PICU residents and Floor interns should be ready to participate in checkout at 7AM and 4:30PM.

Transcription

1 Pediatric Critical Care Medicine: Level Specific Competency Based Objectives: Key: PC = Patient Care, MK = Medical Knowledge, PBL = Practice Based Learning & Improvement, ISC = Interpersonal Skills & Communication, PRO = Professionalism, SBP = System Based Practice Level Objectives PC MK PBL ISC PRO SBP Familiarize with fluid-electrolytes, metabolic and renal disorders, trauma, nutrition, cardiorespiratory management, infection control Recognize congenital anomalies presenting in critical care unit & communicate with family Recognize isolated and multiple organ system failure & interact with team and family Perform clinical assessment to formulate management plan for critically ill patient Familiarize invasive and noninvasive techniques for monitoring and supporting pulmonary, cardiovascular functions Participate in decision making in admitting, discharge, and transfer of patients in the intensive care units and communicate with colleagues, primary care provider and family Understand the role of general pediatrician and the intensivist in perioperative management of surgical patients Evaluation of patients following traumatic injury Know the special multidisciplinary and multiorgan implications of fluid-electrolytes, metabolic and renal disorders, trauma, nutrition, cardiorespiratory management, infection control Recognition and management of congenital anomalies presenting in critical care unit & communicate with family Recognition and management of isolated and multiple organ system failure & interact with team and family Integrate clinical assessment and laboratory data to formulate management plan for critically ill patient and discuss with team and family Know invasive/noninvasive techniques for monitoring and supporting pulmonary, cardiovascular, cerebral and metabolic functions Participate in decision making in admitting, discharge, and transfer of patients in the intensive care units and communicate with colleagues, primary care provider and family Participate in resuscitation, stabilization and transportation of patients to the ICU and within the hospital and communicate with primary care provider and family Understand the role of general pediatrician and the intensivist in perioperative management of surgical patients Evaluation of patients following traumatic injury Junior level resident Senior Level Resident Peds Residency: Curric-Revised/PICU 2008 PICU residents and Floor interns should be ready to participate in checkout at 7AM and 4:30PM.

2 Pediatric Critical Care Medicine Division Department of Pediatrics, University of Illinois College of Medicine at Peoria Children s Hospital of Illinois at OSF St Francis Medical Center INTRODUCTION If this is your first Pediatric Intensive Care Unit (PICU) rotation, then you will be nervous, stressed and rightfully so, as you are going to be at the bedside taking care of some of the sickest patients at the Children s Hospital. Our ultimate goal is to help you become a complete and competent pediatrician by your graduation. As a practicing pediatrician you will be the front-liners, which means you will be involved in initial stabilization of critically ill child either at your office or in your community hospital ward or emergency room. Hence, you need to possess knowledge, skills and expertise to deal with critically ill children. Our job is to make you into one such pediatrician who is comfortable with initial stabilization of critically ill children, before they are transported to tertiary care center. So please utilize this time (yours and ours too!), and energy in acquiring knowledge, experience and skills while taking care of PICU patients. There are several educational mechanisms available for residents to accomplish these goals. The most important educational component is through supervised clinical experience with an attending, a nurse practitioner or a senior resident. The ICU attendings are available to you 24/7 to help you with questions about patient care or clinical problems and assist you with technical procedures. The apprenticeship arrangement will be your most valuable educational tool. In the current era, resident s clinical time in PICU is restricted due to 80-work hour rule, continuity clinics, morning reports, noon conferences and grand rounds (on Thursday). Hence, morning rounds with attendings is the golden time for learning, teaching and resident-attending interactions. Please be observant and try to pick up some important bedside clinical skills (examination, interview with patient s parents etc) from your attendings and consultants. 1

