The ICU can be intimidating. Critically ill patients are often surrounded by machines (ventilators, dialysis, etc) and IV poles, with multiple lines and catheters extending from their face, chest, abdomen, neck, and groin. A standardized approach can help the team synthesize and interpret all the subjective and objective data to establish a diagnosis and devise a treatment plan for these complex patients.

     Rounding in the ICU is different from rounding on floor patients. Floor patients are typically presented in a problem-based format- they are likely to have a short list of active issues being addressed, often just one diagnosis (cholecystitis, bowel obstruction, colon cancer status-post colectomy). Patients can certainly have co-morbidities, such as diabetes and hypertension, but they are usually relatively straightforward. Presentations are briefer than ICU presentations, and largely focus on the acute surgical diagnosis. 

Here is an example of a surgical floor patient. 32 year old female, hospital day 2 following laparotomy for small bowel obstruction. Her pain is controlled with oral analgesics with minimal prn requirements. She is hungry and passing flatus. She is using her incentive spirometry and ambulating. She has had minimal output in her nasogastric tube. Staples are intact along her midline laparotomy incision with no surrounding erythema and appropriate peri-incisional tenderness. Labs are only remarkable for some mild hypokalemia with K 3.4. She is voiding spontaneously with adequate urine output. Plan to replete potassium, remove NGT and advance diet.

     In contrast, ICU patients are fragile with more physiologic derangements that threaten homeostasis. Critical illness can profoundly impact multiple organ systems and the interdependence of organ systems adds another layer of complexity. Patients can be presented in a problem-based format, like floor patients, or a system-based format. There are pros and cons to each. As mentioned, a problem-based format addresses each diagnosis (for example- cholecystitis, bowel obstruction, heart failure, pneumonia, ileus). In contrast, a system-based format addresses each organ system (for example- cardiac, pulmonary, renal, neurologic). Problem-based might seem easier on first glance, but one downside in the ICU setting is the risk of overlooking organ systems without a discrete disease process. One downside of the system-based format is the categorization of one diagnosis to various organ systems. For example, ventilator-associated pneumonia is related to the pulmonary system but overlaps with infectious disease. However, the system-based format is comprehensive and thorough, which helps ensure that all physiologic processes are considered.

     One advantage of the system-based format is it’s adaptability to less complex patients. While it’s challenging to apply floor round formatting to the ICU setting, once you understand how to utilize the ICU system-based model, you can use it to briefly review non-ICU patients to ensure that you don’t forget something. For a young male with cholecystitis, you don’t need to report GCS, medication infusion rates, ventilator settings, insulin requirements, etc. But the systems are still pertinent- address pain (neuro), ensure normal vitals (cardiac) and use of incentive spirometer (pulmonary), check oral intake, assess return of bowel function and examine wounds (GI), inquire about adequate urination and review BMP (renal), ensure no fever, review CBC (heme and ID), and ensure ambulation/ SCDs (prophylaxis).

     ICU care is a team endeavor, requiring the integration of nursing, respiratory therapy (RT), dieticians, pharmacists, physical therapy and other team members to provide comprehensive care. ICUs must implement a system to integrate care plans between all team members. This can occur in different formats, either with “prerounds” (brief discussion with multidisciplinary team about each patient before formal rounds) or with multidisciplinary rounds (team members present their key data points/ plans in a structured format). One example of multi-disciplinary rounds (abbreviated): resident reports one-liner (see example below); nurse reports their assessments (pain/ sedation scores, delirium assessment, etc); RT reports current ventilator settings, results of spontaneous breathing trials and respiratory treatments; the resident then presents the patient as below.

Order of Presentation during Rounds

1.  Brief one-liner [presented by the resident, APP or student caring for the patient]. See below.

2.  Bedside nurse- report on sedation, pain, infusion rates, etc

3.  Respiratory therapy- report on ventilator settings, respiratory interventions, etc

4.  Formal patient presentation [presented by the resident, APP or student caring for the patient]. See below.

5.  Pharmacist- review of medications, including potential dose adjustments, antibiotic tailoring, etc

6.  Attending

7.  FAST-HUG- ensure that key aspects of care are addressed (feeding, analgesia, sedation, thromboprophylaxis, head of bed elevated, ulcer prophylaxis, glycemic control)

8.  Readback- nurse briefly summarizes the key goals of the day

One-liner: brief patient history, acute overnight events.

Example: 32 year old male, POD 7 exploratory laparotomy following motor vehicle collision, remains intubated for VAP.

Formal Patient Presentation [Systems Based]

Neurologic (Neuro)

 Diagnosis:

 Exam/ objective data. GCS, reflexes, pupils. ICP monitor.

