1. NCCS Orientation
February 27, 2013 1

2. Structure
Co-management of all neurosurgical and some Neurology ICU patients
Neurosurgical patients
Primary management of non-surgical issues (airway, pressors, sedation, etc.)
Collaborative management of neuro problems, with Neurosurgery leading 2

3. Teams Two teams, NCCS-1 and NCCS-2 Admit every other day
Mix of Trauma and Vascular Neurosurgery, and Neurology
NCCS-1: Linked to Neurology-S
NCCS-2: Linked to Neurology-C
One resident covers both teams at night
Detailed signout important!

4. Neurosurgery Patient Orders
Orders must be written or co-signed by NCCS, with the following exceptions:
Emergency orders
Spine clearance, drain management, and imaging studies
NOTE: Neurosurgery should write ALL orders regarding ventriculostomy (EVD) management 4

5. Neurosurgery Orders
There is an order set for general ICU issues, and specific order sets for:
Vascular neurosurgical patients
Trauma neurosurgical patients 5

6. Neurology Patients NCCS assignment (“first call”):
NCCS manages patients and writes all orders, with the exception of admission orders
Neurology directs management of anticoagulation, antiplatelet therapy, imaging and other aspects of neurology workup
Collaborative relationship in all aspects of care, including family/patient conferences

7. Neurology Patients Neurology assignment:
NCCS follows patients and provides recommendations on medical/ICU issues
If patient becomes critically ill (see “NCCS assignment criteria”), NCCS will take over primary management
If there is any debate/dispute about who should be managing the patient, call the attending or fellow

8. Neurology Order sets General order set Stroke order sets Ischemic
Intraparenchymal hemorrhage

9. In-house Resident Calls Fellow/R4 For:
All new admissions that are not considered to be routine post-op or overnight observation (especially Neurology)
Reintubations
New hypoxia, hypercarbia, or hypotension
New neurologic changes that necessitated testing (CT, MR) or intervention (angio +/- plasty)
Prior to starting vasopressors for any reason or the changing or addition of another pressor
Any other major clinical change for which a conversation with the fellow or R4 would be beneficial for the patient and educational for the resident.

10. Fellow/R4 Calls Attending For:
All Neurology patients admitted to NCCS
Any time you have to come back into the hospital
Any other major clinical change for which a conversation with the attending would be beneficial for the patient and educational for the fellow/resident.

11. Admissions/Orders
You will be called to write admission orders on Neurosurgery patients
From ED
From wards
From OR
Orders must be done prospectively (write orders before patient comes to ICU)
For OR, you will be called by Anesthesia provider minutes prior to finish of case
Either come to OR and write orders, or write them and give to NCCS charge RN 11

12. Admissions/Orders
Neurology resident will write admission orders on patients and notify you of the admission
You should review the patient and service-specific orders with the neurosurgery or neurology resident
If this is not immediately possible, write the basic ICU admission orders and follow up later with service-specific orders 12

13. Admissions/Orders
If you are too busy to write admission orders within 30 minutes of being called:
You may request that the ED attending or resident write “ICU Holding Orders”
The patient will then be moved to the ICU where you can see them and write full orders within 60 minutes of their arrival
If you remain too busy to see the patient within this time interval, please request help from your fellow or attending
Failure to write orders in a timely fashion will result in delays in transport of patients out of OR and ED, and more importantly delays in patient care 13

14. Communication NCCSNeurosurgery
Should flow in both directions
If NS is not communicating plans or interventions with the NCCS team, please notify your fellow and attending
Please communicate any major changes in therapy or status to the neurosurgery resident on call
Emergencies should be reported within minutes of assessment, with discussion of proposed plan
Family conferences should generally be attended by members from both teams 14

15. Communication NCCSNeurology
Formal communication during morning rounds and afternoon checkout rounds
Spot communication during the day as needed
Please communicate any major changes in therapy or status to the neurology resident on call
Emergencies should be reported within minutes of assessment, with discussion of proposed plan
Family conferences should generally be attended by members from both teams 15

