Flow Of The DayBefore 8am:8:00 - 8:30am:

8:30 - 9:00am:

9:00 - 9:30am:

9:30 - 11:00 am:

11:00 - 12:00pm:

Pre-Round/Receive sign outMorning report or PICU fellow lecture (Mo/Th)…MANDATORY

Rounds begin

Radiology rounds

Completion of morning

rounds

Work time/didactics/first

post-op admits

Flow of the Day12:00 – 1:00pm Noon Conference1:00 – 4:30pm Follow up consultations,

procedures, post-op admits, didactics4:00 – 4:30pm Residents receive NP

sign out4:30 – Resident/fellow sit down sign out, followed by night team only walk rounds

Resident Teaching ConferencesPICU resident lectures:Monday / Thursday 8 – 8:30amIn place of morning reportAt front desk in PICUMandatory lectures

Other Teaching ConferencesMonday 12-1 PM PICU Divisional

Conference2E PICU Conference Room

Tuesday 7:30 AM CVICU lecture 2E PICU Conference Room

Thursday 12-1 PM PICU Resident small group conferences (palliative care x2, vent teaching with RT, code team/cart teaching)

TBD each week, emails sent from pediatric chiefs

Friday 7:30 AM CVICU Conference with Dr. Hanley

2E PICU Conference Room

Educational Resources

PICU resident handbook with relevant PICU topics is available at

http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html

Hard copy is available in the resident call room.

PICU chapters at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html

Monitors in ICUVascular AccessCodesICP managementStatus EpilepticusSedationPediatric AirwayAirway Management

Mechanical Ventilation

ARDSStatus AsthmaticusInotropesShockSepsisMeningococcus

PICU chapters at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html

CardiomyopathyLiver FailureAcute Renal FalilureFluids, Electrolytes,

NutritionOncologyTransfusionsDKA

Submersion InjuriesBrain DeathEnd of life issues

PICU Tables at http://peds.stanford.edu/Rotations/picu/picu_rec_readings.html

SedationInotropesShock

Team A Team B

Attending Attending

Fellow Fellow

Senior pediatric resident Senior pediatric resident

Pediatric intern Pediatric intern

ED resident Nurse practitioner

Resident RoleReceive sign out from overnight residentPre-round on PICU patients Present patients at morning rounds

beginning promptly at 8:30am After rounds carry out developed plan

for each patient: e.g. call consults, follow up on radiologic studies, etc.

Discuss any management changes of patients with the attending / fellow prior to carrying out changes

Resident RoleBe actively involved in stabilization of

acutely ill patientsEvaluate new admissions to the ICU and

develop a management planPresent new admissions to the ICU fellow /

attending Sign out and transfer care of patients to

overnight residentAttend teaching conferences conducted by

the ICU attendings / fellows

Other Trainees in PICU

Anesthesia fellowsEmergency medicine residentsMedical Students

Anesthesia Fellows

Present for half the blocksPrimarily provide support for fellow level

activities in the ICUWill not primarily follow patients

ED ResidentsWill act as a 7th resident in the PICUMay care for equal number of patients as

pediatric residentsRounds one day on weekend, typically

SaturdayExcused for Wednesday AM ED conferences:

must pre-round & hand over notes to on call resident prior to leaving for education rounds

Starting this academic year, ED residents will be complete 3 weeks of days and one week of nights

Medical StudentsPrimarily 2 rotations in PICUCritical care core clerkship – all patients

followed by students on this rotation must be co-followed by residents (most students on this rotation)

Sub-internship – these students can follow their own patients

Resident needs to write progress note

PICU NPsMichelle Burns-JamesKrysta NicholsonKarley MarianoWork independently and carry their own

patientsThey are present in PICU 4 days/week for 10

hour shifts (variable days and starting times…i.e. may work noon-10pm some day depending on staffing needs)

Typically round one day on weekends, alternating with ED resident

PICU Evaluations for Pediatric Residents Faculty evaluations completed on Med-HubVerbal feedback from attendings while on the

rotation – Be sure to elicit feedback if not provided

NotesThe following need a full H&P:

Trauma (even if went to OR first)TransportED admitsDirect admit from outside

The following need an accept note:Post-op surgicalTransfer from floor/ rapid response

NotesEach patient needs PICU daily progress

note (unless admitted in early am)Significant events:

codes/procedure/interventionRequire a note: confer with fellow or

attending who may do this noteTemplates exist for most procedures

Interim summary weekly on Thursday for any patient with LOS > 5d in PICU

NotesOnlinePICU specific templatesSystems-based noteIndicate attending on your team and select

“sign” not “review”Please remember to update physical exam

daily

TIPS for PICU NotesThese are the official legal medical recordThey support level of care providedTherefore:

Avoid colloquials or not universally understood abbreviations

Use words to support ICU care— instead of dehydration—mild tachycardia but

stable, CR monitor Try: dehydration with tachycardia, compensated

shock in ICU for continuous hemodynamic monitoring

ICU Transfers RequirementsApproval of the ICU AttendingTransfer summary

If going to a resident team, usually non-surgical and ICU stay >48h

Transfer ordersSurgical patients: surgeons often write ordersAlways clarify with surgeon if OK to transfer &

WHO will write transfer orderSign patient out to ward resident FACE to

FACE in the PICU

PICU-to-Floor Hand-offsGoals: Safe patient sign out

Issue: Sign-out often does not happen close to transfer time due to bed availability

Issue: No “stops” within the system to prevent transfer when hand-offs not completed.

