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SICU ORIENTATION

SICU TEAM

SICU Director: Mandi Roberts, MD

SICU Associate Director:

Surgical Critical Care Fellows:

TACS Fellows: Alexandrea Ferre, MD; Adrian Coleoglous Centeno, MD

Surgical Critical Care Specialists (SCCS): Candice Preslaski, PharmD; Lauren Rich, PA

Advanced Practice Providers (APPs): Emily Perkins-Pride, NP; Kim Hardin, NP; Larissa Fritts, PA; Chelseigh Newkerk, NP

Nursing Manager: Heather Escudero, RN

Nursing Educator: Molly Fox, RN

SICU EXPECTATIONS

The SICU is a 24-7 unit. Deliver the same care at night as you would during the days. This means that fever work ups, imaging, invasive procedures, intubation/extubation, etc. should not be delayed or compromised due to the time of day.

 

You should make sure you understand the plan for each of your patient’s each day after rounds with the chief resident or fellow or attending. If that plan changes for any reason during the day or there are any acute issues with any of your patients, you should inform your upper level.

 

You should remain engaged during SICU rounds for every patient – including those who are not yours.  Offer your thoughts on all assessments and plans.  Be assertive, proactive and volunteer to take new admissions or transfers.

When in doubt, load the boat. This means escalating concerns or issues to higher level providers. See card in SICU doc box for reference.

  • CALL FELLOW/CHIEF: bedside procedures, transfusion, when ordering STAT imaging, starting antibiotics, change in wounds or drain output, neuro changes, medication or treatment errors requiring intervention.

  • CALL ATTENDINGdeaths, codes, unstable arrhythmias, worsening respiratory status, need for intubation, self extubation, stroke alerts, failure to clear lactate/base deficit, transfusion of >2u blood during a shift, starting or restarting pressors/paralytics/anticoagulation/CRRT, change in vascular exam

 

Never be afraid to ask for help and all big clinical changes must be communicated to your chief/fellow/attending.  You should be at bedside of all procedures, including extubations.

 

There are often SICU sub-interns (MSIVs). They are expected to carry and present patients on their own. However, a resident or APP will also be assigned to their patients. Helping them with formulating plans, presenting on rounds, and with procedures.

 

Teaching rounds are every Friday at 11am. The attending/fellow will pick a patient with a good learning topic and the resident/APP/MS who has them will present them. This presentation is not systems based but is more of a hospital/ICU course presentation with case based learning.

Typical day

STAFFING: SICU attending, critical care fellow, 3 providers (mix of residents and APPs), and critical care specialist

5 AM: Receive sign out from night resident. This is done bedside and is a brief, system based sign out completed in a top down manner to ensure all pertinent details communicated to oncoming team. It should finish with the shift to-do’s / follow up.

 

AFTER SIGN-OUT: Assign yourself as the 1st call provider for each of your patients on EPIC care team.  2nd call is SCCS. Fellow will also sign in.

 

7 AM: TACS/EGS morning report (Pav C basement Nightingale). Day resident is responsible for presenting the 24hr SICU ins/outs and therefore should become familiar with each of these patient’s hospital course and any pending studies the TACS/EGS team need to follow up. You do not need to re-discuss any new admissions already presented by the TACS/EGS team. If a patient is transferred out to subspecialty services they should be presented simply as John Doe with ____ diagnosis and was transferred out to ____ service.

 

8 AM: ICU Rounds. Please print a hand-off and patient list for the attending. Patient’s provider will present the patient. The other resident and APP will either put in all new orders discussed during rounds, pull up pertinent imaging or update the patient’s daily “to do” list.

 

For details on how to present on SICU rounds, please watch the video at www.vimeo.com/DHTACS prior to starting your rotation.

 

AFTER ROUNDS: Complete tasks from high to low priority: procedures, call consults, update family, write notes, update handoff and order AM labs. New admissions, transfers or discharges are a top priority. Confirm all plans created during rounds have been addressed.

 

5 PM: Sign out to the night resident in same manner as morning sign out (i.e. bedside, system based) with emphasis on things that still need to be completed or followed up on and all plans for overnight.

Typical NIGHT

STAFFING: Trauma/EGS attending, 1 resident, Trauma/EGS chief or fellow

5 PM: Receive signout from day resident/APP at bedside, system based, top down format.

 

AFTER SIGNOUT: Assign yourself as the 1st call provider for each of your patients on EPIC care team.

 

8-10 PM: Overnight rounds. Attending, chief/fellow, charge nurse, respiratory therapy and patient nurse. The resident provides a brief one sentence summary of the hospital course, active issues and pending overnight studies. Team discusses the plan for the evening and addresses any concerns. It is expected that the night resident "knows" the patients completely.

 

5 AM: Sign out to the day resident/APP. This is done bedside and is a brief, system based sign out completed in a top down manner to ensure all pertinent details communicated to oncoming team. It should finish with the shift to-do’s / follow up.

 

6-6:30 AM: Fellow and overnight resident discuss overnight events.

admit/discharge/transfers

ADMISSIONS

The SICU is a CLOSED unit and the SICU team is responsible for ALL orders on patients EXCEPT specific sub-specialty orders. (i.e. EVD/bolt management, flap checks, TPN etc.)

 

All patients admitted to SICU require an H&P (see Note Templates section).

SICU admission order set should be used for ALL patients admitted to SICU.

“Admit to inpatient”:

  • Service: Surgical ICU

  • Primary Team: Surgical ICU

  • Attending Provider: SICU attending of the week

 

The following need to be completed within 24hrs of admission:

  • Tertiary: Exam can be completed while the patient is intubated and/or sedated. If there are items to be followed up on after tertiary exam, please note these in the progress note. If tertiary was completed while patient sedated, a repeat tertiary should be completed once patient can participate in exam.

