QMC MICU ORIENTATION

1
QMC MICU ORIENTATION

• April 5, 2004
• MICU Director Dr. R. Friedman, MD
• DME Bruce Soll, M.D.
• CMR Sandra Loo, M.D.

2
PHILOSOPHY

• EXCELLENT PATIENT CARE
• COLLEGIALITY AND CAMRADERIE
• Team work is the KEY to survival in MICU!
• LEARNING
• Key ICU topics i.e. ventilator management, MOF
• How to stabilize critically ill patients
• Procedures i.e. cathether placement, intubation
• HAVING FUN

3
TEAM STRUCTURE

• MICU (QET4M) is a closed, separate unit from
  wards
• R2 Categorical residents (4)
• R1 (FP, Preliminary,Transitional) residents
• R3 on elective
• Medical Students (MS IV or Sub-I)
• Intensivist (in-house 24 hrs/day)
• MULTI-D APPROACH
• Pharm-D, RTs, Nurses, SW

4
Intensivist Coverage

• Usually, there is an intensivist in house 24hrs
• Recently, there has been shortage and some talk
  about R3 doing overnight call without intensivist
  in house (home call)
• However, ideally, there should be intensivist in
  house
• It is ok for R3 to be on call in MICU when
  intensivist not in house with following
  safeguards
• QMC will recruit new intensivists aggressively
• Intensivist will be available by phone and will
  come into hospital if R3 asks

5
Intensivist Coverage

• Hospitalist will assist with Code 500s and will
  be available to help with emergencies
• Private intensivists and attending on case will
  come if requested to come in
• Private pulmonologists have offered to assist if
  needed
• Trauma surgeon will be of service if able for
  emergencies
• If R2 on call without intensivist, can ask CMR to
  be on call with them if necessary
• Not a problem thus far this year

6
Work Hour Rule

• New ACGME Guideline as of 7/1/03 Residents
  Interns should be working lt 80hrs/week on average
  over a 4 week period
• Ex If work 85hrs for first week, this is not a
  violation however, would then need to work lt
  75hrs the next week to come out with an average
  of lt 80hrs/week

7
Work Hour Rule Contd

• Work Hours on next slide sheet are the maximum
  times you can work until and still be under
  80hrs/week on average (see MICU Work Rule Sheet)
• You should go home earlier than these maximums if
  your work is completely done
• If you go over time, then you must compensate by
  leaving earlier at a later date
• It is your responsibility together with your
  attending to take comprehensive care of each pt,
  work efficiently, comply with these work hours,
  notify the CMR if going over 80hrs/week on
  average
• After the Work Hour Rule Sheet is reviewed with
  you by the CMR and your questions are answered,
  please sign the Work Hr Rule Sheet Contract
  turn into the CMR today

8
WORK HOURSACGME Work Hrs 80hrs/Week

• WEEKDAYS
• Arrive by 7 am
• MICU AM rounds start at 830am SICU Xray Rm
  (QET4C)
• Sign Out Leave by 4 pm
• Post-call leave by 1 PM
• WEEKENDS AND HOLIDAYS
• Arrive by 7am
• Leave by 1 PM

9
Call Schedule

• Call schedule 7A-7A
• R1 (Prelims, FP) Q4 overnight call
• R2 Q4 overnight call (7/mo)
• R3 on elective, med students optional call

10
Days Off

• 1 day off / week
• If want to switch days off with another person,
  please let CMR know after discussing with
  appropriate residents/attending
• MS on elective should get day off on weekends

11
Responsibilities Overview

• Admit ICU patients
• Admit patient to MICU from ER
• Accept transfer from our wards
• Accept transfer from outer island ICU
• (Note Pls let intensivist know about the
  admission before going to work patient up if they
  were not the ones who contacted you regarding the
  admit/transfer)
• Transfer patient out of MICU
• Respond to Code 500 (UL on call leads Code!)
• Assist with unstable patients on floor
• TEAM WORK is very important!

