Intern’s Rough Guide to the MICU

Updated 6/19/17 – written by MICU fellows/APNs

Due to the complexity of your patients in the MICU, you will have an incredible amount of data on each patient, and it can be challenging to organize and present all that information in a way that is easy to follow for everyone on rounds. Here are our suggestions to help.

PRESENT BY ORGAN SYSTEM -What we mean by this is to abandon your typical SOAP note format for presentations. Lump together hemodynamic data with CV and volume assessment; pulmonary data with vent settings and blood gas results; neurologic data with wake-up assessment, etc. For a typical follow-up patient on rounds, this means stating the patient’s major events overnight (if any) and then launching in to assessment as below. Except in rare instances, the 1st systems addressed should be hemodynamics, pulmonary or neuro. Both an outline format and sample narratives are below.

  1. Hemodynamics- BP has remained X/Y on the following vasoactive drugs and doses. She appears to be (wet/dry/euvolemic) based on a CVP of X (with/without) respiratory variation. A-line (does/does not) show respiratory variation. Pulse pressure variation is X. Central venous sat (SVO2) is X. UOP has remained (good vs oliguric) and the patient feels (warm with good cap refill vs cold with thread pulses). Tips: ok to give vitals as either a representative sample or as ranges, but if giving ranges, report blood pressure as X/Y – A/B – not as a systolic range and diastolic range – to allow us to hear the pulse pressure. Assessment of cardiac function, myocardial ischemia, dysrhythmia etc. would go here.
  1. Blood pressure
  2. Vasoactive meds and doses
  3. Volume status (with data – CVP, SVO2, I/Os, UOP, PPV)
  4. Heart rate/rhythm
  5. Ischemia or heart function
  1. Pulmonary: Pt remains intubated on the following vent settings: XXXX. By convention, we report vent settings as Mode (AC vs PC vs PS) / Rate/ Tidal Volume/ PEEP/FiO2 – and on these settings the ABG is (report as pH/ CO2/ paO2/ sat –ok to round up to the nearest whole number). Patient’s oxygenation is (improving vs worsening) and the CXR is (better vs worse). We plan a SBT today but are concerned that pt’s (oxygenation/ventilation/neuro status/airway) may prevent extubation. Patient’s acid-base status is …. and the respiratory alkalosis we are observing might be explained by ……
  1. Vent or oxygen status and effort
  2. ABG
  3. CXR
  4. Plan for SBT/extubation


  1. Neurologic: Pt remains sedated on the ventilator. Awoke when sedation held yesterday, followed all commands. Still requires sedation because… For comatose patients off sedation in whom we are trying to prognosticate, the 3 most helpful parameters are papillary response, doll’s eyes (oculocephalic reflex) and corneal reflex.
    1. Exam
    2. Sedation
    3. Radiographic studies
  2. ID: Pt is febrile with a rising WBC despite antibiotics (X,Y, and Z). We think the source of infection is …. because….
    1. Temp, WBC, Culture data
    2. Antibiotics
    3. Source of infection
  3. Heme/Onc: Hb dropped from X to Z with 400cc of coffee grounds from OGT. Plan for an EGD today. She required X units PRBCs, Y platelets, and Z FFP overnight
    1. CBC
    2. Onc issues
  4. Renal: Only necessary if this pertinent information is not already addressed in hemodynamics. UOP, Creatinine trends probably belong under hemodynamic data. Patient tolerated intermittent dialysis yesterday and needs more volume off today.

RESOURCES

Listen to nurses – They are extremely experienced and have very important information to tell you. If they are paging you, it is because they REALLY need you to come evaluate the patient.

Use your pharmacist – Great resource for information about meds (dosing, interactions, etc)

Ask your residents, fellows, attending and APNs for help – You will learn a lot on this rotation. This will be enhanced if you ask when you don’t completely understand something. If you are ever in a situation where you are writing an order without knowing why you are doing so, ask your residents, fellows, attending or APN .

THE DAILY GRIND

When pre-rounding – Look at the orders written overnight and ask your cross cover why they made a change. What prompted them to change the vent/start pressors/extubate etc.

Sign outs and cross-cover are critical– The MICU is an around the clock endeavor. You must leave by noon 10:00 post-call and at some point on other non-call days. Thus, our mentality is that each MICU patient is a communal patient. Your sign out is one way you communicate your plan and anticipated problems to the cross-covering team. High quality sign out is the only way to deliver quality around the clock critical care.

