MICU overview for housestaff

This overview was initially written by Dr. Kress and was revised in July 2013.

ICU Epic Order Sets

There are a number of order sets that were created by critical care faculty, pharmacists, and nurses; these order sets are reviewed on an annual basis. For common diagnoses, we have order sets available on EPIC. These evidence-based tools MUST BE UTILIZED. Please review and “favorite” each of these order sets:

  • ICU admission – 796 – General ICU admission
  • ICU sepsis admission – 618 – Sepsis-specific admission including antibiotic recommendations
  • ICU pneumonia – 515 – PNA-specific admission including antibiotics
  • ICU critical care sedation – 1110 – Sedation orders including daily awakening trial
  • ICU comfort care – 3200 – Comfort orders
  • ICU q12h labs – 1502 – Usual ICU labs q12h (0200, 1400) in the ICU

Radiology Rounds

Occur DURING MORNING ROUNDS using large HD monitor.

Presenting intern/student is expected to read chest radiograph systematically starting with hardware [e.g. ETT, vascular access, etc.].

CXR interpretation is a critical component of the training program. It is mandatory that everyone on rounds view all of the radiographs.

Post call hand-offs

ACGME RULES REGARDING WORK HOURS MUST BE FOLLOWED.

ACGME work hour limitations (frequent intern switches) complicate the post-call day and require careful planning to ensure a safe transition of care. Likewise, after a day (or evening) away from the unit, you must update yourself on patient events occurring in your absence. “Catching up” requires extra time. It is NOT acceptable to be unaware of new information on your patients because you weren’t here. Come in earlier the day after the post-call day.

The MICU resident is a centerpiece of the patient care model and training program for the Department of Medicine.

Accordingly, it is MANDATORY that ALL 4 residents on the MICU rotation know ALL of the patients on service — not just their own patients.

Every evening, the on-call MICU interns AND resident must receive a concise sign-out from each of the other 3 teams before these other teams leave for the day. This sign-out is the responsibility of the resident/“resitern” on EACH of the other 3 teams. In addition, they may choose to “run the unit” with the on-call MICU fellow to discuss important overnight goals for active patients.

Patient transfers out of the ICU can NEVER happen without a “hand-off” from the ICU resident to the floor receiving resident.

Because of bed availability, such transfers may happen “after hours”.

Once resident/“resitern” gives MANDATORY daily sign out, his/her patients become the responsibility of the on-call resident until the following morning.
It is the responsibility of the on-call resident to know which MICU patients have transfer orders and are awaiting a bed. The following process MUST OCCUR FOR EACH PATIENT transferred from the MICU service.

  1. ICU nurse pages on call intern/resident to inform of bed assignment.
  2. On-call RESIDENT pages the appropriate team for signout.
    1. If floor team is capped, on-call intern/resident adds the patient’s name to the hold over list with patient “one liner”, MRN, bed and contact pager.
    2. Team accepting holdovers pages ICU team to get signout the next morning.
  3. Fellow runs the list of patients in AM with post-call resident to ensure all patients that left the ICU were assigned a team (either before or after rounds)
  4. Primary team arrives in AM to find patient has left the unit. They page the accepting team to ensure sign-out on critical issues was clear.

THIS PROCESS IS MANDATORY. We CANNOT have patients leaving the MICU to the ward without direct hand-off.

Rounds

Census tends to be high, so rounds MUST be streamlined. A practical time limit of less than 10 minutes per new admit and 5 minutes for old patients should be targeted.

Do not repeat information (e.g. repeating PMH data already mentioned in the HPI, the summary wrap up: “So in summary, we have a 68 year-old man with COPD who presents with respiratory failure . . .”). Please report relevant data only. It may be difficult to know how to do streamline your presentation early on; fellows and attendings are here to teach this skill!

Speak loudly; a lot of people need to hear you.

Presentations should be problem-based. Please practice presentations. Residents, fellows and attendings are available to help interns/students.