 Medication: continuous infusions, requirements of prn analgesics

 Plan:

Neuro- patient remains intubated and sedated, GCS 11T off sedation, currently on Fentanyl @ 100 mcg/ hr and propofol @ 20. Minimal requirements of prn analgesics. We will wean fentanyl infusion and use enteral multi-modal analgesia.

Cardiac

 Diagnosis:

 Exam/ objective data. Vitals: describe the trend, know when outliers occurred (for example, an isolated heart rate (HR) of 130 during a procedure at noon the previous day is different from a sustained HR of 130s). If patient has any invasive monitoring, such as arterial pressure waveform analysis (FloTrac, Vigileo), pulmonary artery catheter or central line, include these as well.

 Medication:

 Plan:

Cardiac: HR 90s-100s, Flotrac shows normal SVV. On norepinephrine, requirement is currently down to only 2 from a max of 10 yesterday, MAP goal of >65. Continue to wean norepinephrine. Remove arterial line once off norepinephrine for 12 hours.

Pulmonary (Pulm)

 Diagnosis:

 Exam/ objective data: intubated, secretions, breath sounds, breathing pattern. Ventilator settings. Labs: ABG if performed. Imaging: note findings, and describe how it’s changed relative to prior imaging

 Medication:

 Plan:

Example: Pulm- pt remains intubated, current ventilator settings. CXR still shows bilateral fluffy infiltrates. *on antibiotics day x of x for VAP, CXR worsening/ stable, secretions improving. Then, later: ID- patient is on antibiotics day x of x for UTI, and day x of x for VAP.

Gastrointestinal (GI)/ Nutrition

 Diagnosis:

 Exam/ objective data: abdominal wounds, drains, stool management system, bowel function, nutrition.

 Medication: bowel regimen

 Plan:

GI- patient started on tube feeds two days ago, but he’s having minimal stool output. Abdomen is distended and tympanitic. We held feeds this morning and have an abdominal plain film pending.

Renal/ Fluids/ Electrolytes (Renal)

 Diagnosis:

 Exam/ objective data. IV fluids. Intake/ output. BMP.

 Medication:

 Plan:

Renal- foley in place with good urine output, I/O 3.2L/2.9L. No continuous IV fluids. Electrolytes within normal limits.

Hematologic (Heme)

 Diagnosis:

 Exam/ objective data. Labs: Hgb, Plt. Transfusion.

 Medication:

 Plan:

Heme- stable mild anemia, checking CBC every Monday/ Wednesday/ Friday.

Infectious Disease (ID)

 Diagnosis:

 Exam/ objective data. Labs: WBC, neutrophils. Culture results (sample source, date, results).

 Medication: current antimicrobials.

 Plan:

ID- patient is on antibiotics day 2/5 for UTI, and day 2/5 for VAP. He has remained afebrile for the last 48 hrs. His WBC is downtrending. No pending cultures.

Endocrine (Endo)

 Diagnosis:

 Exam/ objective data. Labs: glucose trend, insulin requirements

 Medication:

 Plan:

Endo- stress hyperglycemia, glucose range from 210-240. Currently on SSI with 24 hr requirement of 22U. Increase to more aggressive sliding scale, but holding off adding scheduled/ basal insulin while adjusting his enteral nutrition.

Prophylaxis/ Lines and Tubes

 GI prophylaxis

 DVT prophylaxis

 Location/ date of invasive lines and tubes

Patient is on IV PPI for ulcer prophylaxis, on enoxaparin BID. PICC RUE, day 10. Foley, day 5.

Helpful hints:

-  Be succinct and synthesize the data. Have all the information available if asked, but don’t report every single bit of data.

-  Some problems can be relevant to multiple systems. For example, ventilator-associated pneumonia is related to the pulmonary system but overlaps with infectious disease. You can pick one system to discuss it, but you can also briefly mention it in the other relevant system. For example: Pulmonary- patient remains intubated, on antibiotics day x of x for VAP, CXR worsening/ stable, secretions improving. Then, later: ID- patient is on antibiotics day x of x for UTI, and day x of x for VAP.

-  If the patient’s BMP is normal, you can state that instead of reading every value. If there is one lab value that is abnormal but the remainder is normal, you can say “normal except for [elevated potassium of 5.5]”

-  Be thoughtful about ordering labs and imaging. Daily CXR purely because a patient is intubated for a bad TBI is not necessarily helpful. Even if the patient is being treated for pneumonia, daily CXR is unlikely to change your management unless there is a clinical change. CXR is appropriate if there are specific interventions that were performed or if the patient has a clinical deterioration- for example, following placement of chest tube for pleural effusion, following 24 hours of aggressive diuresis, for evaluation of acute dyspnea/ hypoxia.

-  Don’t repeat information presented by other team members- if the nurse has already provided infusion rates or RT has already provided ventilator settings, just move through the next part of the presentation.