Family Medicine ICU Rotation

1. Rotation Description

Location:  Loma Linda University Health Critical Care Center: East Campus ICU (Unit 1400).  Unit phone 909.558.6695

Duration:  2 weeks during PGY 1

Contact Person:  Your Family Medicine Liaison is Dr. Mary Hanna

Format: Clinical rotation with teaching rounds designed to provide Family Medicine residents with basic skills in recognizing critically ill patients helping them develop adequate familiarity with the spectrum of ICU diagnoses.

Requirements:  Admission history and physical and daily management and progress notes on a total of 5 patients in ECICU over the 2 week period.  Procedures performed and documented as clinically appropriate.              

General duty hours: From 0700 to 1900 Monday to Wednesday, 0700 to 1200 Thursday (excused for clinic) and 0700-1200 Friday (excused for didactic). You may choose which weekend day you would like off, but expect to be here from 0700-1700 either Saturday or Sunday. “To be early is to be on time”, so be respectful towards your colleagues and DO NOT BE LATE. On your first day, meet in ECICU at 0645 for orientation.  If there’s a federal holiday during your rotation, you have that off as well. Vacation may NOT be taken on this rotation. You may request additional time in ICU for an elective rotation if you so choose.

Goal: To become familiar with the spectrum of common ICU diagnoses and obtain skills to recognize critical illness and initiate appropriate evaluation, stabilization, and transfer to the ICU.

Knowledge: Will vary, but we will try to cover

• Identifying clinical parameters that would require transfer to ICU

  • Altered mental status

  • Cardiopulmonary abnormalities

  • Metabolic disarray

• Initiating appropriate orders for evaluation and initial stabilization, including POCUS utilization

• Management of common diseases in ICU based on patient presentation:

  • Respiratory failure and ventilator settings

  • Shock pathophysiology and vasopressor use

  • Goals of care for the critically ill

Required Reading:  Pre-reading required before your start date includes sections 1-4 of this page. Watch the videos on GCS and the neuro exam linked in section 2. Familiarize yourself with how to present a patient in the ICU for rounds by clicking here to this guide. Please follow the paper rubric provided via email for the rest of the sections and links that are required this rotation (some links are supplemental only). Please ensure you have access to a workup/differential resource such as the Mass General Pocket Medicine, UpToDate, OpenEvidence or eMedicine Online. We have copies of the Marino ICU Book if you are interested in a textbook for reference. 

2. ICU Admission Criteria

Patients are admitted to the ICU for cardiopulmonary, metabolic, or neurological instability (or the potential for such) and intensive (minimum hourly) nursing care.  Consider the following:

 Abnormal (cardiac) vital signs:

• Hypotension (SBP <80) despite adequate fluid resuscitation with need for vasopressors to maintain BP

  • Watch these 4 short crash course videos on shock and vasopressors

• Tachycardia with need for >2 IV push boluses of metoprolol or diltiazem boluses or need for amiodarone given hypotension

• Hypertensive urgency (>210/110) requiring >2 IV push boluses

Neurologic status change:

• GCS <8 requiring intubation

  • Watch the following videos on how to calculate the Glasgow Coma Scale and how to evaluate a comatose patient’s neuro exam

• Hemorrhagic stroke on hCT

Metabolic disarray:

• Severe acidosis with pH <7.0 (usually associated with septic shock, kidney failure, or DKA)

  • Review this video on assessing acid-base disorders via ABG analysis

Change in respiratory needs:

• Non-invasive positive pressure ventilation (like BiPAP or CPAP) for COPD exacerbation, CHF exacerbation, or new suspected OSA

• High Flow Nasal Cannula (HFNC) for short term oxygenation in PNA or COPD

• Intubation with MV for inability to protect airway due to GCS <8 or loss of gag, AMS with vomiting, over-sedation, excessive or inadequate work of breathing, or PaO2 (on ABG) of <60 on FiO2 >50% or PCO2 (on ABG) of >60 with significant acidosis or narcosis

• Anticipated neurological or cardiopulmonary decline requiring transport or immediate treatment

3. Assessing the ICU Patient

Your assessment will gather information from the electronic medical record, the nurse, the monitors in the room (cardiac monitor, ECG, ventilator), and the patient/family. ALL THESE SOURCES ARE IMPORTANT!  Try to avoid making assumptions until you have gathered all the data as our patients are complex at baseline and critically ill at the moment.  There are a few places in the chart to review:

• Summary report screens including Overview, Meds Hx, Fever and ICU QI Report

• Orders tab (current and home medications, consults, and nursing/respiratory cares)

• Results tab (or elsewhere for imaging and diagnostics)

• Flowsheets

More generally speaking, the following are questions you should ask yourself about your patients on a daily basis:

• Does the patient need continued intensive care? Do they still have an unstable or potentially unstable cardiopulmonary or neurologic issue (Note: neither their underlying diagnosis nor workup has to be completely resolved)?

