Orientation for (visiting) PICU Fellows at UCSF BCH Mission Bay November, 2018

Introduction to the PICU at Mission Bay Service Basics Schedules, Team Structure, Rounds, Signout Times Rapid Response Policies and Documentation Procedures Supervision and Documentation Transport Calls PICU M&M Conference CICU specific

Service basics

Service Basics Day fellow week is Monday – Friday Night fellow: Starts week on Sunday and ends Saturday morning After sign-out, log into the voalte phone (use your epic login credentials)

Service Basics- Team Structure There are two teams during the weekday, each with a different attending, same fellow: NP Team: attending, PICU day fellow, NP Resident team: attending, PICU day fellow, and ~4 residents (pediatric and emergency medicine) There is one team at night: Attending, PICU night fellow, resident, NP

Service Basics- Day Rounds 7:45 AM NP rounds 8:30 AM Resident team rounds It’s expected that you join both teams for rounds every day unless you are engaged in active patient care issues NP rounds generally finish by 8:30AM. If NP rounds are running late, join the resident team rounds at 8:30 On Wednesdays, resident team rounds start at 9 AM and you skip NP team rounds.

Service Basics- Taking advantage of the NP attending Urgent situations during resident rounds (rapid response team calls, transport calls, need for procedures, etc): staff with the NP attending

Service Basics- Night Rounds Rounds typically occur at midnight, led by the fellow. Charge nurse, bedside nurse, resident, and NP will join, attending will NOT. Goals of rounds: Discuss active medical issues Review the patient MAR (make sure medications are all appropriate) Review lab frequency Review (infectious) labs that are pending Identify patients who require a spontaneous breathing trial (SBT) Identify patients that can be ready for transfer out in the morning.

Service Basics: SBT Spontaneous Breathing Trials (SBT) Every intubated patient should be assessed on a daily basis to determine extubation readiness Creating a SBT plan is an important part of midnight rounds Ie does the fellow need to be present, do feeds need to be held, does sedation need to be adjusted, etc

Service Basics: Signout Most days, Day Fellow comes at 7 AM, Night Fellow comes at 5:30 PM Exception = Wednesday Day fellow should come in early and finish receiving signout before 7 AM so that everyone can get to the 7 AM conference on time Night fellows are expected to return at 7 PM on Wednesdays (10 hours off after the 7-9 AM conference ends). PICU Rounds should start immediately after conference ends (9:00AM)

Service Basics: Signout Saturday covered by off-service fellow (28 hr shift) Sunday covered by on-service night time fellow for the following week Saturday fellow receives signout at 8AM from Friday night fellow Sunday night fellow receives signout at 11 AM from Saturday fellow. The Saturday fellow must leave by 12 PM.

Rapid Response Team (RRT): Policies and documentation

RRT Rapid Response Team (RRT) calls originate most frequently from the hospital floors or radiology The PICU fellow is in charge of the RRT process RRT calls come through your voalte phone from the Access Center PICU Charge RN, RT, and PICU fellow are part of the Rapid Response Team When an RRT is called, you have 20 minutes to go and assess the patient but should go as soon as you can. Once you assess the patient, make sure to discuss the case and plan with your attending You can escalate an RRT to a Code White at any time

RRT vs Code RRT*: PICU Fellow, PICU Charge RN, RN Supervisor, RT CODE TEAM:  RRT PLUS CICU Charge RN, ICU Attending, Pharmacy, On-call Anesthesia Attending, Chaplain, Security Code white – pediatric Code blue – adult ONLY the PICU team responds to code white calls outside of the ICU’s   *RRT in CTCU – same team members but CICU team.

RRT Sometimes residents or other providers may come to the PICU to ask for management advice for floor patients You can give general advice; however, if you leave the PICU to go see the patient on the floor, you must call an RRT (primary team can call or you can call yourself) When in doubt and/or a patient sounds sick, call an RRT

RRT For every RRT you are called to, you are responsible for: The RRT Flowsheet The RRT Note These are essential for charting and tracking

RRT Flowsheet In the left hand of the patient’s chart, there should be a tab that says Rounding If you don’t have this tab, you can add it by going to “more” in the bottom left hand corner, and then selecting the star next to it

RRT Flowsheet Clicking on the Rounding tab will open up a new panel From here, select RRT Flowsheet

RRT Flowsheet This opens the flowsheet Click through each section (should be super quick) At the end hit close

RRT Documentation That’s it for the Flowsheet For the RRT Note…

RRT Note Next, in that same rounding tab, click on RRT Note That should trigger a pop-up Hit Enter to select the first suggestion, “PEDIATRIC PICU RAPID RESPONSE TEAM IP”

