PICU

Overview

Last updated 5/3/2018 (Loehr)

HOME BASE: 5700 PICU; sometimes patients on 5800 step-down are still covered by the PICU team

TEAM: One PICU attending and one CICU attending that switches q week (Mondays), 6 residents (5Peds & 1 ER), one PICU fellow who rounds per week, but multiple PICU fellows that take call.

SCHEDULE: As of 2/2018, now a night float system. You will have 4-6 nights in a row scheduled. View your schedule on amion.com. Type "llup3 lastname" (using your name, obviously) to jump straight to your schedule.

When am I off? Any weekend day that is not NF/PICU 2/workshift/dayshift. You should have 4 total days off, 5 on holiday months. If the weekend days off do not add up to that total, there will be "comp days" given on weekdays. You need to ask the chiefs/scheduler (PediatricChiefReside@llu.edu) when they are.

CALL:

"Dayshift": You take sign out from night float at 6 AM. You are responsible for passing this sign out on to anyone on a regular shift who comes in later than 6 AM. You stay until 5 PM and sign out to night float. You will take sign out from regular shift residents who are able to leave early. Usually you will carry the code/admit pager but you can share this with the other people on the team. Sometimes, PICU 2 takes the pagers. Same deal on weekends.

"PICU 2":

Weekdays: Starting at 5:30 AM you are first call for transports, so keep your pager handy. Come in to work as early as you need to in order to pre-round on your patients. You may get sent on a transport during this time, so often you will sign out your patients to the rest of the team before rounds. Sometimes, your team will sign out their simpler patients to you after pre-rounding and you will see those with the "sedation" attending. Usually the fellow decides who these simpler "PICU 2" patients are. This means you round on patients you didn't see which is as insane as it sounds. After 5:30 PM you become second call for transports (home call) all night until 5:30 AM the next morning.
Weekends: Same as above but you are second call for transports for the whole 24 hours. You have to come to work to round on your patients, it's not otherwise a day off.
If you are out on a transport after midnight, the next day is considered "post call" and you go home by 10 AM.

"Workshift": Come in as early as needed to pre-round on your patients, round, and be out by 10 AM - noon at the latest.

Night float: 5PM to 6AM. You take all the admissions and cover the floor. There is always a fellow and attending in house. Typically they will do night rounds around 10PM-MN, which are usually a quick walk-around to make sure all the plans are on track. Some attendings are a bit more formal about this.

Weekdays that are none of the above: Come in early enough to pre-round. Get sign out from the dayshift resident, or the night float directly if you get there early enough. Sign out to the dayshift resident when you are done with floor work, hopefully early in the afternoon if your team is efficient.

CALL ROOM:Located on 5700. Remember the 4700 MICU call rooms, except 1 floor up. Your ID card will open the door. The on-call PICU resident room is the last door on the left. During daytime, it is usually occupied by pediatrics residents for the computer. Now that it's a night float system, you probably won't use the call room and will spend most of your time in the workroom on the unit.

TYPICAL DAY:

6 – 6:30am: Come in and get update on your patients from night float resident. Pre-round on your patients and complete progress notes.

8am: Round with PICU attending (On M, T, and Fri, rounds may start later due to conference or PICU attending sign-out)

M-Thu 12pm – 1pm: Pediatric Resident conference (free lunch – not drug sponsored)

1:15pm: Finish rounds with PICU attending.

After rounds, finish up discharges, transfers, & paperwork. If on dayshift, take sign out from the team and stay until 5pm. If on PICU 2, you can go home, but be aware that you are first call for transports until 5:30 so ask the front desk if anything is coming.

SIBR ROUNDS:Structured Interdisciplinary Bedside Rounding: Basics are that each discipline has their own piece to present: Residents, Nurses, RTs, Pharmacists. The family is attending rounds as well, and they have a time for them to ask questions (we've put this at the end - so they can see if their questions are answered).

