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ICU Orientation 2007-2008.doc Document Transcript

  • 1. MICU RESIDENT ORIENTATION For questions contact MICU director: Lisa Chen 206-8072, p 719-3335 or your chief residents at SFGH Responsibilities: Specific details outlined in attachment from Chief Residents. Major highlights – • Admit and manage the care of all MICU patients. May continue to care for patients transferred from ICU to 4B. In general, 4B transfers should remain on the ICU service if the ICU patient census is <10 (at our discretion based on ICU case-load and acuity). • Consult on all mechanically ventilated CCU patients to manage ventilator and sedation. • Coordinate critical care bed allotment with nursing staff and 4E resident. Approval of admissions and bed management in 4B. • R3s have HOD duties, evening and weekend medicine consults, admits for medicine/cardiology teams if reach they reach their limits, Code-blue pager • R3 is the senior in-house medical resident and should be aware of unstable Medicine service pts., and pts. with complex medical problems on other services. • There must be at least two R2/R3 level residents (one of these must be an R3) in-house for patient care between 8am and 5pm. Admitting policies/procedures: • MICU R3 must see all patients considered for ICU admission and is the final authority (via the attending) for approving all MICU admissions. • Coordinate with nurse in charge of triage, nursing supervisor, and 4E resident, for critical care bed allotment. Discuss admissions as soon as possible with the charge nurse to assess bed strategy. Alert MICU attending if problems. • Admission Notes: R1/R2 writes admission note and orders, R3 writes summary note. R1/R2s follow patients they admitted and write daily progress notes. HOD responsible for notes if R1/R2 is gone (or may divide note writing among R3s). Only Initial Consults for CCU pts. on ventilators need to be on 4 page forms (attendings to sign all pages and complete page 4). All other ICU notes may be on progress note paper or the pre-printed forms (if forms are used, need to write “See attending note” in place of attending signature). General MICU reminders: • The primary nurse and RT for a patient should be kept informed of the plan for the patient and any changes. Team-work is essential. • Patient transport out of the ICU – certain categories of critically ill patients must be accompanied by and MD. See transport guidelines at nursing station. • Do not call a team to transfer care until a floor/4B bed has been assigned • Sonosite must be returned to 5E after use (plug in to recharge, lock, and clean). Ask charge nurse for location of key. • All cardiac arrest pts. – need to be evaluated for hypothermia protocol (ordered by cardiology service) ideally within 2 hours of event. MICU manages mechanical ventilation and sedation. • Restraint orders must be reassessed and written for daily. Printed: 10/25/10 Revised: 10/25/2010
  • 2. • Have low threshold to call MICU attending for questions or uncertainties regarding patient management. Procedures: As a general rule, non-urgent procedures should be done during daytime hours when the MICU attending or his/her designee is either present or readily available. MICU residents may not perform procedures for which they have not been adequately trained prior to this rotation unless supervised. The determination of “adequate training” is based upon ABIM requirements. • All procedures require a procedure note (forms in 5R/5E file cabinets). Document consent status and any complications. Give forms to attending to sign (if present for procedure), and put white copy in chart and yellow/pink copies into Procedure Log (binder on bookshelf in 5E) for billing and QA. Central Access: When the MICU attending or designee is not available (i.e. nighttime), central access may be obtained by the neck route if the resident has had adequate experience in the placement of central lines in the neck and if ultrasound localization of the vein is performed prior to the procedure. Residents who are not comfortable with the placement of neck lines should use the femoral approach. During urgent or emergent situations, ultrasound localization is not required prior to placement of a central line. • Back-up for assistance with difficult access may be obtained by consulting the 4E on-call resident or anesthesia. PA Catheters: Placement of a pulmonary artery catheter may only be done in the presence of the MICU attending or cardiology fellow(consult). • Consult with cardiology fellow should be first-line call for assistance. If not available, anesthesia attending may be appropriate back-up, but requires presence of MICU attending. Last resort – John MacGregor (cardiac cath attending) can be contacted for placement under flouroscopic-guidance. Teaching: See posted calendar for daily lecture schedule. R3 Lectures - All R3s will be asked to prepare a lecture for the team. Topics should be assigned at the beginning of the month. Two topics to be repeated monthly: 1. Basic ventilator modes/management (for new interns at end of month) 2. Vasopressors R2/R1 Journal Article review - R2/R1s will be asked to review pertinent critical care literature for the team. The Critical Care Knowledgebase found in the Pulm. Division website at http://pulmonary.ucsf.edu offers a list of articles. R3s are also encouraged to review articles if the service is not too busy. Arrange a schedule with attendings of 1-2 presentations per week to be added on to lecture/rounding times (it is understood that time for journal discussion is very much dependent on how busy the service is). Printed: 10/25/10 Revised: 10/25/2010