  • Everyone should know each patient in the MICU
  • For the post call team, the APN/ED dayfloat are designated “helpers”, especially for procedures, roadtrips, etc
  • Call consults early – you know your patients the best
  • OBTAIN CONSENT and OPTIMIZE COAGS for procedures to be done by cross-cover
  • Have family contact information and any limits of care (code status) on sign out
  • X-cover patients going to the ward should be given to appropriate service (GENS, HONC, etc)
  • ASK whether X-cover spoke to ward team about your patients who went out overnight

Transfers out of the MICU: All orders must have complete team info (attg,res/intern/pager) even if ward teams are full and the MICU is covering overnight

  • Remember to complete the order reconciliation prior to transfer
  • EXPLICITLY discuss which residents assumed care for your patients on the ward

Buff family qD! – So much can happen in a MICU day and the ICU patients are relatively more likely to have major condition changes compared to floor patients. You will find the family is more prepared for adverse events / need for procedures /status changes, if you keep them in the loop all along. To do this, have the family identify the one person who will be the point person and you can update him/her, then he/she will update the family. Also please remember to ask for the CODE (last 4 SS#) before giving info via phone or in person.

Keep the work rooms clean –We share these spaces that are almost continually in use 24/7. Please be cognizant of your belongings. Hang up coats. Store bags in/on top of cabinets. Return medical records to the patient’s chart. DO NOT bring supplies into workroom. Unlocked needles are in violation of Illinois Department of Public Health requirements.

 

CONFERENCES

7:00am – Multidisciplinary Rounds

  • Bedside patient care rounds are performed outside of patient room. If you do not see the patient’s RN participating in rounds, please notify them that rounds are taking place.
  • Resident presents patient within 7 minutes. When interpreting CXR, Identify hardware à Assess lung volumes à Assess lung parenchyma
  • RN presents FASTHUGS.
  • Pharmacy needs are addressed.

9:00 am – Pulmonary Morning Report

  • Brief presentation of salient history. Physical including vitals. Pertinent lab data including ABG. We’ll let you know what you want to withhold. Allow fellow discussing the case to interpret films.

2:00pm – Afternoon Lecture

  • Great lecture series. Attend every day unless a patient is actively crashing. By the end of the month, you should understand the 4 types of respiratory failure, mechanisms of hypoxemia, types of shock, familiarity with vasoactive meds, modes of mechanical ventilation, and sepsis

 

MICU Multidisciplinary Daily Routine

Time Process Participants Goals
7:00 AM – 7:30 AM Nursing Report Night and day shift RNs Patient handoff.
7:00 AM – 9:00 AM Multidisciplinary Rounds Attendings, Fellows, Residents, APNs, RNs, Pharmacist Patient presentation. Establish multidisciplinary plan of care for the day. Education.
9:00 AM – 9:30AM Pulmonary Morning Report Attendings, Fellows, Residents,  APNs Case presentations. Education.
10:00 AM – 10:15 AM Post-Rounds Multidisciplinary Huddle Charge RN, Fellows, PT, OT, SW, CM, Dietician Brief outline of daily patient goals. Address geography of MICU service patients. Address social work issues, needs, and barriers. Identify patients ready for PT/OTnutiriton.
11:30 AM – 1:00 PM Medicine Morning Report Residents Education
2:00 PM – 3:00 PM Afternoon Lecture Attendings, Fellows, Residents, APNs, RNs, Pharmacist Education
3:00 PM – 3:05 PM Measuring for Daily Improvement Huddle Charge RN, RNs Quality improvement
3:00 PM – 3:45 PM Afternoon Rounds Attendings, Fellows, On-Call Resident, APNs, Charge RN Present patient to on-call resident. Address progress on daily patient goals. Charge RN to identify patient through-put and staffing issues.
5:00 PM Resident Sign out Residents Patient handoff
7:00 PM – 7:30 PM Nursing Report Night and day shift RNs Patient handoff
7:30 PM Resident Sign Out to Night Float Residents Patient handoff

 

PROCEDURES

Expectations

  • Start planning and preparing for procedures immediately after rounds. Goal to complete procedures prior to lunch/lectures.
  • Obtain consent.
  • Gather supplies prior to start of procedure. Return all extra supplies to supply room (not the work room!)
  • Notify RN of procedure. Perform procedure timeout as a team. Request RN to complete time out documentation. Request RN to set up transduction supplies for arterial lines.
  • Perform procedure with attending +/- fellow.

