WELCOME TO THE PICU

Flow Of The Day Pre-round Morning Report/ PICU Fellow Lecture (Mo/Th) Rounds (Except Fridays 9 am) Radiology Rounds Finish Rounds Work time/Didactics/First post-op admit Before 8am: 8:00 - 8:30am: 8:30 - 9:00am: 9:00 - 9:30am: 9:30 - 11:00 am: 11:00 - 12:00am:

Flow Of The Day 12:00 - 1:00pm: 1:00 – 4:00pm: 4:00 - 5:30pm: Noon Conference Follow-up Consultations Procedures Post op admissions didactics Sign-out Rounds with night team

Day Shift Responsibilities Day-time Admissions: Should go to the team NOT on call that night, e.g. B-resident on call, A-team admits Teams will be adjusted by fellow or attending to maintain equity in patient numbers and acuity between teams Be flexible When resident in clinic: All remaining team members, including residents from other team must help cover patients, e.g team B resident in clinic, team A will help NP cover

Patient Load Residents expected to carry 5-7 patients each Admissions above this number or chronic ICU patients will be covered by NPs

Pre-rounding Weekday pre-rounding: Weekend pre-rounding: Residents expected to pre-round on all of their patient Weekend pre-rounding: 3 pre-rounding individuals: post-call NF resident, Daytime resident, NP or ED Resident If high patient acuity, fellows can present patients or “discovery rounds” with attending if in-adequate time to pre-round

Night Shift Responsibilities Every other night for 2 weeks Goal: Admit to your assigned team, but may be redistributed Present new admissions on rounds; can shift between teams if required Expectation is that you stay through rounds, leave around noon No continuity clinic before your night shifts Signout at 4pm

Resident Teaching Conferences PICU resident lectures: Monday / Thursday: 8 – 8:30am In place of morning report At front desk in PICU

Other Teaching Conferences DAY TIME CONFERENCE LOCATION Tuesday 7-8 am CVICU Conference 2E PICU Conference room 12-1 PICU Fellows Conference 2E PICU Conference Thursday PICU Conference: M&M, and others 1-2 PICU Weekly Sign Out Welcome to join any and all!

Educational Resources PICU resident handbook with relevant PICU topics is available at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html Hard copy is available in the resident call room.

PICU chapters at http://peds. stanford 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 Cardiomyopathy Liver Failure Acute Renal Falilure Fluids, Electrolytes, Nutrition Oncology Transfusions DKA Submersion Injuries Brain Death End of life issues

PICU Tables at http://peds. stanford Sedation Inotropes Shock

Team Composition

Resident Role Receive sign out from overnight resident Pre-round on PICU patients Present patients at morning rounds beginning promptly at 8:30am DEVELOP A PLAN & PRESENT IT (Your opportunity to be a doctor!!) 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 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/fellow Attend teaching conferences conducted by the ICU attendings / fellows

PICU NPs Julie Reed Kiersten Wells Acute care NP coursework UCSF Doctorate of Nursing Practice USF, in progress PICU RN several years Kiersten Wells Member of LPCH SCAN team (Suspected Child Abuse & Neglect) Special focus in Adolescent Several years as cardiology PNP LPCH

PICU NPs Integral member of team Work directly with Attending/fellow Provide ongoing continuity in PICU from week to week Hours available in PICU: Mon-Sat: 7:30am - 5:00pm; Some weekend flexibility Enhance PICU flow Between subspecialists and PICU team Between bedside RNs and PICU team—participate in daily discussion about patient dashboard

PICU NPs Assist with admissions as needed throughout day for either team Participate in pre-rounding on weekdays/weekend Receive sign-out to assist with patient care From post-call fellow From pm clinic residents May perform procedures: based on unit need & as deemed appropriate by Attending/Fellow (i.e. new admit, the pt’s resident is post-call, etc.) Questions regarding PICU NPs? Contact Deb Franzon, Pager 23108, dfranzon@stanford.edu

PICU NPs PICU NP: admits patients, based on fellow/attending decisions, typically to A team, but when resident in clinic may admit patients to B team as well Weekends: Equal distribution of all patients between residents and NP

Other Trainees in PICU Anesthesia fellows Emergency medicine residents Medical Students

