What to expect during your PICU rotation

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Before you start your rotation

Welcome to your rotation in the Pediatric Intensive Care Unit! The PICU is a fast-paced, exciting, sometimes scary, mostly fun, and overall great place to learn how to take care of sick kids. Our expectations of you are to be excited to learn, be proactive, be engaged, and take responsibility for your patients. We do not expect you to know all the nuances of how to care for critically ill children – we will teach you that and provide the support you need.

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Overview of the PICU

​The Pediatric Intensive Care Unit (PICU) at Mattel Children’s hospital consists of 24 level-1 PICU/CTICU beds and is located on the 5th floor of Ronald Reagan Medical Center. The PICU averages approximately 900-1000 admissions annually, including both medical and surgical critical care cases. Some of the diagnosis include: sepsis, shock, trauma, ARDS, cardiomyopathy, heart failure, pneumonia, liver/kidney/small bowel transplant, bone marrow transplant, DKA, status asthmaticus, seizures, AVMs, neurosurgical procedures, near-drowning, intoxications, complex surgeries and other multisystem organ failure patients. Residents and medical students will be exposed to many aspects of pediatric critical care medicine. The PICU team includes twelve board-certified pediatric intensivists, ten PICU fellows, several nurse practitioners, and is supported by pediatric critical care nurses, resident physicians, respiratory therapists, nutritionists, pharmacists, and social workers.

 

 

Who is on the TEAM?

Attendings

The attending directs patient care delivered by the entire team. They will provide feedback, education, and are available throughout the day for anything that you might need. Attendings also provide night-time in-house coverage.

 

Fellows

The PICU fellow will act in a supervisory capacity, under the direction of the PICU attending. They care for all patients admitted to the PICU. They will also provide you with education and feedback. The fellow should know about any and all patient care management decisions. They are available to answer and address any concerns you may have, big or small, and as frequently as you see fit. It's always better to ask than not.

 

Residents

Residents each take patients primarily and provide direct patient care – you will be the primary provider on your patients! You are responsible for writing admission orders and notes, pre-rounding on patients, being prepared for rounds, and writing daily notes, transfer summaries, and discharge notes. You should frequently check on your patients as things are dynamic in the ICU setting. In addition, it is your duty to communicate with the rest of the team members, sub-specialties, patients and parents, and to advocate for your patient. Thus, you are expected to read about your patients and share with the rest of team. PGY2 and PGY3 residents should also strive to be mentors for rotating EM residents and medical students (usually 4th year Sub-Is).

 

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Medical Students

Medical students will follow patients as their primary caregiver with a resident as "backup." They should follow 1 to 2 patients. While they can help by writing notes, they cannot put in orders. They are expected to read about their patients and teach the rest of the team. In addition, they should be allowed to switch patients every couple days to provide them variety.   

 

Nurse Practitioners

Nurse practitioners work in collaboration with the rest of the multidisciplinary team. They are great resources for both medical and nursing knowledge. Available only during nights, they will help cover the entire unit and help with admissions, if needed. While acute patient care decisions are the responsibility of the resident, the nurse practitioners are here to help coordinate care and communication between bedside nurses and the physicians.

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Daily schedule

Day shift: morning sign-out starts at 5:30am, evening sign-out starts at 5:30pm. Please expect to stay for the duration of your shift. You may leave early in case of personal emergencies only after attending approval.

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Morning Rounds: Start everyday promptly at 7:30 am. Rounds on Friday start earlier at 7 am (to allow everyone to attend Ground Rounds)

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PICU noon conference:  Monday, Tuesday, Wednesday at 12:15 on Zoom:

https://uclahs.zoom.us/j/96643500080

 

Liver Rounds: Monday and Thursday at 2 pm. Be sure to be present for your patients!

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Pre-rounding

After receiving sign-out from the night resident, you will have until 0730 to gather information needed for rounds while also completing your progress notes for the day. The goal is for you to have all of your notes ready to be signed by the time rounds begin. They will not be signed on rounds, you will be able to edit them after rounds with any new information/changes that are decided on rounds. Our goal is for you to be able to participate in patient care and various methods of learning during your time in the PICU. If you are still writing notes in the afternoon, this takes away from your experience in the PICU. To accomplish this, daily progress notes should be short and concise (see section on progress notes) and we’d like your prerounding to be as efficient as possible.

