Sample daily routine on the ICU

Reviewing the ICU patient

Know the history and progress first. Acknowledge any limitations on movement (eg spinal injury restrictions, known or suspected high ICP recent history of desaturation on rolling etc.) and removing dressings.

Stand back and observe

• Mental state, GCS, sedation score
• Monitors
• Equipment attached
• Infusions
• Drains

Speak to the patient

• Symptoms, trends, pain score etc.
• Gain consent to examine.

Use your unit’s proforma review sheet or follow this:

Airway

Mouth – perioral skin, lips, tongue, Candida?, dental hygiene, bleeding, cyanosis

Tubes/devices – ETT length at teeth, other airway device, oesophageal Doppler, OG tube,

Nose – airway device, NG tube (secure?), discharge, bleeding.

Standard respiratory exam (probably can’t sit them forward, worth auscultating after suction/cough, as anteriorly and posteriorly as possible (often only axillae)

Look at tidal/minute volume.

Note settings (FiO­₂, mode and pressures) and doses of bronchodilator nebulizers or  infusions.

CVS

Peripheries – colour, perfusion, pulses, skin changes, anaemia

Standard examination

CVS parameters and infusion rates of pressors, dilators, chrono/inotropes.

Abdomen

Wounds. Feeding regimen. Palpate, ascultate. Stoma output. Drain output. Rectal tube output / stool type. Drain/catheter sites, integrity, output.

Neurology and mental state

Eyes – erythema, oedema, pupil size and function,

Agitation score and delirium assessment. Ask about hallucinations, anxiety.

Focal neurology if appropriate

Fluid balance and kidneys

Last 24hr and whole stay

Diuretics used?

Renal function results.

Urine sample required?

Skin and lines

Lines in date and site ok

Skin survey

Then continue with the notes/chart/computer

Haematology

Hb, platelet and coagulation values.

Consider blood products if lines/procedures planned

Microbiology

New results – inflammatory markers and specimens. Known colonizers.

New cultures required?

Drugs, day and reason for doses and levels.

Drug chart review

Anything to stop.

Interaction/allergy check.

Treatment limitations

Therapeutic ‘ceilings’ or DNAR orders etc.?

Jehovah’s witness re blood products

Advance directives

Next of kin or advocate

Updated and in agreement with the plans.

Document all the above

Start with the current main issues, and indicate whether they are improving or deteriorating.Then:

Your review findings

In the order as above

Your impression

A summary line, likely to conclude with ‘deteriorating’, ‘improving’, ‘weaning’ etc!

Your plan

Address the current issues in turn

Sample ward Round Structure

Decision re who gets seen first – potential discharges ‘v’ most unwell ‘v’ just sticking to the order.

At each patient

Admission diagnosis and background (PMH)

Clarify if necessary

Progress summary

The stage of their critical illness

The general trend

Systems reviewed – as per above structure

Results reviewed

Imaging reviewed

View, compare, view report, discuss with radiologist or specialist, ?repeat, opinions in notes

Echo?

Drug review

For each drug, check: still required, not contraindicated, level checked, dose adjustment, convert route or convert to alternative, interactions.

Pre-admission drugs restarted where appropriate.

Referral

Speciality review (?other hospital).

Palliative care

Pain team

Family and home team update

Instructions in notes and for nurses clearly written

Then:

Final rapid-fire cross-check – eg FAST HUG or adapted version eg ‘FLAST HUG DRIFT’:

1. Fluids/feeding/faeces (ie aperients)
2. Lines – still required, VIP, correctly sited
3. Analgesia/Sedation started/stopped/altered
4. Thromboprophylaxis started/stopped(for procedures/bleeding)/HIT,
5. Head-up/rolling/spinal precautions,
6. Ulcer prophylaxis started/stopped/correct,
7. Glucose control – ?alter scale or change feeding regimen or restart long-acting insulin etc
8. Drugs stopped/adjusted/restarted (inc pre-admission drugs)
9. Referrals made/done and home team updated
10. Imaging needed/reviewed/referred
11. Family updated
12. Team up to date and in agreement (nurses instructions etc)