House Staff Orientation:

MICU
Educational Goals and
Objectives
 Educational goals and objectives
• Basic and advanced critical care medicine
– Management of acute respiratory failure
• Vents, NIPPV, status asthmaticus, ARDS
– Shock management
• Resuscitation, sepsis RX, use of vasopressors/ionotrophs
– Principles of critical care
• Prophylaxis, antibiotics, sedation
• Procedures
• End of life skills
• ECMO
– VV, VA ECMO
• To be managed by PGYII/III/IVs
 Educational goals and objectives
• Hand-offs
• Collaboration
• How to identify important information
• How to prioritize information
• Keeping track of details
• When to be appropriately “nervous” about a patient
• When to call for back up (fellow and attending)
 Educational goals and objectives
• Given the current limitations on time spent in
hospital, teaching will occur in one of two ways.
– The fellow will do a brief didactic lecture before rounds
two-three times / week
– The attending may use a current new case to do expanded
case-based teaching during ICU rounds
• Residents are expected to ACTIVELY pursue
independent study through, books, journal, website or
discussions with faculty
– Refer to Google Drive folder (MANY important articles)
Patient Care
 The house staff teams
Resident / Intern pairs
• The day teams: Long Call, Short Call /Float
– Long call day ends after evening rounds (~10PM)
– Short call days ends after afternoon rounds (~5PM)
– Six consecutive days
– Long  Short  Long  Float  Long  Short
• The night team
– Begins at evening rounds (7:30PM), ends ~10AM
– Three consecutive days followed by three days off
• Interns: 16 hour limit, 8 hours between on call
and post call days
 Pre-rounding
1. Patient Assignment
– Every effort is made to assign house staff to
patients they admitted or previously cared for
– Receive sign out from night float team
– Overnight team presents ONLY the patients that
they admitted (no “old” patients)
 Pre-rounding
2. Round with nurse / examine your patients

*** Remember: the computer is not your patient,

your patient is your patient ***

A. Info from the nurse: overnight events, amount of

sedation administered and why, interactions with
family, orders needed, changes in vent (also
discuss with RT)
 Pre-rounding
2. Round with nurse / examine your patients

B. Info from the patient: examination, I’s/O’s,

bowel movements, lines and tubes (how lung in
place), drips (what, how long, why), tube feeds,
vent settings

C. Info from computer: labs, active meds (renew

meds as necessary), consultant notes, place orders
 Pre-rounding
3. Update progress note
*** Every day, ask yourself, “Why is this patient
critically-ill?”
– Generate a list of ACTIVE medical problems
• BE SPECIFIC
– NO: “Acute respiratory failure”
– YES: “Acute respiratory failure due to COPD exacerbation”
• May include problems that are not active or have
resolved but DO NOT discuss on rounds
 Pre-rounding
3. Update progress note
– Generate a PLAN by systems
• DO NOT summarize, present a specific plan
• Discuss how you will address REVERSIBLE processes
in the context of IRREVERSIBLE processes
– NO: “Plan is to wean from the vent”
– YES: “The patient has a pulmonary edema on a background of
severe emphysema so we’ll diurese, goal net negative 1-2L,
continue bronchodilators q4 hours and do a PS trial this
afternoon.”
 Pre-rounding
4. Didactic session: 7:45 – 8:15AM
– With the fellow
– Two days / week. Rounds start immediately
afterwards
– Combined MICU/TICU rounds, 2nd and 4th
Wednesday, 8-9AM
– On days with no didactic session, morning
rounds start at 8 AM
 Specific responsibilities
Overnight Team