Introduce (takes less than 15 seconds) Lead team to room, greet parent.
Next, RN will provide update of objective information, RT will provide vent/RT updates
Update Hospital Course (2-5 minutes) *Less is more*
Assessment and plan by system: Includes reason for admission and brief past medical history. Review active problems and response to treatment. Discuss interval test results/MAR/Consult input. Pertinent Physical exam findings
Invite inputs from family, nurses: Nurses, RCPs, Pharmacist will present most of the information.

Here is a link to a SIBR video that was made to give you an idea of how it works.

PROGRESS NOTES: There are built in EPIC templates for PICU H&Ps and progress notes, or you can borrow improved versions from the peds residents. Generally it is expected that they are completed and signed prior to rounds; some attendings will edit them during rounds, others don't look at them until later.

ATTIRE: Scrubs. White coat optional.

PAPERWORK: If you take an LLUMC Peds ED admit, you write an H&P in Peds Prog Notes and admit orders once the patient arrives in PICU. Going down to the ED is not something you do. If it is a transfer from OSH, the transport resident will write H&P and admit orders. If it is a transfer from the floors, the transferring resident will write transfer orders and transfer progress note, but you also have to write an “accept note” in EPIC. After seeing patient, you will review admit orders and make additions if needed. Notify fellow & attending when patient arrives, if they are not already there.

When transferring a patient to Stepdown or Basic, write transfer orders and a transfer summary. Two-way “wamopeds” and send them patient’s name, MR#, and pertinent information - discuss with the peds residents what team they should go to and include that info, too. Ask a peds resident how to write transfer summaries. The peds residents are very particular about these. Basically it has to be a complete paragraph-form discharge summary.

It can be really helpful to create H&P, prog notes, and transfer summaries for common diagnoses i.e. DKA, asthma, bronchiolitis etc.

CONFERENCES:

M - Thu: 12pm-1pm Pediatric Resident Conferences (free lunch – not drug sponsored)
Tuesday 8am-9am: “Super Tuesday” – pediatric conference where they present cases
Wednesdays 8am: Nutrition Rounds: Bagels, pastries and juice are provided and the nutritionists come and talk about pts nutrition needs (g-tube feeds, TPN etc)
Most Fridays 8am-9am: Pediatric Conference
Most M-F (9 or 10am): Radiology rounds with radiology attending & resident - in resident/radiology room in 5762.

STUFF TO REVIEW:

Mechanical ventilation – SIMV (pressure control, volume control, appropriate tidal volumes)
High frequency oscillatory ventilation (HFO)
How and when to wean mech. ventilation
Acid-Base physiology
Status asthmaticus, status epilepticus, DKA, neutropenic fever, pediatric shock & treatment
Cardiac – Glenn, Fontan, cardiac malformations, Pulmonary HTN
- Currently the PICU resident team does not cover the cardiac ICU, so (un)fortunately you will probably not deal with cardiac ICU cases
Extracorporeal membrane oxygenation (ECMO)
You will get an account to http://www.sccm.org/ for a mandatory PICU pre and post-test and an optional PICU course (no longer true as of 2/2018)

PEARLS

Download Dr. Tinsley's PICU cards - you should be given a copy of these
Anticipate discharges and transfers and begin the transfer/discharge summary note EARLY.
A progress note is not necessary on patients who arrive after midnight.
For procedures, it is Fellow > Primary Resident > Resident.
Calculate and report urine output in mL/kg/hr during rounds
When writing medication orders, write the dosage in mg/kg/day or mg/kg/dose or else you will get called by pharmacist. If patient is >40kg, you can write, “Adult Dose,” instead. The PHARMACIST will page you EVERYTIME so get used to it!!
Pick up meal tickets from Pediatric Residency secretary when you start your month (not provided any more now that the rotation is night float, as of 2/2018)
Use the ultrasound machine (Sonosite w/ linear, hockey stick, & abdominal probes). It is located in the equipment room on 5757A. Ask a nurse or fellow to open the door with their ID card, as our cards do not work. You may have more experience with ultrasound, so please educate PRN. Find some ultrasound tips here.

