Olive View ICU Orientation

Welcome! ICU: located on 5B ICU: located on 5B 5B-North: 4 isolation + 8 non-isolation beds 5B-North: 4 isolation + 8 non-isolation beds 5B-South: 6 isolation beds 5B-South: 6 isolation beds OV Critical Care Core Faculty: OV Critical Care Core Faculty: Dr. Nikhil Barot Dr. Nikhil Barot Dr. Keren Fogelfeld Dr. Keren Fogelfeld Dr. Nader Kamangar Dr. Nader Kamangar Dr. Joanne Martires Dr. Joanne Martires Dr. Dennis Yick Dr. Dennis Yick Pulm/Crit Fellows Pulm/Crit Fellows UCLA UCLA

Structure & Schedule Daily Routine: Daily Routine: Weekdays: Weekdays: Fellow Lecture: 8:00-8:30AM (except Thursdays, which is orientation). Attendance is MANDATORY! Fellow Lecture: 8:00-8:30AM (except Thursdays, which is orientation). Attendance is MANDATORY! Attending Rounds: Start at 8:30AM. Attendance is MANDATORY! Attending Rounds: Start at 8:30AM. Attendance is MANDATORY! Radiology Rounds: 11:30AM-Noon Radiology Rounds: 11:30AM-Noon Weekends: Weekends: No Fellow Lecture No Fellow Lecture Rounds start at 8:30AM Rounds start at 8:30AM

Structure & Schedule 3 ICU teams (A, B, C) 3 ICU teams (A, B, C) 1 resident and 1-2 interns per team 1 resident and 1-2 interns per team 1 night admitting intern at all times, generally rotating every 4 nights 1 night admitting intern at all times, generally rotating every 4 nights Call Schedule Call Schedule ICU teams take Q3 Day Call ICU teams take Q3 Day Call Resident is on call for 24 hours starting at 8am Resident is on call for 24 hours starting at 8am Day Call Intern is on pager 8am-8pm Day Call Intern is on pager 8am-8pm Night Call Intern is on pager 8pm-8am Night Call Intern is on pager 8pm-8am

Duties on DAY CALL Admissions Admissions Day Call Team receives hand-off from prior Night Call Team about all overnight admissions and assumes primary responsibility for these patients Day Call Team receives hand-off from prior Night Call Team about all overnight admissions and assumes primary responsibility for these patients Day Call Team admits all patients called from 6:30a - 6:30p () Day Call Team admits all patients called from 6:30a - 6:30p (full assessment and management, H&P) Day Call Team holds over on all patients called after 6:30p ( ) for the Night Call team Day Call Team holds over on all patients called after 6:30p (get sign-out, assess patient, write any admission orders, do necessary procedures, document any critical information) for the Night Call team Rounds Rounds On-call intern WRITES ALL ORDERS under supervision of the on-call resident so the call team knows the patients On-call intern WRITES ALL ORDERS under supervision of the on-call resident so the call team knows the patients On-call resident PAYS ATTENTION during rounds to know the plan of care for all ICU patients On-call resident PAYS ATTENTION during rounds to know the plan of care for all ICU patients On-pager (8a - 8p) On-pager (8a - 8p) Respond to all CODE BLUE’s and RRT’s (rapid response team). ICU resident is the code leader. Respond to all CODE BLUE’s and RRT’s (rapid response team). ICU resident is the code leader. Day Call team cross-covers on patients after the primary ICU teams has sign out for the day. Day Call team cross-covers on patients after the primary ICU teams has sign out for the day.

Code Blue & Code RRT The ICU resident is the RRT/Code Blue Team leader The ICU resident is the RRT/Code Blue Team leader Overhead tone will sound 3 times for either RRT or code blue (single tone for all other codes.) Overhead tone will sound 3 times for either RRT or code blue (single tone for all other codes.) Notify fellow or attending asap if they are not in house Notify fellow or attending asap if they are not in house Event documentation outside of ICU can be done under critical care consult note and name it accordingly (RRT or code blue) Event documentation outside of ICU can be done under critical care consult note and name it accordingly (RRT or code blue)

Day Call Duties New Admissions New Admissions Every request for ICU admission will be logged on Admission Request form in 5BN (Red Clipboard) Every request for ICU admission will be logged on Admission Request form in 5BN (Red Clipboard) ED requests will be seen by team within 30 minutes ED requests will be seen by team within 30 minutes Resident will determine priority if there are multiple requests Resident will determine priority if there are multiple requests ED patients will remain under ED physician control until the patient physically arrives in ICU ED patients will remain under ED physician control until the patient physically arrives in ICU ICU team can make recommendations to ED if there are no ICU beds available ICU team can make recommendations to ED if there are no ICU beds available