• If the patient is on a ventilator or other positive pressure ventilation, can the patient be weaned? If no, are you addressing the reason why not (i.e. fluid overload, bronchospasm, secretions, respiratory fatigue, pneumonia, high minute ventilation)?

• If the patient is on inotropes or vasoactive medications, can they be weaned off a drip into IV push doses? If no, are you addressing the reason why not?

• What IV fluids is the patient on? If not TKO, what is the goal of the IVFs? What is their volume status?

• Has the patient been treated for pain with scheduled or PRN medications? What meds, how much and how often? What is their response to these interventions?

• What is the patient’s CAM-ICU score? Have they been delirious during their stay? Were they hypoactive or hyperactive (agitated)? What measures have been tried to combat delirium? If meds were given, what meds, how much and how often? What is their response to these interventions?

• Does the patient have a new or significant fever? What is the cause of the fever or what diagnostics have been ordered to assess for root cause?

• If the patient is on antibiotics, what are they, what are they treating, and how long have they been on them? Is this the most appropriate (tapered) regimen possible? Are dosing levels appropriate given current GFR, weight, and trough values?

Specifically, your assessment should be step-wise and systems-based.  This mimics our critical care progress note template:

• Overnight changes or events? Comment either on the unanticipated or a trend you’ve been following.

• Review labs, vital signs, intake and output over the past 24 hours (and admission), and verify dosing of medications ordered vs. what was actually given

• Head-to-toe systems review

• Disposition (and other family or social concerns)

• Quality metrics: There are a bundle of cares that have been shown –together- to decrease ICU length of stay, morbidity, and mortality called the ABCDEF bundle. You can find the data under the “ICU QI Overview” Summary and you will discuss it under the Quality Indicators box at the bottom of your note (which is reviewed by the Patient Safety and Reliability office).

  • Assess, prevent, and manage pain (AKA address pain/agitation/ delirium):

    • Know your patient’s CAM ICU score

    • Monitor for and treat pain/agitation/ delirium

    • Know the indications for opioid prescribing and consider alternative agents first

  • Both spontaneous awakening trials and spontaneous breathing trials (AKA ventilator bundle)

    • Daily SAT and SBT as above

    • Other bundle aspects: stress ulcer ppx, VTE ppx, HOB elevation, frequent suctioning, avoiding hyperoxygenation, Peridex mouth wash

  • Choice of analgesia and sedation

    • Generally avoid benzo gtts

    • Goal is light sedation RASS 0 or -1

    • Consider which patients need analgesic or sedative gtts (i.e. not everyone)

  • Delirium: Assess, prevent, and manage

    • Normalize sleep-wake cycle if able by avoiding nighttime meds or therapies

    • Group cares including blood draws

    • Treat based off CAM ICU scores

  • Early mobility and exercise (AKA early PT and mobility to avoid ICU myopathy)

    • Includes HAPU prevention techniques including Q2H turns, Mipelex to sacrum, waffle mattresses or specialty beds, and offloading

  • Family engagement and empowerment

REMEMBER: In the ICU, data is collected at least hourly and assessments are frequent.  Continue to check your patient and their chart for response to therapies throughout the shift, not just prior to your note in the AM.  Addend your note or make necessary changes to orders and communicate changes to the bedside nurse.

4. ICU Documentation

Your charting should describe the complexity of assessments and interventions required to provide critical care.  It should also accurately reflect on a daily basis the hospital course up to this point and the working or definitive diagnoses being treated.

You can “borrow” a critical care note template from an ICU colleague; there are a few options available.  The template will help you save time by pulling in data from the EMR.  However, it will pull much more and potentially somewhat less than the specific data you need.  Please delete irrelevant data fields and bring in data that is important for a complete picture of the patient.  For instance, most notes generate information regarding mechanical ventilation, but if your patient is not on the ventilator, those pre-populated data points should be deleted.  Other relevant data such as past imaging (for instance, a recent cardiac echo from last admission) may be worth documenting.  A good rule of thumb is: if you wouldn’t hand-copy the data into the chart delete it, and if you would write it in, copy it over. The notes should look very different from patient to patient.

