THORNTON INTENSIVE CARE UNIT (TICU) RESIDENT ORIENTATION GUIDE
Written by Kimberly Robbins, M.D. and Ankur Patel, M.D. 2011
Last updated 8/19/2013 BJN
The Thornton Intensive Care Unit (TICU) rotation provides ICU experience tailored for senior (CA-2 and
CA-3) anesthesiology residents at UCSD. The format of the four-week-long rotation is unique in that an
anesthesiology critical care medicine (ACCM) attending or a surgical attending, fellow, and resident(s)
comprise the treatment team. The faculty and fellows are dedicated to making this a valuable and
worthwhile learning experience for each resident who rotates on the service. A curriculum of core
topics has been developed and will be provided during the resident-focused lectures at ~11:00am on
Tuesdays, Wednesdays, and Fridays. When time permits, lecture will also occur on Mondays.
This is an interactive rotation that builds on the experience gained during the SICU and Neuro-critical
care rotations; and serves to hone the anesthesiologist’s skills in critical care. Advanced skills and
training in critical care is essential because the anesthesiologist's role in the perioperative care of
surgical patients is expanding.
Attendings who cover the team include all of the Anes-critical care faculty as well as some of the Trauma
surgeons.
SIGN-OUT prior to first day of rotation:
You should receive a sign-out from the resident who is completing the rotation! If they don’t call you,
you should call them! And remember to call your colleague when you finish the rotation.
Sign out should include:
1) How to access the ACCM patient list
2) How to access the ACCM progress note template(s)
3) Brief sign-out on each patient
4) Brief overview of what to do on the first day (what time to get there, which patients to see first,
etc)
Expectations/Goals:
On the TICU Rotation the senior resident is expected to:
-Conduct detailed daily rounds on all ICU patients (TICU and Sulpizio Cardiovascular Center) being
followed by the ACCM team.
-Present the patients to the Fellow and Faculty Member on daily Attending Rounds (typically starting
about 8:30 am). When we have CT surgery patients, we will start with multidisciplinary rounds at
8:30am in CVC. The multidisciplinary team includes ACCM, CT surgery, Cardiology, ID, pharmacy,
nursing, and cardiac device reps.
-Improve their skills in diagnosis, treatment, monitoring, presentation, documentation, and other clinical
practices relevant to critically ill surgical or perioperative patients.
-Formulate advanced clinical plans on each patient under care.
-Communicate professionally as a competent consultant in critical care.
-Perform advanced procedures (under the supervision of the faculty or fellow) such as central vascular
access, diagnostic and therapeutic bronchoscopy, advanced airway management in critically ill patients,
become familiar with Transthoracic Echo (TTE), and ultrasound aided evaluation of ascites, effusions,
and vascular access.
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-The resident will become invested in all of the primary and consult patients and will be expected to
follow these patients until they are stable for discharge from the TICU/CVC-ICU. The resident will be
responsible for maintaining and following the ‘list’ of patients.
Didactics:
Daily teaching during morning rounds.
Lecture for residents and medical students ~ 11:00am on Tuesdays, Wednesdays, and Fridays, and
possibly on Mondays.
The residents are also expected to attend the Fellow Journal Club on Thursdays at 2:00 pm.
Structure:
The TICU is a 12 bed unit on the 2nd floor of Thornton Hospital. The code to the doors is 6038*. The unit
is shared by surgical, medical and anesthesiology teams. The patients who will be cared for by the
ACCM team will be predominantly surgical patients. Surgical subspecialties without ICU admitting
privileges (Ortho, Urology, ENT, OB-GYN, Plastic Surgery, IR) will contact the resident with an admission
to the ICU. These patients become ACCM "primary" patients while in the ICU. Although the surgical
resident should write admission orders, it is our responsibility to review the orders. After admission
orders, only the ACCM team should write orders on our "primary" patients. Upon discharge from the
ICU, the patient will be ‘called-out’ and the receiving team will write the transfer orders. The
neurosurgical patients represent a unique experience where the ACCM team co-manages these patients
with the Neurosurgery team. The neurosurgical resident will write admission orders to the unit and
both teams will be responsible for orders while the patient is in the ICU.
Regardless of the surgical team, post-op patients go to the ACCM service as either "primary" or
"consult", and medical patients go to pulmonary. Some non-operated patients will also go to the ACCM
team. For example a patient who comes in through the ED with a SAH (normally would go to
Neurosurgery), will be cared for with the neurosurgeons on the ACCM team. Whereas a patient who
comes through the ED with an ischemic stroke (normally seen by neurology) will be cared for by the
pulmonary service.
It is the goal of the ACCM Service and Department of Anesthesiology to collaborate with the surgical
teams and collectively manage all perioperative patients who require critical care in the TICU. As such, it
is important that the ACCM resident maintain the utmost professional behavior when interacting with
all surgical services in the care of these patients. To put it in perspective, these patients deserve critical
care boarded physicians making decisions regarding their intensive care. The ACCM resident and fellow
are extensions of the ACCM attending. Below are some specific points about certain categories of
surgical patients.
