WELCOME TO THE PICU
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
Flow Of The Day
12:00 - 1:00pm: Noon Conference
1:00 - 4:30pm: Follow-up
consultations/procedures/postop admissions/didactics
4:30 - 5:30pm:
Sign-out Rounds with night team
Resident Teaching Conferences
PICU resident lectures:
• Monday / Thursday
• 8 – 8:30am
• In place of morning report
• At front desk in PICU
Other Teaching Conferences
Tuesday
12-1
PICU Fellows
Conference
2E PICU
Conference
Thursday
12-1
PICU Conference:
M&M, Journal
Club, Fellows
research
2E PICU
Conference
Educational Resources
• PICU resident handbook with relevant PICU
topics is available at
http://peds.stanford.edu/Rotations/picu/picu_re
c_readings.html
Hard copy is available in the resident call
room.
PICU chapters at
http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
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Monitors in ICU
Vascular Access
Codes
ICP management
Status Epilepticus
Sedation
Pediatric Airway
Airway Management
• Mechanical
Ventilation
• ARDS
• Status Asthmaticus
• Inotropes
• Shock
• Sepsis
• Meningococcus
PICU chapters at
http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
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Cardiomyopathy
Liver Failure
Acute Renal Falilure
Fluids, Electrolytes,
Nutrition
• Oncology
• Transfusions
• DKA
• Submersion Injuries
• Brain Death
• End of life issues
PICU Tables at
http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
• Sedation
• Inotropes
• Shock
2 Teams in PICU
Team A
Team B
Attending
Attending
Fellow
Fellow
Second year pediatric resident
Third year pediatric resident
+/- NP
ED resident
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
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
Other Trainees in PICU
• Anesthesia fellows
• Emergency medicine residents
• Medical Students
Anesthesia Fellows
• Present for half the blocks
• Primarily provide support for fellow level
activities in the ICU
• Will not primarily follow patients
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
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
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
Notes
• The following need a full H&P:
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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
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
Notes
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Online
PICU specific templates
Systems-based note
Indicate attending on your team and select
“sign” not “review”
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
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
Rounding & Presenting Patients
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
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
• 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
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!!
Procedures
• PICU fellows are given priority for all
procedures (particularly 1st year fellows)
– Prerequisite for CCM training
• Acute situations : fellow or attending
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
Bedside Nurses
COMMUNICATION
COMMUNICATION
COMMUNICATION
– Tell bedside nurse you are the resident caring
for that patient
– Give them your pager #
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
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! **
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
Order Entry
• Most routine labs and CXR require daily orders:
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CBC
Coags
Chemistries
CXR
• Qam labs in PICU are drawn at 4 or 5 am
• TIP: Use PICU Daily Orderset during rounds!!
PICU specific
Power - Plans
• In Cerner
• PICU folder found
under Power-plan
folders
PICU specific
Power - Plans
• On Cerner
• Specific Powerplans available in
PICU folder
include:
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Fever work-up
Trauma admit
PICU Daily orders
Respiratory failure
DKA
Hyperkalemia
Admitting Trauma Patients
• ANY TRAUMA patient—admit as follows:
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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
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
Discharges
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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
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
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
PICU Dashboard Tab
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Ensure Best
Practices for
✔CABSI
Prevention
✔Pressure
Ulcer
Prevention
✔VAP
Prevention
Discharge Planning
Catheter Associated Bloodstream Infections
Ventilator Associated Pneumonia
Patient Safety
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 !!!
PICU Etiquette
• Please speak in quiet voices, particularly
around main nurses station
• We follow HUSH in the PICU
Final Thoughts
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Take ownership of your patients
Be present
Be involved
Ask questions
Suggestions on improving the rotation
Questions, concerns, thoughts on the rotation
Contact PICU rotation director Dr. Courtenay Barlow at
cbarlow@stanford.edu
Pager: 23492