3 You will be required to attend weekly didactics presented by attendings, which will be scheduled depending upon availability of the resident (if there are only 3 residents on service, one has afternoon clinic, one is postcall, then that leaves only one resident to do all the other work). Structure of the PICU: At present, PICU/Peds CVICU is a 12-bed (expandable to 14 beds) unit staffed with RN s, Pediatric Nurse Practioners, etc., and is equipped with modern monitoring systems. The patients: The PICU provides intensive care to all children outside NICU and up to 18 years of age. Most of the patients are admitted through ED, from outlying hospitals, or directly from pediatric floors and operating suites. Staff: Please note following important phone number: Theresa Dixon (office) (309) Pediatric Intensivists: Your attending physicians are fellowship trained pediatric intensivist who are Board Certified (American Board of Pediatrics) or are Board eligible. Adalberto Torres, Jr, MD, Director Julie Wohrley, MD Girish G. Deshpande, MD Steve Lestrud, MD (weekends) Anwarul Haque, MD Sergi Shushunov, MD Pediatric Nurse Practitioners/Advanced Practice Nurses: These are nurse clinicians who are pediatric trained and certified as advanced practice nurses, who are practicing exclusively in pediatric critical care. Usually, these nurses have been PICU nurses for a number of years prior to their PNP training. Kelly Skender, PNP Kris Schultz, PNP at night 2

4 RESIDENT RESPONSIBILITIES: 1. For all medical admissions, the resident will perform a comprehensive history and physical examination with delineation of initial diagnostic impressions, approach to confirmation of those diagnoses, and initiation of treatment care plans, and will dictate admit note (H&P). 2. For all surgical admissions, excluding cardiovascular ICU, the resident will dictate a critical care consultation note and discuss suggestions for diagnosis and management with both intensive care and surgical attending physicians, and surgical house staff. 3. The resident will dictate a discharge or interim transfer summary on all patients leaving the PICU, will communicate with the accepting resident (attending will communicate with the attending accepting) and will write an order to notify resident when patient arrives on the floor. 4. The resident will participate in PICU and Pediatric Intermediate Care (PIC) rounds with attending intensivist in the morning. Rounds start promptly at 0830 this will include both medical and surgical disciplines. The resident should be able to present the patient in detail and formulate appropriate care plans. The resident should have read about all new patients and be able to answer questions. The resident may be asked to present 5-10 minutes on his/her patient the following day (pathophysiology, recognition and management). 5. The resident will make written progress notes on all pediatric intensive care patients using the problemoriented systems approach as compiled in pre-printed PICU progress note format. Please review it with the attending orienting at the beginning of the month for any clarification. 6. At the beginning of the rotation, the resident will provide the attending physician and the assistant nurse manager with a written schedule of mandatory clinics and conferences. Except for continuity clinics and special resident functions, residents will be available by pager for all emergencies in the PICU from on weekdays. The resident should maintain a presence on the unit at all times. Nurses will first ask residents for all patient-related questions. If there are any questions that a resident needs help on, the resident should call the attending. 3

5 7. Personal business and meeting or vacation time should be kept to a minimum and prearranged with the residency program director and the PICU attending physician prior to the beginning of the rotation. In case of illness or emergency, the attending physician as well as the residency program director must be notified. 8. All orders in the PICU are to be hand written. Verbal orders are unacceptable. All written and telephone orders should be dated, timed and signed accompanied by your IDX number, then given to the bedside nurse for implementation. All orders should be reviewed with the nurse, especially STAT orders. Once the chart has been placed in the rack, please notify the unit clerk of the STAT order. All orders should be clear and concise. Please use pharmacy safety rules such as no trailing zeros (write 1 mg instead of 1.0 mg), using a zero prior to a decimal point (as 0.1 mg instead of.1 mg), using ml instead of cc, etc. Please keep abbreviations to a minimum and use only acceptable abbreviations. 9. Ventilator changes are to be made by respiratory therapists only. Requests for changes should be made by written order in the chart and given to the bedside nurse who will be responsible for conveying this information to the therapist. 10. All technical procedures are to be documented by the resident by completing preprinted procedure notes. Following completion, the note should be signed by the supervising physician and the white copy placed in the chart. The pink copy is to be taken to the residency program director's office for placement in the resident's permanent record. The yellow copy goes in the out box in the PICU office. 11. Hard charts are to be kept at the bedside except when making written or dictated entries. Please be considerate of the nursing staff and avoid making entries at change of shift. 12. All requests for admission, especially by transport, are to be referred immediately to the attending intensivist. Referring physician callbacks are to be handled by the attending intensivist unless the resident is specifically requested to do so. 13. No long distance phone calls are to be made from the PICU telephones unless specifically relating to patients admitted to the PICU. 4

