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Organization and Efficiency in the ICU

One the biggest problems our new hires face is getting overwhelmed and being incredibly inefficient when they first get on training. It is understandable - this job is incredibly unique and you are forced to face challenges that you haven’t encountered in the past (even if you have a strong clinical background in medicine). You are forced to learn to “fight” when encountered with a situation that puts you into your “fight or flight” mode; it can be unnatural, unnerving and frankly terrifying. If it’s any consolation, it is something everyone in our group shares to some degree no matter what our background or personality.

1) Improvement Over Time: A huge component of becoming more organized and efficient is one that you can only get with time: experience. The more you experience and the more you get ‘burnt’ the more you will remember; and therefore, the more efficient you will be in the future. There’s nothing like the emotional connection associated with a specific event to get you to do things efficiently.

2) Just breathe: Often when things get overwhelming we “freak out”. We hyperfocus on details that we can control/that we know and end up neglecting the important stuff; or even worse, we don’t even see the big picture and shut down completely. In a stressful situation, or when a lot happens at once, it is very important to just breathe. Physically step back and give yourself a mental reset.

3) Intentional Practice in Chaos: The ICU is can be a chaotic place. You’re in the middle of doing a vascath on a screaming guy that is actively bleeding out all over the bed below you when a code BLUE is called across the hospital; running to the code, you get a call from another serivce about a patient with pneumonia and ‘kinda unresponsive’ but not intubated, then another nurse calls you about getting potassium, all while you're trying to get to this code. This chaos is something that is more often recognized when you are off of training and alone.

But the thing is - You may not be able to control the fact that there is chaos, but you can control your reaction and preparedness to it. By having consistent, routine practices for every patient and every situation you can make chaos a lot more organized (even though it will likely never be perfectly organized).

Intentional practices

  The “Top” sheet where you list new patients

The “Top” sheet where you list new patients

  The patients list (patient names omitted) with the “sticky box” (space to write stuff)

The patients list (patient names omitted) with the “sticky box” (space to write stuff)

The Patient List - General Concepts

  • This is your mother hub; this is what KEEPS you organized in all the craziness

  • Everyone will tell you different ideas on how they personally keep things organized; I will try to compile things I hear on this site so you can adopt ideas to your own practice. Remember, your own practice is a combination of everything that is taught to you from every preceptor - there is not always one “way” to do things, you can pull a little bit from everyone and do things in your own unique way

  • Imagine your sheet is a five year old child. You would not let a five year old child be on their own for too long without checking on them; they could be sticking their fork in an outlet, drowning in the pool, or smearing feces all over the wall. Always check on your child. At least once an hour - if not more at the beginning of your career. Go through your list and look at things you need to follow up on, what you need to do. Because your child WILL electrocute themselves if left to their own devices.

The Top Sheet

Here you list new patients. You list what bed they are in, their name, their DOB, whats going on with them

  • The most valuable part of this sheet is knowing who is seeing the patient (if there is more than one PA/doc) and if the note is done. Some things I’ve seen:

    • NSC Method: N/S/C in the “primary” column denoting note/sticky/charge. Cross the letter once you are done with it; circle the letter if you have started it but are not done yet

      • Another alternative: N/S/C/O (note/sticky/chart/orders)

      • If you aren’t seeing patient/doing note: under “primary” write name of
        PA/doc doing note (“Rachel” or “Katie”)

    • Checkmark method: Three checkmarks under “Hosp” or next to patient name; the first check mark meaning note is done, second check mark meaning you charged for patient, the third meaning

The Patient List - Basics

The patient list is stapled below your top sheet. It lists patients currently on the ICU list; whether they are in the ICU or not. This contains room number, name, DOB, code status and sticky note text.

  • For day shift, at the beginning of shift, write N/S/C, N/S/C/O or leave it blank if you use the checkmark method (see to the left of this text)

  • If on nights, leave blank and only add N/S/C or checkmarks if you need to do note

  • One important concept is differentiating what was received in sign-out vs what happened during shift. To do this, you can:

    • Get sign out and highlight anything said there; rest of night do not highlight anything (see above)

    • Use two different colored pens

    • Divide box in half with line and right sign-out info on left, new things on right

    • Don’t do anything (and just know)

Triaging Patients

  The “star”, “squiggle” you would write next to patients name

The “star”, “squiggle” you would write next to patients name

Part of working well in chaos is knowing what patients to focus on. You need to know - will this patient likely die tonight? Or do they have floor orders and are waiting on a bed?

One way to do this is with “Star/squiggle”. You will draw a star, a squiggle or neither next to patients name.

  • No star, no squiggle —> no issues, doing very well

Just because they have no star and no squiggle doesn’t mean you ignore them. It just means they are your least prioritized patients; you know you have sicker patients to focus on. In order to assign a star or a squiggle you ask yourself two questions - “If a code BLUE was called on this patient, would I be surprised?” and “How much attention does this patient need?”