PICU Resident Rotation –

The following list of subjects will be reviewed during the month (in theory). The topics will be either reviewed by the fellow or the attending. To avoid duplication of presentations it is recommended that you discussion the choice of topics at the beginning of each week with the attending and fellow.

Important PICU Topics:

Respiratory Management and Review of Mechanical Ventilation
Status Asthmatics
DKA
Sedation medications
Inotropic agents
Status epileptics
Renal failure, CRRT and hemodialysis
Head trauma
Shock
Airway management

See below for more information that is sometimes sent out to new rotators on the PICU:

Daily Activities

Resident Independent work rounds 6:30 to 8:00 am

A. Residents should come in early enough to be able to:

1. Meet with previous night call resident to obtain an update on the residents assigned patients.

2. Residents should meet and reassign patients as necessary to more evenly distribute the patient load

a. The goal being 5 patients per resident

b. The PICU attending reserves the right to redistribute patients as he or she feels is necessary

3. Resident should examine each of their assigned patients

a. Collect data from the patients flow sheet

b. Collect most recent laboratory data

c. Check recommendations made by consulting services

d. Formulate their own assessment and plan for the each patient

B. Attending and residents rounds

1. 9:00am PICU rounds with the attending on 5700 or 5800

2. Rounds may start later on days when attendings have meetings or grand rounds are scheduled.

3. Remember duty hours. You must only work a total of 28 hours/day. Therefore on nights that you are on call it is best that you come in at 8:00 am and make sure you leave the next day by 12:00 am.

4. The person going off call should sign out to the person on call before rounds starts. The post-call resident can begin to sign out their patients on rounds. At 9:30 you should turn your patient’s over to the on call person finish your work and leave the unit by 12:00 pm.

C. X-Ray rounds

1. Monday through Friday x-ray rounds are done approximately at 9:30 am

2. Provide a brief history of relevant problems and reason for ordering the X-ray to the pediatric radiologist when reviewing your patient’s film.

D. Post Call residents

1. When possible should present their patients first

2. The resident should then attempt to complete their work and leave the hospital by 10:00 am. .

E. Sign Out Rounds:

1. Aim to sign out your patients to the resident on call by 4:00 pm

2. After you sign out, you are free to leave the unit.

3. The attending on call will have sign out rounds with the attending and fellow on call at approximately 4:30 pm. You are welcome to join them

F. Evening Rounds

1. Rounds will be done (as patient care permits) with the night charge nurse, resident, fellow and attending on call. Times may vary goal is 9:00 pm. to 10:00 pm.

G. PICU 1 and PICU 2 Resident

PICU 1 resident is the resident on 28-hour call that day

PICU 2 resident is the resident on call for day time transports last call will at 4:30 for a 5:00 pm transport.

Transport resident takes call at 5:00 pm and will be called after 4:30 for a 5:00 pm transport .

Transport Resident need to arrive in the PICU 30 minutes after the call.

PICU NOTES POLICY

H&P

All patients admitted to the PICU service require an H&P.

The H&P should include all the following elements. Do not leave blanks in the template.

Identifying Data

History

Family History

Review of System

Physical Exam

Assessmentand Plan-system based.

The H&P should be done on EPIC using templates provided. They will need to be cosigned by the PICU attending involved in the admission

DAILY NOTES

Write a progress note daily using a system based approach.

Be careful when you cut and paste a note that the information in the new note is current and accurate. Example cutting and inserting the ventilator settings when the patient has been extubated should not happen.

Keep the patients problem list up to date. Example a patient is admitted with respiratory distress and the diagnosis is bacterial pneumonia but the problem list remains respiratory distress.

DISCHARGE SUMMARY or TRANSFER SUMMARY

The key word is SUMMARY. When you send a patient out of the PICU or out of the hospital it is not necessary to include day to day nuances of the care. If you tell them every time you increased the dopamine or every time you held the feeds for 10 minutes they will not be able to understand the big picture. Use summary sentences to tell the story. For instance it is acceptable to say, the patient was in hypovolemic shock requiring multiple transfusions of RBC, PLT and FFP, Dopamine, dobutamine, norepinephrine and epinephrine drips were started on admission and weaned off over a three week period. It is not important to include which one you weaned first, if you chose to wean to 10 each or 8 each etc etc.

