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ICU RN Report- How does your unit do it?

Specializes in ICU.

Hi there! I am a part of my units shared governance committee and have volunteered to try to improve my unit's report process. We have had complaints from a couple providers and family members about information being lost during report.

We usually have 2 patients at a time. My unit is a mix of everything- medical/surgical/coronary/open hearts/neuro/trauma. So there is no hard and fast system that I would imagine would be a bit more obvious with a specialty ICU.

Currently we start with name, age, admit date, allergies, MDs covering, and code status. Then go in to history and then reason for admit. From there, certain nurses seem to veer off however they so choose. I like to state hospital course and plan of care right after admission reason, but sometimes this does not happen. Also, some nurses only state (or only want to know) about the past day or so, but I feel it is most helpful to know the entire course (from admission, on). Anybody agree on this?

Then we go into systems - neuro, respiratory, CV, GI, GU, IV gtts, labs, mobility, skin, psychosocial (family issues, etc).

Then, we are supposed to go through the caredex and meds- but rarely does this occur. It seems our intensivists rarely d/c orders that need to be cleaned up, and don't like us to do this ourselves- so the caredex is a big blur of old and new orders. However, often, important orders are missed because of people skipping this step. Does anybody have any tips as to how to get out intensivists on board with clearing up orders PRN? Anybody had success at their hospitals doing this?

Then we finish report with a 2-RN skin check of both the patients (which can often take at least 10 minutes, itself). After all is said and done, RARELY is report finished in the allotted half hour. Not only are we trying to improve efficiency, but quality of information.

My questions for you-

1. What is your process for report? Does it follow this general guide or is there an easier, more direct way to do it?

2. Does your facility use one standard report sheet? My last hospital did and it seemed to help- everybody has the same template in front of them, so we can be sure not to miss anything. Most the nurses at this hospital just use a blank sheet of paper and write as they go/are told info.

3. Do your MDs routinely clean up the caredex/orders? Is this a nursing responsibility? Is it different for different docs? I would love to make this a nursing responsibility just to make sure it actually gets done, but there has been push back from certain MDs- who, however, still don't do it themselves, so we are left with a mess of orders to sift through.

4. For people who have implemented a new report system, HOW did you manage to educate those nurses that are...(ahem) "set in their ways" and refuse to adopt a new process? I could see developing a great system- and not having it followed, thus, not improving our problem at all (problem being loss of info and lack of efficiency in giving/receiving report.)

Would really appreciate help if anybody has suggestions for any of those questions! Thanks a lot!!!

Larry3373

Specializes in Critical Care; Recovery.

The most straightforward way I would think would be to follow a system that after collaboration with management has become mandatory. This has to be followed up with consequences when the system is not followed. If it does seem important to leadership, then why should those who are set in their ways change anything. I do believe that most of the things you have mentioned are good if followed consistently. I for one would like to know about the course since admission so that I can speak intelligently with the family.

commonsense

Specializes in ICU.

Hi there! I am a part of my units shared governance committee and have volunteered to try to improve my unit's report process. We have had complaints from a couple providers and family members about information being lost during report.

We usually have 2 patients at a time. My unit is a mix of everything- medical/surgical/coronary/open hearts/neuro/trauma. So there is no hard and fast system that I would imagine would be a bit more obvious with a specialty ICU.

Currently we start with name, age, admit date, allergies, MDs covering, and code status. Then go in to history and then reason for admit. From there, certain nurses seem to veer off however they so choose. I like to state hospital course and plan of care right after admission reason, but sometimes this does not happen. Also, some nurses only state (or only want to know) about the past day or so, but I feel it is most helpful to know the entire course (from admission, on). Anybody agree on this?

Then we go into systems - neuro, respiratory, CV, GI, GU, IV gtts, labs, mobility, skin, psychosocial (family issues, etc).