 

We’d like you to use your progress notes as your information sheet for rounds. You should start by updating your progress note (overnight events, refresh I/Os, update any changes that were made overnight [drip rates, medication changes/additions, etc.]), print your note, then write any other information you need for rounds on your printed note (labs, imaging, etc.). This will also allow you to organize your information and plan by system as most attendings like it to be presented, simply by looking at your progress note. Your progress note can then be saved, briefly adjusted after rounds, and signed quickly after rounds to free up your afternoon for patient care, bedside learning, etc.

 

 

Morning rounds

Rounds in the PICU include the PICU attending, fellow, resource fellow, charge nurse, bedside nurse, and pediatric residents. Parents are also invited to join rounds. Occasionally, rotators from anesthesiology and pharmacy will join rounds for a limited time (usually 2 weeks).

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During rounds, patients are presented first by the bedside nurse, who will summarize recent events, vitals, I/Os, line and access issues, and parental and nursing concerns. The resident assigned to care for the patient will then present, during which time the plan for the day will be discussed and formulated.

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For new admissions give a brief history, examination and admitting differential diagnosis. For existing patients, presentations should begin with a summary of overnight events. You do not need to repeat information from the nurse’s presentation unless clinically relevant to your plan or you have further information to add. Example: Nurse presents that patient had a fever overnight and received Tylenol. You can add any details regarding the patient’s clinical picture, and that the patient had labs and cultures drawn at that time of that fever. Significant patient events (codes, significant bleeds, acute mental status changes, etc) usually need further detail. This should be followed by a physical exam, focusing on the pertinent positive and negative findings only. It is acceptable to postpone your exam until after rounds if the patient was still sleeping prior, as long as the patient has been stable overnight.

 

Next will be a presentation of the major medical concerns by system. Laboratory and imaging results should be discussed in the system they pertain to (i.e. CT head results in neuro, electrolyte in FEN/GI, etc.), not separately. If a system is not active in a given patient, it is appropriate to simply mention that that system is stable or has no active issues, however please do not skip any systems so that all team members are on the same page and things are not missed. Vital signs should be discussed in their respective systems and only mentioned if a plan needs to be made to address concerns, as a full summary of vitals will have already been given by the bedside nurse. Remember that although you are presenting a lot of information, you should try to formulate a plan as well. Try to think about what the goals should be for the day and for the week and incorporate this into your presentation.

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Since many parents will participate in rounds, please think about the way you present information. Try not to use too much jargon and don’t say things like “cardiology didn’t care” or “GI never came by.” Be courteous, professional, and understanding of the situation they are in.

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Teaching during rounds will be directed by the attending physician, and will generally focus on questions as they arise (not pre-determined topics). On occasion, you may be asked to give a 2-5-minute presentation on a topic that pertains to one of your patients. These will usually be given when rounding on that same patient in the following days. Questions asked for the purposes of teaching are generally asked to the entire team, not just the resident presenting. All are expected to participate.

 

A portable computer should accompany the team on rounds. One of the residents who is not presenting will be in charge of submitting orders, opening imaging studies or pertinent notes, and checking recent labs during rounds. Please be sure to have daily chest x-rays open and ready to be viewed by the team before the resident starts their presentation. The resident writing orders should read-back all orders at the end of the presentation to ensure accuracy and confirm with the bedside RN that all team members agree. Another resident may be updating the handoff. Please be mindful that the summary of daily events should be concise and succinct (e.g. “weaned sedation” rather than “WAT scores low in the last 24 hours so decided to wean sedation by 10% and will attempt next wean in 3 days”).

 

When you receive a page or call during rounds, the resource fellow on for that day can help respond to those. Residents should not be leaving rounds for non-urgent reason to respond to nursing concerns.  Exceptions would be emergencies also requiring the presence of the fellow or attending, in which case rounds may be briefly halted until the issue is addressed. If a resident need to leave rounds for any reason, they should communicate the need to the attending physician prior to leaving.

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Remember that you will often assume care of other residents’ primary patients when they have the day off. For this reason and also for educational purposes, you should pay attention and remain involved with every patient presentation. We have so many interesting patients in our PICU; you will always learn something from each of them.

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In between rounds

After morning rounds end, consultants should be called first. This is an important first priority to be courteous to our consultants, but also because we want prompt recommendations to the medical care of our critically ill patients. Secondly, any orders that were not placed on rounds should be entered, i.e. TPN orders that are due by noon. Please also review ALL orders on your patients to ensure that everything was placed appropriately during rounds. Third, an attempt should be made to update any family that was not present on rounds (see section on family communication) in regards to the patient’s condition and plan of care.  Finally, progress notes should be finished once all patient care matters are attended to. Notes can be addended after submission if your patient has a significant clinical event. If you have all your work done please do not hesitate to seize opportunities to learn from the RTs, RNs, and fellows.