One area you can greatly influence care continuity and communication (and thus reduce misinformation and duplication errors) is by adequately updating the HPI (or hospital course) every day.  You can either create an interval or ICU history section with bullet items by date or continue a narrative history.  Be sure to include working diagnosis, critical treatments or diagnostics, consults, and notable events.  When it comes time for the patient to leave the ICU, the discharge note should be basically already written.  No provider coming on during a night or weekend shift (or responding to a consult request) should have to piece together the hospital course.

5. ICU-isms

Unique to the ICU are certain care patterns.  Below are some things we do in the ICU to keep in mind when providing the standard of care

Many of our patients get daily CBC, BMP, Mg, Phos, and almost always CXR because our patients are critically ill and so we are acting on the results each day.  HOWEVER, don't order daily labs if you won't act on it as they are costly, painful, and will cause blood loss anemia over time.  At LLUMC, anyone on a NEW ventilator gets an ABG every morning as we prepare to extubate. ABG orders are PRN/recurring.

Replete K to 4.  Replete Mg and Phos to 1. Use the order set “Electrolyte Replacement Adult Module” for guidance.

Transfuse PRBCs for Hgb <7 OR if Hgb <8.5 and meets specialized parameters (hypotensive, actively bleeding, having an MI or in septic shock). Use the order set “Blood Product Orders” to ensure you meet the criteria. Remember the patient needs a new type and screen every 3 days and that in the order set you need to enter 2 separate orders: to designate the blood bank prepare the blood and another for the nurse to transfuse it. Make sure the transfuse order is scheduled for “ASAP” or “STAT” and never “Routine".”

If you have more than 2 POCT glucoses over 180, make a change to your insulin regimen. Use the summary screen “Glucose” to guide you.

For patients being admitted with a concern for sepsis, always consider pan-culturing upon unit admit.  Discuss with the attending before ordering ANY cultures.  It may be equally advantageous to treat empirically without cultures.  You should also discuss whether a procalcitonin or lactate would be helpful to determine if occult bacterial sepsis is present.

Critically ill new admissions – in extremis— are NPO (except for meds if able) with bedrest orders (except for PT ROM exercises).

Order PRN labetolol 10-20mg IV Q4-6H PRN as “First line for SBP >140.  Hold for HR <60.”  Also order PRN hydralazine 10-20mg IV Q4-6H PRN as “Second line for SBP >140.”  Decide on the adjusting the dose, interval, and SBP cutoff based on individual patient needs.

ICU patients are on continuous cardiac monitoring, Q1H vital signs, and continuous pulse oximetry almost always.

There are standard orders for intubated patients to prevent complications. Use the order set “Mechanical Ventilation - Adult”. Watch this video to make sure you understand the basics of mechanical ventilation (and bookmark this webpage for information on vent settings). Then read this web post on advanced respiratory support with BiPAP or HFNC, as sometimes these therapies are used to prevent intubation or as a bridge to nasal cannula after extubating. Please review the LLUMC Guideline on how we assess for readiness to extubate.

To prevent DVTs and PEs, ICU patients generally need BOTH chemoprophylaxis (with Lovenox or SQ heparin) AND mechanical prophylaxis with SCD machines.  If you do not give chemoppx (SQH or LMWH) then describe why, as this is best practice.

Avoid standing IVF orders if possible, order whatever is necessary in small boluses with frequent reassessments of fluid status.

Consider ordering something PRN for fever, pain, and constipation on admission.

The goal of ICU care is discharge to floor care- so we need to actively progress our patients towards mobilization (order PT), a diet (even if it’s tube feeds), spontaneous voiding, breathing on their own (evaluate their ability to wean from the mechanical ventilator every day), and interacting with us as their medical team (avoid excessive sedation, goal is RASS 0) EVERY DAY!

We use lots of scoring calculators for various purposes.  Familiarize yourself (GOOGLE!) with RASS for sedation, Braden for skin breakdown, CAM-ICU for delirium, STOP-BANG for OSA, LINERC for necrotizing fasciitis, FENa and FEUra for AKI, CHADS2 VASC for stroke risk, HAS BLED for bleed risk, HEART for MI, PERC and Well’s for PE, and 4T for HIT. 

