ICU Orientation What You Need to Know The

ICU Orientation What You Need to Know

The Six COMPETENCIES Patient care Medical knowledge Communication Professionalism Practice based learning System based practice

Patient Care: Cognitive Skills Improve the skills to provide optimal methodology to work up and deliver care to critically ill patients Communicate effectively with and demonstrate empathy and respectful behavior when interacting with patients and their families Ensure relevant and accurate information about their patients Oversee diagnostic and therapeutic plans for their patients based on history, physical examination and laboratory data tempered with evidence-based medicine, clinical judgment and patient preference Ensure management plans are implemented Counsel and educate patients and their families

Patient Care: Technical skills Insertion of and instruction in the insertion of intra-arterial (radial, femoral, axillary) and central venous catheters (internal jugular, subclavian, femoral) Insertion of and the instruction in the insertion of pulmonary artery catheters (internal jugular, subclavian and femoral) Emergency airway management Insertion of chest tubes (optional) Percutaneous tracheostomies (optional)

Medical Knowledge Master the following: Physiology Pharmacology Clinical Knowledge and Management: Respiratory Mechanical Ventilation Management of acute lung injury and the acute respiratory distress syndrome Weaning from mechanical ventilation Cardiovascular Hemodynamic monitoring Oxygen transport Use of inotropes and vasopressors Pharmacokinetics and pharmacodynamics Management of Increased ICP Management of renal insufficiency Liver failure Acute Chronic Care of the liver transplant patient Massive bleeding and transfusion Nutrition Infectious diseases Microbiology Antimicrobials Shock Evaluation Management

Practice-based Learning By appraising and assimilating scientific evidence, residents must be able to investigate, evaluate and improve their patient care practices. The resident will be able to: § Locate, appraise and assimilate evidence from scientific studies that are relevant to their patients' health problems; § Use evidence-based medicine methodology to ascertain the utility and effectiveness of certain diagnostic tests and therapeutic strategies in the care of their patients; § Use information technology to manage information, access on-line medical information and support their own education; § Assist in the teaching of CA-2 residents, medical students and allied health personnel.

Communication Residents must be able to demonstrate interpersonal and communication skills that result in effective exchange of information and provide a framework for the development of a cohesive critical care team. Residents are expected to: § Create and sustain a therapeutic and ethically sound relationship with their patients; § Use effective communication techniques to provide and elicit information: o Efficient and effective presentations during daily rounds; o Timely, complete and legible progress and procedure notes; o Effective dissemination of information to consultants and allied health care providers o Providing updates to family members; o As part of the CCM team, discuss end-of-life issues with families

Professionalism Residents must demonstrate a commitment to completing their professional responsibilities, adhering to ethical principles and being sensitive to a diverse patient population. Residents are expected to demonstrate: § Respect, compassion and integrity; § Responsiveness to the needs of patients and society that supersedes self-interest § Accountability to patients, society and the profession; § Commitment to excellence; § On-going professional development; § Commitment of ethical principles: o Provision/withholding of care; o Patient confidentiality; o Informed consent; o Business practices § Sensitivity and responsiveness to patients' age, culture, gender and disabilities.

System-based Practice Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to: § Understand how their patient care and other professional practices affect other health care, the health care organization and the larger society and how these elements of the system affect their own practice; § Practice cost-effective health care and resource allocation that does not compromise quality of care; § Advocate for quality patient care and safety; § Know how to partner with health care managers and providers to assess, co-ordinate and improve health care and know how these activities can affect system performance.

Educational Goals 80 hour work week must be adhered w/o exception Didactic activities: lectures 7: 00 -8: 00 Tuesdays and Thursdays only! § Anesthesia (first week) § Trauma (second week) § Neuro Critical Care (third week) § Resident Lecture Multidisciplinary critical care conferences 4 pm on Wednesdays Patient bedside teaching rounds: Friday at 1 PM

Educational Goals Evaluation and Feedback: § Monthly evaluation by attendings § Evaluation by selected nurses & Affiliate Practitioners § Evaluation of each attending by residents § Evaluation of rotation § Work hour documentation

Resident “Call Out ” Procedure Anesthesia 1. 2. 3. Resident attempts to cover with fellow residents Failing#1: resident notifies Administrative Chief and Clinical Director Failing #1 & #2: Program Director is notified Emergency Medicine Resident calls their administrative Chief, who then arranges coverage Surgery Resident attempts to cover with fellow residents: switches, etc. 2. Failing #1: Resident notifies Surgery Chief Resident on-call at that campus. He/she gauges impact and acts accordingly 3. Failing #1 & #2: Chief Resident notifies Dr. Anne Larkin to decide if other resources needed 1.

