Structure and Call Schedule
Lunch
- Residents on CUH MICU will NOT pick up their food at the normal IM noon conference. Instead, they will automatically get $10 per day loaded onto an Internal Medicine lunch card. If you have not yet received an Internal Medicine lunch card, please pick yours up from Maria (in the Medical Education suits on the 3rd floor).
Team
- There are 4 teams with a total of 5 residents and 5 interns.
- Each team will consist of 1 resident and 1 intern.
- 1 resident and intern will be the night team assisting the on-call resident for 5-6 nights during the month.
- All residents and interns will rotate through night medicine during their month on service.
- Overnight team consists of the on-call resident, night resident and night intern. In addition, there is a night intensivist on call who should staff all admissions that come in overnight.
Hours
The day intern on call will admit patients until 5PM and check out to the night medicine resident between 6:30-7:00PM. The day intern on call must leave the hospital by 9PM. The day intern will then return the following morning by 7AM (no earlier than 5AM) and is expected to stay until all work is finished on post-call patients.
- Non-call Residents: 6:00AM-7:00PM
- Non-call Interns: 5:30AM-6:30PM
- On-Call Resident: 7:00AM-10:30AM (in the car by 11:00AM post-call)
- On-Call Intern: 5:30AM-7:00PM
- Night Shift Resident: 6:30PM-7:00 AM (unless primarily managing a critical event overnight - left up to the discretion of the resident - in which case you are asked to stay until the beginning of AM rounds to present directly to the attending)
- Night Shift Intern: 7:00PM-9:00AM (must be in the car by no later than 9:00 AM)
- On the night-float resident's / intern's last night, s/he should leave by 6 AM to ensure they have 24 hours off before returning to days.
See this video to review the process of structured ICU rounds being implemented in the CUH MICU.
Admissions
General admission guidelines
- Residents will admit from 7am - 5am the following day.
- Residents can not block admissions from the ED. The ER makes the decision regarding admissions to the ICU. Under rare circumstances, you may discuss the patient with your fellow or attending to discuss re-triage to another service. However, you are also responsible for discussing and coordinating transfer of care to the other service. You will remain responsible for the patient's care (labs, vitals, procedures, etc) while this happens. In this instance, you should leave a brief note in the patient's chart discussing your rationale for re-triage.
- If you are called about a floor patient who you do not think needs ICU care, you must involve the ICU fellow or the attending. If the attending or fellow believe the patient will be better served elsewhere, the MICU team is responsible for speaking with the other service to communicate the decision. You must speak with the attending or fellow before making this decision.
- Until the transfer and handoff to another service, you are responsible for the patient's medical care
- If an admission is called into the MICU on call resident between 5am and 7am, the off-going call resident is responsible for seeing the patient, stabilizing them, and putting in admission orders until they can hand off to the incoming call resident and intern. This is to prevent delays in care for these tenuous patients.
- Lack of beds should never play into your decision regarding a patient's admission to the ICU. If you are ever approached with a bed problem, notify your faculty member immediately.
- Insulin drips can be run on the floor.
- BMT patients require different approach to goals of care discussions than most patients. In general, avoid end-of-life discussions with these patients unless you have discussed your plans with the BMT team.
- Outside transfers/Zale Transfers/Service Transfers – These are also faculty decisions. Refer any calls or requests to your faculty (example: surgical resident calls you to transfer a patient to our service). Exceptions would be if the request comes from our consult fellows (moving from one ICU to another ICU service is not encouraged)
- Write a transfer note with current assessment and remaining goals and plans to assist the acceptance with care continuity
-------Hospitalists accept patients up to 12noon daily. Do not call until patient is physically in a non-ICU bed.
MICU C Coordination (APP team)
- Residents will work alongside the MICU C team to distribute admissions fairly by acuity and number. The MICU C team has a soft cap of ~12-14, depending on acuity. They strive to keep as close as possible to that number as possible.
