Rounding in the Intensive Care Unit

Fast Hug (Crit Care Med 2005;33:1225)

More daily goals

Medlist

Neuro

Pulm

Renal/Lytes

Endo

Heme/Onc

Proph/FASTHUG

ABCDE

AwakeBreathe (Spont)Choice of sedativesDelerium assess and rx Exercise and Early mobility(Crit Care 2010;14:157)

ABCDE Bundle

On rounds, ask yourself

Why was this patient admitted to intensive care in the first place? What happened subsequently? What complications occurred? What chronic health problems does the patient have? Why is this patient still in intensive care? What are his problems? How are we addressing these problems? What is this patients physiologic reserve? Is this situation futile?

stdy of the addition of a checklist to lower icu error rates (J Trauma 2008;64:22)

An explicit approach to rounds improves communication and satisfaction (Inten Care Med 2003;29:1584)

Anesthesia to Surg Handoff

Stephen Streat’s Rounds:

Morning Ward Round

The morning ward round is a disciplined activity which follows a set format. Side conversations should be avoided. All issues relevant to a patient should be discussed before the ward round leaves each bed space. The format is Case presentation by the night registrar or intensivist:eitherSuccinct case summary (for a new admission or a previous admission to new staff) using the Admission Note as a crib sheet:

Prior health status

Sequence of events

Assessment of vital systems

Diagnosis

Injury List (for trauma patients)

Treatment already undertaken

Treatment and Investigations being planned

Who the family are, who has spoken with them and what they have been told

Brief progress report (for other patients):

Changes and Events of the last 24 hours

Problems and Plans for the next 24 hours

Information from the special nurse
Systematic Review of all aspects of patient care

The Systematic Review

The systematic review is led by the specialist of the day. The responsibility for charting and recording all decisions on the 24 hour chart lies with the Long Day registrar. The review follows a sequence designed to cover all aspects of care of the critically ill patient

Airway: type, patency, tracheobronchial secretions, cough
Breathing: type, blood gases, machine settings, turns, physiotherapy, x-ray changes
Circulation and Fluids: fluid input and output from all sites, haemodynamic status, biochemistry, nutrition, cardiovascular medications, renal function
Infection and Antibiotics: signs of infection, bacteriology results, antibiotics, aminoglycoside levels, specimens required
Neurologic: signs of consciousness (eye opening, motor responses, vocal responses), lateralising signs, sedative and relaxant medications, ICP, EVD, CT scan, SEPs, EEG
Miscellaneous: other lab results, special procedures, dressings, medications, etc
Instrumentation: tubes, lines, catheters, how long in, changes due, etc.
Documentation: review of charting. The previous days duty intensivist will update the Document Form.
Communication: make sure that the Special Nurse and the Long Day registrar have no unanswered questions.
Family issues as above.

Long Day Registrar Responsibilities

Note the Plans of the Day and Requests for Next Day for each patient and record them on the patients 24 hour chart. During the ward round note procedures to be done or booked, consultations to be sought, information to be acquired etc. Perform or delegate these tasks after the ward round.
Chart therapy on Treatment Sheet, Fluid Order Sheet, Detailed Order Sheet, and Instrumentation Chart as decided on the ward round and update these forms at the request of the nursing staff.

It will be possible to anticipate some of the plans from Requests for the Next Day recorded on the previous days 24 hour chart.

Monday, XXX 2008 DCCM 0830 Morning Ward Round Review

XXXX; age 48, bedspace 01

Mr XXX is a 48 year old XXX man admitted yesterday following liver transplantation for hepatitis B cirrhosis with multifocal hepatocellular carcinoma.

He also has a past history of gastro-oesophageal reflux and previously treated syphilis, pulmonary TB and schistosomiasis.

Liver transplant procedure was uncomplicated and no blood products were required intraoperatively. Following admission to the DCCM there was good graft function and the only significant issue was that of some haemoconcentration. This required repeated venesection to bring haematocrit down to acceptable levels. He has been weaned and extubated overnight and this morning is able to transfer to the ward.

He currently has a prothrombin ratio of 1.1, platelets 76, normal renal function and is receiving 40% oxygen by mask. X-ray shows some interstitial pulmonary oedema and a single dose of frusemide has been given. Enteral nutrition has been commenced via the jejunal route and analgesia provided with morphine via PCA. He requires 3 units/hour of insulin for glucose control. He is receiving standard immunosuppression and antibiotic/antifungal prophylaxis in addition to hepatitis B immunoglobulin, lamivudine and adefovir.

