ST BARNABAS HOSPITAL ICU
Duties of the Intern/Resident:
Come in between 7:00 - 7.30am Enough time to get patient assignment sign
outs
and pre-round.
Attending rounds begin(between 8:15-8:30).
Xray rounds after attending rounds
Afternoon sign out rounds(between 3:30-3:45)
Short call team leaves 4:00 pm
Night team arrives approx 8:00 pm to receive sign out from long call team
who
leave after sign outs completed
Day 1
Check the schedule to find out which district you have been assigned.
Take sign outs from the night float team.
Flow sheets are to be used during the sign outs.
Obtain all details regarding the patient i.e. reason for being in the ICU,
history, physical exam and lab values at admission, goals of ICU care,
intervention done in the ICU and progress of all of the above during the
previous shift. Any sign outs specifically regarding monitoring certain
physical findings, labs and ventilator setting changes are to be noted.
Pre round on the patients assigned to you.
Daily rounds consist of complete physical exam, and reviewing the following:
hemodynamic parameters, ventilator parameters, EKG’s, sedation regimen,
electrolytes, fluid balance, nutrition, renal function, lines, medications
list and drug reactions as well as the patient’s code status.
Have the daily worksheet complete which can then be used to present at
rounds. Input from the nurses is very valuable too.
Presentation skills are very important and shows how much you know about
your
patient.
Presenting the patient at rounds to the ICU attending in a systematic manner
includes how the patient presented to the ICU, initial interventions done,
the response and an assessment and plan for the patient for that day.
System wise approach prevents missing out on important issues and is also
easy to work with (RICHFEN)
R Respiratory i.e. ventilation details, CXR changes. Aim to get
patient
off toxic FiO2 i.e. <60%
I ID i.e. causative organisms if known, ABx day, temperature and WBC
trend, all cultures and sensitivities.
C Cardiovascular i.e. vasopressors, BP & HR, details of CAD,
Medications.
H Hematology i.e. H/H, platlets, Transfusion details and goals.
Coagulation profile/ anticoagulation details.
F Fluids/ Electrolytes/ Nutrition i.e. I/O Chart, IVF’s, urine cc/hr,
Renal functions, monitoring and correction of lytes, feeds.
E Endocrine
N Neurology i.e. Sedation, if on paralytics Train of 4’s, Neurocheck
details, CT scan details
P Prophylaxis. GI & DVT prophylaxis.
Any of the orders discussed during rounds regarding medications etc are to
be
written immediately while on rounds and the nursing staff made aware. Always
flag orders.
Knowing your patient is mandatory. Always be attentive about what is
happening with all the patients in your district too, as this helps you
learn
as well as comes in handy when on call, to deal with problems that may crop
up when you cover the other patients.
X-ray rounds usually follow the attending rounds.
But make it a point to call ‘Consults’ and order add on labs, drawing
emergency blood work and order transfusion prior to going to X-ray rounds.
X rays are found in the designated shelf for ‘ICU’ in the Radiology
department and are read along with the attending. Things noted on x-ray’s
that should be included in the daily progress notes are changes in the
pattern of findings, position of the central lines/ PA cath ( if present),
ET
position and NGT position.
Once back from the X-ray rounds complete all the other things that were
discussed on rounds. This is a good time to re-evaluate any patient who is
being weaned or whose ventilator settings were changed during the rounds.
Discuss with your superior and the attending regarding extubation time.
Extubations done early gives you more time to asses patient stability prior
to sign outs.
Take turns to go for lunch and always sign out your patients to the resident
who is going to stay back regarding any problem you think may come up so
that
you don’t get beeped during your lunch. Let your senior be aware when you
step out.
If you do a procedure like a neck line, subclavian line or a PA cath make
sure to immediately order a X ray and also call the technician at 4203 so
that it gets done ASAP and rule out any complications. It is a good habit to
follow up your X rays before leaving for the day.
Write a procedure note immediately after doing ro attempting to do the
procedure.
