Pediatric Intensive Care Unit Elective

Roles and Responsibilities (PL3/4)

Rotation Director: Dr. Grace Chong – gchong@peds.bsd.uchicago.edu

INTRODUCTION
Welcome to the Pediatric Intensive Care Unit! Residents have the unique opportunity to learn the assessment,
stabilization, and management of critically ill pediatric patients in a well-supported setting. During the two- or
four-week elective, residents will be introduced to the fundamentals of critical care from a multidisciplinary
approach including direct patient care and management, participation in educational activities (see below for
Pediatric Critical Care Curriculum), and learning opportunities with nursing, respiratory therapy, pharmacy and/or
nutrition services.
While participating in direct patient care, residents will provide support for those patients admitted from the
post-call resident, acting as a day float. During this elective, residents will be exposed to a multitude of
disease pathologies in early diagnostic and therapeutic states, with an emphasis on management and critical
decision-making. Through this process, residents will refine their clinical insight and judgment with evidence-
based medicine by locating, appraising, and assimilating evidence from scientific studies related to their
patients’ health issues.
Residents will also accompany fellows to all emergent calls on the floor (PET/RRT) and trauma pages, ensuring
exposure to clinical scenarios where rapid critical decisions are met.
The elective requires attendance from Monday through Friday plus one weekend day. Shifts are from 6:30 am
to 4:30 pm daily with the exception of learning opportunities provided by ancillary staff, which may extend
until 7:00 pm. These shifts with ancillary staff will be determined prior to the start of the elective as they are
subject to availability of ancillary care providers.
Residents will be introduced to the basics of bedside nursing and respiratory therapy care by shadowing
ancillary care members. These shifts will be determined prior to the start of the elective.
During the PICU elective, other learning opportunities are available upon request where one will work with
specialized care providers in topics such as: fundamentals of bedside nursing, introduction to ventilators with
respiratory therapists, pharmacy considerations in complex multi-organ disease, and setting nutritional goals
in critical illness.
Learning opportunities will be provided under the Pediatric Critical Care Curriculum (see below). In addition,
the Rotation Director will meet with the resident weekly to provide additional case-based learning on common
ICU topics.
A sample of the schedule, schedule details, and roles/responsibilities are listed below.

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WEEKLY SCHEDULE
Saturday or
Time Monday Tuesday Wednesday Thursday Friday
Sunday
6:30 am to Fellow-Led Fellow-Led Fellow-Led Fellow-Led Fellow-Led Fellow-Led
7:00 am Signout Signout Signout Signout Signout Signout
7:00 am to Resident Day Resident Day Resident Day Resident Day Resident Day
8:00 am Float Float Float Float Float
Fellow- or Fellow- or Fellow- or Fellow- or Resident
8:00 am to Faculty-Led Faculty-Led Radiology Faculty-Led Faculty-Led Day Float
8:30 am Didactic Didactic Rounds Didactic Didactic
Session Session Session Session

8:30 am to Bedside Bedside Bedside Bedside Bedside Bedside

11:00 am Rounds Rounds Rounds Rounds Rounds Rounds

11:00 am to Resident Day Resident Day Resident Day Resident Day Resident Day
12:00 pm Float Float Float Float Float

Case-Based Case-Based • Patient Care

Noon Pediatric
12:00 pm to CAPS Lecture Learning Learning
Conference Grand Rounds • Walk
1:00 pm (K145) Curriculum Curriculum
(K145) (P117) Rounds
(K469) (K469)
• EPIC Signout
• PatientCare • Patient Care • PatientCare • PatientCare • PatientCare
1:00 pm to • Walk Rounds • Walk Rounds • Walk Rounds • Walk Rounds • Walk Rounds
4:30 pm
• EPIC Signout • EPIC Signout • EPIC Signout • EPIC Signout • EPIC Signout

Fellow-Led
4:30 pm to Fellow-Led Fellow-Led Fellow-Led Fellow-Led Fellow-Led
Team
5:30 pm Team Signout Team Signout Team Signout Team Signout Team Signout
Signout

SCHEDULE DETAILS WITH ROLES/RESPONSIBILITIES

Residents are responsible for all patient care for patients in the care of the post-call resident. Residents may
be required to write H&Ps, progress notes, and/or transfer notes for the post-call resident. They will be the
primary care provider for these patients in the post-call period.

• Elective Schedule
o Emailed by Rotation Director prior to start of elective.
o Residents will be assume patient care needs for all patients from the post-call resident.
Residents will work as a day float for blue and green teams.
o Residents will work from Monday through Friday plus one weekend day. Shifts are from 6:30
am to 4:30 pm daily with the exception of learning opportunities provided by ancillary staff,
which may extend until 7:00 pm.
o Days off occur on the other weekend day.

• Emergencies
o Residents will also accompany fellows to all emergent calls on the floor (PET/RRT) and trauma
pages, ensuring exposure to clinical scenarios where rapid critical decisions are met.
o Residents have the opportunity to write event notes to PET/RRT calls and review pertinent
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 details and effective note-writing with the Rotation Director.

• EPIC Signout
o Vehicle for team-based communication during morning and afternoon signout.
o Patient’s assessment, problem list, and key tasks/needs should be updated frequently.
o EPIC signout and the two-team system ensure up-to-date information on all patients, thereby
eliminating the need for post-rounding signout among residents.
o It is the responsibility of the day float resident to update the EPIC signout for each post-call
team.

• Resident Day Float

o Before rounds, the resident can assist the post-call resident with data gathering, subspecialty
consultations, and/or procedures.
o After rounds, the resident assumes care of all patients on the post-call resident’s census.
o Residents may be required to write H&Ps, progress notes, and/or transfer notes for the post-
call resident to ensure that duty hours are not violated.
o Residents are encouraged to reinforce medical knowledge and support clinical decision-
making with evidence-based medicine
o Residents are encouraged to provide supervision and teaching for junior residents, interns, or
medical students.

• Fellow- or Attending-Led Didactic Sessions

o Every weekday mornings at 8:00 am, fellows or attendings will give lectures on important
ICU topics, except Wednesdays when Dr. Kate Feinstein will give Radiology Rounds in the
Radiology Reading Room.
o Attendance to all conferences is mandatory unless urgent patient care issues require
attention.

• Bedside Rounds
o If new patients should transfer teams (i.e. Heme/Onc patient admitted overnight on Green
team reassigned to Blue team the next day), the post-call resident will present the patient on
rounds and the new resident will assume care after rounds.
o Bedside rounds begin with nurse presentations of CLASS. Residents then provide succinct
presentations with plans followed by fellow/attending-led discussions with teaching. The
resident team is responsible for completing all orders discussed.

• Educational Opportunities
o Pediatric Critical Care Core Curriculum
o Pediatric Residency Critical Care Curriculum Lecture Series
! Morning Didactic Sessions
! Case-Based Learning Curriculum
o Radiology Rounds
o Clinically Applied Pathophysiology Series
o Grand Rounds
o Noon Conference Lecture Series
o Interactive Bedside Teaching
o Simulation/Mock Code Cases
o Introduction to Bedside Nursing
o Establishing intravenous access
o Delivering medications via pump system
o Setting up monitors
o Setting up invasive hemodynamic monitoring (arterial, central venous lines)
o Endotracheal and oral care
o Systems-based practices (lab draws, point-of-care testing)
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 o Introduction to Respiratory Therapy Care
o Reviewing methods of oxygen administration and support
o Administering respiratory treatments
o Pulmonary hygiene (suctioning, CPT/therapy vests)
o Introduction to non-invasive positive pressure ventilation (BIPAP, CPAP, ram cannula,
HFNC)
o Introduction to mechanical ventilators, set up, and maintenance
o Introduction to Pharmacy
o Introduction to pharmacokinetics and pharmacodynamics (distribution, elimination)
o Understanding sedation and analgesia in critical care
o Developing resource utilization tools
o Introduction to Nutrition Services
o Introduction to nutrition needs in critical illness
o Developing nutrition plans for patients based on energy expenditure
o Reviewing different types of formula

