Intensive Care Unit

Welcome & Orientation

UCSF Moffitt & Long Hospitals

Rotation Learning Goals• To learn to care for critically

ill patients• To understand

management of respiratory failure with mechanical ventilation

• To develop a better appreciation of cardiopulmonary physiology

• To understand indications for different modalities of hemodynamic monitoring

• To improve on techniques to place invasive monitors

• Understand the pharmacodynamics and pharmacokinetics of sedatives

• Learn the communication skills required in the role of the critical care consultant

• Develop a multidisciplinary treatment plan for critically ill patients

Learning Goals

Have a fun and educational month

Background

• Open and closed critical care units

• Diverse patient population

• Multi-disciplinary teams• MD, NP, PharmD

• Intensivists from different backgrounds• Anesthesia, Pulmonary, Nephrology, Surgery,

Emergency Medicine, Neurology

Organization

WEEKDAY NIGHT/WKND

Open and Closed ICU’s

The data:Multiple studies show that the daily presence of an intensivist improves outcomes, including mortality and length of stay. There was no advantage to closed units

UCSF ICU’s

• UCSF ICU’s are “semi-open” • Primary service still writes the majority of the orders, but we

co-manage with them

• We write all orders for: Ventilator, Sedation/Pain & Place invasive lines

• ICU is the PRIMARY SERVICE for:• Malgnant Hematology (CRI), Orthopedic Surgery, Oral

Surgery (OMFS), Head & Neck Surgery (OHNS/ENT), Gynecology, Gyn-Onc Surgery, Post-partum Obstetrics, Urology, and Plastic Surgery

“Closed” patient issues

• Labs - CBC, electrolytes, glucose• Nutrition - NPO, tube feeding, TPN• Activity - bedrest, ad lib• IVF - rate, heplock• Transfusions – triggers, CMV negative, irradiated• Studies - radiology, echo, PT - need to make a

phone call• Check patient frequently and communicate with

primary team often

HOUSEKEEPING

Housekeeping - daily routine

• 8:00am daily lectures *• M-919 • Check schedule for topic and speaker (it may be you!!!)• * Wednesdays there are no longer mandatory 8:00am

lectures for anesthesia residents (12:00noon conference will replace 8:00am conference)

• 9:00am daily team rounds• 0800 on weekends*

• 17:00pm afternoon rounds with fellow(s) • DO NOT LEAVE before checking in with the fellow or

attending

Weekends/Holidays

• Only on-call and post-call residents round• If you are neither, you have the day off

• Try to pre-round on the sick patients

• Remainder of patients can be discovery rounds (at the discretion of the attending)

• Notes are written either before or after rounds (at the discretion of the attending)

• Place emphasis on assessment/plan

Housekeeping - call schedule

• Call is approximately once every 3-4 nights, averaged over the entire rotation

• Post-call resident leaves before 11:00am• Please do not violate your duty hours

• Schedule changes are not allowed unless approved by Dr. Shimabukuro • (an extremely complex schedule)

11 ICU Signout & Call

• Residents not taking call should rotate staying late to sign out to NP at 1900

• Residents need to take sign out from overnight NP by 0700

• If you are the resident on call for 11 ICU you will also cover 8 ICU (overnight/weekends)

• Your call room is also the “9 ICU call room”

Call Room: 13 ICU• M1318

• Outside of ICU

• Hallway between Moffitt & Long

• Swipe in with UCSF badge

• Door labeled “ICU Resident”

• Shared bathroom with surgery resident

• Do NOT leave valuables in call rooms

Call Rooms: 9 ICU

• Inside of 9 ICU

• “Proximal” room• “Distal” room is fellow

call room

• No code/outside lock

• Shared bathroom with ICU fellow

• Do NOT leave valuables in call rooms

Medical Students

• Stay late 1 night per week - their choice

• They should read about their patients

• Quality not quantity (2 patients max)

• They are not expected to function as a resident during this rotation

• There should be a resident identified as the supervisor for each patient the students follows• Residents should be writing their own note as well

Lectures

• Each resident and medical student will be responsible for a 30-minute lecture during the rotation

• Please check the lecture schedule for assigned topic and date

• Medical students are allowed to pick a topic of their choice

• Read schedule carefully, lectures are split (ie, 2 lectures on a day) based on level of training and ICU experience

RESIDENT RESPONSIBILITIES

Responsibilities

Central Lines

• We are responsible for all line placements • Except for a few services (CT surgery and Cardiology)

• At the request of the CT Surgery or Cardiology Fellow/Attending, we will assist with line placement

• All central lines must have an ICU attending or fellow at the bedside during placement• For all residents regardless of training background or

level

Intubations

• “Airway Provider” should be available for all ICU intubations• The airway pager (443-4990) will always be with an

anesthesiologist (attending, fellow or resident)• Do not start sedation/paralysis without someone from anesthesia

being present (CA-1 residents should also always get back-up)

• Airway backup available:• OR E1 Anesthesia Attending: 3-1581 (Spectralink)• OR Front Desk: 3-1545• OB Anesthesia Resident: 443-9261• ED: 3-1238

Ventilation

• We are responsible for ALL ventilator orders, intubations and extubations• (For those on 10ICC, please clarify with your attending for

each CT surgery non-fast-track CABG patient)

• If the primary team wants something that is unreasonable, please discuss it with the fellow or attending

• DO NOT make changes directly on the ventilator

Sedation

• We write pain and sedation orders on all patients• (For those on 10ICC, please clarify with your attending for

each CT surgery non-fast-track CABG patient)

• Management of pain in ICU patients with epidural catheters is the responsibility of the acute pain service, but we do keep a close eye on this*

• Work with the primary team when appropriate to determine the best sedation plan

Code Blue Coverage

• 10 ICC team will respond to codes during weekdays (M-F 0800-1700)

• Everyone will respond to codes from 1700p-0800a weekdays & all day/night weekends and holidays

• We are responsible for the airway - FIRST• Please make sure that whatever you use in

the CODE bags are refilled immediately

Code Bags

• Available per ICU• Use at all codes,

intubations, sedations• Make sure this bag is

stocked and locked daily• Pharmacy

• Refill outside 13ICU

• Other:• ICU OR O.R.

Code Sepsis

• Initiated by the ICU bedside nurse when sepsis screening tool is positive and there is evidence of end-organ dysfunction

• Nurses are allowed to send lactates when severe sepsis or septic shock is suspected

• Immediately go to patient’s beside and start severe sepsis/septic shock resuscitation bundle; help the nurses, if needed

Code Sepsis: Resuscitation Bundle

• Lactate (whole blood and NOT serum)

• Blood cultures (Time to positivity) prior to broadspectrum antibiotics (BSA)

• Start of BSA within 1 hour from time of Code Sepsis

• 20-30 mL/kg or 1000 mL of crystalloid for hypotension or lactate > 4 mmol/L

Code Sepsis: BSA

Emergency Calls

• Calls regarding unstable patients often go to the ICU team

• If situation is truly an emergency, deal with the problem while the primary team is being summoned

• If there is time, discuss with the team, often the night float will be thankful for a friendly word of advice

Communication

• Understanding the primary team’s plans and goals often make it easier to understand the course of action that is planned

• Communication makes it easier for all parties involved and improves patient care (use the signout tool in APeX)

• If there is a disagreement about care, consult your fellow or attending

PAPERWORKAPEX & Patient Database

Paperwork

• List to be described on following slides• New Resident/NP Office

• Database List

• Patient list

• General APeX comments• Notes• Admit Orders• Central Line Procedure Note• Procedure Note

CCM Resident/NP Office

• Door code: 6917#

Patient list

• Database List• Can be accessed via Chrome on any MC computer, but PLEASE

print only in Resident/NP Office across from M919• This is a HIPAA violation if left in random printers

• Post call resident will print out copies for the team• Keep track of this list

• Do not leave it anywhere, throw away daily

• Please keep this list up to date!

