Episode 21: How to participate and give pharmacy recommendations on ICU rounds

In episode 20, I discussed how I prepare for ICU rounds.

In this episode I’ll be talking about how ICU rounds are structured and how I participate in ICU rounds, including when and how I present my recommendations.

For context, know that I am in a 20-bed community hospital open medical/surgical ICU. There are no physician residents. Although the ICU is open, hospitalists and most physicians defer management of the patient to the intensivist. About a dozen intensivists and 3 mid-level providers provide coverage for the ICU, with one mid-level and one physician being present during the day shift when rounds occur.

Structure of rounds at my community hospital:

Team

Physician, Patient’s Nurse, Charge Nurse, Pharmacist, Respiratory Therapist, and Dietician are the service providers that most regularly attend ICU rounds.

Time & Location

10am outside of room 1 is the standard time and location for rounds at my hospital.  The time and location are not strict however and will often change based on patient acuity.

Roles for each health care provider

Typically the physician will “present the patient” which amounts to a 1 or 2 sentence explanation of who the patient is and why they are in the ICU. The physician will then ask the nurse to complete a systems-based review of the patient following RICHMAN which stands for:

Respiratory
Infection
Cardiac
Hematologic
Metabolic
Alimentary
Neurologic

After this review of systems each member of the team is expected to offer any recommendations or ask any appropriate questions before moving on to the next patient. Any prophylaxis or “checklist items” such as central line / foley days that were not covered in the review of systems is usually discussed here as well.

When I present my recommendations

The most effective time to give recommendations to a provider is when they are trying to solve the patient’s problems. I try as much as possible to be elbow-to-elbow with the providers as they are “seeing the patient” and determining orders. Getting the best recommendation accepted at the beginning of care is so much easier than trying to change therapy later.

I also prefer to give many of my basic recommendations related to prophylaxis or renal dose adjustments to the provider via a sticky note placed in their workflow. I give specific examples of how I use sticky notes in episode 20. Then I can review the orders for the patient on rounds to double check that the recommendations were accepted. The key is to place my unofficial note in a spot that I know is within a physician’s workflow. This could be the flow sheet, the physician’s computer screen, or in the case of “Intensivist Anna”, a clip board that she has with her specifically for sticky notes to be placed on.

During rounds, I make my recommendations during the discussion of the relevant system.  For example, I’ll ask for stress ulcer prophylaxis when “Alimentary” is being discussed, or antibiotic changes during discussion of “Infection”.

There are two main things I keep in mind when presenting recommendations on ICU rounds:

1. Has the provider “seen the patient” yet?
2. What are the goals of care?

Has the provider “seen the patient” yet?

When giving a recommendation I try to be mindful of whether or not the provider has seen and evaluated the patient yet that day. If they have not, I always start my recommendation with “I know you haven’t seen the patient yet…” The reason I do this is that I have found providers have a defensive reflex when they are being asked to change something they haven’t evaluated yet. Prefacing my recommendation in this way diffuses the potential issue and allows my recommendation to be considered based on its merits. It is like saying “I know its not your fault but…”

What are the goals of care?

I’ve described myself to providers before like a “blind golf caddy”.  A caddy knows the ins and outs of when and how to use each club, just like I should know the ins and outs of when and how to use each drug. But I can’t always see the course clearly. I’ll explain:

The team is discussing how to control a patient’s acute agitation on rounds. I could easily recommend giving benzodiazepines in escalating doses until the patient is controlled. But what if the patient’s ejection fraction is 15%? The physician may feel that this patient would be impossible to wean from a ventilator and therefore the risk of respiratory depression from using benzodiazepines may be too great. Sometimes I pick up on this type of thing during my pre-rounding (which I cover in episode 20) but not always, hence my blind golf caddy analogy.

I frequently will explicitly ask what the goals of care are before providing my recommendations. Here are some examples:

For controlling agitation I ask: Can we intubate this patient if we give too many sedatives? This helps me decide which sedatives I should use and which I should avoid.

For weaning off long-term fentanyl infusions I ask: Is the fentanyl infusion the only thing keeping the patient in the ICU? This helps me choose how aggressively to wean the fentanyl.

Just this week I asked: Do you think the patient might have necrotizing fasciitis? This helped me decide whether to add a dose of clindamycin to decrease toxin production before the patient went to the OR for source control.

A special circumstance to consider is when the team feels that care is futile, but the advance directives have not been changed to reflect this. Earlier this week I had a very elderly patient on 5 vasopressors with a lactate of 15. On rounds I noticed her piperacillin-tazobactam needed renal adjustment. It seemed obvious given the team’s discussion that this patient was not going to survive her critical illness, and a discussion with the family was going to occur before the next antibiotic dose was due. I elected to withhold my recommendation, knowing that I could always give it later if the family did not decide to pursue comfort measures for the patient.

Evidence-informed practices for rounds

I’ve recently come across an article titled Systematic Review of Evidence-Informed Practices for Patient Care Rounds in the ICU that was published in Critical Care Medicine 2013. I’ve shared this article with some members of the ICU team at my hospital, and I think it has interesting implications for improving the way ICU rounds are conducted. In this article, there are many practice recommendations given based on various levels of evidence. Here are the 6 strong recommendations given in the article:

1. Implement multidisciplinary rounds (including at least a medical doctor, registered nurse, and pharmacist)
2. Standardize location, time, and team composition
3. Define explicit roles for each HCP participating on rounds
4. Develop and implement structured tool (best practices checklist)
5. Minimize unnecessary interruptions
6. Focus discussions on development of daily goals and document all discussed goals in health record

How do you participate on ICU rounds?  I’d love to hear!  Do you document all the goals discussed in the medical record?

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If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.

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