PICU & NICU ORIENTATION GUIDELINES FOR REGISTRARS

Welcome to PICU & NICU. We hope that you enjoy your time here. These brief notes are designed to
introduce you to our ICU routine. Please have a low threshold to ask questions if you are not sure
about anything.

ICU WHO’S WHO

P/NICU
Consultants: Dr Joe Brierley
Dr Paula Lister
Dr Quen Mok
Dr Mark Peters (Academic Lead)
Dr Andy Petros (Clinical Unit Lead)
Dr Christine Pierce
Dr Sanjiv Sharma
Dr Sophie Skellett

Modern Matron Darren Darby

Office and Administration Manager Carol Parkes ext 7950

Medical Secretary PICU/NICU Paula Smith ext 8213

Family Liaison Admin Assistant Emma Harris

Clinicians Assistant, PICU Eugenia Abaleke

Operations Manager Sarah Metson

Business Manager Christopher Foster-McBride

SpR Rota Co-ordinator Gabor Reder ext 0585

Senior Physiotherapist Sarah Hines (sabbatical for 2010)

Senior Ventilator Technician Claire Beckwith
PICU Pharmacist Rachelle Booth
NICU Pharmacist (+TPN) Venetia Horn
Psychologist Harriett Conniff

CCC
Consultants: Dr Kate Brown
Dr Mike Broadhead
Dr Troy Dominguez
Dr Allan Goldman
Dr Aparna Hoskote
Dr Anne Karimova
Dr Cho Ng (Clinical Unit Lead)
Dr Tim Thiruchelvam (locum)
Modern Matron Barbara Childs

CATS
Consultants: Dr Joe Brierley
Dr Paula Lister
Dr Daniel Lutman
Dr Mary Montgomery
Dr Mark Peters
Dr Andy Petros (Director)
Dr Padmanabhan Ramnarayan (Ram)

Senior Nurse, CATS Eithne Polke

Office Manager, CATS Mhairi Emery

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NICU / PICU REGISTRAR ROLES & DUTIES

General Duties:
This is a closed ITU.
This means the ITU consultant has primary clinical responsibility for the patient while they are on the
unit. However, many patients are cared for in partnership with the referring team/s, e.g. general
surgery, neurosurgery. As in all partnerships, be courteous and diplomatic to the referring teams.
However, all management decisions by the referring teams need to involve PICU. Similarly, major
PICU decisions should also involve a courtesy phone call to the referring team.

HAVE A LOW THRESHOLD TO SPEAK TO THE ICU CONSULTANT:

- IF YOU ARE NOT SURE ABOUT ANYTHING
- IF THERE HAS BEEN A MAJOR CHANGE IN A PATIENT’S CONDITION
- THE REFERRING TEAM WISH TO CHANGE THE TREATMENT

The Daytime ITU Fellow & Long Day (LD) ICON Fellow:
The ITU fellows are senior PICU trainees that rotate through PICU/NICU and ICON. The fellow is on
service during the day (Monday to Friday, 8.15 – 18.00, for a week at a time) will lead the ward rounds,
direct clinical care and will support the registrars and nursing staff.
The LD ICON fellow, if free of ward duties, will shadow the support consultant.

Long Day (LD) & Short Day (SD) registrar shifts:

• The patients are divided between the registrars of each unit (3xPICU & 2xNICU). However; all
registrars must have an overview of the other patients in their unit in case their colleague is off
the unit for a period e.g. in CT scanner. Please ensure the nursing staff know which registrars
are responsible for which patients – put your initials on the main white board next to your
patient.
• You are the responsible physician for your patients during your shift; with all the
professional attributes this invokes.
• It is your duty to undertake a daily full clinical examination with a review of laboratory results.
This must be documented, legibly, in the medical record as a daily progress note.
• It is your responsibility to be certain you understand the patient’s clinical management plans
as discussed on the ward rounds. Ask if you are unsure. You must ensure that your patients’
bedside nurses also clearly understand the management plan.
• The LD shift person carries the bleep.
• If you leave the ward, please let the nurse in charge know where you will be.
• Any acute event or procedure must be documented in the case notes.
• Review the IV fluid orders and prescribe the new orders as early as possible
• TPN needs to be ordered by 10.30 am (On Fridays please remember to order for the
weekend). The Nutrition Support Team may come to NICU/PICU from 2 pm on Tuesdays to
discuss the patients on TPN.
• Make all referrals to specialist teams (eg neurology, respiratory etc) and order special
investigations (MRI, ultrasound, EEG) as soon as possible after the ward round. The
clinicians’ assistant will help with these requests. There is a portable US round which starts at
2:00 pm; requests must be received before this starts.
• Try to perform trials of extubation as early in the day as possible.
• Keep the handover sheet up-to-date and succinct on the K:Drive PICUNICU Handover Folder.
Please save one am & pm version daily.

Second PICU Short Day Shift (pSD2)

In addition to the above duties this role also has the following responsibilities:
• Daily management of long term patients. This includes “housekeeping” roles e.g. weight
charts, developmental assessments, interim summaries.
• Daily management of ONLY 1-2 other PICU patients as per role above, however, in a more in-
depth fashion, with reading around the case.
• Provision of teaching “moments” on the afternoon round – 5 minutes of teaching about an
issue thrown up by one of the clinical cases.

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Night Time ICON Fellow:
The fellow will take handover from the daytime ICON fellow and will attend the CSP handover. The
ICON fellow will then attend the hospital handover. The ICON fellow will meet with the PICU and NICU
night registrars to discuss the patients and any potential problems. The ICON fellow is a resource for
the night shift registrars on PICU and NICU and should be contacted for advice or support. In the
event the ICON fellow is unable to attend due to duties elsewhere in hospital, then the night registrar
should contact the consultant on call.

Night Shift Registrar (N):

• Undertake a ward round with the nurse-in-charge after your handover. This will clarify clinical
management plans & familiarise you with the patients, identifying jobs and potential problems for
the shift.
• Liaise with the night registrar on the other unit and work as a team. Provide assistance as needed.
• Document any acute events or procedure in the patient notes.
• Dictate discharge summaries for those patients likely to be extubated/discharged the following
day.
• Order the daily bloods by 6:00 am to ensure the results are ready for the ward round. The bedside
nurse will generate the forms on the PIMS system, take the bloods and will send them. If you have
any specific request other than the usual FBC, U&Es and clotting screen, either tell the bedside
nurse or print off the form yourself and give it to him/her.
• Order (place form in the tray and bleep radiographer) the portable x-rays by 8:00 am.
• Out of hours x-rays and CT scans are arranged by contacting the Radiographer on-call.
• Update the patient handover sheet and save a copy on the K Drive: PICU NICU Handover folder.
• Please let the nurse in charge know where you will be if you leave the ward to go to the hot office,
coffee room etc. Please let the registrar across the floor know if you leave the unit to go to CT
scan.
• Update the ICON Fellow with the patients you are most concerned about. He/she should be
consulted prior to contacting the on-call consultant.

Research Registrar Role (R):

This occurs for one week in the 17 week rolling rota when possible.
The aim is to introduce you to research principles, to learn critical appraisal of the literature, to
participate in ongoing research & audit projects and to design & run your own projects.
• Contact Mark Peters by email a few weeks before your research week to understand what will
be required of you.
• On Monday you will contact Mark Peters (or Joe Brierley, Paula Lister in his absence) to
discuss your objectives for the week. On Friday you will discuss your progress.
• On Monday you will meet with research fellows and nurses already running studies on the unit,
to see how you might assist them. The fellows may be from different disciplines e.g. surgery.
• At the end of the week, run through the unit activity with the ward clinicians assistants
ensuring that the speciality designation, source of referral and emergency/elective designation
for each patient on the ward is correct.
• Undertake any presentations required at ITU or joint meetings (see list below). It is your duty
to contact the responsible consultant a few weeks beforehand so your presentation is not last
minute.
• Present in the journal club.

Zero – Hour Shifts:

The concept of these shifts comes from the EWTD. These are normal working days, at your place of
work, on which you work zero hours. Therefore, once averaged out over the rota, you work <48hour
week.
As these are normal working days, you are expected to be at your place of work in an emergency – for
example a major incident or emergency cover for a sick colleague.

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ICU / PICU WARD ROUNDS
Day team:
On service consultant, supporting consultant (weekdays), LD & SD SpR NICU, LD & SD & pSD2 SpR
PICU, Research Registrar, ITU fellow, ICON Fellow

Night team:
On service consultant, night SpR’s NICU & PICU, ICON Fellow

• The ward round starts on NICU at 8:15 am and continues on PICU, initially as a sit-down round
then a walk- round the patients. The night registrars stay until the end of the PICU sit-down round.
This must be completed by 9:30 am so that the night SpRs stay within EWTD hours.
• All the day registrars are expected to attend both ward rounds (NICU & PICU).
The SD NICU person may occasionally miss the PICU round if there are urgent matters to be
dealt with on NICU after the NICU round.
• Parents will be asked to wait outside during the morning rounds.
• In the morning, a brief presentation on each patient will be made by the night registrar. Please
refer to “Handover Guidelines” for advice. The presentation must include a reason for admission,
brief history if necessary, progress and plan for the day. It must be succinct.
• Please “face” your audience so everyone can hear you.
• Use the patient handover sheets to help structure your presentation. These are kept on computer
hard drive and updated twice daily. The hand over folders are stored on the GOSH system K drive
and are labelled according to the unit and date.
• The patient handover sheets contain patient-identifiable, confidential information. They must be
disposed of in confidential waste bins available on both wards. Please do not leave them lying
around. Please do not print more copies than are required.
• The general surgeons join us on the NICU ward round daily. Thursday is the Surgical Grand
Round so it tends to be larger.
• Afternoon ward rounds commence at 16:00 pm in the PICU followed by NICU at 17:00.
• The handover on the evening round is led by the bedside nurse, discussing progress against the
clinical management plan. The responsible registrar will provide additional information regarding
investigation results, other medical team consultations or nay other relevant information.
• The short day shift leaves after the afternoon ward round on weekdays. On the weekend, the short
shift may aim to handover to the long shift at 14:00 if the unit is quiet. This is a bonus - NOT a
matter of routine.
• Evening handover to the night shift begins at 20:30 on each unit. The day registrars must leave by
21:15. The night registrars then liaise with the nurses in charge for an informal ward round to
consolidate plans for the night.
• At both morning and evening ward rounds a checklist is used to ensure all aspects of patient
management have been discussed and a plan made: DEFAULT, D – DNAR status, E – ET tube,
length, securing and cuff, F – Fluid management, A – Analgesia and sedation, U – Ulcer
prophylaxis/management (skin and gut), L – Lines, T – Tidal volumes <7ml/kg

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REGULAR CLINICAL MEETINGS
The weekly meetings are clinical meetings with other medical teams about current ITU patients and
take place on the unit. It is the duty of the day staff to attend, present relevant patient information and
to document any discussion outcomes in the notes.
Dates Meeting

Monday afternoon Weekly Informal microbiology drop-in

Monday 14:00 Weekly Joint Neurology, Neuroradiology, ethics and
ITU in PACS room
Tuesday 14:00 Weekly Joint ID, Microbiology & ITU round

Wednesday 11:00 Weekly Radiology Review in PACS room

Thursday 08:15 Weekly Surgical - NICU Grand Round

Thursday 12:30 Weekly Reflective Practice (for SpRs on service)

Thursday 14.00 Weekly Nutrition round

Thursday 14:30 Weekly Joint ID, Microbiology & ITU round

Friday 14:00 Weekly Radiology Review in PACS room

Friday afternoon Weekly Informal microbiology drop-in

For additional meetings and training opportunities please see Education and Training guide.

