Welcome & Orientation UCSF Moffitt & Long Hospitals Intensive Care Unit Welcome & Orientation UCSF Moffitt & Long Hospitals

Rotation 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 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 Learning Goals Have a fun and educational month

Background Open and closed critical care units Diverse patient population Multi-disciplinary teams MD, NP, PharmD Intensivists from different backgrounds Anesthesia, Pulmonary, Nephrology, Surgery, Emergency Medicine, Neurology

Organization 8 ICU 11 ICU 10 ICU 9 ICU 13 ICU Neurological Cardiovascular 10 ICU Medical-Surgical 9 ICU 13 ICU

WEEKDAY NIGHT/WKND 8 ICU 11 ICU 9 ICU 10 ICU 13 ICU FELLOWS NP MD/NP (8/11)* 11 ICU Interns & Residents 9 ICU 2 NPs & 2-3 MDs NP/MD 10 ICU 2-3 MDs & NP 13 ICU 4-5 MDs MD FELLOWS 4-5 Fellows 1 Fellow Team organization DAY to NIGHT

Open and Closed ICU’s The data: Disadvantages: Difference in perspective on priorities “Loss of control” Advantages: Variety of Patients: Medical, Surgical, Neuro, CV Ability to concentrate on critical care issues Training: attendings/fellows from multiple specialties 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

UCSF ICU’s UCSF ICU’s are “semi-open” ICU is the PRIMARY SERVICE for: Primary service still writes the majority of the orders, but we co-manage with them We write all orders for: Ventilator, Sedation/Pain & Place invasive lines ICU is the PRIMARY SERVICE for: Malgnant Hematology (CRI), Orthopedic Surgery, Oral Surgery (OMFS), Head & Neck Surgery (OHNS/ENT), Gynecology, Gyn-Onc Surgery, Post-partum Obstetrics, Urology, and Plastic Surgery

“Closed” patient issues 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

HOUSEKEEPING

Housekeeping - daily routine 8:00am daily lectures * M-919 Check schedule for topic and speaker (it may be you!!!) * Wednesdays there are no longer mandatory 8:00am lectures for anesthesia residents (12:00noon conference will replace 8:00am conference) 9:00am daily team rounds 0800 on weekends* 17:00pm afternoon rounds with fellow(s) DO NOT LEAVE before checking in with the fellow or attending

Weekends/Holidays Only on-call and post-call residents round If you are neither, you have the day off Try to pre-round on the sick 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 - call schedule Call is approximately once every 3-4 nights, averaged over the entire rotation Post-call resident leaves before 11:00am Please do not violate your duty hours Schedule changes are not allowed unless approved by Dr. Shimabukuro (an extremely complex schedule)

11 ICU Signout & Call 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 If you are the resident on call for 11 ICU you will also cover 8 ICU (overnight/weekends) Your call room is also the “9 ICU call room”

Call Room: 13 ICU M1318 Outside of ICU Hallway between Moffitt & Long Swipe in with UCSF badge Door labeled “ICU Resident” Shared bathroom with surgery resident Do NOT leave valuables in call rooms

Call Rooms: 9 ICU Inside of 9 ICU “Proximal” room No code/outside lock “Distal” room is fellow call room No code/outside lock Shared bathroom with ICU fellow Do NOT leave valuables in call rooms

Medical Students 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

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 and ICU experience

RESIDENT RESPONSIBILITIES

Critical Care Rotation Responsibilities Critical Care Rotation Unit Specific Direct Patient Care Attend Daily Lectures Respond to Code Blues 10ICU Others: nights/weekends Help your team Manage unit code bag Respond to Code Sepsis & Code Blues H&P, Daily rounds, Progress Notes Ventilator and Pain & Sedation Management Placement of invasive lines

Central Lines We are responsible for all line placements Except for a few services (CT surgery and Cardiology) At the request of the CT Surgery or Cardiology Fellow/Attending, we will assist with line placement All central lines must have an ICU attending or fellow at the bedside during placement For all residents regardless of training background or level