Surgical Subspecialty Patients General Surgery and Surgical Specialty services can be primary for their own patients General Surgery and Surgical Specialty services can be primary for their own patients MICU team does not perform consult service; offer to take patient MICU team does not perform consult service; offer to take patient Often MICU team will become primary if the patient has multiple medical issues Often MICU team will become primary if the patient has multiple medical issues OB-GYN patients tend to fall under MICU as primary OB-GYN patients tend to fall under MICU as primary

Duties on NIGHT CALL Sign-Out Sign-Out Night Call Team arrives by 8p and receives sign-out from the Day Call team about all ICU patients, including all new admissions called to the ICU Night Call Team arrives by 8p and receives sign-out from the Day Call team about all ICU patients, including all new admissions called to the ICU On Pager (8p - 8a) On Pager (8p - 8a) Respond to all CODE BLUE’s and RRT’s (rapid response team). ICU resident is the code leader. Respond to all CODE BLUE’s and RRT’s (rapid response team). ICU resident is the code leader. Night Call Team cross-covers on all patients in the ICU and any patients on the Wards/SDU awaiting transfer from ICU to a Ward Team. Resident supervises intern. Night Call Team cross-covers on all patients in the ICU and any patients on the Wards/SDU awaiting transfer from ICU to a Ward Team. Resident supervises intern. Admissions Admissions Night Call Team admits all patients called from 6:30p - 6:30a () Night Call Team admits all patients called from 6:30p - 6:30a (full assessment and management, H&P) Night Call Team holds over on all patients called after 6:30a ( ) for the next Day Call team Night Call Team holds over on all patients called after 6:30a (get sign-out, assess patient, write any admission orders, do necessary procedures, document any critical information) for the next Day Call team Admissions are fully presented on rounds in the morning Admissions are fully presented on rounds in the morning

Duties when POST-NIGHT Documentation Documentation All notes (MRANs, H&Ps, progress notes) WRITTEN AND SIGNED BEFORE 8:00 AM. All notes (MRANs, H&Ps, progress notes) WRITTEN AND SIGNED BEFORE 8:00 AM. H&Ps should be written and signed as soon as possible after seeing the patient. H&Ps should be written and signed as soon as possible after seeing the patient. Rounds = Sign-out. Rounds = Sign-out. Most post-nights: Post-night Team presents new admissions and hands-off patients to the Day Call team. Most post-nights: Post-night Team presents new admissions and hands-off patients to the Day Call team. Last post-night: Post-Night Team presents new admissions and hands-off these patients to the Day Call team. Post-Night Team also rounds and writes notes on old patients on the team they are taking over. Last post-night: Post-Night Team presents new admissions and hands-off these patients to the Day Call team. Post-Night Team also rounds and writes notes on old patients on the team they are taking over.

Interns: Nights  Days At the beginning of your last night before switching to days, you will get sign-out on the patients you will be following. At the beginning of your last night before switching to days, you will get sign-out on the patients you will be following. This sign-out will be from the intern/resident switching to nights. This sign-out will be from the intern/resident switching to nights. The night intern switching from nights to days will be expected to also present the patients on the team they are taking over for The night intern switching from nights to days will be expected to also present the patients on the team they are taking over for Spend time getting to know these patients on your last night of nights Spend time getting to know these patients on your last night of nights

Sign Out Post night call team Post night call team Rounds are “sign out” Rounds are “sign out” Non call teams Non call teams Sign out to day call team as early as 2 pm on weekdays Sign out to day call team as early as 2 pm on weekdays Sign out to day call team as early as 12 pm on weekends Sign out to day call team as early as 12 pm on weekends

Expectations & Reminders Everyone must stay for the entire duration of rounds, with the exception of the post-night team. Everyone must stay for the entire duration of rounds, with the exception of the post-night team. Night resident-intern: present their patients and go home by 10am; or by noon on last post-night shift to round and present patients on the ICU team they are taking over Night resident-intern: present their patients and go home by 10am; or by noon on last post-night shift to round and present patients on the ICU team they are taking over Remaining teams: present their patients and stay for remainder of rounds Remaining teams: present their patients and stay for remainder of rounds This is important since everyone needs to know all the patients in the ICU. This is important since everyone needs to know all the patients in the ICU. On-Call teams please remember to pick up the Code Blue pager from the previous team on call On-Call teams please remember to pick up the Code Blue pager from the previous team on call

Workload Maximum capacity is 18 beds Maximum capacity is 18 beds Patient redistribution will be enforced if one team exceeds the others by 4 or more patients Patient redistribution will be enforced if one team exceeds the others by 4 or more patients For continuity purposes, newest admissions will be redistributed first For continuity purposes, newest admissions will be redistributed first

Orphans You are never alone You are never alone There is a Fellow on service 24/7 There is a Fellow on service 24/7 They are under utilized for day to day duties They are under utilized for day to day duties The Fellows cannot read your mind; they won’t bite if you ask for help… at least most of them won’t. The Fellows cannot read your mind; they won’t bite if you ask for help… at least most of them won’t.