OTHER ISSUES

Professional attitudes:
The unit can become very busy. Particularly at these times, all requests from bedside nurses will be
channelled through the nurse in charge. This will limit the sheer number of interruptions that you may
have. She will manage those requests that do not need your immediate attention. You should not feel
like you are struggling! Please call for help from your colleagues or consultants.

Cardiorespiratory Arrests:
Know what the ICU arrest bell sounds like. Familiarise yourself with the equipment on the
intubation/crash trolleys. There are regular scenario and defibrillation training sessions on ICU and
weekly simulator training sessions.

You do not attend arrests on the wards. There is a medical emergency team including ICON, CSPs
and anaesthetists that fulfil this role.

Prescribing:
We have adopted a “zero tolerance” approach to prescription errors to minimise risk and harm.
You MUST use the prescription desk to prescribe all your drugs and infusions. The nursing staff know
that they should not interrupt you while you are at this desk unless it is an emergency.
Please prescribe in CAPITALS and write your name legibly in CAPITALS. Medications need to be
charted on the ICU drug charts only and only ITU medical staff are authorised to prescribe on ITU drug
charts. Nursing staff have been told not to administer any drug with an incomplete, illegible or incorrect
prescription.
Most drugs can be found on the monthly rough guides. Consult the Orange GOS Antibiotic Guideline
booklet and the GOSH intranet for anti-microbial prescriptions
Prescription errors are monitored and you will receive a monthly update on error rates and common
errors for that month.

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Intubation:
Two doctors MUST be present at each intubation. At night, the registrar on the other unit offers
assistance. Each endotracheal intubation MUST be confirmed using end-tidal CO2 monitoring. The
ETCO2 reading MUST be entered in the incident documentation.

PICU Anaesthetic machine:

This machine may only be used by anaesthetic staff trained in its use; it must not be used by
paediatric trained staff without an anaesthetist present. The machine should be checked by the
operator prior to use. There is a checklist attached to the machine.
Inhalational agents for top-up are kept in the lower, far right-hand cupboard in the drugs room.

ADMISSIONS AND DISCHARGES

EXTERNAL PICU / NICU ADMISSIONS

All calls regarding potential or actual PICU admissions from outside the hospital should be directed to
CATS. Occasionally a call may come directly to NICU or PICU from a caller who is unaware of the
CATS service. If it is a referral, and not simply a call for advice, refer to CATS on 0800 085 003.

DO NOT REFUSE AN ADMISSION WITHOUT FIRST DISCUSSING WITH A CONSULTANT.

INTERNAL PICU / NICU ADMISSIONS (EMERGENCY AND BOOKED)

Booked
Registrars from other teams wishing to book beds for elective admissions should be directed towards
the nurse in charge. The consultants must be contacted to approve the admission. The patient details
are entered into the designated internal referral sheet (located in the referrals folder at the main
PICU/NICU desk).

Emergency
ITU registrars do not manage patients outside the PICU & NICU.
The protocol for the management of acutely unwell children in the Trust MUST be followed.

Acutely unwell children on the wards will be managed by ICON (Intensive care outreach network) and
the CSP (clinical site practitioner). A care pathway for this is attached.

The PICU/NICU registrars DO NOT leave the units to attend patients on the ward. Requests to do so
must be referred to the ICON consultant between 8am – 6pm, Monday – Friday and the duty ITU
consultant at all other times. You may answer requests for telephone advice if it is within your level of
competence; otherwise refer to the duty ITU consultant.

ICU DISCHARGES (PICU and NICU Patients)

The government target for hospital discharge summaries is 24 hours; we get fined if we do not achieve
this! As a consequence we are reviewing our written discharge summary practice. Guidelines and
templates are kept on the K Drive: PICU NICU handover: Discharge Summaries.

The current practice is the all patients must have a medical team-to-team discharge telephonically
which details the ongoing clinical plan and outstanding investigations. The name of the doctor referred
to must be recorded in the notes. Forward planning is essential and the night time registrar should
dictate a summary for all those patients likely to be discharged in the next 24 hours. This should be
done on the Winscribe digital recording system. Private patients discharged to Butterfly, Sky and
Bumblebee wards will have two teams involved in their ongoing care – the specialist team (e.g.
haem/onc) and the IPP doctor. Both require a telephonic handover. If you ask one of them to discuss
the case with the other please document this in the notes.

All patients must have a completed discharge/death checklist sticker in the notes prior to discharge.
This is the responsibility of the medical staff.

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PICU DEATHS
The Family Liaison Sisters and the senior nursing staff are experienced in managing deaths on ITU.
Please approach them for advice.

We try to approach as many families as possible for organ donation. Please record if this was done by
the consultants, and if not, what the reasons were for not considering it.

When a patient dies in ICU:

• Immediately inform the ITU consultant.

• Discuss the need for referral to the coroner:
(There is a checklist within the Death Certificate Book cover)
The deaths to be referred include:
• sudden or unexpected deaths
• cause of death is unknown & therefore a doctor is unable to issue a death certificate;
• deaths due to, or thought to be due to, negligence. Always refer if the family are or are
likely to complain.
• all unnatural deaths (including accidents, suspected suicide. suspicious deaths &
NAI);
• deaths thought to be due to industrial disease;
• deaths occurring within 24h of surgery or anaesthesia;
• if the death may have been hastened or brought about by any form of treatment or
procedure.
• deaths in the first 28 days of life
• If the death is not a Coroner’s case, then discuss the need for a hospital post mortem
examination with the consultant FIRST. If desirable, then obtain consent from the parents
before they leave. The Pathology Department will only perform a post mortem if the consent
form is signed by the parents.
• Issue a death certificate (if not a Coroner’s case) and give it to the family so that they can
register the death. You must print your name and GMC number. The parents need to book an
appointment at the Camden Registrars office.
• Ensure the family have details on how to arrange the funeral. The nursing staff will give the
appropriate information.
• Inform the family that they will be contacted and offered bereavement counselling (usually
around 6-8 weeks).
• Notify the relevant GOS teams, the GP and referring paediatrician within 12 hours.
• Make sure you complete the telephone checklist stuck in the notes on who has been
contacted.
• Complete a rapid death summary (template on K Drive: PICU NICU Handover) BEFORE
you leave your shift. Email to Paula Smith. Fax this to the Child Death Review Panel. Number
on the form.
• Ensure a death checklist sticker has been completed and stuck in the notes.

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 Acutely unwell child
CSP blp 0313 / 0314
ICON Fellow blp 0522
ICON Consultant via Switch

Need immediate help

No Yes

Bleep CSP & specialty SpR Activate Clinical

for joint review Emergency Team (2222)

* Discuss management
with child’s Consultant and Resuscitate, stabilise
? referral to ICON
Deteriorates

ICON Fellow offers medical

consult & management plan

CSP/ICON Fellow discusses Complex or PICU

plan with speciality Consultant admission anticipated ?
+/- ICON Consultant

ICON/PICU consultant
*
contacts speciality consultant
to discuss admission

Child remains on ward &

managed by speciality Decision to admit to PICU
consultant, & CSP
+/- ICON Fellow No Yes
Transfer to PICU
* If the child’s lead consultant cannot be contacted:
• The PICU consultant will organise admission and continue resuscitation
• Efforts will continue to contact the lead consultant
Acutely Unwell Child Protocol Sept 2008

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