XXX, Specialist Intensivist

Monday, XXX 2008 DCCM 0830 Morning Ward Round Review

XXXX; age 64, bedspace 03

Mr XXXX is a 64 year old man admitted postoperatively on XX (month) after a complicated cholecystectomy and right hemicolectomy.

He has a past history of viral cardiomyopathy leading to placement of an implantable defibrillator. He has moderate systolic dysfunction with LV dilatation and the defibrillator fires once or twice a year. He also has hypertension and atrial fibrillation (normally on warfarin). Rate control is with metoprolol and digoxin and he requires 40mg of frusemide a day.

He was diagnosed as having gallstone disease in July 2008, but while awaiting a laparoscopic cholecystectomy he presented acutely to XXX Hospital with cholangitis. An ERCP and sphincterotomy was performed, a small stone remove but a large stone was identified but unable to be removed. He was transferred to Auckland City Hospital for further investigation and treatment and a subsequent ERCP enabled a stent to be placed but the stone remained. He therefore proceeded to open cholecystectomy and exploration of common bile duct 2 days ago. Operative findings were of Mirizzis syndrome with obstruction of the common hepatic duct and subsequent jaundice. He also had compromised perfusion of the right colon associated with the inflammatory process and this required the right hemicolectomy. Intraoperatively he had a moderate inotropic requirement and was admitted to the DCCM on invasive ventilation.

Over the following 2 days he has progressively improved coming off inotropic support and subsequently being able to be weaned and extubated yesterday. Renal function has remained good and he has commenced enteral and oral feeding. Antibiotics have been continued with amoxycillin, gentamicin and metronidazole and his digoxin has been reintroduced as his AF ventricular response has steadily risen.

He is able to transfer to the ward today, and will require re-introduction of his normal cardiac medications including re-warfarinisation before discharge

XXX, Specialist Intensivist

Wednesday, XXX 2008 DCCM 0830 Morning Ward Round Review

XXXX; age 16, bedspace 03

This young girl has been in the DCCM now for 2 days with severe hepatitis and this morning has become encephalopathic.

She therefore has acute liver failure and she has been listed for emergency transplant, initially at category 2. However, later this morning she has been intubated and should probably be then relisted as category 1. I understand that there are no other patients in Australasia on the urgent list. She is blood group O.

Over the last 24 hours she has had a slow deterioration in several ways. Firstly she has become encephalopathic as mentioned, secondly she has had some abdominal pain and thirdly her right pleural effusion has grown in size and has been associated with some respiratory deterioration and mediastinal shift; of possible relevance I note that yesterday she had a short lived bout of self-terminating supraventricular tachycardia which was haemodynamically insignificant.

The plan now is to correct her coagulopathy, provide all the necessary instrumentation including a Seldinger right chest drain and await a donor liver. Her steroids and zinc and chelating agent have been stopped. A copper dry weight may be available later today, but this will not change the management plan. I understand that there may be discussions with her mother about the possibility of her being a live donor. We will await further information from the Liver Transplant Service about this.

The present status includes a platelet count of 65, haemoglobin of 71, INR (prior to correction) of 3.1, bilirubin of 1100, AST of 310, normal renal function, spontaneous hypertension and normal acid base. For the moment we will try and avoid an ICP monitor as long as she is reasonably serially examinable with low dose propofol + low dose fentanyl.

Email copy to:

Stephen Streat, Specialist Intensivist

Remember the kidneys follow the heart

Advice from ED Intensivists

From the call room, 6th straight overnight, so forgive the grammar, typo, conceptual errors of an exhausted brain. One fellow to another, this attempt at an answer from the perspective of seeing some light near the end of 2 ccm fellowships after 10 years of EM attending practice, first was anes, then internal med.

So, 2 pieces of advice, one from the best EM doc, if not the best doc, period, I know, Rick Bruno. The other from my former fellowship director Jean Charchaflieh, ie from the anes ccm program, but much built in from other wise folks.

From Rick Bruno when I asked him as a new 4th year EM res, how to run a complicated trauma or medical or peds resus,”Rick, what’s in your brain as background noise,” he said: “what am I missing, what am I missing, what am I missing?”.

From Jean Charchaflieh, my anes-ccm fellowship director: “Seth this world is too complex, and you’re not Spiro (a pulm-ccm mentor from that first fellowship), so no ER attending or 30-year unit veteran one sentence gestalts on rounds or consults. Do like this…”

‘First, from yourself or verified from reliable informant, “who is this patient, how did they get here, what is their past and especially recent past med and surg hx, why are they in my unit or why does someone want them in my unit, or what does someone want me to advise them about, what is (are) the ccm questions for today.”

Then: vitals, including vent and abg, which in the unit are vitals.

