Welcome to the rounding team at West Bloomfield Hospital (WBH). Please review these essentials for a successful rotation at WBH.
PARKING
Physician parking is located on the “hill” outside of the main entrance. The patient and family parking lot is the lower lot outside the main entrance.
ROUNDS
The MICU is located in the back of the hospital in the “Chestnut” or C lodge on the 1st floor.
The ICU census list and sign-out is now located in Epic. We are responsible for rounding on all patients in the 1C-ICU (MICU) regardless of their status.
The expectation is that you will arrive promptly at 7am to obtain sign-out from the HFH Nighttime Intensivist. The mid-level practioners (MLPs) will arrive around 7:30 am and obtain sign-out from you to begin their work rounds. The time from 7:30 to 9am is like pre-rounding time in any MICU at Detroit Campus. Use this time to see the sickest patients or patients who require your input. It is helpful if you address any acute patient issues during this time while the MLPs are reviewing their patients. Rounds with the staff typically begin at 9am. Physical Therapy will review patients with you prior to rounds to make sure early mobility can be initiated on patient’s that qualify.
Also, if there is a very high census level (10 patients or more), please be proactive in identifying patients who might be able to be transferred early in the day to open up beds. Alert the APP team and the Nursing staff of these patients to facilitate a seamless and rapid transfer. It is ok to transfer patients to the GPU without them being seen by the staff if census is very high.
When you finish rounding on a particular patient, it is the expectation that the team (including the Senior Staff) will enter the room and update the patient and the family. This is similar to what is done on F2. This update may be brief but is essential to improving communication with our patients and their families. We also encourage family members to join the team on rounds if they so desire. Please ask any family member (1) who joins during rounds to please ask questions at the end of presentation.
ADMISSIONS
Like at Detroit Campus, all MICU evaluations are called to the MICU Spectralink (25-3001). This is as close as you will get to a community hospital experience during your training and it is important to develop appropriate ICU triage skills for your future career. Therefore, it is encouraged to evaluate patients prior to acceptance, especially if you think the patient may not require ICU level care. If, after evaluation, you do not believe the patient needs ICU level care, please write a note in epic (can be either an ICU consult note or a brief note of your evaluation). Please also document appropriateness for either the GPU or stepdown unit. These cases should be discussed with the attending physician just like at HFH-Detroit
If the patient is a clearly appropriate for the ICU, accepting them via telephone is reasonable.
If the patient is being admitted through the ED, we try to provide expedited services as much as possible. Nonetheless, it is reasonable to ask for things in the ED that are standard of care (2 large bore IV’s for GI bleed, CVC for septic patients who require vasopressors, etc). If there is pushback, accept the patient and send me a communication outlining the care issues.
Once patient is accepted to the MICU please inform both the charge nurse (25-2986) and the MLPs (25-2990 or 25-2874). This allows both nursing and the MLPs to anticipate the admission and improves their workflow.
CODE SEPSIS –
You may receive calls from the GPU if a code sepsis is activated. The goal would be to quickly review patient’s chart and ensure the floor team is checking the appropriate labs and see if the patient may need an ICU bed. There is no expectation for us to physically see the patient unless we feel it is in the patient’s best interest. This also does not replace the official call for a bed assignment in cases where ICU admission in required.
APP’s –
As of 11/2014, there has been some attrition in the MLPs covering the ICU. This has left the MICU with 1 MLP covering 12 beds on some days. As such, they will need help. It is up to the staff and you to divide up the patients whom the MLP cannot cover. Duties will include primary bedside management including any acute management, progress notes, addressing nursing concerns, speaking with families. You may also be asked to assist with admissions. If the MICU is busy, a single MLP cannot cover the entire unit primarily with the staff and the fellow providing supervisory support only.
If there are specific questions regarding this issue, please contact me directly.
Finally, to ensure professional satisfaction and ongoing educational development for the HF-West Bloomfield MLPs, hospital leadership has implemented monthly Lunch and Learns for them. These conferences will occur on a agreed upon Wednesday of the given month from 1pm-2pm. It is expected that the staff and fellow handle any issues during this time so the MLPs can attend the lecture.