General Surgery Patients:
There are 2 general surgical teams that typically admit to the TICU. Blue (general surgery) and Green
(surgical oncology) are the color codes for these services. In addition, the Red (vascular) service admits
patients to the Sulpizio CVC. Each team has a chief surgical resident who will be the contact point for
recommendations. These patients are under the primary care of these services, and the ACCM team
functions as a "consult" team. The ACCM resident will be expected to take on an active role in the care
of these patients.
Neurosurgical Patients:
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As above, these patients will be co-managed by Neurosurgery and ACCM. The neurosurgery team
usually writes admission orders for these patients, but occasionally this is done by the ACCM team.
Orthopedic Patients:
Ortho-spine comprise the bulk of these patients (often Dr. Steve Garfin is attending). These patients will
be primary on the ACCM service. The Ortho team usually writes admission orders for these patients, but
occasionally this is done by the ACCM team (as with neurosurg patients). Upon transfer out of the ICU,
these patients need to be 'called out' to the expecting floor team (usually Ortho, but sometimes
Medicine).
Cardiac Surgery Patients:
The cardiac surgeons typically split their consults between the ACCM and PCCM teams. Most
postoperative PTE and lung transplant patients go to the pulmonary team whereas most device (VAD,
TAH) and heart transplant patients go to the ACCM team. Postop CABG, valve, etc patients can go to
either team, at the discretion of the CT surg attending. When we are consulted on CT surg patients, we
co-manage them along with the CT surgery (and Cardiology) teams. This means the patient is getting a
lot of attention but this also requires close communication among all teams. We will have an active
role in 'fast-tracking' many of the CT surgery patients (this process is being finalized now).
Daily Schedule:
0630-0700
Arrive to the TICU, begin pre-rounds, receive sign-out from the overnight PCCM fellow
0700-0830
Pre-round on patients
0830-0930
ACCM and Multidisciplinary rounds
0930-1100
ACCM rounds
1100-1200
Didactic lecture
Afternoon
Complete notes
Follow up on plans made during rounds
Follow up on pending labs/studies
Complete necessary procedures
Communicate with primary surgical teams and consult teams (e.g. ID, Renal)
Admit new post-op patients
Afternoon rounds – This may be with the Fellow and/or Attending (Be prepared to give
updates on the day’s events, vitals, I/O, new labs/cultures/studies/consultant recs, what
to sign out for overnight).
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Sign-out to PCCM overnight fellow
Typical Day:
Arrive in the TICU between 6:45 and 7:00 am and receive sign out from the pulmonary critical care
fellow. Currently, they cover the ICU at night from 7pm to 7am Monday through Saturday. On Sunday
night, the ACCM Fellow covers the unit. After receiving sign out from the pulmonary fellow, the resident
is expected to pre-round on the primary patients and the consults. You should start your rounds on the
CVC patients who are being co-managed with CT surg and Cardiology (because these will be the first
patients we round on). Occasionally, as circumstances dictate, the ACCM fellow will assist with prerounds and patient presentation to the ACCM faculty member. Examples of situations where the ACCM
fellow will be expected to assist with pre-rounds include overwhelming number of patients on the
service, when patients are so unstable that individual prolonged attention is required at that bedside,
and when other emergencies occur requiring ACCM assistance inside or outside the unit. The fellow's
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main job from 7-8:30am is to perform TTE on all patients in the CVC and on unstable patients in the
TICU.
After pre-rounding and preparing the daily progress note, the resident will round with the ACCM
Attending and Fellow. When we are covering CT surg patients in the CVC, we will start with
multidisciplinary rounds at 8:30am. Be prepared to present the patient to the entire team, including
ACCM, CT surgery, and Cardiology. Often members of other disciplines, such as pharmacy, will also
round with the ACCM team. Using the computers on wheels (COWS), it is helpful if the fellow puts in
orders as the resident is presenting, or vice versa if the fellow is presenting.
Note: The ACCM team always locates the bedside nurse and involves him or her in the daily Attending
Rounds. If the bedside nurse is on break, we may skip a patient and return to that patient after the
nurse returns from break. Remember, the bedside nurse is with the patient nearly 12 hours straight and
has a wealth of information that can be missed during a superficial chart biopsy and cursory physical
exam. Be sure to ask the bedside nurse about significant events during pre-rounding to avoid
“surprises” on Attending Rounds. One strategy is to do a quick walk around during the 6:45-7:00 am
period to get the report from the night shift nurse about unstable events, sleep and delirium issues
occurring at night.
After rounds, the notes are finalized and the plans are communicated to the primary teams, or carried
out by the ACCM team (the ACCM Fellow will run the list and determine the distribution of resources).
Following this, there will be a lecture by the ACCM attending on (Monday), Tuesday, Wednesday, and
Friday. The residents are also required to attend the fellow journal club on Thursdays.
After lunch, the resident should follow up on plans made during the morning rounds and pending
labs/studies. The resident should also proactively evaluate patients who will be admitted to the ICU
postoperatively. To do this, the resident should go to the OR, find out which patients will be admitted to
the ICU, review the charts, and talk to the Anesthesia team in the OR. We are working on improved
hand-offs between surgical/anesthesia teams and the ACCM team.
