Ward Rounds in ICU

Please note that some this section is specific to Eastern Health Intensive Care Units, however principles can be easily applied to all units.

The three ward rounds in ICU

The ICU daily ward round is an integral part of our care for patients. There are often three rounds a day.

Morning rounds

• Starts with a handover from the night to the day team
  • Led by the night registrar
  • All patients are handed over sequentially with a brief statement as to the patient’s demographics and a succinct coverage of their past medical history, HOPC, issues and important treatment to date
  • If the day team are coming of for their first day this handover tends to be longer
• Following handover the patients are rounded upon, generally in the order of unstable patients first, then the more stable. Rounds are split into two, with the liaison consultant and “outside” registrar seeing the dischargeable patients and the consultant on the floor seeing the patients that will remain in ICU for at least the day.
• The ICU pharmacist joins the team for the ward round and is an invaluable resource in checking dosages and appropriateness of medications.
• The ICU physiotherapist/s, dietician and social worker may also check in and add to management plans at certain patients in the round.

Afternoon rounds

• Afternoon rounds are:
  •  a chance to ensure that the plans from the morning round were successfully implemented.
  • to follow up on any tests that were performed (bloods or imaging).
  • to review how patients have progressed through the day with treatment.
  • to put in place a clear plan overnight for the night registrar to follow.

Night registrar round

• Starts with a handover from the day team to the night team
  • Handover is sequential, again it tends to be longer if it’s the night registrar/HMO’s first night shift
• Night ward rounds
  • for the night registrar to review what occurred during the day
  • to better review the patient’s histories
  • get a clear impression of the plan overnight for each patient

Ward round structure

The ICU ward round structure involves documenting:

• Who is present
• Length of stay in the unit
• Current issues (and their treatment)
• A physical exam, taking a rough A->E approach
  • A: Airway – size and position
  • B: Breathing – current FiO2 requirement and ventilator support, findings on respiratory examination
  • C: Circulation – current vasopressor/inotrope support, finding on a cardiovascular/haemodynamic examination (including capillary refill, urine output, ECG)
  • D: Disability/drugs – current conscious state of the patient, sedation requirement
  • E: Environment – including temperature, drains, other infusions running (e.g. actrapid infusion and current BSL)
• All pathology and radiology is reviewed
• The medication chart is reviewed
• Lines and their date of insertion is documented
• ICU daily goals of care is ordered (the physiological targets for the day that therapy is titrated to e.g. MAP>65mmHg)
• The plan for the day is documented

FASTHUGID

After each patient has been reviewed along with all of their medications, pathology and radiology, FASTHUGID is a checklist to ensure nothing has been missed. Meticulous attention to these details is important in ICU.

• Feeding/Bowel
  • Is the patient being fed? If not, why not and should enteral or parental nutrition be commenced?
  • If they are eating, is it sufficient?
  • Do aperients need to be charted if bowels not open
• Analgesia
  • Is the analgesia appropriate – does analgesia need to be increased, or can it be de-escalated?
• Sedation
  • Can the sedation be reduced?
  • Should a sedation hold be carried out today?
• Thromboprophylaxis
  • If not charted, can it be commenced?
  • Is VTE prophylaxis appropriate?
  • Do we need any special monitoring e.g. Anti Xa Level?
• Head of Bed @ 30 degrees
  • If appropriate i.e. not in cervical spinal precautions
• Ulcer Prophylaxis
  • If high risk of ulcer and not on enteral feeding should a PPI or H2RA be prescribed or stopped?
• Glucose Control
  • Are glucose levels appropriate, and if not what changes to insulin or oral hypoglycaemics are needed?
  • Can oral hypoglycaemics be restarted?
• Invasive Lines/Tubes
  • How old is each line and can it be removed?
• Drug Therapy
  • Can any medications be ceased (in particular diuretics, antibiotics, sedatives) or can any of the patient’s usual medications be recommenced?

The ICU ward round is also a fantastic opportunity for learning and teaching and a great opportunity to ask questions!

Author: Nick Ryan