The focus on rounds should be a thoughtful discussion of the patient’s problems. While we rely on having all the “numbers” available, we expect more than reporting numbers. We expect that you will craft and present a concise diagnostic and therapeutic plan for each patient each day. Fellows and attendings are here to help.
Patients’ conditions change rapidly, and it can be frustrating when your presentation is not consistent with the patient’s condition on rounds. Faculty/fellows recognize and acknowledge the dynamic nature of the ICU; you can’t always be up to speed on something that just happened. Remember that rounds are meant to be a dialogue and a teaching opportunity where numerous team members discuss the patients’ current conditions and formulate a plan.
Orders should be entered in real time on rounds. Use your iPad or “computer on wheels.”
MULTIDISCIPLINARY ROUNDS BENEFIT PATIENTS. NURSE PARTICIPATION ON ROUNDS IS MANDATORY, EXCEPT DURING A PATIENT EMERGENCY. A MEMBER OF THE PHYSICIAN TEAM SHOULD NOTIFY THE NURSE WHEN ROUNDS ARRIVE AT THE BEDSIDE. The nurses will then use the “FAASTERHUGS” mnemonic when presenting patients on rounds:
F—FEEDING
A—ANALGESIA
A—ACCESS
S—SEDATION
E—EXAMS SCHEDULED (e.g. CXR, CT)
R—RESTRAINT ORDER UPDATE
T—THROMBOEMBOLISM PROPHYLAXIS
H—HEAD OF BED ELEVATION > 30 DEGREES
U—STRESS ULCER PROPHYLAXIS
G—GLUCOSE CONTROL
S—SKIN INTEGRITY, DECUBITI, ETC.

ICU Patient Care Format

The MICU is a “closed” ICU. When patients are admitted, the MICU becomes the primary care team. While all patients require collaborative care, there are certain types of patients where this is particularly critical.

  • Advanced liver disease. Notification of the Hepatology and Transplant teams regarding patient care plans is MANDATORY. Failure to do so may compromise transplantation opportunity. Any change in patient condition or care plan must lead to notification of ONE person on each team (Hepatology fellow, Transplant fellow) in addition to MICU fellow/attending. Differences of opinion will occasionally happen. You are not expected to engage in dialogue with Hepatology and/or Transplant fellows and/or attendings in the event of a such a difference of medical opinion. Please notify MICU attending IMMEDIATELY if you relay a care plan and/or patient condition change to the Hepatology/Transplant teams and there are questions/disagreements.
  • Lung transplant patients. As above, except lung transplant services.
  • Oncology patients. Similar to above, you must notify the oncology fellow with care plans and changes in condition. It is NOT your responsibility to notify every person in the section of Heme/Onc about a patient in the MICU. The Oncology fellow is responsible for notifying interested parties.
  • Urology patients. The MICU is the primary service; however, the urology service must be involved. This is particularly relevant to the GI and GU systems since the anatomy of these patients usually is altered. DO NOT EVER PLACE OR MANIPULATE NG tube, Dobbhoff feeding tube, rectal tubes, or Foley catheter without talking to the Urology team.
  • ENT Patients. As Urology, keep the services informed and appreciate the ubiquitous altered anatomy and fresh surgical sites which should be managed by ENT (particularly important for airway issues).
  • Palliative Care Team. Please take advantage of this team as appropriate after discussion with your MICU attending.

ICU Pharmacist

Dr. Ishaq Lat rounds with the ICU team every morning M-F (pager 3965). He is a tremendous resource and teacher. He typically surveys the MAR and offers advice with regard to pharmacological issues.
Dr. Lat usually works with one or more ICU pharmacy residents. These members of the team are also critical.

ICU Procedures

You MUST page the Procedure Service (pager 1111) and/or notify your ICU attending before beginning a procedure. If this service is not available, then you MUST contact the MICU attending (“plan B”). On weekends, you MUST contact the MICU attending before doing procedures.
During non-daytime hours, when there are no faculty members available, you must contact the fellow and/or attending before proceeding with any procedure (except patient emergencies). This expectation optimizes procedure teaching and billing. Being “signed off” on a procedure does NOT exempt you from this requirement.

Triaging patients into the MICU

The MICU resident will be called first for evaluation of a patient for admission.

Most cases are straightforward: Evaluation occurs; patient is admitted; and resident calls fellow and attending to discuss. A request for MICU admission by an ER faculty member should not go unheeded. Where there is disagreement, attendings (MICU and ER) will discuss.

If the resident feels the patient does not merit MICU admission, he/she MUST call the fellow to discuss the case. A MICU resident CANNOT unilaterally refuse to admit a patient to the MICU. There are NO EXCEPTIONS to this rule.

Evaluations that do not result in MICU admissions should be documented as a note in Epic as a brief consult.

You must notify the charge nurse about any incoming transfers from ward or ER.

Bed assignments and insurance screening are the responsibility of the bed desk and transfer center staff. This responsibility should NEVER be directed to the residents. Administrative work is NOT the responsibility of the resident.

ICU Research

You are expected to work with the research team(s) when your patient is involved in a research project. This includes adhering to the orders as a part of the research project(s).
MICU team has primary patient care responsibility, you CANNOT modify or discontinue ANY research related orders. You MUST contact the research team first. There are NO EXCEPTIONS to this rule.