DIVISION OF CRITICAL CARE MEDICINE GWUMC Welcome to the George Washington University ICU.

DIVISION OF CRITICAL CARE MEDICINE GWUMC

Welcome to the Welcome to the George George

Washington Washington University ICUUniversity ICU


Your rotation Your rotation will be a great experiencewill be a great experience very different from your usual dutiesvery different from your usual duties

You will learn a great dealYou will learn a great deal

You will become comfortable with You will become comfortable with caring for critically ill patientscaring for critically ill patients


Our ICU is multidisciplinaryOur ICU is multidisciplinary Patients are under the care of the ICU housestaff, Patients are under the care of the ICU housestaff,

usually in collaboration with the admitting serviceusually in collaboration with the admitting service Medical, Surgical, Neuro and Neurosurgical PatientsMedical, Surgical, Neuro and Neurosurgical Patients

Communicate with the admitting serviceCommunicate with the admitting service Coordinate care, avoid duplication of effortsCoordinate care, avoid duplication of efforts Essential when significant changes in clinical status Essential when significant changes in clinical status

occuroccur

OnlyOnly ICU Team and occasionally ICU Team and occasionally admitting service are allowed to write admitting service are allowed to write ordersorders


ICU TEAM COMPONENTSICU TEAM COMPONENTS

Attending (Monday switch)Attending (Monday switch) ICU 5 AttendingICU 5 Attending ICU 4 AttendingICU 4 Attending

Critical Care Fellow (Thursday switch)Critical Care Fellow (Thursday switch) 4-5 Residents4-5 Residents

Anesthesia, Surgery, MedicineAnesthesia, Surgery, Medicine 4-6 Interns4-6 Interns

Anesthesia, ER, OB, Medicine, SurgeryAnesthesia, ER, OB, Medicine, Surgery ICU Physician AssistantsICU Physician Assistants 4th year medical students4th year medical students Night FellowNight Fellow Night AttendingNight Attending


Intern ScheduleIntern Schedule

Dayfloat: 6a-8pDayfloat: 6a-8p Nightfloat: 8p-6a Sun-ThurNightfloat: 8p-6a Sun-Thur

Friday night and Saturday night intern Friday night and Saturday night intern must stay until they finish rounds on must stay until they finish rounds on Sat/Sun (16 hour limit)Sat/Sun (16 hour limit)

As the night intern you will not be on As the night intern you will not be on call on consecutive Friday/Saturday call on consecutive Friday/Saturday nights to avoid 2 16 hours shifts back to nights to avoid 2 16 hours shifts back to backback

Intern schedule Intern schedule continuedcontinued

If it is M-F and you are not listed as day or If it is M-F and you are not listed as day or night you work a regular daynight you work a regular day Come in for rounds, leave after afternoon Come in for rounds, leave after afternoon

signoutsignout Details on daily routine later in this Details on daily routine later in this

presentationpresentation Off days weekends (if not on day/night shift Off days weekends (if not on day/night shift

/weekend rounder you do not come in)/weekend rounder you do not come in) Occasionally you will be given a weekday off in Occasionally you will be given a weekday off in

order to have enough weekend coverageorder to have enough weekend coverage


Weekend RounderWeekend Rounder

Comes in only for rounds and to write Comes in only for rounds and to write notes on Sat/Sunnotes on Sat/Sun

We try to have one both days but don’t We try to have one both days but don’t always have enough staffalways have enough staff

The role of this person is to dec the The role of this person is to dec the number of notes the post-call resident number of notes the post-call resident and night intern write so that we can get and night intern write so that we can get them out on time.them out on time.

