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Rounding and Pre-Rounding�for Residents

T

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Proposal for New Rounding Structure

Goals:

  • Evaluate all available subjective and objective data on the patient

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  • Create a plan for patient care for the next 24 hours

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  • Create a shared mental model of the patient’s current illness and illness trajectory for all caregivers

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  • Education for all team members

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Concerns with current rounding structure

  • Current presentation structure and expectations is not standardized
    • Confusion for the presenters (nurses and residents)
    • Allows for the possibility of missed information

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  • Resident not always able to demonstrate the full plan

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  • New structure would focus on adaptability as a goal of the PICU rotation

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“Adaptability” as goal of PICU rotation

  • In critical care patients’ conditions frequently change quickly
    • Changes should be anticipated
    • Plans need to rapidly be altered based on the patient’s updated condition

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  • Goal: To get residents more comfortable with new information and adapting plans based on that information

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PICU Rounding Structure

1

    • Resident “One-Liner”, Overnight Events and System-Based Presentation

2

    • Bedside Nurse Presentation(s)

3

    • Other Input: Pharmacy, Consultants, RT (if applicable and/or available)

4

    • Resident Assessment and System-Based Plan

5

    • Primary Fellow/APP Amendment of Resident’s Plan

6

    • Parent Input/Questions

7

    • Attending Amendment of Plan (if needed)

8

    • Nurse Summary of Plan (Using Goal Sheet)

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Resident Subjective and Objective Presentation

  • One-liner to include a brief patient history
    • Succinct with pertinent information only. Do not add information that is more than 2 weeks old unless it is part of an active problem.
      • “Johnny is a 2 year old ex 31 week boy with h/o reactive airway disease admitted with multifocal pneumonia in the setting rhinovirus and secondary moraxella infection requiring invasive mechanical ventilation.”

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  • Major overnight events (codes, intubations, resuscitations)
      • “Johnny remained hemodynamically stable on current therapies”

1

    • Resident Presentation

2

    • Nurse Presentation(s)

3

    • Other Input

4

    • Resident Assessment/Plan

5

    • Primary Fellow/APP

6

    • Parent Input/Questions

7

    • Attending Amendment

8

    • Nurse Summary

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Resident Objective and Subjective

  • Presentation by systems
  • Therapies should be presented in the appropriate system, not how they are listed on the sign out
    • e.g. Clonidine not for hypertension but for neuroagitation/dexmedetomidine withdrawal
  • All should have pertinent exam, new imaging, pertinent labs, medications, I/O, input from consultants) in addition to:
    • Neuro: EVD settings, drainage and ICPs. Pain score, WATs Score, sedation drips with current dose & number of prns (pain, sedation, NMB) given in the last 24 hours
    • Resp: current respiratory support and measures of compliance, Critical airway (y/n)
      • e.g. “on PRVC with tidal volume of 8 ml/kg, with peak pressures of 28-32, which are increased compared to yesterday”
    • CV: Echo results (last 24 hours), vasoactive infusions with current doses, perfusion
    • FEN/GI: Exam should include fluid status on all patients (appears dehydrated/ volume overloaded, euvolemic) in combination with HR, CVP and arterial line variability), current nutrition, current rate of fluid administration, urine output
    • Heme: Blood products given in the last 24 hours; chest tube output
    • ID: Recent microbiology results, day of antibiotics with proposed course

1

    • Resident Presentation

2

    • Nurse Presentation(s)

3

    • Other Input

4

    • Resident Assessment/Plan

5

    • Primary Fellow/APP

6

    • Parent Input/Questions

7

    • Attending Amendment

8

    • Nurse Summary

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New Rounding Structure

  • Nurse Presentation
    • Nursing concerns, e.g. clinical concerns, sedation, access, secretions/suctioning
    • Safety Checks – CVL Day, Foley Day, restraints, skin concerns, PT/OT speech concerns
    • CRRT or ECMO nurse to present concerns

1

    • Resident Presentation

2

    • Nurse Presentation(s)

3

    • Other Input

4

    • Resident Assessment/Plan

5

    • Primary Fellow/APP

6

    • Parent Input/Questions

7

    • Attending Amendment

8

    • Nurse Summary

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New Rounding Structure

  • Other Specialist Input
    • Consultant (if present)
    • Pharmacy
    • Respiratory Therapist (if available)

1

    • Resident Presentation

2

    • Nurse Presentation(s)

3

    • Other Input

4

    • Resident Assessment/Plan

5

    • Primary Fellow/APP

6

    • Parent Input/Questions

7

    • Attending Amendment

8

    • Nurse Summary

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Resident Assessment and Plan