MPM0
We are collecting MPM0 data and census data from the ICU. The MLP’s are invested in doing this. However, it would be great if you could offer assistance in both entering and collecting of this data.
CONFERENCES
You will be asked to prepare a 30 minute lecture on an ICU topic or Journal article on the second Wednesday of your rotation. Please coordinate this with Leeah.
On Friday afternoons, it is expected by the program that you attend fellow conference. If there is no conference on a given Friday, you are expected to remain at WBH until the end of the work day.
PROCEDURES
Most procedures should be performed in the MICU proper. MLPs are given priority on procedures of their patients and you may be asked to help teach or supervise the procedure. Documentation can be entered into the EMR via Epic.
Of note, any dialysis catheters that need to be placed urgently on patients OUTSIDE the MICU are the responsibility of the IR team. Have the GPU/MPCU team contact them directly. All dialysis catheters on patients in the MICU are the responsibility of the MICU team.
BILLING
Similar to the bronchoscopies at the Detroit Campus, Senior Staff is expected to be present for all bronchoscopies in the MICU at WBH.
Other billing is clearly augmented with senior staff presence. Being present for the key portions of CVC, arterial line placement, etc. will aid in increasing revenue for the division.
WEEKENDS
Saturday is your day off.
On Sunday, the day starts for you at 7am as during the week. The Senior Staff will start rounds at 9am. Senior staff can leave when their work is finished (i.e. rounding is completed and all consults are completed) as long as they are available via telephone until 7pm. It is expected you will be in house on Sundays until at least 5pm as on other regular work days.
On the weekends and after hours during the week, if the particular service you need to speak with is not in house, the person you should contact is the house manager. Most commonly, this occurs when we need to consult IR urgently after hours.
PULMONARY CONSULTS
At this time, you are not responsible for any pulmonary consults. These patients are seen primarily by the WBH Daytime IPD staff.
SIGNOUT
Before leaving for each day, please let the MLPs know. On occasion, they will have issues that need to be addressed before you leave, but were not urgent enough to contact you directly. It is expected that you will leave around 5pm.
CARE LOCATION DISPUTES
Occasionally, there are disputes on the best place to care for a patient. The ideal way to handle these episodes is involve the MICU and 2 ICU staff early in the process. If the staff is not available (and this should be a rare event), the next place to start would be to contact the house manager. The house manager can be contacted at 248-325-3054 and they are present in the building from ~ 3pm-7am. If no resolution (or it is outside of these hours), you can contact the MICU Nurse Manager, John Roberts at 586-925-1213.
NEURO ICU/SURGICAL ICU
As of 8/4/2014, the Garden ICU (which houses neurology, neurosurgery and surgical ICU patients) is staffed by a Pulmonary and Critical Care physician.
The current rules are that if surgery/neurosurgery plans to operate or the patient is post-operative, the patient will be admitted to the SICU/NSICU service with the operating surgeon as the admitting/attending physician.
Any other patient admitted for a neurological ICU issue (CVA, status epilepticus, etc.), will still be admitted to the 2 ICU preferentially. This is because of geographic nursing expertise and should not be challenged unless you have an extenuating circumstance. These patients should be admitted to the P&CCM senior staff who is rounding the following day.
There are some times that a MLP is rounding in the 2 ICU and the staff is not physically on the premises. This should be infrequent. However, if it does happen (especially early AM on weekdays and in the afternoon on Sunday), you may be called to assist with those patients.
Absences/Holidays: If there is any reason you are unable to work on any given day, the same set of steps applies here as it would to ICU rounding downtown. In case of an emergency you should inform your chief fellow and they can inform the team and rounder of the situation. If you must take a day off for any personal reasons, other than illness, you first need to find coverage for that day either by yourself or with the assistance of your chief fellow or program director. Same holiday schedule applies to HFHWB as if you were rounding at Main.
Please feel free to contact me with any questions or concerns.
Thanks.
Dominik Starosta