This person is usually an intern but may This person is usually an intern but may be a resident as wellbe a resident as well


Resident ScheduleResident Schedule

Generally Q4 overnightGenerally Q4 overnight 28 hour limit now28 hour limit now Come in at 8am all days except Sunday**Come in at 8am all days except Sunday**

No prerounding except for SundayNo prerounding except for Sunday **If there is a weekend rounder on **If there is a weekend rounder on

Sunday the on call resident does not Sunday the on call resident does not preroundpreround

Stay until noon the next dayStay until noon the next day When post-call on Monday, must leave after 28 When post-call on Monday, must leave after 28

hours (roughly 10AM) which means you must hours (roughly 10AM) which means you must round on the 5round on the 5thth floor patients only floor patients only


DAILY SCHEDULEDAILY SCHEDULE

0630-0800 – Housestaff pre-round0630-0800 – Housestaff pre-round Review overnight eventsReview overnight events Patient exams and review of pertinent dataPatient exams and review of pertinent data

labs, consults, X-rays, ventilator adjustments, labs, consults, X-rays, ventilator adjustments, medication changes, extubations, medication changes, extubations, transfusions,etc..transfusions,etc..

MUST document:MUST document:

CulturesCultures

AntibioticsAntibiotics

Line day #Line day #



0800-1130 – Rounds (08:30 on Sat-Sun)0800-1130 – Rounds (08:30 on Sat-Sun) Interns/students transport bargeInterns/students transport barge Interns not presenting are responsible for finding Interns not presenting are responsible for finding

the chart for the next patient, ask the nurse to join the chart for the next patient, ask the nurse to join roundsrounds

Order writing is done by anyone not presentingOrder writing is done by anyone not presenting If you have any questions about what to order or you missed If you have any questions about what to order or you missed

something something ASKASK Everyone assists in calling in tests, consults, Everyone assists in calling in tests, consults,

gathering additional information, keeping rounds gathering additional information, keeping rounds movingmoving

YOU MUST PAY ATTENTION, even when it's not YOU MUST PAY ATTENTION, even when it's not your patientyour patient

New admissions are presented in H&P formatNew admissions are presented in H&P format All others in ICU Standard Progress note formatAll others in ICU Standard Progress note format



1130 – 12001130 – 1200 Signout then post-call resident is sent homeSignout then post-call resident is sent home

1200 – 1300 Lunch1200 – 1300 Lunch

Conference Tu, Wed, Friday 8-9 am, Rm Conference Tu, Wed, Friday 8-9 am, Rm 6121 Rounds begin afterwards.6121 Rounds begin afterwards.

Tuesday/Wednesday – Fellow lecture Tuesday/Wednesday – Fellow lecture Friday – Attending Case ConferenceFriday – Attending Case Conference



1300 – 16301300 – 1630 Work timeWork time

1600-1700 – Evening signout1600-1700 – Evening signout Review events of afternoon, lab studies, radiologyReview events of afternoon, lab studies, radiology Establish plan for overnight Establish plan for overnight Non-call housestaff leaveNon-call housestaff leave

The goal is to get non-call housestaff out before The goal is to get non-call housestaff out before 1700, but 1700, but the patients come firstthe patients come first Help each other! If the fellow and on call Help each other! If the fellow and on call

residents are busy with admissions, it may delay residents are busy with admissions, it may delay signout…signout…


AdmissionsAdmissions

AllAll admissions go through ICU (DUCK) admissions go through ICU (DUCK) PagerPager

741-1234741-1234 Duck PagerDuck Pager

Carried by the ICUPA 7:00am - noon Carried by the ICUPA 7:00am - noon Carried by the fellow noon to 7:00 amCarried by the fellow noon to 7:00 am

On call team sees admissions in the ER and On call team sees admissions in the ER and FloorFloor

PACU admits seen by anyonePACU admits seen by anyone

OVERALL GOALOVERALL GOAL: Take care of patients: Take care of patients



Night Call Intern / StudentNight Call Intern / Student Responsible for DAILY updates of Responsible for DAILY updates of

cultures and antibioticscultures and antibiotics Final list update by 6amFinal list update by 6am Please have new patients added to the Please have new patients added to the

list in the evening by 6pm as welllist in the evening by 6pm as well


AdmissionsAdmissions

The charge nurse (Ext 6130) must be The charge nurse (Ext 6130) must be notified ASAP when an admission is likelynotified ASAP when an admission is likely Usually notified by the fellowUsually notified by the fellow

The fellow must be notified for every The fellow must be notified for every admissionadmission

Admitting intern or resident is responsible Admitting intern or resident is responsible for ensuring the patient's primary care for ensuring the patient's primary care physician and family are aware of the ICU physician and family are aware of the ICU admissionadmission


NotesNotes

H&P for all patients admitted H&P for all patients admitted through ED or outside hospitalthrough ED or outside hospital

ICU accept note for PACU patients ICU accept note for PACU patients or floor transfersor floor transfers

DonDon’’t forget to assign notes to an t forget to assign notes to an attending. attending. Any notes done in the afternoon should Any notes done in the afternoon should

be assigned to the night attending.be assigned to the night attending.