Anesthesia Fellows Present for half the blocks Primarily provide support for fellow level activities in the ICU Will not primarily follow patients

ED Residents Will act as a day resident in the PICU on the B team May care for equal number of patients as pediatric residents Rounds one day on weekend (Sunday) Excused for Wednesday AM ED conferences: must pre-round & 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 Resident needs to write progress note

PICU Evaluations for Pediatric Residents Group faculty evaluation completed on Med-Hub Verbal feedback from attendings while on the rotation – Be sure to illicit feedback if not provided

Notes The following need a full H&P: Trauma (even if went to OR first) Transport ED admits Direct admit from outside The following need an accept note: Post-op surgical Transfer from floor/ rapid response

Notes Each patient needs PICU daily progress note (unless admitted in early am) Significant events: codes/procedure/intervention Require a note: confer with fellow who may do this note Templates exist for most procedures Interim summary weekly on Thursday for any patient with LOS > 5d in PICU

Notes Online PICU specific templates Systems-based note Indicate attending on your team and select “sign” not “review” Official legal documents, so use medical terms Justify level of ICU stay

Transfers out of ICU Approval of the ICU Attending Transfer summary For non-surgical patients with >48hr ICU stay Transfer orders Surgical patients: surgeons often write orders Confirm transfer with surgical team and who will write transfer orders Sign patient out to ward resident

Rounding & Presenting Patients

Patient Presentation Ask attending re presentation preference: data first then plan, or data and plan by system On line PICU Progress Note available Can be cumbersome, difficult to navigate during rounds If presenting from COW – assure all information available – e.g. lab results, radiology studies, etc.

Tips for Success on Rounds Review films and know results Know results of studies completed over-night Be succinct during presentations Pertinent positives and negatives only DEVELOP A PLAN & PRESENT IT (Your opportunity to be a doctor!!)

Patient identification Quick assessment: i.e. patient improving, worsening, or unchanged Major (not all) interval events Vitals: Tmax (time), HR SBP/DBP(MAP), RR, sats, CVP (vital sign ranges)

Physical exam: present exam appropriate for patient’s disease Present meds within appropriate system as present: e.g. steroids for asthmatic in respiratory vs. steroids for liver transplant in GI May need to make specific sections for certain patients: e.g. Transplant, endocrine, orthopedics, etc.

Data & Plan to consider in each system Respiratory: Data:CXR findings, mode of support - NC vs BiPAP vs ventilator, amount of support 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

Data & Plan to consider in each system FEN/GI: Data: I/O’s, nutritional source, calories per day, Labs, LFTs 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

Data & Plan to consider in each system 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

Completing patient presentation One line overall assessment of patient condition List major plans for the day at the end Review orders Address Bedside RN concerns Address patient dashboard

PICU Quality and Safety PICU Patient Safety Dashboard Real time clinical decision support Enhance patient safety and care coordination Multidisciplinary- pulls from documentation in EMR Bottom tab for each patient Review at conclusion of rounds for EACH patient

✔ ✔ PICU Dashboard Tab Ensure Best Practices for ✔CABSI Prevention ✔Pressure Ulcer Prevention ✔VAP Prevention ✔ ✔

Procedures PICU fellows are given priority for all procedures (particularly 1st year fellows) Prerequisite for CCM training Acute situations : fellow or attending NPs: at discretion of attending or for their own patients

Procedures Procedures residents should acquire some degree of comfort with while in the PICU Bag-mask ventilation Operating an anesthesia bag Placement of peripheral IVs Chest compression Familiarity with defibrillator

Bedside Nurses 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 & to minimize line entry Only enter drug time if needs to be given at a specific time Do not time labs *** except for immunosupression drugs *** e.g. Prograf, CSA

Order Entry Qam labs in PICU are drawn at 4 or 5 am Most routine labs and CXR require daily orders: CBC Coags Chemistries CXR Qam labs in PICU are drawn at 4 or 5 am TIP: Use PICU Daily Orderset during rounds!!

PICU specific Power - Plans On Cerner PICU folder found under Power-plan folders

PICU specific Power - Plans On Cerner Specific Power-plans available in PICU folder include: Fever work-up Trauma admit PICU Daily orders Respiratory failure DKA Hyperkalemia

Final Thoughts 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 skache@stanford.edu 723-5495 Pager: 13483