Efficient shift report

HakunaMatata10 · Jan 18, 2018

In my opinion, less is more with patients who have been on the unit for weeks because its all about the big picture at that point. The key is passing on the correct information, not the most or any and all of the information. I highlight the significant events, +findings, and the events with potential for reoccurrence. Random example:

2/1 Pt was admitted after being found down in ECF, intubated in the ED. Cxray showed bilateral pna, lactic was 6.9, and 2/2 BCs collected in ED came back + later on 2/1 for Streptococcus pneumoniae. **Was the pt hypotensive after intubation.. probably. If they never had that issue again and never saw a pressor, who cares if they got 1 liter of NS 10 days ago. However. If you're going to include those details then know how much and of what. Likewise, I leave out irrelevant negatives from the original w/u.

On 2/2 started on Vanc and Merrem.

2/3: Pt with increased Fio2 and PEEP requirements, was bronched at bedside by Dr. ____. Those results came back on 2/4 +for Streph Pna and H1N1.

2/4-2/7: Repeat Cxrays improved but still Having difficulty weaning vent d/t COPD age of 105

2/9: discussed TW vs trach/ PEG with family, they opted for aggressive care

2/10: Trached by Dr. ___, no complications.

2/11: PEG done at beside, no complications.

...On and on.

Regarding your colleagues: How are you phrasing the repeated issues? If you are simply just saying "the patient has been hypotensive and anemic on and off and recieved blood and several boluses," I can see why they would want more info. Be specific. When did it first occur, what was the underlying cause, what was the intervention, and did it resolve.

If someone expects you to know the time a patient left/came back 2 weeks ago give them a confident "I have no idea." If they want that info let them find it.

chare · Jan 18, 2018

I agree with HakunaMatata. Regarding a patient that has been on the unit more than a few days, I give a brief overview of reason for admission, along with significant and/or ongoing events along the way. As for detailed report, I cover my shift, as well as significant events reported to me when I began my shift. If they feel the need to know details of fluid resuscitation and blood products received weeks ago, they can look it up themselves.

And, unless you are on the clock when you do so, stop coming in an hour early and reviewing your patient's record.

Leader25, ASN, BSN, RN · Jan 19, 2018

I think you are being bullied by more experienced co-workers,seen them known them, they will ask about the most irrelevant trivial nonsense ,if it is important say you do not know but will find out.

Cowboyardee · Jan 19, 2018

I don't know how the doctors at your facility do notes, but at most facilities the most current note by the intensivist or attending physician give an overview of the hospitalization, a list of the current issues, and a general plan of care. I typically start with reading this most recent note and then look up other notes as necessary to fill in any gaps that might be important.

Here's the other thing about ICU nurses: just because a more experienced coworker asks for some bit of information doesn't necessarily mean that bit of info is particularly relevant to the patient's care moving forward. Some nurses ask for bits of info because it's important; some ask just to test you out or lord it up over you (nursing, like most professions, takes all kinds); and a lot of RNs including some experienced ones ask for information based on a misunderstanding or simply to fill out some blank on their prefab report sheet. But as a newer nurse, it can be hard for you to tell which is which. So ask them, as humbly as you can, to explain why that piece of info is important moving forward. Don't insult them - you're picking their brains, not second-guessing them. But it's a great way to learn. And you'll soon come to realize how your coworkers think and which questions you can safely punt back at them to research themselves vs which details are important parts of patient care that you just don't know yet.

ruby_jane, BSN, RN · Jan 19, 2018

Currently I come in to work an hour early and start looking up my two patients. I start by reading the oldest note...I have to scroll down most of the time...And I try to read EVERY note.

That was me in the ICU seven years ago. I was miserable. I appreciate that you're asking how to make yourself more efficient. I developed a head-to-toe brain sheet and used that to be brief. If you're giving report to a particular nurse who always has questions, add those values to the report. If the nurse changes the questions up the yes, previous posters may be correct and you're being "tested," for whatever that's worth.

And also, as a PP said...don't work for free. Try to work down to 15 minutes prior to shift.

osceteacher · Jan 19, 2018

I think you are being bullied by more experienced co-workers,seen them known them, they will ask about the most irrelevant trivial nonsense ,if it is important say you do not know but will find out.

This.

I work on ICU and if a certain nurse is on I'll zone out as I'm told about their bowel pattern for the last 3 months.

We use

Airway, Breathing, Circulation, Disability, Exposure, Fluid, Gastro and follow a rigid structure with the last socially bits at the end.

Forest2 · Jan 19, 2018

Hey, if it is not pertinent and they ask about something from 2 weeks ago that is not pertinent to the story of today then say so. Use an SBAR type or report. This should be in policy what is reported, etc.

Burnvegas · Jan 29, 2018

We have some nurses like that too, who want to know every minute detail down to the total number of poops this eight week admission, and what drugs they had in theatre 4 weeks ago... Some are genuinely interested in such matters, others are just being awkward or testing me (less so as I'm more senior than most of them). My standard response is usually "why do you want to know?" And if they give me a good reason I'll look it up. If they say "just wondering" as they usually do, I tell them to look it up themselves if they're that interested, but I have a home to go to.

Handover should be concise, not the entire journey start to finish, just what's relevant. If you go into too much detail, people stop listening and will then claim you didn't hand something over, or ask you a question at the end you already covered in your longass handover

Giving a good concise and safe handover comes with experience. Use a brain or abcde. I usually just state the history (often from the review done by the intensivist that day) and then "from the top down..." And summarise abcde assessment, family and go through the medication orders - with an "any questions?" at the end.

Also, you should really stop coming into work an hour early. It doesn't matter if you think it's safer, or you don't mind wasting your item time doing it... It will give a certain impression and it might not be a positive one. It's pretty much always unnecessary to go through every note to provide safe effective care.

**canoehead, BSN, RN** · Jan 30, 2018

I'm one of those nurses that asks a lot of questions. (I'm in the ER)I know perfectly well that the offgoing nurse might not know the answers, but if they do, it saves me from looking it up, or asking family again. So if the patient has homecare, if they live alone, how long ago their last heart attack was- all stuff I might be able to use to get them home again, or troubleshoot their current illness. I tell newbies straight up that its OK if they don't know,

CCU BSN RN · Feb 1, 2018

On our unit, we have a couple of standard forms that help me a lot, even though some of my co-workers are less crazy about them.

We have a small paper bedside chart for face sheets, EKGs, consents, and things of that ilk. When a patient is admitted, we fill out the 1 page sheet that is essentially a nurse's paraphrasing of an H&P: A brief synopsis of chief complaint/present illness, PMH, allergies, code status, dates of any procedures, where any wounds are located, if they have a Cordis/Swan/Arterial Line/CTs/IABP and where those are located and when they were placed, along with contact info for their HCP or any important general considerations i.e. doesn't speak English, is violent, is having any behavioral issues on the unit. This paper stays in the bedside chart, and it helps our type A nurses feel less like they need to come in every shift and copy down the exact same info day after day. If you discover more info, you just add it.

If the patient has been with us in CCU for more than 3-4 days, or comes back to us after after a longer hospitalization, I flip that paper over to the blank side, and I add/start either a 'hospital course' section, or a list of postop complications they experienced. For example:

Hospital Course

1/1 admit c/o CP, STEMI, cath lab, 3 vessel disease

1/2-1/4 Surg consult and pre-op testing and optimization

1/5 CABGx4, MVR, and MAZE, extubated w/in 6h window

1/6-1/9 Remained in CCU weaning inotropic support, req

NIPPV and lasix gtt. CTs and wires out, swan out

1/10 Stable, de-lined and transferred to telemetry

1/10-1/13 Doing telemetry stuff, ambulating, weaning O2,

pain control, ongoing diuresis

1/14 RAF with hypotension, transferred back to CCU for

amiodarone, inotrope, and new central line placement

Or List of Complications example:

Pt is POD 18 from CABGx4. He had an unfortunate slew of postoperative complications including and hopefully limited to:

1. A Fib- AC with Heparin bridge to coumadin

2. Sepsis secondary to aspiration pneumonia, ID consult, pan-cultured, ABX, volume, levo

3. Pleural effusions- B/L pigtails placed in IR- remain in

4. HIITS- heparin switched to Argatroban, heme c/s

The way I choose between course of events and list of complications is: course of events when they're having 1 or 2 problems at a time, so a linear timeline suffices. List of complications when they're having current/ongoing problems with virtually every body system, there are 24 different MD specialty consults, and all of these doctors come around every day to tweak their specific problem.

and then I go on to give my head to toe

Hope that helped at least a bit