WELCOME TO YOUR ICU ROTATION. WE'VE BEEN EXPECTING YOU.

OUR PHILOSOPHY

The ICU is where the sickest patients in the hospital come to get a shot at survival. In order to accomplish this they need aggressive upfront care.

We are here, first and foremost, to protect and care for our patients. This is a 24/7/365 investment for us. By virtue of the fact that we chose to do this for a living, we expect phone calls at night and we expect to come in to perform procedures and to manage our patients.

We know that none of you are coming to or leaving this rotation as experts in ICU procedures or critical care. YOU need to know that too which is why you need to keep us informed at night.

There can be no ego when it comes to taking care of patients and no loss of pride in calling for help. We expect YOU to know your limitations and to call us

about admissions

if a patients who is already admitted unexpectedly deteriorates

if you are becoming too busy to provide good care

if you are unsure of your central line procedure skills

if you are feeling overwhelmed.

Consults and admissions are not a burden of work, they are an opportunity to help patients, help our colleagues from other services, and learn along the way.

The walls of the ICU are flexible. We are never full. We will never say no to admitting a sick patient. We will always figure out a way to get them the care they need in the ICU.

We are careful about criticizing others. In the ICU we see every major complication in the hospital. We often have the benefit of all the information and the retrospectoscope. We have plenty of mishaps of our own.

Medicine is both rewarding and humbling. The humbling moments are important to keep us grounded and keep us from becoming overconfident.

Having said all of that, even though the ICU is the highest acuity unit in the hospital, the environment is enjoyable and we think you will enjoy this rotation. You can relax in knowing that we are here to teach you, to support you, and we will always have your backs.

You are going to learn a lot here.

YOU WILL GET OUT WHAT YOU PUT INTO THIS ROTATION

The ICU is a physiology lab. This is your opportunity to learn and see physiology and pathophysiology real time, and watch how patients responds to intervention.

This is also your opportunity to learn and hone skills in prioritizing the issues for a patient, developing an approach to each issue, and comprising a plan

If you are finished your work, help your colleagues. The more you see and do around here, the more you will learn.

If you are a senior, take the initiative to teach. Teaching helps us solidify our knowledge

If you are a junior, come along whenever there is any action in the ICU. This is YOUR rotation. You do not need an invitation and you will not be a burden or in the way.

Embrace the fact that you will be assigned different patients and sometimes will have to swap teams in the ICU. This is real life. We have no control over what comes through the ICU doors and have to figure it out on the fly. So do you.

Take pride in your notes. The are a reflection of YOU. They reflect your understanding of the patients and the plans and we read them with that in mind. Make sure they are up to date and accurate.

THE TRUTH

The truth is that we can run the ICU more efficiently without residents but we want you here to learn. We want to be a part of making you into better and safer doctors. We want to teach you but we also want you to take responsibility for your own learning because as attending physicians, this is a skill you must have.

With this in mind

Take ownership of your patients and read around them

Know your patients well. Examine them every day. Know if they are getting better, worse, or unchanged. Know their issues. Know their test results. Know their medications. Audit their medications.

Commit to a plan and communicate it on rounds

Do not be afraid to be wrong about your plan on rounds or when you call us about consults at night. We are here to teach you and you are here to learn from us.

Get to know your patients as people and get to know them better though their families. Treat them as you would a friend or family member and you will never do wrong by them

THE WORKDAY FLOW

THE DAY NEVER REALLY BEGINS OR ENDS

0730 Morning Teaching Rounds

Civic Campus McCoy Room

General Campus ICU Conference Room

The ICU attendings or Fellows will provide a morning teaching session every day except for Wednesdays

We expect you to be on time for teaching in the mornings.

We provide these lectures to you to prepare you for your rotation.

We do not have teaching on Wednesday to provide you with an opportunity to attend your own grand rounds.

If you are not attending your grand rounds, we expect that you will take the extra time to learn your patients and help your colleagues finish up orders and admissions if they've had a busy night.

Please fill in your evaluations of these rounds. We want these rounds to be helpful to you and want to know if there are ways we can improve

Pre-Rounds

Unbeknownst to you, the attending physicians and fellows are rounding in the units while you are in teaching rounds.

The ICU workdays are 24/7. We cannot possibly wait to the end of teaching rounds to have plans for all the patients. As much as we want you to own your patients and make their plan for the day, some decisions and plans have to be made early and without you

With this in mind, you should therefore now that bedside teaching rounds are for YOU. We have already rounded before 0930hrs rounds begin.

