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Surgical Critical Care Service Resident Survival Guide 2017 www.pennsicu.org Fa

Surgical Critical Care Service Resident Survival Guide 2017 www.pennsicu.org Faculty Surgery: Benjamin Braslow, Jeremy Cannon, Daniel Holena, Lewis Kaplan, Patrick Kim, Niels Martin, Jose Pascual, Shariq Raza, Patrick Reilly, Mark Seamon, Carrie Sims, Adam Shiroff, Brian Smith Anesthesia: Maurizio Cereda, Scott Falk, Andrea Gabrielli, Emily Gordon, C. William Hanson, Jiri Horak, Meghan Lane-Fall, Krzysztof Laudanski, Howard Nearman, Kristen Rock, Hazel Werlhof Critical Care Fellows: Niraj Agarwalla, Ryan Dumas, Ksenia Guvakova, Mark Hoofnagle, John Jacob, Jennifer Leonard, Tal Mandelbaum, Sarah Mathew, Rita Milewski, Annie Moore, Alexis Moren, Joshua Nelson, Arpit Patel, Michael Stentz, Michael Tiller, Brian Weiss APPs: Jason Saucier (CRNP; Manager), Ashley Geller (CRNP), Amanda Martin (CRNP), Elizabeth Peitzman (PA-C), Alexandra Pendrak (CRNP), Michael Pisa (CRNP), Tara Collins (CRNP), Elizabeth Scarvaglione (CRNP), Corinna Sicoutris (CRNP), Stephanie Smith (PA-C), Reka Somodi (CRNP), Kate Sullivan (CRNP), Sofia Wronski (CRNP), Elizabeth Senese (CRNP), Amy Matta (CRNP), Emily Stelmaski (PA-C) Structure of Surgical Critical Care Service Green team coverage: (215) 410-2221  Rhoads 5 SICU beds 5001-5012  Founders 5/Rhoads 2-- Even room numbers Gold team coverage: (215) 410-2222  Rhoads SICU bed 5013-5024  Founders /Rhoads 2-- Odd room numbers Resident responsibilities Day -  Complete physical exams, and present patients during rounds (Use SICU forms to guide your presentation of the physical exam, recent studies, consults, changes in plan of care)  Enter orders and call consults while rounding (don’t wait until after)  Update patient doors with daily “to-do’s” and antibiotics regimen w/dates  Contact Primary service resident to update on patients’ plans of care o Attending to attending communications for discrepancies  Enter labs/CXR/TPN orders during rounds for following day  Obtain ICU consent on ALL patients when they arrive  Ensure Carelign is up to date: o “SICU Management” should be added as an “Active/Acute Problem”, assigning “Surgical Critical Care” under the Service drop-down.  Once added, click “Add consultant notes”, and choose “Surgical Critical Care” as the consulting service from the drop-down.  In the blank box, type “.sicu” and then fill out the respective systems o You should also update the top “Assessment” section: HPI, PMH/PSH, OR dates, daily events (most recent 3-5 days) o “HPI” section: daily events (older than 3-5 days) Night -  Contact primary service resident with any significant changes in patients condition  Complete physical exam and update documentation/Carelign as indicated  Patient discharges/transfers 5pm-7am: o Assess patient for appropriateness of transfer, give verbal signout to primary team, clean up orders (remove any ICU specific orders), write transfer note in PennChart (steal procedure templates from Ashley Geller, CRNP’s SmartPhrase list-use the .SCCSTRANSFER), place transfer order o If overnight transfer is unplanned (“bump”) for emergent bed needs, and if patient is transferring to Rhoads 4 or Silverstein 12, communicate with SICU RN that patient must be designated as a “Green Sheet” & place order for “Inpatient Consult to Respiratory Care” (type “Green Sheet” in comments of order)  New admissions 5pm-7am: o Construct comprehensive admission note in PennChart for all new patients. Steal note template from Ashley Geller, CRNP’s SmartPhrase list (use the .SCCSGENERAL note, or any note that starts with SCCS) o Ensure all orders are appropriate o In PennChart, add SICU green/gold to pt Treatment Team (in admission tab) o Create SICU Management Carelign section (see Carelign above) o Obtain ICU consent and med recs on arrival Advanced Practice Provider responsibilities:  Admit/Transfer/Discharge patients between 7 am – 5 pm  1+ APP per side during weekdays, 1 APP for entire SICU during weekends  Maintain SCCS Database  Ensure compliance with SCCS Clinical Practice Guidelines (CPGs)  Cover VISICU PACU beds (admissions, transfers and ICU care)  Communicate plan of care with primary service (APP/Fellow/Chief)  Assist/train or perform ICU procedures  Outreach (see at-risk patients on floor who have transferred from SICU) General:  Admissions 662-4106  Anesthesia 615-3497  Blood bank 662-3448  Blood culture 301-7970  Supervisor: 215 221-4021  Critical Care Lab 662-3724  CDR 662-2904  Chaplain 662- 2904  Dialysis 662-2646  Echo lab 662-2691  Echo read 662-2687  EEG 662-2661  Endoscopy 662-2122  EPS 662-3999  ER 662-3920  Gift of life: 1-800-KIDNEY 1  Hyperbaric 898-9095  Lab (Main) 662-6830  Legal Affairs 662-2546  Medical Records 662-3155  Morgue 662-3214  ME 