Medical Intensive Care Units - Boston University Medical .

Boston University School of MedicineDepartment of MedicinePulmonary/Critical CareMedical Intensive Care UnitsPhysician Operations ManualTABLE OF CONTENTSOverview of Clinical Experience .4Introduction.4Learning Objectives .4Teaching Methods.4Evaluations.4References.5Monthly Quality Assurance/Improvement Review .5Administration, Location and Organization .6Administrative Personnel.6Faculty.6Location .6Organization of MICU Ward Teams .6Physician Responsibilities .7General.7Codes.7Interns .7Residents .8Fellow .9Attending.9Daily Schedule .10Rounds Schedule .12MICU Coverage Responsibilities.13Short Call .13Long Call .13Post Call .13Routine.13Sample Coverage Schedule.141

Admission Guidelines and Procedures.15Overview.15Admissions Originating from the Emergency Department .15Transfers from other hospitals .16Clinics and floor transfers.16Bed availability .16OccupancySuspension of Admissions by MICU Attending.17Night and Weekend Coverage Systems.18Weekend Rounds .18Intern and Resident Coverage.18Pulmonary/Critical Care Fellow .19Attending.19Chart Documentation .20Admission Notes.20Daily Progress Notes.20Procedure Notes .20Transfer/Discharge Notes .20Performance Requirements and Recommendations .21Communication.21Demeanor.21Bounce Backs.21Problems .21Core Curriculum.22Overview.22Topics.22When to Contact the ICU Facilitator.23The ICU Facilitator .23Procedure when MICU bed occupancy approaches capacity on either campus.23ICU Facilitator Functions .24When, How and Who to Contact for Organ Donation.25Policy .25Procedure for patients with brain death or impending brain death.25Procedure for Asystolic Deaths (Tissue Donation) .25Medical Examiner Cases.26Code Blue Cardiopulmonary Resuscitation .27HAC MICU Resident.272

HAC MICU Intern .27Internal Transfer Policy .28Procedure for stable patients to non-critical care areas .28Procedure for patients to other critical care areas.28Admission Algorithm.29Admission Criteria for the MICU .30Discharge Criteria from the MICU.31MICU Refusal Documentation Form.32MICU Readmission Documentation Form .33Ventilator Weaning Protocols.34Ventilator Weaning Protocol Orders .37Oxygen/PEEP Wean .37Rate/Pressure Support Wean.38Spontaneous Breathing Trial.39Drotrecogin Alpha (Xigris) – Physician Ordering Procedure .40Admission Policy of MICU Patients to ENC 6 East CCU413.

Medical Intensive Care UnitsInformation for Physicians at Boston Medical CenterOverview of Clinical Experience{ TC \l1 "Overview of Clinical Experience}Introduction{ TC \l2 "Introduction}Rotation in the Medical Intensive Care Unit (MICU) is designed to provide state of theart care to seriously or critically ill patients in an environment that emphasizes learning,teaching and independence. Residents and interns are exposed to a large spectrum of clinicalproblems including, but not limited to, respiratory failure with or without mechanicalventilation, ARDS, shock, sepsis, gastrointestinal hemorrhage, diseases related to alcohol ordrug excess, HIV-related conditions, pulmonary edema, pulmonary emboli, renal, hepatic orcardiac failure, DKA, fluid, electrolyte or thermic disturbances, CVA or complications ofmalignancies. The House Officer admits and manages all patients in the MICU with thesupervision of the MICU Attending/Fellow. Additional support is provided by the faculty ofthe Department of Medicine either as sub-specialists or as primary physicians.Care is provided in a team format which includes physicians, nurses, respiratorytherapists, pharmacists, nutritionists, physical therapists and social workers. This multidisciplinary approach provides excellent care to patients by capitalizing on the expertise ofmany services.Learning ObjectivesBy the end of their rotation, house staff will be able to evaluate and diagnose thepathophysiological process, anticipate complications and administer treatment to critically illpatients with multi-system disease. Inherent in this process is the development of thethinking patterns required to deliver superior health care employing state of the arttechnology. In addition, house staff are expected to become proficient in the insertion ofcentral vein catheters, management of ventilators, interpretation of data from Swan-Ganzcatheters, the interpretation of CXRs and other radiological examinations. Other commonlyperformed procedures, such as lumbar puncture, thoracentesis, paracentesis, arterial puncture,contribute to the experience of ward medicine.Teaching Methods{ TC \l2 "Teaching Methods}Daily didactic seminars are provided by the MICU Attending and Fellow on the MICUcore curriculum.Direct guidance and commentary is afforded daily on chest films.Application of medical knowledge to clinical conditions are provided during work and walkrounds.4

