PEDIATRIC INTENSIVE CARE UNIT (PICU) INTRODUCTION

Purposes

1. The provision of specialized care for children with critical illness which may best be provided by concentrating these patients in areas under the supervision of skilled and specially trained team of physicians and nurses.

2. The continuing education of health-care team members.

Administrative Structure

The Medical Directors of the PICU are Dr. Dana Braner and Dr. Laura Ibsen. Attending Pediatrics Intensivists are Dr. Dana Braner, Dr. Laura Ibsen, Dr. Miles Ellenby, Dr. Ken Tegtmeyer, Dr. Aileen Kirby, and Dr. Bob Steelman. The Pediatric Intensivists are the primary caretakers (medical patients), or consultants (surgical patients), for each patient admitted to the PICU. There is an intensivist in house 24 hours/day.

The Clinical Manager of the PICU is Annie Logan. She supervises the nursing and administrative staff of the unit and is responsible for the day-to-day operations of the unit. The nursing administrative structure of DCH is in flux, so the administration of the unit may change in the coming year.

Nursing Staff

1. General organization. The PICU nursing staff consists of RNs and appropriate ancillary personnel. Nursing assignments and acuity decisions are made by the nursing staff. If parents make a request to you that relates to nursing staffing, please inform the charge nurse.

2. Continuing education of the nursing staff. An on-going program of education in pediatric intensive care nursing has been the responsibility of the nursing service. In addition, appropriate seminars discussing subjects of pertinence in pediatric intensive care have been and will continue to be organized with physician participation. This will be an effort to maintain and further the critical care skills of nursing personnel in the PICU.

Respiratory Care

The personnel of PICU will work jointly with the Director of Respiratory Therapy so that optimum respiratory care may be provided. The respiratory therapy staff are responsible for setting up and maintaining the ventilators, delivering respiratory treatments, and assisting with patient care that involves respiratory care (ie, suctioning).

Pediatric Respiratory Therapists rotate through the PICU, DNCC, and the floors.

Physicians

A PL-3 and PL-2 are assigned to the PICU, and they with the Pediatric Critical Care staff and other services will care for all pediatric patients. The Pediatric Intensive Care Unit is available to all pediatric patients regardless of the service primarily responsible for the child.

Admission and Discharge

Any child requiring pediatric intensive care must be admitted to PICU. This is accomplished by calling the PICU attending physician. If a bed is available the patient may be admitted. If the PICU is full, and all beds are occupied, then the physician wishing to admit a patient to the PICU must contact the PICU attending. The critical care attending will then make the disposition regarding discharge of another patient from the PICU after appropriate consultation with the patients primary service and the PICU nursing staff, or other appropriate disposition. There are policies in place regarding triage of surgical and medical patients that are used when beds or nurses are scarce.

These policies are necessary to insure optimum care for all children who require pediatric intensive care.

Type of Patients admitted to the PICU

§ Medical patients from the ED. The ED will contact the PICU attending. The intensivist is the attending of record

§ Medical patients from the floor. The floor attending or resident will contact the PICU attending who will decide about transfer, then call the PICU charge RN and resident. The intensivist is the attending of record

§ Medical patients transported in for outside institutions. The PICU attending will contact the PICU charge RN and resident about the admission. The intensivist is the attending of record

§ Cardiac patients may be admitted from the OR, the floor, the ED, or DNCC. If they are immediately post or pre-operative, the primary service is Pediatric Cardiac Surgery, with medical consultation. Functionally, these patients are managed on an hour to hour basis by the PICU attendings. Pediatric residents are the primary residents for the pediatric cardiac surgery patients. If they are not pre or post-operative patients (ie, they are medical cardiac patients), the attending of record is the PICU attending and cardiology is a consulting service.

§ Surgical patients from the ED or the floor. The surgical attending or resident must contact the PICU attending to admit a patient to the PICU. The surgical attending is the attending of record, the PICU acts as a consultant for medical issues. Surgical residents write admission orders. The degree to which the surgical services manage the medical issues of their patients will depend on the service and the patient.