  • 3. 5R ICU Structure 2007-2008 (Memo from Chief Residents) Key Changes:  The ICU at SFGH is a closed unit.  The ICU team consists of 4-R3s, 2-3-R1s, and one R2 from Family Practice who functions as an intern. R3s are q4 / R1s and R2s q3.  R3s are assigned 5 days off. Additional days off can be negotiated with the entire team with priority given to ICU duties, ICU didactics, and adequate ward coverage.  Medicine R1s rotate for two weeks and are assigned 2 days off by the residents.  Family Practice R2s rotate for four weeks and are assigned 7 days off (if they have 10 calls) or 6 days off (if they have 9 calls), or 5 days off if they have < 9 calls by the chief residents.  Every resident and intern is responsible for making sure all post-call clinics are cancelled.  The ICU team at their discretion may follow ICU patients transferred to 4B. As a matter of style, transferring a pt to a ward team after 5pm is considered bad form unless the ICU census is > 10. In this case stable patients may be transferred to the appropriate medical or family practice service when a bed becomes available. Key Principle:  THERE MUST BE TWO ICU RESIDENTS IN THE HOSPITAL AT ALL TIMES BETWEEN 8 AND 5PM, UNLESS COVERAGE HAS BEEN CLEARED BY THE CHIEFS. Resident Roles/responsibilities: As a team you all are the main caregivers of all the ICU patients. It is extremely important that you all are aware of the details of each patient so as to be able to make and implement effective care plans for the patients. o On-Call resident:  It is important for this resident to hear all patient presentations during rounds because they will be the main caregiver throughout the day and night. Make a solid to-do list to help assure important tasks of the day are accomplished. Also, holds the code blue pager after rounds and is in charge of running codes. This role can be alternated with the cardiology R2 if they wish to have more experience.  Takes the on-call pager after work rounds and starts admitting with the on- call intern until the next morning rounds. Residents should write a brief summary note on all ICU admissions and supervise the orders and assessment and plan made by the intern.  Pre-rounding starts at 7am. R1/R2s will follow the patients they admit and write daily progress notes. HOD is responsible for organizing pre- rounding and daily notes if the R1/R2 has the day off. Printed: 10/25/10 Revised: 10/25/2010
  • 4. Other responsibilities: • Be aware of floor patients on medicine, cardiology, family practice, etc. who are tenuous. Serve as back-up for medicine, cardiology, and nightfloat residents when needed. • Admit for medicine and cardiology if both teams cap and the nightfloat caps. If the ICU resident is busy with ICU issues, jeopardy should be called in. • Consult on vents and sedation for all intubated CCU patients. Write on the pre-printed H & P forms and provide page 4 for the attending the next day. • Round on all ventilated CCU patients. • Coordinate with the charge nurses and 4E resident about critical care bed allotment. When called to admit a patient to the ICU, first talk to the nurse in charge of triage to obtain a bed assignment. • The on-call resident is responsible for medicine consults in the evenings and on the weekends, as well as urgent med consults when MC is in clinic. If you are busy with ICU duties, any non- urgent transfers can be deferred to the next weekday. In terms of when you need to staff the med consults with the MC attending:  All emergent/urgent pre-op assessments/interventions: MUST call attending  All pre-ops must be staffed by attending before going to OR  All pre-ops done by YOU must be presented by YOU (e.g. on a weekend day)  for all others: use your judgment but don’t hesitate to call • Attend morning report when possible. o HOD: Usually the pre-call ICU resident. There must always be an HOD in house between 8 am and 5 pm. Arrive at 7 am to assist with pre-rounding and note writing for interns who have a day off. Holds the on-call pager and Code blue pager during work rounds so the on-call resident can pay full attention to the case presentations. Runs 4B rounds with the charge nurse after rounding on patients for the purpose of clearing 4B. During the daytime, the HOD is responsible for performing/supervising the majority of procedures in the ICU and helping the ward teams with any procedures they may have. The HOD also covers on-call ward team residents when they are in clinic as well as pre-call cardiology teams with one member off and the other in clinic. o Post-Post resident: This will often be a day off, but don’t assume it always is. Sometimes, this resident is needed as a back-up HOD when two HODs are needed for ward teams. If not needed as HOD and there are no required lectures, this could be a negotiated extra day off. This will need to be worked out with your teammates and attending. Printed: 10/25/10 Revised: 10/25/2010
