1. WELCOME TO THE PICU

2. 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: :00 am: 11: :00am:

3. 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

4. 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

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

6. 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

7. 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

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

9. 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!

10. Educational Resources
PICU resident handbook with relevant PICU topics is available at
Hard copy is available in the resident call room.

11. 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

12. 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

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

14. Team Composition

15. 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

16. 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

17. 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

18. 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

19. 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,

20. 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

21. Other Trainees in PICU Anesthesia fellows Emergency medicine residents
Medical Students

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. Rounding & Presenting Patients

31. 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.

32. 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!!)

33. 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)

34. 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.

35. 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

36. 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

37. 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

38. 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

39. 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

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

41. 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

42. 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

43. Bedside Nurses COMMUNICATION
Tell bedside nurse you are the resident caring for that patient
Give them your pager #

44. 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

45. 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.

46. 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! **

47. 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

48. 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!!

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

50. 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

51. Final Thoughts Take ownership of your patients Be present Be involved
Ask questions
Suggestions on improving the rotation

52. Questions, concerns, thoughts on the rotation
Contact PICU rotation director -
Dr. S. Kache at
Pager: