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FICU

Team Structure

  • Day Intern
    • Works 7am – 7:30pm (12.5hrs) x 6 days per week.
    • Supervised by the day resident.
    • Pass-off to moonlighter at 7pm.
    • Day off: Saturday
  • Day Resident
    • Works 7am – 7:30pm (12.5hrs) x 6 days per week.
    • Supervises the day intern.
    • Code leader for “Code Blue” in the hospital.
    • Pass-off to moonlighter at 7pm.
    • Day off: Saturday
  • Night MOONLIGHTER: 7pm – 7:30am
  • Weekends: The FICU is covered by Moonlighters from Friday 7:00 PM – Sunday 7:00 AM (see below for details).

Schedule

  • 7:00 AM – 7:30 AM: Night team passes off to the day team in the resident work room. FICU intern and resident should call the operator (dial 0) and SIGN in 40000 and 50000 pager to the resident and intern, respectively.
  • 7:30 AM – 8:00 AM: Intern pre-rounds
  • 8:00 AM – 8:15 AM: Radiology rounds with attending
  • 8:15 AM – 10:00 AM: Morning rounds
  • 10:00 AM – 11:00 AM: Morning report in Pariser
  • 11:00 AM – 12:00 PM: Work
  • 12:00 – 1:00: Noon conference / lunch
  • 2:00 PM – 2:30 PM: Multidisciplinary rounds with PT, nutrition, CC, SW (not every day)
  • 3:00 PM- 3:15 PM: Faulkner 5 Teaching in Pariser
  • 4:00 PM – 5:00 PM: Evening rounds (time varies by attending, they will let you know)

Admitting Structure

  • No admission cap – total census cap defined by number of available beds (usually less than 6)
  • Daily admitting.
  • ED Admissions: All patients must be accepted by the attending, after which the resident will be paged to get passoff. It is not necessary to go to the ED to see the patient—the time between passoff and FICU arrival can be variable.
  • Floor to FICU transfers: Based on resident-to-resident conversation and assessment by FICU resident. Patients coming from the floor MUST be accepted by the FICU resident prior to transfer (but do not have to be accepted by the FICU attending before transfer.) However, when they arrive, you MUST call the on-call attending to discuss; otherwise, they will not be aware of the admission. If you aren’t sure about whether the patient needs transfer, call the attending to discuss.
  • FICU to Floor transfers: Our goal is to have FICU to floor transfers on the floor by 2 PM. To help facilitate this, please start ICU transfer notes the day/night before transfer. Have the nurse manager call admitting during/after rounds to facilitate the process and have the nurse manager notify you when a bed is available.
  • Desensitizations: On Tuesdays, you may have “admissions” for densensitizations to certain medications. Dr. Silver from the Division of Allergy typically will write any necessary orders, but you will be responsible for writing an H&P and discharge summary. You may or may not round on them.

Emergencies

  • Airway management: Anesthesia is in-house from 7 AM to 6 PM (M-F). ED attendings will do emergent intubations after hours and on weekends. They do not come to codes unless directly paged, so you will need to bag the patient until the ED attending arrives.
    • Respiratory therapy is in-house 24 hours/ day, but you should always call the attending if there are ANY concerns about vent management.
    • As of March 2015, the respiratory therapist will intubate patients overnight with ED attending back-up.
    • Please note that we have a new oxygen mask that replaces everything from a normal facemask to a non-rebreather. It can deliver up to 15L at 100% FiO2.
  • RRTs: FICU residents do not attend RRTs. The FICU charge nurse will go to all RRTs—they will notify the FICU resident if a higher level of care is required and will request the resident’s assessment.
  • Codes: FICU resident is the code leader for ALL locations in the hospital. These virtual pagers should be signed over to you in the morning and then signed over to the moonlighter at night.
    • The virtual code pager for the FICU resident is 40000
    • The virtual code pager for the FICU intern is 50000
    • The GMS long call resident also carries a physical code pager, as does the GMS long call intern. The twilight residents and the nocturnist hold these pagers overnight.
  • If you need a patient intubated, you must call anesthesia during business hours or the ED attending during off hours (they do not automatically go to codes).
  • If a code occurs in a non-clinical area (i.e. Belkin House dialysis center, lab, pharmacy, lobby, etc.), the protocol is to do BLS and then bring the patient to the ED for full ACLS management. The capacity to do full ACLS in non-clinical areas does not exist (no code cart, etc). If a code is called in Belkin House, the FICU resident is still the code leader, but EMS is also called (i.e. 911) for an ambulance to transfer the patient to the ED.
    • The FICU resident is the code leader in all surgical areas as well. Contact the appropriate attending after codes for urology, neuro, ortho, plastics, etc. patients as there are no in-house residents for these services. Surgical residents will come to all codes, as does the ICU nurse.

Attendings/Fellows

  • Weekday Attendings: Dr. Tarpy, Dr. Lahive (each do 1-month blocks)
  • Nights: Weeknights are covered by Tarpy and Lahive on a QOD schedule, unless the moonlighter is an attending-level pulmonologist.
  • Weekends are covered by a rotating group of weekend attendings.

Cardiac patients: Rarely, if the patient has a pure cardiac issue, the cards attending will attend on a patient directly. Discuss with both the ICU and cards attending to determine who will be attending of record. The FICU is a combined MICU/SICU. We are not the providers for the surgical patients. It functions as an open unit for the surgical team and the surgical residents/attendings will provide all care for surgical patients. Surgical patients do, however, count towards the overall patient capacity in the unit due to nursing needs.

There is a BWH pulm/critical care fellow in the FICU for 6 months of the year – they can be incredibly helpful for teaching, procedure supervision, so please use them as a resource.

FICU Workflow Issues

  1. Please verbally communicate with RNs when you put in any urgent orders (i.e. D50 for hypogylcemia).
  2. Please make sure all appropriate orders (i.e. vent, restraint, drips) are in EPIC.

FICU Weekend Signout Guidelines

Moonlighter Coverage: The FICU is covered by moonlighters from Friday afternoon at 7 PM until Sunday morning at 7 AM. There is also generally a covering ICU attending. You will receive an email from Susan Cohen indicating the FICU coverage for the week/weekend by Wednesday of each week. Use this grid to determine who you should email signout to on Friday evening.

  • In order to facilitate transitions of care, the following things MUST happen on Friday afternoon before leaving the FICU:
    • A pass-off email must be sent by the FICU resident to ALL of the weekend moonlighters AND to the covering attending (see below); this should be similar to the e-mail you would send to a weekend rounder with patient blurbs/active issues and weekend to-do’s.The FICU resident will receive an email from Susan Cohen indicating the FICU coverage for the week/weekend by Wednesday of each week. He/she will use this grid to determine whmo he/she should email signout to on Friday evening.
    • Transfer notes (including hospital course) must be prepped for any ICU patients who may be transferred to the floor over the weekend. Typically, this is done by the FICU intern.
    • Progress notes must be reviewed and updated to ensure accuracy. This is especially important on the weekend since the progress notes will serve as a crutch for the covering team while you are away.
    • Each moonlighter will update the pass-off e-mail with updates of each patient’s events during their moonlighting shift (3 total shifts). The FICU team will receive the final passback email with when they return to the FICU on Sunday morning. This process will enable the FICU team to track the patient’s management over the weekend and ensure patient safety.

If there are any issues with moonlighter coverage, please contact the Faulkner chief resident or Susan Cohen.

Clinic

  • The FICU intern may be scheduled for their regular weekly continuity clinic. The FICU resident will not be scheduled for clinic during their block.
  • If the FICU intern is in clinic, the FICU resident will carry the list for the afternoon.