0930 Bedside Teaching Rounds

You will be expected to introduce the patient and the reason for admission

The RT will provide a run down of ventilator settings and any changes overnight.

The nurse will give a head to toe summary

You will be expected to present an itemized, prioritized list of the patient's issues and your plan for dealing with each issue

Rounds will end when they end but usually between 1100hrs and 1300hrs depending upon how busy it is

Sign Out Rounds

Will take place between 1600hrs-1830hrs depending how busy it is

Do your own pre-round prior to sign out rounds in order to tidy up any issues the. nurses may have

All residents regardless of what side you are assigned to are expected to attend sign out rounds. This is an opportunity to learn and familiarize yourself with patients you will be managing on call

You will be expected to introduce the patient and the reason for admission

You will be expected to only provide a synopsis of issues the MD on call may encounter and any tests they must follow up on

Tuck In Rounds with the Care Facilitator

Senior and Junior residents round with the Care Facilitator when time permits in the evening (2000hrs-2300hrs)

To reassess all the patients and ensure there are no new issues

To follow up on any issues you've not had time to get to yet

To take care of any issues the nurses may have

These are not intended for you to address day time issues that should be addressed by the team when they round

Contact the ICU attending to run the list after tuck in rounds are finished

ICU CHART NOTES

TRANSFER NOTES AND PATIENT TRANSFERS OUT OF ICU

Procedure Notes

The Epic procedure notes are pre-populated with answers on and may contain incorrect information if you don't change it

Ensure they are edited for accuracy

Progress Notes

Notes are an essential means of communication. Write your notes as if they are a message to your colleague on call indicating what they should be watching out for.

Notes are also an important way for us to evaluate your understanding of the patient and your attention to details on rounds.

Certain portions that do not change during the admission such as the presenting history, can be carried over in notes.

Issues in the last 24 hours must be edited every single day

The problem list must be viewed and edited for accuracy every single day

TRANSFER NOTES AND PATIENT TRANSFERS OUT OF ICU

THESE ARE EXTREMELY IMPORTANT NOTES

THIS IS A VERY HIGH RISK TIME FOR ICU PATIENTS

Click on the link below to access the dedicated section onPatient Transfers

Patient Transfers

PSCU (CIVIC)

TRANSFER NOTES AND PATIENT TRANSFERS OUT OF ICU

PSCU (CIVIC)

Post Surgical Care step down unit.

Beds 29-33

The most responsible physician (MRP) remains the surgeon and his/her team (as opposed to the ICU where the MRP is always the intensivist)

RACE MD rounds on them during the day and signs them over to the on call team at night

You will be notified by the MRP service if a patient requires admission. Your only job is to let the CF know

The MRP service with write the transfer order

ICU service will be available for emergencies (no RACE call required)

You do not have to write an admission note or admission orders however it is good to familiarize yourself with the patient in case you are called to assist

CONSULTING OTHER SERVICES

The ICU is closed unit, meaning, we take care of all aspects of patient care

Closed units have been proven to improve patient outcomes

It is important that we coordinate all aspects of care because we are aware of all the issues and how they interplay

Please ensure you discuss consulting other services with the ICU attending before doing so

The one exception is the mandatory consult that has to go to medicine in order for them to see and accept a patient in transfer

FAMILY MEETINGS

CONSULTING OTHER SERVICES

Make a point of attending family meetings.

Empathy is not something that can be taught, it is something you feel when you get to know patients through getting to know their families.

You will have no better learning on how to navigate difficult conversations than learning by seeing how we approach this - most of our conversations involve the delivery of bad or devastating news when families are at their worst

It is our job to ensure they understand what is happening, what to expect, and that we will be there to help and guide them

When updating families, be cautious of providing them with too much information because it is overwhelming and they cannot process it. They do not need to know that the WBC has increased from 7 to 9, that they had an isolated temperature of 37.9, or that their potassium was low and required replacement.

The SDM requires a daily update.