Then, we are supposed to go through the caredex and meds- but rarely does this occur. It seems our intensivists rarely d/c orders that need to be cleaned up, and don't like us to do this ourselves- so the caredex is a big blur of old and new orders. However, often, important orders are missed because of people skipping this step. Does anybody have any tips as to how to get out intensivists on board with clearing up orders PRN? Anybody had success at their hospitals doing this?

Then we finish report with a 2-RN skin check of both the patients (which can often take at least 10 minutes, itself). After all is said and done, RARELY is report finished in the allotted half hour. Not only are we trying to improve efficiency, but quality of information.

My questions for you-

1. What is your process for report? Does it follow this general guide or is there an easier, more direct way to do it?

2. Does your facility use one standard report sheet? My last hospital did and it seemed to help- everybody has the same template in front of them, so we can be sure not to miss anything. Most the nurses at this hospital just use a blank sheet of paper and write as they go/are told info.

3. Do your MDs routinely clean up the caredex/orders? Is this a nursing responsibility? Is it different for different docs? I would love to make this a nursing responsibility just to make sure it actually gets done, but there has been push back from certain MDs- who, however, still don't do it themselves, so we are left with a mess of orders to sift through.

4. For people who have implemented a new report system, HOW did you manage to educate those nurses that are...(ahem) "set in their ways" and refuse to adopt a new process? I could see developing a great system- and not having it followed, thus, not improving our problem at all (problem being loss of info and lack of efficiency in giving/receiving report.)

Would really appreciate help if anybody has suggestions for any of those questions! Thanks a lot!!!

I'm fighting the urge to go off on a tangent, due to my extreme dislike of nursing report sheets. However, I realize this is a personal feeling and not up to date with the best practice. I'll start off with the fact that I have never tackled this issue, but as an experienced ICU staff RN I will provide my best advice.

Your facility's system seems efficient, admission/history/MD's/head to toe, very well done. However, I disagree on the report covering the entire course of admission. Let me give you an example,

You stated in your original post that your facility cares for post-op open heart patients, as does my current facility. Let's take into account a patient who is post-op day 2-3. I get three reports:

First Report: Admitted for CABG x4 on 11/17, Dr. Jones, Hx of XXX, NKDA, A&O, SR/ST, 2LNC, Cardiac Diet, Accuchecks ACHS, Right Hand 18G with D51/2NS @ 30 mL/hr, Mediastinal CTx2, to 20 cm suction drainage on my shift 70 mL, Uses Urinal, Up ad lib, dressing on sternum, leg wounds open to air, clean, dry, and intact, Labs are stable, ready for transfer to step-down unit, just waiting on the CT surgeon to put in the orders. End of story.

-Time of report: 1 minute 15 seconds, happiness of oncoming nurse (10/10)(Great Report)

Second Report: Admitted for CABG x4 on 11/17 (Lima to LAD, Lima to Proximal RCA, Internal Mammary to Distal RCA, and saphneous vein to Circumflex), Dr. Jones (CT Surgeon), Dr. Cake (Anesthesiologist), Dr. Brown (ER physician), Dr. Hemme (Out of Hospital PCP), Hx of XXX, NKDA (However, reports itching at the site of his peripheral IV, I talked to his daughter about the itching, she feels like its an allergy to the metoprolol he's been taking for 27 years, I put the allergy in the chart), He was extubated on 11/18 @ 0600, Swan/Cordis was pulled at 0612, A-Line was pulled at 0617, pressure was held for 5 minutes on each site, no excess bleeding was present, He is A&O but sometimes he forgets exactly what day it is (it's Tuesday and he thinks its something like Tuesday/Wednesday, otherwise intact neuro-wise). He is on 2LNC but earlier today he felt like he was short of breath, I put him on 3LNC and he felt better, I left him on 3LNC for approximately 18 minutes and then took him back to 2LNC, he's doing alright now. He's on a Cardiac Diet but he keeps eating whole eggs, he latest research shows that only egg whites are ok for cardiac patient, but the cafeteria keeps bringing him the whole egg, I don't know what's wrong with them. His accuchecks are ACHS but the daughter is concerned that his CBG is running > 120, so I held the dinner meal, according to the latest research hyperglycemia a major drawback in the recovery of post open-heart patients so I've been trying to keep the glucose level between 116-118. He has a right hand 18G that is slightly sluggish, does not draw blood, but flushes ok, with D51/2NS @ 30 mL/hr, Mediastinal CTx2 with a JP that are working great at 20cm of suction, drainage on my shift 70 mL, Atrium was last changed on 11/17, Uses Urinal, urine is slightly clear, I'm not sure what the specific gravity is but I think it's low., Up ad lib, uses the walker, daughter wants him to ambulate q2hrs per the latest research, dressing on sternum, dressing has approximately 13 mL of serosanguinous drainage on the dressing, right leg wounds open to air, proximal wound on the right leg is approximately 3 cm, wound on the distal right leg is approximately 6 cm, both are clean, dry, and intact, Labs are stable, but WBC count is up to 12 and HGB is down to 9, no orders for transfusion yet, they say he is ready for transfer to step-down unit, but he's still pretty sick (Day-Shift Nurse's Opinion).