After midnight, start a new MICU QI checklist with fellow

 Specific responsibilities
Overnight Team
• Follow up on as many AM labs as possible
– Replenish lytes, transfuse etc…
• 5AM lightning rounds with fellow, RT, RNs
– If appropriate, plan SAT (adjust sedation so that RASS is 0 to -2) and
SBT (low PSV or T-piece) for all intubated
– Extubate patients who pass SAT/SBT
– Identify new patients who are candidates for PT/OT
• Generate a rounding list
– Very sick/active, new, the rest …
– Update the role of each house staff on the rounding sheet
– Update the name of the float MD and charge RN on the erase boards
(S and W sides)
 Specific responsibilities
Float

• Get the nurse for every patient that we

discuss on rounds
• Put out fires
– Orders
– Evaluating unstable patients
• Help with procedures
 Specific responsibilities
Long Call/Short Call

• Be present on rounds (especially, the long call team)

• Long call resident: summarize the plan for the day after
each patient presentation
• Orders: do not let the team disperse until all of the
orders are placed
• Admit patients through rounds (short) and after rounds
(long)
• Long call team: brief walk rounds to follow up on daily
plan. To be done before afternoon sign
 Workflow for MDs and RNs
• Rounds are multidisciplinary
– Nursing plays an integral role in rounding
• Frequent communication with the primary nurse
– Any new orders, any changes in care plan, any
procedures or tests ordered, family meeting
• Important change in clinical status
– Evaluate the patient with the nurse
 Workflow for MDs and RNs
• Make sure orders are entered appropriately
– D/C PO meds/convert to IV if the patient is NPO or is
incapable of taking POs
– If an OGT is in place, meds should be ordered “per
OGT” not “PO”
– Correct preparation (ask RN and/or pharmacist if
unsure)
• Batch blood draws
– Game plan with RN
– Minimize how often a patient is stuck
– “Add on”, if appropriate/possible
 Presenting patients
• After presenting a patient, the team should
understand:
– What you think is wrong with the patient
– What do you want to do about it
• Be concise
– Do not repeat information
• ALWAYS stick to the template
• Context is everything
– What’s a “normal” blood pressure for the patient?
– What’s a “normal” PaC02 for the patient?
 Presenting a new patient
1. Age/ gender / reason for admission to ICU
2. HPI
- Including key PMH , labs, x-ray or other data essential to
understand illness.
- If the diagnosis has been established do not include detailed
description of onset.
- Continue HPI up until morning.
-Any other significant organ dysfunction should be mentioned here
3. Meds/ PMH
4. Physical Exam
5. Data: key labs/imaging/ ECG /other
6. Assessment and development of problem list
7. Plan
 Presenting an old patient
1. One line summation
2. Goals of care yesterday and were they met
3. Significant events of last 24hrs
4. Active problems
5. Plan (goals of care for today)

*** Data (IN EACH SYSTEM): Pertinent

PE, labs, imaging, consult input
 Family contact
• One of the most IMPORTANT aspects of
care – rates very highly in terms of
satisfaction
• Put yourself in their place – a little
information goes a long way
• “Difficult families” warrant MORE
communication not less
 End-of-life issues
• Whenever possible, major EOL meetings
are conducted by attending.
• Resident and nurse should be present
• Avoid “hallway” meetings
• Be prepared for any and all philosophies
about EOL
 IV Opiate Shortage
• IV Dilaudid and Demerol are tier 2: less than a 30 day hospital
supply with NO ability to obtain more when we run out
• All other IV narcotics are tier 1 (less than a 30 day hospital
supply with limited ability to obtain more when we run out) but
will quickly become tier 2
• For now
– IV Dilaudid can only be ordered under extreme and unusual
circumstances
– Rapid transition to po narcotics if the gut works
– Non-narcotic analgesics: Toradol, PR/IV Tylenol
– Early initiation of antipsychotics in intubated patients that are “agitated”
– Use your clinical judgement:
• If anxiety  benzo
• If delirium  antipsychotic
• If pain  analgesic
 New England Donor Services
• Impending brain death (potential ORGAN donors)
– Timely referral when it has been determined that the
patient has severe neurologic injury

• Asystolic deaths (potential TISSUE donors)