You can start this document on one day and authenticate it on a separate day. Please do not let this cause you to add small details each day until you have written a novel. It should still be a summary not a blow by blow narration of the hospital course.

Please use at least the following:

Accepting service

transferring service

Date of transfer

Hospital course

Problem list-by systems in which all systems are briefly addressed

Procedures

Recommendations

Current Medications

Allergies

REMEMBER TRANSFER OR DISCHARGE ORDERS ARE WRITTEN BY THE PICU TEAM NOT THE ACCEPTING SERVICE

REMEMBER TO CALL WAMO when a patient is going to be transferred and what team the PICU may recommend. WAMO however may assign to a different team.

SIGNING OFF SERVICE: EXAMPLE SURGERY PATIENTS

Often we will follow a surgery patients when the come from the ED or OR. After a few days the PICU attending will determine that the surgery service will no longer need the PICU team to continue to follow the patient. The resident will do the following:

The resident will two-way page the surgery team to let them know they have signed off the case.

The residents do not need to write a complete transfer summary.

They will write on their last progress note at the bottom of the note. (See example below)

"Thank you for your consult. The PICU team will be signing off care today.

The PICU Service recommends:

1. Another BMP will need to be checked in the morning to follow the patient K since we stopped Lasix today

2. Another vancomycin level will be due before the next 3rd dose since we increased the dose this morning

3. ID recommended a 3 week course of antibiotics

If you have any further questions please page Dr. Jones at 44444."

CONSULTS IN THE PICU

1) When the PICU wants a consult they will complete an order for a consult. The consult residents will be able to pick this up from the chart.

2) The PICU attending will "triage" consults. If the consult is emergent the team likely will be speaking to the consulting attending directly.

If it is Urgent the PICU residents will take time from rounds to speak with the consulting resident. If the consult resident is in the hospital they should come to the unit, see the patient and talk with the team. If they are across the street at the FMO/PTO then they may speak with the residents via phone to give them a brief summary of the patient. The PICU team will not review every lab and test with the consulting resident. It will still be the consulting residents job to review EPICbut the PICU team will provide the information that is normally found in a note about the current decision making and current concerns.

All admission to the PICU will have an H and P the past medical history will be available to the consultants.

If the consult is more routine and can wait until after rounds the PICU team will complete the consult order, page the consult resident but any discussion/ reviewing of the patients current PICU course will occur after rounds.

3) Daily follow up of how the patient is doing can occur by conversations with the PICU team BEFORE morning rounds. If the consulting resident has clinic they can come to 5700 before their clinic and talk with the PICU resident to see how the patient is doing and if there are new/additional questions.

Please note there is no mention of using 2way pagers for these discussions. They are a great way to send the patients name and MR# but an entire history should not be narrowed down to two lines. For effective communication we should talk about the patients person to person or over the phone.

TRANSPORT NOTES

If you are involved in transporting a patient to the Children’s Hospital you will need

To do the following:

1. Call the attending before you leave the transporting facility

2. You need to write the admitting orders and transport orders

3. You need to do a complete H&P

4. Bring signed consents with you

5. Bring a copy of the transporting facilities chart and x-rays with you

6. Give a summary of the details of the transport in your H&P

7. If the child is admitted to the wards or step down call WAMO

8. Give a handoff to the accepting resident.

Other items:

1. Instead of super-tuesday the residents will attend the PICU M&M rounds on 3rd Tuesday of the month.

2. Make sure you fill out your 360 self evaluation which will be sent to you by Dr. Tinsley

3. Make sure you fill out an evaluation for each attending you work with.

4. Make sure you complete the PICU pretest and posttest which Dr. Tinsley will send you

5. Make sure you complete the required reading on line.

6. Articles for your review:

a. Articles are on Canvas for your use

b. The PICU fellow and or attending will assign articles for you to read and discuss on a weekly basis

c. Please see the curriculum form that was emailed to you for suggested

Subjects and articles.

