THORNTON INTENSIVE CARE UNIT (TICU) RESIDENT ORIENTATION GUIDE
Written by Kimberly Robbins, M.D. and Ankur Patel, M.D. 2011
Last updated 8/19/2013 BJN
The Thornton Intensive Care Unit (TICU) rotation provides ICU experience tailored for senior (CA-2 and CA-3) anesthesiology residents at UCSD. The format of the four-week-long rotation is unique in that an anesthesiology critical care medicine (ACCM) attending or a surgical attending, fellow, and resident(s) comprise the treatment team. The faculty and fellows are dedicated to making this a valuable and worthwhile learning experience for each resident who rotates on the service. A curriculum of core topics has been developed and will be provided during the resident-focused lectures at ~11:00am on Tuesdays, Wednesdays, and Fridays. When time permits, lecture will also occur on Mondays.
This is an interactive rotation that builds on the experience gained during the SICU and Neuro-critical care rotations; and serves to hone the anesthesiologist’s skills in critical care. Advanced skills and training in critical care is essential because the anesthesiologist's role in the perioperative care of surgical patients is expanding.
Attendings who cover the team include all of the Anes-critical care faculty as well as some of the Trauma surgeons.
SIGN-OUT prior to first day of rotation:
You should receive a sign-out from the resident who is completing the rotation! If they don’t call you, you should call them! And remember to call your colleague when you finish the rotation.
Sign out should include:
1) How to access the ACCM patient list
2) How to access the ACCM progress note template(s)
3) Brief sign-out on each patient
4) Brief overview of what to do on the first day (what time to get there, which patients to see first, etc)
Expectations/Goals:
On the TICU Rotation the senior resident is expected to:
-Conduct detailed daily rounds on all ICU patients (TICU and Sulpizio Cardiovascular Center) being followed by the ACCM team.
-Present the patients to the Fellow and Faculty Member on daily Attending Rounds (typically starting about 8:30 am). When we have CT surgery patients, we will start with multidisciplinary rounds at 8:30am in CVC. The multidisciplinary team includes ACCM, CT surgery, Cardiology, ID, pharmacy, nursing, and cardiac device reps.
-Improve their skills in diagnosis, treatment, monitoring, presentation, documentation, and other clinical practices relevant to critically ill surgical or perioperative patients.
-Formulate advanced clinical plans on each patient under care.
-Communicate professionally as a competent consultant in critical care.
-Perform advanced procedures (under the supervision of the faculty or fellow) such as central vascular access, diagnostic and therapeutic bronchoscopy, advanced airway management in critically ill patients, become familiar with Transthoracic Echo (TTE), and ultrasound aided evaluation of ascites, effusions, and vascular access.
-The resident will become invested in all of the primary and consult patients and will be expected to follow these patients until they are stable for discharge from the TICU/CVC-ICU. The resident will be responsible for maintaining and following the ‘list’ of patients.
Didactics:
Daily teaching during morning rounds.
Lecture for residents and medical students ~ 11:00am on Tuesdays, Wednesdays, and Fridays, and possibly on Mondays.
The residents are also expected to attend the Fellow Journal Club on Thursdays at 2:00 pm.
Structure:
The TICU is a 12 bed unit on the 2nd floor of Thornton Hospital. The code to the doors is 6038*. The unit is shared by surgical, medical and anesthesiology teams. The patients who will be cared for by the ACCM team will be predominantly surgical patients. Surgical subspecialties without ICU admitting privileges (Ortho, Urology, ENT, OB-GYN, Plastic Surgery, IR) will contact the resident with an admission to the ICU. These patients become ACCM "primary" patients while in the ICU. Although the surgical resident should write admission orders, it is our responsibility to review the orders. After admission orders, only the ACCM team should write orders on our "primary" patients. Upon discharge from the ICU, the patient will be ‘called-out’ and the receiving team will write the transfer orders. The neurosurgical patients represent a unique experience where the ACCM team co-manages these patients with the Neurosurgery team. The neurosurgical resident will write admission orders to the unit and both teams will be responsible for orders while the patient is in the ICU.
