Intensive Care Unit -- Information for Residents


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Intensive Care Unit -- Information for Residents

  1. 1. 1 Intensive Care Unit -- Information for Residents Welcome to the ICU and the Critical Care Service (CCS)! Please read this information packet before you start your rotation; it will help answer questions about your ICU rotation. Please ask additional questions or bring up concerns you may have about your rotation at any time. The Intensive Care Unit at Dartmouth-Hitchcock Medical Center is a 26 bed multi-specialty unit, caring for adult patients from all medical and surgical services. The ICU environment provides intensive treatment for critically ill patients on a concentrated and continuous basis. Patients are generally admitted because of the need for close observation, vasoactive drugs, aggressive pulmonary care, or mechanical ventilation. The ICU provides physiological monitoring equipment, a highly skilled nursing staff, and a readily available physician staff. Humanistic considerations of the patient and family provide the framework for medical and nursing decisions made in the ICU. CCS Attendings: The multidisciplinary ICU of DHMC functions according to a collaborative model. For most medical patients, the critical care attending serves as the primary attending (attending of record). For surgical patients and some medical patients (e.g. bone marrow transplant patient), the critical care attending serves as the co-attending physician of record. Critical Care Attendings include: David Axelrod, MD – Transplant Surgery Perry Ball, MD - Neurosurgery Kenneth Burchard, MD - General Surgery, Associate Director, ICU Howard Corwin, MD - Medical Director, ICU Peter DeLong, MD - Pulmonary Medicine, Associate Director, ICU William Dewhirst, MD - Anesthesiology, Associate Director, ICU D. David Glass, MD - Anesthesiology, Chair, Dept of Anesthesiology Rajan Gupta, MD – General Surgery Paul Kispert, MD - General Surgery Harold Manning, MD - Pulmonary Medicine Thomas Prendergast, MD - Pulmonary Medicine Timothy Quill, MD - Anesthesiology Athos J. Rassias, MD - Anesthesiology, Associate Director, ICU Peggy Simon, MD - Pulmonary Medicine Stephen Surgenor, MD. – Anesthesiology, Chief of Critical Care Medicine The critical care attendings generally rotate through the ICU in 1 to 2 week blocks of time.
  2. 2. 2 CCS Teams: House Officers and CCS Fellows in the ICU are divided into two Teams, Red and Blue. Each Team works under the direction of one CCS attending physician. A CCS Fellow is the senior House Officer on each Team. Each Team is comprised of Four House Officers from the Departments of Surgery, Internal Medicine, and Anesthesiology, as well as residents from the Departments of Obstetrics, Neurosurgery, and Orthopedics. ICU Morning Rounds: Morning rounds in the ICU begin at 8:00 AM, 7 days a week, including holidays. The task of pre-rounding and presenting the patients is shared each day by the available residents. The more senior residents on each team are responsible for ensuring fair distribution of patients to each resident on the team. Although individual attendings may vary in their preferences, a general framework for presenting is as follows: 1. Identifying statement: to remind everyone who the patient is (we don't need a recital of the history on a daily basis); e.g.: 59 y.o. with renal failure and ARDS s/p resection abdominal aortic aneurysm. 2. Events past 24 hours: these should be significant events (such as bleeding, need for re- intubation, serious arrythmias, new onset seizures, hypotension, etc.) and not simply a rehash of all the routine sorts of things that took place the previous day (i.e. Mr. T got 40 meq of potassium for a K of 3.2). 