MICU Nightfloat Orientation

The Basics

  • Service structure
    • When to arrive
      • Shift: 7:30pm – 8:30am
    • 4 Day Call teams (1 R + 2 I), 2 Dayfloats (R)
      • Day call for interns, overnight for residents
      • Day float to help with cross-cover and timely departure on weekdays (post-call resident or on-call interns)
    • 1 Night Float team (1 R, 1 I)
      • The NF team is responsible for cross-covering the MICU service and admitting new patients overnight.
      • Communication with the day interns & residents is paramount!
        • The NF team (Resident + Intern) should “run the unit” early in the shift with the on-call resident to get everyone up to speed with each patient’s clinical course and nightly goals.
        • There should be a quality, written signout about each patient in the unit with “To Do”, anticipated problems, and any major changes.
        • In the morning, sign out any important events or updates to the returning day teams. (It is OK to give specific feedback if the signout could be improved for next time!)
    • 2 Attendings, 2 Fellows – The leadership. Do not hesitate to call the fellow (pager SHOK / 7465) or attending if you are worried about the patient or you have a question!
  • Expectations: The minimum: cross cover, admissions, AM rounds
    • The NF team is responsible for the MICU service overnight with the help of the on-call (overnight) resident. You should discuss as a team how you will split up the work.
      • Cross-cover – NF intern should get signout from dayfloats and/or on-call team and field cross-cover issues. Either the NF resident or on-call resident should be available for backup at all times.
      • New Admissions
        • The whole team should be prepared to work on admissions that the day team has started as well as new ones that come in during the shift.
        • This work includes all documentation that needs to occur and being prepared to present patients at AM rounds.
        • The on-call MICU resident carries the admitting pager until midnight. The MICU-NF will carry the pager after 12 midnight.
      • Walking the Unit – The whole NF team (NF resident, NF intern, and on-call resident) should literally “walk the unit” briefly at the start of every NF shift. This hand-off is critical to get the NF team up to speed on the day’s events and the goals for each patient for the night.
      • Education – There are not formal didactics for the NF rotation at this time, but there are still opportunities to learn at night. The resident should make some effort to teach the intern about ICU basics, particularly if the intern has not rotated in the ICU. Teaching can include the following:
        • Reviewing CXR’s
        • Setting up and adjusting ventilators
        • ABG interpretations
  • Presentation tips for MICU:
    • Practice your presentations! Presenting a complex patient is a learnable skill. However, if you only do it on rounds, you will struggle to do it well. Practice with your resident, attending, fellow, etc. and ask for feedback. Listen to the other residents; what skills can you pick up from them?
    • Start with the most important problem!
      • Are they in the unit for their stable heart failure or because of DKA?
      • Give away the diagnosis if it is known. “Shortness of breath” should not be the presenting complaint if “hypoxic respiratory failure, ARDS, and septic shock” is known to be the most likely etiology.
    •  Efficiency is key. There are many complex patients, so avoid repeating extraneous data that was already presented (or is superfluous). Rounds will go faster, stay focused on the pertinent issues, and be a better learning experience.
      • 2 examples of extraneous information:
      • E.g. “… Endocrine: problem #1) Hypothyroidism: Well controlled. TSH pending. Continuing home dose of levothyroxine…”
        (These types of problems are not too important for their ICU stay!)
      • “In summary, this is a 68-y/o man with hypertension, tobacco abuse, and COPD presenting with fevers, chills, and a positive RVP for Parainfluneza presenting with ventilatory failure…”
        (Did you already go over all of this information in your presentation? Jump straight to the problem list.)
    • ICU typically has system-based presentations with problems for each system**. Many attendings prefer to hear about the relevant physical exam, data, etc. within the context of each system followed by the plan:
      • ***All attendings are different, so ask if you have questions about the preferred style
        • E.g. “Cardiovascular system – Heart rate ranged from 90-120, BP from 80-110 / 40-60 on norepinephrine and vasopressin. The urine output picked up to 5.2 liters over the last 24 hrs, lactate has fallen from 7 to 3.2. There were no telemetry events. Physical exam was unchanged / showed… The plan is: #1) Septic shock – Likely due to pyelonephritis and complicated by hypovolemia. CVP is 10, MAP is > 65 so we will turn off the vasopressin… (#2) Atrial fibrillation – Controlled on diltiazem drip. Transitioning to PO dilt today… Respiratory system: … Ventilator settings, vital signs, blood gas, chest x-ray…”
        • Look over the X-ray before rounds! (a) It is obvious when someone is looking at it for the first time and (b) you ordered it for a reason! Are the lines and tubes still in place? Is the edema better
      • Make a plan and try not to focus on the numbers!
        • Things can change so quickly, and someone can look up the numbers more quickly than you can say them. It is better to have an understanding of the data than to have every last piece of it.
        • Example: Your patient is suffering from hyponatremia, hyperkalemia, gap acidosis, and acute kidney injury. It is better to know how you’re treating the K+, why the acidosis is present, and how you’re working up the AKI than to know the Na+ is 128, K+ is 5.9, etc.
        • If your patient doesn’t need daily/BID CBC, BMP, x-rays, etc, then don’t order them!!

