WELCOME TO THE PICU

1. WELCOME TO THE PICU

2. Flow Of The Day Before 8am: Pre-round 8:00 - 8:30am: Morning Report 8:30 - 9:00am: Rounds (Except Fridays, rounds start at 9am after Grand Rounds) 9:00 - 9:30am: Radiology Rounds 9:30 - 11:00 am: Finish Rounds 11:00 - 12:00am: Work time

3. Flow Of The Day 12:00 - 1:00pm: Noon Conference 1:00 - 4:30pm: Completing work of the day 4:30 - 5:30pm: Sign-out Rounds with night team

4. Prevention of Resident Duty Hour Violations • Do not begin pre-rounds before 6am • Evening rounds begin at 4:30pm • Be sure to leave by 12pm on post-call days • If your patients are not rounded on by 11:30, hand your notes to on-call resident

5. Teaching Conferences • Tuesday 7 – 8am CV ICU Conference • PICU Conference Room • Tuesday 12 – 1pm: PICU fellow conference • PICU Conference Room • Thursday 3 – 4pm: Sign out round • PICU Conference Room Welcome to all!

6. Educational Resources • PICU resident handbook with relevant PICU topics is available at http://peds.stanford.edu/Rotations/picu/picu.html Hard copy is available in the resident call room

7. PICU chapters at http://peds.stanford.edu/Rotations/picu/picu.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

8. PICU chapters at http://peds.stanford.edu/Rotations/picu/picu.html • Cardiomyopathy • Liver Failure • Acute Renal Falilure • Fluids, Electrolytes, Nutrition • Oncology • Transfusions • DKA • Submersion Injuries • Brain Death • End of life issues

9. PICU Tables at peds.stanford.edu • Sedation • Inotropes • Shock

10. 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

11. Resident Role • Recognize the patients are often very complicated and managed collaboratively with other services – e.g. neurosurgery, liver transplant, heme-onc, cardiology, etc. • Significant changes to patient status should be discussed with the other services

12. 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

13. PICU Evaluations • Group faculty evaluation completed on MedHub • Verbal feedback from attendings while on the rotation – Be sure to ellicit feedback if not provided

14. Other Trainees & HCPs in PICU • Anesthesia fellows • Emergency medicine residents • Medical students • Nurse Practitioners

15. Anesthesia Fellows • Only present for half the blocks • Primarily provide support for fellow level activities in the ICU • Will not carry any patients

16. ED Residents • Will act as a 5th resident in the PICU • To care for equal number of patients as pediatric residents • Will take call with a pediatric resident and cover half the patients • Excused for Wednesday AM ED conferences, but must pre-round and hand over notes to on call resident prior to leaving for education rounds

17. 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

18. PICU NP Role • Hours of coverage in PICU: • Mon-Sat: 7:30am - 5:00pm • Assist residents with ICU specific systems issues, e.g. writing PICU notes • Complete daily goal sheets and review with Bedside RN at completion of rounds • Pre-round on patients on Saturday

19. PICU NP Role • Assist with patient flow: • Pre-round with consultants, i.e. neurosuregery, and update resident with recommendations • Writing accept notes and orders on post-op patients as needed, i.e. during am / pm sign-out • Entering transfer orders for patients requiring transfer during rounds, etc. • Attend Multidisciplinary rounds on Tuesdays at 11am

20. Notes • New admissions require a dictated H&P and a brief note in the chart • Post-operative admissions can have a post-op admission note written in the chart • Patients in the ICU for longer than one week require a dictated clinical summary each Thursday

21. ICU Transfers Patients being transferred from the ICU require • Transfer summary • Transfer orders • Surgical patients: surgeons often write orders • Sign patient out to ward resident

22. Rounding & Presenting Patients

23. Sample PICU • Progress Note • Each patient’s note printed from Cerner (LPCH computer system) • Assure printed information up to date, i.e. ventilator settings

24. Patient identification • Quick assessment: i.e. patient improving, worsening, or unchanged • Major (not all) interval events • Vitals

25. Physical exam: present exam appropriate for patient’s disease, e.g. neuro exam on neurosurgical patient (but examine all of patient) • Present meds in appropriate system: e.g. steroids for asthmatic vs. steroids for liver transplant • Respiratory: • Data: CXR findings, mode of support - NC vs BiPAP vs ventilator • A/P: changes in pulmonary compliance and changes in respiratory support accordingly

26. 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 • FEN/GI: • Data: I/O’s, nutritional source, calories per day, Labs • A/P: changes in fluid status or liver functions, modifying nutritional support

27. Renal: • Data: urine output, any renal replacement therapy, changes in BUN/Cr • A/P: changes in renal function or diuretics • 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

28. One line of overall assessment and major plans for the day at the end • Review orders

29. Procedures • PICU fellows are given priority for all procedures (particularly 1st year fellows) • They must be trained in them prior to completion of their fellowship • Acute situations – fellow or attending will do procedure to optimize patient care

30. Procedures Procedures residents should acquire some degree of comfort with while in the PICU • Bag-mask ventilation • Operating an anesthesia bag • Chest compression • Placement of peripheral IVs

31. Bedside Nurses COMMUNICATION COMMUNICATION COMMUNICATION • Tell bedside nurse you are the resident caring for that patient • Give them your pager #

32. 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

33. 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.

34. 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! **

35. Orders • Do not write specific times for meds – allows RN to time them as possible for existing lines • Do not time labs *** except for immunosupression drugs *** e.g. Prograf, CSA

36. Order Entry • PICU order sets available on Cerner include: • Delete previous diet orders • Orders that require daily entry: • CBC • Coags • Chemistries • CXR • If labs or radiology studies listed in power-plan, no re-entry required

37. On Cerner PICU folder under Power-plan folders Order Entry

38. On Cerner Power-plans found in PICU folder Order Entry

39. 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 !!!

40. Final Thoughts • Take ownership of your patients • Be present • Be involved • Ask questions • Suggestions on improving the rotation

41. Questions, concerns, thoughts on the rotation Contact PICU rotation director - Dr. S. Kache at Skache@stanford.edu 723-5495 Pager: 13483