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Jack Zimmerman ICUResident Orientation
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The GWU ICU experience
• Multidisciplinary and mixed ICU• Variety of population à neurocritical, trauma, medical and surgical• Multiple teams involved in care à requires close collaboration
• ALWAYS BETTER TO OVER COMMUNICATE
• As the ICU resident à you are integral to your patients care
• If this is your first ICU rotation don’t be nervous. You will have a lot of help and guidance. Only expectation on day 1 is to show up with a positive attitude and be involved!
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The ICU Team – Multidisciplinary
• Attending• Rounding Fellow – x6141• Swing Fellow – x5973• 4-5 senior residents• 4-5 junior residents• ICU APPs – x6137• 4th year AI medical students• Charge RN - x73771• Circulating RN - x73936
• Charge RN - x73771• Circulating RN - x73936• Dietician• ICU Pharmacist• Respiratory Therapist• SW/Case Manager
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The ICU Work-Flow
• Open notes – 6 AM• Pre-rounds – 6-8 AM• Lecture – 8-8:30 AM• Rounds – 8:30-12:00 AM• Task completion – rounds till afternoon sign-out• Includes à updating hospital course, CORES and calling family DAILY
• Afternoon sign-out – 3 or 3:30 PM
• Call team continues admissions after afternoon sign-out till 6 AM
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Patient Presentation
• Keep it brief à less than 10 minutes MAX• Provide initial reason for admission and reason for ICU admissionà
go straight to punch line• Proceed with brief HPI if new patient and then PERTINENT overnight
events• Proceed in a systems based fashion (neuro, CV, respiratory, etc.)• Each section should NOT be copy pasta of days/days of information; only
information pertinent for the day (hence “progress” note)
• With your plan always seek ways to simplify care
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Tiger Text – ICU Residents
• Main group comprising all residents and fellows• Pass along any important and pertinent information to patient care in
this group• New admissions will be through this group• Fellows monitor this group extremely closely for updates
• ALWAYS OVERCOMMUNICATE
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10 Rules to ICU success
1. Be responsive to changes immediately
2. Talk to the bedside nurse3. Know your drips and rates4. Know your ventilator
settings 5. Always look to simplify care
(daily med-rec is mandatory)
6. Know your patients neurological exam
7. Appropriate order sets8. Be vigilant about antibiotics/
nutrition/mobility/DVT ppx9. Don’t culture without
discussing with fellow10. Always over communicate
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Appropriate Order Set – ICU Admission
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Appropriate Order Set - Ventilator
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Appropriate Order Sets - Stroke
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Choosing Wisely Evidence Based Cost Effective Quality Care
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ICU CORES
• Admitting diagnosis on top in bold• Brief summary of pertinent hospital events (no more than small
paragraph – 4-5 lines)• Information MUST be up to date – DAILY BASIS• Contact information for family• Tasks for the day and for follow-up• Delete old tasks (more than 24 hours old)
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CORES Bad Example
What not to do
What’s the point of listing every single medical problem à pertinent problems onlySimple enough to say transferred for cervical myelopathy with concurrent lumbar osteomyelitis
Avoid words like “yesterday”. Instead of providing a narrative; better to summarize à multiple rapid responses and was ultimately found to be altered and hypotensive leading to a code blue and difficult intubation. Subsequently has failed ventilator liberation trials
Avoid a daily narrative. Intent is to summarize
Note: missing bolded admission diagnosis à ventilatory failure or hypoxic hypercarbic respiratory failure
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CORES Good Example
What to do
Very brief summary even manages to identify pertinent independence status. No mention of pre-hospital symptoms, drips, how sick she was on arrival and hospital narrative à all generally belongs in progress notes and H&P
Appropriate sign-out of tasks. Although potentially could make better by being more specific (e.g. if/then statements – “if febrile then broaden antibiotics)
Clearly identifies primary admission diagnosis
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Schedule Assignments
• Listed on GW Website• If assignment are not clear; then clarify with senior resident or fellow• Expected to show up M-F; if name is on schedule for weekend
• Assignments for the day are completed by senior resident + fellow• Goal is ensure continuity and ensure assignments match resident training• Complex patients to seniors; less complex to junior
• Intent is for post-call to have 0 assignments; if residents have 5-6 patients each then can assign outliers to Admitter APP • All assigned patients (even outliers) need to be staffed with an attending
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See you at the GW ICU
We look forward to seeing you in the ICU and remember the ICU team is here to help. We hope you learn and enjoy from your rotation.
For further questions please don’t hesitate to call x6141 or email/TT Ghazi Rizvi ([email protected])
Please email/TT Dr. Mustafa Al-Mashat ([email protected]) for any issue or concern regarding the schedule or the rotation in general