12
Responsibilities Admission to MICU

• Cap of 8 pts for upper level residents per call
  (resident carries no more than 12 pts at any one
  time)
• Cap of 5 pts for intern per call (intern will
  carry no more than 4 pts at any time)
• MS IV will follow no more than 2 pts at a time
  write daily PN in chart a brief addendum to note
  is required by resident!
• MS IV can write HP Transfer Summaries, but
  need short addendum/signature by resident
  (students do not have dictating priveleges at
  QMC)
• Contact appropriate attending and consultants
  only courtesy!!!
• May choose to handwrite or dictate Admit HP

13
Responsibilities CODE 500

• MICU TEAM Upper Level is the code leader
  (position is at the foot of the bed)
• If pt is on MTC, then the ward team may take
  responsibility for the code
• If ward upper wants to run code, allow them
  (decide amongst yourself)
• MICU Residents, Interns, MS3/4s assume duties as
  ability/experience allows (i.e., lines, CPR, ABG,
  chart review, etc)
• Code leader must sign code sheet and write code
  note as well as notify attg of event
• Decide together with ward team whether pt goes to
  CCU or MICU

14
Responsibilities Accepting Transfer - from WARD
to MICU

• Please help ward residents stabilize and transfer
  the patient to the MICU
• Both Attending MICU physician must be aware of
  and agree with the transfer
• MICU vs CCU transfer Think for the pt!
• Handoff (between MTC and MICU)
• There must be a verbal as well as written handoff
• Ward team Transfer Note to MICU
• MICU team Accept Note/Admission HP from Ward

15
Transfer Out - from MICU to MTC

• Both private attending intensivist should agree
  on transfer
• If Private Attending has MTC priveleges, ask them
  if they want MTC
• If pt coming out to MTC, please call MTC
  admissions pager as early as possible at
  578-8169
• If Pt without Private Attg coming into MICU, now
  needs an attg as transferred out of MICU call
  triage hospitalist on call at 5-8751
  hospitalist must accept 1st if hospitalist wants
  residents, he will notify UHS attg team (or
  Ward Long Call team if after 430pm)
• Handoff verbal and written handoff
• MICU Transfer Note (written ok dictation okay if
  can get stat, within the hour let mtc know
  dictating)
• For MICU to private care transfer, full transfer
  summary is not required unless requested!

16
CCU Admissions/Transfers

• CCU (Ward team)
• Primary cardiac problem
• Low to moderate acuity
• e.g. angina, CHF, PTCA, VT alone

• MICU (ICU team)
• Multiple organ systems involved
• High acuity even if primary cardiac problem
• e.g. intubated, multiple drips, HD or CVVHD,
  sepsis

If in doubt, consider appropriateness of coverage
by R1 night float vs ICU team Remember The ward
team cant stay in CCU all day
17
PAPERWORK

• Handwritten or Dictated
• Admission HP (within 24hours) if dictate, ask
  to dictate STAT
• Transfer Summary out of MICU (same day)
• Be detailed/complete by systems on main events
  that occurred in MICU
• Must be in chart PRIOR to having MTC pick up pt
  if running around, pls let accepting resident
  will get in chart ASAP MTC can refuse to see pt
  unless transfer summary available for them
• Only needs to be done if MTC accepting pt or if
  hospitalist accepting pt if private attg taking
  care of pt on own, then no need as they have been
  following while in MICU
• Off-service (Interim) Summaries when sign off or
  leave service
• Dictated Death summary by UL only (even for
  interns pts should be following along with
  them if admitted with them)

18
Oncology / Neurology Services

• Please notify appropriate resident of all cases
  of interest (for their learning)
• Oncology resident works with Dr. Higuchi
• Neurology resident/students work with Dr. Watters
• Pager numbers are on back of QMC Ward/MICU Call
  Schedule (bright green sheet)

