micu policies

communication policies
  • MICU Team will maintain a constant physical presence in the MICU to ensure timely care and constant communication with nursing staff and consultants.

  • Fellow and attending must be informed at the time of all new request for MICU consults or admissions.

  • Code Status discussions should include presence of fellow or attending when possible. This is an excellent opportunity for Mini-CEX observation, as the trainee can and should lead the discussion.

  • MICU team members will maintain close and timely communication.

  • Verbally notify primary nurse of new orders placed in the CPRS. Each Monday AM team members will exchange contact information.

  • Engage consultants to promote optimal and timely patient care

  • Communicate with care team to see how care plans are progressing

  • Ask for help if you need help 

MICU TEAM STEPDOWN POLICY
A patient in the physical MICU under the MICU primary team can only be transferred from the MICU as a stepdown to Medicine if they have an assigned bed somewhere outside the MICU. In other words, VA medicine teams do not accept boarders in the MICU if the patient was originally a primary MICU patient. This policy is unique to the VA so please be aware.
pcu policy

 

The PCU is the Progressive Care Unit, where patients have a higher level of care then the floor, but do not necessarily need the ICU. When patients are being transferred from the ICU to the PCU, the ICU team will cover the patients in the PCU for 24 hours in the PCU to ensure they are stable and do not need to be re-stepped-up to the ICU. Once they are stable for 24 hours in the PCU, then the ICU team may call the floor team for sign-out. This ICU-PCU transfer can only occur between 7am and 11:59pm. From midnight to 7am, these transitions are prohibited unless there is an attending to attending conversation. HOWEVER, stepdown from MICU to medicine/med-surg is allowed at anytime (less high risk compared to PCU stepdowns). 

notification standards

Intern will notify Resident immediately of all: Hemodynamically unstable patients (MAP<60, HR>120), new arrhythmia, patients with new hypotension/pressor requirements, escalation of ventilatory support, or new RR>30 or a rising RR >30
 

Resident will notify the Fellow and/or Attending:

  • All codes, deaths, and complications, immediately and prior to any invasive procedure

  • All newly admitted intubated, NPPV, or hemodynamically unstable patients (MAP<60, HR>120), and patients with new arrhythmias, or escalation in ventilatory or pressor requirements, new RR>30 or a rising RR >30, w/in 15 minutes

  • All ICU admissions w/in 30 mins

 

Fellows will notify attending of:

  • All codes, deaths, and procedural complications immediately (within 15 min)

  • Fellows will notify attending within 1 hour of all new admission that occur from 0700 to midnight.

  • From midnight to 0600, Fellow will notify attending wi 1 hour of all admission that meet the following criteria:

    • Are intubated

    • Are hemodynamically unstable

    • Require massive transfusion protocol

    • If the fellow has any concerns or questions

    • Prior to any (non-emergent) invasive procedure or extubations

    • Prior to elective implementation of care that has significant risk such as administration of thrombolytic therapy or transport of an unstable patient

    • Prior to transferring or discharging any patients

  • Attending discretion may be used to alter this supervision on an individual basis. Fellows in these cases will receive direct communication from the responsible attending.

 

IT IS ALWAYS BETTER TO OVER CALL RATHER THAN UNDER CALL

 

Also consider placing a Patient Safety Reports: Open internet explorer→ Employees → JPSR

notes

Notes are the primary manner of documenting patient care and communicating between care teams. Concise, comprehensive, accurate, and timely documentation must occur daily:

  • Admission H&Ps, Daily, Consult, Accept, Transfer, Discharge, Death and Code/RRT Notes written by the most junior responsible team member and cosigned by the attending

    • Transfer Notes must be written for ANY patient transferring, even if they have only been in the ICU for a few hours. These shorter stays do not need comprehensive notes, but at the very least a quick summary of what happened in the ICU and updates on the plans that had been staffed with the attending.​

  • All admission that occur between 1700 and 2200 will be seen and evaluated by the Fellow. A brief admission note will be entered in CPRS at the time of admission

  • Event Notes most senior trainee (i.e. Fellow between 0700 and 2200) documents Change in Status, Codes and high-risk therapies notes.

  • For Residents, any events that occur after 1900 that requires an assessment or intervention MUST be documented with a brief note by the resident

  • Formal Family meetings will be documented by the fellow, attending, or resident as directed by the attending.

code blue policy

See RR/CODE GUIDE for most updated information and necessary phone numbers for RR and Code Blue/Stroke/Heart.

The MICU resident On-Call runs all Code Blues. Regardless of who gets to the code first, the MICU resident is the team leader and must step into that role as soon as he/she gets to the code. The MICU intern is also expected to be at the code. Only the On-Call resident and intern need to leave rounds to go to the code (not the entire team).

 

Airway: Airways will be managed by either anesthesia or the ED. Out Of Operating Room Airway Management, aka the provider who will secure airways during Code Blues and other situations, is anesthesia at all times of day. You can reach them by saying "Anesthesia On Call" on your vocera. 

.

Other members of the code blue team includes:

  • A MICU nurse is On-Call and should be present at all Code Blues. If the MICU nurse does not arrive, it is very important that you dispatch somebody to retrieve them.

  • Respiratory therapy

  • On-call wards teams

 

Notes: A separate code blue note must be written after all codes. Note title under CPRS is “CODE BLUE: MEDICINE NOTE”. Of note, any urgent/emergent event which occurs outside of normal patient care areas (e.g. the atrium, cafeteria, radiology, CLC, etc) will be a Code Blue in order to ensure that the appropriate level of care arrives to all situations. If the patient is not already admitted to the hospital, they need to be transported to the ED once they are stable enough to be moved. The MICU is responsible for writing a Code Blue note for EVERY Code Blue which occurs, even those in which there was no true cardiopulmonary arrest.

See RR/CODE GUIDE for most updated information and necessary phone numbers for RR and Code Blue/Stroke/Heart.

As of 2022, CODE STROKES should only be called by the MICU team (except in the ED). If someone is concerned that an admitted patient is having a stroke, a RAPID RESPONSE should be called and the MICU team should assess and determine if a CODE STROKE should be called. 

The goal of Code Strokes is to have a streamlined process in order to minimize time to CT scan and evaluation for possible TPA or other intervention.

  • Upon arrival to a Rapid Response, if there is concern for stroke, make a BRIEF evaluation of the patient (minimal neuro exam, fingerstick, etc) and if deemed necessary, the MICU Team should call a CODE STROKE and immediately send the patient to the CT scanner. The Code Nurse (an ICU nurse) and MICU intern should accompany the patient to the CT scanner.

  • The CT Scan is the top priority. The MICU team can speak with Telehealth Neurology regarding triage if the patient needs MICU transfer.

  • Activate Code Stroke (5-5000) when patient meets activation criteria 2. Call Triage Report to National Telestroke: 844-448-6877 3. Ward/RRT Resident Activates “Telestroke” orderset in CPRS: NCCT, CTA, Labs

  • At the CT Scan, the Telehealth Neurologist will direct you through the NIH stroke scale, remotely review the CT imaging, and ultimately tell you what the next steps will be (TPA, transfer to OSH, do nothing, etc)

 

Disposition:

  • tPA → MICU (Goal: determine tPA candiates by 40 minutes; give tPA at 45 minutes)

  • IVH or LVO in need of thrombectomy → MICU → interfacility transfer 

  • Stroke but no tPA → PCU

  • No Stroke → revert RRT disposition

  • If the patient does not require intervention or neurochecks more frequently than q4h, they may be returned to the medicine floor with a note describing the Code Stroke.

Make sure if you are admitting a Code Stroke patient to use the Stroke order set which will take you through best practices (please order a dysphagia screen for stroke patients).

code heart policy

See RR/CODE GUIDE for most updated information and necessary phone numbers for RR and Code Blue/Stroke/Heart.

The ED will activate a Code Heart which will mobilize the on-call team to come into the cath lab. The Interventional Cardiologist will call the ED attending to discuss in person. The MICU Resident/Intern will go evaluate the patient in the ED and should contact the CCU Fellow on-call as well.  The ED physician should order all appropriate medication after discussing with the on-call cardiologist. An ED nurse and ICU resident will bring the patient up to the cath lab in <20 minutes from time of presentation. A cath lab tech will be there waiting to receive the patient. The ED and ICU nurses will assist the cath lab tech to transfer the pt unto the cath table, and prepare the pt for cath The ICU nurse will stay to administer conscious sedation and the nursing supervisor will oversee the ICU/CATH LAB process. The case will start as soon as the interventional cardiologist arrives. Please follow up with the interventional cardiologist and CCU fellow after the case is complete to initiate your admission and ensure the correct plan is in place