LabsLabs

Do not assume that every patient needs every lab Do not assume that every patient needs every lab test every daytest every day AVOID MEDICAL VAMPIRISMAVOID MEDICAL VAMPIRISM If you're not sure on rounds…askIf you're not sure on rounds…ask

Not every patient needs a daily chest X-rayNot every patient needs a daily chest X-ray

Very few vent changes require an ABGVery few vent changes require an ABG

Not all patients need arterial and / or central linesNot all patients need arterial and / or central lines


ProceduresProcedures

Safety is the primary concernSafety is the primary concern

Do not attempt a procedure that you are not Do not attempt a procedure that you are not familiar with or certain aboutfamiliar with or certain about

GET HELPGET HELP

All invasive procedures require a standard All invasive procedures require a standard procedure note in SALARprocedure note in SALAR

No intern is to be doing procedures No intern is to be doing procedures unsupervised by a resident, fellow or PA!!!!unsupervised by a resident, fellow or PA!!!!


Infection Control


Wash your handsWash your hands

before you start!before you start!


Preferred practices


Clean up your mess


Bad form


Antibiotic rotationAntibiotic rotation

Broad spectrum for empiric sepsisBroad spectrum for empiric sepsis Changes every 3 monthsChanges every 3 months

cefipime (Maxipime)cefipime (Maxipime) imipenem/cilastatin (Primaxin)imipenem/cilastatin (Primaxin) piperacillin/tazobactam (Zosyn)piperacillin/tazobactam (Zosyn) If you want one that is not on rotation you must If you want one that is not on rotation you must

get ID approvalget ID approval

Broad spectrum Gram +Broad spectrum Gram + No rotationNo rotation VancomycinVancomycin LinezolidLinezolid Daptomycin (remember no lung penetration)Daptomycin (remember no lung penetration) TigecyclineTigecycline


DischargesDischarges

Transfer notes - Medicine ONLYTransfer notes - Medicine ONLY When pt has been here OVER 48 hrsWhen pt has been here OVER 48 hrs summarize important events and ongoing summarize important events and ongoing

issuesissues provide information essential for continuity provide information essential for continuity

of careof care

Transfers to surgical services do Transfers to surgical services do not need transfer notesnot need transfer notes


Dress CodeDress Code

You are doctors and adults, dress You are doctors and adults, dress professionally.professionally. Scrubs are appropriateScrubs are appropriate Not mixed with street clothesNot mixed with street clothes White coat not mandatoryWhite coat not mandatory

Nose, lip, and tongue piercings must Nose, lip, and tongue piercings must be discrete and tastefulbe discrete and tasteful


NursingNursing

ICU nurses work here permanentlyICU nurses work here permanently

You are the visitorYou are the visitor

If a nurse questions an order, always If a nurse questions an order, always reconsider itreconsider it

There is a charge nurse for every shift x6130There is a charge nurse for every shift x6130 They are chosen for their experience, and are a They are chosen for their experience, and are a

valuable resource for both in unit operations and valuable resource for both in unit operations and specific patient difficultiesspecific patient difficulties


NursingNursing

Nursing shift changes occur at Nursing shift changes occur at

0700-0730 and 1900-19300700-0730 and 1900-1930

An important time to relay patient informationAn important time to relay patient information Do not interrupt the nurses or take charts at Do not interrupt the nurses or take charts at

this timethis time The entire report on a particular patient takes The entire report on a particular patient takes

about 10 minutes if the nurses are not about 10 minutes if the nurses are not interruptedinterrupted


NursingNursing

Provide valuable information about Provide valuable information about patientspatients

Usually present on roundsUsually present on rounds Keep nurses informedKeep nurses informed Tell them about any new ordersTell them about any new orders

Make room for the nurse on the barge!Make room for the nurse on the barge!


