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

2. 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

3. Service basics

4. 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)

5. 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

6. 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.

7. 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

8. 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.

9. 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

10. 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)

11. 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.

12. Rapid Response Team (RRT): Policies and documentation

13. 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

14. 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.

15. 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

16. 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

17. 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

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

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

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

21. 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”

22. 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

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

24. Procedures in the picu

25. 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

26. 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!

27. 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

28. 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

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

30. Procedure Notes
Select IP Bedside Procedure Note

31. 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!

32. Transport calls

33. 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

34. 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.

35. 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

36. PICU M&M

37. PICU M&M
Please remember to keep track of your RRTs, morbidities, and mortalities while on service
The M&M fellow will you at the beginning of the month asking for cases.
It is your responsibility to 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)

38. Conference

39. 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

40. CICU specific

41. 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