  • 5. o Interns and FP R2: Q3 call. Medicine interns rotate for two weeks, FP R2 for four weeks.  On call: Arrive 7 am for pre-rounding, responsible for writing admission notes and orders, including vents and sedation, with the supervision of the R3.  Post-call, leave after lecture (12 noon) and cancel all post-call clinics.  Pre-call; either a day off or a work day. If not off, arrive at 7 am to pre- round and write notes on your patients. Schedule: 7 am: The post-call team and the pre-call team members meet to divide the pre-rounding and note-writing (sometimes this is better done the night before). The post-call resident will decide how to best divide the work. 7:30am: The ICU service is invited to morning report. Your attendance as the senior resident is extremely important. 8:30am: Rounds with the attending (may begin earlier dependent on patient load). Effective rounds are an integral part of an effective system, so prepare your interns and R2 on ICU presentations early. To ensure efficient and effective rounding, please keep distractions while rounding to a minimum. After rounding on any 4B patients, meet with the charge nurse by 11 am to triage patients. Your role is to evaluate the 4B bed needs and usage. This requires discussion with the 4B charge nurse (they usually know who needs to go) and quick pages to the teams. Encourage teams to write orders for transfers early. Exception, the neurosurgery service has unlimited access to 10 beds for their traumatic brain injury service. 10:45am: Radiology rounds. All films should be available on the board in 5K2. 11 am-12 pm: ICU Teaching rounds: ICU lectures located in 5K3 or 4F36 (see calendar) Afternoon: Sign-out rounds with attending Days off: The new focus for the ICU team is an emphasis on superior patient care, education, and provision of excellent support for ward teams. Because of this mission, it is important to have a critical mass of team members on most days. Old ICU lore is that you have 8 days off a month. Unfortunately, this is no longer possible because THERE MUST BE AN HOD IN HOUSE EVERY DAY FROM 8-5! So, when the HOD is in clinic, the post-post ICU resident must be available to do the afternoon work. Also, if a ward team needs coverage and BOTH the HOD and med consult have clinic or are otherwise occupied that day, there must be another HOD to help with those admissions. • Residents: assigned 5 days off. Additional days may be negotiated according to the above guidelines. • FP R2: 4-7 days off a month,.pre-assigned. 4 clinics per month, which are pre- assigned. • Medicine interns: assigned 2 days off by the residents on the first day of the rotation. Printed: 10/25/10 Revised: 10/25/2010
  • 6. Teaching: Remember, the interns really value the ICU rotation, so involve them as much as you can. Each intern should get first try at any procedures. If a patient’s clinical status is changing or treatment decisions are being made, please make sure the intern is involved with the situation and included throughout the process. Call them to the ED early for admissions; much preferred over being called to the unit. Every ICU resident should prepare an ICU chalk talk for the interns to be assigned by the attending at the beginning of the rotation. Residents and interns will also lead discussion of journal articles each rotation. Sign out and transfers: The on-call resident and HOD will have quick afternoon rounds on all patients with the attending to go over the day’s events and prepare for possible evening events. Readiness for transfer to a ward team is at the discretion of the ICU team. When a patient is deemed ready to leave the unit, either the ICU team continues to follow them in 4B if the census allows, or the resident communicates the patient’s ICU course with an accepting resident (FP or medicine). In general, stable transfers may go to short call, but tenuous transfers should be given to the long call team. A patient should only go back to their original team if the unit stay was short and the team knew the patient very well prior to ICU transfer. A call must be made to the accepting ward resident about the patient’s clinical course to that day and current plan. If the ward resident is off, the ICU team must help the intern with the transfer orders to ensure nothing is missed, then call the resident the next day. Each patient being transferred to another team MUST have a note in the chart by the ICU team on the day of transfer, and the ICU course/ transfer summary must be stat dictated by the intern or resident if the patient was cared for in the unit for > 24 hours. Do not call a team to transfer a patient from the ICU until the supervising nurse has verified that a floor or 4B bed is available. . GOOD LUCK AND HAVE FUN!!!!!! CALL US WITH ANY QUESTIONS OR PROBLEMS EARLY !!! Office 206-8322, pagers Gabe Ortiz 443-2194, Stephanie Cohen 443-7193. Printed: 10/25/10 Revised: 10/25/2010