Tests/treatments that were discussed during rounds are assumed by attendings
to be followed through on. If for any reason there appears to be a delay in
getting them done notify the attending.
Order AM labs,Xrays and EKG’s before leaving for the day.
Any acute or unexpected changes in the patient condition at any time needs
to
be notified immediately to the next superior following chain of commands
even
before or in between rounds.
(PGY1 – > PGY2 – > PGY3 – > ICU ATTENDING).
If the issue is thought to be a very serious one, the ICU attending should
be
made aware regarding the same at the earliest.(primary care attendings,
consultants and family members should also be promptly notified)
Finally the most important thing: Always document everything that is
done. “Without documentation even a heroic effort on your part witnessed by
everyone is without proof”. If something is not documented it was never done.
Additional duties for residents on call:
The senior most resident in the call team assigns admissions.
Do your admission orders early so that nurses can carry out the same.
Go over the admission and the orders with the 3rd year resident.
EVERY ADMISSION MUST BE DISCUSSED WITH THE ATTENDING ON DUTY FOR THAT
DISTRICT OR THE ON CALL ATTENDING. DIFFERENTIAL DIAGNOSIS, PLAN, AND ORDERS
ARE TO BE REVIEWED WITH THAT ATTENDING IN A TIMELY FASHION.
THE RESIDENT/INTERN MUST DOCUMENT AT THE END OF THEIR ADMIT NOTE THAT THEY
HAVE GONE OVER THE CASE/ORDERS WITH THE ICU ATTENDING.
Any sign outs from the previous shift team should be carried out and
documented.
Additional duties for residents on call during night float:
Keep a close eye on the patients and sign outs given. Any admissions that
are
assigned are to be done. Around midnight you have to order X rays for all
the
patients who are intubated to see the position of the ET. In the non-
intubated patients X-rays are to be done only if there any specific thing
is
being followed by daily x-rays, e.g. infiltrates, worsening pnemothorax,
pneumonia or pleural effusion.
Every patient on the ventilator also needs an ABG unless specified otherwise.
The intern is responsible for his patients.
The 2nd year resident is responsible for his patients as well as his interns
patients i.e. all the patients in his district.
The senior resident on call is responsible for all the patients in the ICU
i.e. all the three districts.
It is imperative that you understand that as residents at all levels of
training, you make therapeutic decisions, write orders and perform
procedures
only if you are 110% comfortable doing so.
Any uncertainty needs to be confirmed or supervised by a senior to you.
Your role in the ICU is to learn and grow as physicians under a very well
supervised setting.
Utilize the nurses as a valuable source of knowledge as they possess many
years of experience.
Do not write any orders that you are not confident in.
Work Hard and Enjoy.
I DR. ___________________________ HAVE REVIEWED THE DUTIES OF THE
HOUSEOFFICER ICU HANDOUT. I UNDERSTAND THEM FULLY.
__________________ _________________________
DATE
SIGNATURE
In order to comply with Bell Commission Rules:
1. Post-call residents should leave no later than 11:00AM
2. Post-call residents should present their patients first.
3. The Wednesday on call team, should leave on Thurs AM @ 8:00 AM, to
insure that all teams have at least 1 24-hour period off / week
4. Residents pronouncing a mortality should immediately fill out the
death certificate (PROPERLY) (this avoids unfairly burdening your
colleagues and also avoids interfering with Bell Commission Rules
Date: 3/5/02 10:03:18 PM Eastern Standard Time
Anticoagulation Caution
Please follow guidelines for anti-coagulation's (Heparin and Lovenox)
on new order sheets.
Attending physicians (IM and Neurology) are required before
instituting anticoagulation in the ICU:
Blood pressure must be controlled prior to using either heparin or low
molecular weight heparin (LMWH).
In the event that coagulation profile (PTT) is out of range, in
high-risk patients (elderly, Neurological patients) the PTT should be
drawn and checked before reinstitution unfractionated heparin at new
dose.
In the event of bleeding or change in neurological or mental status
heparin and LMWH should immediately be discontinued.
Thank you,
Dr. Menkel
