WELCOME TO THE PICU

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WELCOME TO THE PICU
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Flow Of The Day

• Before 8am Pre-round
• 800 - 830am Morning Report
• 830 - 900am Rounds
• (Except Fridays, rounds start at 9am after Grand
  Rounds)
• 900 - 930am Radiology Rounds
• 930 - 1100 am Finish Rounds
• 1100 - 1200am Work time

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Flow Of The Day

• 1200 - 100pm Noon Conference
• 100 - 430pm Completing work of the day
• 430 - 530pm Sign-out Rounds with night team

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Prevention of Resident Duty Hour Violations

• Do not begin pre-rounds before 6am
• Evening rounds begin at 430pm
• Be sure to leave by 12pm on post-call days
• If your patients are not rounded on by 1130,
  hand your notes to on-call resident

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Teaching Conferences

• Tuesday 7 8am CV ICU Conference
• PICU Conference Room
• Tuesday 12 1pm PICU fellow conference
• PICU Conference Room
• Thursday 3 4pm Sign out round
• PICU Conference Room
• Welcome to all!

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Educational Resources

• PICU resident handbook with relevant PICU topics
  is available at
• http//peds.stanford.edu/Rotations/picu/picu.html
• Hard copy is available in the resident call room

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PICU chapters at http//peds.stanford.edu/Rotation
s/picu/picu.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

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PICU chapters at http//peds.stanford.edu/Rotation
s/picu/picu.html

• Cardiomyopathy
• Liver Failure
• Acute Renal Falilure
• Fluids, Electrolytes, Nutrition
• Oncology
• Transfusions
• DKA

• Submersion Injuries
• Brain Death
• End of life issues

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PICU Tables at peds.stanford.edu

• Sedation
• Inotropes
• Shock

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Resident Role

• Receive sign out from overnight resident
• Pre-round on PICU patients
• Present patients at morning rounds beginning
  promptly at 830am
• 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

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Resident Role

• Recognize the patients are often very complicated
  and managed collaboratively with other services
  e.g. neurosurgery, liver transplant, heme-onc,
  cardiology, etc.
• Significant changes to patient status should be
  discussed with the other services

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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

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PICU Evaluations

• Group faculty evaluation completed on MedHub
• Verbal feedback from attendings while on the
  rotation Be sure to ellicit feedback if not
  provided

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Other Trainees HCPs in PICU

• Anesthesia fellows
• Emergency medicine residents
• Medical students
• Nurse Practitioners

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Anesthesia Fellows

• Only present for half the blocks
• Primarily provide support for fellow level
  activities in the ICU
• Will not carry any patients

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ED Residents

• Will act as a 5th resident in the PICU
• To care for equal number of patients as pediatric
  residents
• Will take call with a pediatric resident and
  cover half the patients
• Excused for Wednesday AM ED conferences, but must
  pre-round and hand over notes to on call resident
  prior to leaving for education rounds

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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

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PICU NP Role

• Hours of coverage in PICU
• Mon-Sat 730am - 500pm
• Assist residents with ICU specific systems
  issues, e.g. writing PICU notes
• Complete daily goal sheets and review with
  Bedside RN at completion of rounds
• Pre-round on patients on Saturday

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PICU NP Role

• Assist with patient flow
• Pre-round with consultants, i.e. neurosuregery,
  and update resident with recommendations
• Writing accept notes and orders on post-op
  patients as needed, i.e. during am / pm sign-out
• Entering transfer orders for patients requiring
  transfer during rounds, etc.
• Attend Multidisciplinary rounds on Tuesdays at
  11am

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Notes

• New admissions require a dictated HP and a brief
  note in the chart
• Post-operative admissions can have a post-op
  admission note written in the chart
• Patients in the ICU for longer than one week
  require a dictated clinical summary each Thursday

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ICU Transfers

• Patients being transferred from the ICU require
• Transfer summary
• Transfer orders
• Surgical patients surgeons often write orders
• Sign patient out to ward resident

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Rounding Presenting Patients
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• Sample PICU
• Progress Note
• Each patients note printed from Cerner (LPCH
  computer system)
• Assure printed information up to date, i.e.
  ventilator settings

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• Patient identification
• Quick assessment i.e. patient improving,
  worsening, or unchanged
• Major (not all) interval events
• Vitals

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• Physical exam present exam appropriate for
  patients disease, e.g. neuro exam on
  neurosurgical patient (but examine all of
  patient)
• Present meds in appropriate system e.g. steroids
  for asthmatic vs. steroids for liver transplant
• Respiratory
• Data CXR findings, mode of support - NC vs BiPAP
  vs ventilator
• A/P changes in pulmonary compliance and changes
  in respiratory support accordingly

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• CV
• Data inotropic support, rhythm, echo results
• A/P changes in hemodynamic status and need for
  changes in inotropic support
• Neuro
• Data sedation medications, imaging studies
• A/P changes in neuro status, requirements for
  sedation
• FEN/GI
• Data I/Os, nutritional source, calories per
  day, Labs
• A/P changes in fluid status or liver functions,
  modifying nutritional support

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• Renal
• Data urine output, any renal replacement
  therapy, changes in BUN/Cr
• A/P changes in renal function or diuretics
• Heme
• Data labs, anti-coagulants
• A/P changes in Hct, need for transfusion,
  coagulation status
• ID
• Data WBC, cultures, antibiotic levels
• A/P changes in antibiotics, etc.
• Psycho-social
• Family conferences or discussions with family

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• One line of overall assessment and major plans
  for the day at the end
• Review orders

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Procedures

• PICU fellows are given priority for all
  procedures (particularly 1st year fellows)
• They must be trained in them prior to completion
  of their fellowship
• Acute situations fellow or attending will do
  procedure to optimize patient care

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Procedures

• Procedures residents should acquire some degree
  of comfort with while in the PICU
• Bag-mask ventilation
• Operating an anesthesia bag
• Chest compression
• Placement of peripheral IVs

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Bedside Nurses

• COMMUNICATION
• COMMUNICATION
• COMMUNICATION
• Tell bedside nurse you are the resident caring
  for that patient
• Give them your pager

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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 cant
  make it to bedside

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Bedside Nurses

• Assure bedside RN present for rounds
• Morning rounds discuss orders for the day
• Evening rounds discuss plan for the night
• Midnight rounds discuss am labs, x-rays, etc.

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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!

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Orders

• Do not write specific times for meds allows RN
  to time them as possible for existing lines
• Do not time labs
• except for immunosupression drugs
• e.g. Prograf, CSA

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Order Entry

• PICU order sets available on Cerner include
• Delete previous diet orders
• Orders that require daily entry
• CBC
• Coags
• Chemistries
• CXR
• If labs or radiology studies listed in
  power-plan, no re-entry required

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Order Entry

• On Cerner
• PICU folder under Power-plan folders

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Order Entry

• On Cerner
• Power-plans found in PICU folder

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COWS

• Be sure to sign off
• Dont leave patient information exposed
• Plug them back in (a dying cow is not pretty)
• !! No cow tipping !!!

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Final Thoughts

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

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• Questions, concerns, thoughts on the rotation
• Contact PICU rotation director -
• Dr. S. Kache at
• Skache_at_stanford.edu
• 723-5495
• Pager 13483