what is the layout of your unit

Pediatric Critical Care Columnist · Oct 16, 2008

Our current unit is a mishmash of private rooms and open bed spaces. There is only one room that can be seen into directly from our nurse's station and it has been occupied for the last eight months by one of our chronics. Along one long side of the unit we have what used to be the x-ray viewing room then a closet and now a minuscule two-bed room that has no door on it and no privacy curtains, just a rolling screen. Next to it is the room we usually use for end-of-life care, another very small space that has been used for an amazing number of different sorts of patients lately. Then there are our two ECLS rooms, larger and with sliding glass doors onto the hallway and between the two rooms. Then there's a hallway, followed by two pressurized isolation rooms separated by an anteroom. Perpendicular to these rooms roughly opposite the door of the first room are two more pressurized isolation rooms that we usually have two beds apiece in. The two sets of pressurized rooms have windows between with integrated mini-blinds for privacy. Along the other long side there are five open beds where we admit our cardiac post-ops. At the other short end are three open beds, very crowded and inconvenient. In the center there are the computers for digital xray viewing, the nurse's station, the PYXIS and sternotomy cart and the respiratory department alcove. Parents are not permitted to sleep anywhere on the unit. We have parent rooms for that.

The unit is horribly crowded and we've had OH&S in to do an ergonomic assessment that recommended we do a lot of renovations and close a bunch of beds! Instead we're going to take over half of the former adult CVICU when they move into their new building next month. We have no idea what they're planning for that space because we're not considered to need a voice in that sort of planning. We can't currently staff for the beds we have, so adding more will be interesting.

Sedation is a huge deal in our unit. We run all intubated kids on either morphine (as much as 250 mcg/kg/hr for some kids) or fentanyl infusions (1-3 mcg/kg/hr), plus usually midazolam (up to 10 mcg/kg/minute) infusions as well. Some kids will be on intermittent scheduled doses of phenobarbital at sedative doses to augment, and we're starting to use clonidine too. Then we have liberal PRNs of chloral hydrate (up to about 25 mg/kg/dose), lorazepam (0.05 to 0.1 mg/kg/dose), morphine (0.1 mg/kg/dose) or fentanyl (1 mcg/kg/dose) and sometimes ketamine (1 mg/kg/dose). We only rarely use neuromuscular blockers. We also have the province's only methadone program! Our kids are usually so sedate that they don't move, cough or eliminate wastes.

I wish you all the best with your move.

googabin02 · Oct 16, 2008

Our unit is a twelve bed unit. we have only two private rooms on each end but the rest is an open layout so each bed is visible from the nurse's desk. We have plans in progress for a Children's Hospital in which every room will be private..scary to us as well..

Janfrn...just reading through your sedation issues. I was suprised to hear you don't use paralytics much. Every intubated kid in our unit has orders for usually fentany, versed, and vecuronium. We use it often and can give it up to every hour. I've heard that many PICU's do not use paralytics and am surprised at that. Do sedatives usually maintain your kids at a proper level of sedation? I thank God for paralytics because we all know intubated kids can be very wild. Along with our PRN sedation we usually have fentanyl and versed drips running. Almost never use Morphine drips. Only kids we ever use Morphine PRN on are the open heart kids.

Interesting! :nurse:

kessadawn, BSN, RN · Oct 17, 2008

we have 23 beds, all are private rooms. every other wall between the rooms has a small window in it, with drapes to pull for privacy. the unit is shaped like a horseshoe with 4 nurse's stations, one at each corner. a short hallway cuts across the middle of the horseshoe with a med room, kitchen, clean supply and dirty utility rooms in it. there's also a 2nd smaller med room and clean supply room up front, as one leg of the horseshoe is longer than the other. the longer leg has negative pressure rooms with anti-rooms, they have no windows between them.

i can't imagine having a 2 pt assignment with an intubated pt, all of our tubed kids are 1 on 1 assignments. we rarely use paralytics, first day or so of a new post-op trach, kids who we just can't successfully ventilate no matter what, stuff like that. most tubed kids are on morphine and versed gtts, sometimes we use fentanyl or ketamine, occasionally a teen may have propofol for short term sedation, less than 24hrs. we have lately been utilizing precedex gtts, i'm not sure how i feel about them yet. there's a fine line with precedex, either your jumping out of the bed, or getting too much and becoming bradycardic, imo. prns include methadone, ativan, versed, morphine and chloral hydrate. oh, and pentabarb for those tough to sedate kiddos, like down's kids. we have an extremely low self-extubation rate.