§ Surgical patients from the OR. Surgical attending is the attending of record. The PICU acts as a consultant for medical issues. Surgical residents write admission orders. The degree to which the surgical services manage the medical issues of their patients will depend on the service and the patient.

§ Orthopedic patients from Shriners are admitted to the service of the Pediatric Intensivist if the orthopedic surgeon does not have privileges. The pediatric residents write admitting orders for most of these patients.

§ BBBD/IAC patients. The BBBD service is the primary service and writes all orders on the patients. They should be called for anything that is needed short of immediate resuscitation.

Routine Procedures

There are pre-printed orders for general PICU admits, CV surgery admits (track A and general), and ECMO admits. If you use a pre-printed order and want to write more things, use regular order paper. There are also pre printed orders for sedation drips, muscle relaxant drips, cardiac patient ventilator weaning. Others are being added on an ongoing basis. Admitting orders to the PICU should include the following categories:

Diagnosis
Attending physician
Condition
Vital sign frequency (routine is q2). If you want things documented more frequently, be specific. (hourly is reasonable for sick patients)
Allergies
Nursing—specific nursing requirements
Dressing changes
Chest tube orders
CVP/A-line orders
NG
Foley
Diet/NPO
IVF (type/rate)
Meds
Drips written in amount/kg/minute (vasoactive) or amount/kg/hour (sedation/narcotic); consult with PICU MD or nursing staff about concentration to order.
Labs—labs wanted on admission as well as lab schedule if needed.
Ventilator settings along with weaning parameters (ie, wean oxygen for O2 sat>???)
Call HO orders. It is best to write these and also to speak with the RN caring for the patient about specific issues you are worried about, to ensure accurate communication.
There are special order sheets for muscle relaxants, sedation, and PCA. If you are unfamiliar with them, ask the intensivist or the nurse to assist in using them.
Post operative cardiac patiens and ECMO patients have pre-printed orders. These will be completed by the intensivist or the pediatric resident with attending supervision.

Verbal Orders

Verbal orders may be taken only when necessary. These must be written and signed as soon as possible after having been executed.

Emergency Procedures

In the absence of a physician, if a child's condition changes while waiting for the physician caring for the child, the nurse may do the following where appropriate:

1. Draw blood gases, electrolytes and hematocrit, and send these to the lab for stat results.

2. Call for chest x-ray or other appropriate x-ray.

3. Administer oxygen.

4. Institute cardio-pulmonary resuscitation with Ambu bag and external cardiac massage.

5. The PICU attending should be called immediately for any sudden, unexplained change in a patients condition. In the event of a cardio-respiratory or respiratory arrest where the PICU attending is not immediately available, the Pediatric Code 99 team may be called.

6. If an anesthesiologist is needed emergently, the pediatric on call anesthesiology number should be paged. At the present time, the pediatric anesthesiologists are in house 24 hours/day.

Discharge/Transfer Procedures

Decisions regarding transfer of patients from the PICU to the ward will be made in conjunction with the primary service and RN staff. Confirmation of the availability of a ward bed as well as an accepting physician must be made prior to transfer. The PICU attending will contact the receiving attending for medical patients, the residents should contact the receiving resident to give report.

For surgical patients, the surgery service will write transfer orders. For medical patients, the PICU residents write transfer orders. On occasion, the PICU residents can help the flow of patients by writing transfer orders on surgical patients (confirm with surgical service first).

On medical patients, the PICU resident should write a transfer summary prior to transfer to the floor. Any patient discharged from the PICU (including Shriner’s patients going back to Shriner’s) need a dictated summary.

The Medical Record

A record of patient admissions, diagnoses, date of discharge, and attending physician will be kept in the PICU.

Visiting Regulations

1. Visitors other than parents may be present with parental permission.

2. Visitors may be limited to two persons at a time at the discretion of the bedside RN.

3. One immediate family member may stay with the patient 24 hours a day.

4. Visitors must check at the desk outside PICU for permission to visit the child.

Pediatric Resuscitation Course

Pediatric resuscitation courses such as Pediatric Advanced Life Support (PALS) will be offered several times per year. All residents are required to complete this course. You will need to recertify for this course at the end of your second year.