 

Please remember that you are the primary provider for your patients. While the ICU can be a new and daunting experience, we encourage you to take ownership of your patients, and to seek support from your fellow and attending. It is a good idea to check in on your patients several times throughout the day – this means being at the bedside at least every 2-3 hours throughout the day, whether for reassessment, giving updates to families, and/or checking in with the bedside nurse. Remember that the more frequently you are seen at the bedside, the more likely nurses/RTs/etc will come to you with questions.

 

Good communication is imperative in the ICU. Faculty/Fellows will do their best to communicate any changes with you, but please remember that the ICU is a high-acuity and dynamic environment, and patient management/safety takes precedence.

 

If you have any questions after rounds, aim for in-person communication for all matters with nurses and fellows. You may call the fellow if you cannot find them in-person (epic chat or paging is not preferred). The fellow will also run through the patients with the team at least 1-2x per day, contingent on patient care.

 

 

Evening sign out

Fellow-to-fellow evening sign out takes place at 5:00 pm. Resident evening sign out begins at 5:30 pm.​

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Evening sign out takes place in the PICU conference room. PICU residents should take turns signing out their list of patients to the entire night team (fellow, PICU night resident, and NP). 

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Sign out Template:

 

Key Points

1. Day Resident: Don’t read off your note, there is information in there that can be referenced

2. Night Resident: If you have questions overnight, understand that you can refer to the primary team and consult teams notes

3. It’s a summary, not rounds

 

Order of signout

1. Present 1-liner regarding the patient. One liner should include ACTIVE issues, not that they had an ECMO run 5 months ago.

2. Provide major updates for the day (ie. New culture results and antibiotics, starting of major medications/drips, procedures). Things like replacing electrolytes are not necessary to repeat

3. Review plans by system, and only discuss systems that are active (No need to say: “Cardiac, nothing”)

4. Include what you want the overnight resident to do overnight

   1. For example, are we weaning sedation? What sedation goals do we want overnight, what medications be added if sedation is inadequate

   2. Do we have saturation and blood pressure goals?

   3. Electrolyte parameters, anticoagulation parameters etc.

   4. Are there things to follow up overnight or to prep for the next day? (Imaging, OR prep etc)

5. Anticipatory guidance for specific problems, especially if recommended by a sub specialist. If x, then Y. Also if subspecialist notes have not been finalized for the day, remind the night team to follow up.

 

Things that do not need to be communicated:

• Current doses of drips, unless it is something that needs to be actively changed/monitored o/n

• Current vent settings - will see those when we assess at bedside overnight

 

 

EXAMPLE

6 year old patient with status epilepticus, now hospital day 5 and still titrating AEDs. 

 

Neuro: Started versed gtt today,  Goal is for burst suppression, titrating up versed per Neurology recommendations. Contact Neurology with major push button events in addition to checking in with them around 1 pm. Also added precedex given intubation.

Respiratory: Required intubation today 2/2 to versed gtt. PC/SIMV, good compliance, low vent settings. Titrate to maintain adequate ventilation.

Cardiology: A line placed given increased sedation. MAP goals > 65. If vasoactive is needed. 1st line NE, 2nd line Vaso, 3rd line Epi.

FEN: D5NS at ¾ MIVF.  Can start Pedialyte overnight and escalate either by volume or by formula

ID: 24 hour sepsis rulout until tomorrow. Started CTX/Vanc today.

 

 

Communication

(1) Talking to consultants

As a courtesy, and to allow the consultant sufficient time to see the patient, it is advisable to speak to the consultant as early in the day as possible. It is not acceptable to just put in a consult order in CareConnect. The consultant must be spoken to and given a brief synopsis of the patient as well as the clinical question or problem which is the reason for the consult. You need to have a clinical question always before calling a consultant. Recommendations given by the consultant are simply recommendations and need to be discussed with the primary team (PICU fellow and/or attending) before acting on them. When given recommendations by a consultant that you do not understand you should always ask the reasons behind the recommendations so as to advance your knowledge and to share that information with the PICU team. Needless to say, please be courteous and respectful to consultants at all times.

 

(2) Talking with families

Due to the nature of critical care practice it is very important that everyone works as a cohesive team. Patient’s families should be updated on a daily basis whether they are present in the unit or not. Oftentimes, the bedside nurse will have the best number at which to contact the family.  When updating family about sensitive issues please be sure to touch base with your fellow and/or attending. Circumstances in which this is the case include changes in plan or direction of care, making patient DNR or DNI, or any significant new findings that may alter the patient's course in the PICU. This communication is important so that the team presents a unified approach and does not confuse the patient and his or her family with differing opinions or plans. Having a unified plan makes the family and patient feel more at ease with the care they are receiving.