– Contact NEDS within one hour of ALL deaths

• Notify the medical examiner’s office in all instances

when a donation is to take place
Quality Indicators
 Quality Indicators
RIH MICU Goal
Active Restraint Order 100%
Active Foley Order 100%
Weaning From Vent Order 100%
VAP Bundle Order 100%
PT/OT Consulted > 88%
SAT Performed/Being Coordinated > 95%
SBT Performed/Being Coordinated > 95%
Daily Assessment, Need for Central Line > 88%
Daily Assessment, Need for Foley > 88%
GI Proph Order Written 100%
DVT Proph Order Written 100%
GI Proph Discontinued When Not Indicated 100%
DVT Proph Discontinued When Not Indicated 100%
 Specific expectations
Compliance with quality indicators

• For ALL patients

– If a foley catheter is in place
• There must be an ACTIVE foley order (7 day)
• Determine (at least daily) if the foley is still indicated and d/c if not
– If a central venous catheter is in place
• Determine (at least daily) if it is still indicated and d/c if not
– Activity order
• DEFAULT order for ALL patients: “Activity as tolerated”
– GI and DVT prophylaxis
• Determine if they are indicated
• If so, ENSURE that they are ordered
 Specific expectations
Compliance with quality indicators
• For patients on a VENTILATOR
– If indicated, a spontaneous awakening trial (SAT) MUST
be performed DAILY (at least)
• Sedatives/analgesics being administered in such a way that a
reliable neuro exam can be performed
– If indicated, a spontaneous breathing trial (SBT) MUST be
performed DAILY (at least)
• Low PSV or T-piece
– If needed, an ACTIVE restraint order (renewed every 24
hours)
MICU Evaluation
 MICU Evaluation
1. Works in a collaborative and professional manner with patients, their
families and with the interprofessional team (peers, consultants,
nurses, respiratory therapists, ancillary professionals and other
support personnel)
2. Recognizes when a patient is becoming or has become critically ill
and takes appropriate steps to address the change in patient’s status
3. Gathers and synthesizes data in order to generate a coherent and
rational patient assessment and daily care plan
4. Completes assigned tasks for the day independently
5. Demonstrates an understanding of key principles and practices for
resuscitation of patients in shock
6. Demonstrates an understanding of appropriate antibiotic use in
critically-ill patients
7. Incorporates quality improvement initiatives in the daily care of
critically-ill patients
Sedation Protocol

