1. WELCOME TO THE PICU

2. Flow Of The Day
Before 8am: 8:00 - 8:30am: 8:30 - 9:00am: 9:00 - 9:30am: 9: :00 am: 11: :00pm:
Pre-Round/Receive sign out Morning report or PICU fellow lecture (Mo/Th)…MANDATORY Rounds begin Radiology rounds Completion of morning rounds Work time/didactics/first post-op admits

3. Flow of the Day
12:00 – 1:00pm Noon Conference 1:00 – 4:30pm Follow up consultations, procedures, post-op admits, didactics 4:00 – 4:30pm Residents receive NP sign out 4:30 – Resident/fellow sit down sign out, followed by night team only walk rounds

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

5. Other Teaching Conferences
Monday
12-1 PM
PICU Divisional Conference
2E PICU Conference Room
Tuesday
7:30 AM
CVICU lecture
Thursday
PICU Resident small group conferences (palliative care x2, vent teaching with RT, code team/cart teaching)
TBD each week, s sent from pediatric chiefs
Friday
CVICU Conference with Dr. Hanley
Confirm edit--

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

7. 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

8. 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

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

10. 2 Teams in PICU Team A Team B Attending Fellow
Senior pediatric resident
Pediatric intern
ED resident
Nurse practitioner
Slightly different now due to night float system

11. 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

12. 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
Sign out and transfer care of patients to overnight resident
Attend teaching conferences conducted by the ICU attendings / fellows
Again seems obvious…

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

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

15. ED Residents Will act as a 7th resident in the PICU
May care for equal number of patients as pediatric residents
Rounds one day on weekend, typically Saturday
Excused for Wednesday AM ED conferences: must pre-round & hand over notes to on call resident prior to leaving for education rounds
Starting this academic year, ED residents will be complete 3 weeks of days and one week of nights

16. 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

17. PICU NPs Michelle Burns-James Krysta Nicholson Karley Mariano
Work independently and carry their own patients
They are present in PICU 4 days/week for 10 hour shifts (variable days and starting times…i.e. may work noon-10pm some day depending on staffing needs)
Typically round one day on weekends, alternating with ED resident

18. PICU Evaluations for Pediatric Residents
Faculty evaluations completed on Med-Hub
Verbal feedback from attendings while on the rotation – Be sure to elicit feedback if not provided

19. 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

20. Notes
Each patient needs PICU daily progress note (unless admitted in early am)
Significant events: codes/procedure/intervention
Require a note: confer with fellow or attending who may do this note
Templates exist for most procedures
Interim summary weekly on Thursday for any patient with LOS > 5d in PICU

21. Notes Online PICU specific templates Systems-based note
Indicate attending on your team and select “sign” not “review”
Please remember to update physical exam daily

22. 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

23. 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 FACE to FACE in the PICU

24. PICU-to-Floor Hand-offs
Goals: Safe patient sign out
Issue: Sign-out often does not happen close to transfer time due to bed availability
Issue: No “stops” within the system to prevent transfer when hand-offs not completed.

25. PICU-to-Medical Team Hand-offs (including Renal transplant patients)
Floor Resource Nurse/USA
Floor MD orders “Okay to transfer”
Floor Bedside RN
Floor MD
PICU MD orders “transfer bed request”
PICU RN requests bed in Tele Trekking
USA or Spectralink alerts Floor Resource Nurse that bed ready in Tele Trekking
Floor MD calls PICU and goes to PICU for sign-out
Patient Transfers to Floor*
Phone sign-out
PICU Resource Nurse
PICU Bedside RN
PICU MD

26. PICU to Floor Hand-offs: MD Roles
1. PICU resident orders “Transfer Bed Request” including accepting team and orders “Change of Care to Acute care” and prints out PICU to Acute care IPASS report
2. Floor Resource Nurse or USA will call Accepting Floor Resident when PICU patient has been assigned a bed through Tele Trekking.
3. Accepting Floor Resident will call asking to talk to fellow to arrange time to get face to face sign-out, ideally within 30 minutes.
4. Accepting Floor Resident (and ideally fellow and attending) goes down to PICU for verbal sign-out.
5. Accepting Floor Resident puts in “Okay to Transfer” order.
6. Prior to sending patient or accepting patient PICU Bedside Nurse and Floor Bedside Nurse verify “Okay to Transfer” order has been placed
7. Patient comes to floor.

27. Please use the printed tool: Floor residents should print out but you can also

28. Printed Tool: Where to Find

29. Printed Tool

30. Rounding & Presenting Patients

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

32. 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

33. 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

34. 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 rounding checklist on every patient
Engage Bedside RN in rounds!!

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

36. 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

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

38. 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

39. 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! **

40. 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

41. Order Entry 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!!

42. 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,
Trauma service should write admit orders
Surgical service should write the discharge summary unless transferred to PICU service for ongoing medical issues

44. 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)
Allows some autonomy to RT to develop plan for best mode of therapy

45. Discharges Patient rounding checklist useful tool!
Prescription paper available from USA; please send 24 hours before
Loads into one printer and special tray
Select the PICU prescription printer for all D/C scripts
Rx_picu_fntdsk

46. Discharge
During rounds if discharge is anticipated in the next 48 hours please update the target discharge date
When you get admissions from surgery please ask about when they are anticipating discharge and what clinical criteria will need to be met.
If discharge is anticipated use the discharge checklist to help aid in the planning process (it will be on the patient door)
After you discharge a patient there is a survey that we are asking you to complete regarding your experience with the process

47. PICU Quality and Safety
PICU Handoff Initiative for ALL OR, 1N Handoffs
One Message, One Time
Role cards utilized
IPASS tool for handoff comes with 45 min call

48. PICU Quality and Safety
PICU Rounding Checklist
Real time clinical decision support
Enhance patient safety and care coordination
Review at conclusion of rounds for EACH patient

49. COWS Be sure to sign off Don’t leave patient information exposed
Plug them back in (a dying cow is not pretty)

50. PICU Etiquette
Please speak in quiet voices, particularly around main nurses station
We follow HUSH (healthcare workers utilizing silence for healing) in the PICU
Please no open food or drink containers unless in specified areas
Make sure you do follow the appropriate hand hygiene and have bare hands at all time in the unit

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. Courtenay Barlow at
Pager: