ICU safety checklist for COVID pandemic

Rationale: During this pandemic, many people working in ICU’s are NOT trained in critical care. This includes nurses, residents, attendings, respiratory therapists, and every other type of provider involved in critical care. For example, currently some ICUs are being run by psychiatry, dermatology, radiology, ophthalmology, or pathology residents, who obviously are not experienced in critical care, as first call providers. Similarly, some ICUs are being supervised by surgery attendings or other types of attendings who are volunteering in this time of need but are also not trained in critical care. Some of our nurses   Was rom outpatient clinics and aren’t used to vents or drips or inpatient documentation. The purpose of this document is to create a comprehensive zcrowd-sourced ICU safety checklist that can be used to ensure that nothing gets overlooked and that our patients are kept safe from us. Feel free to edit!


ICU safety checklist: Please contribute to make this checklist as comprehensive as possible!

  • Airway safety
  • Airway tubing secure? (if not, secure it to prevent accidental dislodgement)
  • can secure using anchorfast or tape (should be changed q12h)

  • Check for air leak:                                                                                 (use “minimal leak technique” to avoid tracheal necrosis from excessive pressure)
  • Airway tubing all connected?
  • Cuff inflated? (can use manometer pressure 20-30 mm h2o)
  • * Exhaled tidal volumes matches preset tidal volumes?                         

(Exhaled Vt less than 60 mL of preset Vt)

  • Hissing sound? (can auscultate neck while adding air)
  • End-tidal CO2 low? (suggests exhaled CO2 may be escaping)

  • If tracheostomy filter, ensure it’s not clogged or filled with water

  • How much secretions?

  • Vent safety
  • Adjust the vent as needed. How to adjust the vent is beyond the scope of this list, but vent adjustment needs will be guided by checking the items listed below:
  • What are the current vent settings? (tidal volume, resp rate, FiO2, & PEEP)
  • If on pressure support, check the actual resp rate & tidal volumes
  • Does tidal volume correspond to ideal body weight based on height? (can use MDCalc)
  • * Check the peak inspiratory pressure, plateau pressure, & driving pressure
  • * Calculate lung compliance (can use MDCalc)
  • Calculate PaO2 / FiO2 ratio
  • Monitor ABG frequently (esp before & after changing any vent settings)

   

     * items with asterisk are harder / less useful to measure if pt making spontaneous effort

  • Does end-tidal CO2 return to 0 after each expiration? If not, check CO2 absorber & make sure pt is not breath-stacking.

  • Did CO2 absorber turn purple? If so, it may need replacement. (see example at right)

  • Pump safety
  • Are the pumps each set to the correct rates?
  • Do the dosing weights match? Verify that the dosing weight in the pump matches the drug that is actually running through that pump and that the dosing weight matches what is ordered for the drug.

  • Are the pumps each set to the correct patient weight?
  • Does each pump have enough medication? (especially pressors!)
  • Is each pump set up to alarm before its medication runs out?
  • KVO (keep vein open) - should run fluids at 10 cc/hr
  • Correct medications? Is there any medication that’s missing, OR conversely is there any extra medication that should NOT be there?
  • Heparin gtt for dialysis - Heparin gtt should run through HD circuit, not directly to patient.

  • IV line safety
  • Lines labeled correctly?
  • Lines all actually connected to patient?
  • Lines secure? (if not, secure them to prevent them falling out or being tripped on)

  • Arterial lines safety
  • Is the a-line transducer at the level of the heart? If not, values will be false!
  • Does the a-line value change with wrist positioning? If so, values may be false! Make sure not to titrate medications to a false blood pressure value.

  • Is the a-line pressure bag at the right pressure? (check if within the marker limits)
  • Does the A-line have a good waveform? (eg link) If not, try these techniques…
  • Adjust wrist
  • Flush A-line
  • Check pressure bag
  • When drawing ABG’s, make sure to flush the a-line afterwards.

  • Physical exam
  • Check RASS Score every day (link).
  • Evaluate pupils every day (especially if patient is sedated, this could be the only sign of stroke, either ischemic given COVID’s hypercoagulable state, or hemorrhagic if on anticoagulation)
  • Assess pain - use CPOT or BPS
  • Head of bed at 30°
  • Check lines & tubes
  • Are they all connected appropriately?
  • Do any look infected or bleeding?
  • Eye protection
  • Wound care

  • Communication
  • Questions? Concerns? Changes in the plan?  Communicate with the rest of the team directly! Nurses may NOT see the order you placed, or may not know what to prioritize most. Similarly, EMR data may be inaccurate, and nurses or resp therapists may have important insights that you don’t. Make sure to check in with others frequently, and communicate any changes in the plan and the rationale behind it so that everyone is always on the same page.