A member of the ACCM team is expected to be in the hospital every day until 7pm to be immediately
available for patient care and to handle new admissions. A schedule has been devised that splits this
weekday duty over the month between the resident(s) and the fellow. It is reasonable that the person
who is not staying late may leave after rounds, work, and didactics are completed (usually midafternoon), as directed by the fellow and approved by the attending. The monthly schedule will be
provided to the resident at the beginning of the rotation. At 7pm, a sign-out is given to the PCCM night
fellow who will be cross-covering our patients at night. The resident will cover the ICU on Saturday
7am-7pm as this is the fellow's day off. The fellow takes 24 hour call on Sunday and the resident has
Sunday off (unless there are 2 residents, in which case one will have Saturday off and the other will have
Sunday off).
ACCM Pager: 290-8888
The resident will hold the ACCM pager daily and will hand it off to the covering pulmonary fellow at
night. The ACCM team also responds to all codes in the hospital. The pulmonary fellow typically
functions as the code blue leader. However if you arrive at the code and do not see the pulm fellow,
you should be the code-blue leader. In that situation, resist the temptation to perform procedures and
instead focus on your ability to delegate a team of medical providers. The resident will obviously use
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their best judgment in this situation. For example, if it is a difficult airway, it would be prudent to take
over as an expert of airway management. In general, however, this is an opportunity to ‘run the code’
and allow others to perform their assigned duties.
Procedures:
Consent is required from the family member, or from the surrogate decision maker for all procedures
which are not emergent in nature (e.g. central lines, PA catheters, arterial lines, dialysis lines, and
bronchoscopy). After a procedure, a note is entered into EPIC with the attending selected as the cosigner for billing purposes. To do this, the resident must first place the order in epic, for placement of a
line, or bronchoscopy, etc. The order is then signed. After the procedure, the rounding-consult tab is
selected and the ‘procedure notes’ is selected. The order is then highlighted for the procedure done.
Click on “document order” and fill out the template as appropriate. Make sure to have the ACCM
attending co-sign the note. If you are not familiar with this documentation process, please ask the
fellow or attending for assistance.
Progress Notes:
Go to the Notes tab and select New Note.
Use the .ticu template (type .ticu) and add or subtract as necessary for a cohesive medical document. If
this template is not available to you, please call or email your chief resident and you will be added to list
of users who may access this template.
Note: Resident/Fellow notes will be co-signed by the Attending. All medical student notes need to be
signed by a Resident/Fellow and co-signed by the Attending.
Orders:
Add the following order sets to your favorites on EPIC by right clicking on them and selecting add to
favorites:
IP GEN Electrolyte Replacement Protocol (ICU/PCU Only)
IP GEN Subcutaneous Insulin Therapy – Initial Regimen
IP GEN VTE Prophylaxis
Admitting From the OR:
Go to the Admit-Txfr-Disch tab on the left side of the screen.
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If this is not seen go to more activities and select post op to floor, then select “order recon- txfr”.
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This will then prompt you to review all the patient’s previous orders on the admission and either
reorder them, or discontinue them.
Then click “next” and reconcile the PTA medications.
Again click “next” and add any new orders upon transfer to the ICU. Again click “next” and review and
sign.
A similar process is undertaken when admitting from the ED, but the tab to click on is called “Admit from
ED”.
Again, if you are not familiar with orders in EPIC, ask the fellow for assistance. The vast majority of the
time, admission orders will be entered by the surgical teams.
Please feel free to contact any of the ACCM faculty with questions about the rotation, issues that arise,
and revisions to this document so that it can be appropriately updated for future residents. We hope
that this will be a valuable experience for each of you.
ACCM Faculty
Anushirvan Minokadeh, MD, Director of Anes-Critical Care and ACCM Fellowship
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Beverly Newhouse, MD, Associate Director of Anes-Critical Care, Residency Education Director
Erik Kistler, MD, Director of ACCM Research
Kimberly Robbins, MD, Associate Director of ACCM Fellowship
E. Orestes O'Brien, MD, Director of Critical Care Echocardiography
Zeb McMillan, MD, Director of ACCM Journal Club
Rotation Coordinator - Julie Nguyen
jungyuen@ucsd.edu
Reading Materials and other information:
 Books (we have copies in the Anesthesia Resident Lounge):
1. Marino PL, Sutin KM. The ICU Book. Lippincott Williams & Wilkins 2007.
2. Wilson WC, Grande CM, Hoyt DB, eds. Trauma: Critical Care. Informa Healthcare 2007.
 There will be papers referred to and given to you by individual attendings or fellows.
*Please ask the fellow for the 3 papers regarding critical care management of 1) Heart Transplants,
2) LVADs, 3) TAHs
*The fellow can also provide resources for TTE
 Website: http://www.ccmtutorials.com is an excellent website developed by the Society of Critical
Care Medicine to assist residents in learning critical care.
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