Relations with other servicesRelations with other services

Keep the primary service informed of Keep the primary service informed of statusstatus

Do not engage in prolonged Do not engage in prolonged controversies with consultantscontroversies with consultants

Involve the fellows, who can mediate Involve the fellows, who can mediate and facilitate a spectrum of clinical and facilitate a spectrum of clinical and personal issues.and personal issues.


Relations with familiesRelations with families

Be careful about the information your provide Be careful about the information your provide to families, especially concerning prognosisto families, especially concerning prognosis

When families are frustrated or hostile, allow When families are frustrated or hostile, allow the fellow or attending to speak with them to the fellow or attending to speak with them to avoid mixed messages whenever possibleavoid mixed messages whenever possible

Keep the case manager informed about family Keep the case manager informed about family dynamicsdynamics

If you are uncomfortable or unsure about If you are uncomfortable or unsure about discussions involving prognosisdiscussions involving prognosis

On your patients…please update family daily On your patients…please update family daily with a quick phone callwith a quick phone call


VentilatorsVentilators

Respiratory therapists are in charge of all Respiratory therapists are in charge of all ventilators and O2 equipment 24/7ventilators and O2 equipment 24/7

They assist with treatment decisions, assist They assist with treatment decisions, assist with intubations, extubations, and codeswith intubations, extubations, and codes

Only the ICU attending Only the ICU attending and fellow may make and fellow may make ventilator changesventilator changes

All others must inform the respiratory All others must inform the respiratory therapisttherapist

Make sure that the nurse is aware of all Make sure that the nurse is aware of all ventilator changes.ventilator changes.

Write orders for all vent setting changesWrite orders for all vent setting changes


Code BlueCode Blue

ICU team attends all codesICU team attends all codes Call the team if anyone is missingCall the team if anyone is missing If no one else has taken charge – you do itIf no one else has taken charge – you do it On the floor – attendance will depend on time On the floor – attendance will depend on time

of dayof day Critical care nurse always present to help you outCritical care nurse always present to help you out An anesthesiologist will arrive quicklyAn anesthesiologist will arrive quickly Eventually you will likely take the patient to the ICU Eventually you will likely take the patient to the ICU

so stick aroundso stick around In ICU – the attending, fellow, or resident is in In ICU – the attending, fellow, or resident is in

charge charge


ICUPA ServiceICUPA Service

In house 7am-7pm, daily, 365 days/yearIn house 7am-7pm, daily, 365 days/year Sees new consults and admissions 7AM-Sees new consults and admissions 7AM-

12PM12PM Admissions to ICU2 will be followed by PA Admissions to ICU2 will be followed by PA

Service during the day and the PA or ICU2 Service during the day and the PA or ICU2 moonlighter at night. moonlighter at night. If you are called about an ICU2 patient first ask If you are called about an ICU2 patient first ask

if it is an urgent/emergent problem. If so…go if it is an urgent/emergent problem. If so…go help. If not, direct the nurse politely to the PA help. If not, direct the nurse politely to the PA phone (6137)phone (6137)

PA Service may admit patients to ICU5 or PA Service may admit patients to ICU5 or ICU4 during rounds, will hand patients off ICU4 during rounds, will hand patients off to main teamto main team


GOLDGOLD Team ConsultsTeam Consults

All Gold Team patients on a ventilator are All Gold Team patients on a ventilator are required to have an ICU consultrequired to have an ICU consult

Overnight consults should be seen by the Overnight consults should be seen by the Night fellowNight fellow

Resident DOES NOT do the official consultResident DOES NOT do the official consult Consult notes should be done by the fellow or Consult notes should be done by the fellow or

PA (Depending on floor)PA (Depending on floor) Please add/ensure consults are on the censusPlease add/ensure consults are on the census