3. Review of current medications, particularly emphasizing: A. Antibiotics: what day of which antibiotics, for what reason: e.g. day 5 out of 10 of ampicillin and gentamycin for E. coli UTI. B. Steroids (how long, plan to taper?) C. GI and DVT prophylaxis D. Bronchodilators E. Dose adjustments for renal, hepatic disease 4. Nutrition: what, if anything, the patient is getting. 5. Physical exam: specific vital signs will usually be of interest. Include only positive findings or very pertinent negatives (e.g. an asthmatic now free of wheezing) 6. Data: ICU patients generate lots of data. Rounds can become a lengthy recital of numbers, particularly when the ICU is busy. Listening to a long list of numbers gets boring rather quickly, and the unimportant numbers often distract attention from the important numbers and the "big picture". To make rounds both more palatable and more useful (and even more interesting and enjoyable), we need to streamline the flow of information. The mere fact that a piece of data is available does not mean that it needs to be presented on rounds (likewise, just because you examined the entire patient does not mean you need to describe the entire physical exam on rounds). Furthermore, if occasionally you do not mention something that we would like to know, we can always ask you for the specific information. We have to depend on you to distill all the available data and information into the essentials for rounds, thus we depend on your ability to
  3. 3. 3 distinguish the important from the less important. Present only the data that is relevant for that particular patient. We do not need to know the exact I's and O's, NG tube drainage, platelet count, LFT's, phosphate, etc. for every patient. A. Net fluid balance (and change in weight relative to previous day and admission) is often more informative than the exact I's and O's. B. We almost always need to know most recent ventilator settings and ABG (if available). C. Summary of hemodynamics, highlighting trends and changes (e.g. “the cardiac index was averaging about 1.6, and increased to around 2.4 after dobutamine was begun”). D. Labs: if normal, just say so unless there is some overriding reason to report the exact value. If abnormal, it's always helpful to put things in perspective by comparison with previous values (e.g. creat 2.6, up from 1.9 yesterday). 7. Summary of problems and plans: A. Review the big picture: what is the underlying process, prognosis, etc. B. Outline each of the patient's active problems. Include an assessment and plan. Come up with a specific plan. Do not just say "we can try weaning again today". Instead, state specifically what you think should be done with respect to each of the problems (e.g. "spontaneous breathing trial; extubate if he does well for 30 minutes"). This is a chance to try to make sure things get done the way you think they should. 8. Be concise: The above guidelines apply to established ICU patients. A. New patients will require a more detailed presentation, particularly of the history. B. During rounds, the team will arrive at the plan of care for each patient for the day. Appropriate orders will be written at this time. 9. Computerized daily progress notes: A. All progress notes must be computerized notes entered in CIS B. These notes should contain events and data from the previous 24 hours; the notes no longer need to be printed and placed in the patients’ chart. C. Each resident is given priority use of a rolling laptop unit (one unit per team) to complete his/her daily progress notes. The mobile units must be charged appropriately, so please plug mobile units into outlets whenever possible (battery life is about 2 hours). D. Every effort has been made to make these notes as similar to the previous written progress notes as possible. The notes should be started during the on-call day and largely completed before rounds (a few details, such as the CXR findings, may not be filled in until after rounds). E. Additional notes or addendums should be written to document important changes and major diagnostic and/or therapeutic interventions.
