This does NOT reflect the practice pattern of every SICU. All the components must be addressed, but there are many variations on how they are incorporated into the daily routine.

Flash Rounds

     A multi-disciplinary process that includes the charge nurse, respiratory therapist, clinical nutritionist, physical therapists/ occupational therapists, clinical case manager, and a senior member of the team (attending, fellow, APP). Focused on ensuring that each patient has daily goals and a plan from each of the team members, ensuring that key issues are addressed early instead of waiting until after rounds (nutrition, plans for ventilator weaning, disposition planning, etc.).

Working Rounds

     A multi-professional process that includes the bedside nurse, "learners" (broad term to include students, residents, advanced practice provider (APP) fellows), as well as the APPs (nurse practitioners (NP) and physicians assistants (PA)) and a clinical pharmacist. The team is led by the attending physician or critical care fellow. Engagement and communication by all team members are encouraged. After reviewing overnight events, a system-based approach is used to methodically evaluate the patient's current clinical status and then develop a management plan.

1. Systems-Based Rounds- presented by resident or APP

- Neurologic- assessment of mental status, including the Glasgow Coma Scale (GCS), Richmond Agitation-Sedation Scale (RASS), etc. Current sedation and analgesia regimen. Review relevant radiologic imaging.

- Cardiovascular- relevant vital signs and hemodynamic monitoring parameters, including trends and ranges. Review current cardioactive medication.

- Pulmonary- current ventilator settings, relevant laboratory values (arterial blood gas), relevant radiologic imaging (chest radiograph).

- Gastrointestinal- physical exam. Assess nutritional status (tolerating enteral nutrition, contraindication for enteral feeds, plan for parenteral nutrition). Review relevant radiologic imaging (abdominal radiograph).

- Genitourinary/ Renal- review intake/ output (I/Os). The total volume of fluid intake (intravenous fluids, nutrition, blood, antibiotics, etc.) and fluid output (urine, stool, drains, etc.). Relevant laboratory values (basic metabolic panel).

- Endocrine- review glycemic control.

- Hematology- assessment of coagulation status or abnormal blood counts (hemoglobin, platelets).

- Infectious Disease- physical exam- fever and evaluation of all possible infection sources (catheters, wounds, respiratory secretions). Review relevant laboratory values (white blood cell count, culture results), review current antibiotic therapy.

- Prophylaxis- review needs for venous thromboembolism and stress ulcer prophylaxis.

2. A-F Bundle presentation by bedside nurse [SCCM ICU Liberation Bundle]

- Assess, prevent, and manage pain

- Breathing (Spontaneous awakening and breathing trials)

- Choice of analgesia and sedation

- Delirium assessment, prevention, and management

- Early mobility and exercise

- Family engagement

3. Develop a management plan based on comprehensive patient assessment.