ICU RN Report- How does your unit do it?

[seamel]

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!!!

[CJMR]

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]

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]

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]

Thx ..