In this episode, I’ll discuss how to prepare for ICU rounds on a critical care pharmacy rotation.
Most of my pharmacy students are surprised that I look at medications last in my pre-rounding review of ICU patients.
I am constantly tweaking and improving my method for pre-rounding on ICU patients. Here is my current routine for evaluating new ICU patients in preparation for patient care rounds.
Whenever possible I like to be in front of the patient’s room when I evaluate them before rounds. By observing the patient I can see how sick they look, whether they are intubated or have SCDs on. If the NG tube is being used for tube feeding, I know it can be used for meds too. Inadequate sedation or other problems can easily be identified by a brief observation of the patient. Also, being this close to the bedside I am available for nurses to ask me questions and to be side-by-side with the provider as they determine solutions to the patient’s problems.
In this episode, I’ll discuss how I build my pharmacy problem list, use a paper report to supplement the electronic system, list my current 5 step pre-rounding process, and explain how I prioritize which patient to see first.
Pharmacy problem list
At each step of my evaluation of the patient, I am filling out my note template in the pharmacy computer system with my “pharmacy problem list”. This note template is not meant as a permanent part of the record and is not viewable to non-pharmacy staff, rather it is meant for me (or my resident/student) to track the patient’s problems and our recommendations.
Recommendations –
VAP –
VTE –
SUP –
Reason for Admission –
PMH –
Drips –
Respiratory –
Infectious –
Cardiac –
Hematologic –
Metabolic –
Alimentary –
Neurologic –
The purpose of this note template is to:
-help track and solve problems
-remember my recommendations for rounds
-provide basic information to “refresh my memory” about a patient when asked a question in the middle of the day
-provide a starting point to begin my review of the patient the next day
I have limited time to finish pre-rounding, and the purpose of the note is to facilitate problem solving so I do not copy-paste lab values or medication orders into my note.
Paper report
I use a paper report to facilitate my pre-rounding review of patients. The report also serves as a “bare minimum” for me to review if other priorities cut into the time I have to pre-round on patients. The report includes basic demographic information for the patient, creatinine clearance estimate, allergies, creatinine/potassium/magnesium/wbc/hb/plt and any current orders for antibiotics, stress ulcer prevention, steroids, anticoagulants, or chlorhexidine.
The paper report serves as a “2nd computer screen” and allows me to see more information at once.
My 5 step pre-rounding process:
1. Read the history & physical, consult and progress notes to determine who is the patient and why are they here
2. Review home medications
3. Review labs, cultures and imaging reports
4. Review the bedside flow sheet
5. Review current medications
Read the history & physical, consult and progress notes to determine who is the patient and why are they here
Who is the patient and why are they here?
There are 3 reasons why a patient might be in an ICU. I want to make sure I identify the reason as early as possible in my review. I talk in more detail about these reasons in episode 11 but in brief the 3 reasons are:
1. A vital system has failed and we need to support it (respiratory failure, on vasopressors, etc…).
2. Something has happened that makes it likely a vital system will fail, and we need to recognize and support it when that happens (tPA for stroke within the last 24 hours, overdose of unknown substances, high risk surgical procedure).
3. Nonsense.
Reading the history & physical and consult and progress notes
I pay particular attention to the history of present illness and the assessment/plan. My focus during pre-rounding is to identify problems so that I can evaluate the best solutions for those problems.
Review home medications
When I review the patient’s home medication list, I look for medications that, if held, could cause a withdrawal syndrome. Then I write “on venlafaxine at home” under the neurologic section of my note. Combining home meds on the problem list with doing my pre-rounds in view of the patient makes things more efficient. When I observe the patient and see they can take oral meds I already have a list of the most important meds to get ordered for the patient. If I am seeing the patient before the physician has that day, this is a perfect opportunity to place a sticky note in their workflow suggesting for them to resume the patient’s venlafaxine. Listen to episode 19 for more on how I use sticky notes before ICU rounds.