Admissions to Admissions to ICU During business hours, notify the ICU Attending or Fellow of new admissions ASAP. During business hours, notify the ICU Attending or Fellow of new admissions ASAP. After hours, notify either the ICU Attending or Pulmonary/Critical Care Fellow on call about new patients WITHIN 4 HOURS. Notify about sicker patients or other issues sooner. After hours, notify either the ICU Attending or Pulmonary/Critical Care Fellow on call about new patients WITHIN 4 HOURS. Notify about sicker patients or other issues sooner. Do NOT block admissions. Only the ICU Attending is capable of down-grading level of care. Do NOT block admissions. Only the ICU Attending is capable of down-grading level of care. There is no such thing as an ICU consult. If a team asks advice about patient management, consider it a request for admission and accept the patient. There is no such thing as an ICU consult. If a team asks advice about patient management, consider it a request for admission and accept the patient.

Transfers from ICU ICU Team assumes all care while the patient is in the ICU, including writing all orders and progress notes ICU Team assumes all care while the patient is in the ICU, including writing all orders and progress notes Patient may be transferred to a Ward Team after the patient is physically in the medical ward or step-down unit. Patient may be transferred to a Ward Team after the patient is physically in the medical ward or step-down unit. ICU Team should page Medicine On-Call to notify of the transfer and get a ward team assignment. If a patient is transferred late in the day (after the Ward Team is capable of accepting the transfer), the ICU Team continues patient care until a Ward Team receives sign-out the next morning. ICU Team should page Medicine On-Call to notify of the transfer and get a ward team assignment. If a patient is transferred late in the day (after the Ward Team is capable of accepting the transfer), the ICU Team continues patient care until a Ward Team receives sign-out the next morning. Patients admitted directly to the ICU will be transferred to a new ward team. Patients transferred from a Ward Team will bounce back to the intern if the transfer is within 14 days and the intern is still on service Patients admitted directly to the ICU will be transferred to a new ward team. Patients transferred from a Ward Team will bounce back to the intern if the transfer is within 14 days and the intern is still on service ICU team writes the transfer ORDERS and TRANSFER SUMMARY on the day the patient is called out ICU team writes the transfer ORDERS and TRANSFER SUMMARY on the day the patient is called out Sign-outs should be resident-to-resident Sign-outs should be resident-to-resident

Transfers To/From Other Facilities County insured patients must be accepted if admitted to outside hospital County insured patients must be accepted if admitted to outside hospital Sending facility needs to give reasonable sign out and assessment of stability for transfer Sending facility needs to give reasonable sign out and assessment of stability for transfer Transfers to higher level of care: MAC transfers (Medical Alert Center) Transfers to higher level of care: MAC transfers (Medical Alert Center) Ex. neurosurgical emergencies: see posted Guidelines Ex. neurosurgical emergencies: see posted Guidelines Must coordinate via MAC Must coordinate via MAC

Documentation Interns: Interns: Full H&P Full H&P Residents: Residents: MRAN (medicine resident admission note) MRAN (medicine resident admission note) Forward all notes to attending for co-signature Forward all notes to attending for co-signature For patients with central lines (includes TLCs, HD lines, PICC lines, A-lines), complete required documentation For patients with central lines (includes TLCs, HD lines, PICC lines, A-lines), complete required documentation Required Provider Note information tab Required Provider Note information tab ICU Progress Note Required Details ICU Progress Note Required Details (THIS IS A JOINT COMMISSION REQUIREMENT) (THIS IS A JOINT COMMISSION REQUIREMENT)

ALL PROCEDURE NOTES ie thoracentesis, central line GO to “Provider View” on L sided tabs, “Admit/Clinic” tab on the top, hit the plus sign on “Required Provider Note Information”

Fill out the form appropriately and click on checkmark to complete Click on “Procedure Note Required Details”

Finally go to “Documentation” tab on the Left. Pick “Procedure Note” Type, Under Title type the name of the procedure that was done, and select the “Procedure Note” template (which will import the “Procedure Note Required Details” info into the note)

Finally, dot phrase the Procedure Note into the “Procedure Results” area. To create your dot phrases for common procedures, see the sharepoint drive and an attending.

