WELCOME TO THE PICU

1. WELCOME TO THE PICU

2. 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

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

5. Other Teaching Conferences

6. 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.

7. 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

8. 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

9. PICU Tables at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html • Sedation • Inotropes • Shock

10. 2 Teams in PICU

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

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. 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. 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!!

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

29. 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

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

31. 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

32. 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! **

33. 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

34. 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!!

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

36. On Cerner Specific Power-plans available in PICU folder include: Fever work-up Trauma admit PICU Daily orders Respiratory failure DKA Hyperkalemia PICU specific Power - Plans

37. 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

39. 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

40. 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

41. 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

42. 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

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

44. Discharge Planning

45. Catheter Associated Bloodstream Infections

46. Ventilator Associated Pneumonia

47. Patient Safety

48. 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 !!!

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

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