1. REMEMBER THERE IS A PHARMACIST IN THE PICU 24 HRS A DAY

1. A pharmacist attends daily SIBAR rounds

2. They are also available to consult 24 hours a day.

HOW TO WRITE ORDERS FOR INOTROPIC AGENTS

Complete Order for infusion including

Drug name
Concentration
Volume & diluent
Route
Start rate
Include increments, frequency, max dose
Titration parameters or wean off parameters

OR titrate per guideline and include Drug. Start rate and titration parameters or wean off parameters or goals

Patient specific goals (ie. RASS, MAP, SBP, etc)
- Recommendation: MD identify 1 goal for titration meds

If any of the elements are missing in the order, MD must rewrite the order with all required components.

Critical Care Content

1. Recognition of impending systemic failure

Change in vital signs
Cardiogenic shock
Hepatic failure
Brain death

2. Emergency life support

Plan appropriate ventilator management in patents of various ages
Plan appropriate ventilator support for patients with various conditions
Understand correct method for cardiopulmonary resuscitation in patients of various ages
Differentiate the findings associated with hypovolemic shock from those of septic shock, and manage appropriately
Plan the appropriate use of intra-osseous therapy

3. Common conditions requiring emergency life support

Plan appropriate management of near drowning
Understand the prognostic factors associated with near drowning
Recognize the clinical findings associated with a hemi thorax or flail chest
Recognize the clinical features of acute respiratory distress syndrome
Recognize complications of acute respiratory distress syndrome that can lead to death
Identify the etiologies of acute respiratory distress syndrome
Recognize the clinical findings associated with pericardial tamponade

Goals and Objectives

GENERAL COMPETENCIES

The Pediatric Critical Care Residency Program is committed to providing education and an environment that will produce pediatric intensivists who will have all cognitive and procedural skills necessary to provide state of the art care for any critically ill child. The focus of clinical teaching is on organ systems pathophysiology and its application to patient care. The academic emphasis on teaching and research, in addition to the broad clinical experience provided by our patient population, will prepare graduating fellows to provide high quality patient care and to be very competitive in an academic or clinical arena. Assessment of achievement of these goals is based on acquiring the skills of the General Competencies. Appropriate progression is expected in all of the competencies through the first, second, and third years of training with the final goal being a skilled pediatric intensivist who will transition easily to independent practice. In the first year of training all residents will be closely supervised in all of the competencies. In the second year of training gradual independence will be given as the resident shows proficiency. By the third year of training, again based on proficiency, the most allowable independence will be set with the expectation that the resident is able to function with minimal supervision. By the end of their training, the resident will demonstrate sufficient professional ability and leadership qualities to function independently and competently as a Pediatric Critical Care Practitioner.

Patient Care: Residents will demonstrate patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health in critically ill children.

Recognize and obtain essential and accurate information about children presenting with a critical illness
Develop a therapeutic plan based upon relevant clinical, radiological and pathologic information
Oversee diagnostic testing to ensure appropriateness and adequacy of studies performed
Counsel patients and their families regarding the nature of their illness and overall prognosis including end of life care if necessary
Counsel patients in preparation for specific diagnostic testing and procedures by obtaining informed consent
Demonstrate the ability to use the Internet, textbooks, and discussion as an educational instrument to expand diagnoses and therapies when caring for a critically ill child
Demonstrate knowledge of the indications, risks, and complications of common pediatric critical care procedures such as intubation, central venous line placement, arterial catheter placement, cardiopulmonary resuscitation, and chest tube placement, as well as competency in performing these procedures.
Senior residents will demonstrate the ability to systematically assess, prioritize and manage patients with increasing complexity.

Medical Knowledge: Residents must demonstrate knowledge about established and evolving basic and clinical sciences and the application of this knowledge to patient care for the child with a critical illness.