Pearls

  • Order lidocaine 1% injection (WITHOUT epinephrine) 20ml bottle
  • Utilize order sets to order diagnostics
    • XYZ: IP Lumbar Punctions(#1947)
    • XYZ: IP Thoracentesis/Paracentesis (#1101)
  • Verify specimens have been labeled. Request RN to release the labs in the system. Hand deliver specimens to Mitchell lab
  • Proceduralist should collect and dispose of all sharps.
  • Clean up all procedure supplies and garbage.
  • Order and follow up CXR following central line placement and thoracentesis.
  • Document central line placement
    • Click on left sided “Procedure” tab. Document under CL Insert 1 section. Request RN to complete observer documentation.
    • Place ok to use order after CXR verification

NEJM Procedure Resources

VASCULAR ACCESS

Consult procedure service for midline/ PICC placement.

  • Midline: Standard line used for long term (>5days) medication administration of non-vesicants. Considered a “short PICC” that does not cross the midline. No CXR is needed to confirm placement. Ordered as “PICC” in Epic.
  • PICC: Catheter tip ends in distal third of superior vena cava. Indicated for chemotherapy, TPN and vasoactives. CXR must confirm placement. RN requires “ok to use” order.
  • Renal Clearance: Obtain approval from nephrology prior to consulting procedure service for GFR <45.
  • Tip: Order the least number of lumens possible to minimize the risk of infection and intra-lumen clot.
  • Troubleshooting:
    • Bleeding à Apply manual pressure at insertion site for at least 5 minutes. Do not apply external pressure dressing or leave bedside until hemostasis is achieved.
    • Sluggish/No Blood Return à Order alteplase 2mg for each non-functioning lumen. Let drug dwell up to 2 hours. If no blood return, repeat another 2mg dose and dwell x2hr.
    • Leaking à Order Doppler to rule out clot.

 

SUPPLIES

Central line

  • Chux
  • Sterile Gloves
  • Additional PPE (masks, gloves, bouffants, gowns) for additional proceduralists
  • Central line supply pack
  • Central line
  • 2inch 16g angiocath
  • Scalpel (not included in triple lumen catheter kits)

Lumbar Puncture

  • Sterile gloves
  • Mask
  • 1 Chux
  • Betadine
  • Gauze pack
  • LP kit
  • Specimen bag
  • Consider ordering additional lidocaine

Arterial Line

  • Sterile gloves
  • Mask
  • Chux
  • Chlorhexidine
  • OR sterile towel pack
  • Gauze pack
  • Arterial line arrow
  • Tegaderm

Thoracentesis

  • Lidocaineà Order in epic. Request RN to get out of omincell prior to procedure
  • Sterile gloves
  • Mask
  • Skin marking pen
  • 1 Chux
  • Chlorhexidine
  • Thoracentesis kit
  • 60 cc syringe
  • 19g needle or pink vacutainer to transfer fluid for diagnostic specimens
  • ABG syringe
  • Anaerobic culture bottle
  • Aerobic culture bottle
  • Lavender top tube
  • Gold top tube
  • Sterile specimen cup
  • Specimen bag

Paracentesis

  • Lidocaineà Order in epic. Request RN to get out of omincell prior to procedure
  • Sterile gloves
  • Mask
  • Skin marking pen
  • 2Chux à1 for patient’s lap, 1 for floor
  • Chlorhexidine
  • OR towel pack
  • 14 g angiocath
  • 10 ml syringe
  • 5ml syringe
  • 19g needle
  • 25g needle
  • 19g needle or pink vacutainer to transfer fluid for diagnostic specimens
  • 60cc syringe
  • Suction tubing
  • Orange containers
  • Gauze pack
  • Tegaderm
  • Anaerobic culture bottle
  • Aerobic culture bottle
  • Lavender top tube
  • Gold top tube
  • Sterile specimen cup
  • Specimen bag
  • Gold top tube
  • Sterile specimen cup
  • Specimen bag

 

MICU MULTIDISCIPLINARY TEAM

Advanced Practice Nurses (APNs)

  • Contact:
    • Stefanie Blummer, #4039
    • Kelly Coudron, #9823
    • Megan Mattingly, #6011
  • Role: Assist with post-call team. Rotate through procedure service. Provide procedural oversights. Provide pulmonary consults for CCU patients on mechanical ventilation.
  • Tips: Get back-up for goals of care meetings. Utilize the ICU order sets.

