Surgical Critical Care Rotations and Duty Hours

UNIVERSITY OF UTAH HOSPITALS AND CLINICS SURGICAL INTENSIVE CARE UNIT
3 months

LEARNING OBJECTIVES

The fellows will: 

• Develop expertise in the management of critically ill surgical patients in the SICU.
  • Gain an understanding of the principles of critical care management, including hemodynamic monitoring, ventilatory support, and fluid resuscitation.
  • Learn to recognize and manage common surgical critical care conditions, such as sepsis, acute respiratory distress syndrome (ARDS), and multiple organ dysfunction syndrome (MODS). 
  • Understand the principles of nutritional support and metabolic management in critically ill surgical patients. 
  • Develop proficiency in utilizing evidence-based protocols and guidelines for optimal care in the SICU.
• Enhance clinical decision-making skills for the management of complex surgical cases in the critical care setting. 
  • Participate in the daily management and decision-making for critically ill surgical patients admitted to the SICU. 
  • Develop proficiency in interpreting and integrating data from various monitoring modalities, laboratory tests, and imaging studies to guide patient management. 
  • Learn to prioritize interventions and make timely decisions for surgical procedures, imaging studies, and consultations in critically ill patients. 
  • Gain expertise in recognizing and managing complications related to surgical procedures, such as post-operative bleeding, anastomotic leaks, and surgical site infections. 
• Acquire advanced knowledge and skills in ventilatory management and respiratory support. 
  • Understand the indications, contraindications, and management principles of mechanical ventilation in critically ill surgical patients. 
  • Learn to interpret and adjust ventilator settings based on patient physiology, lung mechanics, and oxygenation parameters. 
  • Develop proficiency in managing patients requiring non-invasive ventilation, high-frequency oscillatory ventilation, or extracorporeal membrane oxygenation (ECMO). 
  • Participate in multidisciplinary discussions regarding difficult ventilator weaning and extubation decisions. 
• Gain expertise in hemodynamic monitoring and management. 
  • Understand the principles and interpretation of invasive hemodynamic monitoring, including central venous pressure (CVP), pulmonary artery catheterization, and arterial pressure monitoring. 
  • Develop skills in assessing fluid states and volume resuscitation in critically ill surgical patients. 
  • Learn to recognize and manage hemodynamic instability, including shock states, hypovolemia, and cardiac dysfunction. 
  • Gain proficiency in utilizing vasoactive medications and inotropic support to optimize hemodynamic parameters. 

ROTATION OVERVIEW

The SICU is an open unit, meaning that the surgical teams remain the primary teams and the SICU team is technically a consulting team and is responsible for the critical care of the patient. The surgical teams will manage their own drains, tubes, and dressings. The primary team is responsible for writing basic admission orders. After admission, the SICU team writes ALL other orders. Why, you ask? Because the SICU team needs to know when a patient is leaving the unit for a study, if labs are being drawn so the team can follow up on them appropriately, so there is streamline communication between the SICU team and the bedside nurse, so as to minimize the number of cooks in the kitchen. 

Shifts

• Day Shift (for residents and medical students): 0600-1800
  • The day team will receive sign out from the night team at 0600.
• Night Shift (for residents and medical students): 1800-0600
  • The night team will receive sign out from the day team at 1800.
• Day Shift (for fellows and attendings): 0700-1700
  • The day team will receive sign out from the night team at 0700. Residents and medical students will be present for the fellow/attending to sign out for educational purposes and to participate with updated information as needed. 
• Night Shift (for fellows and attendings): 1700-0700.
  • The night team will receive sign out from the day team at 1700. Residents and medical students will be present for the fellow/attending to sign out for educational purposes and to participate with updated information as needed. 

SICU Rounding

• Daily SICU rounds will typically begin between 0800 and 0900 pending active patient issues and team member availability.
• It is expected that fellows will perform a physical exam on each patient before they present prior to the start of rounds. Fellows should also check in with the bedside nurse for any additional pertinent information.
• Evening SICU rounds will involve the night attending/fellow, resident, medical student, charge nurse, and bedside nurse. 
  • Evening rounds typically occur between 2100 and 0000 pending availability of the night attending/fellow. 
  • Evening rounds are more focused on pertinent information such as confirming plans formulated on day rounds, any clinical status changes, hemodynamic status, current respiratory status/vent settings, fluid balance goals, and infectious disease issues.
• Throughout the day, the primary surgical teams will round on their patients in the SICU. It is advised that a member of the SICU team be present during primary surgical team rounds in the ICU to provide any pertinent updated information and to ensure appropriate communication between the teams. This is also a way to know what the plan of the day is and any requested orders from the primary surgical teams.
• Process: House officers/APCs present 24-hour events (or identifying information on new admit). Nurses present vital signs, labs, and exam findings in a system-based format (neurologic, cardiovascular, pulmonary, gastrointestinal, genitourinary, musculoskeletal, heme/infectious disease, endocrine, prophylaxis). House officers/APCs then present their plan in a systems-based format. House officers/APCs that are not presenting should be writing orders (orders are expected to be placed during rounds). House officers/APCs will then complete an order read back for closed loop communication. 
• The SICU Checklist/Plan of the Day form must be filled out on every patient, every day, during rounds. This ensures all pertinent information for patient care and communication has been discussed and addressed. This also allows the providers and nurses the ability to give up-to-date information and plans to patients and their family members, as well as serves as a continuity plan of care form that night teams can reference when on evening rounds. This form is evidence-based and has been shown to improve patient outcomes. After the sheets have been completed, they will then be given to the bedside nurse for the day. The sheets should be reviewed by the night team during evening rounds to verify continuity of plans and that there have been no new orders placed that the SICU team is unaware of. 
• Ideally, progress notes should be completed by 1400. 
• When rounding on a patient, fellows should complete their thought process in a systems-based format to avoid missing anything. In addition, there is a handy acronym for the specific items that should be addressed every day: FAST HUGS BID (see below). 
  • Categories that should be evaluated every day in ICU patients include: 
    • Feeding
    • Analgesia
    • Sedation
    • Thromboembolism prophylaxis
    • Head of bed (elevation)
    • Ulcer prophylaxis
    • Glycemic control
    • Spontaneous breathing trial
    • Bowel movements (or lack thereof)
    • Invasive devices (and duration they have been in place)
    • Ability to de-escalate antibiotics

