Surgical Critical Care

Resident Pocket Guide

Daily progress notes:

  • Ensure DPN are accurate and up to date! Expectations include:
  • Days of abx and what is being treated
  • Anticoagulation plan and VTE ppx documented vs reason no ppx and date ok to start)
  • Specific blood pressure goals (for vascular, neuro injury or otherwise)
  • Diet plan (specifically what is being fed through where)
  • Updated physical exam
  • Lines/tubes with dates; suture/staple removal dates (or date to be removed)
  • OR dates, surgery and attending surgeon

Presentation on Rounds:

  • Discuss HPI on new attending days or patient day 1, thereafter only include overnight events
  • Followed by a systematic approach wherein labs, vitals, exam findings and plan are discussed within each appropriate system
  • Finish with optional ICU yellow checklist discussed verbally (completed by the student)
  • Each resident should have a role on rounds: order entry, imaging review, sticky note

Discharge summary:

  • D/C summaries need to be started upon admission to SCC
  • Problem based and updated DAILY (or if a very high patient census then at minimum every few days)
  • Updated with any incidental findings in the follow up section as well as any outpatient follow ups needed, such as f/u scans for fracture or injury, or f/u with a consulting service.

Non-Critical Care notes:

  • Notes such as: non-ICU specialty consults, anesthesia pre-op notes, etc are the responsibility of the non-ICU service
  • Trauma tertiaries are an ongoing discussion. They are always done by the Trauma team (typically the trauma chief) on weekdays. Ensure there is discussion about tertiary responsibility on the weekend.

Non-ICU placed devices

  • Tubes, lines, drains, devices (c-collars, braces) that are placed by a non-ICU service are the primary responsibility of that service however optimally will be co-managed with the ICU team
  • management or removal of these devices can be performed by the ICU team but only in direct communication with the non-ICU service
  • Ex: surgical drains, epidurals, t-tubes, TLSO/braces, c-collars, vasc sheaths, etc
  • Any removal/adjustment of devices after direct discussion with the non-ICU service should be documented including the specific person with which it was discussed

Transfers out of ICU:

  • Discuss transferring patients out of the ICU with the primary surgical team prior to order entry
  • Clean up all orders to look “floor ready” (i.e. no drips, q1h vitals, frequent labs, cont pulsox, etc)
  • Place a transfer order to the appropriate floor (ex: IMC, “med surg”, “tele floor” etc)
  • Once the patient is ON the floor, at that point call the primary team for detailed signout
  • For trauma patients: write a transfer note (dotphrase) including whom you signed out to
  • Do not transfer patients out until: >48hrs fresh trach, >24hrs trach collar, >24hrs extubated (for patients w/extended intubation), >24hrs off dex gtt, other drips

Trauma Response & Code Pager:

  • Respond to traumas as requested by the trauma team for concern of ICU need
  • Resident should learn about the patient and facilitate transition to SCC
  • Ownership and primary management of the patient by the SCC team begins when the patient arrives in the ICU
  • The SCC role for codes is “access”. This is typically an IO but often may be an arterial line or central line. Residents should rotate who carries the blue code pager.

Timing:

  • Morning signout (SCC workroom): Everyday 6:00-6:30am
  • Morning huddle (SCU 3 RN station): M-F 8:00am
  • SCC rounds (location TBD): M-F 8:15am, Sat/Sun TBD attending
  • Evening signout (SCC workroom): M-W, F-Sun 6:00-6:30pm, Thurs 7:00pm-7:30pm
    • APP signout remains at 6:00pm on Thursdays
  • All residents on their SCC rotation have 4 days off (one full weekend and 2 weekdays, either Tuesday or Fridays) in addition to their post call day after their one Saturday night overnight.

Notes:

  • Use the most recently updated SCC notes. To find this accurate list, use the smartphrase list manager to take SCC notes from Ashley Geller.  Examples include:
  • .surgsccadmit     .surgsccdaily     .surgsccfloor     .surgscutransfer