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 - 12:00am:
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:
1:00 – 4:00pm:
Noon Conference
Follow-up
• Consultations
• Procedures
• Post op admissions
• didactics
4:00 - 5:30pm:
Sign-out Rounds with
night team
Day Shift Responsibilities
Day-time Admissions:
When resident in clinic:
• Should go to the team • All remaining team
NOT on call that
members, including
night, e.g. B-resident
residents from other
on call, A-team admits
team must help cover
patients, e.g team B
• Teams will be adjusted
resident in clinic, team
by fellow or attending
A will help NP cover
to maintain equity in
patient numbers and
acuity between teams
• Be flexible
Patient Load
• Residents expected to carry 5-7 patients
each
• Admissions above this number or chronic
ICU patients will be covered by NPs
Pre-rounding
• Weekday pre-rounding:
– Residents expected to pre-round on all of their
patient
• Weekend pre-rounding:
– 3 pre-rounding individuals: post-call NF
resident, Daytime resident, NP or ED Resident
– If high patient acuity, fellows can present
patients or “discovery rounds” with attending if
in-adequate time to pre-round
Night Shift Responsibilities
• Every other night for 2
weeks
• Goal: Admit to your
assigned team, but
may be redistributed
• Present new
admissions on rounds;
can shift between
teams if required
• Expectation is that you
stay through rounds,
leave around noon
• No continuity clinic
before your night
shifts
• Signout at 4pm
Resident Teaching Conferences
PICU resident lectures:
• Monday / Thursday: 8 – 8:30am
• In place of morning report
• At front desk in PICU
Other Teaching Conferences
DAY
TIME
CONFERENCE
LOCATION
Tuesday
7-8 am
CVICU
Conference
2E PICU
Conference room
Tuesday
12-1
PICU Fellows
Conference
2E PICU
Conference
Thursday
12-1
PICU Conference:
M&M, and others
2E PICU
Conference
Thursday
1-2
PICU Weekly Sign 2E PICU
Out
Conference
Welcome to join any and all!
Educational Resources
• PICU resident handbook with relevant PICU
topics is available at
http://peds.stanford.edu/Rotations/picu/picu_rec_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
Team Composition
Resident Role
• Receive sign out from overnight resident
• Pre-round on PICU patients
• Present patients at morning rounds beginning promptly at
8:30am
• DEVELOP A PLAN & PRESENT IT (Your
opportunity to be a doctor!!)
• 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/fellow
• Attend teaching conferences conducted by the
ICU attendings / fellows
PICU NPs
• Julie Reed
– Acute care NP coursework UCSF
– Doctorate of Nursing Practice USF, in progress
– PICU RN several years
• Kiersten Wells
– Member of LPCH SCAN team (Suspected
Child Abuse & Neglect)
– Special focus in Adolescent
– Several years as cardiology PNP LPCH
PICU NPs
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Integral member of team
Work directly with Attending/fellow
Provide ongoing continuity in PICU from week to week
Hours available in PICU:
– Mon-Sat: 7:30am - 5:00pm; Some weekend flexibility
• Enhance PICU flow
– Between subspecialists and PICU team
– Between bedside RNs and PICU team—participate in
daily discussion about patient dashboard
PICU NPs
• Assist with admissions as needed throughout day
for either team
• Participate in pre-rounding on weekdays/weekend
• Receive sign-out to assist with patient care
– From post-call fellow
– From pm clinic residents
• May perform procedures: based on unit need & as
deemed appropriate by Attending/Fellow
– (i.e. new admit, the pt’s resident is post-call, etc.)
Questions regarding PICU NPs?
Contact Deb Franzon, Pager 23108, dfranzon@stanford.edu
PICU NPs
• PICU NP: admits patients, based on
fellow/attending decisions, typically to A
team, but when resident in clinic may admit
patients to B team as well
• Weekends: Equal distribution of all patients
between residents and NP
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 day resident in the PICU on
the B team
• May care for equal number of patients as
pediatric residents
• Rounds one day on weekend (Sunday)
• 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”
• Official legal documents, so use medical
terms
• Justify level of ICU stay
Transfers out of ICU
• Approval of the ICU Attending
• Transfer summary
– For non-surgical patients with >48hr ICU stay
• Transfer orders
– Surgical patients: surgeons often write orders
– Confirm transfer with surgical team and who
will write transfer orders
• Sign patient out to ward resident
Rounding & Presenting Patients
Patient Presentation
• Ask attending re presentation preference: data first then
plan, or data and plan by system
• On line PICU Progress Note available
• Can be cumbersome, difficult to navigate during rounds
• If presenting from COW – assure all information available
– e.g. lab results, radiology studies, etc.
Tips for Success on Rounds
• Review films and know results
• Know results of studies completed overnight
• Be succinct during presentations
– Pertinent positives and negatives only
• DEVELOP A PLAN & PRESENT IT
(Your opportunity to be a doctor!!)
• Patient identification
• Quick assessment: i.e. patient improving,
worsening, or unchanged
• Major (not all) interval events
• Vitals: Tmax (time), HR SBP/DBP(MAP),
RR, sats, CVP
(vital sign ranges)
• Physical exam: present exam appropriate for
patient’s disease
• Present meds within appropriate system as present:
e.g. steroids for asthmatic in respiratory vs.
steroids for liver transplant in GI
• May need to make specific sections for certain
patients: e.g. Transplant, endocrine, orthopedics,
etc.
Data & Plan to consider in each system
• Respiratory:
– Data:CXR findings, mode of support - NC vs BiPAP vs
ventilator, amount of support
– A/P: changes in pulmonary compliance and changes in
respiratory support accordingly
• 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
Data & Plan to consider in each system
• FEN/GI:
– Data: I/O’s, nutritional source, calories per day, Labs,
LFTs
– A/P: Changes in fluid status or liver functions,
modifying nutritional support
• Renal:
– Data: Urine output, any renal replacement therapy,
changes in BUN/Cr
– A/P: Changes in renal function or diuretics
Data & Plan to consider in each system
• 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
Completing patient presentation
• One line overall assessment of patient
condition
– List major plans for the day at the end
• Review orders
• Address Bedside RN concerns
• Address patient dashboard
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
✔
✔
Ensure Best
Practices for
✔CABSI
Prevention
✔Pressure
Ulcer
Prevention
✔VAP
Prevention
Procedures
• PICU fellows are given priority for all
procedures (particularly 1st year fellows)
– Prerequisite for CCM training
• Acute situations : fellow or attending
• NPs: at discretion of attending or for their
own patients
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
• Familiarity with defibrillator
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
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.
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
• Do not write specific times for meds –
allows RN to time them as possible for
existing lines & to minimize line entry
– Only enter drug time if needs to be given at a
specific time
• Do not time labs
*** 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
• On 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
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. S. Kache at
skache@stanford.edu
723-5495
Pager: 13483