This document outlines workflow for common ICU and/or coverage questions. It is meant to clarify current expectations, and will be updated as new processes change or new questions come up. I hope you find it to be a useful reference.
Workflow Guidelines
This is a living document, which outlines workflow for common ICU and/or coverage questions. It is meant to clarify current expectations, and will be updated as processes change or new questions come up.
General ICU guidelines
Patients evaluated in-house (GPU, ED) for ICU transfer should be seen urgently, within 1 hour.
If you anticipate/expect a delay in your ability to go to the bedside, please inform the primary team (GPU) or ED attending.
There is always an ICU staff on call, who is listed as “ICU call” in momentum, who can provide indirect supervision over the phone. Additionally, there is an in-house ICU staff Sun-Thurs night to provide direct supervision if needed.
ICU transfers
We have a “just say yes” policy for patients being transferred from other hospitals. Declining transfers from an outside hospital is highly discouraged.
Any patient declined for ICU transfer must be discussed with the ICU attending on call.
- If the patient is not in house, you must document your rationale for declining the ICU transfer.
- It is not a fellows’ responsibility to determine whether a patient is stable for transfer. The sending physician who is assessing the patient determines the need, and is responsible for the patient’s status until they make it to us.
If the patient is in house, you must assess the patient and document your assessment in the EMR.
MICU charge nurse is the source of truth for our MICU bed status. Please communicate with them frequently for updates.
MICU Capacity “Cap”
MICU is at capacity (“capped”) when there are 74 MICU patients in beds in the hospital (18 on red, white, blue and 20 patients on green service). You must call an attending when MICU is capped. Sunday-Thursday during the day and anytime Friday-Saturday call Dr. Swiderek (734-309-1578). During the week, call the in house intensivist on 6N/6C. We will then notify ATMO and the trauma staff. SICU will then take MICU admissions as primary (if they have beds). Remember, even if CICU or NICU have beds, they cannot be primary. Please take report from ATMO/ED/GPU, etc once we reach our cap. Fellows still evaluate/accept the patient and call for a bed.
ICU Bed shortage
If there are no ICU beds in the hospital, regardless of whether or not we are capped, staff needs to be involved. Sending the least sick patient(s) to the floor is top priority to make beds.
Non-cirrhotic GIB to SICU
SICU has agreed to admit non-cirrhotic GI bleeds to their service to help with our cap; however, if SICU is full, we will admit these patients from time to time and Dr. Swiderek will notify MICU fellows if this occurs. After you accept a patient and are given a bed in the SICU you must call report to the SICU team. In addition, you need to sign out these patients to the next bed fellow until the patient arrives.
Intubation
Intubations in the ICU must be supervised. The ICU attending or GAP staff must be notified of an intubation. If an ICU staff is not available – weekends after rounds or between day staff leaving and night staff coming in – anesthesia must be called for supervision.
RSI is currently not allowed in the MICU. Any patient needing paralytics to establish an airway must have anesthesia called.
ECMO
Patients transferred “for ECMO” must be evaluated for the appropriateness of ECMO, as there is no guarantee that any patient transferred will be placed on ECMO. The ECMO Care Team (ECT) staff must be consulted to assess for ECMO.
ECT staff are listed in momentum. ECT staff are on call 7 am through 7am the following day.
There is a separate ECT document on HFHpulm if more info is needed.
IPD Consults
- Weekdays
Consult fellow and staff should round when mutually agreeable, if there are time-sensitive issues (potential same-day bronchoscopy or thoracentesis), those patients should be discussed/seen early in the day
If consult fellow is in clinic in the afternoon the resident on consult should take pager, see consults and staff with attending in the afternoon
If consult fellow is in clinic in the afternoon and there is no resident, then attending should take pager and staff consults that same day
- Friday afternoon: same rule as if fellow is in clinic applies
- Weekends
IPD consults should be seen by F2 rounder if received while still in-house
If F2 rounder is not in house but gets a request for a consult, preliminary recommendations can be made and formal consult completed the next day (within 24 hours)
If there is a request for a patient in an ICU to be seen:
- For ventilator management (or other critical care issues) it should be seen by the Green fellow and staffed by the ICU attending on call
- For ICU to ICU transfers it should be seen by the Green fellow.
- For a pulmonary issue it should be seen by the F2 rounder covering IPD consults
Holiday Coverage
Holidays are covered according to a weekend coverage schema. Fellows who are on rotations where they are not required to cover on weekends (PH, Transplant, ILD, IPD consult, F2, bronchoscopy, WB IPD consult) even though their rotation may have inpatient coverage, will not be expected to cover on a holiday.
ICU Phones on Friday afternoon
ICU phones (triage and pod phones) are covered by your rounding staff during educational conference time (12-3pm) in order to ensure fellows are in conference. If there are additional educational sessions (sim, outpatient curriculum, US,etc), fellows are expected to inform their staff, so staff will be aware that they will need to cover the phone beyond the usual 3pm time. If issues arise, please let an APD, PD, or the Division Head know.