Ptinfo > Demographics/Visit

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

$^{a, b}$We typically first round on Pediatric patients with Pediatric Intensivist from Children’s National Hospital. Otherwise, the order of rounds is based on the presence of the primary team, and priority is given to teams who arrive to participate in rounds. At the end of your review of systems and presentation, nursing, RT, pharmacy, nutrition, and social work should be asked if there are any concerns before there is general discussion amongst attendings, etc. Then the bedside nurse will review the patient’s goals of care for the day. Surgical teams don’t usually attend rounds; they pre-round earlier with a CCMD provider and provide recommendations as appropriate.

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

After rounds, we run the list and ensure orders are placed, and consults and procedures are scheduled.

• 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

We do 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 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

• For anyone that wants a patient transferred to the ICU, you must see the patient before bringing them to the unit. There is a wide range of clinical experience among practitioners here - some are not very good at identifying a sick patient; you will get urgent calls to see patients who are fine and can stay on the floor and relaxed-sounding calls about patients who are very sick and need emergent care.

  • If the patient needs immediate care (intubation, pressors etc.) DO NOT MOVE… CALL A CODE so you can get more help/equipment right away
  • If they are not crashing and patient needs to be upgraded, call the ICU charge nurse for a bed, and ask the floor nurse to call report
  • Floor patients need an order to transfer to the ICU census, the primary team should do it but in the essence of time, we can do it as well.
    * If patient remains on floor, use document “Critical Care Free Text” to write your assessment and recs
  • If upgrading, use document “Critical Care Transfer/Accept Note”
  • Transfer Order to bring patient into ICU census
    • Enter Order “Transfer: Inpt to Inpt Unit”
    • Ask nursing to click the transfer order on the worklist manager.
  • Review/modify orders and medications as appropriate for ICU
    

  Outside Admissions
• If the patient is newly admitted to the hospital, the primary team needs to be reminded to write the H&P and we write the “Critical Care Transfer/Acceptance Note”.

  • Outside patients/outpatients need an ATV (admission/travel voucher) prior to admission
  • Ask the primary team to put one in, then call admitting and tell them this is a STAT ICU admission
  • Wait for the patient to get on the ICU census before putting in orders
  • Any orders that are put in prior to hospital admission from outpatient will be canceled when the patient is transferred to inpatient

  Admission Orders
• CCMD III - Admission Order (ICU Visit Reason)
  • 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)
• CCMD III - Admission Orders (ICU Admission Orders) or CCMD III - Pediatric Admission Orders
  

  Triage Responses

• Code team: ICU fellow, x2 ICU RNs, RT, ICU pharmacist, surgery fellow (central access / crich)
• Code equipment: code cart, portable ultrasound.
• Airway: If needed, you can ask for the glidescope from the ICU.
• Disposition for visitors/employees: we don’t have an ER so they have to go to Suburban via NIH ambulance that is only BLS capable. If they need any monitoring or meds, or even just an IV, you need an ALS ambulance
• 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

  Difficult Airway Response Team (DART)
• Activated during code blue and brings you DART Cart
• ENT, Anesthesia, Surgery Attending also responds if in house

• Need to 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, page Suburban Stroke Team 301-896-3100

• Called on NIH patients with change in clinical condition (not medical emergency)
• Need to respond to the patient bedside within 20 minutes
• Low threshold to upgrade these to codes if patient is unstable and you need more hands

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

Expected preparation times: a) Emergency release (uncross matched) packed red cells: 15 minutes b) Crossmatched packed red cells: 45 minutes c) Platelets: 15 minutes d) Plasma: 40 minutes e) Cryoprecipitate: 40 minutes

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

Ask nurses for rapid infuser

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

• Start rounds at 8:00am with the post call fellow and CCMD attending.
• Saturday: There is intermittently a NP staffed Saturday morning to help with morning rounds. The Friday night fellow and NP will share responsibility for writing notes for all the patients on Saturday.
• 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 fellow needs to be informed to write them. Please discuss the note assignment so it doesn’t get missed.

  • Attending usually brings in breakfast on weekends

  How Do I Order

• 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

• CT scan: Page CT tech (17226) to request same day/STAT study, THEN put in CRIS order after you get approval with a time

  • MRI: Place order and call MRI Charge Tech (240-507-4676) to request same day study
  • Ultrasound: Place order and call Ultrasound Tech (301-594-8430) to request study
  • XRAY: Place order and page XRay Tech (17237) to request study
  • After 5pm/weekends

  ○ Page the XRay tech for any radiology studies ○ 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

• Enter order and call ECHO lab (301-435-6038) to add on same day TTEs
• 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
    

  Expiration
• Enter Discharge Expiration Note to generate Discharge order

  • Need Discharge Summary within 30 days - if patient has been in the ICU < 14 days, the primary team writes this. If > 14 days, ICU writes the summary
  • Admissions will call you to discuss the death certificate process

  PVCS (Vascular Access Service)
• VAD (Vascular Access Device) RNs place PICC lines and ultrasound guided PIVs
• CRIS order for PICC: VAD o Click on box for Consult
• CRIS order for PIV: VAD o 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.
  

  Lines
• 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)

  • 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
  • During daytime hours: hand deliver the specimens to the micro lab and cytology lab (tube system and transport services are not reliable for difficult to obtain specimens)

  o After 5pm: 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

  IR aka Special Procedures
• 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

  CCMD Nurse Practitioners
• Therese and Patricia are full time.

  • Rely on them to help you with systems questions, and generally getting things to happen. In addition, they are able to be assigned to patients and help out with all patients except for pediatric patients. They are all Acute Care NPs who are licensed for adults and cannot write orders for pediatrics.
     

  Essential Phone Numbers

Admissions 301-496-3141

Anesthesia On=Call Nights after 5:30pm/Weekends Ph: 301-913-6453 Call room: 301-435-8207

Blood Bank Accessioning: 301-496-4506 Transfusion Medicine Fellow: 240-534-9559

CT CT front desk: 301-402-4066 CT Tech pager #: 17226

ECHO ECHO lab: 301-435-6038

ICU ICU: 301-451-0567 ICU Fellow: 301-256-5774 NPS: Nancy: 202-560-2331 Therese: 202-413-0286 Patricia: 240-762-2663 Rashidah (Saturdays): 301-728-6023 Nutrition (Stacie): 301-771-1209 Respiratory Therapy: 301-913-6081

IR Front desk: 301-402-0256

Laboratory Chemistry lab: 301-496-3386 Hematology lab: 301-402-2171 Micro lab: 301-496-4433

MRI MRI front desk: 301-496-0026 MRI Tech: 240-507-4676

OR Front desk: 301-496-5646

Pharmacy Janell: 301-832-1538 Willy: 240-762-3633 Pharmacy Main: 301-480-6337

Radiology Body on all modalities: 301-832-5970 Neuro: 240-743-8862 Nuclear med: 301-496-5675 Xray Tech pager 17237

Ultrasound Tech: 301-594-8430

VAD 301-594-8430

Children’s: 202-476-5000 Suburban ER: 301-896-3880 *For all other services, call the page operator 301-496-1211 or send pages through http://102pager.nih.gov/