What You Need to Know

ICU Orientation

Patient careMedical knowledge

CommunicationProfessionalism

Practice based learningSystem based practice

The Six COMPETENCIES

Patient Care: Cognitive Skills Improve the skills to provide optimal methodology

to work up and deliver care to critically ill patients Communicate effectively with and demonstrate

empathy and respectful behavior when interacting with patients and their families

Ensure relevant and accurate information about their patients

Oversee diagnostic and therapeutic plans for their patients based on history, physical examination and laboratory data tempered with evidence-based medicine, clinical judgment and patient preference

Ensure management plans are implemented Counsel and educate patients and their families

Patient Care: Technical skills

Insertion of and instruction in the insertion of intra-arterial (radial, femoral, axillary) and central venous catheters (internal jugular, subclavian, femoral)

Insertion of and the instruction in the insertion of pulmonary artery catheters (internal jugular, subclavian and femoral)

Emergency airway managementInsertion of chest tubes (optional)Percutaneous tracheostomies (optional)

Medical KnowledgeMaster the following:

Physiology Pharmacology Clinical Knowledge and

Management: Respiratory

Mechanical Ventilation Management of acute

lung injury and the acute

respiratory distress syndrome

Weaning from mechanical ventilation

Cardiovascular Hemodynamic monitoring Oxygen transport Use of inotropes and vasopressors

Pharmacokinetics and

pharmacodynamics Management of Increased ICP Management of renal

insufficiency Liver failure

Acute Chronic Care of the liver transplant patient

Massive bleeding and transfusion

Nutrition Infectious diseases

Microbiology Antimicrobials

Shock Evaluation Management

Practice-based Learning By appraising and assimilating scientific evidence,

residents must be able to investigate, evaluate and improve their patient care practices. The resident will be able to: Locate, appraise and assimilate evidence from scientific

studies that are relevant to their patients' health problems;

Use evidence-based medicine methodology to ascertain the utility and effectiveness of certain diagnostic tests and therapeutic strategies in the care of their patients;

Use information technology to manage information, access on-line medical information and support their own education;

Assist in the teaching of CA-2 residents, medical students and allied health personnel.

Communication Residents must be able to demonstrate

interpersonal and communication skills that result in effective exchange of information and provide a framework for the development of a cohesive critical care team. Residents are expected to: Create and sustain a therapeutic and ethically sound

relationship with their patients; Use effective communication techniques to provide and

elicit information:o Efficient and effective presentations during daily rounds;o Timely, complete and legible progress and procedure notes;

o Effective dissemination of information to consultants and allied health care providers

o Providing updates to family members;o As part of the CCM team, discuss end-of-life issues with families

Professionalism Residents must demonstrate a commitment to

completing their professional responsibilities, adhering to ethical principles and being sensitive to a diverse patient population. Residents are expected to demonstrate: Respect, compassion and integrity; Responsiveness to the needs of patients and society that

supersedes self-interest Accountability to patients, society and the profession; Commitment to excellence; On-going professional development; Commitment of ethical principles:

o Provision/withholding of care;o Patient confidentiality;o Informed consent;o Business practices

Sensitivity and responsiveness to patients' age, culture, gender and disabilities.

System-based Practice Residents must demonstrate an awareness of and

responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:

Understand how their patient care and other professional practices affect other health care, the health care organization and the larger society and how these elements of the system affect their own practice;

Practice cost-effective health care and resource allocation that does not compromise quality of care;

Advocate for quality patient care and safety;

Know how to partner with health care managers and providers to assess, co-ordinate and improve health care and know how these activities can affect system performance.

Educational Goals80 hour work week must be adhered w/o

exceptionDidactic activities: lectures 7:00-8:00

Tuesdays and Thursdays only! Anesthesia (first week) Trauma (second week) Neuro Critical Care (third week) Resident Lecture

Multidisciplinary critical care conferences 4pm on Wednesdays

Patient bedside teaching rounds: Friday at 1PM

Educational GoalsEvaluation and Feedback:

Monthly evaluation by attendings Evaluation by selected nurses & Affiliate Practitioners

Evaluation of each attending by residents

Evaluation of rotation Work hour documentation

Resident “Call Out ” Procedure

Anesthesia1. Resident attempts to cover

with fellow residents2. Failing#1: resident notifies

Administrative Chief and Clinical Director

3. Failing #1 & #2: Program Director is notified

Emergency Medicine Resident calls their

administrative Chief, who then arranges coverage

Surgery1. Resident attempts to

cover with fellow residents: switches, etc.