- MICU C is the first call for admissions between 7am and 5pm. If MICU C is at or over their cap, if they have a high number if high-acuity patients, or if the team gets multiple admissions at once, they will give an admission to the on-call MICU A/B resident.
- From 7pm to 5am, admissions will go to to the on-call MICU A/B resident. However, if the on-call resident is getting a lot of admissions at once and the MICU C team isn't at their cap, the night attending may choose to distribute an admission to the MICU C night APP. Any disputes, day or night, will be handled by faculty only.
- Please note that any cystic fibrosis or pulmonary hypertension patient should always go to the MICU A/B resident regardless of time of day; never MICU C.
- The MICU C APPs are also available to help with procedures, putting in orders, going to codes, etc. 24/7.
Codes
- Codes in the orange tower are responded to by the SICU team 24/7. After the code, it's decided which ICU is appropriate for the patient.
- Nursing staff requests that the resident running the codes (in all towers) wears a red bouffant to identify themselves as the code leader.
Service Caps
At no time should a resident or intern carry more than 10 patients.
An overcapped team should be managed by:
- buddy residents being first call and writing notes on patients, if they themselves are not overcapped;
- fellows being first call and writing notes on patients;
- redistribution of patients amongst teams;
- pulling a temporary float to help relieve the services.
Supervision
Nights: The night resident must touch base with the night intensivist - even if just to confirm names. If you haven't heard from the night intensivist by 7 pm, page them to confirm contact information (paging system - "CUH Night ICU Attending").
Your evaluations will be completed by the attending at the completion of the rotation. You are encouraged to solicit verbal feedback throughout the rotation as well.
Rounding
Pre-rounding Tools
Pre-Rounding Tools
ICU Checklist
In an effort to make pre-rounding easier, there's a handy tab on Epic called "ICU Checklist." It's been developed in conjunction with the MICU faculty, administration, and nursing. Add it by entering any patient chart > summary tab > wrench > add tabs to toolbar > search ICU checklist. This tab includes a conglomerate of useful information for pre-rounding (vitals, pressors, sedation, antibiotics, diet orders, VTE ppx, LDA's, etc.) which will allow you to be systematic and efficient.
Here is a tip sheet with instructions
Note: One of the major benefits/utilities of this tab is the first section, titled "Daily Goals." This is a section that should be updated daily to include a brief daily plan (ex. wean pressors, SBT, de-escalate antibiotics, etc.). This should be entered by the intern/resident who is doing orders during rounds. Click "add comment" to fill. Nursing and RT will be able to see it, which will allow for more consistent communication about goals.
ICU Patient Dashboard
The first tab in Epic (before entering a patient chart) is called the dashboard. The default is usually Physician Practice Dashboard. You can change this to an ICU specific dashboard. Do this by entering by clicking the down arrow and searching for "ICU Patient Explorer" > "Show Catalog." You can keep this as a favorite by clicking the gold star.
This tab will then expand to show patients admitted across ICUs in CUH. Filter by scrolling down to service and selecting "MICU."
Once there, the list of MICU patients will show up. You can then continue to filter MICU patients via various filters on the left. To do so, click "Add Service" or "Add Filter" depending on what you're looking for. An example below is that you could for example see all the MICU patients who are being treated on the Pulmonary Hypertension Service and have Benzos prescribed as below (patient list would be listed to the right but is omitted to protect PHI). This is a highly efficient way of asking a specific question for a subset of patients without having to enter each chart individually. The goal is to help identify care gaps and improve care/outcomes.
General Rounding Structure
Pre-round until 8:00am at which time Attending Rounds start in the rounding room (8.131). See below for new and improved pre-rounding tools!
Overnight admissions have traditionally been staffed in the morning with the day attending (in addition to having been staffed the night prior). However, some attendings are now not formally staffing overnight admissions if they have already been staffed by an overnight attending. If this is the case, these admissions can be discussed on rounds with the rest of the patients.
