
Background
• Open and closed critical care units
• Diverse patient population
• Multi-disciplinary teams
• MD, NP, PharmD
• Intensivists from different backgrounds
• Anesthesia, Pulmonary, Nephrology, Surgery,
Emergency Medicine, Neurology
Organization
Neurological
Cardiovascular
8 ICU
11
ICU
MedicalSurgical
9 ICU
10
ICU
13
ICU
WEEKDAY NIGHT/WKND
8 ICU
NP
MD/NP
(8/11)*
11 ICU
Interns &
Residents
MD/NP
(8/11)*
9 ICU
2 NPs &
2-3 MDs
NP/MD
10 ICU
2-3 MDs
& NP
NP/MD
13 ICU
4-5 MDs
MD
FELLOWS
4-5
Fellows
1 Fellow
Open and Closed ICU’s
Disadvantages:
The data:
Multiple studies
show that the daily
presence of an
intensivist improves
outcomes, including
mortality and length
of stay. There was
no advantage to
closed units
• Difference in
perspective on
priorities
• “Loss of control”
Advantages:
• Variety of Patients:
• Medical, Surgical, Neuro, CV
• Ability to concentrate on critical
care issues
• Training: attendings/fellows from
multiple specialties
UCSF ICU’s
• UCSF ICU’s are “semi-open”
• Primary service still writes the majority of the orders, but
we co-manage with them
• We write all orders for: Ventilator, Sedation/Pain &
Place invasive lines
• ICU is the PRIMARY SERVICE for:
• Malgnant Hematology (CRI), Orthopedic Surgery, Oral
Surgery (OMFS), Head & Neck Surgery (OHNS/ENT),
Gynecology, Gyn-Onc Surgery, Post-partum Obstetrics,
Urology, and Plastic Surgery
“Closed” patient issues
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Labs - CBC, electrolytes, glucose
Nutrition - NPO, tube feeding, TPN
Activity - bedrest, ad lib
IVF - rate, heplock
Transfusions – triggers, CMV negative, irradiated
Studies - radiology, echo, PT - need to make a
phone call
• Check patient frequently and communicate with
primary team often
HOUSEKEEPING
Housekeeping - daily routine
• 8:00am daily lectures *
• M-919
• Check schedule for topic and speaker (it may be you!!!)
• * Wednesdays there are no longer mandatory 8:00am
lectures for anesthesia residents (12:00noon conference
will replace 8:00am conference)
• 9:00am daily team rounds
• 0800 on weekends*
• 17:00pm afternoon rounds with fellow(s)
• DO NOT LEAVE before checking in with the fellow or
attending
Weekends/Holidays
• Only on-call and post-call residents round
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• If you are neither, you have the day off
Try to pre-round on the sick patients
Remainder of patients can be discovery
rounds (at the discretion of the attending)
Notes are written either before or after rounds
(at the discretion of the attending)
Place emphasis on assessment/plan
Housekeeping - call schedule
• Call is approximately once every 3-4 nights,
averaged over the entire rotation
• Post-call resident leaves before 11:00am
• Please do not violate your duty hours
• Schedule changes are not allowed unless
approved by Dr. Shimabukuro
• (an extremely complex schedule)
11 ICU Signout & Call
• Residents not taking call should rotate staying
late to sign out to NP at 1900
• Residents need to take sign out from overnight
NP by 0700
• If you are the resident on call for 11 ICU you will
also cover 8 ICU (overnight/weekends)
• Your call room is also the “9 ICU call room”
Call Room: 13 ICU
• M1318
• Outside of ICU
• Hallway between Moffitt &
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Long
Swipe in with UCSF badge
Door labeled “ICU Resident”
Shared bathroom with
surgery resident
Do NOT leave valuables in
call rooms
Call Rooms: 9 ICU
• Inside of 9 ICU
• “Proximal” room
• “Distal” room is
fellow call room
• No code/outside lock
• Shared bathroom
with ICU fellow
• Do NOT leave
valuables in call
rooms
Medical Students
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Stay late 1 night per week - their choice
They should read about their patients
Quality not quantity (2 patients max)
They are not expected to function as a resident
during this rotation
• There should be a resident identified as the
supervisor for each patient the students follows
• Residents should be writing their own note as well
Lectures
• Each resident and medical student will be
responsible for a 30-minute lecture during the
rotation
• Please check the lecture schedule for assigned
topic and date
• Medical students are allowed to pick a topic of their
choice
• Read schedule carefully, lectures are split (ie, 2
lectures on a day) based on level of training and
ICU experience
RESIDENT RESPONSIBILITIES
