Welcome to the TLC!

TLC Teams• Each TLC Team Consists of:• Attending• Fellow• Nurse practitioner• 2 Residents• 2-3 Interns• 4th Year medical student• Team 1 residents are staffed from ANESTH & EM, Interns are staffed

from ANES, EM, ENT & NEURO Residents • Team 2 residents and interns are staffed from IM

Attendings change each Monday, fellows change on the 1st of each month

TLC Organization• Most patients will be in the TLC but some “board” in Burn Unit (B4/3),

CCU (F4/M5), and Neurosurgical ICU (B4/4), Cardiothoracic ICU (B4/5).

• TLC is typically the primary service for these patients and will be triaged in the rounding order according to acuity.

• Occasionally we serve as a critical care consultant for other services (cardiology, CT surgery)

• ICU is a multi-disciplinary field (doctors, nurses, pharmacists, nutritionists, respiratory therapists, case mangement/social workers, physical therapy, occupational therapy).

TLC StaffPierre Kory Loren Denlinger William

Ehlenbach

Joshua Glazer Kara Goss Laura Hammel

Shawana Hussain Jonathan Ketzler Micah Long

Dennis Maki Amy Malik JaganRamammoorthy

Mark Regan James Runo Nathan Sandbo

Benjamin Seides Joshua Smith Jeffrey Wells

Advanced Practice & Fellows

Courtney HoyNurse Practitioner

Anna TaschPhysician Assistant

Richard Nunez Lopez

Chief Fellow

Nestor Anguiano Bill Bzdawka Amy Jaeger

Ryan Lok Melissa MacDonald Sumeet Soni

Yaoli Yang

Care Team Visit(Rounds)

Interdisciplinary rounds that include the medical team, nurse, pharmacy, patient’s family and frequently respiratory therapy and nutrition1. Nurse presents interval events using pink card (interval changes,

SAT/SBT, CAM/RASS/pain, vasoactive gtts, activity and wounds/drains)

2. Resident presents system-based plan using diagnoses 3. Another resident enters orders during other resident

presentation4. Rounding checklist using blue card (order readback, line/tube

necessity, prophylaxis, antibiotics, plan of the day, family issues/meetings)

Patient Safety Checklist & RN Presentation Care

Daily ScheduleWhen you arrive at TLC be prepared to round on your patients, and be ready to present before 8 AM

• 7:45 AM (Tues-Fri) : Education in medical conference room– Tues-Thurs attending physician presents– Fridays on-call resident presents; the schedule is located on the TLC website

• 8:15 AM: X-Ray rounds in medical conference room– Resident gives a one-sentence summary of case

• 8:30 - 10:30 AM: Care team visits– Two computers per team for order-entry and data acquisition– Present the patients you saw that morning to the team

• If it’s on a Monday or new admission the attending has not yet seen, provide the attending with a summary of the patients HPI, PMH, prior hospital course, etc

• If it’s a Tues– Sun, the nurse will start rounds with overnight events– All team members need to know about all patients, so keep extraneous work and

conversation to a minimum

Daily Schedule• 10:30 AM – 4:30 PM: Daily work (new admits, follow-up tests, call consults, etc.), and medicine

residents attend morning report if time allows• 4:30 PM: Sign-out of rounds with the on-call team (provide a brief summary of the patient’s reason

for admission, ICU stay, and items that need to be followed-up overnight)• 7:00 PM: On-call intern arrives and received sign-out from leaving intern• 9:00 PM: Evening rounds with fellow, residents, and charge nurses• Fellows may leave after overnight call once they have rounded on the new patients (from overnight)

with the team. They are expected to sign out to the on-call fellow before leaving. • The Non-call fellow can leave before sign out if caught up on work (no pending procedures,

meetings, sick patients needing attention)• The senior resident is expected to be present for sign out rounds at 4:30p on all days except

weekends.• The residents should touch base with the fellow at the beginning of the month about their

days off and let them know if the days off are changed.

