Transcript Notes - UCSF Department of Anesthesia and Perioperative Care

Welcome
to the
Intensive Care Unit
Learning Goals
• To learn to care for critically ill patients
• To understand management of respiratory
failure with mechanical ventilation
• To develop a better appreciation of
cardiopulmonary physiology
• To understand indications for different
modalities of hemodynamic monitoring
• To improve on techniques to place invasive
monitors
Learning Goals
• Understand the pharmacodynamics and
pharmacokinetics of sedatives
• Learn the communication skills required
in the role of the critical care consultant
• Develop a multidisciplinary treatment plan
for critically ill patients
• Have a fun and educational month
Organization
• 8/11 ICU = ± intern, ± 1-2 CA-1 residents, 1
CA-3 resident, fellow(s), attending
• 9 ICU = 2 NPs, 2-3 residents (CA-2, ED, IM),
fellow(s), attending
• 10 ICU = 1 NP, 1 CA-3 resident, fellow(s),
attending
• 13 ICU = 4-5 residents (CA-2, ED, IM), fellow(s),
attending
Fellow(s) = Anesthesia, Pulmonary, Neurovascular, Surgery
Housekeeping - call schedule
• Call is approximately once every 3-4
nights, averaged over the entire rotation.
• Post-call resident leaves before 1100
• Schedule changes are not allowed unless
approved by Dr. Shimabukuro (an
extremely complex schedule)
Housekeeping - Call rooms
• 13 ICU – M1318 (outside of ICU, corridor
between Moffitt and Long, on left side as you
walk towards Long), use your name badge, use
room with door labeled “ICU resident”
• Shared bathroom (with surgery resident)
• 8/9/10 ICU - in 9 ICU, use north room (one on
right when facing both doors), no code or lock
(ie, DO NOT LEAVE VALUABLES)
• Shared bathroom (with ICU fellow)
• ICU fellow – in 9ICU, south room.
Housekeeping - Call rooms
• If someone else is using the call room, find out
what department and/or service and notify Dr.
Shimabukuro immediately by pagerbox or email.
Housekeeping - daily routine
• Lectures start at 8am sharp every weekday
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(0815 on Wednesdays) in room M919
Check schedule for topic and speaker (it may be
you!!!)
Rounds start at 0900 weekdays and at 0800 on
weekends
X-ray rounds immediately follow attending
rounds (at the discretion of the attending)
Afternoon rounds with fellow(s) start at 1700
DO NOT LEAVE before checking in with the
fellow or attending
Housekeeping –
weekends/holidays
• Only on-call and post-call residents round
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• If you are neither, you have the day off
Try to pre-round on the sick ICU patients
Remainder of patients can be discovery
rounds (at the discretion of the attending)
Notes are written either before or after
rounds (at the discretion of the attending)
Place emphasis on assessment/plan
Housekeeping - Lectures
• Each resident and medical student will be
responsible for a 30-minute lecture during the
rotation
• Please check the lecture schedule for assigned
topic and date
• Medical students are allowed to pick a topic of
their choice
• Read schedule carefully, lectures are split (ie, 2
lectures on a day) based on level of training or
ICU experience
Housekeeping – “paperwork”
• List to be described on following slides
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General APeX comments
Notes
Patient list
Admit Orders
Central Line Procedure Note
Procedure Note
APeX
• Context: CRITICAL CARE MEDICINE SVC
Click here to
search/change
APeX
• “wrenching” in flow sheets/reports/accordions
APeX
APeX
Finalize
To reorder on the bar
APeX
• Flow Sheets/Reports/Accordions
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MAR Report/ Med List (if not already there)
Comprehensive/Comp (if not already there)
Hemodynamics (for those on 10ICC)
LDA (current and past central/arterial lines
with insertion/discontinue dates and
locations)
APeX
• Flow Sheets/Reports/Accordions
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Hematology (Blood products administered)
Fever OR ID/Sepsis
Insulin/Glucose
Labs since admission
Radiology
Microbiology
• Critical Care SO/RND
APeX
• Nurses Notes: Use “Notes” Tab: All notes
APeX
Nurses Notes: Comp flow sheet at very bottom or at top
Progress Notes
• General progress note template is in the
“rounding” navigator
Progress Notes
Open problem list
Add a problem
Add an assessment and plan
Progress Notes
• Problems added to the Problem List are
seen by all providers
• Assessment and plan added to each
problem are seen by all but ONLY appear
in the CCM SVC notes (ie, what a surgery
resident writes under the same problem
will NOT appear in your note)
Progress Notes
Progress Notes
Progress Notes
Attending of the week
Progress Notes
Progress Notes
Progress Note
Progress Notes
• If using another’s template or your own
Progress Notes
• Using copy forward
Copy Forward
Notes
• Using copy forward
Select note
Notes
• Using copy forward
Notes
• Be very careful about copy-forwarding
notes. Always review the entire note for
accuracy. (ie, a patient cannot be
“POD#2” for 5 days in a row)
Notes
• Be as specific as possible for the
assessment/ problem list
• Altered mental status versus ICU delirium
• COPD Exacerbation versus acute hypercarbic
respiratory failure from pneumonia on (and)
COPD
• UTI with hypotension versus septic shock
from (and) UTI
Notes
• Be specific as possible with the plan
• For instance, “wean vent as tolerated” vs.