RRT Note This automatically opens a pre-templated note It should already have their one liner, so you complete: RRT Documentation Notable Physical Exam Findings Assessment Recommendations

RRT Note Concisely describe the situation you found on arrival, your exam findings and a very brief assessment and plan

Procedures in the picu

Procedures in the PICU In general, the PICU fellows should do all procedures (central lines, intubations, arterial lines, peripheral IVs, etc) If you are busy and feel very comfortable with a procedure, you can offer the procedure to an NP or resident after talking to your attending Please let your attending/program director know if other providers are “taking away” procedures from you- this should not be happening

Peripheral IVs in the PICU It is important to become comfortable with placing peripheral IVs in children When an IV is needed, PICU nursing has been asked to contact the PICU fellow first (instead of the vascular access team) in order to give fellows opportunities to develop this skill set Please make every effort to take advantage of this opportunity!

Procedural Supervision Discuss the level of supervision needed for the procedure with your attending prior to initiating the procedure Review what medications will be used for sedation/analgesia with your attending Remember to use the sedation navigator for procedural sedation This is under the procedure tab in the left hand toolbar in the patient’s chart

Procedure Notes It is important to use the NoteWriter template for procedure notes because The template asks you to document a lot of important information (that you may forget to free text in otherwise) Procedures can be tracked by Apex! We hope that in the next few months/year, you can rely on Epic for procedure documentation rather than medhub

Procedure Notes 3 2 Click on Notes In the Notes tab, click on Procedures Click on Create in NoteWriter 1

Procedure Notes Select IP Bedside Procedure Note

Procedure Notes Click on the appropriate procedure and click through the flowsheet questions. Please remember to free text important information in the comments section (especially for intubations – easy mask? Was an oral airway used ? Intubation medications used?, etc) Don’t forget to log in procedures in MedHub as well!

Transport calls

Transport Calls The Access center (x31611) will call your voalte with a transfer request. Grab the Transport sheet (located behind PICU charge nurse desk) Typically, the access center will give you age, chief complaint, and MRN (if known UCSF patient) before speaking with the referring provider It’s helpful to go through the transport sheet systematically (get HPI, vitals, labs, etc). Try to be complete but concise

Transport Calls- Bridging in Others When taking a transport call for the first time, it’s helpful to either find your attending to take the call with you in person or ask the access center to bridge in your attending so they can listen along with you Do NOT delay in formally accepting a sick patient (so that the transport process can proceed).  Discussions such as further history, advice from consultants, etc can occur in parallel.  Whenever in doubt, ask your attending.

Transport Calls- Bridging in Others There are circumstances when it’s required or helpful to have subspecialists bridged into the transport call Code Stroke: If a code stroke is activated, the pediatric neurovascular team needs to be on the initial call. The access center workflow is to bridge in the neurology team, and then others (eg Neuroradiology, Interventional Radiology, etc) as directed by ICU and Neurology.”” Subspecialty patients: if patients are being transferred for subspeciality care (ie peds neurosurgical management, 2nd opinion for seizure disorder, etc)- it’s helpful to have the subspecialist in on the initial call If you would like to have a subspecialist bridged in on the transport call, just ask the Access Center to page the appropriate team

PICU M&M

PICU M&M Please remember to keep track of your RRTs, morbidities, and mortalities while on service The M&M fellow will email you at the beginning of the month asking for cases. It is your responsibility to email the M&M fellow back with cases The M&M fellow will help you create your M&M presentation (especially in the beginning of your first year)

Conference

Conference We have weekly didactic conference every Wednesday from 7-11 AM. On service fellows (BCH San Francisco and Oakland) attend conference from 7-9 AM. Board Review and Bedside teaching (9-11AM) occurs for off service fellows

CICU specific

CICU specific Weekend call: Transport: Saturday/Sunday day is covered by an off-service fellow (two 10 hr shifts), as is Saturday night (15 hr shift) Sunday night is covered by the on-service night time fellow for the week starting at 5 PM Saturday AM: Weekend fellow receives signout at 7:30 AM by Friday night fellow Night fellow presents on sickest patients and leaves by 9 AM. Night fellow should gather numbers for weekend day fellow so they can present patients after 9 AM Transport: It’s often very helpful to have the cardiology fellow bridged in on transport calls, especially in patients well known to the heart center Some calls may come in through cardiology, but for any patient that comes to the CICU the ICU fellow should take over as MCP