The goal of daily rounds is to do multidisciplinary rounds with the primary RN, RT and a MICU Pharmacist present at the bedside/outside the room. Sometimes it can be challenging to coordinate all personnel but at minimum the primary RN should be included when possible. In order to be efficient, the best way to do this is to call him/her on your way to the room. You can use your cell phone to call 214-633-XXXX (the final four numbers listed in the chart by the nurses name). If Vocera is listed, call 214-645-7229, and either say the primary RN's name or say the patient room. Let the nurse know you are on the way to their patient's room.
In general, we are trying to emphasize resident's being involved mostly with assessment and plan rather than listing off a lot of objective data that is not only easily accessible from the chart, but also may be different from what you saw when pre-rounding hours prior.
Please see this video for an example of how multidisciplinary rounds should go:https://vimeo.com/brazosfilms/review/631079114/6a61323d01
So, as a general structure for presentations:
1) Intern/Resident: 1-liner and 24-hr/overnight events
2) RN: any additional overnight events, vitals, pressors, Is/Os, LDAs
3) RT: Vent settings/Oxygen requirements, SBT's
4) Pharm D: Meds
5) Intern/Resident: Exam, labs, imaging, and assessment and plan.
Placing Orders
Rounds should occur with the mobile computers stationed around the unit. This will allow for charts to be easily accessible and for the intern or resident who is not presenting the patient to efficiently placed orders and consults while on rounds. This is also the time to update the Daily Goals Tab (see below in pre-rounding tools for details).
Call and Rounding Rooms
Rounds start at 8:00 am in the rounding room.
- The rounding room (8.131) is located on the 8th floor in the CUH MICU. Take the blue elevators (the ones closest to the emergency room) to the 8th floor, and then walk toward the window. Soon after passing the window, you'll see the CUH MICU rounding room on your left (unmarked door with a keypad on it). The code for the rounding room is 1-3-5-7-9#. There is a refrigerator and microwave available for your use in that room.
Call Rooms
MICU Resident On Call 8.125
MICU Resident Cross-cover: 8.129
MICU Intern call room is right below, on the 7th floor. To get to it, you are going to have to go through this door - 07.127. Call Room number: 7.131
Learning Topics
- Assessment and management of the airway, including optimal use of mechanical ventilation
- Pathophysiology and management of respiratory failure
- Assessment and management of hypotension and shock
- Indications for and use of invasive hemodynamic monitoring
- Indications for and use of sedatives, analgesics, and neuromuscular-blocking agents
- Indications for and use of vasopressors and inotropic agents
- Assessment and management of delirium and acute neurologic syndromes
- Assessment and management of gastrointestinal bleeding and liver failure
- Assessment and management of life-threatening infections, including appropriate antimicrobial selection.
- Toxicologic syndromes and their management, including management of drug overdose
- Appropriate use of blood products in the critically ill
- Prevention and treatment of nosocomial infections
- Assessment and management of electrolyte disorders
- Assessment and management of acute renal failure including use of renal replacement therapy
- Prevention of stress ulceration and thromboembolism in the critically ill patient
- Issues in end-of-life care including the withholding and withdrawing of life-sustaining therapies, advance directives, code status and family conferences
When to Call Attending
You must call your attending at night:
| Before doing any of the following (time allowing): |
If any of the following happen: |
| Procedures: Cardioversion, pericardiocentesis, thoracentesis, central line |
BiPAP initiated for either hypoxic or hypercarbic respiratory failure |
| Therapies: Emergency dialysis, exchange transfusion, thrombolytic therapy |
Code blue or unexpected death |
|
Events: End of life discussions, Order of protective custody (OPC), transfer to higher level of care
|
Patient/family grievance, inpatient suicide attempt, or patient leaves AMA |
Any acute clinical decompensation including, but not limited to:
- Whenever to plan to intubate, use paralytics
- Pressor requirements are increasing