215-685-7457  Nutrition support 662-3285  OR Rooms 662-66+Room #  OR coordinator 662-2101  Orthotics 662-3616  PennStar 662-7430  Pharmacy In-patient 662-2907  Pharmacy IV/TPN 662-2918  PM&R 662-3464  PT/OT 662-3260  Security 662-2677  Speech and Swallow 662-2784  Transfer center 662-3555  Transport 662-2478 In-patient floors:  Rhoads 5 SICU 662-3830  Rhoads 2 NT SICU 662-3898  Founders 5 CT SICU 662-3842  PACU 662-6860  Rhoads 4 662-3856  Silver 12 662-3882  Ravdin 9 662-3864 Consult pagers:  Anesthesia 614-1560 ext. 398  Blood Bank MD (Day) 980-9873  Blood Bank MD (Night) 306-0286  Dermatology 610-734-6560  ENT 308-2170  GYN 838-2681  ID Approval 306-0336  Neurosurg 312-3418  OMFS 610-738-6946  Ortho 406-6525  Pain 452-PAIN  PICC 290-5657  PICC Office 662-3551  Psych 401-1155  Stroke team 452-2793  TXP ID 314-0513 Radiology:  Scheduling 662-3000  File room 662-3058  CT-main 662-3142  CT-body read 662-3256  CT-head read 662-3480  CT ER scan 662-3084  CT ER PM read 662-3011  STAT X-Ray 662-3011  Chest reading room 662-3061  GI radiology 662-3515  IR 662-4034  IR angio 662-3080  MRI Devon 349-5596  MRI Founders 349-5270  MRI body read 349-5275  MRI head read 662-3480  Neuro-rad/Angio 662-3064  Nuclear Card/stress 662-2681  Nuclear C/S read 662-7519  Nuclear medicine 662-3076  Nuclear med read 662-3114  Ultrasound 662-3123  Vascular lab 662-2084 Fellow Call Triggers-MUST call fellow for the following:  Patient requires intubation  Decisions to extubate  Change in ventilator mode or need for increased support (i.e. FiO2, PEEP)  Greater than 2L fluid resuscitation  Transfusion decisions  Hypotension unresolved by 2L fluid resuscitation  Addition of vasopressors or titration to upper drug limit  Oliguria greater than 2-hours or anuria  Addition of antibiotics Helpful tips:  When in doubt, ask!  Only the SICU team is permitted to enter orders (except immunosuppression)  Review SCCS Clinical Practice Guidelines at: www.pennsicu.org  Discuss with and update covering RN re: new orders/tests/plans of care  ICU consent must be obtained on all patients on arrival  Med recs preferably on arrival (must be done within 24 hours of admission)  Discuss enteral feeding plan with primary team  Must call for all STAT studies  Call hematology fellow for approval of HIT panel  Hemodynamically stable patient transfusion trigger is Hgb<7  when ordering STAT antibiotics for sepsis, verbally inform RN of order.  www.uphs.upenn.edu/antibiotics  Order nutrition labs on Sunday night for every Monday morning  Ensure type and screen ordered every 3 days  Think before you “pan culture”. Selectively send cultures if you suspect infection. *Obtain urine culture on all direct admissions  Nutrition- main number 662-3223, weekends 215-559-4701 o Start standard TEN at 20mL/hr while waiting for nutrition TEN recs o TPN infusions start at night, and TPN orders must be in by 1500 (ask nutrition for help) Procedures:  MUST be certified to perform each procedure independently o If you aren’t certified, you cannot perform independently  If you don’t know, check on homepage http://uphsnet.uphs.upenn.edu/providerprivileges/  Dobhoff tubes- Providers MUST have completed training at SIM center before placing  Ensure procedure notes are completed for ALL procedures- in PennChart, steal procedure templates from Ashley Geller, CRNP’s SmartPhrase list (use the .SCCS notes only) A few surgical team preferences: (Unless otherwise specified)  Transplant –  See transplant guidelines on www.pennsicu.org  Only Albumin for resuscitation, no Crystalloid  NO FFP/PLT/Cryo for correction of coagulation unless directed by transplant attending or fellow  CBC q4 hours X 24 hours post transplant  LFT, LDH, Panel 5, CBC, Coags immediate postop & qAM  Transplant team to order immunosupression  CALL transplant team for everything  ENT-TORS pathway  Intubated 48 to 72 hours. Monitored in the ICU 24hrs post extubation  Start TEN on POD #1  Consult Diabetes if hyperglycemic & requires SSI  Urology- cystectomy and diversion-  IV fluids should be LR  NPO until urology team reports otherwise  Vascular- AAA  Q4 CBC for first 24 hours  Pulse checks and strict BP goals per vascular team SICU List:  print from Carelign site (see Carelign signout instructions above). Codes for rooms:  Nursing locker room (near 5005): 531  Founders 5 call room:4632  Staff lounge (middle hallway): 243  Supply rooms: 342  Med rooms: 2323 Nursing issues contact: Sebastian Ramagnano (RP5 RN manager) 267-283-8781 Christine Aiello (RP5 Clinical Nurse Specialist) 267-586-3361 Julianna Santine (RP5 assist. RN manager) 215-490-6209 Penn-Elert/VISICU: 215-893-7310  Staffed with critical care Attending from 7 pm to 7 am Schedule: Any schedule changes: resolve among co-residents, notify Jose Pascual (surgery) uploads/Sante/ survival-guide 4 .pdf