WELCOME TO THE PICU

Flow Of The Day

Before 8am:8:00 - 8:30am:

8:30 - 9:00am:

9:00 - 9:30am:

9:30 - 11:00 am:

11:00 - 12:00pm:

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

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

Resident Teaching Conferences

PICU resident lectures:• Monday / Thursday • 8 – 8:30am• In place of morning report• At front desk in PICU

Other Teaching Conferences

Tuesday 12-1 PICU Fellows Conference

2E PICU Conference

Thursday 12-1 PICU Conference: M&M, Journal Club, Fellows research

2E PICU Conference

Educational Resources

• PICU resident handbook with relevant PICU topics is available at

http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html

Hard copy is available in the resident call room.

PICU chapters at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.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

PICU chapters at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html

• Cardiomyopathy• Liver Failure• Acute Renal Falilure• Fluids, Electrolytes,

Nutrition• Oncology• Transfusions• DKA

• Submersion Injuries• Brain Death• End of life issues

PICU Tables at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html

• Sedation

• Inotropes

• Shock

2 Teams in PICU

Team A Team B

Attending Attending

Fellow Fellow

Second year pediatric resident Third year pediatric resident

+/- NP ED resident

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

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

Other Trainees in PICU

• Anesthesia fellows

• Emergency medicine residents

• Medical Students

Anesthesia Fellows

• Present for half the blocks

• Primarily provide support for fellow level activities in the ICU

• Will not primarily follow patients

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

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

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

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

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

Notes

• Online

• PICU specific templates

• Systems-based note

• Indicate attending on your team and select “sign” not “review”

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

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

Rounding & Presenting Patients

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

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

• 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

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!!

Procedures

• PICU fellows are given priority for all procedures (particularly 1st year fellows)– Prerequisite for CCM training

• Acute situations : fellow or attending

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

Bedside Nurses

COMMUNICATION

COMMUNICATION

COMMUNICATION

– Tell bedside nurse you are the resident caring for that patient

– Give them your pager #

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

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! **

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

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!!

PICU specific Power - Plans

• In Cerner

• PICU folder found under Power-plan folders

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

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

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

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

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

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

PICU Dashboard Tab

✔ ✔

Ensure Best

Practices for

✔CABSI Prevention✔Pressure

Ulcer Prevention

✔VAP Prevention

Discharge Planning

Catheter Associated Bloodstream Infections

Ventilator Associated Pneumonia

Patient Safety

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 !!!

PICU Etiquette

• Please speak in quiet voices, particularly around main nurses station

• We follow HUSH in the PICU

Final Thoughts

• Take ownership of your patients• Be present• Be involved• Ask questions• Suggestions on improving the rotation

Questions, concerns, thoughts on the rotation

Contact PICU rotation director -

Dr. Courtenay Barlow at

cbarlow@stanford.edu

Pager: 23492