Neuro-ICU Orientation


NeuroICU: Orientation to the Unit for Rotators

Goal for the NeuroICU rotation is to become familiar with: GCS and neuro assessments, seizure/EEG, brain death exam, stroke scale, ventilator management, intubation/extubation, line placement (arterial/central), external ventricular drain (EVD) management, Codman ICP monitor, lumbar drain management, CSF studies and drawing CSF labs, sodium goals, blood pressure management, evaluating neuro-imaging, management of complicated multi-system organ dysfunction.

 

Patient Population: traumatic brain injury, subarachnoid hemorrhage, epidural/subdural hematoma, seizures and status epilepticus, ischemic stroke, hemorrhagic stroke, spinal cord injury, brain tumors, neuromuscular disorders, CSF leaks, meningitis/encephalitis, the undifferentiated altered patient, and the post-operative neurosurgery patient.

 

Pre- Rounding:

  • Arrive daily to NSICU workroom by 0500 ready for overnight sign-out
  • MSIIIs should take only 1 patient
  • MSIVs 2 patients
  • Interns 2-3 patients
  • Residents >/= 3 patients
  • Rounding report vs rounding form to collect pt data such as: overnight events, vitals, ER/OR info if applicable, labs, recent studies, consult recommendations, etc
  • Examine patients thoroughly; talk to nurses to get information on overnight events
  • Prepare organized, systems based presentation with assessment and plan

 

ICU Rounds:

  • Start at 0830; expect to do a thorough presentation with a plan on your patient to the attending during rounds
  • Responsible for writing a progress note, communicating with consulting teams and nursing staff, and placing/following up on all orders for your assigned patient (s)
  • All notes should co-sign for active neurointensivist
  • Evening sign-out at 1700

 

Presentations:

  • Present system by system leading with overnight events.
  • Have a plan for what you would like to do (ventilator changes, medicine, changes, workups, etc…)
  • Medical students should discuss plans with resident or mid-level provider
  • We understand you are learners and don’t expect perfection but effort is appreciated!

 

Teamwork:

  • During rounds one person is presenting, another will pull up imaging and the third will be putting orders in. If there are only two people (one midlevel and one intern) then one person will do both imaging and orders.  Please sort this out before rounds begin
  • Keep a list of orders as you’re putting them in and check them off as you go. Likewise write down all orders for your patient and verify after rounds that they were properly placed. You’re responsible for all orders on your patients and following up on them throughout the day.
  • Follow-up on your patients.  Patients need reassessments during the day, ensuring orders are completed, interventions with intended outcomes

 

Orders:

  • Attention to detail!
  • STAT on all imaging, studies and labs unless otherwise specifically timed.
  •  Neurosurgery Parameter orders should be verified/updated daily including ICP/EVD instructions, sodium goals, SBP goals, etc.
  • Restraints need to be updated every morning before rounds and again before you leave.
  • Do not order any labs for >24 hours at a time except for patients with sodium goals.    Patients will be assessed daily for the need for daily CXR or AM labs studies.  ICU does not = daily full labs and CXR.
  • Hypertonics, restraint orders and albumin must be placed under the attending’s name.
  • Anyone getting hypertonic saline for specific sodium goals needs q6 hour chemistry panesl
  • Enteral tube flushes should be normal saline initially.
  • If patient NPO and has enteral access, make sure no orders say oral
  • Insulin Sliding scale: always q4 when patient is on tube feeds. Use the order set and make all 3 orders match. If on po diet then change sliding scale to before/after meals.
  • Nebulizer medications ASO after 3 days. Some paralytic drips require to be ordered daily as well.

 

Documentation:

  • Succinct daily progress note for each of your assigned patients including HPI, 24hr events, exam, pertinent labs and recent imaging, assessment and plan.
  • Judicious and appropriate use of copy/paste
  • All ICU notes should co-sign for the neurointensivist on service
  • Please do not work on progress notes during rounds
  • Unfortunately, people die in the ICU.  Those patients require a death note and a death summary
  • Downgraded patients require a transfer note
  • Patients leaving to go home, other facilities need a discharge summary

 

Procedures:

  • Arterial lines, dobhoff tube placement, bronchoscopy, central line, intubation are the most common
  • If you are not signed-off on a procedure, you require supervision
  • Write a procedure note in addition to progress note for line and tube placements.

 

Friday:

  • Neuroscience Grand Rounds: will sign-out and pre-round 0500 then attend grand rounds from 0800-0930 in 309L. Business attire and white coat for medical students.  Return to the unit after grand rounds to continue with rounds and patient care.

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Coverage and Expectations:

  • Generally, expect to be here 0500 to 1700
  • Hours will be per GME policy
  • Sat/Sun: times are the same as the weekdays
  • If you are a resident and doing nights, hours are 5pm -5am .  You will participate in afternoon rounds with the ICU team and then sign out to oncoming ICU team in the morning on any overnight events
  • Expectations overnight are to round on your patients in the evening, address any nursing concerns and do admit H&P’s on any new ICU admits
  • Overnight residents are required to call faculty for:  new admissions that are unstable and any patient that decompensates, any questions whatsoever!
  • The more you put in, the more you will get out.  The attendings love questions and love to teach. Good patient care is a priority though so be professional, kind and thorough.