2. Failing #1: Resident notifies Surgery Chief Resident on-call at that campus. He/she gauges impact and acts accordingly

3. Failing #1 & #2: Chief Resident notifies Dr. Anne Larkin to decide if other resources needed

SICU TeamICU Attendings: Rotate weekly Monday

through SundayICU Fellow - intermittentlyE ICU

After 6pm review all new admissions Nocturnal bed triage

Affiliate Practitioners SICU Neuro Critical Care

Pharm DPA ResidentsStudents – Medical, NP, PA

eICU24 hour Intensivist and Affiliate

Practitioner to assist with patient management

Present all nocturnal (19:00-07:00) admissions to eICU attending

Review unexpected patient deterioration

Remember: covering Intensivist may need to know also!

Work FlowGet sign out from previous shiftPre round on pts

NOTE: Vascular Rounds in 3ICU at 0630 AM

AM lectureFinish pre-roundingRound with attending, teamVerify, allocate the work to be doneDo the workAfternoon RoundsSign out

Lectures / Reading ListMorning conference includes post-call

resident

7:00 – 8:00 Tuesdays and Thursdays: L2

Residents responsible for one lecture per month (last week)

End of month written test

Critical care conference: Wednesdays at 4pm (anesthesia conference room)

Reading list: select chapters in Irwin & Rippe’s “Manual of Intensive Care Medicine” (2010)

RoundsVascular rounds in 3ICU at 6:30 AMWeekend/holidays rounds 8:00 Top priorities:

A good exam Know what has happened in past 12 hours

Review studies We can make plan as a group and note can be completed later

Upon Completion of Rounds:

SICU team gathers to run list Ensures we’re all on same page Delegate tasks Assign procedures

First - Call consultsArrange procedures Sit-down rounds with SICU attending

4-5pm

Admissions:All admissions accepted by Attending only

All admission cleared through eICU eICU calls unit ATTENDING for acceptance Must present all admits to eICU attending after hours

All admission orders reviewed by ICU resident/mid-level; changes made as needed

See patients in PACU as soon as notified of arrival

Attending decides which unit covers SICU patients in PACU (if necessary) Notify EICU of admissions - can put in pre-

admit bed so note can be started prior to pt arrival

Discharges:Discharges out of SICU determined by

Attending/Surgery team Delay in transfer d/t bed availability

requires re-evaluation prior to transfer All patients that have been in SICU > 48

hours will need dictated transfer summary (exception: trauma patients)

Receiving teams write transfer orders. When this can not be completed in a timely fashion holding orders can be written.

DeathsBefore making CMO notify NEOBNotify family and attendingReview what needs to be called to Medical

ExaminerReview new Brain death criteria on intranetFinal note in chart

Circumstances of death

Death summary dictation (trauma does their own)

Pronouncement and time of death: Mid-levels can pronounce but can’t sign death certificate

Printing SICU List “TEAMNOTES”

Salar “TeamNotes”Update daily : add new patients

Daily SICU NotesStart notes after 1pm in VISICUUpdate as needed and at 4am:

preround information inserted Separate event notes and notes for line

insertion/procedures as well as a postop check

Notes saved as open draft until ready to sign/print. Notes expire after 24 hours

SICU Routine OrdersStress ulcer prophylaxisRestraint ordersTPNCWASSedation protocol with daily

holidayVentilator wean protocolLow tidal volume protocolGlycemic protocol: All patients except

pancreatic transplants or HHNK or DKA

SICU Routine Orders: Writing Orders

VISICU: Orders-CreateStandard Order : free text

Medication: pick list/formularyAdd /Stop

Formularyo Allergy checkingo Med Compatibility checking o Visible to nurse/Pharm D

OtherHardcopy of Verbal order

Not availableWith

“free texting”

USE IT !!

SICU ProceduresInformed consent for electiveInform Intensivist !!Nurse in room and time-outRadial arterial lines only:

Gloves/mask/capCentral lines : Chlorhexadine prep

and full barrier precautionsProcedure note after all

procedures (no matter how they turned out)

General ResponsibilitiesDischarges to home are the exception

PDI in Soarian Dictations Prescriptions

Night duties Restraint forms TPN started – not faxed – attendings to

review prior to faxing Dictate patients every 14 days Dictate prior to moving to other ICU or off

service (except traumas)

Critical Care Clinical Practice Guidelines

Developed by dedicated team of critical care providers at UMMHC

Evidenced basedAvailable on intranet under CCOC Includes specific order sheets

CPG’s include:Transfusion “trigger”ARDS/ALISepsisHypothermia s/p VF arrestAnalgesia and sedationVentilator WeaningVAP: prevention ofGlycemic ControlElectrolyte replacement

Blood Transfusion Threshold CPG

Conservative transfusion trigger in euvolemic, non-bleeding, critically ill patient is proven superior regarding hospital mortality, pulmonary and cardiac complications

Applies to all critically ill patients @ UMMMC except: Actively bleeding Post/pre-op resuscitations Pregnant patients NICU patients

Transfusion CPGTransfusion trigger: Hgb < 7gm/dl Subgroup patient populationsTransfusions require attending approval

unless patient actively bleedingConsider repeat Hgb/Hct if there have

not been any sign or symptomsTransfuse 1 unit RBC at time unless

bleeding.

