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Organization and Efficiency in the ICU

One the biggest problems our new hires face is getting overwhelmed and being 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 Patient List - General Concepts

Think of the patient list as your central command hub; it's what keeps you sane amidst all the chaos.

Now, everyone has their own unique ways of staying organized, and you'll hear plenty of suggestions. Here, I'll gather some ideas I've come across so that you can pick and choose what works best for your own practice. Remember, your approach is a blend of everything you've learned from different mentors - there's no single "right" way to do things. You can draw inspiration from various sources and craft your own distinctive approach.

Picture your sheet as a five-year-old child. You wouldn't leave a five-year-old unsupervised for too long; they might get into all sorts of trouble, from sticking a fork in an outlet to messing around near a pool or creating a mess. The same goes for your sheet – check on it regularly. At least once an hour, especially when you're just starting your career, go through your list and see what needs follow-up and action. Because if you neglect it, just like an unsupervised child, it can lead to some pretty shocking outcomes.

Triaging Patients

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” or “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” or “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 patients are

Keeping Up With Tasks + New Events

Now, let's talk about the real deal. Many folks might feel they've got a handle on things at the start of their shift when it's all calm and quiet. But when the ICU phone starts ringing off the hook and patients become seriously demanding, that's when chaos strikes.

Step one: Embrace the chaos. You knew it was coming. Your metaphorical five-year-old is running wild. Remember, this is the ICU, not a cozy family clinic. People are seriously ill. While it may be terrifying initially, you'll learn to thrive in this environment because you understand that it's not only a chance for you to improve your skills, but also an opportunity to help and maybe even save a patient.

Think of the chaos like a hurricane. Initially, the weather is calm, but when the hurricane hits, you're in the midst of 100+ mph winds. The only way to find some peace in the eye of the storm is to stay focused and 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 patients.

Keeping up with “To-Do” Actions

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.