6 14. Residents are responsible for communicating with parents of PICU medical patients daily. Primary responsibility for communication with surgical patients should rest with the surgical attendings or house staff. 15. Consultation requests for primary ICU patients must be discussed with the attending physician before the referral is made. 16. Personal items are to be stored in the residents' on call room. 17. When conflicts between a resident and a nurse arise, they should be directly resolved at that time. If specific interpersonal problems persist, the attending intensivist or nurse manager should be notified. 18. If a resident has any problems or concerns, you may contact Dr. Deshpande directly to discuss it. 19. Residents are evaluated by the attending physicians halfway through the month to identify any potential issues. This review is also an opportunity for the resident to bring to light any issues he/she may encounter with the rotation. 20. As a requirement for each rotation, residents are required to complete a questionnaire furnished by the Society of Critical Care Medicine which is located on their website: Following completion of the exam, please review it with your attending on service or Dr. Deshpande. 21. On the last day of your rotation, the resident should write off-service notes on patients who have been under their care for longer than 3 days. 22. PICU residents typically present 2 morning reports during their month of rotation. They need to prepare each case well in advance after receiving approval by an attending. The resident will be responsible to notify the attending which case will be presented. Notification needs to be given to the attending assigned to the PICU service on the Monday of the week they are to present. 5

7 ON CALL RESPONSIBILITIES: Call in the PICU is from weekdays and on weekends and holidays. Work rounds on weekends and holidays will be prearranged with the on-call attending physician. The charge nurse should be advised of the residents whereabouts at all times and the best method for verbal notification of any problems (e.g., cell phone, pager, on call room phone). When notified, the resident is expected to examine the patient and record the findings and plan of action in the progress notes (referred to as an event note). The resident should directly communicate with the attending physician when the patient's status has significantly changed. Page the senior resident on call (Peds admit pager) for emergencies while waiting for the attending physician on call to arrive. Page anesthesia attending on call for help with emergent airways while awaiting for your attending. Page or call the attending on call with any questions and concerns for ALL patients including those in the Pediatric Intermediate Care Unit and the Home Vent patient room (Transitional Care Unit). Notify senior resident regarding potential emergencies of intermediate care patients (e.g., patient with recurrent croup who was recently transferred to PIC). Daily Routine: Pre-Round work: 1. Show up early enough so that you finish all data-gathering and note-writing on your patients. 2. Be considerate of the nurses need for the bedside computer to gather information about patients. There is a computer at the east corner of the desk for resident use; if they are occupied by your colleagues, then politely request the nurse for one. (ICU attendings have laptop of their own that you may use if it is free). 3. Ask the nurse and on-call resident about any events which happened the prior night with your patient. 4. Finish writing progress note before rounds (copy of the progress note is attached here). 5. Keep right side of progress note beyond the vertical line for attendings to write their own note if they wish to. 6. Check all cultures before rounds. 7. Be ready for rounds by

8 The Rounds: 1. Gather all patient data by Organ system presentation. 3. Non-presenting resident writes the orders and reviews that with either the senior resident or attending before moving on to the next patient. 4. Please write a complete, legible order. Examples of incomplete orders: a. Start IV amp at 200-mg/kg/d divided q 6 h b. Add D5W to current IVF (in DKA once BS < 300) 5. Write total and per kg dose. 6. Write order while on morning rounds with the attending intensivist. 7. Give the nurse the patient s chart with new orders ASAP. 8. Let the nurses know the plan about their patients. 9. Ask Kelly Skender/ Kris Schultz for advice/guidance. 10. Ask questions (RTs, nurses, dietitians). 11. Attend conferences; please remind the attendings if rounds are approaching conference time. 12. Cover and know the details of each other s patients during conference, clinic, days off, etc. 13. Discuss plan/recommendations with other services. 14. Prepare a typed problem list to person on-call (what if s). 15. Remind attending to review complicated X-rays with pediatric radiologist. 16. No personal phone calls or pages should be accepted during morning rounds except for emergencies. Educational goals in PICU per recommendations of RRC: 1. Residents rotating through pediatric intensive care must get familiarized with the special multidisciplinary and multiorgan implications of fluid, electrolyte, and metabolic disorders; renal disorders, trauma, nutrition, and cardiorespiratory management; infection control; recognition and management of congenital anomalies. 2. It also must be designed to teach the recognition and management of isolated and multiorgan system failure and assessment of its reversibility; understanding of the variations in organ system dysfunction by age of patient. 7