  4. 4. 4 10. Important caveats: Many physicians make frequent use of “cutting and pasting.” Although this often saves time, it also often leads to the incorporation of outdated or incorrect information in the patient’s medical record (e.g. it may not reflect changes in a patient’s medications, ventilator settings, etc.). Therefore, if you cut and paste when putting your notes together, it is your responsibility to make sure that any all the information incorporated in your notes is current and accurate. Because notes are usually started the day prior to rounds, the “Encounter Date” in CIS must be changed to the actual rounding date before signing. For example, if you are on call Weds and begin your note that day but complete and sign it after rounds the following day (Thursday), the computer will list Wednesday as the Encounter Date. You must manually change the date to reflect the date that you are finalizing and signing the note. Radiology Rounds: Each weekday at 10:00 AM - 10:30 AM (depending on the ICU census), both teams gather in the Department of Radiology with an attending radiologist to review and discuss the most recent plain roentgenograms, CT scans, etc. that have been performed on their patients. Lecture Schedule: Each weekday at 11:15 AM there will be a Critical Care Lecture given in the ICU Conference Room for the House Officers in the ICU. The lectures encompass a wide variety of basic Critical Care topics. All House Officers in the ICU are required to attend these lectures. Please sign in on the attendance sheet. Routine patient care issues should not interfere with attendance at conference. Such issues may be dealt with by the Fellow and/or Attending while you are at conference. You should NOT start procedures, such as routine line changes, immediately before conference. In the event of an emergency, page 2419. (Saturday on-call resident does not attend Thursday conference – they are “excused”.) In addition to the didactic sessions, there are two loose-leaf folders that contain articles on a variety of critical care topics. The articles are of two types: recent, review articles that provide a nice overview of important topics in critical care medicine and original papers that have important implications for the treatment of some or many of our ICU patients. Please do NOT remove the articles or folders from the ICU. If you want copies of any of the articles, most can be downloaded electronically. “Hand-off” Rounds: At 1:30 PM Monday through Friday there will be Hand-off Report in the ICU conference room. During this report, the consult service will sign over any pertinent patient issues to the on-call fellow and staff. Blue and Red teams will report on remaining patient activities such as procedures, studies that need follow up, and discharges. Follow up on any discharged patients of interest can be discussed. The intent of the hand-off is to communicate key issues to the on-call providers. (Residents that are post-call, day-off, or have clinic are excused form Hand-off Rounds.)
  5. 5. 5 The Call Schedule: The Call Schedule is posted on the Critical Care Web page. It is also posted in the ICU Chart Room. House Officers in the ICU are on-call every fourth day. The general outline for the four-day rotation is as follows: Monday Tuesday Wednesday Thursday Friday Saturday Sunday R1 On Call Post Call Swing Early Round/ Clinic On Call Post Call “Off” R2 Early Round/ Clinic On Call Post Call “Off” Early Round On Call Post Call R3 Swing Early Round/ Clinic On Call Post Call “Off” Early Round On Call R4 Post Call Swing Early Round/ Clinic On Call Post Call “Off” Early Round Call begins at 8:00 AM and ends at 8:00 AM the following day. The post-call House Officer is expected to stay for radiology rounds and for the 11:15 AM Lecture. The post-call resident my leave after lecture if clinical duties have been completed. The general outline for the four-day rotation is as follows: Day 1 (Call Day): 8:00 AM - 8:00 AM Call begins at 8:00 AM and ends at 8:00 AM the following day. The resident is responsible for new admissions after the morning lecture Monday-Friday and throughout the day on weekends. The on-call resident is responsible for coverage of the entire service at night but will write a maximum of 10 inpatient notes for the following day’s rounds. The remaining notes will be written and presented by the “early rounder” (Day 4, see below) Day 2 (Post-Call Day): Leave after 11:15 AM resident lecture if clinical duties have been completed. Day 3 (Swing Day): 8:00 AM – 4:00 PM There is no admitting responsibility for the “swing” resident. Responsibilities include: attendance at morning rounds, radiology rounds, and the 11:15 AM lecture. The swing resident should also be available to assist the on-call resident with the completion of any planned procedures, lines, or other tasks on the patients on the team. Day 4 (Early Round): 7:00 AM – 5:00 PM, Monday-Friday, 7:00 AM – 12 noon, Saturday and Sunday. In order to reduce the burden of rounding for the post-call resident, the “early round” resident will arrive before rounds to help write notes and assist the resident who is post- call in preparing for rounds. The number of patients that the “early rounder” will be responsible for will vary as a function of the ICU census. Whenever the census on the team is greater than 10 patients, the early rounder is expected to pre-round and write notes on all patients that the post-call resident has not seen. Ideally the “early round” resident will take responsibility for the more chronic (i.e.less acute) patients who are less
