In this episode, I’ll discuss how to prepare for ICU rounds on a critical care pharmacy rotation.
Most of my pharmacy students are surprised that I look at medications last in my pre-rounding review of ICU patients.
I am constantly tweaking and improving my method for pre-rounding on ICU patients. Here is my current routine for evaluating new ICU patients in preparation for patient care rounds.
Whenever possible I like to be in front of the patient’s room when I evaluate them before rounds. By observing the patient I can see how sick they look, whether they are intubated or have SCDs on. If the NG tube is being used for tube feeding, I know it can be used for meds too. Inadequate sedation or other problems can easily be identified by a brief observation of the patient. Also, being this close to the bedside I am available for nurses to ask me questions and to be side-by-side with the provider as they determine solutions to the patient’s problems.
In this episode, I’ll discuss how I build my pharmacy problem list, use a paper report to supplement the electronic system, list my current 5 step pre-rounding process, and explain how I prioritize which patient to see first.
Pharmacy problem list
At each step of my evaluation of the patient, I am filling out my note template in the pharmacy computer system with my “pharmacy problem list”. This note template is not meant as a permanent part of the record and is not viewable to non-pharmacy staff, rather it is meant for me (or my resident/student) to track the patient’s problems and our recommendations.
Reason for Admission –
The purpose of this note template is to:
-help track and solve problems
-remember my recommendations for rounds
-provide basic information to “refresh my memory” about a patient when asked a question in the middle of the day
-provide a starting point to begin my review of the patient the next day
I have limited time to finish pre-rounding, and the purpose of the note is to facilitate problem solving so I do not copy-paste lab values or medication orders into my note.
I use a paper report to facilitate my pre-rounding review of patients. The report also serves as a “bare minimum” for me to review if other priorities cut into the time I have to pre-round on patients. The report includes basic demographic information for the patient, creatinine clearance estimate, allergies, creatinine/potassium/magnesium/wbc/hb/plt and any current orders for antibiotics, stress ulcer prevention, steroids, anticoagulants, or chlorhexidine.
The paper report serves as a “2nd computer screen” and allows me to see more information at once.
My 5 step pre-rounding process:
1. Read the history & physical, consult and progress notes to determine who is the patient and why are they here
2. Review home medications
3. Review labs, cultures and imaging reports
4. Review the bedside flow sheet
5. Review current medications
Read the history & physical, consult and progress notes to determine who is the patient and why are they here
Who is the patient and why are they here?
There are 3 reasons why a patient might be in an ICU. I want to make sure I identify the reason as early as possible in my review. I talk in more detail about these reasons in episode 11 but in brief the 3 reasons are:
1. A vital system has failed and we need to support it (respiratory failure, on vasopressors, etc…).
2. Something has happened that makes it likely a vital system will fail, and we need to recognize and support it when that happens (tPA for stroke within the last 24 hours, overdose of unknown substances, high risk surgical procedure).
Reading the history & physical and consult and progress notes
I pay particular attention to the history of present illness and the assessment/plan. My focus during pre-rounding is to identify problems so that I can evaluate the best solutions for those problems.
Review home medications
When I review the patient’s home medication list, I look for medications that, if held, could cause a withdrawal syndrome. Then I write “on venlafaxine at home” under the neurologic section of my note. Combining home meds on the problem list with doing my pre-rounds in view of the patient makes things more efficient. When I observe the patient and see they can take oral meds I already have a list of the most important meds to get ordered for the patient. If I am seeing the patient before the physician has that day, this is a perfect opportunity to place a sticky note in their workflow suggesting for them to resume the patient’s venlafaxine. Listen to episode 19 for more on how I use sticky notes before ICU rounds.
Review labs, cultures and imaging
Again the focus is on identifying patient problems. I frequently find information that supports crossing a problem off the list. Maybe the radiologist doesn’t see an infiltrate on the chest x-ray, or the cdiff test came back negative, or the urine legionella screen is negative.
Review bedside flow sheet
Despite my hospital being mostly electronic, the critical care flowsheet is still on paper at my hospital. It is a 6 page document that is a treasure trove of patient data. One of the best things to look at the flow sheet for, is to determine “how sick is this patient?”. I look for oxygen requirements, ventilator settings, vital signs, pressor and sedative requirements, depth of sedation, and urine output on the flow sheet.
Review current medications
I’ve saved the best for last! As I review the current medications, I am looking at the choice of medication regimen, dose, considering the patient’s renal function, interactions, clinical condition, etc. and completing my pharmacy problem list and recommendations for rounds. Looking at the medications last helps me develop a more complete pharmacy problem list. Problems that might not be recognized by looking at the meds first often jump out at me if I have already reviewed the rest of the patient’s record. Here are some examples:
-Propofol alone as sedation might be OK for some patients, but if I know they are s/p exploratory laparotomy with lysis of adhesions, the absence of fentanyl becomes clear.
-Determining the cause of a patient’s agitation can be very time consuming, but if I know they were on paroxetine at home and haven’t had it for 2 days it is easier to narrow down the possible causes.
-Seeing oral vancomycin as an order doesn’t necessarily mean anything, but knowing that the cdiff test was negative and the CT did not find colitis makes it immediately clear the vancomycin can be discontinued safely.
How long does this take and who should I see first?
You may be wondering, how long does this process take? In most cases I can complete my review of a new patient in 20-30 minutes, and an existing patient in 10-15 minutes. When I have a pharmacy resident or student, we are able to spread some of the pre-rounding tasks between us. I also prioritize who I am going to see first based on how sick they appear. I take a quick walk around the unit in the morning, looking for clues for sick patients that should get my attention first:
-The code cart has been placed in front of their room, preparing for the inevitable.
-There is a CRRT machine in a room where there wasn’t one yesterday.
-There is more than 1 nurse in a patient’s room.
Additionally, I prioritize who I see first based on the unit’s bed board. This electronic patient tracking board identifies those patients who are planned to transfer to a lower level of care and therefore are not as sick. I see the patients who are anticipated to stay in the unit before moving on to those who are identified for transfer out.
Now that I have a complete pharmacy problem list and my recommendations are planned, it is time to attend ICU rounds. In the next episode, I’ll share how I participate in ICU rounds, including how I present my recommendations.
How do you prepare for ICU rounds? I’d love to hear!
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.