Demonstrate sufficient knowledge of pediatric critical care and apply this knowledge in a clinical context; synthesize information to generate meaningful differential diagnoses and therapies
Demonstrate knowledge of the principles of research design and implementation
Generate a clinically appropriate therapeutic treatment plan
Demonstrate the ability to use all relevant information resources to acquire evidence based data
Understand how diagnostic testing and equipment can be used to generate appropriate medical information with attention to patient safety and principles of risk vs. benefit
Senior residents will demonstrate increasing depth of medical knowledge for common clinical conditions and breadth of knowledge for rare or infrequent diagnoses.

Interpersonal and Communication Skills: Residents must demonstrate interpersonal and communication skills that result in effective information exchange with patients, patient family members, medical students, other residents, supervising faculty, referring physicians, nurses, respiratory care practitioners, and other members of the health care team.

Provide a clear and informative written progress note/consult including a physical examination, a precise diagnosis whenever possible, a differential diagnosis when appropriate, recommended therapies or additional studies when appropriate, and prognosis
Provide direct communication to the consulting/referring physician or appropriate clinical personnel when patient status has an urgent or unexpected change and document this communication in the patient chart
Demonstrate effective skills of face-to-face listening and speaking with physicians, patients, patient’s families and support personnel
Demonstrate appropriate telephone communication skills
Demonstrate skills in obtaining informed consent, including effective communication to patients of the procedure, alternatives and possible complications.
Senior residents will demonstrate the use of effective listening, narrative and non-verbal skills to elicit and provide information and work effectively as a leader of the health care team on increasingly complex patients.

Professionalism: Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.

Demonstrate altruism and compassion; be understanding and respectful of patients, patient families, and staff and physicians caring for patients
Demonstrate excellences: perform responsibilities at the highest level and continue active learning throughout one’s career
Be honest with patients and all members of the health care team
Demonstrate honor and integrity: avoid conflicts of interest when accepting gifts from patients or vendors
Interact with others without discriminating on the basis of religious, ethnic, sexual or educational differences and without employing sexual or other types of harassment
Demonstrate knowledge of issues of impairment (physical, mental alcohol or other substance abuse), obligations for impaired physician reporting, and resources and options for care of self impairment or impaired colleagues
Demonstrate positive work habits, including punctuality and professional appearance, as well as recognition of fatigue and “burn-out”
Demonstrate an understanding of broad principles of biomedical ethics
Demonstrate principles of confidentiality with all information transmitted during a patient encounter
Demonstrate knowledge of regulatory issues pertaining to the use of human subjects in research.
Senior residents will demonstrate improved professionalism in leading thehealthcare team and in their interactions with referring and consulting physicians.

Practice-Based Learning and Improvement: Residents must be able to investigate and evaluate their patient care practices, and appraise and assimilate scientific evidence in order to improve their pediatric critical care practices.

Analyze practice experience and perform practice based improvements in cognitive knowledge, observational skills, formulating a diagnosis and impression, overall patient care, and procedural skills
Demonstrate critical assessment of the scientific literature
Demonstrate knowledge of and apply the principles of evidence-based medicine in practice
Use multiple sources, including information technology to optimize lifelong learning and support patient care decisions
Facilitate the learning of students, peers and other health care professionals.
Senior residents will demonstrate increasing insight in their self-evaluations; analyze personal practice patterns systematically, and show personal initiative in making improvements.

Systems-Based Practice: Residents must demonstrate an awareness and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide optimal care.

Demonstrate the ability to organize multidisciplinary patient care using all available resources
Demonstrate the ability to design cost effective care plans based on knowledge of best practices
Demonstrate knowledge of hospital quality improvement and how to participate effectively in quality improvement discussions
Demonstrate knowledge of basic health care reimbursement methods and how to interact with insurance agencies when necessary
Demonstrate knowledge of the regulatory environment including state licensing authority, state and local public health rules and regulations, and regulatory agencies such as Joint Commission for the Accreditation of Healthcare Organizations (JCAHO)
Demonstrate knowledge of basic practice management principles such as budgeting, record keeping, medical records, and the recruitment, hiring, supervision and management of staff.
Senior residents will demonstrate increasing ability to partner with other health care providers to assess, coordinate and improve patient care. They will display increasing maturity in using systems based quality improvement processes to improve patient care.