  • Minimize your own exposure when possible.
  • Keep a list of things you need to do when going into the room next. Before going in, ask other team members if they need anything else done while you’re in there.
  • Schedule medications and labs to be done at the same time when possible

  • Burnout? Make sure you & the rest of your team is doing ok. Make sure everyone gets a lunch break if possible. Debrief after adverse events if possible. Be there for each other.


Rounding checklist by system:

        Neuro

  • Sedation vacation / Spontaneous awakening trial? (see “Wake up and breath” protocol)
  • Wean sedation / paralysis? (do NOT paralyze without sedation, or at least amnestic)
  • Adequate analgesia? Assess pain using CPOT or BPS
  • ICU delirium? Assess for delirium using CAM-ICU score

Cardiovascular

  • Titrate pressors
  • Watch out for hypertension, esp in setting of anticoagulation
  • EKG? (monitor QTc)

Respiratory / Ventilator settings

  • Oxygenation
  • Start with low flow nasal cannula (up to 10L). If that doesn’t work, go to vapotherm (high flow, with some PEEP to open those alveoli and improve oxygenation).
  • Secretions: Arobika, Metanebs, Normal saline spray
  • Spontaneous breathing trial? (see “Wake up and breath” protocol)
  • Daily spontaneous breathing trial (40% FIO2, PEEP 5, Pressure Support 5 for 30 minutes ONLY), then put them back on at least PEEP 10, pressure support 5! Or back on a rate. If you don’t this is torture. It’s like breathing through a straw.

  • Adjust the ventilator settings as needed
  • PCO2 can be adjusted with minute ventilation (RR, pressure support)
  • O2 can be adjusted with FiO2, PEEP
  • Consider if different ventilation mode is needed
  • Monitor ABGs - Daily ABG, plus 30 minutes before and 30 minutes after vent change

Renal

  • Renally dose meds?
  • Volume status? Furosemide is for volume overload, not to increase urine output.

GI

  • Nutrition
  • Start within 1-2 days.
  • For intubated patients, place orogastric tube and dobhoff tube immediately. Confirm with KUB. Start trickle feeds unless patient is on high pressors (levo >15) or has raging ileus (NGT output >1500/day).
  • For non-intubated patients, advance as tolerated.
  • For spinal cord injuries, swallow evaluation if injury is above T1
  • Bowel regimen?
  • Docusate/senna BID is standard.
  • If the patient doesn’t have bowel movement within 2 days, start daily Miralax with PRN Dulcolax suppositories.
  • If that doesn’t work, then you can bring out the enemas, mag citrate, etc.
  • GI prophylaxis? (PPI)
  • Famotidine 20 BID for head bleeds, trauma, or any high-stress situations.
  • Therapeutic PPI if you have actual GI bleeding
  • IV to PO medication conversion?
  • Even if patient is intubated, I always try to push for PO meds (place a DHT early). Use Tylenol/Oxycodone, wean off the IV stuff.

GU

  • Urinary incontinence
  • Q4H bladder scan w/ PRN straight cath for >400cc is standard. The length of time a foley is in determines risk of UTI, not how many times a sterile catheter is inserted.
  • If UOP is >2000 cc/day, then use a foley.
  • Tamsulosin

ID

  • Sepsis in the intubated patient
  • Blood culture x2 + any central line, miniBAL/BAL, change foley, CXR, UA (no urine culture - risk of false positive!), check wounds, consider CTPE, DVT US.
  • Consider empiric Vanc/Cefepime (avoid Zosyn if concern for AKI)
  • Procalcitonin used as a marker for response

Heme

  • VTE prophylaxis? (SQH, Lovenox, compression boots)
  • Should always be on unless someone is actively bleeding or going for surgery
  • Can be restarted 24 hours after stable head bleed
  • SQH 5000 Q8H for Cr >1.3, Lovenox 30 BID for most trauma patients.
  • Hemoglobin trend?
  • Consider dilution (most ICU patients are volume up) vs acute blood loss anemia (from surgery). Look at the op note for blood loss. Transfuse for Hg <7 unless they are a heart patient (then it’s Hg <8).

Endo

  • Glycemic control
  • Goal is 140-180.
  • No non-insulin meds in the ICU (metformin, etc)
  • Insulin calculation: Take weight in Kg, multiple by 0.55. That’s the total daily NPH dose. Half in the AM, half in the PM. The rest is sliding scale.

Eg. 70kg male. 70x 0.55 = 38.5. Order NPH 19 BID w/ sliding scale.

  • If patient’s insulin is whack, order insulin drip. Once it’s under control, then use the daily total as your total for transition to NPH/sliding scale.

Derm

  • Wound care?

Other

  • Should any lines/tubes be removed or exchanged? (eg Foley, central lines)
  • Need restraints?
  • PT/OT?
  • Family updates & GOC discussions


Other resources for ICU safety:

lf you find any other helpful resources or checklists for ICU safety, please paste links below.