STEP 1
Pain Assessment q2hr at minimum
GOAL: CPOT < 2
Yes
At Goal?
Proceed to STEP 2
No
IV Fentanyl
- 25 mcg q5 min prn CPOT 2 to 3
- 50 mcg q5 min prn CPOT 4 to 6
- 100 mcg q5 min prn CPOT 7 to 8
** Notify physician if CPOT score not
achieved within 1 hr. Start IV Propofol or
Dexmedetomidine per MD orders (Step 2)
Once CPOT < 2 achieved,
proceed to STEP 2
To be used ONLY with patients
treated with paralytic agents
Fentanyl Continuous Infusion
- Start infusion at 50 mcg/hr
- If CPOT not 0-2, bolus as follows:
25 mcg q5min prn CPOT 2 to 3
50 mcg q5min prn CPOT 4 to 6
100 mcg q5min prn CPOT 7 to 8
- If patient requires > 2 boluses/hr,
increase infusion rate by 25 mcg/hr
- Max dose: 200 mcg/hr
** Notify physician if CPOT score not
achieved at max dose
** Over sedation: wean by 25 mcg/hr q10
min until goal CPOT score is achieved
** Start paralytics only after goal CPOT is
achieved.
Sedation Protocol for Intubated Patients
Rhode Island Hospital MICU and the Miriam Hospital ICU
Pain, Agitation, Delirium Assessments
pharmacologic treatment choice per MD orders
STEP 3
STEP 2 Delirium Assessment q4hrs
Agitation Assessment 2hr at minimum GOAL: CAM-ICU negative
GOAL: RASS 0 to -2
Yes
At Goal? At Goal?
Proceed to STEP 3 Yes
No No
IV Propofol
- Start infusion at 10 mcg/kg/min Consider non-pharmacologic interventions
- Titrate by 10 mcg/kg/min q5 min until goal RASS achieved prior to or in addition to pharmacologic
- Max dose: 100 mcg/kg/min treatments for delirium (see next page)
** Notify physician if target RASS score not achieved at max dose
IV Haloperidol
** Over sedation: wean by 10 mcg/kg/min q10 min until goal RASS
- For very mild symptoms (consider for elderly
score is achieved
patients), 2.5 mg IV q6 hrs
- For mild symptoms, 5 mg IV q6 hrs
- For moderate symptoms, 10 mg IV q6hrs
OR
- For severe symptoms, 10 mg IV then double
q20 min (max dose 40mg IV). Once desired
effect, start 25% of the last bolus dose q6 hrs
IV Dexmedetomidine
standing.
- Load 1 mcg/kg IV over 10 min unless HR < 70 BPM, SBP <100
mmHg or MAP <70 mmHg
OR
- Start infusion at 0.4 mcg/kg/hr
- Titrate by 0.1 mcg/kg/hr q20 min until target RASS achieved PO Quetiapine
- Max dose: 1.5 mcg/kg/hr - Start at 25mg po q8 hrs
** Notify physician if target RASS score not achieved at max dose - Increase dose by 25mg po q8 hrs
** Over sedation: wean by 0.1 mcg/kg/hr q20 min until goal RASS - Maximum dose 800mg daily
score is achieved
OR
Once RASS 0 to -2 achieved,
PO Olanzapine
proceed to STEP 3
- Start at 5mg po q12 hrs
- Increase dose by 5mg po daily
- Maximum dose 20mg daily
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 Sedation Protocol for Intubated Patients
Rhode Island Hospital MICU and the Miriam Hospital ICU

Important Considerations
 Titrating off fentanyl infusions: Potential for opiate withdrawal should be considered for patients receiving high doses of opiates for greater
than 7 days of continuous therapy.
• Greater than 7 days: Dose should be tapered by 25% daily to prevent withdrawal symptom. When the dose has been decreased to
100 mcg/hr, discontinue continuous infusion and transition to fentanyl boluses.
• 7 days or less: Discontinue continuous infusion without tapering and transition to fentanyl boluses.

 Spontaneous awakening trial (SAT): To be performed if the patient meets criteria per ABCDE protocol
• Bolus fentanyl: Hold boluses. Restart at ½ dose ONLY if the patient fails SAT.
• Propofol infusion: Hold infusion. Restart at ½ dose ONLY if the patient fails SAT.
• Dexmedetomidine infusion: Hold infusion. Restart at ½ dose ONLY if the patient fails SAT. If it is likely that the patient will require
Dexmedetomidine post extubation then for SAT, decrease rate by 0.1mcg/kg/hr q10 min until goal RASS score is achieved. Post
extubation, decrease rate by 0.1mcg/kg/hr q hr until off.

 Non-pharmacologic interventions for delirium: The following can be considered prior to or in addition to pharmacologic treatments for
delirium:
• Ensure daily awakening trials are conducted
• Continually reorient patient
• Perform early mobilization
• Promote effective sleep / awake cycles
• Perform timely removal of catheters / physical restraints
• Ensure the use of eyeglasses, magnifying lenses and hearing aids
• Minimize noise / stimulation at night

 Routine monitoring
• Haloperidol, Quetiapine, Olanzapine: Check EKG daily. Discontinue if significant QTc prolongation (> 500 msec)
• Propofol: Check triglycerides and lipase on day 1 of infusion and q 3 days. Discontinue if triglycerides >500 mg/dl or if lipase > 60
IU/L.

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