RACE

RACE is staffed by an Intensivist from 0730 - 1700hrs

The Junior Resident will hold the RACE pager at night and be responsible to attend all RACE calls

There are two MD RACE pagers. one is for the attending during the day and the senior at night. The second is for the RACE resident (if there is one) or for the junior resident on-call if there is no RACE resident (see next)

If there is no RACE resident on the block, the junior, when possible, should attend the RACE calls during the day. This is the best 1:1 teaching you will receive and it will prepare you for your calls at night

The junior should have a low threshold for calling the senior resident if a patient is unstable

The junior must review all RACE calls with the senior

The senior will review RACE calls with the attending or fellow at their discretion

ICU CONSULTS

OUTSIDE OF HOSPITAL CALLS AND PERT CALLS

INFECTIOUS DISEASES IN THE ICU

If you are called for a consult go see the patient ASAP or let the service know if you are busy and there is going to be a delay

Let the care facilitator know that you are going to see the consult so they can start preparing

Let the care facilitator know as soon as you know about any isolation requirements

If you need help, you can ask the RACE nurse and RT to come with you

If you need help, you can always call the attending sooner than later

INFECTIOUS DISEASES IN THE ICU

OUTSIDE OF HOSPITAL CALLS AND PERT CALLS

INFECTIOUS DISEASES IN THE ICU

C. diff, MRSA, ESBL, VRE, Carbapenem resistant organisms are all a reality now

The patients in the ICU are sick and often immunocompromised and it is essential that we don't transmit communicable infections

Make sure to wash your hands before and after every patient and if you are using your own stethoscope, wash it as well between patients

For the same reason, don't hang on or touch the patient's beds and contaminate yourselves

OUTSIDE OF HOSPITAL CALLS AND PERT CALLS

Outside of Hospital Calls

All outside calls must go through the attending phyisican or fellow

If you receive a call from a peripheral hospital or Criticall Ontario - redirect the call

Pulmonary Embolism Response Team (PERT) calls

All PERT calls are screened by the attending physician or fellow

All PERT calls are discussed between the ICU, Thrombosis, and IR attendings

The attending physician or fellow will contact you thereafter to see the consult and advise you of the plan

EXPECTATIONS

OUTSIDE OF HOSPITAL CALLS AND PERT CALLS

Senior Resident

Will be responsible for all ICU consults and management of admissions

Will be responsible for all the patients in the unit

Will be asked to teach the junior residents in order to hone your teaching skills

Junior Resident

Will carry the RACE pager during the day if there is no RACE resident during the block

Will carry the RACE pager at night

We expect you to call and review each consult with your senior

If you are having a quiet night, we expect you to assist the senior and learn from the senior. Remember that most of you are coming back as seniors the next go around.

In General

We expect you to take ownership of your patients on the rotation and will look to you to comprise a plan and commit to decisions every day. Do not worry, we won't let you proceed with an incorrect plan or dangerous decision

If you are sick or have to be away, we expect you to notify Chantal Theriault, the ICU attendings and fellows, and your program director.

If your illness/absence involves on-call responsibilities, we expect you to try to find coverage. Part of your residency is preparing you for life after residency. Finding coverage when we are unavailable to perform our duties is part of our responsibilities to our patients and to our colleagues.

We expect you to follow up on test that were ordered on your patients

If you can't get all your work done before half day, we expect you to sign over any outstanding responsibilities to a colleague, fellow, or your attending

PROBLEMS

EXPECTATIONS

PROBLEMS

We are aware of the issue of residents receiving enumerable epic texts and are working to improve this. Please let us know if this problem occurs

If you have an opportunity to sleep, you are well within your right to turn off your messages. If there is something important you need to know about you should be paged

If you have had a difficult encounter in the ICU with any of the support staff, please let us know and we will follow up on it. You will remain anonymous.

If you have concerns about a fellow resident, please let us know. You are all in the process of becoming competent and professional MDs, Teachers, and Preceptors with the primary goal of protecting and caring for patients. We need to know if there are issues with competence, safety, or professionalism and it is your responsibility to protect patients, same as it is ours. You will remain anonymous

EVALUATIONS

All one 45 resident evaluations for your

Civic rotation are to be sent to Dr. Hilary Meggison

General rotation are to be sent to Dr. Alex Fottinger

Medical students are to distribute their evaluations to the intensivist they worked most with

The respective campus intensivists meet as a committee in the week prior to the end of the block to provide input into the evaluations. Additionally we seek input from our fellows and other residents to ensure a fair and complete evaluation

All residents will have an exit interview at the end of the block to review their performance and to provide feedback to us as to how we can make this rotation better for you

WELCOME TO YOUR ICU ROTATION. WE'VE BEEN EXPECTING YOU.