kidsccrn, you mentioned about having parents around during the day with intubated kids. i have to say that i'd be more stressed with having a parent at the bedside to prevent extubation, even for just a few minutes...some parents are, well...well-meaning but clueless. we do have pull-outs in the room, and one parent may stay at night, but many of them don't sleep, and can sometimes get in the way. it's hard to deal with, no matter how well-meaning they are. the senior nurses here long for the days of the picu when it was a large ward with groups of beds, and no parents overnight.

Pediatric Critical Care Columnist · Oct 17, 2008

Janfrn...just reading through your sedation issues. I was suprised to hear you don't use paralytics much. Every intubated kid in our unit has orders for usually fentany, versed, and vecuronium. We use it often and can give it up to every hour. I've heard that many PICU's do not use paralytics and am surprised at that. Do sedatives usually maintain your kids at a proper level of sedation? I thank God for paralytics because we all know intubated kids can be very wild. Along with our PRN sedation we usually have fentanyl and versed drips running. Almost never use Morphine drips. Only kids we ever use Morphine PRN on are the open heart kids.
Interesting!

In the unit where I used to work we used a lot more neuromuscular blockers than we do in my present unit. And we use even less now that our previous ENT has left. The only kids we paralyze are kids we're actively cooling who are shivering, and the occasional difficult to ventilate kid. We don't even paralyze our ECLS or HFOV patients. If we do choose to, we use rocuronium or atracurium (we have a gung-ho pushy anesthesia/critical care fellow who has lots of... umm... interesting ideas); I dont think we even stock vecuronium and I haven't given it in >six years. We use morphine over fentanyl for routine sedation and analgesia because of the cost. Single-payer health care.

kidsccrn · Oct 18, 2008

Thanks everyone for the info. Keeshadawn,don't get me wrong I never trust a parent to be responsible for an intubated kid but a lot of parents flip out if the kid moves at all (and scream for a nurse) so that can be helpful to at least know if the kid moves while I am in with another kid. I to am an oldie who works nights and loves it when the parents go out to the waiting room or to RMH to sleep. I'm just getting too old to climb over people to get to their child!! When they park in front of the IV pumps or monitor:yeah:. I would love to have 1:1 on intubated kids with our staffing levels that will not happen. We use fentanyl gtts some versed gtts. Mostly use PRN versed/ativan and vecuronium for the wild ones,ARDS on high PEEP and ventilated fresh trachs.I'm glad to heard I'm not the only one nervous about private rooms. I love the open unit with curtains so I can see all the kids. Just one more change we will have to deal with:) I love the kid that very quietly sits up with an ETT. What a way to get the adrenaline flowing!!!!! We now have a very low self extubation rate I want to keep it that way.

What do you do with parents during rounds? I work in a teaching hospital.

Pediatric Critical Care Columnist · Oct 18, 2008

Parents are welcome in rounds. They're told the first day that we're a teaching hospital and that there will be things discussed during rounds that probably won't ever happen to their child, but it might happen to someone else's and the doctor needs to know how to plan for the unexpected. They're encouraged to ask questions and add to the information we have on their child. We generally don't worry too much about confidentiality because most parents really don't listen to what's going on at the next bed and because we know they all discuss their own children with others in the waiting room.

PICNICRN, BSN, RN · Oct 18, 2008

We currently have a 18 bed unit that will be doubling in about 6 months when our new place is finished---- yippee!! Currently we have all private rooms with sliding glass doors and sliders between the rooms with curtains for privacy. Shaped in a big circle with the nursing station in the middle. There is a small computer desk between every 2 rooms- so basically, you sit right outside your pt's room and document- we are pushing for computers in EVERY room when we move. I feel pretty comfortable with this set up- you can still visualize your pt and hear all alarms- we also have a central monitor.

Self extubations are pretty rare for the most part. I feel that our kids are well sedated. Typical pt is on fentanyl and versed drips with liberal prns. Many are on vec drips- especially those who are on high peeps/HFOV/open chests/ cooling blankets/ or just really sick. I cannot even imagine having an ECMO pt not paralysed, JanFrn!!! That just seems kinda mean. IMHO. We also use propofol quite frequently- we usually wean the fent/versed and start propofol for a day prior to extubation.