Case Management

  • Contact: Jessica Torres,# 6683; Melanie Boyd, #6692
  • Consult: For assistance setting up home health, home equipment, medication authorization

Nursing

  • Bedside Nurse
    • Tips:
      • Please do not adjust IV pumps and/or ventilators without nurse in room.
      • If you enter a STAT order, please speak with the bedside RN.
      • Restraint orders must be entered in EPIC within an hour of application and every 24 hours. DO NOT LET YOUR RESTRAINTS EXPIRE!! Check/renew during rounds.
      • When medications are OG/ NG please enter in EPIC “Per Tube “.
      • Try to cluster labs together. If labs were just sent, please place order as “add on”.
    • Charge Nurse, x61504
    • Nursing Management
      • Marisol Arellano, #6309
      • Amber Turi, #5825 (nights)

Nutrition

  • Contact: Christine Boesdorfer,# 6185, x22450. On weekends, use the on-call pager 8406 from 9am-6pm
  • Consult: Epic is preferred. Also available verbally, by page and during MICU Multidisciplinary Huddle
  • Role: Assess patients (lab data, medical/surgical history, nutrition focused physical exam, anthropometric data, diet history, medical plan of care), diagnose malnutrition (where applicable), and provide recommendations regarding: tube feeding for patients with enteral tubes (OG, NG, DHT, PEG/PEJ), standard peripheral or standard central parenteral nutrition (PPN/TPN), oral nutrition supplements, oral diet, vitamin/mineral repletion, nutrition related medications (bowel meds, appetite stimulants), etc., monitor progress toward goals and re-evaluate as appropriate.
  • Tips: I do not follow transplant surgery service patients or GI nutrition patients.  ASPEN/SCCM guideline “highlights” regarding feeding critically ill patients are: 1. Early enteral feeding (within first 24-48 hours) reduces infectious morbidity, mortality, and length of stay. 2. We DO NOT routinely check gastric residual volumes as they are poorly correlated with aspiration events. 3. Serum protein markers (albumin, transferrin, pre-albumin, retinol binding protein) are NOT a good representation of the nutritional status of critically ill patients. 4. PLEASE do not change a tube feeding formula without talking with a dietitian (changing a formula may increase/decrease calories/protein or certain vitamins/minerals, significantly).

Occupational Therapy

  • Contact: Brittanie Blaber #1962
  • Consult: Please make sure to place two consult orders (one to evaluate and one to treat).
  • Role: Assist with early mobilization with PT as well as assess/treat cognitive impairments; prolonged periods of immobility lead to increased rates of delirium and skeletal muscle breakdown resulting in ICU acquired weakness. Occupational Therapists also perform splint fabrication to prevent joint immobility.
  • Tips: Address the CAM ICU sooner than later. Occupational therapy can assist with helping family members understand delirium and provide interventions to prevent this while in the ICU.

Pharmacy

Physical Therapy

  • Contact: Jen Ryan, #6089
  • Role: Facilitate early mobility on any hemodynamically stable patient regardless of their level of alertness.
  • Consult: When consulting PT and OT, place two consult orders (one to evaluate and another to treat).
  • Tips: Consult as soon as possible and consider upon MICU admission. PT also provides wound care, specifically negative pressure therapy and debridement.

Respiratory Therapy

  • Contact: 9N RT x 61889, 9S RT x61898
  • Tips: Verify all of your intubated patients have a “Mechanical Ventilation” order that includes vent settings. Notify RT of all vent changes.

Social Work

  • Contact: Lauren Hall, Social Worker for all MICU services EXCEPT patients getting solid organ transplants- MICU SW virtual pager: #1009
  • Consult: Epic consult, page, conversation, interdisciplinary daily rounds with fellows
  • Role: Placement (LTACH, rehab, hospice, etc.), Healthcare Power of Attorney, psychosocial pt/family needs, participate in family meetings and goals of care discussions, assist pt/families with financial needs such as UCM financial aid/SSDI/etc., substance abuse treatment resources, identification of unidentified pts and/or location of families, and a varying assortment of other interesting pt needs (I might not know the answer, but I’m happy to work as a team to figure it out!).
  • Tips: Please do NOT consult me for (I won’t yell, just redirect 😉 home healthcare or home equipment needs (CM), making follow up appointments (MDs), hotel locations (patient experience), diabetes supplies (CM and diabetes educator)