-Time of report: 14 minute 35 seconds, happiness of oncoming nurse (4/10)(Too-Detailed Report)

Third Report: Admitted for CABG a couple days ago, Dr. Jones I think, now sure if he has anybody else on the case, OMG, daughter is crazy, she wants us to ambulate him q2hrs, can you believe that, we don't even have any PCA's, I'm telling you this place is really going to shi*. He has an IV site with fluids going, and Ashley actually expected me to help her move her new admission into the bed, can you believe that woman, she must be crazy. I hate this place, I only have a few more years to go till retirement, I can't wait, my husband is going to take me to Cabo, this place is awful. Oh, so sorry, I'm gossiping, he uses the urinal, by the way his daughter is crazy, I think she has some serious mental issues, I'll won't be back in the morning, oh, by the way his blood pressure decreased a little today, they still had the anesthesia concentrations plugged in the IMED (4mcg/250mL Levophed) in for his drips but I just used our drips (16 mcg/250mL Levophed), it's at 7.5 mcg/min (30 mcg/min in reality), I haven't called the surgeon yet, but he's going through a rough time with his divorce, I'd try to handle it yourself. See you later.

-Time of report: 57 minute 22 seconds, happiness of oncoming nurse (0/10)(Ridiculous)

As you can see, the type of report you get depends upon the nurse that you're getting report from. Now, biases aside, here's what my facility does.

-We use report sheets, I hate them, they are not updated on a regular basis.

-Regardless of report sheets, the quality of your report depends completely upon the previous nurse.

-In regards to the MD's cleaning up orders, I think it depends upon the orders. For example, I will discontinue an order for CO/CI/SVR/SVI/Core Temp q1 hour if the Swan/Cordis/Arterial Line was already pulled, however, I am more nervous discontinuing an actual scheduled medication, I believe this needs to be further clarified.

-I have never implemented a new report system, but I wish you the best of luck.

Edited by commonsense
Clarification

At our hospital we use standardized SBAR forms and make use of the Safety page in our EMR to supplement that all needed items are covered. These forms include a system assessment, plus core measure completion/patient education already covered with patient; POC updates and lines, tubes and drains information (start date, mediport needle change dates, etc). Nurses are responsible for q 12 hour Orders Management (deleting any duplication, discontinuing orders no longer relevant -eg: if extubated, discontinue ventilator orders, etc) Medications, treatments, interventions that are still relavent should also be shared with report change of shift hand offs and if needed assist/remind the MD's to update orders when they round. (Our nurses round with the MD's). With 12 hour orders management we have had success with eliminating errors surrounding orders within our EMR. The SBAR format is the same within the hospital and just edited to meet specific areas so report is given in same order no matter which area patient is coming from (this also means the ED/PACU/diagnostic arenas) Works well for all concerned. We also had nurses make this in clinical practice committee so it made sense coming from the bedside caregivers.

