NeuroICU: Orientation to the unit for Rotators Goal for the NeuroICU rotation is to become familiar with: GCS and neuro assessments, seizure/EEG, brain death exam, stroke scale, ventilator management, intubation/extubation, line placement (arterial/central), external ventricular drain (EVD) management, Codman ICP monitor, lumbar drain management, CSF studies and drawing CSF labs, sodium goals, blood pressure management. Patient Population: traumatic brain injury, subarachnoid hemorrhage, epidural/subdural hematoma, seizures, ischemic stroke, spinal cord injury, brain tumors, neuromuscular disorders, CSF leaks, and the post-operative neurosurgery patient. Pre- Rounding: Arrive daily to NSICU workroom by 0600 MSIIIs should take 1 patient each MSIVs 2 patients Interns 2-3 patients Residents > 3 patients Rounding report vs rounding form to collect pt data such as: overnight events, vitals, ER/OR info if applicable, labs, recent studies, consult recommendations, etc Examine patients thoroughly; talk to nurses to get information on overnight events Prepare organized, systems based presentation with assessment and plan ICU Rounds: 0830- 1300; expect to present your patient to the attending during rounds Responsible for writing a progress note, communicating with consulting teams and nursing staff, and placing/following up on all orders for your assigned patient (s) Consult patients: begin a note during rounds for the person who is presenting including the plan and save as incomplete. The person presenting is responsible for completion of the note. All notes should co-sign for active neurointensivist Afternoon rounds usually between 4:30 and 5pm Presentations: Present system by system leading with overnight events. Somewhat vary attending to attending. Have a plan for what you would like to do (ie.. vent changes, medicine, changes, workups, etc..) Medical students should discuss plans with resident or mid-level provider Teamwork: During rounds one person is presenting, another will pull up imaging and the third will be putting orders in. If there are only two people (one midlevel and one intern) then one person will do both imaging and orders. Keep a list of orders as you’re putting them in and check them off as you go. Likewise write down all orders for your patient and verify after rounds that they were properly placed. You’re responsible for all orders on your patients and following up on them throughout the day. Orders: Attention to detail! STAT on all imaging, studies and labs unless otherwise specifically timed. Neurosurgery Parameter orders should be verified/updated daily including ICP/EVD instructions, sodium goals, SBP goals, etc. Restraints need to be updated every morning before rounds and again before you leave. Do not order any labs for >24 hours at a time. Patients will be assessed daily for the need for daily CXR or certain labs studies. ICU does not = daily full labs and CXR. Hypertonics, restraint orders and albumin must be placed under the attending’s name. Hypertonics: ensure the order (3%, 6.4%) parameter matches in the prn and admin instructions, along with the neurosurgery parameter order Enteral tube flushes should be normal saline initially. If patient NPO and has enteral access, make sure no orders say oral Insulin Sliding scale: always q4 when patient is on tube feeds. Use the order set and make all 3 orders match. If on po diet then change sliding scale to before/after meals. Nebulizer medications ASO after 3 days. Some paralytic drips require to be ordered daily as well. Documentation: Succinct daily progress note for each of your assigned patients including HPI, 24hr events, exam, pertinent labs and recent imaging, assessment and plan. Heading: Neurocritical Care Progress Note with Staff neurointensivist name and footer stating “Will continue to follow patient in ICU. Patient was examined by ______ attending and ________ chief this AM on rounds. Start the consult note for the person who’s presenting on non-primary patients. All ICU notes should co-sign for the neurointensivist on service Procedures: Arterial lines, dobhoff tube placement, bronchoscopy, central line, intubation are most common. Write a procedure note in addition to progress note for line and tube placements. Friday: Neuroscience Grand Rounds: will still pre-round 0600 then attend grand rounds from 0800-0930 in 309L. Business attire and white coat recommended. Return to the unit after grand rounds to continue with rounds and patient care. Coverage and Expectations: Generally expect to be here 0600 to 1800 M-F. You’re expected to cover two weekends per month Sat/Sun: times are the same as the weekdays There will be another person (midlevel/intern) also covering the weekend with you. You’re responsible for notes, consults, orders, etc just as during the week on your patients. If you are a resident and doing night float, hours are 5pm -5am Tuesday to Sunday. You will participate in afternoon rounds with the ICU team and then sign out to oncoming ICU team in the morning on any overnight events Expectations overnight are to round on your patients in the evening, address any nursing concerns and do admit H&P’s on any new ICU admits Overnight residents are required to call faculty for: new admissions that are unstable and any patient that decompensates, any questions whatsoever! Welcome to the NeuroICU!