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 - 12:00pm:

Flow Of The Day 12:00 - 1:00pm: 1:00 - 4:30pm: 4:30 - 5:30pm: Noon Conference Follow-up consultations/procedures/post-op admissions/didactics Sign-out Rounds with night team

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

Other Teaching Conferences Tuesday 12-1 PICU Fellows Conference 2E PICU Conference Thursday PICU Conference: M&M, Journal Club, Fellows research Confirm edit--

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 Informational—not discussion

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 same

2 Teams in PICU Team A Team B Attending Fellow Second year pediatric resident Third year pediatric resident +/- NP ED resident Slightly different now due to night float system

Resident Role Receive sign out from overnight resident Pre-round on PICU patients Present patients at morning rounds beginning promptly at 8:30am 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 Seems obvious

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 Attend teaching conferences conducted by the ICU attendings / fellows Again seems obvious…

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 5th resident in the PICU May care for equal number of patients as pediatric residents Rounds one day on weekend 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”

TIPS for PICU Notes These are the official legal medical record They support level of care provided Therefore: Avoid colloquials or not universally understood abbreviations Use words to support ICU care— instead of dehydration—mild tachycardia but stable, CR monitor Try: dehydration with tachycardia, compensated shock in ICU for continuous hemodynamic monitoring

ICU Transfers Requirements Approval of the ICU Attending Transfer summary If going to a resident team, usually non-surgical and ICU stay >48h Transfer orders Surgical patients: surgeons often write orders Always clarify with surgeon if OK to transfer & WHO will write transfer order Sign patient out to ward resident

Rounding & Presenting Patients

Flow of Rounds 8:30 Typically BMT, Liver, Renal Transplant Followed by: Sick/high acuity Transfers Remainder Neurosurgeons round on their patients between 7:30-8:30 usually

Tips for Success on Rounds See CXR if available before rounds start…ETT high/low, new findings that can’t wait for rounds to start? Any special drains in place? JP, Chest tube, EVD…know how much output total & per shift Any pending studies completed from prior day? EEG, MRI, US, ECHO, cultures ….know the result

Patient identification Quick assessment: i.e. patient improving, worsening, or unchanged Major (not all) interval events Vitals: Tmax (time) , vital sign ranges, including CVP, ICP if applicable

Physical exam: present exam appropriate for patient’s disease Present meds within appropriate system : e.g. steroids for asthmatic in respiratory vs. steroids for liver transplant in GI May need to make a section for Transplant: Liver/Kidney/BMT

Completing patient presentation Be succinct; try not to present same data more than once One line overall assessment of patient condition Review orders Address patient dashboard Engage Bedside RN in rounds!!

Procedures PICU fellows are given priority for all procedures (particularly 1st year fellows) Prerequisite for CCM training Acute situations : fellow or attending

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/Defibrillator familiarity Code cart familiarity

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 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 To minimize line entry RNs like to have flexibility to time meds UNLESS You want drug given at a specific time Qday ordered at 8pm won’t happen until 8 am next day RNs may batch labs to minimize line entry *** 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 In 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

Admitting Trauma Patients ANY TRAUMA patient—admit as follows: LOCATION: 2E/PICU Ward Attending: select PICU Attdg Service: Select Trauma (even if head trauma) Sub-specialty attending: Select Trauma or Neurosurgery Attending If head trauma or NAT: Peds surgery/trauma must be notified to do tertiary survey Trauma H&P in Epic, co-write admit orders

Order Entry Reminders Extubation: Requires an extubation order Don’t just D/C vent order Other important orders are linked to extubation Blood product orders Still require a call slip Inform patient’s RN that products ordered ACE(airway clearance evaluation) vs CPT Allows some autonomy to RT to develop plan for best mode of therapy

Discharges Patient safety dashboard useful tool! Prescription paper available from USA Loads into one printer and special tray Select the PICU prescription printer for all D/C scripts Rx_picu_fntdsk

PICU Quality and Safety PICU Handoff Initiative for ALL OR Handoffs One Message, One Time Role cards utilized IPASS tool for handoff comes with 45 min call

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 ✔ ✔

Discharge Planning

Catheter Associated Bloodstream Infections

Ventilator Associated Pneumonia

Patient Safety

COWS Be sure to sign off Don’t leave patient information exposed Plug them back in (a dying cow is not pretty) !! No cow tipping !!!

PICU Etiquette Please speak in quiet voices, particularly around main nurses station We follow HUSH in the PICU

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. Courtenay Barlow at cbarlow@stanford.edu Pager: 23492