“Patient continues to require a high
minute ventilation due to a likely large
dead space fraction from resolving ARDS.
He is not tolerating a rapid wean. Failed
SBT yesterday due to sustained
respiratory rate in the 40’s with
desaturation. Will try again today.”
Notes
• “Co-sign Required” should be checked
unless otherwise specified by your
attending
• Title of note should have:
• “Critical Care Medicine Progress Note”
• “Critical Care Medicine Admission Note”
Admission Notes
Admission Notes
Remember the tabs
Admission Notes
Admission Notes
H&P Note
Admission Notes
• You are allowed to use your own/others
H&P template via a dot-phrase.
• Don’t forget about co-signature and
title/header of note
• Chose the correct note type
Patient list
• The filemaker database is in the fellow’s
office. It should be updated daily. The
password is m917icu
• Post call resident will print out copies for
the team
• Do not leave in the ICU (patient
confidentiality)
• Make sure to enter morbidities and
mortalities
Admit Orders
Admit Orders
IP Adult Core Admission Orders
Orders
• Other order sets of interest:
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IP Adult Core Admission Orders
IP Adult ICU Addendum
IP Adult Sepsis
IP Adult Continuous Neuromuscular Blocking
Agent
• IP Adult Blood Product Transfusion
• IP Adult PCA
Orders
• The IP Adult ICU Addendum Order Set
needs to be completed by the ICU resident
for every patient admitted to 9/13 ICU. On
8/11 and 10, they only need to be
completed for patients the service is
following
• The IP Adult Core Admission Order Set
may also need to completed. Ask your
fellow.
Orders
• Use “Order Management” to modify/discontinue
existing orders and/or add new orders
Orders
• Mechanical Ventilation
• There is NO order set
• Search under “ventilation” or use IP Adult
ICU Addendum Order Set
ARDSNet Protocol
PSV/CPAP
Orders
• Mechanical Ventilation
• Don’t forget to write for oxygen titration
orders under admin instructions
• When changing between modes, don’t forget
to discontinue the old one
• SBT: search under “SBT”
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Note
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Notes
Procedure Notes
• Person who is primarily responsible for
the patient has first dibs on the procedure
• Person who performs the procedure is
responsible for the note
• “Cosign Required” MUST be checked
• “Cosigner” is your attending of the week
Moving away from APeX
Resident Responsibilities
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Code Blue Coverage (next slide)
Emergency calls in the ICU
Co-Managing patient with primary teams
With special emphasis on:
• Airway
• Central lines
• Mechanical ventilation
• Pain and sedative medications
Code Blue Coverage
• 10 ICC team will respond to codes during
weekdays (M-F 0800-1700); everyone
should go outside these times
• We are responsible for the airway - FIRST
• Please make sure that whatever you use
in the CODE bags are refilled immediately
Code Blue Coverage
• New medication syringes are available
from pharmacy (across from M919); bring
label of patient for which the prior drugs
were used
• Anesthesia workroom has other supplies
– it is located in the OR on the fourth floor
• Place ET tubes with subglottic suctioning,
if length of mechanical ventilation is
expected to be longer than 48 hours
Resident Responsibilities
• 8/11 ICU
• Residents not taking call should rotate
staying late to sign out to NP at 1900
• Residents need to take sign out from
overnight NP by 0700
• CA-3 resident should have greater
responsibility running team and teaching
Emergency Calls
• Calls regarding unstable patients often go
to the ICU team
• If situation is truly an emergency, deal
with the problem while the primary team is
being summoned
• If there is time, discuss with the team,
often the night float will be thankful for a
friendly word of advice
Communication
• Understanding the primary team’s plans
and goals often make it easier to
understand the course of action that is
planned
• Communication makes it easier for all
parties involved and improves patient
care
• If there is a disagreement about care,
consult your fellow or attending
A Word from the NPs
• We can be a resource for you. Ask and
we will try to help
• Be prepared for sign out by knowing the
ventilator and sedation plan for patients.