Admissions• Team 1 and Team 2 alternate admitting days• Attending physician or EICU (night coverage) is called for transfers from

outside facilities by the Access Center• Fellow or senior resident is called to triage transfers from the floor and

admissions from the ED• Patient placement is coordinated by the nursing coordinator and accepting

physician. Admit and transfer orders need to be placed by the TLC team for bed assignment

• Each patient will have a primary resident who sees them daily– Typically, both the senior and intern should be helping with the admission of

every patient (notes, orders, procedures, talking to families)

Paperwork• H&P – please use the TLCHP4 template• Progress note – each patient needs one daily, unless the H&P was started after

midnight and there are no new problems that morning – please use the TLCDAILYNOTE2 template

• Discharge summary – needed for every patient discharging to home, SNF/LTACH, or morgue

• Interim summary – needed for every patient transferring out of the ICU if their ICU stay has been >72 hours (not necessary in the situation the receiving team has been following the patient through their ICU stay as often done by BMT and advanced pulmonary service) – Please use the TLCINTERIMSUMMARY

Please do not copy the templates to make yourself an “owner”All new admits and transfers need new orders

– “IP Intensive Care – Adult Admission”

Orders• During rounds, one resident should be entering orders. Only sign orders

after order read back has been done with the team.• Verbal and telephone orders are for emergencies only• ALL written orders should be verbally communicated to the RN• Be thoughtful regarding orders

– Not every patient needs every lab test every day– Chest x-rays may not be needed daily, consider US as alternative– Few vent changes require an ABG/VBG

• Order stat only when necessary• Before leaving, make sure your patients have appropriate AM orders

Procedures• Consent is mandatory (except for emergent procedures) –consent POA

(check the blue Advance Directive hyperlink or consent tab under chart review) or next of kin if no POA designated

• Nurses should be informed ahead of time for planned procedures• Nurses have a checklist to ensure sterile technique used for central lines• Sterile technique should be used for all lines• All invasive procedures require a standard procedure note• After procedure, enter order to “Maintain Non-Tunneled ***” • NEJM.org has a series of very helpful instructional videos

TLC EquipmentUltrasound Procedure Carts

• Sonosite machines in supply room or back hallway on North side

• One Sparq machine on each side of the TLC

• Machines should be cleaned (NO bleach) and plugged in when not in use

• In supply room• Needs to be returned in order to be

re-stocked

Sparq

Sonosite

Machines on Wheels• Please store computers and

ultrasound machines INSIDE the red tape

Yes!Yes!

No!

Computers at the Desk

Occasionally the medical teams can seem to monopolize the computers in the nursing station. Please be mindful of this and move if nursing asks.

Ventilators• Must place an order for mechanical ventilation in all

intubated patients– Ask Fellow/Attending/NP to specify the settings: enter the

Mode/Tidal Volume/Rate/PEEP & SpO2 range

– Respiratory Therapists (RT’s) are an excellent resource for information guiding respiratory treatment decisions including intubations, extubations, and codes

– Do not physically change any settings on the ventilator unless an emergency – only the RT’s may physically change settings on the ventilator

Transfers to Floor/Discharges

• To transfer a patient out of the TLC, they need to be accepted by another service– Most patients can be transferred out by paging Hospitalist Triage unless

there is a specialty service more appropriate (BMT, advanced pulmonary, transplant, etc.)

– Accepting service will place transfer orders– Patients who transfer to IMC status stay on our service until there is

an IMC bed available • When changing to IMC status, give a courtesy call to the Hospitalist

Triage• Full report will be given when a IMC bed is available

– We write interim summary for those in ICU >72 hours; unless there has been a primary service following daily while in the TLC

Nursing• Reliable source of information about patients in particular and

ICU in general• Able to monitor minute-to-minute changes in patients status• Need to be present during rounds – we fill out a rounding

order to help them anticipate our rounding time• If a nurse questions an order or contacts you because of a

patient change, take their concerns seriously• Two Care Team leaders each shift in TLC (one manages

placement of patients within TLC, one manages staffing)

Nurse Practitioners• Pre-round in the morning• Communicate with ancillary staff (PT/OT, SW, nutrition, etc.)• Help with family meetings• Help complete admissions during rounds• Available to help you learn processes in the ICU• An element of continuity on a service with rotating staff• Help initiate and maintain TLC process change/quality initiatives• Round on patients in the morning when the census is high• Work on quality improvement projects

Pharmacists• Pharmacists staff the TLC 24/7 and are an invaluable

asset for medication-related issues• On weekdays there are two daytime pharmacists and

one will typically round with each team

Social Worker & Nurse Care Manager

Meredith VitaioliHCPOA questions & completion

Complex family dynamicsCrisis intervention

GuardianshipGovernment programs/insurance

Ethics committeeCovers when Julie is off

Julie CanterMedically complex situations

Utilization reviewWorkman’s comp

Covers when Mereddith is off

Nutrition Staff

Cassandra Kight Lesley Appleyard

Kathy Golos

The Nutrition staff evaluate all patients in the TLC and can write TF orders if you order the delegation protocol within the nutrition consults.

