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WELCOME TO THE PICU
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Flow Of The Day
Before 8am: Pre-round8:00 - 8:30am: Morning Report8:30 - 9:00am: Rounds(Except Fridays, rounds start at 9am after Grand Rounds)
9:00 - 9:30am: Radiology Rounds9:30 - 11:00 am: Finish Rounds11:00 - 12:00am: Work time
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Flow Of The Day
12:00 - 1:00pm: Noon Conference
1:00 - 4:30pm: Completing work of the day
4:30 - 5:30pm: Sign-out Rounds with night team
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Prevention of Resident Duty Hour Violations
• Do not begin pre-rounds before 6am
• Evening rounds begin at 4:30pm
• Be sure to leave by 12pm on post-call days– If your patients are not rounded on by 11:30,
hand your notes to on-call resident
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Teaching Conferences
• Tuesday 7 – 8am CV ICU Conference– PICU Conference Room
• Tuesday 12 – 1pm: PICU fellow conference– PICU Conference Room
• Thursday 3 – 4pm: Sign out round– PICU Conference Room
Welcome to all!
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Educational Resources
• PICU resident handbook with relevant PICU topics is available at
http://peds.stanford.edu/Rotations/picu/picu.html
Hard copy is available in the resident call room
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PICU chapters at http://peds.stanford.edu/Rotations/picu/picu.html
• Monitors in ICU• Vascular Access• Codes• ICP management• Status Epilepticus• Sedation• Pediatric Airway• Airway Management
• Mechanical Ventilation
• ARDS• Status Asthmaticus• Inotropes• Shock• Sepsis• Meningococcus
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PICU chapters at http://peds.stanford.edu/Rotations/picu/picu.html
• Cardiomyopathy• Liver Failure• Acute Renal Falilure• Fluids, Electrolytes,
Nutrition• Oncology• Transfusions• DKA
• Submersion Injuries• Brain Death• End of life issues
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PICU Tables at peds.stanford.edu
• Sedation• Inotropes• Shock
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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
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Resident Role
• Recognize the patients are often very complicated and managed collaboratively with other services – e.g. neurosurgery, liver transplant, heme-onc, cardiology, etc.
• Significant changes to patient status should be discussed with the other services
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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
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PICU Evaluations
• Group faculty evaluation completed on MedHub
• Verbal feedback from attendings while on the rotation – Be sure to ellicit feedback if not provided
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Other Trainees & HCPs in PICU
• Anesthesia fellows
• Emergency medicine residents
• Medical students
• Nurse Practitioners
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Anesthesia Fellows
• Only present for half the blocks
• Primarily provide support for fellow level activities in the ICU
• Will not carry any patients
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ED Residents
• Will act as a 5th resident in the PICU
• To care for equal number of patients as pediatric residents
• Will take call with a pediatric resident and cover half the patients
• Excused for Wednesday AM ED conferences, but must pre-round and hand over notes to on call resident prior to leaving for education rounds
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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
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PICU NP Role
• Hours of coverage in PICU: – Mon-Sat: 7:30am - 5:00pm
• Assist residents with ICU specific systems issues, e.g. writing PICU notes
• Complete daily goal sheets and review with Bedside RN at completion of rounds
• Pre-round on patients on Saturday
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PICU NP Role
• Assist with patient flow: – Pre-round with consultants, i.e. neurosuregery, and
update resident with recommendations
– Writing accept notes and orders on post-op patients as needed, i.e. during am / pm sign-out
– Entering transfer orders for patients requiring transfer during rounds, etc.
• Attend Multidisciplinary rounds on Tuesdays at 11am
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Notes
• New admissions require a dictated H&P and a brief note in the chart
• Post-operative admissions can have a post-op admission note written in the chart
• Patients in the ICU for longer than one week require a dictated clinical summary each Thursday
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ICU Transfers
Patients being transferred from the ICU require
• Transfer summary
• Transfer orders– Surgical patients: surgeons often write orders
• Sign patient out to ward resident
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Rounding & Presenting Patients
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Sample PICU Progress Note
-Each patient’s note printed from Cerner (LPCH computer system)-Assure printed information up to date, i.e. ventilator settings
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• Patient identification
• Quick assessment: i.e. patient improving, worsening, or unchanged
• Major (not all) interval events
• Vitals
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• Physical exam: present exam appropriate for patient’s disease, e.g. neuro exam on neurosurgical patient (but examine all of patient)
• Present meds in appropriate system: e.g. steroids for asthmatic vs. steroids for liver transplant
• Respiratory: – Data: CXR findings, mode of support - NC vs BiPAP vs
ventilator
– A/P: changes in pulmonary compliance and changes in respiratory support accordingly
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• 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
• FEN/GI: – Data: I/O’s, nutritional source, calories per day, Labs– A/P: changes in fluid status or liver functions,
modifying nutritional support
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• Renal:– Data: urine output, any renal replacement therapy,
changes in BUN/Cr
– A/P: changes in renal function or diuretics
• 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
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• One line of overall assessment and major plans for the day at the end
• Review orders
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Procedures
• PICU fellows are given priority for all procedures (particularly 1st year fellows)– They must be trained in them prior to
completion of their fellowship
• Acute situations – fellow or attending will do procedure to optimize patient care
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Procedures
Procedures residents should acquire some degree of comfort with while in the PICU
• Bag-mask ventilation
• Operating an anesthesia bag
• Chest compression
• Placement of peripheral IVs
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Bedside Nurses
COMMUNICATION
COMMUNICATION
COMMUNICATION
– Tell bedside nurse you are the resident caring for that patient
– Give them your pager #
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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
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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.
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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! **
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Orders
• Do not write specific times for meds – allows RN to time them as possible for existing lines
• Do not time labs*** except for immunosupression drugs ***
e.g. Prograf, CSA
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Order Entry
• PICU order sets available on Cerner include:• Delete previous diet orders• Orders that require daily entry:
– CBC
– Coags
– Chemistries
– CXR
• If labs or radiology studies listed in power-plan, no re-entry required
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Order Entry
• On Cerner
• PICU folder under Power-plan folders
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Order Entry
• On Cerner
• Power-plans found in PICU folder
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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 !!!
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Final Thoughts
• Take ownership of your patients• Be present• Be involved• Ask questions• Suggestions on improving the rotation
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Questions, concerns, thoughts on the rotation
Contact PICU rotation director -
Dr. S. Kache at
723-5495
Pager: 13483