Regardless of the surgical team, post-op patients go to the ACCM service as either "primary" or "consult", and medical patients go to pulmonary. Some non-operated patients will also go to the ACCM team. For example a patient who comes in through the ED with a SAH (normally would go to Neurosurgery), will be cared for with the neurosurgeons on the ACCM team. Whereas a patient who comes through the ED with an ischemic stroke (normally seen by neurology) will be cared for by the pulmonary service.
It is the goal of the ACCM Service and Department of Anesthesiology to collaborate with the surgical teams and collectively manage all perioperative patients who require critical care in the TICU. As such, it is important that the ACCM resident maintain the utmost professional behavior when interacting with all surgical services in the care of these patients. To put it in perspective, these patients deserve critical care boarded physicians making decisions regarding their intensive care. The ACCM resident and fellow are extensions of the ACCM attending. Below are some specific points about certain categories of surgical patients.
General Surgery Patients:
There are 2 general surgical teams that typically admit to the TICU. Blue (general surgery) and Green (surgical oncology) are the color codes for these services. In addition, the Red (vascular) service admits patients to the Sulpizio CVC. Each team has a chief surgical resident who will be the contact point for recommendations. These patients are under the primary care of these services, and the ACCM team functions as a "consult" team. The ACCM resident will be expected to take on an active role in the care of these patients.
Neurosurgical Patients:
As above, these patients will be co-managed by Neurosurgery and ACCM. The neurosurgery team usually writes admission orders for these patients, but occasionally this is done by the ACCM team.
Orthopedic Patients:
Ortho-spine comprise the bulk of these patients (often Dr. Steve Garfin is attending). These patients will be primary on the ACCM service. The Ortho team usually writes admission orders for these patients, but occasionally this is done by the ACCM team (as with neurosurg patients). Upon transfer out of the ICU, these patients need to be 'called out' to the expecting floor team (usually Ortho, but sometimes Medicine).
Cardiac Surgery Patients:
The cardiac surgeons typically split their consults between the ACCM and PCCM teams. Most postoperative PTE and lung transplant patients go to the pulmonary team whereas most device (VAD, TAH) and heart transplant patients go to the ACCM team. Postop CABG, valve, etc patients can go to either team, at the discretion of the CT surg attending. When we are consulted on CT surg patients, we co-manage them along with the CT surgery (and Cardiology) teams. This means the patient is getting a lot of attention but this also requires close communication among all teams. We will have an active role in 'fast-tracking' many of the CT surgery patients (this process is being finalized now).
Daily Schedule:
0630-0700 Arrive to the TICU, begin pre-rounds, receive sign-out from the overnight PCCM fellow
0700-0830 Pre-round on patients
0830-0930 ACCM and Multidisciplinary rounds
0930-1100 ACCM rounds
1100-1200 Didactic lecture
Afternoon Complete notes
Follow up on plans made during rounds
Follow up on pending labs/studies
Complete necessary procedures
Communicate with primary surgical teams and consult teams (e.g. ID, Renal)
Admit new post-op patients
Afternoon rounds – This may be with the Fellow and/or Attending (Be prepared to give updates on the day’s events, vitals, I/O, new labs/cultures/studies/consultant recs, what to sign out for overnight).
1900 Sign-out to PCCM overnight fellow
Typical Day:
Arrive in the TICU between 6:45 and 7:00 am and receive sign out from the pulmonary critical care fellow. Currently, they cover the ICU at night from 7pm to 7am Monday through Saturday. On Sunday night, the ACCM Fellow covers the unit. After receiving sign out from the pulmonary fellow, the resident is expected to pre-round on the primary patients and the consults. You should start your rounds on the CVC patients who are being co-managed with CT surg and Cardiology (because these will be the first patients we round on). Occasionally, as circumstances dictate, the ACCM fellow will assist with pre-rounds and patient presentation to the ACCM faculty member. Examples of situations where the ACCM fellow will be expected to assist with pre-rounds include overwhelming number of patients on the service, when patients are so unstable that individual prolonged attention is required at that bedside, and when other emergencies occur requiring ACCM assistance inside or outside the unit. The fellow's main job from 7-8:30am is to perform TTE on all patients in the CVC and on unstable patients in the TICU.