Database List

• http://anesthesia.ucsf.edu/iculist

• Sign-on with• SFxxxxxx

• SOM\, UCSFMC\, etc

• Make sure you log-out

APeX

• Context: CRITICAL CARE MEDICINE SVC

Click here to search/change

New Notes

• Select “Notes” Tab on Left Column• From top heading bar- select either:

1. “New Note” (dot phrase) OR2. Create in Notewriter

Notewriter Notes

Progress Notes

• Using copy forward

Copy Forward

Be very careful about copy-forwarding notes. Always review the entire note for accuracy. (ie, a patient cannot be “POD#2” for 5 days in a row)

Notes

• Progress Notes:• “Co-sign Required” is at the discretion of your

attending

• Procedure Notes:• “Co-sign Required” is REQUIRED, and is always your

attending of the week

• Title of note should have:• “Critical Care Medicine Progress Note”

• “Critical Care Medicine Admission Note”

Notes

• Be as specific as possible for the assessment/ problem list• Altered mental status versus ICU delirium

• COPD Exacerbation versus acute hypercarbic respiratory failure from pneumonia on (and) COPD

• UTI with hypotension versus septic shock from (and) UTI

Notes• Be specific as possible with the plan

• For instance, “wean vent as tolerated” vs. “Patient continues to require a high minute ventilation due to a likely large dead space fraction from resolving ARDS. He is not tolerating a rapid wean. Failed SBT yesterday due to sustained respiratory rate in the 40’s with desaturation. Will try again today.”

Procedure Notes

• Resident who rounds/admits the patient has “first dibs” on procedure

• Provider who performs procedure is responsible for procedure note

• Procedure notes are added under a different template than progress notes

• “Cosign Required” MUST be checked & “” is your attending of the week

Orders

• The IP Adult ICU Addendum Order Set needs to be completed by the ICU resident for every patient admitted to 8/9/11/13 ICU. • On 10, they only need to be completed for

patients the service is following

• The IP Adult Core Admission Order Set may also need to completed. Ask your fellow.

Orders

• Other order sets of interest:• IP Adult Core Admission Orders

• IP Adult ICU Addendum

• IP Adult Sepsis

• IP Adult Continuous Neuromuscular Blocking Agent

• IP Adult Blood Product Transfusion

• IP Adult PCA

• IP ICU Withdrawal of Care

Orders

• Mechanical Ventilation• There is NO order set

• Search under “ventilation” or use IP Adult ICU Addendum Order Set

ARDSNet Protocol

PSV/CPAP

Orders

• Mechanical Ventilation• Don’t forget to write for oxygen titration orders

under admin instructions

• When changing between modes, don’t forget to discontinue the old one

• SBT: search under “SBT”

APeX Flowsheets

• Useful flowsheets to “wrench” in• MAR Report/ Med List (if not already there)

• Comprehensive/Comp (if not already there)

• Hemodynamics (for those on 10ICC)

• LDA (current and past central/arterial lines with insertion/discontinue dates and locations)

APeX

• Other useful flowsheets to “wrench” in• Hematology (Blood products administered)

• Fever OR ID/Sepsis

• Insulin/Glucose

• Labs since admission

• Radiology

• Microbiology

• Critical Care SO/RND

A Word from the NPs

• We can be a resource for you. Ask and we will try to help

• Be prepared for sign out by knowing the ventilator and sedation plan for patients.

• If you can’t restock the code bag before sign out, let us know. We will help you.

• The list is our life line. It needs a thorough update before 6AM/6PM every day.

Miscellaneous• Radiology does not interpret any studies overnight

unless asked

• Small cards have everybody’s pager and home phone number

• Please don’t hesitate if you identify problems during your rotation to notify your attending

• Please fill out the evaluations. Your comments are confidential and important for future rotation development

Questions?