19
Other Nocturnal Creatures

• ICU Intensivist (24 hour coverage)
• Ward Team (UL, R1, sub I, students)
• Can run things by UL on Ward team or ask for
  assistance
• R1 Night float (1800pm - 0600am)
• Now admits with UL on shift
• Covers non-call team patients
• Will often call you to help with unstable patient
  (possible transfer)
• Hospitalist (24 hour coverage)

20
MICU Case Conference

• MICU Case Conference
• All MICU residents must attend
• Starts at 1230pm, Iol - 5
• Third Wednesday of each block
• Dr. Scott Gallagher in charge
• Required case conference for MICU residents
• Bring cases (2-3)
• bring relevant xrays, ekgs, additional info
• Discuss which cases will present with Dr.
  Gallagher/Dr. Ikeda beforehand
• Case Presentation is brief relevant info only
• Articles welcome, but preparation of formal
  didactic is not necessary unless Dr.
  Gallacher/Ikeda want you to

21
Conferences Contd

• OIM/Board Review/Grand Rounds are optional
• not required during MICU!!!
• if attend OIM anyway, it doesnt count
• should not attend if means going over your work
  hours
• Ward Noon Conferences (I5 or QCC)
• Not required
• See paper schedule for dates/times/place
• Has lunch available except Tuesdays
• MM Rounds (Iol-5)
• Inform CMR of all autopsies immediately!!!
  log deaths on Death Log on bulletin board of ICU
  Call Rm please keep updated!
• Third Thursday of each block
• Not required should try to attend as interesting
  cases
• Ward and MICU cases to be considered may be
  asked to present deaths at MM Conference!!!

22
Pathology Support for Conferences

• Both Team and Case conferences, esp MM
• Great support and teaching
• gt48 hr notification to pathology required
• Contact Dr Kirk Hirata
• They will direct you to pathologist who did the
  autopsy so you can ask them to be at conference
• Please go over slides with pathologist beforehand
  so they know what you want to highlight

23
Autopsy

• Encourage post-mortem exams, especially on
  patients with unknown or unexpected deaths it
  helps us to learn!
• Depending on your relationship with the family,
  you may want the attending to be present as well
• Rayette Kaneshiro (x 2896),Chief Path Assistant,
  to coordinate viewing of post-mortem (usually lt48
  hrs on weekdays)
• Report all deaths to CMR!
• I will contact Rayette to notify of death and
  that autopsy was decided
• She will contact me to let me know when autopsy
  is going on (pls attend if you can)

24
Autopsy Report

• When attend autopsy, sign the Resident Autopsy
  Sign-in Log in the morgue
• Can ask the pathology resident to take pictures
  of gross specimens when attending autopsy (for
  MM Rounds)
• Autopsy Report available in Medical Records gt
  48hrs after autopsy
• Will be flagged for your review
• Sign the Autopsy Report Review Log in Medical
  Records after reviewing the autopsy report

25
MEDICAL RECORDS

• Check WEEKLY for pending dictations or signatures
• Delinquent records posted weekly
• If charts not completed in timely manner,
  suspension (without pay) may be imposed may not
  pass rotation
• Access key application apply at medical
  records for 24hr Medical Records access
• COPIES
• Ask med records staff to help with copying chart
  material in compliance with HIPPA
• Give atleast 24hr notice when want copy of pt
  material from their chart

26
CONFIDENTIALITY

• QMC Monitors Your Actions on CLIQ
• Do not attempt to access any pts record unless
  you are directly involved in the care of the
  patient
• If using PDA (i.e. Palm pilot) for patient
  information, it must be Password Protected in
  case it is misplaced
• Do not discuss pts diagnosis/care in public
  places i.e. elevators (or in front of 3rd parties
  in pts rooms if dx is sensitive i.e. HIV)
• Discard patient specific information in shredding
  bins on floors (grey bins)
• Watch where you leave your sign outs