Documentation The night intern is responsible for writing notes on all patients admitted before 6:30a. The night intern is responsible for writing notes on all patients admitted before 6:30a. Night intern has no responsibility to write notes for patients admitted after 6:30a, but may do so if he/she chooses. If the patient is admitted after 6:30a, the H&P should be written by the day admitting intern and the day resident is required to write an MRAN. Night intern has no responsibility to write notes for patients admitted after 6:30a, but may do so if he/she chooses. If the patient is admitted after 6:30a, the H&P should be written by the day admitting intern and the day resident is required to write an MRAN. Use ICU Progress Note type and template; do not use Critical Care Daily Progress Note Use ICU Progress Note type and template; do not use Critical Care Daily Progress Note

Procedures Only Residents signed-off on a procedure can supervise a procedure; the supervising Resident must be scrubbed into the procedure Only Residents signed-off on a procedure can supervise a procedure; the supervising Resident must be scrubbed into the procedure If an Intern is performing a procedure for the first time, have the senior-most Resident supervise the procedure If an Intern is performing a procedure for the first time, have the senior-most Resident supervise the procedure If you are having difficulty with a procedure, abandon it and call the Attending or Fellow for assistance If you are having difficulty with a procedure, abandon it and call the Attending or Fellow for assistance Intubations must always be supervised by the ICU Attending or on- call Anesthesia Attending Intubations must always be supervised by the ICU Attending or on- call Anesthesia Attending Dialysis catheter insertions must be supervised by ICU Attending or Fellow, regardless of the number performed in the past Dialysis catheter insertions must be supervised by ICU Attending or Fellow, regardless of the number performed in the past Procedure note is required for all procedures performed Procedure note is required for all procedures performed Procedure Note type and template Procedure Note type and template Required Provider Note Information  Procedure Note Required Details Required Provider Note Information  Procedure Note Required Details

Call Rooms ICU Resident Call Room Suite: 5D-101 ICU Resident Call Room Suite: 5D-101 Door code: Door code: ICU Intern Call Room: 5B-117 ICU Intern Call Room: 5B-117 Door code: Door code:

Food Cafeteria closes daily at 7:30pm Cafeteria closes daily at 7:30pm DON’T MISS DINNER!! DON’T MISS DINNER!! Closes earlier on holidays. Closes earlier on holidays. Meal Cards $ cap w/ set time frames Meal Cards $ cap w/ set time frames Breakfast: 6:15a to 10:59a  $6 Breakfast: 6:15a to 10:59a  $6 Lunch: 11:00a to 4:59p  $8 Lunch: 11:00a to 4:59p  $8 Dinner: 5:00p to 7:30p  $7 Dinner: 5:00p to 7:30p  $7

Systems EMR = Orchid EMR = Orchid Vitals, I/O’s Vitals, I/O’s Notes, labs, studies Notes, labs, studies Clinical Workstation – previous EMR Clinical Workstation – previous EMR Historical documentation, Labs, Radiology reports, cardiology reports, etc PACS = Synapse PACS = Synapse If report not up, call radiology for stat read If report not up, call radiology for stat read Amion.com: schedules Amion.com: schedules Password (case-sensitive): “ov im” Password (case-sensitive): “ov im”

Phone Extensions North ICU: x4414 North ICU: x4414 South ICU: x4409 South ICU: x4409 Extensions beginning w/ 3 or 4, the prefix is XXXX Extensions beginning w/ 3 or 4, the prefix is XXXX Only extensions beginning w/ 3 or 4 can be accessed from outside line  if you are outside the hospital, you can only call extensions starting w/ 3 or 4 directly without going through the operator. Only extensions beginning w/ 3 or 4 can be accessed from outside line  if you are outside the hospital, you can only call extensions starting w/ 3 or 4 directly without going through the operator. Operator: Operator: In-house: dial “0” In-house: dial “0” Dialing out: local # only Dialing out: local # only Dial 9-1-area code-number Dial 9-1-area code-number

In Case of Emergencies If ill or in case of emergency, page the Chief Resident on-pager listed on Amion.com: If ill or in case of emergency, page the Chief Resident on-pager listed on Amion.com: Duminda Suraweera Duminda Suraweera Guilianne Morden Guilianne Morden Tony Hung Tony Hung Erica Tate Erica Tate Chief’s Office: 6C-102, x4411 Chief’s Office: 6C-102, x4411