Hi there! I am a part of my units shared governance committee and have volunteered to try to improve my unit's report process. We have had complaints from a couple providers and family members about information being lost during report.

We usually have 2 patients at a time. My unit is a mix of everything- medical/surgical/coronary/open hearts/neuro/trauma. So there is no hard and fast system that I would imagine would be a bit more obvious with a specialty ICU.

Currently we start with name, age, admit date, allergies, MDs covering, and code status. Then go in to history and then reason for admit. From there, certain nurses seem to veer off however they so choose. I like to state hospital course and plan of care right after admission reason, but sometimes this does not happen. Also, some nurses only state (or only want to know) about the past day or so, but I feel it is most helpful to know the entire course (from admission, on). Anybody agree on this?

I agree if the patient has been there a few days to 2 weeks or so. If you have longer term patients, please don't torture me with a play by play of the past 2 months, and don't expect me to know the entire course over 2 months, either.

Then we go into systems - neuro, respiratory, CV, GI, GU, IV gtts, labs, mobility, skin, psychosocial (family issues, etc).

I concur.

Then, we are supposed to go through the caredex and meds- but rarely does this occur. It seems our intensivists rarely d/c orders that need to be cleaned up, and don't like us to do this ourselves- so the caredex is a big blur of old and new orders. However, often, important orders are missed because of people skipping this step. Does anybody have any tips as to how to get out intensivists on board with clearing up orders PRN? Anybody had success at their hospitals doing this?

You're responsible for reviewing orders. Going over every single order is not appropriate for report unless it's a new order and a change in the plan.

Then we finish report with a 2-RN skin check of both the patients (which can often take at least 10 minutes, itself). After all is said and done, RARELY is report finished in the allotted half hour. Not only are we trying to improve efficiency, but quality of information.

Ridiculous. Do your own assessments. You can't finish report in a timely manner like this.

My questions for you-

1. What is your process for report? Does it follow this general guide or is there an easier, more direct way to do it?

Name, admit, allergies, isolation, code status, physician team. PMH, HPI, recent events over the past 24-48 hours/plan for the day, systems. Labs. I/O if pertinent.

2. Does your facility use one standard report sheet? My last hospital did and it seemed to help- everybody has the same template in front of them, so we can be sure not to miss anything. Most the nurses at this hospital just use a blank sheet of paper and write as they go/are told info.

I'm not a fan of standardized report sheets. It's micromanaging and not appropriate in a supposedly professional occupation (although that's another thread).

3. Do your MDs routinely clean up the caredex/orders? Is this a nursing responsibility? Is it different for different docs? I would love to make this a nursing responsibility just to make sure it actually gets done, but there has been push back from certain MDs- who, however, still don't do it themselves, so we are left with a mess of orders to sift through.

Usually the NPs or interns can do this, but it's somewhat on us to point out what needs to be cleaned up.

4. For people who have implemented a new report system, HOW did you manage to educate those nurses that are...(ahem) "set in their ways" and refuse to adopt a new process? I could see developing a great system- and not having it followed, thus, not improving our problem at all (problem being loss of info and lack of efficiency in giving/receiving report.)

I'm not a fan of micromanaged report. It was done at my old hospital and ****** off a lot of veteran nurses unnecessarily.

Would really appreciate help if anybody has suggestions for any of those questions! Thanks a lot!!!

kool-aide, RN

Specializes in Cardiac.

My hospital does bedside report, and while it takes time to get used to, a lot of mistakes are caught during report

We have a small report sheet that we use for the essentials. There are not strict standards, so we all report what we feel is necessary. We rarely have problems with information not getting passed on.

I work in a small CVICU, where we do grand rounds with the night shift and day shift nurses, and surgeons go into each room. This works well for us because we are small, and it allows everyone to be familiar with what's happening on the whole unit.