 

(3) Communicating with nurses

Nurses are a vital part of the ICU team and learning how to communicate with them is an important skill to learn. Many of our nurses are very experienced and their concerns should always be taken seriously. When paged, be prompt and courteous in your response. When writing orders, it is NOT acceptable to write orders without verbally communicating them to the bedside nurse. Communicating orders to the nurse allows the nurse to check the orders and make sure that what you have communicated is what is ordered in CareConnect. This is a safety measure to protect you and most importantly the patient. Finally, you should always try to explain to the bedside nurse why things are being ordered the way they are. This has several purposes: 1) it serves as a teaching opportunity for you and a learning opportunity for them, 2) if the bedside nurse understands why he or she is doing something they are more likely to carry out your orders effectively and this improves patient care, and 3) if the nurse understands the reason for a certain plan of care, then they can more effectively communicate that with the patient and/or family when asked which makes the team more cohesive.

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(4) Updating the fellow/attending

Communication with the fellow and attending is paramount to keeping the team cohesive. The resident is most often the primary contact for consultants, and they will discuss their recommendations with you throughout the day. It is important to keep the team leaders informed of these recommendations and of any other pertinent laboratory or study results. Your first contact should be the fellow, however if the fellow is unreachable and you have an urgent question or concern, you may contact the attending directly. The PICU fellow and attending both carry mobile phones and should be reachable at any time. Occasionally throughout the day, the PICU fellow may run through the list of patients with each resident to obtain important updates and discuss any changes or developments in patient care plans. At times, pediatric critical care can be unpredictable, and the fellow may be busy with procedures, transfers, or consults. However, it is still important to keep the fellow informed of any new developments with your patients, and every effort should be made to do so. The fellow will also communicate with you about any changes in status, new orders, etc. however please note that the ICU can be very busy and we will try to communicate things as quickly as possible (though it may not be right away).

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Progress notes: what should be in a daily note

Progress notes should be as short and succinct as possible. The point of the progress note is to tell a story that describes what has happened to that patient during that day. These should not be a running discharge summary, as these become too long/busy. Progress notes are intended to give a daily update on the patient’s clinical status and plan of care. If you will be copying a note from a prior day or a note from another physician, please make sure that the information contained in the note is accurate and pertinent to the care the patient is receiving for that day.

 

Writing a good progress note is something that takes skill and practice. Please feel free to ask any of the PICU fellows and/or attendings for feedback on your note writing and we will be happy to help you. Please use the note template instruction in the PICU.

 

• An important part of the note is a section on interval events. Here you can update the reader on what changed clinically with the patient overnight. This should be brief and succinct and does not need to include every small detail, but the pertinent changes (e.g. fevers, hemodynamic instability, electrolyte repletion, antibiotic initiations, PRN meds, etc). This section is often written by the overnight resident, however please edit as needed. Example: “called Neurosurgery at 0100 because the EVD would not drain, they came at 0130 and flushed it and drained after” can be summarized more professionally as “EVD not draining, Neurosurgery contacted and flushed it, resolved.” Please avoid statements such as “dad refused PRN med” or “called surgery, they never came by.” Remember that anyone can read your note, including the family.

• The physical exam section of the note should cover pertinent systems with pertinent exam findings.

• Labs and imaging are usually prepopulated. However, please review this section to ensure it does not become too cluttered. Old clinical data, imaging, and labs that are no longer pertinent to the patient’s care should not be included. Please do include the most recent CXR, Ultrasound, CT scan, etc. It is also a good idea to have a list of Micro data here (blood, urine, respiratory cultures, and their results).

• Due to the complexity of patients in the PICU the assessment and plan should be broken down by systems to properly organize the note. Assessments should be brief and relevant. Example: if a patient has been admitted for 2 weeks already, the assessment should not include a paragraph about their initial presenting symptoms, workup, etc. but rather succinctly state the initial presentation and diagnoses and then the clinical course currently (doing well, complicated by, etc.). Plans should be brief bullet point lists of active therapies and plans, with changes noted, that are relevant to the care of your patient for that day.