Transfusion Surgical/Trauma

Post-op patient Hgb BID goal Hg 8mg/dlIf not adequately resuscitated transfuse to

Hg 10 mg/dl

Transfusion: Surgical/Trauma

Consider patient’s operative state: Pre-op Post-op Non-op

Consider adequacy of resuscitation Acid-base balance Hemodynamic stability

o CI > 2.2; FtC 350; CV02 > or equal 70%o No or decreasing vasopressor requirementso No unexplained tachycardiao Restoration UOP > .5ml/kg

Transfusion: Acute Coronary Syndrome

Transfusion trigger Hct < 25

Patients > 65 years old may transfuse at a HIGHER Hct at discretion of attending

Remember: a “troponin leak” is NOT ACS

Transfusion: SepsisEarly Severe Sepsis: must meet all

criteria:oSuspected/confirmed infectiono2/4 SIRS criteriaoSBP < or equal to 90 or lactate > 4oSv02 < or equal to 70% after CVP > 8

and MAP > or equal to 65mmHg

Transfusion: Renal Failure

Patients who are requiring RRT either chronic or acute

Transfusion trigger Hgb < 9 at the discretion of nephrologist/intensivist

Transfusion: SAHSubarachnoid hemorrhage with active

vasospasm Transfusion trigger < 7 There is evidence to support a more

liberal threshold Hgb 10 in severe spasm: this is at discretion of the neurointensivist

Use of Erythropoietin

Most recent studies do not support routine use of erythropoietin

Exception is patient with chronic renal failure on hemodialysis

Sepsis CPGIn USA, severe sepsis/septic shock effects

> 750,000 with overall mortality 29%A systematic and organized approach to

early goal directed therapy to be provided to all our adult patients with sepsis

Goal: early identification and use of sepsis packet with antibiotics within 3 hours in ED and 1 hour in ICU

Sepsis CPG Key elements:

Central access within 2 hours for CVP/fluid/CV02 monitoring

Ultimate goal to be achieved within first 6 hours: o CVP 8-15o CV02 > or equal to 70%o MAP 65-110o Lactate < 4

AntibioticsReview restricted antibioticsVAP treatment based on ATS and IDSA

guidelines: MRSA and GNR Vanco trough for MRSA PNA 15-20 Coverage for pseudomonas PNA with pip/tazo

or cefepime and tobramycin or quinolone (5 days)

1st dose of any antibiotic can be given stat w/o ID approval

De-escalate once cultures back

Central Venous and Arterial Catheter ManagementMandatory education on E LearningStandardized line carts2nd person present during insertion to

assist/monitor and halt procedure if necessary: ensure Intensivist aware!

Standard catheter dressingsStandard documentationNeed for lines reassessed daily on roundsDC “high risk” lines ASAP

Therapeutic Hypothermia for Comatose Survivors of Cardiac ArrestIntubationSedation/analgesiaConsider paralysis to prevent shiveringSupportive measuresInduce hypothermia to 32-34 degrees

within 2 hrs and continue total 24 hrsEvaluate and address potential medical

problemsAddress family concerns

Pain ManagementFentanyl drug of choiceHydromorphone or fentanyl with renal insufficiencyRarely use propofol w/o pain controlNo systemic narcotics with epidural unless

instructed by anesthesia service managing epiduralRarely use narcotic/sedative gtts after extubation,

but must be reorderedConsider ketorolac if no significant bleeding

concerns and normal renal function (48 hours only)

Sedation Protocol CPGStandardized monitoring of pain,

agitation and delirium in mechanically intubated patients

Excludes patients receiving neuromuscular blockade and induced coma for ICP control

Standard order form to be completed include RASS goal and frequency

Sedation ProtocolSedation holiday performed daily on all

patients unless contraindicated Restart analgesic/sedation at 50% dose if

agitatedDelirium assessment daily (CAM-ICU)

Sedation ProtocolFentanyl preferred analgesic in

hemodynamically unstable or severe renal impairment

Remember to include bowel regimenConsider tolerance/withdrawal issues in

patients with heavy opioid requirements and those on narcotic/sedation for a week or more who are at risk for withdrawal