Giving us more freedom during report helps us make sure nothing is missed, in my opinion. I've worked in a place with very strict guidelines, and it seemed like that caused more things to be left out. If it wasn't on the long, detail-heavy sheet, it might get overlooked, because there were so many other unimportant things we were busy looking up. It also caused people to just copy what the previous shift had written, resulting in many mistakes because people weren't looking at actual orders for information.

I like to include health history, what's happened so far in the hospital stay, tests, plan, abnormal assessment findings, and what the specialists/intensivist/surgeons are arguing about, so we can keep an eye out for MDs trying to sneak around and cancel each other's orders (no nurse drama where I am, but CONSTANT doctor drama). I also explain how the patient had been responding to different drips and PRNs, ambulatory status, and, if I'm on night shift, which meds (if any) the day RN may want to try and get increased/decreased/discontinued before morning med time.

StayLost, BSN, RN

Specializes in CVICU, CCU, Heart Transplant.

First Report: Admitted for CABG x4 on 11/17, Dr. Jones, Hx of XXX, NKDA, A&O, SR/ST, 2LNC, Cardiac Diet, Accuchecks ACHS, Right Hand 18G with D51/2NS @ 30 mL/hr, Mediastinal CTx2, to 20 cm suction drainage on my shift 70 mL, Uses Urinal, Up ad lib, dressing on sternum, leg wounds open to air, clean, dry, and intact, Labs are stable, ready for transfer to step-down unit, just waiting on the CT surgeon to put in the orders. End of story.

-Time of report: 1 minute 15 seconds, happiness of oncoming nurse (10/10)(Great Report)

YES! IMO, this is how an experienced nurse gives report- don't need to know how long the bypass/XClamp time was for a patient going to the floor. If at any time I need to know about the patient's grafts (which has never ever happened) I can look them up in the surgical report. Just give me the major issues over the last 24 hours. Reports that drag-on drive me nuts.

delphine22

Specializes in Quality, Cardiac Stepdown, MICU.

We do report sitting at desks outside the room, which I hate. It is comfortable and seems to give the Chatty Cathys license to sit and gripe about their day, family members, etc. I prefer to do it using the COWs (or BMWs, or whatever you call the big rolling computers) in the room. My unit's practice is to look up lab trends together, which I find so annoying (just tell me if his H&H is trending down, or something). We also turn the pt together (taking up the 0700/1900 hour of our q2h turn team process) and clean if necessary. This part I don't mind but I really want to make our report less about sitting and decompressing (and dumping all your negative energy to the oncoming shift) and more about, let's look at this pt, here's the plan for today.

And for goodness sake, the next time I hear a nurse tell me, "His blood sugar was 254, I covered him with x units of novolog" I'm gonna scream. We have EMRs, I can tell you covered him! Just tell me if there's some strange reason you decided not to.

You absolutely should review the past 12 hours' worth of orders. My last employer that had mostly paper charts, we'd flip through together and sign one line together for the 12h chart check. Now that we are computerized, we should initial the EMR and the nursing queue. Night shift is responsible for the 24h chart check, and for cleaning up old orders.

SBAR is a great tool for calling physicians, I always use it (unconsciously). I find that the head-to-toe approach is more useful in ICU report.

I always used a report sheet on the floor, because it helped me remember what was missing (hey, you didn't tell me what his IV site was!). I haven't found/made one I like yet for the unit, so I use a blank paper, but try to write things in the same spot every time. I don't think you'd get experienced nurses to use a specific sheet, that's like telling students to take notes in a particular way.

We do keep a sort of kardex in a folder by the pt room, it is for long-term info that only needs to be recorded once, like were vaccines addressed? When was the foley inserted? Core measures? There is a spot on the back for a qshift update, mostly just stuff the charge nurse needs for audits, like ventilator day, whether the CHG bath was given, central lines, etc. We do not generally refer to this during report.