• As a courtesy to your fellow residents, you should have an up-to-date hospital course as a shared note in case your patient needs to be transferred or gets discharged while you are away. It is important to remember that a hospital course and discharge summary should only contain the information necessary for the receiving team or PMD to understand what has happened to the patient while in the PICU and how to provide appropriate care moving forward. Avoid the habit of writing down daily events in great detail (e.g. “on 10/1 the patient was on 2L NC, on 10/2 escalated to HFNC, on 10/3 back on NC, on 10/4 back on HFNC, on 10/5 intubated,” rather than “patient was placed on NC however required escalation of respiratory support culminating in intubation on 10/5”).

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Teaching sessions

Most teaching in the PICU is accomplished in rounds and throughout the day in the form of discussions about your patients’ problems, pathophysiology and management decisions. A PICU fellow and/or attending will also provide formal teaching sessions during your rotation. These teaching sessions will be between 30-45 minutes long and interactive, covering relevant topics in the PICU. Examples include ventilator management, use of pressors, septic shock, etc.

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There are scheduled PICU noon conferences on Mondays, Tuesdays, Wednesdays on Zoom: https://uclahs.zoom.us/j/96643500080

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New admissions

Patients are typically admitted to the PICU from our Emergency Room, Operating Room, pediatric floor, or transferred from other hospitals. When a new patient arrives, the resident taking the admission, along with the fellow should be present for the patient handoff from the transport team, ER personnel, floor team, or anesthesiologists. Patients from the OR are accompanied by the surgeons, and during the hand off process monitoring parameters are discussed and agreed upon by all teams. It is important that orders are entered into CareConnect in a timely fashion. The nurse practitioners can also help with placing admission orders into CareConnect. Pay particular attention to any drips or medications that may be running out from the OR or outside hospital, and ensure that orders are entered for these medications immediately to allow the pharmacy time to prepare any critical solutions or medications that your patient requires before the current supply runs out. Also take note during the handoff of any medications given in the OR and the timing of those medications, so that you can order any continuing medications correctly. If the patient is on a ventilator, review the ventilator settings with the fellow on transition from the transport equipment.

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Once the patient is stable in the unit, perform a detailed history and physical exam, then discuss your findings, assessment and plan with the PICU fellow. Admissions are excellent opportunities to learn critical care management. Challenge yourself to think through the patient and make an assessment and plan, even if you are not certain it is correct.

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After discussing your admission with the fellow, finish entering the remaining necessary orders into CareConnect, communicating with the patient’s nurse to ensure that nothing is missed and that your orders are understood. Be sure to reconcile the patient’s home medications in CareConnect, and pay attention to the timing of the medications, as some medication orders default to times different than the patient’s usual schedule. On occasion, home medications are held or changed on admission. Be sure to discuss medication changes with the fellow.

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Finally, write your H&P. Your note should contain all the usual sections of an H&P including a detailed review of systems. The assessment and plan should be broken down by systems as in your daily progress notes. Include any relevant data from any transferring outside hospital, including the name of the institution and any contact information you may have in the note. (Do not simply write “OSH” without a reference to the actual location, as it can be difficult for your colleagues to follow up on laboratory results and other studies that may have been performed there.) Your H&P should be cosigned by the PICU attending on service. If you have questions or concerns about your H&P, always feel free to ask the fellow for help or feedback.

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Transfers and Discharges

Most children are transferred to the floor prior to discharge although quite a few are discharged directly from the PICU. The Discharge Planners/Case Managers are there to help with the details of discharge. Transfers to the floor can happen at unpredictable times and depend on floor bed availability and new admissions to the PICU. Ideally, we transfer patients before noon which means that the transfer orders should be written by 10 AM. If it’s not clear which floor team a patient will be transferred to, please discuss with the fellow or attending. Sign-out to the ward team must be given before the patient is transferred. If either the PICU or ward team is very busy, an abbreviated sign-out may need to be given initially with more thorough follow-up at the soonest available time. Please use the fellow, NP, and attending as resources if you have questions as you sign out your patient. Non-emergent transfers should not happen after 2 PM.

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Procedures

The acuity of our patients often necessitates invasive procedures to facilitate appropriate management. These procedures include endotracheal intubation, placement of central venous catheters, arterial catheters, needle thoracostomy, placement of chest tubes, lumbar punctures, and other invasive interventions. Priority is given to the fellows for performance of a procedure, but you are encouraged to participate and help. You can put on a gown and gloves and learn the techniques. The more proactive and present you are, the more opportunities you will get to learn about procedures and possibly perform one. Lumbar puncture is a common procedure performed by residents. For any procedure you perform, you are expected to write a procedure note in CareConnect, to be cosigned by the attending physician on service.

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Last updated: 04/15/2022