  • Assessment: NOT a repetition of the one-liner, but rather a synthesis of the information that was just presented
    • What are the most active issues for this patient?
    • What is their illness trajectory (better, worse, the same? Is the patient deviating from the expected trajectory?) ?
    • What is the most important task for the team today?
      • “Overall Johnny’s pneumonia appears to be improving based on his decreasing oxygen requirement and improvement in lung compliance. He still has signs of pulmonary edema on CXR and will require diuresis as we aim for extubation in the next 1-2 days.”
    • Allow for a “Break” for the resident to verify that their assessment does vastly differ from the fellow/app or attending
  • Plan: Based on systems
    • Be Specific! Don’t say “wean the vent” or “increase the heparin drip”, instead “take the peep from 8 to 6 and wean the rate from 22 to 20” and “increase the heparin drip by 20%, so that would be from 20 unit/kg/hr to 24 unit/kg/hr”
    • Proposed lab schedule going forward, goals (electrolytes, pH, MAP, CPP)
    • For senior residents: What challenges do you anticipate for this patient?

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1

    • Resident Presentation

2

    • Nurse Presentation(s)

3

    • Other Input

4

    • Resident Assessment/Plan

5

    • Primary Fellow/APP

6

    • Parent Input/Questions

7

    • Attending Amendment

8

    • Nurse Summary

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End of Rounds

  • Primary Fellow/APP
    • Amend the plan as needed
    • Teaching
  • Parent Concerns/Questions
    • Will allow for brief questions/clarifications with the assurance that a detailed plan/explanation will be provided to the parents after rounds
  • Attending
    • Final changes and teaching points
  • Nurse summary
    • Summary of changes to the plan by system
    • Non-presenting resident confirms orders have been placed

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1

    • Resident Presentation

2

    • Nurse Presentation(s)

3

    • Other Input

4

    • Resident Assessment/Plan

5

    • Primary Fellow/APP

6

    • Parent Input/Questions

7

    • Attending Amendment

8

    • Nurse Summary

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End of Rounds

  • Nurse summary
    • Summary of changes to the plan by system
    • Non-presenting resident confirms orders have been placed

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1

    • Resident Presentation

2

    • Nurse Presentation(s)

3

    • Other Input

4

    • Resident Assessment/Plan

5

    • Primary Fellow/APP

6

    • Parent Input/Questions

7

    • Attending Amendment

8

    • Nurse Summary

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Order Entry

  • Enter orders for the presenting resident during rounds

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  • Use PICU Order sets

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  • Lab schedules are based on a 4am start unless otherwise specified

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  • Everything should be ordered STAT

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After Rounds

  • Resident or primary fellow/APP to circle back and make sure orders were entered and address concerns with the plan

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  • Frequent patient reassessment is vital to providing effective critical care

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  • Complete Daily Progress Notes by 12pm

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Pre-rounding

  • Sign out at 6am
    • Should be fairly quick, you should know/anticipate who your patients will be
      • Mostly overnight updates
  • After you receive sign out – immediately go see your patients
    • Talk to the overnight nurse (don’t waste your time sleuthing through interdisciplinary reports)
      • Nurses have protected time for 7:10-7:30 and ask you not to examine patients during that time
    • Look at the drips it will name the medication and the rate
    • Look at the ventilator or respiratory support device (i.e. Bipap, Nasal cannula) get the numbers from there
    • Examine your patient

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Infusion Pumps

Medication Name and Rate will run across this screen like a “ticker” every few seconds

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The Servo Ventilator

FiO2

Actual Respiratory Rate

Tidal Volume

Set or Mandatory Respiratory Rate

PEEP

Peak Inspiratory Pressure

Mode of Ventilation

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Pre-Rounding

  • Printed sign out has many labs and medications
    • I/O balance should be updated as of 7am
    • Some labs missing – e.g. CRP/ESR, BNP, try to get latest blood gas
  • iAware
    • Medication prns, I/O, vital sign trends
  • Cerner
    • Microbiology
    • Additional labs (see above)
    • Consult notes

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Enter location name

Hit “Find Encounters”

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Hit “Save List”

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Hover over the chosen date to get a break down of I/Os

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PICU Notes

  • Goal: 10 minutes or less per progress note
  • Notes should be saved (not signed) and forwarded to PICU attending by 1 pm
  • Do NOT transcribe exact medication doses, vent settings, etc in Plan
    • Examples:
      • Instead of “SIMV PRVC with Rate of 12, Volume of 200, PEEP 8, Pressure Support 10”
        • OK to say something more generic
        • “Titrate vent support to maintain pH 7.35-7.40 and SpO2 >92%”
      • Instead of “Epinephrine at 0.08 mcg/kg/min and Dobutamine at 10 mcg/kg/min”
        • “Titrate vasoactive support to maintain MAP goal >60 mmHg”