Review all home medications, code status, and allergies on admission. Clarify PMHx and PSHx.  Obtain the general critical care consent for ventilation, a line, and CVC if possible.

Update families daily at the bedside or with the attending within 48 hours of admission and when there are large changes in projected outcome.

RNs need an order called “OK to use” for all lines and drains.  That said, we generally try to d/c all lines and drains ASAP (especially before discharge from the ICU!)

We do nurse-led multidisciplinary rounds (“SIBR”) Monday through Friday at 1130.  Justin Kinney PharmD, usually comes to the unit for medical rounds Monday, Wednesday, and Friday, depending on his teaching schedule.

Be sure you are ordering medications via the correct route: PEG, NG tube, OG tube, oral, rectal, or IV. DOUBLE CHECK before signing!

6. Family-Centered Care in Critical Illness

The ICU environment is overwhelming! Our goal is family-centered care. There are a few ways we work as a team with the patient, and it starts on the initial discussion of code status on admission. Please read this step-wise guide from American College of Emergency Physicians. Use this rotation as an opportunity to observe the attending and NP discuss goals of care and become more comfortable yourself with end-of-life discourse.  Please click here for Stanford University’s validated Serious Illness Conversation Guide (and additional resources if you’re interested). You should have enough time given our census to make connections with family and update them on a daily basis. We recommend using "Best Case/ Worst Case" scenarios (click here to view the YouTube lecture) and diagrams when giving prognostic information or guiding families through shared decision-making. Sometimes discussions will sway towards palliation and limited medical or surgical offerings; in this case please fill out a POLST with the family. Click here for a good video you can share with families about POLSTs. Our intensivists are well versed in these discussions, but take time if you have a Palliative Care consult to sit in and listen to them as well. It is not that common in the ICU to consult the Palliative Care team because our providers engage in those discussions ourselves, but if you are interested in understanding more about Palliative Care in general, we would refer you to the article "Palliative Care for the Seriously Ill” (optional reading).

8. Evaluating a Rapid Response

While you are on rotation in the ICU, you and the ICU NP will stand-by as observers at Rapid Response Events. The ICU NP will walk you through their thought process when evaluating a patient with an acute change in presentation. When showing up to the Rapid Response with the NP, first ask yourself, “Does this patient look sick or not sick?” then proceed to evaluate their ABCs (airway-breathing-circulation). If the ABCs do not require stabilization, discuss with the NP how you might proceed with a differential and workup.  Below is a list of the most common differentials seen during a Rapid Response, with associated bolded links to blog posts that you can explore on your own time.

Neurologic complaints: Altered mental status

• Hypoactivity

  • Stroke *Identify early and call stroke team

  • Hypoglycemia

  • Hypercarbia and hypoxemia

  • Sepsis

  • Seizures vs. non-epileptic psychogenic spells

  • Hyponatremia

  • Medication-induced somnolence

  • Delirium

• Hyperactivity

  • Hypercarbia

  • EtOH withdrawals

  • Seizures vs. non-epileptic psychogenic spells

  • Delirium

  • Iatrogenic toxidromes due to serotonin or anticholinergic syndrome

  • Medication side effects

• Mixed

Respiratory complaints: Hypoxia and air hunger

• V/Q mismatch

  • Pneumothorax

  • Pulmonary embolism

  • Pulmonary edema 2/2 CHF exacerbation

  • Pleural effusion

  • Pneumonia

  • Bronchospasm 2/2 asthma or emphysema

• Cardiac stress or ischemia

  • Arrythmias

  • ACS

• Anxiety and related psychiatric diagnoses

Cardiac complaints: Arrhythmias and blood pressure variation

• Rhythm disturbances

  • A fib with RVR *Consider underlying causes

  • A flutter

  • Asymptomatic VF

• Rate disturbances

  • SVT

  • Bradycardia

  • Asymptomatic VT

• BP variation

  • Hypotension

    • Anaphylaxis

    • Hemorrhage

    • Sepsis

    • Dehydration from poor PO intake or GI losses

    • Iatrogenic (medication dosing error)

  • Hypertension

    • Pain or agitation

Code Blue *Consider your Hs & Ts as it could instigate emergent transfer to main medical center