 

  • ACP documentation. This is a two step process.

 

  1. Complete either MDPOA form (paper document) or proxy form (electronic document). If a patient is awake and able to speak for themselves, they can appoint their own medical decision maker. If a patient is sedated / unable to make medical decisions for themselves, we must follow the designated proxy process to identify all interested parties, followed by appointing a proxy. Care management can assist in this process.

  2. Complete the “SICU Primary ACP Survey” note – In this note, a brief goals of care conversation needs to be documented and ideally completed in the patient's words. Substituted judgment on the part of the family or interested parties is acceptable. This should be a narrative description that assists in helping identify what burden of treatment would be acceptable to the patient.

 

TRANSFERS

Once a patient has been downgraded by SICU, a transfer order is placed in EPIC by the SICU specifying which floor and new primary service. Exception: NSGY will place their own transfer orders.

When a bed has been assigned, sign out is given to new primary team.

 

TACS/EGS patients - 

PCU: Sign out patient to the midlevel and discuss active issues/pending studies etc.

FLOOR: Sign out patient to intern and discuss active issues / pending studies etc.

Please escalate to chief resident or fellow if you are having issues getting in touch with either intern or mid level.

 

The day a patient is downgraded to PCU or floor (and awaiting a bed) – an interim summary note is written in the place of a progress note for that day (template is the dot phrase “.SICU interim summary for transfers”). If patient remains in SICU additional days, the provider resumes writing progress notes until physically leaves the unit.

 

Once patient assigned new bed and signed out, remove SICU as primary team.

 

All patients geographically located in the SICU (i.e. awaiting a PCU or floor bed) will be rounded on by the SICU service daily. The approach to rounding and documentation may vary based on patient's status.

           

DISCHARGES

TACS/Trauma primary patient: SICU completes discharge summary, medication reconciliation, discharge order.

 

All remaining patient’s will be discharged by the most appropriate sub-specialty service.

 

Discharge summaries should be completed within 24hrs.  

 

Follow up appointments:  in EPIC >> “in basket” >> type “c tacs clinic” in “to” box. In free text area, write follow up instructions. Make sure to include this information in the discharge summary.

 

**All patients who are discharged or transferred out of the SICU must be added to the SICU admissions/discharges shared EPIC list***

Note templates

Note Templates.jpg

consults & order sets

CONSULTS - The following are common consults called by SICU team:

 

Geriatric Trauma (Medicine):  called within 24 hours after arrival

  • > 60 yo with at least one of the following:  

    1. 3 prescription meds 

    2. Partially or fully dependent ADLs 

    3. From nursing facility 

    4. Other active medical conditions on admission (Ex: AKI, syncope, AMS)

  • OR anyone >70 yo

Anesthesia Pain Service (APS): any patients that may benefit from locoregional pain control (i.e. epidural, SA/ES blocks, etc.)

 

Physical Medicine and Rehabilitation (PM&R): all spinal cord, TBI patients; These consults should be obtained as soon as initial resuscitation is complete.

 

Addiction Medicine: any patient with complex management of substance use disorders

 

Trauma Survivors Network: all trauma patients

 

PT/OT:  all trauma patients  

 

SLP: all TBI patients (for cognitive evaluation) or any patient with dysphagia concerns

 

Care Management: all patients

 

** Subspecialty teams transferring patients out of the ICU requesting consultation services are expected to call the consults themselves**

COMMON ORDER SETS

  • SICU Admission​

  • PAD (Pain, Agitation, Delirium)

  • ICU Electrolyte replacement for providers

  • Adult Ventilator Management

  • MINDS Alcohol Withdrawal

  • Spinal Cord Injury Care

  • Heparin Drip protocol

  • Inpatient VAT (Vascular Access Team) Consult

  • Diabetes Management and Education

Knowledge to be gained

SICU Resident Expectations: Your goal by the end of your SICU rotation is to care for the sickest surgical patients. 

 

MEDICAL KNOWLEDGE - understand basic critical care medicine related to:​

  • Neurological Emergencies (TBI, intracranial hypertension, intracranial hemorrhages, acute ischemic stroke, AMS)

  • Proper management of pain, agitation, delirium

  • Respiratory Failure (Etiologies of Acute hypoxic and hypercapneic respiratory failure, indications for intubation/extubation, commonly used mechanical ventilation modes, ARDS management, pneumothorax, pleural effusion, pulmonary embolism)

  • Understand pathophysiology, work up and management of all types of shock

  • Cardiac emergencies: (dysrhythmias, ACS, Acute decompensated heart failure, Post cardiac arrest management)

  • Acute Renal Failure (Indications for CRRT, acid-base interpretation, electrolyte imbalances, IV fluid composition and management)

  • Acute Abdomen: (perforated viscous, bowel obstruction, abdominal compartment syndrome, fluid composition and effect of fluid looses such as pancreatic, gastric and biliary fistuals, pancreatitis, acute liver failure, GI bleed, abdominal compartment syndrome)

  • Hematologic Emergencies: (massive transfusion protocol, DIC, DVT prophylaxis)

  • Nosocomial Infections: (risk factors for resistant organisms, fever work up, initiation appropriate antibiotics)

  • Nutrition (appropriate enteral nutrition, TPN)

  • End of Life / palliative care / ethical issues: (withdrawal of life sustaining mesasures, organ donation)

 

PROCEDURAL SKILLS - under direct supervision resident should be able to:

  • Insert Central Venous Catheter

  • Insert Arterial Line

  • Insert and manage chest tubes

  • Develop bronchoscopy skill

  • Develop intubation skill

  • Perform and interpret EKG

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