Welcome

1. Welcome to the Intensive Care Unit

2. Learning Goals • To learn to care for critically ill patients • To understand management of respiratory failure with mechanical ventilation • To develop a better appreciation of cardiopulmonary physiology • To understand indications for different modalities of hemodynamic monitoring • To improve on techniques to place invasive monitors

3. Learning Goals • Understand the pharmacodynamics and pharmacokinetics of sedatives • Learn the communication skills required in the role of the critical care consultant • Develop a multidisciplinary treatment plan for critically ill patients • Have a fun and educational month

4. Organization • 8/11 ICU = ± intern, ± 1-2 CA-1 residents, 1 CA-3 resident, fellow(s), attending • 9 ICU = 2 NPs, 2-3 residents (CA-2, ED, IM), fellow(s), attending • 10 ICU = 1 NP, 1 CA-3 resident, fellow(s), attending • 13 ICU = 4-5 residents (CA-2, ED, IM), fellow(s), attending Fellow(s) = Anesthesia, Pulmonary, Neurovascular, Surgery

5. Housekeeping - call schedule • Call is approximately once every 3-4 nights, averaged over the entire rotation. • Post-call resident leaves before 1100 • Schedule changes are not allowed unless approved by Dr. Shimabukuro (an extremely complex schedule)

6. Housekeeping - Call rooms • 13 ICU – M1318 (outside of ICU, corridor between Moffitt and Long, on left side as you walk towards Long), use your name badge, use room with door labeled “ICU resident” • Shared bathroom (with surgery resident) • 8/9/10 ICU - in 9 ICU, use north room (one on right when facing both doors), no code or lock (ie, DO NOT LEAVE VALUABLES) • Shared bathroom (with ICU fellow) • ICU fellow – in 9ICU, south room.

7. Housekeeping - Call rooms • If someone else is using the call room, find out what department and/or service and notify Dr. Shimabukuro immediately by pagerbox or email.

8. Housekeeping - daily routine • Lectures start at 8am sharp every weekday (0815 on Wednesdays) in room M919 • Check schedule for topic and speaker (it may be you!!!) • Rounds start at 0900 weekdays and at 0800 on weekends • X-ray rounds immediately follow attending rounds (at the discretion of the attending) • Afternoon rounds with fellow(s) start at 1700 • DO NOT LEAVE before checking in with the fellow or attending

9. Housekeeping – weekends/holidays • Only on-call and post-call residents round • If you are neither, you have the day off • Try to pre-round on the sick ICU patients • Remainder of patients can be discovery rounds (at the discretion of the attending) • Notes are written either before or after rounds (at the discretion of the attending) • Place emphasis on assessment/plan

10. Housekeeping - Lectures • Each resident and medical student will be responsible for a 30-minute lecture during the rotation • Please check the lecture schedule for assigned topic and date • Medical students are allowed to pick a topic of their choice • Read schedule carefully, lectures are split (ie, 2 lectures on a day) based on level of training or ICU experience

11. Housekeeping – “paperwork” • List to be described on following slides • General APeX comments • Notes • Patient list • Admit Orders • Central Line Procedure Note • Procedure Note

12. APeX • Context: CRITICAL CARE MEDICINE SVC Click here to search/change

13. APeX • “wrenching” in flow sheets/reports/accordions

14. APeX

15. APeX Finalize To reorder on the bar

16. APeX • Flow Sheets/Reports/Accordions • MAR Report/ Med List (if not already there) • Comprehensive/Comp (if not already there) • Hemodynamics (for those on 10ICC) • LDA (current and past central/arterial lines with insertion/discontinue dates and locations)

17. APeX • Flow Sheets/Reports/Accordions • Hematology (Blood products administered) • Fever OR ID/Sepsis • Insulin/Glucose • Labs since admission • Radiology • Microbiology • Critical Care SO/RND

18. APeX • Nurses Notes: Use “Notes” Tab: All notes

19. APeX Nurses Notes: Comp flow sheet at very bottom or at top

20. Progress Notes • General progress note template is in the “rounding” navigator

21. Progress Notes Open problem list Add a problem Add an assessment and plan

22. Progress Notes • Problems added to the Problem List are seen by all providers • Assessment and plan added to each problem are seen by all but ONLY appear in the CCM SVC notes (ie, what a surgery resident writes under the same problem will NOT appear in your note)

23. Progress Notes

24. Progress Notes

25. Progress Notes Attending of the week

26. Progress Notes

27. Progress Notes Progress Note

28. Progress Notes • If using another’s template or your own

29. Progress Notes • Using copy forward Copy Forward

30. Notes • Using copy forward Select note

31. Notes • Using copy forward

32. Notes • Be very careful about copy-forwarding notes. Always review the entire note for accuracy. (ie, a patient cannot be “POD#2” for 5 days in a row)

33. Notes • Be as specific as possible for the assessment/ problem list • Altered mental status versus ICU delirium • COPD Exacerbation versus acute hypercarbic respiratory failure from pneumonia on (and) COPD • UTI with hypotension versus septic shock from (and) UTI

34. Notes • Be specific as possible with the plan • For instance, “wean vent as tolerated” vs. “Patient continues to require a high minute ventilation due to a likely large dead space fraction from resolving ARDS. He is not tolerating a rapid wean. Failed SBT yesterday due to sustained respiratory rate in the 40’s with desaturation. Will try again today.”

35. Notes • “Co-sign Required” should be checked unless otherwise specified by your attending • Title of note should have: • “Critical Care Medicine Progress Note” • “Critical Care Medicine Admission Note”

36. Admission Notes

37. Admission Notes Remember the tabs

38. Admission Notes

39. Admission Notes H&P Note

40. Admission Notes • You are allowed to use your own/others H&P template via a dot-phrase. • Don’t forget about co-signature and title/header of note • Chose the correct note type

41. Patient list • The filemaker database is in the fellow’s office. It should be updated daily. The password is m917icu • Post call resident will print out copies for the team • Do not leave in the ICU (patient confidentiality) • Make sure to enter morbidities and mortalities

42. Admit Orders

43. Admit Orders IP Adult Core Admission Orders

44. Orders • Other order sets of interest: • IP Adult Core Admission Orders • IP Adult ICU Addendum • IP Adult Sepsis • IP Adult Continuous Neuromuscular Blocking Agent • IP Adult Blood Product Transfusion • IP Adult PCA

45. Orders • The IP Adult ICU Addendum Order Set needs to be completed by the ICU resident for every patient admitted to 9/13 ICU. On 8/11 and 10, they only need to be completed for patients the service is following • The IP Adult Core Admission Order Set may also need to completed. Ask your fellow.

46. Orders • Use “Order Management” to modify/discontinue existing orders and/or add new orders

47. Orders • Mechanical Ventilation • There is NO order set • Search under “ventilation” or use IP Adult ICU Addendum Order Set ARDSNet Protocol PSV/CPAP

48. Orders • Mechanical Ventilation • Don’t forget to write for oxygen titration orders under admin instructions • When changing between modes, don’t forget to discontinue the old one • SBT: search under “SBT”

49. Procedure Notes

50. Procedure Notes