ParalyticsRequires critical care Attending or fellow

approvalMust use SICU NMB protocol order sheetPatient must be heavily sedated and have

adequate pain controlAvoid if also receiving immunosuppresive

doses steroids

ARDS/ALI - Low Tidal Volume CPG

Institution-wide guidelines for adults with ARDS/ALI includes Order Sheet

Multiple randomized control studies demonstrate use of lower TV in ARDS/ALI

Decreased mortality with use of 6ml/kg TV (IBW)

Ventilator Weaning CPGApplies to any patient intubated for >48 hoursRRT to discuss with SCIU team who shall be

weanedPatients to consider weaning

Evidence of some reversable of cause of respiratory failure

Pa02/Fi02 > 150 PEEP < 8 Fi02 < 0.5 Arterial pH 7.3 - 7.5 No evidence of active cardiac ischemia Hemodynamic stability Some indication of inspiratory effort

Weaning ProtocolIf patient fails weaning evaluate barriers to

weaning Cardiac ischemia / LV dysfunction Volume overload Pulmonary / systemic infection Malnutrition Neurologic dysfunction including over sedation Pain / anxiety Pre-existing pulmonary disease Inappropriate ETT size Electrolyte abnormalities Thyroid disease

Weaning ProtocolDaily worksheet done by RRTSpontaneous breathing trial with CPAP 5 to 8

cm H2O of PEEPIf CPAP successful for 2 hours evaluate for

extubationTermination of SBT

New onset diaphoresis / arrhythmias SBP > 180 or > 20% increase baseline HR > 120 or > 30 from baseline Sa02 < 90% or Fi02 > .6 If ABG obtained: pH < 7.3; paO2 < 60; sa02 < 90% or

pC02 > 10 above baseline

VAP CPG Preventable cause of morbidity/mortality and excess

cost in ICUs Steps in Prevention

HOB elevation to 30 degrees unless contraindicated Oral intubation OGT Rapid extubation as able and adherence to weaning

protocol Sedation protocol Minimization of self-extubation Prevention gastric over distention by checking

residuals q 4 hours Oral hygiene with chlorhexidine @ least q 8 hours Vaccinate for influenza/pneumococcus Avoid contamination respiratory circuit

Venous Thromboembolism CPGAll patients to receive prophylaxis unless

contraindicated (i.e. bleeding or head injury / hemorrhage) Chemical prophylaxis preferred over mechanical Enoxaparin

o 40mg dailyo 30mg BID o Unfractionated heparin in patients with somewhat

elevated risk bleeding or creat clearance < 30. Smaller doses can be used. Higher doses for morbidly obese

o SCD to be utilized unless contraindicatedo In case of inadequate prophylaxis of 3 or more days in

high risk surgical/trauma patients doppler screening LE o Consider IVC filter if unable to adequately prophylax high

risk patient

Glycemic Control CPGTo ensure safe and effective management of

tight glycemic control Goal 80-140 mg/dlAll ICU patients placed on glycemic control

protocol and BS monitored for effectivenessEvaluate for transition to sliding scale/long

acting insulin coverage PO diet Clinical condition stabilizes Stable insulin gtt dose Stable caloric intake Approaching transfer

Increased ICP CPGSix step process

1. Assess at-risk population2. Assess for hyperosmolar therapy3. Initiate hyperosmolar therapy4. Deep Sedation5. Pharmacologic coma6. Paralysis

AlwaysConsider

NeedFor

Surgery

Therapeutic Hypothermia for Comatose Survivors of Cardiac Arrest

2005 AHA Guidelines indicate instituting mild hypothermia improves neurologic outcome

Scope: All patients 18 and older who remain comatose post-VF cardiac arrest, with return of pulse pressure Excluded: major head trauma, recent major

surgery, sepsis, bleeding, pregnancy

Pressure Ulcer Care CPG

PREVENTION including ordering air mattress/specialty bed on high risk patients

Daily skin assessment with report to clinical staff by nursing with weekly PU reports

Education for residents, midlevels and nursing staff

Pressure Ulcer Care CPG1.3 to 3 million adults affected with

incidence of up to 38% hospitalized patients

Aim is to reduce/eliminate hospital acquired pressure ulcers

Pressure Ulcer Risk/Assessment completed with 24 hours of admission (Braden Scale)

Ongoing skin assessment on ECare Manager Flow Sheet

SICU Rotation:Is a GREAT learning opportunity

Has GREAT Faculty

Has GREAT NP/PA support

Is only what you make of it

Intellectual Curiosity