After pre-rounding and preparing the daily progress note, the resident will round with the ACCM Attending and Fellow. When we are covering CT surg patients in the CVC, we will start with multidisciplinary rounds at 8:30am. Be prepared to present the patient to the entire team, including ACCM, CT surgery, and Cardiology. Often members of other disciplines, such as pharmacy, will also round with the ACCM team. Using the computers on wheels (COWS), it is helpful if the fellow puts in orders as the resident is presenting, or vice versa if the fellow is presenting.
Note: The ACCM team always locates the bedside nurse and involves him or her in the daily Attending Rounds. If the bedside nurse is on break, we may skip a patient and return to that patient after the nurse returns from break. Remember, the bedside nurse is with the patient nearly 12 hours straight and has a wealth of information that can be missed during a superficial chart biopsy and cursory physical exam. Be sure to ask the bedside nurse about significant events during pre-rounding to avoid “surprises” on Attending Rounds. One strategy is to do a quick walk around during the 6:45-7:00 am period to get the report from the night shift nurse about unstable events, sleep and delirium issues occurring at night.
After rounds, the notes are finalized and the plans are communicated to the primary teams, or carried out by the ACCM team (the ACCM Fellow will run the list and determine the distribution of resources). Following this, there will be a lecture by the ACCM attending on (Monday), Tuesday, Wednesday, and Friday. The residents are also required to attend the fellow journal club on Thursdays.
After lunch, the resident should follow up on plans made during the morning rounds and pending labs/studies. The resident should also proactively evaluate patients who will be admitted to the ICU postoperatively. To do this, the resident should go to the OR, find out which patients will be admitted to the ICU, review the charts, and talk to the Anesthesia team in the OR. We are working on improved hand-offs between surgical/anesthesia teams and the ACCM team.
A member of the ACCM team is expected to be in the hospital every day until 7pm to be immediately available for patient care and to handle new admissions. A schedule has been devised that splits this weekday duty over the month between the resident(s) and the fellow. It is reasonable that the person who is not staying late may leave after rounds, work, and didactics are completed (usually mid-afternoon), as directed by the fellow and approved by the attending. The monthly schedule will be provided to the resident at the beginning of the rotation. At 7pm, a sign-out is given to the PCCM night fellow who will be cross-covering our patients at night. The resident will cover the ICU on Saturday 7am-7pm as this is the fellow's day off. The fellow takes 24 hour call on Sunday and the resident has Sunday off (unless there are 2 residents, in which case one will have Saturday off and the other will have Sunday off).
ACCM Pager: 290-8888
The resident will hold the ACCM pager daily and will hand it off to the covering pulmonary fellow at night. The ACCM team also responds to all codes in the hospital. The pulmonary fellow typically functions as the code blue leader. However if you arrive at the code and do not see the pulm fellow, you should be the code-blue leader. In that situation, resist the temptation to perform procedures and instead focus on your ability to delegate a team of medical providers. The resident will obviously use their best judgment in this situation. For example, if it is a difficult airway, it would be prudent to take over as an expert of airway management. In general, however, this is an opportunity to ‘run the code’ and allow others to perform their assigned duties.
Procedures:
Consent is required from the family member, or from the surrogate decision maker for all procedures which are not emergent in nature (e.g. central lines, PA catheters, arterial lines, dialysis lines, and bronchoscopy). After a procedure, a note is entered into EPIC with the attending selected as the co-signer for billing purposes. To do this, the resident must first place the order in epic, for placement of a line, or bronchoscopy, etc. The order is then signed. After the procedure, the rounding-consult tab is selected and the ‘procedure notes’ is selected. The order is then highlighted for the procedure done. Click on “document order” and fill out the template as appropriate. Make sure to have the ACCM attending co-sign the note. If you are not familiar with this documentation process, please ask the fellow or attending for assistance.