SICU Team ICU Attendings: Rotate weekly Monday through Sunday ICU Fellow - intermittently E ICU § After 6 pm review all new admissions § Nocturnal bed triage Affiliate Practitioners § SICU § Neuro Critical Care Pharm D PA Residents Students – Medical, NP, PA

e. ICU 24 hour Intensivist and Affiliate Practitioner to assist with patient management Present all nocturnal (19: 00 -07: 00) admissions to e. ICU attending Review unexpected patient deterioration Remember: covering Intensivist may need to know also!

Work Flow Get sign out from previous shift Pre round on pts NOTE: Vascular Rounds in 3 ICU at 0630 AM AM lecture Finish pre-rounding Round with attending, team Verify, allocate the work to be done Do the work Afternoon Rounds Sign out

Lectures / Reading List Morning conference includes post-call resident § 7: 00 – 8: 00 Tuesdays and Thursdays: L 2 § Residents responsible for one lecture per month (last week) § End of month written test Critical care conference: Wednesdays at 4 pm (anesthesia conference room) Reading list: select chapters in Irwin & Rippe’s “Manual of Intensive Care Medicine” (2010)

Rounds Vascular rounds in 3 ICU at 6: 30 AM Weekend/holidays rounds 8: 00 Top priorities: § A good exam § Know what has happened in past 12 hours § Review studies § We can make plan as a group and note can be completed later

Upon Completion of Rounds: SICU team gathers to run list § Ensures we’re all on same page § Delegate tasks § Assign procedures First - Call consults Arrange procedures Sit-down rounds with SICU attending 4 -5 pm

Admissions: All admissions accepted by Attending only § All admission cleared through e. ICU § e. ICU calls unit ATTENDING for acceptance § Must present all admits to e. ICU attending after hours All admission orders reviewed by ICU resident/mid- level; changes made as needed See patients in PACU as soon as notified of arrival Attending decides which unit covers SICU patients in PACU (if necessary) § Notify EICU of admissions - can put in pre-admit bed so note can be started prior to pt arrival

Discharges: Discharges out of SICU determined by Attending/Surgery team § Delay in transfer d/t bed availability requires re- evaluation prior to transfer § All patients that have been in SICU > 48 hours will need dictated transfer summary (exception: trauma patients) Receiving teams write transfer orders. When this can not be completed in a timely fashion holding orders can be written.

Deaths Before making CMO notify NEOB Notify family and attending Review what needs to be called to Medical Examiner Review new Brain death criteria on intranet Final note in chart § Circumstances of death § Death summary dictation (trauma does their own) § Pronouncement and time of death: Mid-levels can pronounce but can’t sign death certificate

Printing SICU List “TEAMNOTES” Salar “Team. Notes” Update daily : add new patients

Daily SICU Notes Start notes after 1 pm in VISICU Update as needed and at 4 am: preround information inserted Separate event notes and notes for line insertion/procedures as well as a postop check Notes saved as open draft until ready to sign/print. Notes expire after 24 hours

SICU Routine Orders Stress ulcer prophylaxis Restraint orders TPN CWAS Sedation protocol with daily holiday Ventilator wean protocol Low tidal volume protocol Glycemic protocol: All patients except pancreatic transplants or HHNK or DKA

SICU Routine Orders: Writing Orders VISICU: Orders-Create Standard Order : free text Medication: Add pick list/formulary /Stop Formulary USE IT !! o Allergy checking o Med Compatibility checking o Visible to nurse/Pharm D Other Hardcopy of Verbal order Not available With “free texting”

SICU Procedures Informed consent for elective Inform Intensivist !! Nurse in room and time-out Radial arterial lines only: Gloves/mask/cap Central lines : Chlorhexadine prep and full barrier precautions Procedure note after all procedures (no matter how they turned out)

General Responsibilities Discharges to home are the exception § PDI in Soarian § Dictations § Prescriptions Night duties § Restraint forms § TPN started – not faxed – attendings to review prior to faxing § Dictate patients every 14 days § Dictate prior to moving to other ICU or off service (except traumas)

Critical Care Clinical Practice Guidelines Developed by dedicated team of critical care providers at UMMHC Evidenced based Available on intranet under CCOC Includes specific order sheets

CPG’s include: Transfusion “trigger” ARDS/ALI Sepsis Hypothermia s/p VF arrest Analgesia and sedation Ventilator Weaning VAP: prevention of Glycemic Control Electrolyte replacement

Blood Transfusion Threshold CPG Conservative transfusion trigger in euvolemic, non-bleeding, critically ill patient is proven superior regarding hospital mortality, pulmonary and cardiac complications Applies to all critically ill patients @ UMMMC except: § Actively bleeding § Post/pre-op resuscitations § Pregnant patients § NICU patients

Transfusion CPG Transfusion trigger: Hgb < 7 gm/dl Subgroup patient populations Transfusions require attending approval unless patient actively bleeding Consider repeat Hgb/Hct if there have not been any sign or symptoms Transfuse 1 unit RBC at time unless bleeding.