  • Squiggle —> "I would be kinda surprised if code blue was called on this patient but it’s not totally crazy” vs “This patient needs some intense follow up in the next 6-8 hours in order to prevent worsening, need to keep an eye”

    • Examples:

      • Patient just admitted and has many labs to follow up on

      • Patient with COPD on vent, slowly increasing FiO2 of unclear etiology

      • Patient is actively being transferred to PAH for pHTN work-up and will need sign out to PAH PA, discharge summary done prior to transfer

      • Patient is on three pressors and LA went from 5 to 7; remains on vent

      • High risk of intubation but doing ‘okay’ on BiPAP

  • Star —> “I wouldn’t be surprised if code BLUE was called overhead right now; he’s definitely going to die” vs “I need to follow up on something in the next 1-60 min”

    • Examples:

      • Patient is getting q4h BMPs for sodium 101, significantly altered

      • Patient on vent in cardiogenic shock progressed from 2 to 4 pressors; now having arrythmias, still full code

      • Patient is transferring to Emory for neurosurgery and has active brain bleed; has to get there in 1-2 hours or will likely decompensate

      • Patient has no access and is hypotensive

      • Patient just transferred to ICU and don’t really know whats going on

Note that squiggles can become stars; and that both squiggles and stars are subjective to the unit as a whole and the person running the unit. The idea of this is you are triaging your patients by your definition of most sick/most needy to least sick/least needy.

  • When you go after sign out to check on your patients you know what patients to do exams on first (i.e. if bed 12 has star, you will see bed 12 before anyone else; followed by your squiggles, then your blanks)

  • Now, when you check on your 5 year old child every hour (aka the list - see above) you know who your sickest car

Keeping Up With Tasks + New Events

Now this is the money maker. A lot of people, if things are chill and its just the beginning of the shift, feel like they have a solid grasp on their unit because nothing has truly happened yet. It’s when the ICU phone starts going off a lot and patients start getting really busy on you that things hit the fan. This is the chaos.

Step one: Thrive off the chaos. You knew it was going to happen. Your five year old child is OFF THE WALL. This is the ICU, not your family practice clinic. People are sick. Although terrifying at first you will learn to thrive off of it because you know that not only is it a chance for you to become better at what you do - you can help, and potentially save, this patient.

Imagine the chaos as hurricane. Initially the weather is great.. when the hurricane rolls in, you’re suffering in the middle of all the 100+ mph winds. The only way to get to the eye of the hurricane, where it’s calm? Stay focused and collected - stay organized. You won’t be able to get out of the hurricane completely but you can at minimum make it as good as possible in order to prevent bad outcomes for your patient(s).

Keeping up with “To-Do” Actions

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As noted before, you used whatever method you want to differentiate sign out from new events. (in this example, used the highlight method)

Anything you need to follow up on or anything new you denote with a circle or square; once that is done, you place a checkmark and what came of it.

You can see in this example that at sign-out a circle was made for a “CTH” follow up; once followed up, it was checked and “bleed” was written next to it indicating some kind of SDH or SAH. More circles were made below it indicating new things to follow up on. Once it is done you check it appropriately. Now, at the end of the shift, you can easily the order of events that happened and give sign out to the oncoming PA. Also in this is example is the first patients troponin; it came back as 0.20, so a follow up troponin was ordered at 0200.

Checking on your “five year old child” is essentially looking for any circles and boxes and seeing what you need to complete. Specifically, focus on the circles/boxes within your starred/squiggled patients first. This is how you are able to do it so quickly and so regularly without getting overwhelmed.

Some notes -

  • Write every task you need to with a circle next to it all the time. When it is less busy it is tempting to not write the task and just remember it on the top of your head; but in the ICU a hurricane can appear at any time. Imagine going from no new patients to getting five at once? A key way to stay organized is to be consistent.

  • Triage your “circles” or “squares” when reassessing your list. A circle to follow up on a CTA on a patient with a likely PE is much more important than a circle to follow up on whether the nurse hung potassium chloride for a K of 3.6. When you look through your circles do the most important ones first.

  • Don’t write too many tasks. Only write what you TRULY need to follow up on during your shift. Some example or poor task writing would be writing circles that say “has a CVL” or “monitor overnight” or “off insulin gtt”. You’re not doing anything to help yourself and you aren’t actually following up on anything.

Trending Labs

This is especially important. Bleeding patients need trended Hgb; a worsening shock patients you need to trend their LA; a hyponatremic patient you have to trend their BMP. Here is one method you can use to effectively track this -

  1. Write the lab you’re trending and how often you need it

  2. Next to that, write baseline lab value from when you came on shift

  3. Calculate when it will be drawn (i.e. next Hgb due at 6 PM); make a line for how often it’ll be drawn while you are working (e.g. if its q6h and starts at 6PM, a repeat would be at 12 AM and 6AM)

  4. Now, when you look on your sheet you know exactly what time its due and what it was before

 
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