welcome to the picu n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
WELCOME TO THE PICU PowerPoint Presentation
Download Presentation
WELCOME TO THE PICU

Loading in 2 Seconds...

play fullscreen
1 / 51

WELCOME TO THE PICU - PowerPoint PPT Presentation


  • 204 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'WELCOME TO THE PICU' - halia


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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:

Pre-round

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

http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html

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
notes
Notes
  • 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
notes1
Notes
  • 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
notes2
Notes
  • 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
slide26
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!!
procedures
Procedures
  • PICU fellows are given priority for all procedures (particularly 1st year fellows)
    • Prerequisite for CCM training
  • Acute situations : fellow or attending
procedures1
Procedures

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

COMMUNICATION

COMMUNICATION

COMMUNICATION

  • 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! **

orders
Orders
  • 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

DKA

Hyperkalemia

PICU specific Power - Plans
admitting trauma patients
Admitting Trauma Patients
  • ANY TRAUMA patient—admit as follows:
    • LOCATION: 2E/PICU
    • 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
discharges
Discharges
  • 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

slide48
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 !!!
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
slide51
Questions, concerns, thoughts on the rotation

Contact PICU rotation director -

Dr. Courtenay Barlow at

cbarlow@stanford.edu

Pager: 23492