Review labs, cultures and imaging
Again the focus is on identifying patient problems. I frequently find information that supports crossing a problem off the list. Maybe the radiologist doesn’t see an infiltrate on the chest x-ray, or the cdiff test came back negative, or the urine legionella screen is negative.
Review bedside flow sheet
Despite my hospital being mostly electronic, the critical care flowsheet is still on paper at my hospital. It is a 6 page document that is a treasure trove of patient data. One of the best things to look at the flow sheet for, is to determine “how sick is this patient?”. I look for oxygen requirements, ventilator settings, vital signs, pressor and sedative requirements, depth of sedation, and urine output on the flow sheet.
Review current medications
I’ve saved the best for last! As I review the current medications, I am looking at the choice of medication regimen, dose, considering the patient’s renal function, interactions, clinical condition, etc. and completing my pharmacy problem list and recommendations for rounds. Looking at the medications last helps me develop a more complete pharmacy problem list. Problems that might not be recognized by looking at the meds first often jump out at me if I have already reviewed the rest of the patient’s record. Here are some examples:
-Propofol alone as sedation might be OK for some patients, but if I know they are s/p exploratory laparotomy with lysis of adhesions, the absence of fentanyl becomes clear.
-Determining the cause of a patient’s agitation can be very time consuming, but if I know they were on paroxetine at home and haven’t had it for 2 days it is easier to narrow down the possible causes.
-Seeing oral vancomycin as an order doesn’t necessarily mean anything, but knowing that the cdiff test was negative and the CT did not find colitis makes it immediately clear the vancomycin can be discontinued safely.
How long does this take and who should I see first?
You may be wondering, how long does this process take? In most cases I can complete my review of a new patient in 20-30 minutes, and an existing patient in 10-15 minutes. When I have a pharmacy resident or student, we are able to spread some of the pre-rounding tasks between us. I also prioritize who I am going to see first based on how sick they appear. I take a quick walk around the unit in the morning, looking for clues for sick patients that should get my attention first:
-The code cart has been placed in front of their room, preparing for the inevitable.
-There is a CRRT machine in a room where there wasn’t one yesterday.
-There is more than 1 nurse in a patient’s room.
Additionally, I prioritize who I see first based on the unit’s bed board. This electronic patient tracking board identifies those patients who are planned to transfer to a lower level of care and therefore are not as sick. I see the patients who are anticipated to stay in the unit before moving on to those who are identified for transfer out.
Now that I have a complete pharmacy problem list and my recommendations are planned, it is time to attend ICU rounds. In the next episode, I’ll share how I participate in ICU rounds, including how I present my recommendations.
How do you prepare for ICU rounds? I’d love to hear!
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.
As a nurse who works in a medical ICU and a cardiothoracic ICU, I often wonder why the pharmacist is present during rounds. Hardly ever says anything, doesn’t really know the patient because they have almost no contact with them, and isn’t trained to evaluate them. They also find that the pharmacist has little understanding of the technology we use. Kind of limits their role unfortunately…
Interesting – I would appreciate it if you directed them to this site!
Joe
Hi Joe,
I am a last year pharmacy student and currently I am in a NICU roation. I am having problems organizing all the information I obtain before rounds. My preceptor has given me a sheet to write down information but it is not user friendly and it dosent really allow me to write down medication information. Do you have a specifc template that you use to write down all your pre-round information or do you just do it all electronically in the computer?
Thank you for any response, Ashley
Hi Ashley, I’ll write basic information on my pre-rounding sheet, like the name and day of therapy for the antibiotics that the patient is on. I’ll think about the dose, frequency, indication, and renal adjustment too, I just don’t need to write all that information down.
I go more in-depth on this topic and share my rounding templates in the ICU Rounds Masterclass within my Critical Care Pharmacy Academy.
