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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 - 12:00pm:. Pre-round Morning Report/ PICU Fellow Lecture (Mo/Th) Rounds (Except Fridays 9 am) Radiology Rounds Finish Rounds

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flow of the day
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 - 12:00pm:


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 day1
Flow Of The Day

12:00 - 1:00pm:

1:00 - 4:30pm:

4:30 - 5:30pm:

Noon Conference

Follow-up consultations/procedures/post-op admissions/didactics

Sign-out Rounds with night team

resident teaching conferences
Resident Teaching Conferences

PICU resident lectures:

  • Monday / Thursday
  • 8 – 8:30am
  • In place of morning report
  • At front desk in PICU
educational resources
Educational Resources
  • PICU resident handbook with relevant PICU topics is available at


Hard copy is available in the resident call room.

picu chapters at http peds stanford edu rotations picu picu rec readings html
PICU chapters at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.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
picu chapters at http peds stanford edu rotations picu picu rec readings html1
PICU chapters at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
  • 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
PICU Tables at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html
  • Sedation
  • Inotropes
  • Shock
resident role
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
resident role1
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
other trainees in picu
Other Trainees in PICU
  • Anesthesia fellows
  • Emergency medicine residents
  • Medical Students
anesthesia fellows
Anesthesia Fellows
  • Present for half the blocks
  • Primarily provide support for fellow level activities in the ICU
  • Will not primarily follow patients
ed residents
ED Residents
  • Will act as a 5th resident in the PICU
  • May care for equal number of patients as pediatric residents
  • Rounds one day on weekend
  • Excused for Wednesday AM ED conferences: must pre-round & hand over notes to on call resident prior to leaving for education rounds
medical students
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
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
  • The following need a full H&P:
    • 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
  • 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
  • Online
  • PICU specific templates
  • Systems-based note
  • Indicate attending on your team and select “sign” not “review”
tips for picu notes
TIPS for PICU Notes
  • These are the official legal medical record
  • They support level of care provided
  • Therefore:
    • Avoid colloquials or not universally understood abbreviations
    • Use words to support ICU care—
      • instead of dehydration—mild tachycardia but stable, CR monitor
      • Try: dehydration with tachycardia, compensated shock in ICU for continuous hemodynamic monitoring
icu transfers requirements
ICU Transfers Requirements
  • Approval of the ICU Attending
  • Transfer summary
    • If going to a resident team, usually non-surgical and ICU stay >48h
  • Transfer orders
    • Surgical patients: surgeons often write orders
    • Always clarify with surgeon if OK to transfer & WHO will write transfer order
  • Sign patient out to ward resident
flow of rounds
Flow of Rounds
  • 8:30 Typically BMT, Liver, Renal Transplant
  • Followed by:
    • Sick/high acuity
    • Transfers
    • Remainder
  • Neurosurgeons round on their patients between 7:30-8:30 usually
tips for success on rounds
Tips for Success on Rounds
  • See CXR if available before rounds start…ETT high/low, new findings that can’t wait for rounds to start?
  • Any special drains in place? JP, Chest tube, EVD…know how much output total & per shift
  • Any pending studies completed from prior day? EEG, MRI, US, ECHO, cultures ….know the result
Patient identification
  • Quick assessment: i.e. patient improving, worsening, or unchanged
  • Major (not all) interval events
  • Vitals: Tmax (time) , vital sign ranges, including CVP, ICP if applicable
completing patient presentation
Completing patient presentation
  • Be succinct; try not to present same data more than once
  • One line overall assessment of patient condition
  • Review orders
  • Address patient dashboard
  • Engage Bedside RN in rounds!!
  • PICU fellows are given priority for all procedures (particularly 1st year fellows)
    • Prerequisite for CCM training
  • Acute situations : fellow or attending

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/Defibrillator familiarity
  • Code cart familiarity
bedside nurses
Bedside Nurses




  • Tell bedside nurse you are the resident caring for that patient
  • Give them your pager #
bedside nurses1
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 nurses2
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! **

  • To minimize line entry RNs like to have flexibility to time meds
    • UNLESS You want drug given at a specific time
    • Qday ordered at 8pm won’t happen until 8 am next day
  • RNs may batch labs to minimize line entry

*** except for immunosupression drugs ***

e.g. Prograf, CSA

order entry
Order Entry
  • Most routine labs and CXR require daily orders:
    • 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
In Cerner

PICU folder found under Power-plan folders

PICU specific Power - Plans
picu specific power plans1
On Cerner

Specific Power-plans available in PICU folder include:

Fever work-up

Trauma admit

PICU Daily orders

Respiratory failure



PICU specific Power - Plans
admitting trauma patients
Admitting Trauma Patients
  • ANY TRAUMA patient—admit as follows:
    • Ward Attending: select PICU Attdg
    • Service: Select Trauma (even if head trauma)
    • Sub-specialty attending: Select Trauma or Neurosurgery Attending
  • If head trauma or NAT: Peds surgery/trauma must be notified to do tertiary survey
  • Trauma H&P in Epic, co-write admit orders
order entry reminders
Order Entry Reminders
  • Extubation: Requires an extubation order
    • Don’t just D/C vent order
    • Other important orders are linked to extubation
  • Blood product orders
    • Still require a call slip
    • Inform patient’s RN that products ordered
  • ACE(airway clearance evaluation) vs CPT
    • Allows some autonomy to RT to develop plan for best mode of therapy
  • Patient safety dashboard useful tool!
  • Prescription paper available from USA
  • Loads into one printer and special tray
  • Select the PICU prescription printer for all D/C scripts
    • Rx_picu_fntdsk
picu quality and safety
PICU Quality and Safety
  • PICU Handoff Initiative for ALL OR Handoffs
    • One Message, One Time
    • Role cards utilized
    • IPASS tool for handoff comes with 45 min call
picu quality and safety1
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
PICU Dashboard Tab

Ensure Best Practices for

✔CABSI Prevention

✔Pressure Ulcer Prevention

✔VAP Prevention

  • Be sure to sign off
  • Don’t leave patient information exposed
  • Plug them back in (a dying cow is not pretty)
  • !! No cow tipping !!!
picu etiquette
PICU Etiquette
  • Please speak in quiet voices, particularly around main nurses station
  • We follow HUSH in the PICU
final thoughts
Final Thoughts
  • 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. Courtenay Barlow at


Pager: 23492