I LOVE propofol!!! :yeah:

The parents seem to like the private rooms of course! And I do feel that it has cut down on parents overhearing discussions on other kids.

I guess I'd say.... It is not as scary as it you might think! I was worried too.

kessadawn, BSN, RN · Oct 18, 2008

rmh is a beautiful thing, isn't it? i have gotten to the point where as soon as i get report, i give the family a little report of my own, telling them what i expect of them and what they should expect of me, what the basic plan of action is for the shift, and going over visitation policies again. it's really made a difference with some families, but then there are some that still do their own thing no matter what! :banghead:

we are also a teaching hospital, and parents are welcome during rounds, however i believe our cardio surgeon doesn't allow that and boots them from the room. most listen to him because he can be intimidating, but some put up a stink and refuse to leave. good for them i say. hippa hasn't been an issue because of the private rooms, and we don't allow any visitors to come in/out of the unit during rounds so noone picks up any tidbits from the halls.

slcpicu · Oct 19, 2008

The unit I work in now (CVICU) is a sort of oblonged circle with nursing stations at both ends. It has 16 beds 8 open bays with 2 rooms and 8 private rooms with sliding glass doors and then 2 small windows if the ajoining room is private to be able to see your other pt. The windows do have blinds built in between the glass and a roller to close for privacy and to just take a quick glance if needed at your other pt. If we have pt's that we expect to be extremely sick and possibly need ecmo they all go into our open bays.

WOW Jan that's alot of sedation. I would be concerned about weaning. I would hope that those kids are breathing some on their own and matching there breathes at least close to the set TV with some compensated Pressure support. Just seems to me like it would make their intubation times longer. On super long intubations I have seen mega gtts. and the addtion of precedex does work great and we use it for days not just the 24 hour rule. great for weaning when you can't use propofol for whatever reason. NO resp depression. but is very expensive.

All of our kids get fent and versed. cis gtt if on ecmo or hfov or they decrease there SVO2 with increasing mvment. We use swans on most of our peds heart cases.

vec was used much more in the picu. we usually stay away from it now that i m in the CICU.

Ahh the methdone/ativan wean is wonderful for 7+days of narcs/benzos. esp with lots of sedation.

Thats how it is here. Been around alittle bit and it's pretty similiar to everywhere I have been. all PICU prior to here.

hope that helps. good luck on the move.

Pediatric Critical Care Columnist · Oct 19, 2008

WOW Jan that's alot of sedation. I would be concerned about weaning. I would hope that those kids are breathing some on their own and matching there breathes at least close to the set TV with some compensated Pressure support. Just seems to me like it would make their intubation times longer.

Yeah, that's a lot of sedation. Most of our kids are on between 50 and 100 mcg/kg/hr of morphine, but there are those who we just escalate and escalate. We do have some prolonged intubations, one little one was over a year! (Parents refused a trach. Self-extubated and so far so good though.) One thing that really bothers me is that we have these kids on mega-sedation and then when the docs want to wean for extubation, we shut everything off then restart it at a much lower dose hours later. One of our docs gauges readiness for extubation on whether the kid is sitting up watching TV or not! He wants them awake, calm and interactive. Okay, let's give you enough morphine and midazolam to stop a bull moose in its tracks for a week then shut it all off and see how calm and cooperative YOU are. I'm really glad that we're getting more and more of our kids back from the OR already extubated.

Ahh the methadone/ativan wean is wonderful for 7+days of narcs/benzos. esp with lots of sedation.

It is, but we're sometimes actually having to send kids home while still on their wean because they don't need to be in hospital for any other reason any more.

We use swans on most of our peds heart cases.

We don't use swans for anybody. I've only seen on in six years, in a 16 year old post explantation of Berlin heart. None of our staff are trained in caring for swans except the really "old" ones who remember it from the old days or when we worked somewhere else. The evidence doesn't support using them in most patients anyway.

slcpicu · Oct 20, 2008

Agreed, most instutions are moving away from swans even in the adult icu world (i work there to) but this is the only hospital I have ever worked at that using them at all in children at least. We use them pretty consistently. I think it is just a CV surg preference at this point. On some of the dilated cardiomyopathy kids it's good to shoot CO at times. otherwise we just use it for PA pressures and SVO2.