Transcript WELCOME TO THE PICU - Stanford University

WELCOME TO THE PICU
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
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
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
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!
Educational Resources
• PICU resident handbook with relevant
PICU topics is available at
http://peds.stanford.edu/Rotations/picu/picu.ht
ml
Hard copy is available in the resident call
room
PICU chapters at
http://peds.stanford.edu/Rotations/picu/picu.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.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 peds.stanford.edu
• Sedation
• Inotropes
• Shock
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
• 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
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
PICU Evaluations
• Group faculty evaluation completed on
MedHub
• Verbal feedback from attendings while on
the rotation – Be sure to ellicit feedback if
not provided
Other Trainees & HCPs in PICU
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Anesthesia fellows
Emergency medicine residents
Medical students
Nurse Practitioners
Anesthesia Fellows
• Only present for half the blocks
• Primarily provide support for fellow level
activities in the ICU
• Will not carry any patients
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
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
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
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
Notes
• New admissions require a dictated H&P and
a brief note in the chart
• Post-operative admissions can have a postop admission note written in the chart
• Patients in the ICU for longer than one
week require a dictated clinical summary
each Thursday
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
Rounding & Presenting Patients
Sample PICU
Progress Note
-Each patient’s note
printed from Cerner
(LPCH computer
system)
-Assure printed
information up to
date, i.e. ventilator
settings
• Patient identification
• Quick assessment: i.e. patient improving,
worsening, or unchanged
• Major (not all) interval events
• Vitals
• 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
• 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
• 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
• One line of overall assessment and major
plans for the day at the end
• Review orders
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
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
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
• Do not time labs
*** except for immunosupression drugs ***
e.g. Prograf, CSA
Order Entry
• PICU order sets available on Cerner include:
• Delete previous diet orders
• Orders that require daily entry:
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CBC
Coags
Chemistries
CXR
• If labs or radiology studies listed in power-plan, no
re-entry required
Order Entry
• On Cerner
• PICU folder under
Power-plan folders
Order Entry
• On Cerner
• Power-plans found
in PICU folder
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 !!!
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
Skache@stanford.edu
723-5495
Pager: 13483