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 Conference1:00 - 4:30pm: Completing work of the day4:30 - 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

COMMUNICATIONCOMMUNICATIONCOMMUNICATION

– 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 rotationContact PICU rotation director - Dr. S. Kache atSkache@stanford.edu

723-5495Pager: 13483