I like report to be quick and dirty. Just tell me why they came to the hospital, what is keeping them in ICU, and what the plan is ("get to stepdown tomorrow as soon as..."). Tell me important things can't be charted, like "watch out for the sister" or "he's super sensitive to vaso, don't try going down more than 0.01 at a time". Don't tell me that pedal pulses were weak to palpation. I might not think so, and I can look at your assessment in the chart, and I can do my own.

MDMBSNRN

Specializes in Trauma ICU, Neuro ICU, Surgical ICU, ED.

Our ICU report is given by the charge nurse to all incoming nurses, and I don't really like this. At shift change, the charge nurse takes all the nurses into the break room, and gives full report on every patient. Even though you may only have two to three patients, you are going to hear every detail of every patient. While your report may have only taken 20 minutes, you may be in the break room for 45. I also think that this is confusing, as you get all the details on every patient, and it can become hard to keep everything straight.

Report wise, I just want the important details. What's the diagnosis, who are the doctors on the case, what was the admission date, what are they allergic to, vent/BiPAP/CPAP settings (if applicable), where are the IV sites, what's infusing and current rate, most recent vital signs, any labs or studies scheduled for the AM, any major events of the day, and any supplemental information. If there is an assessment finding of concern (like new breath sound changes, new EKG changes, new and extreme edema, etc) let me know that information too. But I don't need a run down of the whole head to toe assessment if it is unchanged from the past two days. If there are extremely abnormal labs, or you've noticed a trend of concern (such as a steadily or rapidly declining or increasing lab) that's also fine to include. But I do not expect to have all the information handed to me. I thoroughly research the patients I am caring for, and I feel that this is part of my job.

CJMR

Specializes in Surgery.

At my facility we are given an SBAR with all pertinent information and we do bedside report. I update my SBARs every single shift with a narrative that has a very brief but concise history, treatment, and plan. I also clean up orders every single shift. I will give a brief rundown of my assessment but the oncoming nurse will do their own assessment when I leave so we are not doing it together at the bedside. If they forgot to tell me something re: assessment, I will find it during my own assessment. The oncoming nurse should also go straight to the source to review orders rather than getting them in report. If I do these things it takes me very little time to give report. I am out the door on time almost every shift. That being said, somehow there are nurses on my unit who take forever to give report and despite multiple attempts to help them cut the fat, they still can't do it.

I think your facility has a few policies in place that slow report. If you have to wade through outdated, irrelevant orders to find the "real" orders, that is a problem. Both physicians and nurses are mandated to delete outdated orders at my facility to reduce mistakes. Most of the time the nurse does it, but if it is done every single shift, there are typically very few outdated orders getting in the way. And if the SBAR is used effectively and updated every single shift, you know you can rely on it to pass information so the nurses will know to read it before report, thus shortening report significantly.

whofan, ADN, BSN, RN

Specializes in ICU.

We follow a similar handoff with name, age, etc, then dx, hx, then review of systems. We do a mini skin assessment because we turn our patients at shift change because it gives you two hours to have to do it again and at the beginning of shift this is helpful. As for the order clean up, we use epic an can "pend d/c" items and submit them for review to the providers to approve or ignore. We also have a work list that we review at the end of shift to make sure that the previous nurse has done all their duties, such as assessments and lab draws.

Biffbradford

Specializes in ICU.

Best ICU (CVICU) I worked in had a clip board for each room, so each patient had their own report sheet. It was re-writen on NOCs and updated throughout the day. Format and content was determined by a committee of nurses. Report was easy, you went from box to box and it covered everything from history to drips to skin, labs, the works and you didn't have to worry about scribbling it all down over and over. It was already written down for you, and you could add or change as needed. This unit was run as a very tight ship and it worked. Even the docs would refer to the clip board from time to time. While it was a very hard unit to work in due to the sheer high acutity of patients, I do miss that report system.

buspar

Specializes in ICU/CCU.

Thx ..

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