  6. 6. 6 likely to have significant changes occur overnight. When the team census is less than 10 patients, the “early rounder” may help the post-call resident in general preparations for rounds. The early rounder must be available until 5:00 PM, Monday – Friday, and until 12:00 noon, Saturday and Sunday unless they have clinic. Notes: • During your CCS rotation, all clinical time must be dedicated to the ICU. You are expected to be present in the Unit at all times in order to provide emergent medical care. If there is a schedule conflict, any changes must be approved by Dr. Peter DeLong. • Some residents may have other responsibilities (e.g. continuity clinic) that require their absence from the ICU in the afternoon. Residents with clinic or other clinical responsibilities may leave after the morning lecture. • The House Officer on-call the last day of the month will stay for ICU rounds the next morning (the first day of the new month). Time Off: Each resident is given 1 day per week completely free of all patient care responsibility. When a swing day falls on a Thursday, Friday, Saturday, Sunday, or holiday the resident is given the entire day off (holidays = July 4, Labor Day, Thanksgiving Day, Christmas Eve Day, Christmas Day, New Year’s Eve Day, New Year’s Day, President’s Day, and Memorial Day). Clinical Back Up: The purpose of an academic ICU is to provide the highest possible level of patient care. Commensurate with this goal is the desire to foster learning. Hence, as a physician-in-training, you are expected to increase your knowledge base, and learn from your experiences. Reading, especially when time allows during your short-call and swing days, is expected. As a physician-in-training, you are not expected to be fully competent in Critical Care Medicine. You should not make clinical decisions or perform clinical procedures beyond your level of training without consulting those physicians who are your clinical back up. The CCS Fellow and Attending are on-call 24 hours a day and are dedicated to Critical Care Medicine, patient care, and education. You should feel free to call them; indeed, you are expected to notify them of any serious changes in a patient’s condition. For patients on surgical services, it should be remembered that the House Staff caring for the patient prior to ICU admission have been closely following their course. Consequently, you should feel free to contact the senior House Officers of these services with patient questions at any time. The chief surgical resident on the general surgery consult service is expected to be available 24 hours a day for ICU problems. He or she is to be notified of unexpected changes in condition. Some examples of clinical changes that should prompt notification of the surgical service include: • New fever • New hypotension • New (or accelerating) vasopressor or fluid requirement • Drop in hemoglobin or other evidence of bleeding
  7. 7. 7 • Significant alteration in mental/neurological status • Need for major diagnostic study (e.g. CT, MRI, angiogram, etc.) The bottom line: any time you are unsure of what you’re doing, ASK for help. Do not do anything of which you are not sure. And when there are changes in a patient’s clinical status, err on the side of over-notification of the primary service. Emergent Care: When changes occur in a patient’s condition, it is the CCS House Officer’s responsibility to initiate emergent medical care. At the same time, it is crucial to communicate with the CCS Fellow as well as with senior members of the patient’s primary service. Ordering Labs or Diagnostic Studies: AM labs are generally ordered the day/evening before on the standardized order sheet. The House Officer on-call will fill out the Lab Order sheets for the next day’s AM labs. Diagnostic studies such as CT scans, ultrasounds, echocardiograms, etc. can be ordered by the ICU House Officer after discussion with either the CCS Fellow or Attending. Frequently (especially on weekends), the Resident will need to call the appropriate department (e.g. Radiology, Cardiology) to schedule and/or confirm these studies. Code Status Determination: The determination of a patient’s code status or a change in their code status only takes place after the attending physician from the primary service or the CCS Attending has discussed these issues with the patient or patient’s family. Frequently when code status issues are raised, a family meeting will take place in which the patient’s family members get together with the primary attending physician, CCS attending, any attendings from consulting services, fellow, resident, and nursing staff involved in that patient’s care. The results of such discussions are to be documented in the patient’s chart and the standard code status form filled out. This form is to be signed by one of the attending physicians. Transferring Patients In and Out of the ICU: Patients may be transferred IN to the ICU from a variety of locations including: DHMC Emergency Department, operating room, general medical or surgical wards, or another health care facility. When a patient on a medical or surgical ward is deemed to need ICU care, the intern or resident caring for that patient on the ward will call the CCS fellow or attending carrying the ICU admission pager (#2419). The CCS fellow will evaluate the patient and determine if an admission to the ICU is warranted. If the patient is transferred to the ICU, the House Officer on the primary service should provide a transfer note that summarizes the patient’s major medical problems and current events. When transferring a patient OUT of the ICU, the primary service is contacted to confirm that the transfer is agreed upon. When patients whose primary service is surgical (General Surgery or any of the surgical subspecialties, including OB-GYN) are transferred out of the ICU, a resident on