Transfusion Surgical/Trauma Post-op patient Hgb BID goal Hg 8 mg/dl If not adequately resuscitated transfuse to Hg 10 mg/dl

Transfusion: Surgical/Trauma Consider patient’s operative state: § Pre-op § Post-op § Non-op Consider adequacy of resuscitation § Acid-base balance § Hemodynamic stability o CI > 2. 2; Ft. C 350; CV 02 > or equal 70% o No or decreasing vasopressor requirements o No unexplained tachycardia o Restoration UOP >. 5 ml/kg

Transfusion: Acute Coronary Syndrome Transfusion trigger Hct < 25 Patients > 65 years old may transfuse at a HIGHER Hct at discretion of attending Remember: a “troponin leak” is NOT ACS

Transfusion: Sepsis Early Severe Sepsis: must meet all criteria: o Suspected/confirmed infection o 2/4 SIRS criteria o SBP < or equal to 90 or lactate > 4 o Sv 02 < or equal to 70% after CVP > 8 and MAP > or equal to 65 mm. Hg

Transfusion: Renal Failure Patients who are requiring RRT either chronic or acute Transfusion trigger Hgb < 9 at the discretion of nephrologist/intensivist

Transfusion: SAH Subarachnoid hemorrhage with active vasospasm § Transfusion trigger < 7 § There is evidence to support a more liberal threshold Hgb 10 in severe spasm: this is at discretion of the neurointensivist

Use of Erythropoietin Most recent studies do not support routine use of erythropoietin Exception is patient with chronic renal failure on hemodialysis

Sepsis CPG In USA, severe sepsis/septic shock effects > 750, 000 with overall mortality 29% A systematic and organized approach to early goal directed therapy to be provided to all our adult patients with sepsis Goal: early identification and use of sepsis packet with antibiotics within 3 hours in ED and 1 hour in ICU

Sepsis CPG Key elements: § Central access within 2 hours for CVP/fluid/CV 02 monitoring § Ultimate goal to be achieved within first 6 hours: o CVP 8 -15 o CV 02 > or equal to 70% o MAP 65 -110 o Lactate < 4

Antibiotics Review restricted antibiotics VAP treatment based on ATS and IDSA guidelines: MRSA and GNR § Vanco trough for MRSA PNA 15 -20 § Coverage for pseudomonas PNA with pip/tazo or cefepime and tobramycin or quinolone (5 days) § 1 st dose of any antibiotic can be given stat w/o ID approval § De-escalate once cultures back

Central Venous and Arterial Catheter Management Mandatory education on E Learning Standardized line carts 2 nd person present during insertion to assist/monitor and halt procedure if necessary: ensure Intensivist aware! Standard catheter dressings Standard documentation Need for lines reassessed daily on rounds DC “high risk” lines ASAP

Therapeutic Hypothermia for Comatose Survivors of Cardiac Arrest Intubation Sedation/analgesia Consider paralysis to prevent shivering Supportive measures Induce hypothermia to 32 -34 degrees within 2 hrs and continue total 24 hrs Evaluate and address potential medical problems Address family concerns

Pain Management Fentanyl drug of choice Hydromorphone or fentanyl with renal insufficiency Rarely use propofol w/o pain control No systemic narcotics with epidural unless instructed by anesthesia service managing epidural Rarely use narcotic/sedative gtts after extubation, but must be reordered Consider ketorolac if no significant bleeding concerns and normal renal function (48 hours only)

Sedation Protocol CPG Standardized monitoring of pain, agitation and delirium in mechanically intubated patients Excludes patients receiving neuromuscular blockade and induced coma for ICP control Standard order form to be completed include RASS goal and frequency

Sedation Protocol Sedation holiday performed daily on all patients unless contraindicated Restart analgesic/sedation at 50% dose if agitated Delirium assessment daily (CAM-ICU)

Sedation Protocol Fentanyl preferred analgesic in hemodynamically unstable or severe renal impairment Remember to include bowel regimen Consider tolerance/withdrawal issues in patients with heavy opioid requirements and those on narcotic/sedation for a week or more who are at risk for withdrawal

