NSICU Schedule and Responsibilities
PGY2 residents rotate in the NSICU from September through June where they learn the basics of neurocritical care. The NSICU PGY2 will care for patients with primary neurological issues (strokes, status epilepticus, myasthenic crises, etc.) and can also be involved in peri-surgical care of NSGY patients requiring ICU admission (tumor resection, bleeds). The neurology resident will often facilitate transfer to the stroke or neurology floors when the patient no longer requires an ICU level of care.
Responsibilities vary depending on the attending, the size of the NSICU team, and the patient census, however PGY2s are generally responsible for arriving at the NSICU by 7AM to receive signout from the overnight fellow/NP. The NSICU team will then divide patients and the PGY2 should spend the remaining time before rounds examining each patient (your neurologic exam will be invaluable!) and reviewing lab, radiographic, and other data from overnight.
Rounds generally occur from ~8:30am -12:30pm, subject to change based on the day (all updates will be announced in the WhatsApp group). Attendings write progress notes during rounds.
Roles during rounds: delegated among team members
- imaging - opening PACS to display CXRs, CTs and other images during rounds
- signout - updating the hospital course in a signout tab that the NPs/fellows can show you
- goals - documenting the 5 key care goals of each patient for that day
- lab review - accessing labs during rounds for the attending to review.
When the PGY2 is presenting their patients, another team member will usually take over their role.
Patient presentations:
- Very brief one-liner including highly relevant past medical history, diagnosis, and reason for ICU stay
- Pertinent 24 hour events
- RN presents overnight events, a systems-based review of recent data, and basic exam
- Provider resumes with additional data including imaging and labs
- Plan by system
Biweekly NSICU conferences occur at 12:30pm. The afternoon consists of performing procedures and implementing the plan made during rounds, including writing transfer notes if your patient is leaving the unit. Evening rounds with the attending occur ~4pm. Signout to the night team will be at 7PM.
NSICU Skill-building
This rotation relies heavily on the PGY2s engagement in patient care. While the ICU environment can be hectic, the PGY2 should seek out opportunities to help the team and to build skills that they may not obtain during other rotations. Many neurology residents often become quite involved with updating families and participating in goals of care meetings. Typically the neurology resident provides unique continuity of care during the rotation and can take leadership in explaining management and prognosis in primary neurologic cases (with close guidance from the attending, of course). It is always important to clarify facts with your attending to avoid inconsistencies for families.
There will be opportunities to assist/perform procedures in the NSICU.
- Transcranial doppler (TCD) - ultrasound based technique to identify spasm in SAH patients. The attendings and NeuroICU fellows are typically excited to teach TCDs to the neurology residents.
- line placements - central lines, midlines, subclavians, femoral lines, arterial lines, US guided IVs,
- LPs - sometimes with US
- Point of care ultrasound (POCUS)
- nasogastric tubes - avoid placement on anterior approach C-spine surgeries or ENT patients
Link with official NSICU orientation packet from Dr. Dangayach, 2018-2020: [NSICU orientation packet] (https://www.dropbox.com/sh/iogy122oxt6cjbn/AACG80QXCJh8u6Qhri56XP8Ea?dl=0)
Logistical Tips (Prepared by Dr. Benjamin Brush, 2020):
- When you sign in choose "Critical Care/ICU" context instead of Neurology
- You'll want to create a new epic list and then when selecting fields click copy and type "NSICU_print" to copy setup my which will get you the neurosurgery signout on patients which they (NSGY) do a great job of keeping updated.
- Agnes and Ruth are amazing NPs who have each worked in the unit for 15 years or so. They know a lot and can be a great resource.
- Post-op patients
- get signout from both anesthesia and surgeon
- write down specifics of intubation (blade, view, difficulty, drugs given) as well as procedure (what was done, EBL, IVF/products given)
- send full set of labs (CBC, CMP, Coags, ICU venous panel)
- Note template should be in the NSICU rounding - ask an NP if you can't find it
- write your history and recent events leading to ICU admission, brief exam, make a problem list but then document the plan by system
- Documenting procedures: use the appropriate procedure note if selectable, can use Dr. Reilly's template for TCDs