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/Receive sign out
Morning report…MANDATORY
Rounds begin
Radiology rounds
Completion of morning rounds
Work time/didactics/first post-op
admits
Flow of the Day
12:00 – 1:00pm
1:00 – 4:30pm
4:30 – 6:00pm
Noon Conference
Follow up consultations,
procedures, post-op
admits, didactics
Resident/fellow sit down
sign out, followed by night
team only walk rounds
Resident Teaching Conferences
PICU resident lectures:
 Thursday afternoons
 3-4 pm
 At front desk in PICU
 Mandatory lectures
Other Teaching Conferences
Tuesday
7:30 AM
CVICU lecture
2E PICU
Conference Room
Thursday
12-3 PM
PICU Divisional
conferences
2E PICU
Conference Room
Thursday
12-1 PM
PICU Resident
small group
conferences
(palliative care x2,
vent teaching with
RT, code team/cart
teaching)
TBD each week,
emails sent from
pediatric chiefs
Friday
7:30 AM
CVICU
Conference with
Dr. Hanley
2E PICU
Conference Room
Educational Resources
 PICU resident handbook with relevant PICU topics
is available at
http://peds.stanford.edu/Rotations/picu/picu_rec_re
adings.html
Hard copy is available in the resident call room.
PICU chapters at
http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
 Monitors in ICU
 Mechanical Ventilation
 Vascular Access
 ARDS
 Codes
 Status Asthmaticus
 ICP management
 Inotropes
 Status Epilepticus
 Shock
 Sedation
 Sepsis
 Pediatric Airway
 Meningococcus
 Airway Management
PICU chapters at
http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
 Cardiomyopathy
 Submersion Injuries
 Liver Failure
 Brain Death
 Acute Renal Falilure
 End of life issues
 Fluids, Electrolytes,
Nutrition
 Oncology
 Transfusions
 DKA
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
Junior/Senior pediatric
resident
Junior/Senior pediatric
resident
Pediatric intern
Pediatric intern
ED resident
Nurse practitioner
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
Sign out 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 7th resident in the PICU
 May care for equal number of patients as pediatric
residents
 Rounds one day on weekend, typically Saturday
 Excused for Wednesday AM ED conferences: must
pre-round & hand over notes to on call resident
prior to leaving for education rounds
 ED residents complete 3 weeks of days and one
week of nights
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 NPs
 Michelle Burns-James
 Krysta Nicholson
 Karley Mariano
 Work independently and carry their own patients
 They are present in PICU 4 days/week for 10 hour
shifts (variable days and starting times…i.e. may
work noon-10pm some day depending on staffing
needs)
 Typically round one day on weekends, alternating
with ED resident
PICU Evaluations for
Pediatric Residents
 Faculty evaluations completed on Med-Hub
 Verbal feedback from attendings while on the rotation
– Be sure to elicit feedback if not provided
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
Notes
 Each patient needs PICU daily progress note
(unless admitted in early am)
 Significant events: codes/procedure/intervention
 Require a note: confer with fellow or attending who
may do this note
 Templates exist for most procedures
 Interim summary weekly on Thursday for any
patient with LOS > 5d in PICU
Notes
 Online
 PICU specific templates
 Systems-based note
 Indicate attending on your team and select “sign” not
“review”
 Please remember to update physical exam daily
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 FACE to FACE in the
PICU
PICU-to-Floor Hand-offs
 Goals: Safe patient sign out
 Issue: Sign-out often does not happen close to transfer time due
to bed availability
 Issue: No “stops” within the system to prevent transfer when
hand-offs not completed.
PICU-to-Medical Team Hand-offs
(including Renal transplant patients)
Floor
Resource
Nurse/USA
PICU
MD
orders
“transfer
bed
request”
PICU RN
requests
bed in
Tele
Trekking
USA or
Spectralink alerts
Floor Resource
Nurse that bed
ready in Tele
Trekking
Floor Bedside RN
Phone
sign-out
PICU
Resource
Nurse
PICU Bedside RN
Floor
MD
Floor
MD calls
PICU and
goes to
PICU for
sign-out
PICU MD
Floor MD
orders “Okay
to transfer”
Patient
Transfers to
Floor*
PICU to Floor Hand-offs: MD Roles
1. PICU resident orders “Transfer Bed Request” including accepting team and
orders “Change of Care to Acute care” and prints out PICU to Acute care IPASS report
2. Floor Resource Nurse or USA will call Accepting Floor Resident when PICU
patient has been assigned a bed through Tele Trekking.
3. Accepting Floor Resident will call 5-8770 asking to talk to fellow to arrange time
to get face to face sign-out, ideally within 30 minutes.
4. Accepting Floor Resident (and ideally fellow and attending) goes down to PICU
for verbal sign-out.
5. Accepting Floor Resident puts in “Okay to Transfer” order.
6. Prior to sending patient or accepting patient PICU Bedside Nurse and Floor Bedside
Nurse verify “Okay to Transfer” order has been placed
7. Patient comes to floor.
Please use the printed tool: Floor
residents should print out but you
can also
Printed Tool: Where to Find
Printed Tool
Rounding & Presenting Patients
Flow of Rounds
 8:30 Typically BMT, Liver, Renal Transplant
 Followed by:
 Sick/high acuity
 Transfers
 Remainder
 Neurosurgeons typically round on their patients
between 7:30-8:30
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 rounding checklist on every patient
 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
Respiratory Therapy and
Ventilator Management
A friendly reminder from our respiratory therapists:
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:
 CBC
 Coags
 Chemistries
 CXR
 Qam labs in PICU are drawn at 4 or 5 am
 TIP: Use PICU Daily Orderset during rounds!!
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,
 Trauma service should write admit orders
 Surgical service should write the discharge summary unless
transferred to PICU service for ongoing medical issues
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)
 Allows some autonomy to RT to develop plan for best
mode of therapy
Discharges
 Patient rounding checklist useful tool!
 Prescription paper available from USA; please send 24
hours before
 Loads into one printer and special tray
 Select the PICU prescription printer for all D/C scripts
 Rx_picu_fntdsk
Discharge
 During rounds if discharge is anticipated in the next
48 hours please update the target discharge date
 When you get admissions from surgery please ask
about when they are anticipating discharge and what
clinical criteria will need to be met.
 If discharge is anticipated use the discharge checklist
to help aid in the planning process (it will be on the
patient door)
 After you discharge a patient there is a survey that we
are asking you to complete regarding your experience
with the process
PICU Quality and Safety
 PICU Handoff Initiative
for ALL OR, 1N Handoffs
 One Message, One Time
 Role cards utilized
 IPASS tool for handoff
comes with 45 min call
PICU Quality and Safety
 PICU Rounding Checklist
 Real time clinical decision support
 Enhance patient safety and care coordination
 Review at conclusion of rounds for EACH patient
COWS
 Be sure to sign off
 Don’t leave patient information exposed
 Plug them back in (a dying cow is not pretty)
PICU Etiquette
 Please speak in quiet voices, particularly around main
nurses station
 We follow HUSH (healthcare workers utilizing silence
for healing) in the PICU
 Please no open food or drink containers unless in
specified areas
 Make sure you do follow the appropriate hand hygiene
and have bare hands at all time in the unit
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