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ICU Protocol

Table of Contents


Policy for ICU Rounds

1. Key elements of ICU Rounds

Intensivist/Physician in-charge should lead the rounds.

Rounds must be conducted at the same time of the day everyday (e.g., At 9 am and 4 pm).

Intensivist must evaluate all patients under his/her care with junior staff at least twice daily.

Intensivist must set management plan.

Round should be multidisciplinary, bedside, patient centred and structured.

Doctor, lead nurse and bedside nurse must be present.

The following specialists should be present as far as possible: pharmacist, nutritionist, microbiologist, and physiotherapist.

Discussions must be focused on development of daily goals.

Goals must be documented.

Always try to teach something, always try to learn something.

Make sure all members of the team (including the patient!) get to contribute.

Always ask “does anyone have any questions or concerns?”

2. The Structure of daily activities in ICU

Step

Timing

Responsible

Team members

Discussion points/ Tasks

1. Huddle

Morning and evening at the time of shift change.

Nurse Team Leader/ Shift In-charge.

Non-medical staff who are part of round.

Administrative issues

● Staffing.

● Available beds.

● Bed requests for the day and patients waiting for admission in wards/ER.

● Busyness of the unit.

● Procurement needs for the day.

● Emergency equipment and drugs availability and location.

Ensure all team members know where the emergency equipment is.

Identify team member capabilities and learning needs.

Ensure appropriate tasks are allocated and appropriate teaching opportunities are taken.

2.Clinical Round

a. Patient Introduction and Summary

9 AM (for example)

Resident doctor presents to the team

History – should be taken by yourself and NOT be copied from previous handovers.

Introduction:

● Who is the patient as a person?

● Background co-morbidities?

● Reason for ICU admission?

● Days of hospital stay, ICU stay?

Situation:

● Current issues / overnight problems and interventions done in last 24 hours.

Background:

● What was the presentation?

● What has been done so far for the current illness? And what was the response?

b. Head to Toe Assessment

Bedside nurse presents to the team

● Neuro: GCS/Sedation/Analgesia/

● RASS Score/ CAM-ICU/Cranial nerves/Motor power/Reflexes.

● Respi: Spont breathing vs Mechanical ventilation/ RR / SpO 2 /NIV / ET tube position/Air entry/Abnormal breath sound/Sputum volume, consistency, color.

● CVS: Temp, HR, BP, CRT, Arrhythmias/Inotropes/vasopressors.

● GI: Feeding Route (OG/NG/PEG/TPN), volume, and calorie. Bowel Motions- stool frequency, consistency, volume.

● GU: Urine output volume per hour and total in last 24 hours, Total fluid input – IV, meds, enteral.

● Total fluid intake, output

● Vascular access: site, duration, type of catheters

● Drains: site/type/days

● Skin: any breach in integrity/surgical wounds/ ulcers/ pressure sores and stage.

● Any other issues:patients and family, social issues, police case/medicolegal.

c. Laboratories

● Review all the lab parameters done in last 24 hours and earlier as relevant.

d. Consultation

● Review consultation notes.

● Decide about carrying over the decisions of various consultations.

e. Checklists/ Standards of care

● FAST HUGS BID

● VAP bundle

● Central line care bundle

● CAUTI bundle

● SSI bundle

● ABCDEF bundle

f. Drug chart review

Clinical Pharmacists (if available)

Review the medications.

Decide change in dose, duration, route.

g. Mobility

Physiotherapist

● Set Mobility Plans and Goals.

h. Nutrition

Nutritionist

● Review last 24-hour calorie / protein intake.

● Plan for next 24 hours nutrition.

i. Set targets/goals for the day

● Discuss and identify all the active issues.

● Decides plans to address each issue identified.

● Ensure the issues identified in the previous round are addressed appropriately.

● Decide goals of care (shared decision after family meeting) including CODE status.

j. Highlight learning points

● Identify knowledge gaps and facilitate learning.

● Plan brief teaching sessions.

k.Communication

● Communicate issues, plans and goals of the day amongst all the team members.

● Plan family meeting and update family members.

l. Documentation

● Documents issues, plans, goals, and shared decisions after family meetings daily.

At the end of the round, ask yourself the following questions?

Who is this patient?

How did he/she get here?

What is his/her past?

Why is he/she in ICU now?

What are the goals for today?

What can we do now to progress the patient’s recovery?

Is the treatment provided in keeping with the patient’s values? (e.g., regarding end-of-life care)

What does the patient/family know?

What am I missing?

What are the teaching points for the team?

Further readings:

1. Lane, D., Ferri, M., Lemaire, J., McLaughlin, K., & Stelfox, H. T. (2013). A systematic review of evidence-informed practices for patient care rounds in the ICU. Critical Care Medicine, 41(8), 2015-2029.

2. Louzon, P., Jennings, H., Ali, M., & Kraisinger, M. (2017). Impact of pharmacist management of pain, agitation, and delirium in the intensive care unit through participation in multidisciplinary bundle rounds. American Journal of Health-System Pharmacy, 74(4), 253-262.

3. Abraham, J., Kannampallil, T. G., Patel, V. L., Patel, B., & Almoosa, K. F. (2016). Impact of structured rounding tools on time allocation during multidisciplinary rounds: An observational study. JMIR Human Factors, 3(2), e6642.

Weled, B. J., Adzhigirey, L. A., Hodgman, T. M., Brilli, R. J., Spevetz, A., Kline, A. M., &Wheeler, D. S. (2015). Critical care delivery. Critical Care Medicine, 43(7), 1520-1525.


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