Responsibilities
Critical Care
Rotation
• Attend Daily Lectures
• Respond to Code Blues
• 10ICU
• Others: nights/weekends
Unit Specific
• Help your team
• Manage unit code bag
• Respond to Code Sepsis &
Code Blues
Direct
Patient Care
• H&P, Daily rounds,
Progress Notes
• Ventilator and Pain &
Sedation Management
• Placement of invasive lines
Central Lines
• We are responsible for all line placements
• Except for a few services (CT surgery and Cardiology)
• At the request of the CT Surgery or Cardiology
Fellow/Attending, we will assist with line placement
• All central lines must have an ICU attending or
fellow at the bedside during placement
• For all residents regardless of training background or
level
Intubations
• “Airway Provider” should be available for all ICU
intubations
• The airway pager (443-4990) will always be with an
anesthesiologist (attending, fellow or resident)
• Do not start sedation/paralysis without someone from
anesthesia being present (CA-1 residents should also
always get back-up)
• Airway backup available:
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OR E1 Anesthesia Attending: 3-1581 (Spectralink)
OR Front Desk: 3-1545
OB Anesthesia Resident: 443-9261
ED: 3-1238
Ventilation
• We are responsible for ALL ventilator orders,
intubations and extubations
• (For those on 10ICC, please clarify with your attending for
each CT surgery non-fast-track CABG patient)
• If the primary team wants something that is
unreasonable, please discuss it with the fellow or
attending
• DO NOT make changes directly on the ventilator
Sedation
• We write pain and sedation orders on all patients
• (For those on 10ICC, please clarify with your attending for
each CT surgery non-fast-track CABG patient)
• Management of pain in ICU patients with epidural
catheters is the responsibility of the acute pain service,
but we do keep a close eye on this*
• Work with the primary team when appropriate to
determine the best sedation plan
Code Blue Coverage
• 10 ICC team will respond to codes during
weekdays (M-F 0800-1700)
• Everyone will respond to codes from 1700p0800a weekdays & all day/night weekends
and holidays
• We are responsible for the airway - FIRST
• Please make sure that whatever you use in
the CODE bags are refilled immediately
Code Bags
• Available per ICU
• Use at all codes,
intubations, sedations
• Make sure this bag is
stocked and locked daily
• Pharmacy
• Refill outside 13ICU
• Other:
• ICU OR O.R.
Code Sepsis
• Initiated by the ICU bedside nurse when
sepsis screening tool is positive and there is
evidence of end-organ dysfunction
• Nurses are allowed to send lactates when
severe sepsis or septic shock is suspected
• Immediately go to patient’s beside and start
severe sepsis/septic shock resuscitation
bundle; help the nurses, if needed
Code Sepsis: Resuscitation
Bundle
• Lactate (whole blood and NOT serum)
• Blood cultures (Time to positivity) prior to
broadspectrum antibiotics (BSA)
• Start of BSA within 1 hour from time of Code
Sepsis
• 20-30 mL/kg or 1000 mL of crystalloid for
hypotension or lactate > 4 mmol/L
Code Sepsis: BSA
Emergency Calls
• Calls regarding unstable patients often go to
the ICU team
• If situation is truly an emergency, deal with
the problem while the primary team is being
summoned
• If there is time, discuss with the team, often
the night float will be thankful for a friendly
word of advice
Communication
• Understanding the primary team’s plans and
goals often make it easier to understand the
course of action that is planned
• Communication makes it easier for all parties
involved and improves patient care (use the
signout tool in APeX)
• If there is a disagreement about care, consult
your fellow or attending
APEX & Patient Database
PAPERWORK
Paperwork
• List to be described on following slides
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New Resident/NP Office
Database List
Patient list
General APeX comments
Notes
Admit Orders
Central Line Procedure Note
Procedure Note
CCM Resident/NP Office
• Door code:
6917#
Patient list
• Database List
• Can be accessed via Chrome on any MC computer, but PLEASE
print only in Resident/NP Office across from M919
• This is a HIPAA violation if left in random printers
• Post call resident will print out copies for the team
• Keep track of this list
• Do not leave it anywhere, throw away daily
• Please keep this list up to date!
