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

2. 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

3. Have a fun and educational month
Learning Goals
Have a fun and educational month

4. 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

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

6. 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

7. 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

8. 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

9. “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

10. HOUSEKEEPING

11. 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

12. 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

13. 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)

14. 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”

15. 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

16. 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

17. 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

18. 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

19. RESIDENT RESPONSIBILITIES

20. 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

21. 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

22. Intubations
“Airway Provider” should be available for all ICU intubations
The airway pager ( ) 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: (Spectralink)
OR Front Desk:
OB Anesthesia Resident:
ED:

23. 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

24. 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

25. Code Blue Coverage
10 ICC team will respond to codes during weekdays (M-F )
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

26. 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.

27. 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

28. 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

29. Code Sepsis: BSA

30. 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

31. 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

32. APEX & Patient Database
PAPERWORK

33. 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

34. CCM Resident/NP Office
Door code: 6917#

35. 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

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

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

38. 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

39. Notewriter Notes
This will get imported into the note.

40. 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)

41. 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”

42. 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

43. 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.”

44. 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

45. 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.

46. 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

47. Orders Mechanical Ventilation There is NO order set
Search under “ventilation” or use IP Adult ICU Addendum Order Set
ARDSNet Protocol
PSV/CPAP

48. 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”

49. 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)

50. 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

51. 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.

52. 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

53. Questions?