1. WELCOME TO THE PICU

2. Flow Of The Day Before 8am: Pre-round 8:00 - 8:30am: Morning Report 8:30 - 9:00am: Rounds (Except Fridays, rounds start at 9am after Grand Rounds) 9:00 - 9:30am: Radiology Rounds 9:30 - 11:00 am: Finish Rounds 11:00 - 12:00am: Work time

3. Flow Of The Day 12:00 - 1:00pm: Noon Conference 1:00 - 4:30pm: Completing work of the day 4:30 - 5:30pm: Sign-out Rounds with night team

4. Prevention of Resident Duty Hour Violations Do not begin pre-rounds before 6am Evening rounds begin at 4:30pm Be sure to leave by 12pm on post-call days –If your patients are not rounded on by 11:30, hand your notes to on-call resident

5. Teaching Conferences Tuesday 7 – 8am CV ICU Conference –PICU Conference Room Tuesday 12 – 1pm: PICU fellow conference –PICU Conference Room Thursday 3 – 4pm: Sign out round –PICU Conference Room Welcome to all!

6. Educational Resources PICU resident handbook with relevant PICU topics is available at http://peds.stanford.edu/Rotations/picu/picu.ht ml Hard copy is available in the resident call room

7. PICU chapters at http://peds.stanford.edu/Rotations/picu/picu.html http://peds.stanford.edu/Rotations/picu/picu.html Monitors in ICU Vascular Access Codes ICP management Status Epilepticus Sedation Pediatric Airway Airway Management Mechanical Ventilation ARDS Status Asthmaticus Inotropes Shock Sepsis Meningococcus

8. PICU chapters at http://peds.stanford.edu/Rotations/picu/picu.html http://peds.stanford.edu/Rotations/picu/picu.html Cardiomyopathy Liver Failure Acute Renal Falilure Fluids, Electrolytes, Nutrition Oncology Transfusions DKA Submersion Injuries Brain Death End of life issues

9. PICU Tables at peds.stanford.edu Sedation Inotropes Shock

10. 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

11. Resident Role Recognize the patients are often very complicated and managed collaboratively with other services – e.g. neurosurgery, liver transplant, heme-onc, cardiology, etc. Significant changes to patient status should be discussed with the other services

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

13. PICU Evaluations Group faculty evaluation completed on MedHub Verbal feedback from attendings while on the rotation – Be sure to ellicit feedback if not provided

14. Other Trainees & HCPs in PICU Anesthesia fellows Emergency medicine residents Medical students Nurse Practitioners

15. Anesthesia Fellows Only present for half the blocks Primarily provide support for fellow level activities in the ICU Will not carry any patients

16. ED Residents Will act as a 5 th resident in the PICU To care for equal number of patients as pediatric residents Will take call with a pediatric resident and cover half the patients Excused for Wednesday AM ED conferences, but must pre-round and hand over notes to on call resident prior to leaving for education rounds

17. 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

18. PICU NP Role Hours of coverage in PICU: –Mon-Sat: 7:30am - 5:00pm Assist residents with ICU specific systems issues, e.g. writing PICU notes Complete daily goal sheets and review with Bedside RN at completion of rounds Pre-round on patients on Saturday

19. PICU NP Role Assist with patient flow: –Pre-round with consultants, i.e. neurosuregery, and update resident with recommendations –Writing accept notes and orders on post-op patients as needed, i.e. during am / pm sign-out –Entering transfer orders for patients requiring transfer during rounds, etc. Attend Multidisciplinary rounds on Tuesdays at 11am

20. Notes New admissions require a dictated H&P and a brief note in the chart Post-operative admissions can have a post- op admission note written in the chart Patients in the ICU for longer than one week require a dictated clinical summary each Thursday

21. ICU Transfers Patients being transferred from the ICU require Transfer summary Transfer orders –Surgical patients: surgeons often write orders Sign patient out to ward resident

22. Rounding & Presenting Patients

23. Sample PICU Progress Note -Each patient’s note printed from Cerner (LPCH computer system) -Assure printed information up to date, i.e. ventilator settings

24. Patient identification Quick assessment: i.e. patient improving, worsening, or unchanged Major (not all) interval events Vitals

25. Physical exam: present exam appropriate for patient’s disease, e.g. neuro exam on neurosurgical patient (but examine all of patient) Present meds in appropriate system: e.g. steroids for asthmatic vs. steroids for liver transplant Respiratory: –Data: CXR findings, mode of support - NC vs BiPAP vs ventilator –A/P: changes in pulmonary compliance and changes in respiratory support accordingly

26. 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 FEN/GI: –Data: I/O’s, nutritional source, calories per day, Labs –A/P: changes in fluid status or liver functions, modifying nutritional support

27. Renal: –Data: urine output, any renal replacement therapy, changes in BUN/Cr –A/P: changes in renal function or diuretics 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

28. One line of overall assessment and major plans for the day at the end Review orders

29. Procedures PICU fellows are given priority for all procedures (particularly 1 st year fellows) –They must be trained in them prior to completion of their fellowship Acute situations – fellow or attending will do procedure to optimize patient care

30. Procedures Procedures residents should acquire some degree of comfort with while in the PICU Bag-mask ventilation Operating an anesthesia bag Chest compression Placement of peripheral IVs

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 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.

34. 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! **

35. Orders Do not write specific times for meds – allows RN to time them as possible for existing lines Do not time labs *** except for immunosupression drugs *** e.g. Prograf, CSA

36. Order Entry PICU order sets available on Cerner include: Delete previous diet orders Orders that require daily entry: –CBC –Coags –Chemistries –CXR If labs or radiology studies listed in power-plan, no re-entry required

37. Order Entry On Cerner PICU folder under Power-plan folders

38. Order Entry On Cerner Power-plans found in PICU folder

39. 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 !!!

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

41. Questions, concerns, thoughts on the rotation Contact PICU rotation director - Dr. S. Kache at Skache@stanford.edu 723-5495 Pager: 13483