Intubations “Airway Provider” should be available for all ICU intubations The airway pager (443-4990) will always be with an anesthesiologist (attending, fellow or resident) Do not start sedation/paralysis without someone from anesthesia being present (CA-1 residents should also always get back-up) Airway backup available: OR E1 Anesthesia Attending: 3-1581 (Spectralink) OR Front Desk: 3-1545 OB Anesthesia Resident: 443-9261 ED: 3-1238

Ventilation We are responsible for ALL ventilator orders, intubations and extubations (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

Sedation We write pain and sedation orders on all patients (For those on 10ICC, please clarify with your attending for each CT surgery non-fast-track CABG patient) 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* Work with the primary team when appropriate to determine the best sedation plan

Code Blue Coverage 10 ICC team will respond to codes during weekdays (M-F 0800-1700) Everyone will respond to codes from 1700p-0800a weekdays & all day/night weekends and holidays We are responsible for the airway - FIRST Please make sure that whatever you use in the CODE bags are refilled immediately

Code Bags Available per ICU Use at all codes, intubations, sedations Make sure this bag is stocked and locked daily Pharmacy Refill outside 13ICU Other: ICU OR O.R. Please emphasize that we must know where this bag is at all times. Check everyday that it is present and locked with pharmacy lock.

Code Sepsis Initiated by the ICU bedside nurse when sepsis screening tool is positive and there is evidence of end-organ dysfunction Nurses are allowed to send lactates when severe sepsis or septic shock is suspected Immediately go to patient’s beside and start severe sepsis/septic shock resuscitation bundle; help the nurses, if needed

Code Sepsis: Resuscitation Bundle Lactate (whole blood and NOT serum) Blood cultures (Time to positivity) prior to broadspectrum antibiotics (BSA) Start of BSA within 1 hour from time of Code Sepsis 20-30 mL/kg or 1000 mL of crystalloid for hypotension or lactate > 4 mmol/L

Code Sepsis: BSA

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 (use the signout tool in APeX) If there is a disagreement about care, consult your fellow or attending

APEX & Patient Database PAPERWORK

Paperwork List to be described on following slides New Resident/NP Office Database List Patient list General APeX comments Notes Admit Orders Central Line Procedure Note Procedure Note

CCM Resident/NP Office Door code: 6917#

Patient list Database List Can be accessed via Chrome on any MC computer, but PLEASE print only in Resident/NP Office across from M919 This is a HIPAA violation if left in random printers Post call resident will print out copies for the team Keep track of this list Do not leave it anywhere, throw away daily Please keep this list up to date! We all depend on this list for communication

Database List http://anesthesia.ucsf.edu/iculist Sign-on with SFxxxxxx SOM\, UCSFMC\, etc Make sure you log-out

Click here to search/change APeX Context: CRITICAL CARE MEDICINE SVC Click here to search/change

New Notes Select “Notes” Tab on Left Column This works for progress notes and H&Ps You are allowed to use your own/others H&P template via a dot-phrase. Don’t forget about title/header of note and co-signature (at discretion of attending) Chose the correct note type Select “Notes” Tab on Left Column From top heading bar- select either: “New Note” (dot phrase) OR Create in Notewriter

Notewriter Notes This will get imported into the note.

Progress Notes Using copy forward Copy Forward 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 Progress Notes: Procedure Notes: Title of note should have: “Co-sign Required” is at the discretion of your attending Procedure Notes: “Co-sign Required” is REQUIRED, and is always your attending of the week Title of note should have: “Critical Care Medicine Progress Note” “Critical Care Medicine Admission Note”

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.”

Procedure Notes Resident who rounds/admits the patient has “first dibs” on procedure Provider who performs procedure is responsible for procedure note Procedure notes are added under a different template than progress notes “Cosign Required” MUST be checked & “” is your attending of the week

Orders The IP Adult ICU Addendum Order Set needs to be completed by the ICU resident for every patient admitted to 8/9/11/13 ICU. On 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 Other order sets of interest: 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 IP ICU Withdrawal of Care

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”

APeX Flowsheets Useful flowsheets to “wrench” in 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 Other useful flowsheets to “wrench” in Hematology (Blood products administered) Fever OR ID/Sepsis Insulin/Glucose Labs since admission Radiology Microbiology Critical Care SO/RND

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 is our life line. It needs a thorough update before 6AM/6PM every day.

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

Questions?