Database List
• http://anesthesia.ucsf.edu/iculist
• Sign-on with
• SFxxxxxx
• SOM\, UCSFMC\, etc
• Make sure you log-out
APeX
• Context: CRITICAL CARE MEDICINE SVC
Click here to
search/change
New Notes
• Select “Notes” Tab on Left Column
• From top heading bar- select either:
1. “New Note” (dot phrase)
2. Create in Notewriter
OR
Notewriter Notes
Progress Notes
• Using copy forward
Copy Forward
Be very careful about copy-forwarding
notes. Always review the entire note for
accuracy. (ie, a patient cannot be “POD#2”
for 5 days in a row)
Notes
• Progress Notes:
• “Co-sign Required” is at the discretion of your
attending
• Procedure Notes:
• “Co-sign Required” is REQUIRED, and is always your
attending of the week
• Title of note should have:
• “Critical Care Medicine Progress Note”
• “Critical Care Medicine Admission Note”
Notes
• Be as specific as possible for the
assessment/ problem list
• Altered mental status versus ICU delirium
• COPD Exacerbation versus acute hypercarbic
respiratory failure from pneumonia on (and)
COPD
• UTI with hypotension versus septic shock from
(and) UTI
Notes
• Be specific as possible with the plan
• For instance, “wean vent as tolerated” vs.
“Patient continues to require a high minute
ventilation due to a likely large dead space
fraction from resolving ARDS. He is not tolerating
a rapid wean. Failed SBT yesterday due to
sustained respiratory rate in the 40’s with
desaturation. Will try again today.”
Procedure Notes
• Resident who rounds/admits
the patient has “first dibs” on
procedure
• Provider who performs
procedure is responsible for
procedure note
• Procedure notes are added
under a different template than
progress notes
• “Cosign Required” MUST be
checked & “” is your attending
of the week
Orders
• The IP Adult ICU Addendum Order Set needs
to be completed by the ICU resident for every
patient admitted to 8/9/11/13 ICU.
• On 10, they only need to be completed for
patients the service is following
• The IP Adult Core Admission Order Set may
also need to completed. Ask your fellow.
Orders
• Other order sets of interest:
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IP Adult Core Admission Orders
IP Adult ICU Addendum
IP Adult Sepsis
IP Adult Continuous Neuromuscular Blocking
Agent
• IP Adult Blood Product Transfusion
• IP Adult PCA
• IP ICU Withdrawal of Care
Orders
• Mechanical Ventilation
• There is NO order set
• Search under “ventilation” or use IP Adult ICU
Addendum Order Set
ARDSNet Protocol
PSV/CPAP
Orders
• Mechanical Ventilation
• Don’t forget to write for oxygen titration orders
under admin instructions
• When changing between modes, don’t forget to
discontinue the old one
• SBT: search under “SBT”
APeX Flowsheets
• Useful flowsheets to “wrench” in
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MAR Report/ Med List (if not already there)
Comprehensive/Comp (if not already there)
Hemodynamics (for those on 10ICC)
LDA (current and past central/arterial lines with
insertion/discontinue dates and locations)
APeX
• Other useful flowsheets to “wrench” in
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Hematology (Blood products administered)
Fever OR ID/Sepsis
Insulin/Glucose
Labs since admission
Radiology
Microbiology
Critical Care SO/RND
A Word from the NPs
• We can be a resource for you. Ask and we
will try to help
• Be prepared for sign out by knowing the
ventilator and sedation plan for patients.
• If you can’t restock the code bag before sign
out, let us know. We will help you.
• The list is our life line. It needs a thorough
update before 6AM/6PM every day.
Miscellaneous
• Radiology does not interpret any studies overnight
unless asked
• Small cards have everybody’s pager and home
phone number
• Please don’t hesitate if you identify problems
during your rotation to notify your attending
• Please fill out the evaluations. Your comments are
confidential and important for future rotation
development
Questions?