  8. 8. 8 that primary service will write the transfer orders. The ICU Resident does NOT need to write a transfer note since the residents from the primary service will have continued to follow the patient in the ICU. When a patient on the medicine service is to be transferred out of the ICU, the accepting medical resident or attending should write the transfer orders, but the ICU Resident MUST write a transfer note, since the medical house staff and medical attending will not have followed the patient during the ICU stay. In those rare instances when a patient needs to be transferred out of the ICU quickly (because of the immediate need for an ICU bed) and the medical team is not immediately available, the ICU resident should let the accepting team know the patient is being transferred and the ICU resident should write brief transfer orders to get the patient to the floor. The ICU team should continue to provide care until the patient leaves the ICU. For all patients transferred from the ICU to the medical service, the accepting medicine resident or attending MUST be called (pager 2300) and notified that the patient is being transferred to the medicine ward, and a verbal synopsis of the patient’s condition provided. Procedures and documentation: ** All procedures, regardless of urgency are preceded by a time-out.** Procedure notes should also be completed in CIS using the available templates. It is expected that an attending will be present for procedures performed during the day. You may have to discuss the timing of the procedure to have the attending present. Please forward a copy of your computerized procedure note to the supervising attending. Physician’s orders: Please note that there is no system to flag orders. After you write an order you are required to discuss this with the patient’s bedside nurse. Nursing Staff: The Nursing leadership staff is comprised of the following people: Rose Morgan, RN - CCS Nursing Director Deb Cofell, RN - Care Manager Ingrid Mroz, RN - Clinical Nurse Specialist Please feel free to bring any problems, questions or concerns that you might have about the nursing care in the ICU to this group. The Nursing Staff in the ICU is comprised of all RNs. The Nurses work primarily twelve-hour shifts (7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM), with each nurse responsible for the care of one or two critically ill patients. In addition, there is a Charge Nurse (pager 9259) on each shift to manage shift operational concerns. Questions or concerns about a patient should be directed to the nurse caring for that patient. Each patient cubicle is designed to provide all equipment necessary for routine bedside care. Please familiarize yourself with the Green Cart in each room. It contains syringes, sterile dressing and suture material, as well as many other supplies that you may need. There is also a Unit Technician to assist you with obtaining additional equipment. The Unit Tech sits at the desk in the Nurses' Station, and is cross-trained in secretarial duties and supply maintenance).
  9. 9. 9 Respiratory Therapists: Each ICU Team has a Respiratory Therapist who rounds with the Team in the morning, and helps care for the patients followed by that Team. The responsibilities of the therapists include assisting the CCS Team in the management of patients on mechanical ventilation, administration of bronchodilators and other respiratory treatment modalities, assistance at intubations and extubations, and accompanying all critically ill patients during transport from the ICU. Pharmacy: A pharmacist frequently rounds with one or both of the ICU Teams each day. This person is extremely knowledgeable and helpful with drug choices, dosage issues, and is readily available for consultation. Nutrition Services: For patients requiring parenteral nutrition, an experienced nutritionist is available for consultation (both in the ICU and throughout the hospital). Orders for TPN must be written by 2:00 PM each day. For patients receiving enteral nutrition, nutritionists are also available for consultation. Visiting Hours: The ICU has unlimited visiting hours and you will notice patients’ family members and other visitors coming and going throughout the day and night. In general, this is not a problem. We only ask that patients’ families telephone the bedside RN prior to entering the ICU. Visitors are usually very cooperative and understanding when asked to step out to the waiting room when a patient needs to have a procedure or therapy performed. Revised 6/7/06