PICU-to-Medical Team Hand-offs (including Renal transplant patients)

PICU MD orders “transfer bed request”

PICU RN requests bed in Tele Trekking

USA or Spectralink alerts Floor Resource Nurse that bed ready in Tele Trekking

Floor Resource Nurse/USA

PICU Resource Nurse

Floor Bedside RN

PICU Bedside RN

Floor MD

PICU MD

Floor MD orders “Okay to transfer”

Patient Transfers to Floor*

Phone sign-out

Floor MD calls PICU and goes to PICU for sign-out

 1. PICU resident orders “Transfer Bed Request” including accepting team and orders “Change of Care to Acute care” and prints out PICU to Acute care IPASS report 2. Floor Resource Nurse or USA will call Accepting Floor Resident when PICU patient has been assigned a bed through Tele Trekking.  3. Accepting Floor Resident will call 5-8770 asking to talk to fellow to arrange time to get face to face sign-out, ideally within 30 minutes.  4. Accepting Floor Resident (and ideally fellow and attending) goes down to PICU for verbal sign-out.  5. Accepting Floor Resident puts in “Okay to Transfer” order.  6. Prior to sending patient or accepting patient PICU Bedside Nurse and Floor Bedside Nurse verify “Okay to Transfer” order has been placed 7. Patient comes to floor.

PICU to Floor Hand-offs: MD Roles

Flow of Rounds8:30 Typically BMT, Liver, Renal TransplantFollowed by:

Sick/high acuityTransfersRemainder

Neurosurgeons typically round on their patients between 7:30-8:30

Tips for Success on Rounds

See CXR if available before rounds start…ETT high/low, new findings that can’t wait for rounds to start?

Any special drains in place? JP, Chest tube, EVD…know how much output total & per shift

Any pending studies completed from prior day? EEG, MRI, US, ECHO, cultures ….know the result

Patient identification

Quick assessment: i.e. patient improving, worsening, or unchanged

Major (not all) interval events

Vitals: Tmax (time) , vital sign ranges, including CVP, ICP if applicable

Completing patient presentationBe succinct; try not to present same data

more than onceOne line overall assessment of patient

conditionReview ordersAddress patient rounding checklist on every

patientEngage Bedside RN in rounds!!

Procedures

PICU fellows are given priority for all procedures (particularly 1st year fellows)Prerequisite for CCM training

Acute situations : fellow or attending

ProceduresProcedures residents should acquire some

degree of comfort with while in the PICUBag-mask ventilationOperating an anesthesia bagPlacement of peripheral IVs Chest compression/Defibrillator familiarityCode cart familiarity

Bedside NursesCOMMUNICATIONCOMMUNICATIONCOMMUNICATION

Tell bedside nurse you are the resident caring for that patient

Give them your pager #

Bedside NursesCommunicate all orders to the bedside nurse

after writtenMinimizes confusion about ordersProvides high level consistent patient careImproves patient safetyEvery nurse also has an Ascom phone if you

can’t make it to bedside

Bedside NursesThe bedside RN = your eyes & ears to your

patientProvide “real time” clinical informationIf they know what you are looking for –

they can tell you - Especially with sick patients

**They can make you look good by keeping you updated on all pertinent info! **

OrdersTo minimize line entry RNs like to have

flexibility to time medsUNLESS You want drug given at a specific timeQday ordered at 8pm won’t happen until 8 am

next dayRNs may batch labs to minimize line entry

*** except for immunosupression drugs ***e.g. Prograf, CSA

Order EntryMost routine labs and CXR require daily

orders:CBCCoagsChemistriesCXR

Qam labs in PICU are drawn at 4 or 5 am

TIP: Use PICU Daily Orderset during rounds!!

Admitting Trauma PatientsANY TRAUMA patient—admit as follows:

LOCATION: 2E/PICUWard Attending: select PICU AttdgService: Select Trauma (even if head trauma)Sub-specialty attending: Select Trauma or

Neurosurgery AttendingIf head trauma or NAT: Peds surgery/trauma must be

notified to do tertiary surveyTrauma H&P in Epic, Trauma service should write admit ordersSurgical service should write the discharge summary

unless transferred to PICU service for ongoing medical issues

Order Entry RemindersExtubation: Requires an extubation order

Don’t just D/C vent orderOther important orders are linked to

extubationBlood product orders

Still require a call slipInform patient’s RN that products ordered

ACE(airway clearance evaluation) Allows some autonomy to RT to develop plan

for best mode of therapy

DischargesPatient rounding checklist useful tool!Prescription paper available from USA;

please send 24 hours before Loads into one printer and special traySelect the PICU prescription printer for all

D/C scriptsRx_picu_fntdsk

DischargeDuring rounds if discharge is anticipated in the

next 48 hours please update the target discharge date

When you get admissions from surgery please ask about when they are anticipating discharge and what clinical criteria will need to be met.

If discharge is anticipated use the discharge checklist to help aid in the planning process (it will be on the patient door)

After you discharge a patient there is a survey that we are asking you to complete regarding your experience with the process

PICU Quality and SafetyPICU Handoff

Initiative for ALL OR, 1N HandoffsOne Message, One

TimeRole cards utilizedIPASS tool for

handoff comes with 45 min call

PICU Quality and Safety

PICU Rounding ChecklistReal time clinical decision supportEnhance patient safety and care coordinationReview at conclusion of rounds for EACH

patient

COWSBe sure to sign off Don’t leave patient information exposedPlug them back in (a dying cow is not pretty)

PICU EtiquettePlease speak in quiet voices, particularly

around main nurses stationWe follow HUSH (healthcare workers

utilizing silence for healing) in the PICU

Please no open food or drink containers unless in specified areas

Make sure you do follow the appropriate hand hygiene and have bare hands at all time in the unit

Final ThoughtsTake ownership of your patientsBe presentBe involvedAsk questionsSuggestions on improving the rotation

Questions, concerns, thoughts on the rotation

Contact PICU rotation director - Dr. Courtenay Barlow atcbarlow@stanford.edu

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