16. Notes Notes are entered using ORCA
All Neurosurgery patients and all Neurology patients that NCCS is managing need an admission note
All patients need a daily progress note
All Neurosurgery patients and all Neurology patients that NCCS is managing
Neurology patients that we are consulting on also need a progress note
Strictly PROBLEM BASED 16

17. Note Writing Notes are a means of communication
To other health care professionals
To billers/coders
To lawyers
Each note should be a free-standing summary of the patient’s course and how they are currently doing 17

18. Format for Notes
Use the Admission or ICU Inpatient templates for all admission notes and daily progress notes.
Include the ID/CC on all admission and daily progress notes and update the chief complaint based on the most active issue for that patient.
Include the Past, Social and Family History and Review of Systems on all admission notes. 18

19. Format for Notes
Include a Review of Systems on all daily progress notes.
If an ROS cannot be obtained, check the box indicating that the information cannot be obtained and state a reason why that is so (eg. the patient is intubated or the patient has altered mental status).
On daily progress notes, the review of systems should include 2-4 systems.
It is acceptable to write: “Beside from that noted in the interval events section, the remainder of the review of systems is negative.”
Provide a full description of the previous day’s events/major results under the section Interval Events. 19

20. Format for Notes
Begin your Assessment and Plan with a concise global assessment of why the patient is in the ICU, how they are doing and major issues for that day
The Assessment / Plan should be organized by problems rather than by systems.
Provide specific diagnoses for the patient’s problems (eg. Acute respiratory failure, sepsis, acute renal insufficiency). 20

21. Example of a Sub-optimal Assessment and Plan
Neuro: Continue mannitol, hyperventilation, sedation
Pulm: Continue mechanical ventilation
CV: Stable
ID: No issues
Heme: sq heparin
Fluids: continue tube feeding 21

22. Example of an Informative Assessment and Plan
Subdural hematoma, intracranial hypertension, coma: ICP remains labile; continue mannitol, airway protection, enteral nutrition
Acute respiratory failure: Pulmonary status improving but work of breathing remains high due to volume overload. Continue diuresis, full ventilatory support 22

23. DO NOT….
Copy and paste information (physical exam, assessment and plan, etc) from day to day without reviewing carefully and modifying accordingly
It is embarrassing, a violation of practice standards, and a liability issue to paste inaccurate information into the medical record

24. Transfer/Discharge
The accepting team should be contacted for all transfers out of ICU
Neurosurgical hospitalists (ARNPs)(“uncomplicated” neurosurgical patients)
Medicine hospitalist service (“Med-H”) (complicated neurosurgical patients) (Fellow, ARNP, or attending must call)
Neurology team
Please update the relevant team re: pertinent patient problems
Transfer orders to acute care Neurosurgery written by NCCS 24

25. Transfer/Discharge
Med consult team should be notified for patients with other co-morbidities
Med H service will assist with triage/disposition
For patients discharged directly from ICU to home, NCCS does discharge summaries 25

26. Neurosurgical Patient Discharge Dispositions
Complicated Medical History or ICU Stay
Uncomplicated Medical History and/or ICU Stay
No Active Neurosurgical Issues
Active Medical Issues
Medicine Hospitalists (Med-H) Evaluation
And Triage
Neurosurgical/Neurohospitalist Services
Active Neurosurgical Issues
+ Active Medical Issues
Admit to Med H Service
Neurosurgical/Neurohospitalist Services
Plus Medicine Consult
Med H Pager:
Contact Med H service by 1100 h for transfers
Contact Medicine Consult via paging operator
Neurohospitalist Contact Info:
Hot pagers: ,
June 30, 2011 26

27. Interim Summaries
An interim summary should be done on patients with ICU LOS ≥ 5 days, or complex shorter admissions
Please use the ORCA Interim Summary template (rather than a detailed progress note) (find under IVIEW/PN: Documentation)
The interim summary can serve as the daily progress note (both are not necessary) 27

