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: :00pm:

3. Flow Of The Day 12:00 - 1:00pm: 1:00 - 4:30pm: 4:30 - 5:30pm:
Noon Conference Follow-up consultations/procedures/post-op admissions/didactics Sign-out Rounds with night team

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

5. Other Teaching Conferences
Tuesday
12-1
PICU Fellows Conference
2E PICU Conference
Thursday
PICU Conference: M&M, Journal Club, Fellows research
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
Second year pediatric resident
Third year pediatric resident
+/- NP
ED resident
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
Attend evening rounds 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 5th resident in the PICU
May care for equal number of patients as pediatric residents
Rounds one day on weekend
Excused for Wednesday AM ED conferences: must pre-round & hand over notes to on call resident prior to leaving for education rounds

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 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

18. 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

19. 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

20. Notes Online PICU specific templates Systems-based note
Indicate attending on your team and select “sign” not “review”

21. 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

22. 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

23. Rounding & Presenting Patients

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

25. 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

26. 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

27. Physical exam: present exam appropriate for patient’s disease
Present meds within appropriate system : e.g. steroids for asthmatic in respiratory vs. steroids for liver transplant in GI
May need to make a section for Transplant: Liver/Kidney/BMT

28. 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 dashboard
Engage Bedside RN in rounds!!

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

30. 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

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

32. 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

33. 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! **

34. 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

35. 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!!

36. PICU specific Power - Plans
In Cerner
PICU folder found under Power-plan folders

37. 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

38. 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, co-write admit orders

40. 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) vs CPT
Allows some autonomy to RT to develop plan for best mode of therapy

41. Discharges Patient safety dashboard useful tool!
Prescription paper available from USA
Loads into one printer and special tray
Select the PICU prescription printer for all D/C scripts
Rx_picu_fntdsk

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

43. 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

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

45. Discharge Planning

46. Catheter Associated Bloodstream Infections

47. Ventilator Associated Pneumonia

48. Patient Safety

49. COWS Be sure to sign off Don’t leave patient information exposed
Plug them back in (a dying cow is not pretty)
!! No cow tipping !!!

50. PICU Etiquette
Please speak in quiet voices, particularly around main nurses station
We follow HUSH in the PICU

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: