Our goal is provide compassionate, appropriate and effective care for critically ill patients in the MICU. 

By the end of this rotation, residents will have learned to evaluate and manage a wide variety of diseases encountered in the MICU such as: 

• Severe sepsis and septic shock

• Acute respiratory distress syndrome

• Severe alcohol withdrawal

• Drug overdose

• Acute myocardial infarction

• Cardiac arrest

• Acute renal failure

• Heart failure and cardiogenic shock

• Status asthmaticus

• Status epilepticus

• Gastrointestinal bleeding

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This rotation is an introduction to critical care - residents are not expected to master every skill in such a short time period, but they will gain familiarity with the principles of critical care. 

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Residents will  be active participants on the team providing supportive care in the ICU and these measures include:

• Sedation and analgesia

• Mechanical ventilation

• Invasive hemodynamic monitoring

• Nutritional support

• Rapid resuscitation

• Therapeutic hypothermia

• Comfort measures and end of life care

• Conducting family meetings

• Interdisciplinary collaboration 

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 Residents will have the opportunity to perform procedures in the ICU which may include:

• Central venous catheter insertion

• Arterial line insertion

• Thoracetnesis

• Lumbar puncture

• Point of care ultrasound and echocardiography

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Attendings will discuss the appropriateness of using invasive treatments while caring for critically ill patients. Our goal is to provide the appropriate level of individualized care based on a patient’s medical needs and personal preferences. An important part of practicing critical care is knowing when to forego procedures or treatments that may not be helpful in reaching the patient’s or family’s goals of care.

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Team Structure

1. CC3 team: Pulmonary Critical Care Attending, Internal Medicine Resident and Intern, 1-2 medical students. The intern or resident is to carry the team phone #4-6036.

2. CC4 team: Pulmonary Critical Care Attending, Emergency Medicine Resident and Intern, 1-2 medical students. The intern or resident is to carry the team phone #4-6037.

3. Alicia Dykstra, NP and the Pulmonary Critical Care Fellow will round with either the CC3 or CC4 team based on patient/team needs.

4. PharmD, pharmacy resident, and / or pharmacy student will round with the teams routinely. S6 pharmacy phone #4-4699.

5. On occasion, there are PA residents, transitional year interns, neurology interns, and toxicology fellows that will join a CC team.

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Admissions

Admissions from the Emergency Department:

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The majority of admissions come from the Emergency Department. ED residents and staff will make the initial determination for MICU admission. The ED resident or staff responsible for the patient will give report directly to the MICU Attending between 7am and 11pm. After 11pm, the Night Float MICU resident will take report. The Night Float should call the attending and / or fellow with any questions regarding patient care or appropriateness admission to the MICU. 

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The ED attending or hospitalist triage will contact the MICU attending on call and present the patient for any borderline admissions. The MICU and the hospitalist team may decide together where the patient will recieve appropriate care. When in doubt, the patient should default to the MICU team. 

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Admissions from Outside Facilities or Clinic:

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Admissions from outside facilities will come through Regions Direct. Regions Direct will contact the MICU Attending physician for a direct conversation with the transferring physician. The default is to accept patients. If, on arrival, the patient does not meet critical care criteria, the hospitalist team may be contacted for possible transfer of care. Otherwise, transfer may occur in the morning. 

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Order sets:

Upon admission please complete admission orders. There are several ordersets available that should be referenced.

• MICU admission order set

• Sepsis

• CAP

• Intracerebral Hemmorhage

• Ischemic Stroke

• Therapeutic Hypothermia

• DKA

• Alcohol withdrawal

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Transfers

When transferring patients to our medicine colleagues the following must be completed:

• Call triage hospitalist within the time period acceptable for transfers, ideally before 11 am, but case dependent. 

• Complete the pre-transfer navigator:

  • PLEASE review all medications and orders on transfers, discontinuing all ICU specific orders (including ICU electrolyte replacement protocol unless patient is remaining in ICU or transferring to progressive care). This is a SAFETY STOP that we are responsible for on every patient. Please also review PTA meds and reorder as indicated. 

• Write an MICU Critical Care Transfer Note as the progress note on the day of transfer.

• The triage hospitalist will assign the patient, after which the accepting hospitalist will contact you for sign out.

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Nightfloat

Responsibilities include:

1. Carry night float phone #4-6041. 

2. Implement overnight plans and complete sign-out tasks.

3. Admit new patients. Staff all new admits prior to 11pm with the night-time intensivist. 

4. Write a complete MICU H&P template note on new admissions. 

5. Call the fellow and/or attending on call after 11pm with any questions, concerns, or challenging cases. NEVER WORRY ALONE. It is better to call than not call.

6. Respond to rapid response calls. Write an RRT note.

7. Respond to all codes. Write a code note.

8. Leave a progress note in the EMR on any significant cross cover issues.

 

 Attending or Fellow call parameters:

1. Staffing of initial complex admissions (including ALL high dose insulin patients)

2. New significant neurologic changes

3. Significant procedural complication

4. Unanticipated surgical intervention due to change in clinical status

5. Acute MI

6. Change in code status

7. Patient, family, nurse, or staff requests attending notification

8. Unexpected death

9. Unanticipated intubation

10. Hypotension unresponsive to escalation of pressors or volume resuscitation

11. Unanticipated increase in FiO2 by more than 30% or new PEEP requirements > 10

12. Worsening acidosis such as: ongoing drop in bicarb despite intervention, pH < 7.1, climbing lactate in spite of intervention

13. Consideration of initiation of CRRT (hypervolemia with oliguria or refractory acidosis with limited hemodynamic reserve)

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Rapid Response and Codes

The on-call  team is expected to participate in rapid response calls on the floor when a physician is requested per text page. 

There is an RRT (rapid response team) order set that is helpful to utilize, includes 2 subset order sets: suspected CVA and MI.

The on-call critical care team responds to all codes in the hospital. The on-call critical care resident is expected to be the code team leader with the support of the critical care fellow and attending.

The appropriate note template (RRT of Code Note) shall be completed by the resident as soon as possible after the RRT/Code is over.  The attending of record should be listed as the cosigner.

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