NMCCS

• The service is comprised of Nurse Practitioners and Residents on rotation assigned either an 8 or 12 hour shift. On your first day on service, you will have assigned patients.

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1. Sign out between outgoing and incoming NP/residents occurs at 0545-0600 and 1745-1800. Prompt arrival is expected.
2. The NMCCS pass around pager is 8436—please page the night before your rotation starts the check on census and the potential number of patients you will be assigned.
3. LLEAP sign on: when on service with NMCCS, you MUST change your department to Critical Care Center (CCC).
4. Progress notes
   1. There is a CCC daily progress note template. Go to “Progress” tab in the Note section and type “ccc” in the smart text section. A drop down menu will show all the templates for the CCC. Select the “resident progress note” and complete all fields. Do not use any other non-CCC templates.
   2. There are two sections of quality measures that are incorporated into the note – the weaning/sedation vacation and the vent/central line quality measures.
      1. The weaning and sedation vacation measures are documented by the RCP/RN and will auto populate in the progress note. However you are asked to document whether they occurred or not and if not the reason why not. If the patient is not on the ventilator, these sections may be deleted from the note.
      2. Never delete the quality measures that are incorporated into the note. These include the daily ventilator sedation & breathing trials as well as the vent/central line bundle located toward the end of the note. Indicate “NA” if it does not apply to the patient.
   3. Before you sign the note, make sure to check the “co-sign” box in the upper left corner and assign the note to the designated NMCCS attending. The practice of copying notes is unacceptable.
   4. Other available CCC templates are: brain death, code blue, death note, bronchoscopy, limitation of treatment, PA catheter placement, resident admission note, staff attestation note, staff progress note.
5. Procedure notes
   1. Select the Procedure tab in the Note section.
      1. Select “Create in Note Writer” and a dropdown box will appear--
      2. Click on “Bedside Procedure Note” and click on “Accept”, then
      3. Change the authorizing provider to your assigned NMCCS/SICU attending
      4. Select the appropriate procedure template.
   2. Prior to starting your procedure note, make sure to change the “authorizing physician” to the supervising NMCCS or SICU attending. This MUST be done before you start your note.
   3. Make sure to “co-sign” the note to the designated NMCCS or SICU attending.
6. Rounds will start at 0830 daily. Progress notes must be completed by the start of rounds.
   1. Neurosurgery will round on their patients from 0500 to 0730. A NMCCS team member will then communicate via phone or in person to run the patient list and discuss plan of care for patients with them.
   2. The day shift is responsible for ordering AM labs and diagnostic tests needed for the following morning. There is only one NP/resident during the night and may not have time to follow up.
   3. Each NP and resident should daily review their respective patients’ “Order Management” and delete duplicate and/or old orders.
   4. How much time you need to assess and complete your progress notes will depend on your knowledge base and LLEAP knowledge. Plan accordingly to allow yourself sufficient time to complete your notes for rounds.
   5. Multidisciplinary rounds occur every Wednesday morning. This includes NMCCS team, social work, case management, PT/OT/Speech and dietary. The goal is to discuss each patient’s treatment and discharge plan.
      1. Unit 8100 will meet at 1100
      2. Unit 9100 will meet at 1130
7. Admitting patients to NMCCS
   1. MD/NP to NMCCS MD/NP SBAR needs to occur before the patient is admitted to NMCCS.
   2. Always notify the charge nurse where the patient will be admitted that you have received SBAR from the admitting team or ED.
   3. The admitting physician for neurosurgical patients will be the attending neurosurgeon on call. All others will be admitted under the NMCCS attending name.
   4. Admitting H & P are done on ED and direct admissions to NMCCS from other facilities.
   5. Progress notes will be done for all other admissions (i.e. transfers from floor, in-house ICU transfers).
8. Infection Monitoring
   1. Pan cultures are to be done on all unplanned in-house and OSH transfers with an indwelling catheter or central line.
   2. Blood cultures are to be drawn per hospital guidelines. Currently, all blood cultures are to be drawn peripherally. NO cultures should be obtained through A-line, PICC or CVL.
   3. Unplanned in-house and OSH transfers with CVL and/or PICC are to be discontinued once a suitable alternative is established. NEVER send the tip for culture.
   4. Foley catheters and CVL’s placed in ED can be kept if there is written documentation of sterile placement. Obtain UA (no reflex to culture) and based on results decide if culture is indicated. We do not culture urine if pt has been in the ICU for more than 12 hours, unless if you have attending approval.
9. Foley catheters are to be changed:
   1. On admission to ICU unless the Foley was placed in the OR or documented sterile insertion in the ED.
   2. All patients will have their Foleys changed Q Sunday if the indication remains, unless the Foley has been changed in < 48 hours.
10. NMCCS patient list contains all patients on service and their management
    1. The list is kept updated each shift by the respective NP or resident managing the patient(s).
    2. It is important to include: start dates for all lines and abx, family updates & contact info, therapeutic goals & parameters (i.e. maintain SBP 100 – 140).
    3. Only one person can be updating the list at a time. Make sure to always save and close the list when you are done.
11. Call Room (rm 4012) is located on the 4th floor and is badge operated. Please make sure you ID badge opens the call room. If you badge does not work, contact House Staff office.
12. Resident evaluation is based on but not limited to:
    1. All progress notes should be complete and accurate.
    2. Accurate updated quality measures documented.
    3. Attendance of all NMCCS education requirements—you are excused if scheduled off or post night shift
    4. M & M reports as directed by the attending’s.