DeathsDeaths

The death packet MUST be filled out (Pink papers)The death packet MUST be filled out (Pink papers) The physician section NEEDS to be filled out by the The physician section NEEDS to be filled out by the

person pronouncing death = YOUperson pronouncing death = YOU Time of death recorded in progress notesTime of death recorded in progress notes Family notified – do not forget to ask about autopsy so we can avoid Family notified – do not forget to ask about autopsy so we can avoid

repeat callsrepeat calls Attending notified – document once you tell the fellowAttending notified – document once you tell the fellow Autopsy ? – Ask the familyAutopsy ? – Ask the family Call medical examiner if appropriate – LIST in packetCall medical examiner if appropriate – LIST in packet ANY death from trauma, ICH or ETOH MUST be reported to medical ANY death from trauma, ICH or ETOH MUST be reported to medical

examinerexaminer Fellows / Attendings are responsible for signing death certificate and Fellows / Attendings are responsible for signing death certificate and

causes of deathcauses of death The intern or resident on for the day will usually be assigned the The intern or resident on for the day will usually be assigned the

discharge summarydischarge summary


EvaluationsEvaluations

After 2 weeks on the ICU rotationAfter 2 weeks on the ICU rotation contact the fellow from first week for informal contact the fellow from first week for informal

feedbackfeedback Attendings complete official evaluationAttendings complete official evaluation


ICU Census ExampleICU Census Example

577Doe, Jane1234567

DNR/DNI

81F9/17

BRBPR; anemicPMH: Afib, CABG, DM, anemia

579Friend, Joe1111111INTUBATEDNeurologySurgery-Lee

75 M9/12

AMS, Sepsis Acute cva on old R mca cva- intubated. POD 33 LOA for sbo, ATNPMH: dvt, htn, dm

Linezolid 9/13Cefepime 9/13

9/5: urine/bld MRSABronch cx: Ecoli9/13 Bcx: NGTD9/13 Ucx: negative

580Smith, Bob2222222

Endocrine

46M

9/17

DMI, IDDM, SOB, cough, hyperglycemiaPMH: DM, HTN

Ceftriaxone 9/17Azithro 9/17

581Schmoe, Joe3490393

Cardiology

63MDS9/12

ARF, osteo, CHF, c desats (80’s) on 100% NRB, poss fluid overload vs PE

Cipro 09/12PO Vanco 09/03Fluconazole 09/12Cefepime 09/15

BCx 09/13UA 09/13Ucx 9/13 – serratia marcesens MSSA (+): wound 8/17C.Diff (+)


ICU CensusICU Census On K drive under On K drive under ““ICU censusICU census”” Only one person can work on census at a Only one person can work on census at a

time.time. Close when finished viewing otherwise Close when finished viewing otherwise

cannot be edited elsewherecannot be edited elsewhere Must put PMD/surgeon name next to MRN Must put PMD/surgeon name next to MRN

numbernumber Code status below MRN if not full codeCode status below MRN if not full code Intubated or trached.Intubated or trached. Update cultures/antibiotics dailyUpdate cultures/antibiotics daily Update HPI/pt information daily!Update HPI/pt information daily!


ICU censusICU census Put main reason for admission followed by PMHxPut main reason for admission followed by PMHx Update Cx and Abx even if only NGTDUpdate Cx and Abx even if only NGTD Night internNight intern’’s job if not updated by others s job if not updated by others

throughout daythroughout day Update new diagnosisUpdate new diagnosis Do not type in Do not type in ““To doTo do”” area area Do not assign complex patients who have had Do not assign complex patients who have had

active issues over the weekend to people who active issues over the weekend to people who have been gone whole weekendhave been gone whole weekend

Complicated patients should go to the residents Complicated patients should go to the residents and not the internand not the intern

Consults seen on the floor that remain there Consults seen on the floor that remain there should be placed in italics under the consult should be placed in italics under the consult section for the PA attending to see in the AM.section for the PA attending to see in the AM.


Fellows Office- Room Fellows Office- Room 5104851048

For Fellows onlyFor Fellows only 5 fellows share:5 fellows share:

One officeOne office One small fridgeOne small fridge Couch = our bedCouch = our bed

Residents are Residents are notnot to be in office to be in office without fellow presentwithout fellow present

Clean up after yourselvesClean up after yourselves

Welcome to the Welcome to the GW ICU!GW ICU!

DIVISION OF CRITICAL CARE MEDICINE GWUMC Welcome to the George Washington University ICU.

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Transcript of DIVISION OF CRITICAL CARE MEDICINE GWUMC Welcome to the George Washington University ICU.