Jack Zimmerman ICUResident Orientation

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!

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

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

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

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

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

Appropriate Order Set – ICU Admission

Appropriate Order Set - Ventilator

Appropriate Order Sets - Stroke

Choosing Wisely Evidence Based Cost Effective Quality Care

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)

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

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

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

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 (ghazi.rizvi@gmail.com)

Please email/TT Dr. Mustafa Al-Mashat (mal@mfa.gwu.edu) for any issue or concern regarding the schedule or the rotation in general