Day-to-day
responsibilities
in the SICU
The HGH ICU is a twenty-four bed, mixed medical and surgical intensive care unit. During weekdays ICU + Trauma rounds are typically at 8:15 a.m. unless otherwise determined by the ICU or Trauma attending. The ICU residents are expected to present each trauma patient on rounds. In addition to reporting patient data, residents are expected to synthesize a treatment plan that is evidence based for each of the patient's active problems.
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In addition to presenting on morning rounds, you will be the first ”go to” person for issues in the ICU. Your role will be not only to keep the primary team apprised of new issues with patients, it will be to help manage patients while the primary team is in clinic or the operating room.
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The open unit format requires you to take primary directives from the admitting team of record.
This often will be the trauma service or the Acute Care Surgery service. (occasionally the E1/2 services or Vascular) may have patients in the ICU.
Regardless of primary, the rule still holds: the primary service is in charge of all decisions except for management of the ventilator and sedation.
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In addition to presenting on daily ICU rounds, you will be expected to write an ICU progress note for each patient. These notes should not be cut and pasted from previous notes. They should be synthesized new each day based on overnight events and the daily progression of the patient’s clinical findings. Only the key findings of radiology studies should be relayed in daily progress notes, NOT the entire dictation from the radiologist.
Family Connect Notes
In addition to progress notes, the patient should also get ”family connect notes” twice a week. One note for the first half of the week ending on Tuesday. The second should cover the second half of the week ending on Friday.
These notes should refer to conversations with available family members regarding the patient’s status and cover the key components of the discussion. These notes do not not need to be long unless the patient's bio-psycho-social situation demands it. The goal is for them to be a log of communications with the family regarding the patient's course in the ICU.
Data Review
Each day you should review the following care categories. Connect with primary team to assure they are aware (and acting on) new results.
Medications
Review all medications in the Active medications list.
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Pay special attention to sedation and analgesics. Are there any drugs on the list that can be discontinued? ICU has a primary role in management sedation and analgesia since it is intimately related to ventilator synchrony. Discuss with the ICU attending your plan to change meds. Your goal should always be to use as little as needed to accomplish adequate pain control.
Are there any other medications that can be discontinued? For any meds that are not Analgesia or Sedation, confer with primary service prior to discontinuing.
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Polypharmacy is one of the areas for potential harm in hospitalized patients. Strive for adequate, not excessive Rx.
Radiologic Studies
As surgeons you should constantly increase your diagnostic acumen by examining radiologic images yourself.
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By personally reviewing films, you cement your understanding of relational anatomy. Once you have reviewed the films, then (and only then) should you look at the radiologists interpretation. If something does not 'seem to fit' with what you think you see and what the read says, sit down with your senior residents or an attending to further discuss the findings.
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It is not outside the realm of possibility that you could 'catch' a radiologic misread and save a patient from the potential harm of misdiagnosis.
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Microbiology Cultures
The milieu of the Surgical ICU is one where infections can flourish if not actively kept in check. Fevers and leukocytosis should be investigated and responded to in a timely fashion.
Daily review of cultures falls under the domain of the ICU team AND the primary service. As part of your daily standard work, cultures should be reviewed.
Use of empiric antibiotic therapy should be limited and should only proceed after discussion with the attending of record.