Paging System

ICU Schedule

Ptinfo > Demographics/Visit

• Once the patient is in ICU, CCMD writes all orders (not the primary service)
  • Exceptions: chemotherapy, research blood, lumbar drain settings

$^{a, b}$Round first with Peds Intensivist from Children’s National Hospital.

$^{c}$Attendance is required. Attending or NP holds the ICU phone

• Start rounds at 8:00am with the post-call fellow and CCMD attending.
• Saturday: Friday PM fellow and NP will share responsibility for writing notes for all the patients on Saturday AM.
• Sunday: The Saturday post-call fellow is responsible for writing notes for all patients on Sunday after midnight. If it is too busy, then the on-coming AM fellow needs to be informed to write them.

• Tuesdays at 1:00pm - ICU Interdisciplinary meeting (Webex) includes social work, rehab, spiritual care, pharmacy, nutrition, and bioethics
• Virtual Radiology Rounds with Dr. Arlene Sirajuddin, Fridays at 11am

  • Residents and Medical students will also have separate teaching sessions with various CCMD Attendings/Fellows

• Present Assessment / Plan together
• Follow the order:
  • Neuro
  • Pulm
  • CV
  • GI
  • GU
  • ID
  • Heme
  • Endo

ICU does not write H&Ps; they primary team does.

We write a transfer / accept note, largely copy-pasted from the admitting team's note.

• Daily notes are the Progress Note - Critical Care SOAP notes. You must co-sign the CCMD Attending with each daily SOAP note

• All pediatric patients admitted to the ICU (including postops) are to be staffed by the Pediatric Intensivist from CNMC. You must notify them of any admissions or consults
• See Amion (PW: ccmcnmc) to see the most updated schedule of Attendings

If on arrival to a consult:

Patient is Crashing

Needs immediate care (intubation, pressors etc.)?

CALL A CODE BLUE so you can get more help/equipment right away

Not Crashing, but Needs ICU Bed

Call the ICU charge nurse for a bed, and ask the floor nurse to call report

Apart from ICU charge and floor RN being aware of move, we need this get a patient to ICU list:

• Transfer Order to bring patient into ICU census
  • Primary team should enter this, but we can be helpful if need be
    • Enter Order Transfer: Inpt to Inpt Unit
• We write Critical Care Transfer/Accept Note

Patient stays in place; Does NOT need ICU

• If patient remains on floor, use document Critical Care Free Text to write your assessment and recs

We do NOT write H&P; primary team does

We write: Critical Care Transfer/Acceptance Note

Must Haves for outpatients

• All patients need ATV (Admission / Travel Voucher)
  • primary team enters this
• After ATV is in, we call Admitting and tell them this is a STAT ICU admission
• do NOT enter orders until the patient to gets on the ICU census
  • WHY :: orders entered prior to hospital admission from outpatient will be canceled when the patient is transferred to inpatient

We do not put in admission orders – primary team does.

Instead, we specify reason for transfer (see #1 below) and add any ICU-necessary suborders (see #2 below)).

1) ICU Visit Reason: CCMD III - Admission Order

• Allocate order to protocol, select the protocol that is listed under the Visit Reason (this is so we don’t have to select the protocol number every time we place an order)

2) ICU Admission Orders: CCMD III - Admission Orders or CCMD III - Pediatric Admission Orders

Code team: ICU fellow, x2 ICU RNs, RT, ICU pharmacist, surgery fellow (central access / cric)

Code equipment: code cart, portable ultrasound

Airway: If needed, you can ask for the glidescope from the ICU.

If patient is visitor or employee, must go to Suburban via NIH ambulance; default is BLS, so must specify if ACLS bus is needed

• To get an ALS ambulance:

  • Tell the BLS paramedics that you need an ALS ambulance
  • Have a low threshold for calling for an ALS ambulance - don’t send patients with chest pain or syncope on the BLS ambulance
  • If it seems warranted, call a report to the Suburban ER 301 896-3880. Otherwise just give report to the EMS team
  • An alternative triage option for employees who need only short term monitoring is to triage them to our occupational medical service (OMS)

STEMIs

• NIH Cath lab team is not always available for emergency procedures

  • Options for emergency cardiovascular services:
    • MedStar Transport Communications Center 24/7: 844-877-2424, STEMI team on site 24/7
    • Suburban Hospital BEAT line 24/7: 301-896-BEAT (2328)

Orthopedic Surgery

• Call Page operator to get in touch with Suburban Orthopedic Surgeon on-call

Vascular Surgery

• Call Page operator to get in touch with Walter Reed Vascular Surgeon on-call

• Activated during code blue and brings you DART Cart
• ENT, Anesthesia, Surgery Attending also responds if in house

MUST activate code blue AND brain code

• Gets you Neurology, and CT tech is notified to set up scanner

Bleeding or mass effect: page Neurosurgery

Ischemic / LVO: page Suburban Stroke Team 301-896-3100

Non-emergent clinical change

REQUIRES:

• be at bedside within 20 minutes
• if unstable, call code BLUE

• Call Transfusion Fellow (240-534-9559) to active MTP and verbally order STAT blood products

Runner Logistics: During day time hours, Messenger/Escort will run blood from Blood bank and bring MTP cooler

• CRIS order: MTP
  • Order STAT labs
  • after discussion with Transfusion Fellow, order blood products
  • Consider ordering TEG (Thromboelastography, hemostasis)

• Order all new meds STAT or now or with a defined start time- otherwise the first dose could be scheduled anytime in the next 24 hours.
• Careful when you discontinue/reorder, your next dose might be scheduled too soon or too late. Always figure out the appropriate start time and select “QxH”.
• Utilize CCMD order sets for medication orders (vasopressors, antibiotics, sedation, etc.)
• Order antibiotics as STAT if you want them given right away. We track the time between the order and when it is administered (should be <60 min) use CCMD I - STAT antimicrobials

• Daily labs should be ordered for 4 am
• Use the repeat function for serial labs, time them all so that the cycle starts at 4 am
• Make all lab orders STAT or give them a time, turn around time on all orders should be STAT. Frequently, labs ordered as routine do not seem to get done.
• Specimens for drug levels must be accompanied by recs with time of last dose and draw time.
• Delete old unused lab orders, otherwise they collect and things get confusing

After Hours (17:00 or weekends)

• For any radiology studies, page the XRay tech

  • Xrays, non-contrast head CT or a non-contrast non-high-res chest CT will be done right away
  • Contrast CT, ultrasounds: you will need to speak to the Radiologist on-call, and the on-call tech will be called in; this may take an hour

• For same-day TTE, enter order and call ECHO lab (301-435-6038)
• Weekends: enter order and page tech on call

• Find out from Charge RN what unit the patient can transfer to and if patient needs Telemetry
• Complete the order/med reconciliation prior to transfer (d/c/modify ICU specific orders) and place transfer order: Transfer: Inpt to Inpt Unit
• Verbal signout is usually given to the primary/surgical teams during morning rounds EXCEPT for Urology, Solid Tumor, Lymphoma, and HIV/AIDS Malignancy; these services are also followed by the Inpatient Hospitalist team and they need to be paged to give verbal signout
• Modify your Critical Care SOAP Note and type “Transfer Note” under Document Topic
• Complete the section Transfer/Accept note details
• Cosign the receiving provider (usually the Attending or Fellow) and CCMD Attending once document is complete and if any modifications are made
  

• Enter Discharge Expiration Note to generate a Discharge order

DC Summary Writing

• patient in ICU < 14 days, the primary team writes this
• patient in ICU > 14 days, ICU writes

Death Certificates: Admissions will call you to discuss the death certificate process

• VAD (Vascular Access Device) RNs place PICC lines and ultrasound guided PIVs
• CRIS order for PICC: VAD

  • Click on box for Consult
  • CRIS order for PIV: VAD
  • Click on box for Generic procedure request
  • CCMD is responsible for reading the PICC line CXRs to check placement. Someone from the procedure service will call you to look at the Xray and cosign you to the procedure note.

• Central lines: policy is all lines are done with full barrier precautions and an ultrasound. The VAD nurses are also happy to teach you how to place PICC lines- just ask if you have time.
• CRIS note for Central and Arterial lines: Central VAD Insertion

• Move the patient to one of the negative pressure rooms (room 6 or 12)
• Enter Micro orders: CCMD IV - Procedures: Respiratory Micro (not bronchoscopy procedure)
• Fill in the extra information required in the cytology order
• Submit your orders (or you can place orders linked from the Bronchoscopy procedure note). Then your note will show exactly what you ordered.
  Stickers should print: put them on the specimen or in the bag with the appropriate specimen, make sure there are patient labels on the containers
• Before 17:00: hand deliver the specimens to the micro lab and cytology lab (tube system and transport services are not reliable for difficult to obtain specimens)
• After 17:00: hand deliver the specimens to the micro lab and the cytology fridge located in lab

• CRIS Order: CRRT/Prismaflex

  • CRRT Orders guide is in a folder at the back of the first computer station
  • Call Dr. Danner (#in Fellow phone) for every patient being placed on CRRT and for any CRRT questions/concerns

• Call IR to schedule procedure
• CRIS order “SP___” and SISweb need to be placed

  • Call Anesthesia if you anticipate your patient needs monitored anesthesia care
    • RNs are only allowed to provide conscious sedation with IV fentanyl and midazolam
    • CCMD is NOT allowed to push propofol in IR (only anesthesia)

• Restraints (medical/surgical – NOT behavioral health) Order and a Restraints Progress note must be completed every 24 hours

  • Massive Transfusion Protocol: Call Transfusion Medicine Fellow to activate