• If you can’t restock the code bag before
sign out, let us know. We will help you.
• The list (filemaker) is our life line. It needs
a thorough update before 6AM/6PM every
day.
Airway
• The airway pager (443-4990) will always be with
an anesthesiologist (attending, fellow or
resident)
• Airway backup available:
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OR E1 Anesthesia Attending: 3-1581 (Spectralink)
OR Front Desk: 3-1545
OB Anesthesia Resident: 443-9261
ED: 3-1238
• Do not start sedation/paralysis without
someone from anesthesia being present (CA-1
residents should also always get back-up)
Central Lines
• Except for a few services (CT surgery and
Cardiology) we are responsible for all line
placements
• At the request of the CT Surgery or Cardiology
Fellow/Attending, we will assist with line
placement
• All central lines placed above the diaphragm
must have an ICU attending or fellow at the
bedside
Ventilation
• We are responsible for ALL ventilator orders
and extubation (For those on 10ICC, please
clarify with your attending for each CT surgery
non-fast-track CABG patient)
• If the primary team wants something that is
unreasonable, please discuss it with the fellow
or attending
• DO NOT make changes directly on the ventilator
• Patients should be followed for at least 24 hours
after extubation
Sedation
• We write pain and sedation orders on all
patients we follow (For those on 10ICC, please
clarify with your attending for each CT surgery
non-fast-track CABG patient)
• Do what the primary team wants if it is
reasonable
• Management of pain in ICU patients with
epidural catheters is the responsibility of the
acute pain service, but we do keep a close eye
on this
Miscellaneous
• Radiology does not interpret any studies
overnight unless asked
• Small cards have everybody’s pager and home
phone number
• Please don’t hesitate if you identify problems
during your rotation to notify your attending
• Please fill out the evaluations. Your comments
are confidential and important for future rotation
development
Medical Students
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Stay late 1 night per week - their choice
They should read about their patients
Quality not quantity (2 patients max)
They are not expected to function as a resident
during this rotation
• There should be a resident identified as the
supervisor for each patient the students follows
• Residents should be writing their own note as well
Open and Closed ICU’s
• Most patients in M/L ICU’s are “semi-open” in
that the primary service still writes the majority
of the orders, but we co-manage with them.
• Orthopedics, Ortho-Spine, CRI, OMFS, postpartum OB, OHNS, Gynecology, Gyn-Oncology,
and Urology are “closed” – THE ICU SERVICE IS
THE PRIMARY SERVICE
• Make sure you know their contact #’s to keep them in
the loop
“Closed” patient issues
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Labs - CBC, electrolytes, glucose
Nutrition - NPO, tube feeding, TPN
Activity - bedrest, ad lib
IVF - rate, heplock
Transfusions – triggers, CMV negative,
irradiated
• Studies - radiology, echo, PT - need to make a
phone call
• Check patient frequently and communicate with
primary team often
Open and Closed ICU’s
• The data:
• Multiple studies show that the daily presence of an
intensivist improves outcomes, including mortality
and length of stay. There was no advantage to closed
units.
• Disadvantages of open units:
• Disagreement about management plans
• Loss of control
• Advantages of open units
• Ability to care for a variety of patients (med, surg, etc)
• Ability to focus on critical care issues
Wear your name tags
Calls to evaluate patient
• Go see the patient in the ER or on the floor
• Discuss ALL ICU admissions with fellow (or
attending)
• Any refused admission must be discussed with
attending or fellow
• Do not worry about beds, triage attending (4434443) will take care of that
• Triage covered by 10 ICU fellow