 

MICU-specific Logistics

  1. Supplies – Most supplies can be found in each ICU’s “Clean Supply” area. It is helpful to familiarize yourself with the location of common supplies so you can find them quickly when the time comes. Don’t be afraid to ask if you need help finding something! The unit RNs can help find things or the unit clerks can order from central supply if it isn’t available in the unit. Try to avoid “borrowing” from other units as they have to re-order to maintain their own stock. If crucial things are missing, let your attending and the unit clerk know so they can re-stock for the future. Refer to your intern-card for the supplies you will need for various procedures (e.g. Central line kit: triple-lumen catheter kit, sterile bowl, 250cc normal saline, transducer tubing, hats, gowns, gloves, drape, U/S probe cover, biopatch, tegaderm, etc.)
  2. Who does what –
    1. Pharmacists – Always present on rounds. A PharmD resident is also available by page overnight (6338) for urgent issues.
    2. RNs – Has the most direct contact with the patient of anyone in the unit. Work closely with them to inquire about responses to therapy, inform them of the plan, alert them to big changes (e.g. procedures, road trips, etc.). In return, they’ll let you know about acute changes in the patient’s condition, etc. Respect each other and make an effort to get along with them; chances are they have more experience than you!
    3. Respiratory Therapists – Usually one is assigned to each unit, but they’re available by page. They can help you with getting a ventilator or BiPAP (NIPPV),
      troubleshooting a ventilator, delivering inhaled medications (bronchodilators, nitric oxide), etc.
    4. Unit clerk – Can help you re-order supplies, get outside records, etc.
    5. Research personnel – They usually won’t be there at night. But when they’re around, respect them the way you would anyone else in the hospital. They know to stay out of your way when things are getting crazy.
  3. Backup / Supervision –
    1. The NF team should work like every other service. The intern is overseen by their resident (the NF resident) but also has the on-call resident for backup. If both residents are occupied, contact the MROC or other medicine housestaff (e.g. HONC resident) for help. They’re all here to take care of the patients!
    2. You should feel comfortable contacting the MICU fellow and attending overnight. They need to know if there are major changes in the patients overnight or if you have questions on newly admitted patients. They can also help you troubleshoot some of the logistics of getting things done (e.g. how to get IR in the middle of the night for embolization of an unstable GI bleed.)
    3. All Admissions / evaluations MUST BE RUN BY THE FELLOW! It is unacceptable and dangerous not to involve your supervising physicians in your evaluations. Don’t worry about waking them up overnight. They are on call and would rather hear about the patient from you now rather than be surprised that a new patient was admitted without them knowing about it! You may NOT reject a patient without talking to the fellow (and possibly the attending too).
  4. Portable Ultrasound – This is a useful and valuable tool. Please be careful and respectful of the MICU’s policies on its use. Do NOT lend it out for use outside of MICU patients!

Cross-cover tips

  • The NF intern will do most of the cross-covering in the MICU. This doesn’t mean that they’re alone! Sometimes more than one patient needs to be seen at the same time (maybe even in different units!). Stay in close contact with the other residents to decide how to prioritize the work and talk about any sick patients or if you need backup.
  • Cross-covering the MICU is one of the most difficult things you’ll have to do as a physician, both here while in training and after you leave. The skills of acquiring and interpreting data and finally acting on the various clinical scenarios, all in a timely fashion, will serve you throughout your career. Because the problems are so diverse, it’s almost impossible to give a “quick and dirty” curriculum, but here are a few tips:
    • Get the story – Who is this patient and why are they here? What made the RN call you? Is this problem related to the index problem or a new one?
      Was this an anticipated problem? Is there anything on signout about this? Has this happened before?
    • Do you need more data? Talk to the patient, RN, etc. Look at the chart, do a focused history and physical exam, consider if you need any additional diagnostic testing.
    • Does this need emergent intervention? Don’t forget your ABCs! Oxygen, fluids, etc. can be given while you’re formulating your management strategy.
    • Do you need backup? It is critical to know your limitations. If you’re confronted with something you’ve never seen or an unstable patient, you probably could use some help. Call early; it is better to have a few false alarms than a missed opportunity.
    • Document – If you are called to see a patient, it’s because something is happening. You should leave a brief note describing your encounter and thought process so other providers can know what happened and help put together the whole story.
    • Follow up!! After you’ve seen and intervened on the patient, don’t forget to follow up and make sure that your intervention worked. Did the labs come back? Is the respiratory rate better? Do you need to do more? Should the primary team consider something else?

Common scenarios:

  •  Death of a patient
    • Offer condolences to the family (in person preferably).
    • Let your attending know as well as any other attending who has been particularly close to the patients, e.g. the liver or oncology teams.
    • Perform a “death exam”; ask if you need help.
    • Ask the family about an autopsy and have them sign the form if they want one (no cost to them, can still have open casket.)
    • Fill out the Gift of Hope paperwork; you or the RN can do this form.
    • Write a note to document the event.
  • Transporting patients
    • Let the RN know in advance, and, if you have time, ask how you can help prepare the patient for transport (portable monitor, organize lines/drips, etc.).
    • Before you leave for a road trip, make sure you have all the supplies you would need in an emergency (fluids, another pressor, oxygen tank, bag-mask, 14 ga angiocath, etc.)
    • You may be gone awhile, so let your team know in case they need to reach you (e.g. for other cross-cover issues).
  • Transferring patient OUT of the unit – Put a sign in the workroom where the oncoming team will see it (Gens/Cards = 5th floor, HONC/Leuk = 6th floor) with the patient’s name, MRN, Room number, contact pager and one-liner. You will still cross-cover on that patient overnight, but you also need to ensure safe handoff to the floor service. In the AM, the primary ICU team’s resident should find the floor service to give verbal signout.
  • Receiving a patient INTO the unit – Offer to help the RNs get the patient into the MICU bed but don’t be offended if they ignore you; they are a pretty efficient team. This is, however, a chance for you to do a skin exam.
  • Procedures – Doing a procedure at night can be tough. As with all procedures, safety is the first concern. Does this procedure need to happen right now? Do I have an indication for performing this procedure? Am I putting a central line in to measure the SVO2 and give a pressor, or am I doing it simply because the patient is in the ICU?