WELCOME TO THE PICU

Flow Of The Day

Before 8am: 8:00 - 8:30am: Pre-Round/Receive sign out Morning report or PICU fellow lecture (Mo/Th)…MANDATORY 8:30 - 9:00am: 9:00 - 9:30am: 9:30 - 11:00 am: 11:00 - 12:00pm: Rounds begin Radiology rounds Completion of morning rounds Work time/didactics/first post-op admits

Flow of the Day

12:00 – 1:00pm 1:00 – 4:30pm 4:00 – 4:30pm 4:30 – Noon Conference Follow up consultations, procedures, post-op admits, didactics Residents receive NP sign out Resident/fellow sit down sign out, followed by night team only walk rounds

Resident Teaching Conferences

PICU resident lectures:  Monday / Thursday  8 – 8:30am  In place of morning report  At front desk in PICU  Mandatory lectures

Other Teaching Conferences

Monday Tuesday Thursday Friday 12-1 PM 7:30 AM 12-1 PM 7:30 AM PICU Divisional Conference CVICU lecture PICU Resident small group conferences (palliative care x2, vent teaching with RT, code team/cart teaching) CVICU Conference with Dr. Hanley 2E PICU Conference Room 2E PICU Conference Room TBD each week, emails sent from pediatric chiefs 2E PICU Conference Room

Educational Resources

 PICU resident handbook with relevant PICU topics is available at http://peds.stanford.edu/Rotations/picu/picu_rec_re adings.html

Hard copy is available in the resident call room.

PICU chapters at

http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html

 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

 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

Attending Fellow Senior pediatric resident Pediatric intern ED resident

Team B

Attending Fellow Senior pediatric resident Pediatric intern Nurse practitioner

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

patient: e.g. call consults, follow up on for each radiologic studies, etc. 

Discuss any

changes management

changes

of patients with the attending / fellow prior to carrying out

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  Sign out 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 7 th resident in the PICU  May care for equal number of patients as pediatric residents  Rounds one day on weekend, typically Saturday  Excused for Wednesday AM ED conferences: must pre-round & hand over notes to on call resident prior to leaving for education rounds  Starting this academic year, ED residents will be complete 3 weeks of days and one week of nights

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 NPs

 Michelle Burns-James  Krysta Nicholson  Karley Mariano  Work independently and carry their own patients  They are present in PICU 4 days/week for 10 hour shifts (variable days and starting times…i.e. may work noon-10pm some day depending on staffing needs)  Typically round one day on weekends, alternating with ED resident

PICU Evaluations for Pediatric Residents

 Faculty evaluations completed on Med-Hub  Verbal feedback from attendings while on the rotation – Be sure to elicit feedback if not provided

Notes

 The following need a full H&P:  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 or attending 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 ” “ review ” not  Please remember to update physical exam daily

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 FACE to FACE in the PICU

PICU-to-Floor Hand-offs

 Goals: Safe patient sign out  Issue: Sign-out often does not happen close to transfer time due to bed availability  Issue: No “ stops ” within the system to prevent transfer when hand-offs not completed.

PICU-to-Medical Team Hand-offs (including Renal transplant patients)

PICU MD orders “transfer bed request” PICU RN requests bed in Tele Trekking USA or Spectralink alerts Floor Resource Nurse that bed ready in Tele Trekking Floor Resource Nurse/USA Floor Bedside RN Phone sign-out Floor MD Floor MD calls PICU and goes to PICU for sign-out PICU Resource Nurse PICU Bedside RN PICU MD Floor MD orders “Okay to transfer” Patient Transfers to Floor*

PICU to Floor Hand-offs: MD Roles

1.

PICU resident

orders “Transfer Bed Request” including accepting team and orders “Change of Care to Acute care” and prints out PICU to Acute care IPASS report 2. Floor Resource Nurse or USA will call Accepting

Floor Resident

patient has been assigned a bed through Tele Trekking. when PICU 3. Accepting

Floor Resident

will call 5-8770 asking to talk to fellow to arrange time to get face to face sign-out, ideally within 30 minutes. 4. Accepting

Floor Resident

for verbal sign-out. (and ideally fellow and attending) goes down to PICU 5. Accepting

Floor Resident

puts in “Okay to Transfer” order. 6. Prior to sending patient or accepting patient PICU Bedside Nurse and Floor Bedside Nurse verify “Okay to Transfer” order has been placed 7. Patient comes to floor.

Please use the printed tool: Floor residents should print out but you can also

Printed Tool: Where to Find

Printed Tool

Rounding & Presenting Patients

Flow of Rounds

 8:30 Typically BMT, Liver, Renal Transplant  Followed by:  Sick/high acuity  Transfers  Remainder  Neurosurgeons typically round on their patients between 7:30-8:30

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 rounding checklist on every patient  Engage Bedside RN in rounds!!

Procedures

 PICU fellows are given priority for all procedures (particularly 1 st 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:  CBC  Coags  Chemistries  CXR  Qam labs in PICU are drawn at 4 or 5 am 

TIP:

Use PICU Daily Orderset during rounds!!

Admitting Trauma Patients

     ANY TRAUMA patient—admit as follows:  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, Trauma service should write admit orders Surgical service should write the discharge summary unless transferred to PICU service for ongoing medical issues

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)  Allows some autonomy to RT to develop plan for best mode of therapy

Discharges

 Patient rounding checklist useful tool!

 Prescription paper available from USA; please send 24 hours before  Loads into one printer and special tray  Select the PICU prescription printer for all D/C scripts  Rx_picu_fntdsk

Discharge

 During rounds if discharge is anticipated in the next 48 hours please update the target discharge date  When you get admissions from surgery please ask about when they are anticipating discharge and what clinical criteria will need to be met.

 If discharge is anticipated use the discharge checklist to help aid in the planning process (it will be on the patient door)  After you discharge a patient there is a survey that we are asking you to complete regarding your experience with the process

PICU Quality and Safety

 PICU Handoff Initiative for ALL OR, 1N Handoffs  One Message, One Time  Role cards utilized  IPASS tool for handoff comes with 45 min call

PICU Quality and Safety

 PICU Rounding Checklist  Real time clinical decision support  Enhance patient safety and care coordination  Review at conclusion of rounds for EACH patient

COWS

 Be sure to sign off  Don ’ t leave patient information exposed  Plug them back in (a dying cow is not pretty)

PICU Etiquette

 Please speak in quiet voices, particularly around main nurses station  We follow HUSH (healthcare workers utilizing silence for healing) in the PICU  Please no open food or drink containers unless in specified areas  Make sure you do follow the appropriate hand hygiene and have bare hands at all time in the unit

Final Thoughts

 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