WELCOME TO THE PICU

Flow Of The Day

Before 8am: Pre-round8:00 - 8:30am: Morning Report8:30 - 9:00am: Rounds(Except Fridays, rounds start at 9am after Grand Rounds)

9:00 - 9:30am: Radiology Rounds9:30 - 11:00 am: Finish Rounds11:00 - 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.html

Hard copy is available in the resident call room

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

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

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

• 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 post-op 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:

– 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

• 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