Schedule and other rules

§ Call is generally q4. We don’t make your schedule.

§ Rounds start at 7:30 M-F. Prerounding, including gathering information about events of the night, vitals with I/Os, labs, and examining the patient must be accomplished prior to rounds. The time needed for this will depend on the acuity of the unit. Residents should not arrive before 6:00 am. If you are unable to pre round on all patients, do so on the most ill or acute patients so that decisions can be made on rounds. It is helpful if the post call person gives accurate, summative sign-out so that pre-rounding is not bogged down by trying to figure out what generally happened over night. The post call person should make a quick go-around the unit prior to the day people coming in so any last minute changes can be relayed. “Discovery Rounds” should be avoided.

§ Rounds on the weekend start at 9:00 am. The resident on call the previous night will pre-round on all the patients (subject to change by residents—how you do this is up to you).

§ Signout rounds M-F generally start at 4:30. The PICU residents are responsible for signing out to the incoming resident.

§ The patient signout sheet is kept up to date by the residents. Help each other, do a good job with it.

§ When one of the PICU residents has clinic, he/she should sign out to the other resident. If both residents will be gone for a given time period, please notify the attending on service as soon as possible (ie, when you figure it out). The attendings have a backup system in place, we need to know when 2 attendings will be needed.

§ The residents are responsible for assuring their compliance with work hours regulations, both daily and weekly. We do not keep you schedule. If you are finding it difficult to comply with the regulations, please let us know.

§ PICU attending lectures generally occur daily in the conference room, generally at 11:00am. It is assumed you will be present and the attending on service will cover issues during the lecture.

§ Procedures: Procedures will generally be done by the resident covering the patient, with supervision by the attending. There will be times when the attending will do the procedures and times when a more senior resident will do the procedure. Our first priority is patient care. As a general rule, lines on infants or hemodynamically unstable patients will be done by the attending. Intubation of patients who are not NPO, who are known to have difficult airways, who are extremely hypoxemic, or patients who are hemodynamically unstable will be done by the attending or an experienced resident.

§ Orders: Bedside charts MUST stay at the bedside. Orders should be written on rounds as decisions are made. You MUST tell the nurse if you are writing an order if you would like it to be carried out in a timely fashion.

§ You will take on exam at the end of the rotation. It has been developed by a collaboration of Peds intensivists around the country and is used to tailor our educational objectives. It stays with us.

§ A PICU reference guide is being developed in a collaboration between residents and the attendings. It will exist at some point.

ED residents, fellows, students etc

§ Students do sub-internships in the PICU. They should be assigned patients by the senior resident or attending. In general, it is best if the students have patients with the seniors, though this is not essential. The students take call with the senior.

§ ED interns rotate through the unit. They take patients independently. We have no control over their schedule. They take call with the second year resident.

§ There will sometimes be other sorts of people doing rotations with us (anesthesiologists, surgeons, etc) . Their roles will depend on their learning objectives.

Helpful tips

§ PICU nurses are very experienced and invested in the care of these patients. Learn from them. Take their advice and concerns seriously.

§ If you disagree with a nurse, please discuss the issue with the attending.

§ If a nurse asks you to call the attending, do it.

§ If in doubt, call the attending.

§ The only stupid question is the one you didn’t ask.

§ Follow up on anything that was supposed to happen (including labs and x-rays and CT scans. Even if you aren’t a neurologist, you will likely notice something really bad that we should know about).

§ Keep the surgical residents apprised of any changes in their patients.

§ If in doubt about orders on surgical patients, ask the attending the best course of action.

Double Pages and Code 99

A "double page" is a page indicating the emergency need for the house officer named to respond immediately. A "Code 99" page indicates the need for cardiopulmonary resuscitation. One of the PICU residents must carry the code pager at all times. The PICU resident is a member of the code team.