28. Hours Weekly hours < 80 Non-call days: come in early enough to
Pre-round, gather data
Leave after afternoon rounds (3:30-4:30)
Day Call (mostly R1s)
Admit between 6 am and 2:30 pm
Home when work done, sign-out to night call team
Night Call: 1:30 pm until post-rounds next day
Max 22 hours
Work hour violations are not permissible 28

29. Daily Structure 06:00: Pre-rounding
Post-call resident rounds with Trauma-NS team
7:15 am: Fellows or ARNPs “Run the list” with Neurosurgery Chiefs in cafeteria
0805: Patient work rounds with Neurology
0830-~1100: Patient work rounds continue
12:00: Post-call resident leaves (at the latest)
13:30-14:30*: Night Call resident comes in; afternoon didactics or conference (MWThF)
: Individual signout to night call resident
1530: Checkout rounds (both teams meet)
15:00-18:00 (time variable): Checkout rounds with NS team (on-call resident and fellow or attending) 29

30. Didactics and Conference
NCCS Didactics: Every day but Tuesday and Wed, 1:30 pm, 2W-81
Everyone attends, including call resident (“quiet time”)
NCCS/NS Conference: Wednesday, 1:00 or 1:30 pm, 2W-81
Lunch provided
Please attend!
Multidisciplinary Journal Club: Tuesdays, noon, Maleng 111, lunch provided! 30

31. NCCS/Neurosurg Conf Schedule
Week 1: NCCS Grand Rounds, in R&T
Week 2: Alternates between NCCS, Trauma, and Vascular teams presenting
Week 3 Endocrinology (1 pm)
Identify interesting endo cases ahead of time
Week 4: M & M
Fellows/R4s track cases (pink cards)
Residents expected to present cases; presentations limited to details of case and QA event; informal (no powerpoints!)
Please forward a paragraph synopsis of your case(s) to Dr. Deem ≥ 2 days prior to conference
Discussion by group 31

32. Neurology R1 Didactics Tuesdays and Fridays, 11 am, 3W-108
Schedule will be posted; please try to attend all of these sessions
Fellows/R4s: Please take the R1s pagers so they can attend!
Entire team should attend sessions on Stroke, Neuroradiology, and others if possible

33. Neuroradiology Review
Tuesdays and Fridays, 11 am, Neuroradiology reading room (1W hospital)
Identify patients with images that you’d like reviewed in advance
5/27/2018

34. Procedures
All procedures during the day: Notify NCCS attending prior to starting (includes intubation of NCCS patients)
Subclavian lines: Cannot be done without direct attending supervision!
Internal jugular, femoral lines can be done without supervision if you have completed UW certification process and you are an R2 or greater
Neurosurg procedures (ICP monitors, EVDs): Do not do unless you are a NS R1! 34

35. Intubations
NCCS should perform their own intubations; do not call “Anesthesia”
Anesthesiology residents may supervise EM residents and Pulmonary fellows if they feel comfortable doing so
Do not supervise other residents, paramedics, etc.
Call attending prior to each intubation (with exception of codes)
Assess patient, call attending to discuss plan 35

36. Call Attending Prior to Starting!
If daytime hours and ICU attending is an Anesthesiologist, call them first
If not: OR front desk:
Obtain phone # of anesthesiologist-in-charge or on-call 36

37. Airway Equipment Tubes, airways, laryngoscopes: RT
Difficult airway boxes (ICUs, ED)
LMA, Eschman, cric kit, jet vent hookup
Drugs: Airway boxes in OR, or carry in pockets
If you stash airway boxes in the ICU or MICU workroom, please restock them and/or replace them periodically! 37

38. Intubation Notes Enter as ORCA Procedure Note
IVIEW/PNEncounter PathwayProcedure NoteTracheal intubation
Complete and forward to attending if one was present
Please complete an ORCA note for every intubation! 38

39. End-of-Month
Transmit your personal patient list to the resident who is replacing you
Can be found on next month’s call schedule
Create an interim summary for patients who have been in the ICU > 5 days
And directly communicate with incoming resident about complex patients
Don’t send patient info from or to a non-UW account 39