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
[email protected]
723-5495
Pager: 13483