Evaluations{ TC \l2 "Evaluations}House staff are evaluated by the MICU Attending in oral communication with membersof the Residency Program Office and in written reports at the end of the rotation. Due tosome split months by Pulmonary/Critical Faculty, some house staff may receive reports withinput from more than one Attending. Interim and final oral evaluations may also be providedat the request of the house officer or at the discretion of the Attending.References{ TC \l2 "References}A compendium of critical care articles is located in each of the three Units. Referencetexts are located in the MICU for use by the house staff. Summaries representing the corecurriculum will be provided at the didactic teaching sessions Additional articles are providedfor specific problems by the MICU Attending/Fellow.{ TC \l1 "}Monthly Quality Assurance/Improvement Review{ TC \l2 "Monthly QualityAssurance/Improvement Review}The Medical Director/Associate Medical Director, Nurse Manager/Assistant NurseManager, Attendings, Fellow and other staff will meet at 4 week intervals to review thefollowing for quality assurance:1)2)3)4)5)6)7)8)9)DeathsAdmission Refusals and outcomesRe- admissions (Bounce backs)Incident ReportsReportable Events/OccurrencesOrgan DonorsSystems IssuesPrevious period follow upBronchoscopy/ProceduresReturn to Table of Contents5

Administration, Location and Organization{ TC \l1 "Administration,Location and Organization}Administrative Personnel{ TC \l2 "Administrative Personnel}Director:Arthur C. Theodore, MDAssociate Director:Christine C. Reardon, MDNurse Manager HAC:Liz Tassinari, RNAssistant HAC:Patricia Covelle, RNNurse Manager ENC: Paula Danz, RNPager: 1211 Office: 84933Pager: 2047 Office: 88636Pager: 8289 Office: 47265Pager: 4390 Office: 44392Pager: 4897 Office: 85726The nurse manager’s office on HAC is located outside of 5 East MICUThe nurse manager’s office on ENC is located on the 6 E ICU unit.Faculty{ TC \l2 "Faculty}MICU Faculty: Pulmonary/Critical Care MedicineSupport Staff: Nutritional, Epidemiology, Pharmacy,New England Organ Bank Representative:Robin Ohkagawa; Beeper 617-473-1290Location{ TC \l2 "Location}Harrison AvenueEast Newton5 East MICU: 10 beds expandableTelephone: 414-5825,6,7FAX: 414-31146 East ICU (CCU): 8 beds expandableTelephone: 638-5910FAX: 638-66865 West MICU: 8 beds expandableTelephone: 414-4421,2,4FAX: 414-4423Organization of MICU Ward Teams{ TC \l2 "Organization of MICU Ward Teams}Harrison AvenueEast NewtonTwo separate teams consisting of:One team consisting of:Pulmonary/Critical Care AttendingPulmonary/CriticalCareAttendingOne medical resident (pgy 2/3)One medical internTwo medical residents (pgy 2/3)Two interns (medical/categorical)6

(Fourth year Medical Student)(Two) Family Medicine InternsOne MICU-dedicated Pulmonary/critical care fellow is assigned to the Harrison AvenueMICU and one non-dedicated fellow is assigned to the East Newton CampusReturn to Table of Contents7