Then: Ins and outs, every kind, IV, feeds, drains, urine, stool, products etc. And are we feeding the patient by their gi tract, and if not why not?

Then: Lines — which, what needed, when, how do they look, etc.

Then: Labs/studies, plus what are my consults, nurses, respy, dietary, PT, and other consults saying?

Then: Exam, always neuro, always including skin and limb perfusion (the rest is less commonly missed).

Then; therapies, and for the ICU patient this always includes: are they getting GI/DVT/skin/VAP ppx? What abtx why, how do they match the cx’s. What sedative, what analgesic, ie all the categories.

Then with each of the above in mind, a plan, by systems and a global goal/summary. Lots of memonics, lots of ways to do this, I go top to bottom of patient, do non-locatable ones like ID and dispo at the end, people use other ones, but always assessing for need for more or less support and once stabilized always looking for the opportunity to begin to “de-unitize” the patient at the earliest possible safe time before they become an incubator of clots, foreign-body assoc HAI’s, atrophy, debility and other iatrogenesis. So everyday: “can we do an SBT, can we lighten sedation, can we start PT, can we get a tube or drain out, can we get the patient out of the bed, etc. Balance this with, is this safe, is this humane, is this compatible with my staff and resources.

So what does the above boil down to if I had to expain it as you were standing on one leg? It’s just a longer, more complex, disciplined way of saying:

“what am I missing, what am I missing, what am I missing?”.

The rest is commentary.

Seth

Seth Manoach MD CHCQM

Advice for new fellows?

Posted by: “Huang, David (CCM)” huangdt@ccm.upmc.edu david1520

Sat Oct 22, 2011 1:19 pm (PDT)

The issue of EM docs being able to think more long-term / more detailed (i.e., like a prototypical internist) is one many have been concerned about – hence the 6m IM experience requiremt in the ABEM/ABIM agreemt.

I also struggled w this early in my Fellowship – I remember thinking “Man, maybe I should only practice EM, it’s so hard to switch thinking/work habits”. Let me share with you a few things that I found helpful both for myself and the Pitt EM-CCM Fellows I’ve worked with:

1. Don’t worry excessively – time and dedication will solve all.

First, every new Fellow has trouble adjusting to CCM – regardless of specialty. At Pitt’s multidisciplinary program, it’s almost entirely predictable by base training what each Fellow will have (initial) trouble with: IM (speed, procedures), Surg (in-depth “internist”-style thinking, medical issues), Anes (managing >1 pt at a time, long-term planning), EM (“internist”-style thinking, long-term planning).

With time, I’ve seen every dedicated Pitt Fellow slowly adjust their thinking + style to CCM, while retaining the strengths of their core training.

2. Outside of codes, it’s OK to take a little more time for decision-making.

Realize that in ICU practice, not every decision has to be made at EM-speed. I.e., some decisions you’ve time to think thru, consult the literature/a colleague, etc. As an EM-CCM Fellow, slowness is unlikely to be a weakness – so even if it feels odd at first, take your time during routine rounds, while still being the hyper-efficient code-runner that EM docs pride themselves in being.

With this extra time, practice “thinking like an internist” – could this be something else?, what might the consequences be of this decision a few days from now?, what’s the underlying pathophysiology?, etc.

IM Fellows have the opposite problem – during codes, you can see many running thru differential diagnoses, when a tube needs to be in the trachea NOW.

3. Medicine is medicine, physiology is physiology.

Core knowledge – yours and all of Medicine – are the same – no matter what specialty or care location. Hyponatremia is the same whether you’re an internist, ED doc, or dermatologist. So with all your current knowledge and training, you’ve a very strong base – now you’re just “fine-tuning” things + adding to your training.

4. I’d rather be weak in calculating TPN requirements, than running codes or intubation.

You have a big ADVANTAGE over your IM-CCM Fellow colleagues – if a pt’s FUBAR, you are comfy getting them stabilized, so that once stabilized, now you can take your time in a relaxed fashion and go over long-term stuff. It’s OK to take extra time to look up essential fatty acid requirements – not OK to take extra time to recognize and treat shock.

5. “Let’s run thru this patient like a medical student.”

For all complex and most new ICU pts, this is what I always say to my Fellows – and when I round alone, this is what I silently think to myself. What I mean is that we often teach studs on their ICU rotation to run thru the patient head-to-toe and go over each organ system, every day. I think that even for the best physicians, this is still the “gold standard” approach, and for those not comfortable yet w daily ICU work, should be your starting point.

—David Huang

Have the nurses reiterate the daily goals/plans and then do the checklist