Families• Family members are encouraged to be present for rounds• Keep families updated daily either in person or by phone• When families are frustrated or hostile, allow the fellow or attending to speak

with them to avoid mixed messages• For those anticipated to be in TLC >3 days, family meetings are set up for day

3 or 4, these are sit down meetings that are in addition to daily updates.• Andrew O’Donnell and April Buffo are RNs in the TLC functioning as nurse

communicators – Connect with patients & families early and often to help support them during this

difficult stay– Set up family meetings

Miscellaneous• No eating or drinking in TLC

• Follow isolation rules – sanitizer and gloves when entering each room, patient-specific isolation signs posted outside each room

• ICU is very different from most medicine rotations.

–If you have a question … ask it!

–If you need help … ask for it!

Resources• You will find the TLC conference schedule, daily schedule, as well as other useful

information on or TLC website located here: https://www.medicine.wisc.edu/tlc/welcome (login no longer required)

• The Educational section of the website highlights the following: – Critical Care Survival Guide by Indiana University (5-10 minute videos on ICU topics)– Landmark articles– Video lecture series provided by our staff – Educational websites– Special patient population– Book chapters

• Textbooks can be read through residency– Critical Care Medicine by Marini and Wheeler bases most teaching on physiologic principles to lenthen

its relevancy– Tarascon Internal Medicine & Critical Care Pocketbook may be helpful – Society of Critical Care Medicine has guidelines and helpful resources as well

Recent Changes in TLC

Cardiology Consults for Ventilator Management

A new policy that requires cardiology to consult TLC if they admit a patient who they anticipate will be ventilated for >24 hours OR who are difficult to ventilate or oxygenate

TLCCONSULT for H&PTLCCONSULTFOLLOWUP for daily note

CT Surgery ICU Coverage• On-Call team will be consulted to help co-manage critically

ill patients when there is no other critical care service coverage(i.e. Anesthesia) and continue to round daily until no longer ICU status– Team 1 – Residents/NP/Fellow/Attending– Team 2 – NP/Fellow/Attending

• CT Surgery APP will write all post-op admission notes and daily progress notes

• Page the CT Surgery APP prior to seeing the patient as they will be involved in the plan for the day and directly communicating with the CT Surgery Attending.

JCAHO Violations1. Be sure we set appropriate RASS goals:

JCAHO Violations2. All prn medications that have a therapeutic duplication must have an order in which the nurse is to administer them (1st line therapy, 2nd line, etc).

• Utilize the order panels for common therapeutic duplications:– Hypertension (labetalol, hydralazine)– Bowel Management– Anti-emetics

Restraint ReminderNon-Violent

• Need to be ordered by noon on each calendar day

• Be sure you order the appropriate restraint (soft limb, mitts, etc.)

• HUC will often provide a list of patients who need restraint

orders on rounds if they’re not entered

Violent and/or Self-Destructive

• Need to be ordered every 4 hours

Care of Sepsis Patients

Initiative to standardize care and documentation for patients presenting in sepsis:

Within 3 hours

Lactate blood cultures before antibioticsBroad spectrum antibiotics

30 mL/kg for hypotension or lactate ≥2Within 6 hours

(if patient continues to be hypotensive after fluids OR initial lactate ≥2)

Repeat lactateAssessment of tissue perfusion (heart, lungs, cap refill, skin

and pulse quality)Pressors initiated for persistent hypotension

Sepsis Protocole Note (.sepsis bundle)

ICU InitiativesPeripheral use of

vasopressorsConsider in every patient with adequate and appropriate peripheral access requiring IV pressors apart from vasopressin For TLC patients please order “peripheral use of vasopressors” when starting peripheral pressorsIn the event of extravasation please order “PRN Extravasation management”Both order panels can be found through orders (not order set) by searching “peripheral”

Midodrine use in shock

Consider in patients with stable (4-6 hours) pressor requirements with distributive/vasoplegic shockPatients will need enteral access and ability to absorb PO medsStart with 10 mg TID and titrate up or down by 5 mg as needed Possible contraindications involve patients with bradycardia, underlying heart block

ICU InitiativesAvoidance of Hyperoxia

When ordering mechanical ventiltiation or ANY oxygen delivery device (HFNC, BiPAP, NC, Oxymask, etc) place a target range in the comment box next to the

FiO2 (%) titrate to keep SpO2 >/= to ___%

• General critically ill population is SpO2 range 92-96%• COPD or ARDS populaiton is SpO2 range 88-92%

92-96%

TLC Weekly Update

The “TLC Weekly Update” is an email sent by Dr. Kory every Sunday night to faculty, fellows, and residents with

unit changes for the week.

Please read! Thanks!

Questions?

Courtney Hoy at courtney.hoy@uwmf.wisc.edu