Physician Responsibilities{ TC \l1 "Physician Responsibilities}General{ TC \l2 "General}House officers are directly responsible for the medical care of all patients admitted to theMICU Service, but are not responsible for the care of patients boarded in the MICU on otherservices such as surgery except in the event of life-threatening emergencies.Codes{ TC \l2 "Codes}Harrison Avenue (HA): The long call resident and intern carry the code beepers andrespond to codes in the HA Pavilion. The MICU resident is the physician leader whomanages and terminates the code, determines disposition, communicates with the primarycare/attending physician and family and signs the code record. The intern performsACLS/BLS, obtains venous access, blood gasses and other blood work and other proceduresas necessary.East Newton: The code beepers are carried by an intern and resident on the CCU service.Interns{ TC \l2 "Interns}1)Primary patienta) Coordinates procedures performed by consulting and ancillary servicesb) Schedules tests and completes requisitionsc) Arranges consults2) Note Writinga) Daily progress notesb) Transfer notes with documentation of acceptance by receiving service attending3) Pre Work Roundsa) Review of overnight events with post call intern, respiratory therapists and nursesb) Correction of urgent/emergent problemsc) Recording of patient data from bedside charts to daily progress noted) Physical exame) Completion of progress note summary4) Reads the films in Radiology Rounds5) Presents on work rounds using the following format:a) Review of events from the previous 24 hoursb) Presentation of patient data (running the board)c) Direct examination of the patientd) Synthesis of the data and Impressione) Formulation of medical problem listf) Developing the management plans8

6) Performance of procedures7) Management if acute problems8) Night time cross coverage9

Residents{ TC \l2 "Residents}1)2)All patient primary careSupervision of Interns and Sub-internsa) Proceduresb) Presentationsc) Problemsd) Transfer Notese) Teaching3)Admissionsa) Evaluation and acceptance/refusalb) Admission/refusal Notec) Listing of refusal on QA/QI performance improvement refusal review formd) Documentation of Discussion with Fellow/Attending in admission notee) Communication of admission to nurse manager (day) and nursing supervisor (night)4)Dischargesa) Identify patients meeting discharge criteriab) Creation and communication of “bump lists” to night charge nursec) Dictations and completion of Green Sheet on patients discharged to home or to otherfacilities5)Pre Work Rounds with Fellow and Respiratory Therapya) Identify patients meeting discharge criteria and informing ward secretariesb) Identify patients meeting criteria for ventilator weaning/extubation and initiatingprotocols6)Morning Work Roundsa) Presentation of new admissionsb) Supervision of Intern/Sub-Intern presentations7)Communication with medical and lay communitya) Families/Family meetingsb) Primary care physiciansc) Nursingd) Fellows and Pulmonary/CCM physicians8)Consultation with social services for patients requiring placement in long term care andrehabilitation institutions9) Evening Walk Roundsa)Present new admissionsb)Review data and progress of all patients on the servicec)Develop overnight management plansd)Identify patients likely to meet transfer criteria overnight and in the AMe)Develop Bump list and inform charge nursef)Assign transfer notes to intern/sub-interng)Identify candidate patients for weaning/extubation and initiate overnight protocols10

Fellow{ TC \l2 "Fellow}Review of all admissions with admitting residentSupervision of proceduresKnowledge and experience resource for house staffPlacement of Swan-Ganz cathetersTeachinga) Radiology roundsb) Core curriculumc) Work and walk rounds6) Pre Work roundsa) Leads resident and respiratory therapistb) Assists in problem solving7) Morning Work rounds8) Evening Walk rounds9) Family Communication10) Bronchoscopy1)2)3)4)5)Attending{ TC \l2 "Attending}11) Ultimate responsibility for patient carea) Supervises medical managementb) M

Medical Intensive Care Units Information for Physicians at Boston Medical Center Overview of Clinical Experience{TC \l1 "Overview of Clinical Experience} Introduction{TC \l2 "Introduction} Rotation in the Medical Intensive Care Unit (MICU) is designed to provide state of the