Resident Education

Required:
All residents must read this information prior to the beginning of the rotation

Links:

BRIEF ORIENTATION
PICU STRUCTURES
DAY
- Team A: Rms #1-14, 1 attending, 1 fellow + resident + (M4)
- Team B: Rms #15-22, 1 attending, 1 AAP (+visiting fellow/resident)
- Team C: Rms #23-36, 1 attending, 1 fellow + resident + (M4)
NIGHT
- Team A: Rms #1-18
- Team C: Rms #19-36

WORK FLOW
- Daily rounds at 08:00; (joined ECMO rounds before resuming teams)
- Sign out rounds at 16:00
- Evening rounds between 21:00-23:00
- Resident signout at 18:00 and 0600

NOTES:
- PICU Resident H&P: for all medical admissions and consults
- PICU Transfer Accept: for all transfers from floors to the unit and from other services to the CCM
- PICU Discharge/Transfer/Death: start at the time of admission for all medical patients, update regularly with pertinent information. File it with complete information at the time of discharge.

TRANSFER/DISCHARGE: : Apply only to medical patients
- A complete transfer summary (start one close to admission time; update info along the way to facilitate smooth/easier process for the cross covering residents)
- Transfer orders at the time of transfer
- A call to the floor residents for direct verbal report at the time of transfer
- Call to notify transfer (even already called out at previous shift)

ORDERS:
    The PICU team created a preference list for all orders specific for the PICU. Follow the following steps to copy the preference list. This will help guide you through the complex EPIC orders and drug dosing.
- EPIC ->Tools-> Patient Care Tools ->Preference List Composer
- Copy User (lower left corner)
- From user: Paden, Matthew
- Scroll down to "Orders (Inpatient): with 307 items ->click Copy

EVALUATIONS: Evaluation is compiled from all CCM members at the end of the rotation. Residents are evaluated based on the following criteria:
- Patient care
- Medical knowledge
- Practice based learning and Improvement
- System based practice
- Professionalism
- Interpersonal skills and communication

RESPONSIBILITY:
DAYS: 0600-1800
- Receive sign out from the night team
- Round & complete the progress notes prior to rounds
- Complete admission for new admission after 0700
- 0800 daily rounds
- Complete to-do list for all patients
- Pre-round for sign out rounds at 1600: brief synopsis of the patients, update on new information and the to-do list for the night team
- Sign over to night team

NIGHTS 1800-0600
- Receive sign out from the day team
- Complete all admission after 1600
- Prepare for evening rounds at 2100-2300
- Pre-round and complete progress notes for the next day, keep the same patients in the same pod
- Face time with staff throughout the night; no call room
- Be ready to sign out at 0600

PHONES:
- ASCOM phones
   o Team A: 5-0987
   o Team C: 5-0988
- Fellow A phone: 3-0989
  Fellow B phone: ####
  Fellow C phone: 3-8560
- PNP phone: 3-0959
- ICU direct phone 5-6006 (404-785-6006)

EDUCATION is very important during this rotation. There are several formats we use for this purpose
- Daily bed-side teaching with each team when time allowed
- Evening rounds with one or two interesting patients or topics
- CCM fellow conferences are on Tuesdays @ 1200, in the PICU classroom, and residents are encouraged to attend
- PICU Radiology rounds on Wednesday @ 2PM in the PICU
- PICU Ventilator rounds on Wednesday (alternate with Radiology rounds)
- On-line resources and tests are also part of the rotation. There are two websites available to you during this rotation.
  1. htt://openpediatrics.org is one of the web based learning resources. Participation is a required element of this rotation. You are registered to this site at the beginning of your rotation. Your log in ID is your work e-mail (provided by your home program) and your password is ‘password’. You will receive an invitation to participate with the ‘EMORY PICU” group. Sign in and join the group. You are required to complete the group’s learning tract at the end of your rotation. Failure to complete the tract will result in a ‘Fail’ mark for your rotation. Access to OpenPediatrics at large remains available to you beyond this rotation.
  2. www.pediatrics.emory.edu/divisions/criticalcare/education/index.html is the site with the Department of Pediatrics at Emory University. This site contains the complete orientation package to the PICU. Use it as your resource.
Enjoy your rotation. Do not hesitate to contact me at nga.pham@choa.org if you have any question.

Hints for Residents in the Egleston PICU on Quality Questions:
EVERY morning on EVERY patient while rounding there will be a set of 'Quality' questions asked, (depending on fellow or attending preference these may be asked before or after medical rounding on each specific the patient). These are questions that help to reduce iatrogenic risks that can occur during care of critically ill patients.

1. Medical record number?: Document out loud
Rationale: a sort of 'time out' to be sure we are collecting data on the correct patient

2. New admission since the previous morning? If so was this a readmission of patient who was discharged
Rationale: Bounce-backs to the unit suggest something was missed at ICU/floor transition

3. Hyperglycemia risk/treatment?: Is the patient at risk for ICU hyperglycemia (MV, pressors, CRRT) and if so is s/he on our "Hyperglycemia protocol" and does s/he have hyperglycemia and if so are they being treated with insulin?
Rationale: Hyperglycemia is associated w/ poor ICU outcomes and aggressive management appears to improve outcomes

4. Braden Q score?: This is a measure of patient activity and status which predicts risk for skin breakdown, ulcers, and sores. Higher the number, lower the risk. With a level off <16 make sure measures are discussed to lower risk - i.e turning and correct mattresses and good nutrition.
Rationale: Skin pressure sores in immobilized are a significant problem and cost

5. Invasive apparatuses?: Does a patient have and/or need - CVLs (document # and type), art lines, foley catheters, endotracheal tube. Remove any invasive equipment they do not need.
Rationale: These greatly increase the risk of hospitalized acquired infections (including blood stream infections, ventilated acquired pneumonia, and urinary tract infections.)

6. Meds and lab schedule review: Self explanatory
Rationale: In busy units, meds and labs needed change. Eliminating unneeded meds, changing meds to PO/NG when able, and reducing labs draws improves care (fewer entries into a central line as an example) and lessens costs.

7. Ventilator associated pneumonias (VAP) prevention in intubated patients: a series of questions and interventions to reduce the chance of VAP.
-Ulcer (GI) prophylaxis - H2 blockers, feeder
à Rationale: Reflux and aspiration of acidic gastric fluid contributes to VAP
-Head of bead up (at 30 degree or more)
Rationale: Propping up the head in appropriate patients makes aspiration less likely
-DVT prophylaxis: venous thromboses can break off, lodge in lungs and be a nidus of infections contributing to VAPs.
Rationale: Preventing DVTs by heparin, stockings or SCD may lower VAP risk.

8. Sedation "holidays"?: In patients receiving sedation/analgesia infusions, were the drips stopped and restarted (at a lower dose) the previous day? (hint: ask nurse and look in drip rate to 0 in patient summary area in Epic)
Rationale: A daily break and restarting at a lower dose of analgesia/ in most patients can facilitates appropriate dosing, weaning and help with an suitable level of sedation.

Children's uses an electronic medical record (EMR) system called Epic for inpatient documentation. Therefore, Epic training is required for all Rotating Residents prior to providing inpatient care at Children's. The Medical Executive Committee supports these requirements.

Class sizes are limited, so register as soon as possible for the best selection of days and times. To provide inpatient care, you must score at least 80% on each requirement listed below. Granting access to Epic is an important step in your credentialing process at Children's and requires 2 business days to complete after you finish training. To avoid not having access on your first day, please complete all Epic training at least 2 business days prior to providing inpatient care.

Training Requirements:
Please take the following online training and instructor-led classroom training in the order listed below:

  • "Inpatient MD/AHP Epic.Chart Review 101 Online Training" (~45 min.) (View Only access) **Must be completed before attending any ILT and must be completed first in order to get access**
  • "Inpatient MD/AHP Epic.Documentation 101 Online Training" (~ 20 min.) (Documentation access)
  • "Inpatient MD/AHP Epic.CPOE 101 Online Training" (~20 min.) (CPOE access)
  • "Document Imaging – ChartMaxx Completion" online course (~20 min.) (Chartmaxx access) There are no prerequisites for this, so you may take it at any point during your EMR training process.
  • "Inpatient Resident Epic.Documentation/CPOE class" (4 hours)
Getting Started:
  • Go to www.choa.org/lms to access the learning management system for Children's.
  • Click the link "Visit https://aspen-totallms.choa.org/sumtotal to log in to Aspen-TotalLMS".
  • Your Aspen-TotalLMS user name and password is:
  • User name: first and last initials + last 4 digits of your social security number
  • Password: the word "training" + last digit of your social security number

3.  Upon your first login, you will be asked to change your password.

To Complete Online Training:

  • Near the middle of the Aspen-TotalLMS home page, click Catalog.
  • Click Physician Training, then click the name of the online training module you need to take.
  • Register for the Module and then click Start to begin the training.  

Ensure your computer's volume is turned on and any pop-up blockers are turned off.

To Register for Instructor-Led Classes:

  • Follow steps 1 and 2 above to get to the Physician Training section.
  • Click on the name of the class you want to register for.
  • Click Register, then click the dot next to the desired class.
  • Scroll down and click "submit". Check your email for a registration confirmation.

Upon Completion of All Training Requirements:
The Epic Security team will send you an email containing your Epic user name and password within one business day after you score at least 80% on all of your training requirements.

If You Need Assistance:
Contact the Solution Center, (404) 785-6767