When Should I Call the Attending?

Fellows should expect to be physically by themselves in the SICU at times, but they are never alone as there is always a SICU attending in-house 24/7. Attendings may generally be called for the following reasons: 

• For any significant change in status (e.g., admission to the SICU, prior to transferring a patient out of the SICU)
• Change in status also includes when a patient gets clinically worse:
  • Change in neurological exam (potential need for CVA workup)
  • Hypotension not responsive to 2L IVF (possible need for vasopressor/inotrope support or significant escalation of doses)
  • Arrhythmia
  • Need for intubation or need for PEEP more than 12
  • Self-extubation
  • Peritonitis on a post-surgical patient
  • VTE identified on imaging (potential need for therapeutic anticoagulation)
  • Prior to blood product transfusion
  • Prior to initiating antibiotics, starting infectious workup
  • Prior to ordering imaging studies (potential need for patient to sit in radiology and receive contrast)
  • Prior to any procedure (e.g., central line placement, chest tube placement, bronchoscopy, etc.)
  • Cardiopulmonary arrest
  • Clinical Nurse request
• The primary surgical team should also be notified of significant clinical changes to their patients. 
• Per SICU policy, all patient orders are to be placed by SICU residents/fellows/faculty only. Should there be a specific order from a primary or consulting service, these orders are to be communicated to the SICU team so they may place said order. In the event of an order generating further discussion with the treatment teams (antibiotic initiation and duration, holding of nutrition for a procedure, initiation and pausing of prophylactic or therapeutic anticoagulation, etc.), these may need to be escalated to a higher level (attending-to-attending conversation). In order to minimize untoward complications such as VTE, malnutrition/deconditioning, infectious disease complications, etc., if a request comes in from a surgical team to hold VTE prophylaxis for the OR, etc., start or stop an antibiotic course, or to hold tube feedings, etc., this should be discussed with the SICU attending prior to agreeing upon such order as an attending-to-attending conversation may be generated prior to formulation of these types of care plans. The goal is not to create confusion amongst the ICU, primary, and consulting providers, nor the bedside nursing staff. This potential confusion may subsequently negatively impact outcomes, complication rates, and/or quality measures. Specific exceptions to this policy would be with our Transplant Surgery teams as there are specific order sets and Transplant Pharmacy involvement that deal with timely immunosuppression and fluid replacement orders.
• With any procedure performed on a patient in the SICU; whether by the SICU team or primary team, the SICU attending must be notified prior to the start of the procedure. Certain procedures will require conscious/moderate sedation and per hospital policy, a licensed provider (SICU attending) must be present. This communication is for patient safety and medical/legal purposes.
• Communication is key!

SICU Evening Provider Contact Flowsheet

SICU/ACS Night Team:

• Attendings/Fellows: One attending covers both ACS and SICU except for Wednesdays and Saturdays, when the SCC/ACS fellow covers ACS and the attending covers SICU. 
• PGY-4/PGY-5: One chief-level resident covers ACS, and if available, may assist in the SICU.
• PGY-1/PGY-2: One junior-level resident covers ACS, and if available, may assist the SICU.
• SICU Resident/APC: One junior-level resident or APC covers the SICU. 

Emergent Scenarios (cardiopulmonary arrest, emergent intubation, etc.):

• 1st call: ACS/SICU in-house night call attending
• 2nd call: SCC/ACS fellow (if in-house on ACS shift)
• 3rd call: CVICU in-house attending

Urgent Scenarios (situation requiring resolution or plan formulated within one hour):

• 1st call: ACS/SICU in-house night call attending
• 2nd call: SCC/ACS fellow (if in-house on ACS shift)
• 3rd call: PGY-4/PGY-5 in-house ACS resident
• 4th call: ACS backup attending
• 5th call: SICU daytime attending of the week

Nighttime communication with providers should occur via a phone call or page, not a text message as text messages may not be received in a timely manner. 

If the provider is in the OR or in the Trauma Bay, you should physically go to said location to communication directly with the provider you are trying to reach, or you can call into the OR. 

If you are still unable to locate the provider, please call or page the next person on the flowsheet.