9 3. Residents must learn to integrate clinical assessment and laboratory data to formulate management plans for critically ill patients. 4. They must know and utilize the invasive and noninvasive techniques for monitoring and supporting pulmonary, cardiovascular, cerebral, and metabolic functions. 5. They also must participate in decision making in the admitting, discharge, and transfer of patients in the intensive care units, resuscitation, stabilization, and transportation of patients to the ICUs and within the hospital. 6. They must understand the appropriate roles of the general pediatrician and the intensivist in these settings; participation in preoperative and postoperative management of surgical patients, including understanding the appropriate roles of the general pediatric practitioner and the intensivist in this setting; evaluation and management, during the pediatric intensive care experience, of patients following traumatic injury. Procedural skills: Residents are expected to learn several procedural skills, including training in basic and advanced life support, endotracheal intubation, placement of intraosseous lines (demonstration in a skills lab or PALS course is sufficient), placement of intravenous lines, arterial puncture, venipuncture, umbilical artery and vein catheterization, lumbar puncture, bladder catheterization, wound care and suturing of lacerations, procedural sedation, pain management, chest tube placement, and thoracentesis. Residents must document the procedures including indications, contraindications and complications. Residents must use the on-line log provided by the ACGME to record their procedures. The supervising faculty must document the competence of each resident. The program must also document that residents have completed training in both Pediatric Advanced Life Support and the Neonatal Resuscitation Program. 8

10 Evaluation of Residents Resident performance is assessed in six areas to the level expected of a new practitioner: patient care, medical knowledge, interpersonal skills and communication, practice-based learning and improvement, professionalism, and system-based practice. The ACGME website ( also provides several tools to evaluate the performance of residents. The expectations for residents in these six areas are as follows: Patient Care: Residents must be able to provide family-centered patient care that is culturally effective, developmentally and age appropriate, compassionate, and effective for the treatment of disease and the promotion of health. Medical Knowledge: Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, and the application of this knowledge to patient care. Practice-Based Learning and Improvement: This involves the investigation and evaluation of care for their patients, the appraisal and assimilation of scientific evidence, and improvements in-patient care. Interpersonal and Communication Skills: Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and professional associates. Professionalism: Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to diversity. System-Based Practice: This is manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. SUGGESTED READING 1). Pediatric Critical Care: The Essentials by Joseph Tobias, M.D. 2). Nelson s Textbook of Pediatrics: General Concentrations in the Care of Sick Children 9

11 3). Pediatric Critical Care. By Fuhrman, Zimmerman REQUIRED READING 1). Pain Control and Sedation in the Pediatric Intensive Care Unit. By Joseph D. Tobias, M.D. (Article included in educationalmaterials sent at the beginning of rotation) 10

12 Do s & Dont s In PICU Daily work Attendings Therapeutics Sedatives, Analgesics, NMBs Cardiac meds (digoxin, inotropes, etc.) Bolus drugs (K, Ca, Mg) Standard drips, flushes Catheters, Art lines Nursing, RT QM

13 Do Get all the numbers by 0830 Organ system presentation Non-presenting resident writes orders Write total dose AND per kg dose Give the nurse the patient s chart with new orders ASAP Check all cultures before rounds Discuss plan/recommendations with other services

14 Don t Write on post-op op cardiac patients Touch settings on the ventilators Consult specialists without talking to attending intensivist Discharge/Transfer patient without talking to accepting service resident Forget to write procedure notes Leave your personal belongings laying around

