Critical Care Minutes

***Excerpt taken from SICU Handbook Cleveland Clinic SICU

1. Maintain your availability in the SICU

The nurses and other personnel who work in the unit are seasoned, experienced professionals. Unfortunately, as in other aspects of health care, they are being forced to “do more with less,” which means that frequently there is one nurse to two (or three!) patients; so-called one-on-one nursing assignments are extremely rare. This means that the nurses are busier, and the one thing that they shouldn’t have to do is constantly hunt for you. The usual response to this statement is “I have my beeper; they could have paged me!” However, a nurse having to page you simply means less time devoted to patient care.

Therefore: While you’re on the SICU rotation, please stay in the SICU. If you leave, for lunch or for some other reason, inform the nurse(s) taking care of your patient(s) not only that you’re leaving the vicinity of the SICU, but that an identified colleague will cover for you during your absence.

2. Write ALL of your orders

The busy nursing staff is under no obligation to accept verbal or telephone orders from you because a physician is always present (see #1 above). They will do so as a courtesy, especially if you’re in the call room at night, but verbal/telephone orders require more work (nurses have to write them in the order sheet), and more importantly set the stage for potential miscommunication.

Therefore, when giving an order, take out your pen and write it now, not at some future time, or it may not be carried out. Make your intentions clear, in plain English. It is always good practice to verbally communicate with the nurse in addition to writing orders. This is especially true if in your estimation an order requires immediate attention, as the nurse may not look at the order sheet right away.

Orders for standing tests and labs: currently it is the policy in the SICU that there are no standing orders for labs. The Resident or Fellow taking care of the patient each day should be sure to write orders for the anticipated labs needed for the next day. Critically ill patients should have the need for labs and tests reviewed each day. Orders for total parenteral nutrition (TPN) need to be written daily by 5 PM so that the mixture can be prepared by the pharmacy in time for use at (the usual) 10 PM. Antibiotic orders must be renewed after 1 week, and narcotic orders must be renewed every 72 hours. Indeed, all medications should be reviewed daily for their continued need.

3. Communicate, communicate!

Effective communication skills are required for any successful physician. In the ICU this is especially true because there always many disparate issues and consultant services. Coordination of care of the critically ill should be considered a primary goal.

Therefore, do not hesitate to communicate with the surgical service, the nurses, respiratory therapists, consultants, and family members for all pertinent issues.

4. Follow the prescribed format for Progress notes

Each progress note should begin with “Seen and discussed with Dr. [ x ],” x being name of the Staff physician with whom you are making rounds. Just writing “Seen and discussed with Staff” is insufficient documentation. The Staff who are making rounds are written on the daily assignment sheet by the Fellow.

Critical care billing codes are based on increments of time. The Staff physicians are required to document their presence at the bedside and “treatment time” in addition to your progress note. Thus, though the Staff note may at times be a redundant recapitulation of your note, its presence is necessary.

Procedures that are performed during the day have separate billing codes. Procedure notes, which should be written in red in the clinical record, need to contain the statement “Supervised by Dr. [ x ]” if a Staff physician Dr. x was available to help. If a procedure is performed at night, for example, when a Staff physician is not in the hospital (and thus not billable), the Procedure Note should instead contain the line “Discussed with Dr. [ x ].”

5. Confirm intubations with ETCO2

For a variety of reasons, intubations performed in the ICU are not nearly as straightforward as in the operating room. Yet capnography, considered a “standard-of-care” in the OR, has not reached all ICUs. In the SICU, each bedspace does have the capability for capnography.

Therefore, it is the policy of the SICU that all intubations are to be confirmed by capnographic examination. The respiratory therapists are responsible for maintaining the equipment needed for immediate use. If the hardware or disposables are not ready for your use, please remind them of this rule so that they can obtain the necessary parts and have them ready for you prior to performing the intubation. Your procedure note for the intubation should include a statement that the presence of CO₂ was confirmed by capnography.

6. Confirm venous access with manometry

When placing a central line in ICU patients, differentiating between arterial and venous blood may not be straightforward. Continual review of our own line complications has shown that the usual clinical signs of color and pulsatile flow are not always reliable. Therefore, it is the policy of the SICU that for all “new stick” central line procedures, venous access must be confirmed by a manometric test prior to vessel dilatation.

This test is simply performed using a piece of 36” pressure tubing which the nurse should obtain for you on request. Attach the tubing to the Angiocath/cannula and allow blood to fill the tubing. Then, hold the end of the tubing above the patient. If you’ve successfully cannulated the vein, the blood level in the tubing should drop. If the level does not drop, or continues to trickle out of the end of the tubing, then either the Angiocath/cannula is abutting the vessel wall or you may have cannulated an artery. At this point, you can either try repositioning the Angiocath/cannula or connect the end of the 36” tubing to a transducer. If the transduced pressure tracing is not clearly venous, then you should remove the Angiocath/cannula and start over.

7. Line changes

The SICU routine is to change central lines by clinical need, not by time. This based on many years of our own quality assurance reviews and an accumulating body of literature. However, patients that we have identified as high risk for line-related infections are transfers from outside hospitals. All such patients should have their lines changed (over a wire is sufficient if the insertion sites have an acceptable appearance) upon arrival to the unit.

8. Call consults yourself

In the ICU, if consults are needed they usually involve the complex, disparate issues of our patients and require doctor-to-doctor communication. SICU policy is that the Unit Secretaries will not call consults; you must call them yourself.

9. Be on time!

10. Be on time!

Please allow enough time to adequately assess your patients and to attend conferences and meetings.