Paralytics Requires critical care Attending or fellow approval Must use SICU NMB protocol order sheet Patient must be heavily sedated and have adequate pain control Avoid if also receiving immunosuppresive doses steroids

ARDS/ALI - Low Tidal Volume CPG Institution-wide guidelines for adults with ARDS/ALI includes Order Sheet Multiple randomized control studies demonstrate use of lower TV in ARDS/ALI Decreased mortality with use of 6 ml/kg TV (IBW)

Ventilator Weaning CPG Applies to any patient intubated for >48 hours RRT to discuss with SCIU team who shall be weaned Patients to consider weaning § Evidence of some reversable of cause of respiratory § § § § failure Pa 02/Fi 02 > 150 PEEP < 8 Fi 02 < 0. 5 Arterial p. H 7. 3 - 7. 5 No evidence of active cardiac ischemia Hemodynamic stability Some indication of inspiratory effort

Weaning Protocol If patient fails weaning evaluate barriers to weaning § Cardiac ischemia / LV dysfunction § Volume overload § Pulmonary / systemic infection § Malnutrition § Neurologic dysfunction including over sedation § Pain / anxiety § Pre-existing pulmonary disease § Inappropriate ETT size § Electrolyte abnormalities § Thyroid disease

Weaning Protocol Daily worksheet done by RRT Spontaneous breathing trial with CPAP 5 to 8 cm H 2 O of PEEP If CPAP successful for 2 hours evaluate for extubation Termination of SBT § New onset diaphoresis / arrhythmias § SBP > 180 or > 20% increase baseline § HR > 120 or > 30 from baseline § Sa 02 < 90% or Fi 02 >. 6 § If ABG obtained: p. H < 7. 3; pa. O 2 < 60; sa 02 < 90% or p. C 02 > 10 above baseline

VAP CPG Preventable cause of morbidity/mortality and excess cost in ICUs Steps in Prevention § HOB elevation to 30 degrees unless contraindicated § Oral intubation § OGT § Rapid extubation as able and adherence to weaning § § § protocol Sedation protocol Minimization of self-extubation Prevention gastric over distention by checking residuals q 4 hours Oral hygiene with chlorhexidine @ least q 8 hours Vaccinate for influenza/pneumococcus Avoid contamination respiratory circuit

Venous Thromboembolism CPG All patients to receive prophylaxis unless contraindicated (i. e. bleeding or head injury / hemorrhage) § Chemical prophylaxis preferred over mechanical § Enoxaparin o 40 mg daily o 30 mg BID o Unfractionated heparin in patients with somewhat elevated risk bleeding or creat clearance < 30. Smaller doses can be used. Higher doses for morbidly obese o SCD to be utilized unless contraindicated o In case of inadequate prophylaxis of 3 or more days in high risk surgical/trauma patients doppler screening LE o Consider IVC filter if unable to adequately prophylax high risk patient

Glycemic Control CPG To ensure safe and effective management of tight glycemic control Goal 80 -140 mg/dl All ICU patients placed on glycemic control protocol and BS monitored for effectiveness Evaluate for transition to sliding scale/long acting insulin coverage § PO diet § Clinical condition stabilizes § Stable insulin gtt dose § Stable caloric intake § Approaching transfer

Increased ICP CPG Six step process 1. Assess at-risk population 2. Assess for hyperosmolar therapy 3. Initiate hyperosmolar therapy 4. Deep Sedation 5. Pharmacologic coma 6. Paralysis Always Consider Need For Surgery

Therapeutic Hypothermia for Comatose Survivors of Cardiac Arrest 2005 AHA Guidelines indicate instituting mild hypothermia improves neurologic outcome Scope: All patients 18 and older who remain comatose post-VF cardiac arrest, with return of pulse pressure § Excluded: major head trauma, recent major surgery, sepsis, bleeding, pregnancy

Pressure Ulcer Care CPG PREVENTION including ordering air mattress/specialty bed on high risk patients Daily skin assessment with report to clinical staff by nursing with weekly PU reports Education for residents, midlevels and nursing staff

Pressure Ulcer Care CPG 1. 3 to 3 million adults affected with incidence of up to 38% hospitalized patients Aim is to reduce/eliminate hospital acquired pressure ulcers Pressure Ulcer Risk/Assessment completed with 24 hours of admission (Braden Scale) Ongoing skin assessment on ECare Manager Flow Sheet

SICU Rotation: Is a GREAT learning opportunity Has GREAT Faculty Has GREAT NP/PA support Is only what you make of it Intellectual Curiosity Exercise it !!

QUESTIONS ? ?