27
HIPPA Regulations

• Need your own PACS Code (for CT viewing)
• Call Charles Kam 585-5436
• Also need to fill out request form from CMR
• He will give you an ID Password (resident,
  resident works in ICU xray room)
• Do not e-mail ANY patient information
• Conference preparation
• Need to fill out HIPPA paper work at medical
  record at least 24 hrs BEFORE conference for any
  copy of patients chart
• Eliminate names for public presentation
• MR and Account are OK

28
IMPORTANT!!!

• QMC Blood/Body Fluid Exposure Policy
• 24-hour confidential hotline [phone]
• Dont wait! Based on the risk, the exposed person
  may need immediate care and follow-up
• Alternative Call ER
• Please let CMR know about needlestick injuries
  ASAP next working day (have to notify HRP,
  UHIMRP within 24hrs)
• Please review the Infectious Waste Disposal
  Guideline in packet
• Clean up after your own sharps/mess after each
  procedure to prevent injury to others!!!
• Abuse, harassment, or other inappropriate
  behavior is NOT tolerated
• Please let CMR or Dr. Soll know about any problems

29
Communication

• Communicate the plans with the attending
  physician on a daily basis
• should be by telephone or in person every day
• Update attending, keep everyone on the same page
• Let Attg or consultants know about major changes
  in status or plans
• Please change pager messages appropriately
• Asked to call a Consultant?
• You and the Attending should agree on 3 names
  Call them in order
• If none are available, call the attending and ask
  them to obtain a consultant on their own
• At end of rotation before you leave, always sign
  out your patients to next bunch (decide together
  how you are splitting up patients sign out to
  incoming residents)

30
Reminders

• Sympathy Cards in I-5
• Procedure Cards in I-5
• QMC 9F copier
• Ask for key at 9DH nurse station
• Code ID 1103, Password 6377
• Batteries for pagers available from CMR
• Scrubs can ask for pair to borrow for month
• Prescription Writing on D/C Orders - 1 wk supply
  is max
• Intern in MICU has code pager now as well!!
• If pagers go down while on call call ER
  (4311)/bed control (4389)/console (4501) and let
  them know tell them to contact you using the
  Code Pager as back up pager

31
Reminders Contd

• Asking all MICU residents/interns to track their
  work hours (on yellow work hr tally sheet)
• Please let me know immediately if you are going
  over 80hours per week on average after 2 weeks
  midway so that can assess respond to this
  also, give attendings a heads up if this is
  occuring so they are aware can assist in
  getting out

32
ACGME CompetenciesIncorporated into Curriculum /
Evaluated by Various Tools

• 1) Medical Knowledge
• 2) Interpersonal Communcation
• 3) Patient Care
• 4) Professionalism
• 5) Practice Based Learning
• 6) Systems Based Practice

33
Others...

• Faculty eval via computer throughout month
• WebCT website
• No Continuity Clinic for the block!
• Procedure List
• If have available procedures that may be needed
  by R4/R3, pls give them a chance by calling if
  procedure not emergent (will have list in ICU of
  residents who need major procedures i.e.
  paracentesis, thoracentesis, etc)
• Educational Materials
• Articles available In MICU Call Rm White Binder,
  I5 File
• Textbooks available in I5, Ward Call Rms
• UTD available on any computer with internet
  access (htt//utdol.com)
• Marino Book in ICU Call RM
• ICU PDA/PDF/PowerPt Files on desktop of Call Rm
  computer
• Resident MICU Handbook (in PDF file on Desk
  topI5, MICU)
• MKSAP 13 Books if want to borrow a section for
  the mo, ask CMR

34
MISCELLANEOUS

• Keep your call room clean
• Iol 5 Resident Conference Rm Code 4-3-1-2
• Help the post call colleague! Team work is the
  key for survival in MICU
• CMR will sometimes join MICU rounds
• Call Help Desk right away if on call rm computer
  not operating right (via operator)
• Please dont take textbooks home
• Any Questions, just ask!!!
• At end of block, evals should be turned into
  CMR!!! (Robyn places in your mailbox)
• Let me know about any problems CMR always
  available for assistance