Tips For ICU Ward Round

The Intensive Care Unit (ICU) ward round comprises scheduled discussions in which healthcare providers consider clinical information and develop care plans for critically ill patients.

A remark by Lane et al., 2013 investigated the facilitators of and barriers to effective ICU ward rounds, e.g., Conference room versus bedside ward rounds; both have various facilitating factors and obstacles.

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The CICM (ANZ) 2014 policy on Least Standards for Intensive Care Units states that an intensivist “must-see all patients under his/her care with junior staff at least twice daily and set a management plan, in the form of a structured bedside ward round.”

There is no ‘gold standard’ method for performing an effective and efficient ward round in the ICU; any system should be tailored to local requirements.

FACILITATORS OF EFFECTIVE ICU WARD ROUNDS

Facilitating factors:

• open, collaborative discussion environment

• reduce nonessential time-wasting activities

• access to patient data

• discussion and documentation of goals

• standardized round structure and process

• checklist use

• pharmacist presence

• affiliated with a significant reduction in the total number of avoidable adverse drug events (Leape et al. 1999)

• Associated with advancement in infection control management, anticoagulation therapy, and sedation/analgesia utilization (Preslaki et al. 2013).

• multidisciplinary round

• visibility of HCPs

• greater Health Care Provider (HCP) autonomy

• explicit HCP roles

OBSTACLES TO EFFECTIVE ICU WARD ROUNDS

Barriers:

• interruptions

• increased rounding time

• nonstandard structure

• allied HCP perception of being non-valued

• e-record use

• hierarchical HCP structure

BEST PRACTICE

Lane et al. (2013) made several evidence-based recommendations for best practices in conducting ICU ward rounds that they sorted as:

• Vital recommendations that are based on strong evidence; “definitely do.”

• Suggestions to consider that are based on weak evidence “probably do.”

Essential:

• implement multidisciplinary round (Doctor, Nurse, pharmacist minimum)

• standardize location, time, and team

• explicit roles for each HCP on round

• develop and implement a structured tool

• reduce nonessential time-wasting activity

• minimize interruption

• concentrated discussions on the development of daily goals and documented all discussed goals

Consider:

• bedside discussion for patient-centredness

• conference room discussion for efficiency and communication

• open, collaborative environment

• clear visibility between all HCPs

• empower HCPs to promote a team-based approach

APPROACH TO ICU WARD ROUNDS

Start with a team huddle.

• should include the Nurse Team Leader and other non-medical staff who are elements of the ward round

• handle any administrative or system issues (e.g., staffing, available beds, the busyness of the unit)

• ensure every team members know where emergency equipment is (e.g., airway and resus trolleys)

• explicitly debate how the ward round will run

• determine the order of patients

• e.g., unsteady patients first, patients preparing for discharge/ extubation, new admissions, the other patients

• preferably, coordinate with nursing staff breaks, etc

• recognize team member capabilities and learning requirements before the ward round to ensure appropriate tasks are allocated, and those relevant teaching opportunities are taken for each patient (may be carried out concurrently by numerous team members)

• ask the bedside nurse what problems they are concerned about or need to be addressed (check their ‘do list)

• review the history (talk to the patient and family if possible!)

• review the labs and imaging

• review documentation

• ICU chart (observations, infusions, fluid balance, etc.)

• medication chart

• clinical notes (comprising letters, notes by visiting teams, and notes by other ICU team members such as dieticians and physiotherapists)

• carry out the physical examination

• document a plan with proper targets (e.g., MAP, SpO2, etc.), end-points for therapy, and explicit criteria for notification of the medical team

• highlight learning points / give teaching to the team

• communicate the plan verbally and often ask, “does anybody have any questions or concerns?” until leaving the patient’s bedside

Tips and tricks

• ICU ward rounds should be standardized over the ICU, with the same start time and location every day

• Utilize first names among all team members to flatten the hierarchy and encourage ‘speaking up.’

• better to finish the ward round earlier and address minor details later (e.g., on the evening round) to avoid decision fatigue and allow time for tasks to be completed

• always confirm the information you receive is reliable

• Misinterpretations and incorrect assumptions may accumulate through numerous handovers when a patient arrives in the ICU, worsening the longer a patient stays in the ICU.

• Delegate and allocate information-gathering tasks carefully to guarantee that valuable information is not jumped.

• On the ICU Ward Round, as the senior physician, you may require to take the history yourself, review the patient yourself, or speak directly to people who “were there” (e.g., during a presentation to the emergency department)

• Prefer the family to stay present during the ward round.

• exemptions are if their presence interferes with patient care, is culturally improper, and/or leads to distress

• family presence is approved by the American College of Critical Care Medicine’s guidelines describing evidence-based best practices for patient-and-family-centered care in the ICU as a way to improve bidirectional communication (Davidson et al., 2007; Nugent and Coppersmith, 2017)