• Patient Care/Family-Centered Walk Rounds/EPIC Signout Updates

o Active engagement in clinical decision-making and the stabilization of acutely ill patients.
o Bedside teaching by fellow.
o Updating and printing EPIC signout prior to 4:30 pm afternoon signout.
o Residents are expected to know the clinical course for their patients and carry out the daily
plan in an efficient manner.
o PICU fellows and attendings provide supervision; communicate effectively between team
members for changes in patient care/needs.
o Senior residents are expected to orient and assist interns.
o Evaluation of new admissions to the PICU (transfers from the outside hospital, inpatient
floors, emergency room, trauma bay, OR)
o Communicate effectively with patients, families, and all members of the healthcare
team about patient-specific issues.

TWO-TEAM SYSTEM
In August 2015, pediatric critical care medicine (PCCM) adopted a two-team (Blue and Green) system to
cover patients in the PICU. Two residents, one fellow, and one attending physician constitute each team. The
teams round in parallel to allow more time per patient on rounds for input by all members of the care team
without exceeding resident duty hours.

Admissions:
• Two teams admit on alternating days for 24 hours (07:00 to 07:00).
• Exceptions to this pattern will be reserved for clinically important indications:
o Blue team will admit all Heme/Onc patients, regardless of admitting cycle day
o Green team will admit all Cardiac patients, regardless of admitting cycle day
o Post-operative admissions may be distributed to both teams depending on census/acuity

Rounding order:
• Blue team will start rounds on the third floor, then move upstairs and continue at K439.
• Blue team will break order of rounds for the Heme/Onc service that will join rounds at 09:30.

• Green team will start rounds with the Cardiac service if applicable at 08:30 then move to K476 and
proceed around the unit, ending on the third floor.
• Green team will break order of rounds as needed to accommodate the Liver Transplant service that
will join rounds at 09:30.
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 • With this pattern, it is unlikely that both teams will round at the same time on a single nurse’s patients.
If this occurs, one team should proceed with their next patient and return when the nurse is able to
participate.

• On weekends, both teams will round together so the on-call resident and fellow can participate on all
patients.

BLUE PHONE
ATTENDING 5-7948
FELLOW 5-7947
RESIDENT 1 5-7939
RESIDENT 2 5-7939
BLUE TEAM – Always admits Heme/Onc patients.

GREEN PHONE
ATTENDING 5-7959
FELLOW 5-7949
RESIDENT 1 5-7935
RESIDENT 2 5-7940
GREEN TEAM – Always admits Cardiology and Transplant patients.

Ancillary team members:

• Pharmacy will round with the Blue team on Tuesday and Thursday. Pharmacy will round with the
Green team on Monday, Wednesday, and Friday. This pattern may be altered at the pharmacist’s
discretion based on clinical need.
• Nutrition will round with the Blue team on Monday, Wednesday, and Friday and will round with the
Green team on Tuesday and Thursday. This pattern may be altered at the dietician’s discretion
based on clinical need.
• The Case Manager and Social Worker will each round with one team, at their discretion.

Communication and cross-cover:

• Team assignment will be posted by the admitting nurse with colored tags at each patient room.
• The charge sheet will include team assignments.
• Unit clerks will post updated team members and contacts daily at each nursing workstation and both
physician workrooms in the unit.
• Correct attending assignment must continue in Epic as before.

• Resident schedules have been adjusted such that one member of each team is present on the unit
every weekday. On nights and weekends, the admitting team resident will cross-cover both teams.
Residents will participate in evening handoff (16:30) to provide necessary information to the
covering team.

TIPS FOR SUCCESS

• COMMUNICATE with bedside nurses about all changes made on patient.

• Examine your patients multiple times throughout the day; keep family members up to date.
• Given the high acuity and rapid changes in status, it is essential to communicate with nurses,
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 residents, fellows, and attendings frequently throughout the day – the best way to do this is to stay
out of the conference room and be at the bedside during the day.

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