15 Do Ask nurses what happened during nite let the senior supervise (review orders) Let the nurses know the plan Ask Kelly Skender / Kris Schultz for advice/guidance Ask questions (RTs, nurses, dietitians) Go to conferences Cover each other s patients during conference, clinic, day off

16 Do page anesthesia attending on call for help with emergent airways page or call attending on call with questions/concerns write on call progress notes regarding significant events give a typed problem list to person on call ( what ifs ) Dictate interim discharge summary

17 Do Page senior resident on call (admitting peds pager) for emergencies while waiting for attending physician on call Notify senior resident regarding potential emergencies of Intermediate patients Write procedure notes (white copy in chart, yellow copy for attending) Remind attending to review x-rays x with peds radiologist

18 Don t Use the Peds Intensivist Office as a lounge, restaurant, storage closet Update your patient sign out list multiples times a day

19 Sedatives Drugs < 6 months 6 months to 6 yrs Midazolam Lorazepam Dexmedetomidine Propofol Pentobarbital Chloral Hydrate Ketamine 0.05 mg / kg 0.05 mg / kg mcg/kg/h(?) FDA WARNING 1 mg / kg 25 to 100 mg/ kg 1 to 4 mg/kg 0.1 mg / Kg 0.1 mg / kg mcg/kg/h FDA WARNING 4-6 mg /kg mg /kg 1 to 4 mg/kg

20 Analgesics Drugs < 6 Months 6 months to 6 Yrs Fentanyl Morphine Methadone Ketorolac Trilisate 0.5 mcg / kg 0.05 mg / kg 0.1 mg/kg not indicated mg / kg 1 mcg / kg 0.1 mg / Kg 0.1 mg/kg 0.5 mg /kg (max 30 mg) mg /kg 500 to 1500 mg q D to TID

21 Muscle relaxants Drugs Single Dose Infusion Rocuronium Vecuronium Cis-atracurium Succinylcholine Glycopyrrolate mg / kg 0.1 mg / kg 0.5 mg / kg 1-2 mg/kg mg/kg mg /kg/h 0.1 mg /kg/h 0.5 mg /kg/h max 0.2 mg/dose

22 Cardiac Infusions Drugs Loading Dose Infusion Dopamine Dobutamine Milrinone Epinephrine mcg/kg 1-10 mcg / kg 1-20 mcg/kg/min 5-20 mcg/kg/min mcg/kg/min mcg/kg/min

23 Potassium Bolus 0.5 meq /kg/hr (oral preferred) Max dose for anyone 15 meq Bolus of 1 meq /kg/hr need to be approved by the attending Peripheral IV maximum concentration no more than 60 meq /L Peripheral IV bolus need to be diluted 10x Central line max concentration no more than 100 meq /L Central bolus diluted 1 to 3x

24 Calcium Ca gluconate mg /kg; max 1g if ionized Ca < 1.05 CaCl mg /kg; max 500 mg; should always be given via central line - infuse very slowly Use calcium carbonate or glubionate p.o. Do not infuse through peripheral IV unless emergency

25 Magnesium 25 to 50 mg/kg/dose Check ionized Mg ( ) max dose 2 g Do not use Mg citrate p.o. as supplement

26 Infusions standard mixing orders (concentrate?) sedatives: midazolam, lorazepam, dexmedetomidine analgesics: fentanyl, morphine NMBs: rocuronium, vecuronium

27 Central Venous and Arterial Catheters 0.45 NS with 1U/mL heparin Add 60 mg papaverine/500 ml to arterial line fluid (not in CHI) Minimum rate 1.5 ml/h Placement using sterile technique CVC: subclavian, femoral, IJ arterial: radial, femoral, brachial

28 Quality Management Fill out pre-extubation extubation form before extubation If there are problems with central lines, art lines, fill out QM forms After filling out the forms place em in the QM pouch in the bulletin board

29 Do use the Pediatric Critical Care: The Essentials (Tobias) answer the questionnaire (print a copy) 30 min morning report presentations x 2 in a month (please get the case approved by an attending and remind attending on service about the morning report).