Joe
I m new to yr writings n find immensely useful. Interestingly, some other professions in hospital DO NOT EVEN KNOW what pharmacists do to make patients’ journey smoother and commenting negatively on this. I wonder if their uni lecturers and professors teach what is called interdisciplinary cooperative work in patient care or multidisciplinary team work. If this is missing out, i suggest hospitals should start investing in this for benefits of patients. Sigh…we are in 2018, i cannot believe this as a pharmacist.
Hi Joe,
I’m also an ICU clinical pharmacist and you & I seem to have very similar methods for working up our patients. I am curious to know how many patients you oversee? Our ICU and CCU have recently combined and now have a total of 26 patients. I am a bit overwhelmed to get everything done in an 8 hr shift. Trying to find ways to work “smarter!” 🙂
I have up to 19 patients in my ICU. I also cover several dozen general medical beds, although I do not pre-round/round on those beds. Have you seen my productivity tips in episode 114? I hope they are helpful to you!
Hi Joe,
I’m a pharmacy student and just got done with my critical care elective. I have found your articles very helpful to help me organize myself in this new place. Would you be able to share an example of one of your patient work-ups? I feel like I may be getting too much into the weeds of some things that aren’t as important, but still missing out on other things from the PMH (especially when some patients have been here for 4 weeks and they just got added to my team). Do you have any recommendations?
Hi Dan, I am glad you have found things helpful! I don’t have a patient workup written up in a form I can share.
To stay “out of the weeds” focus on the problems that relate to why the patient is in the ICU. You can always look at the intensivist’s note or talk to the nurse for an idea of what the main problems are.
As a critical care pharmacist, how do you document the recommendations you make on rounds (i.e. take accountability and clearly communicate the pharmaceutical care plan) in the medical record? Do you have a template that you use for each patient rounded on?
I look at documentation as having 2 purposes:
1. To communicate to other members of the healthcare team
2. To record activities for internal tracking purposes
I only document items that meet the first criteria in the medical record. I use the TITRS format as I describe in this post: pharmacyjoe.com/episode19.
If I make a recommendation to adjust a medication dose for renal insufficiency, add VTE/SUP/VAP prophylaxis, or something similar I do not put that in the permanent medical record.
I liked that you pointed out that you should know that the templates are made to help keepings in track. It does seem like a smart thing to be aware of when need to work at a hospital. After all, you need to remember that when at the hospital.
Thank you for this amazing lecture…could you help me please ..I need ICU pharmacist form
Hi Joe,
I am a SICU/NICU pharmacist and I work out my patients the way you do as well. I have an average of 20 patients per day, about 2-3 new admissions to displace discharges on daily basis.
As far as the clinical team [Drs, nurses, respiratory therapists, PTs, dietitians etc] are concerned, we do get good recognition for our work. I am curious to find out, are there any services to which you provide to increase interactions between patient/patient family, so to improve visibility of pharmacist? Many of my pharmacists are heros behind the scene.
Great question!
Most of my interaction with the patient/family is with medication reconciliation or pain management consults.
Whenever I am in the room though I make sure I introduce myself as a pharmacist to the patient/family.
Hi Joe,
I occasionally go back and revisit this particular episode to refresh my rounding process. You mentioned at the beginning that you are constantly revising your method. I was wondering if you have made any changes that would warrant a new episode or revisit to this episode?
Thanks Jim, great idea! I will add it to my list of new episodes!
-Joe
Joe, so happy i came across your podcast. I recently started doing ICU / cardiac ICU rounds in our hospital. We usually have 10-15 patients but my problem is usually the fact that in the mornings i don’t have enough time to pre-round and write my report before the team gets there. So sometimes i need to look up my patients at home before getting in (not ideal!). Most our attending rely heavily on our (pharmacist) recommendation and so I am looking for ways to make this process more efficient. Thanks again for a great podcast!
Hi Ally! So glad you are finding the podcast helpful!
You sir are amazing, I’m a pharmacy student interested on residency and i’m passionate about critical care and emergency medicine, your lectures just motivate me more
Thank you for the kind words Alex!