Report from OR: What do you want to know?

[BridgetJones]

Hi guys,

I work as a circulating nurse in the operating room and we have to call report up to SICU when we send patients directly up there intubated. I have a hard time knowing what pertinent information to give, because a.) I don't get report myself and I only have a minute or two to look at the patient's chart before anesthesia takes them back to the room, and b.) Anesthesia gives report when they get up there anyway.

But in the interest of good patient care, I try to give the floor nurses as good of a picture of the patient as possible so they can plan their care. I usually give: admitting diagnosis, surgeon/procedure, how they tolerated the surgery in general, and the lines and dressings. My question is, what baseline assessment data do you find helpful? I mean, if I say, "he was pretty puffy" are you going to laugh at me and say, "well duh, he's septic from toxic megacolon!" Sometimes I look at nursing notes so I can at least say, "X has been pretty stable" or "they've been keeping his pressure up with norepi and fluid boluses." Anyway, I was just wondering what you guys found to be most helpful, since I'm not even an ICU nurse and I only call report up there once in a while.

Oh yeah, one time when I was giving report I told the nurse that the patient had a triple-lumen central line and she said, "Do you know if that has a Cordis too?" I said that I know they've been doing CVP monitoring, but as far as I know Cordis is the name of a company. Is that shorthand for something up in ICU?

[sunnycalifRN]

"Do you know if that has a Cordis too?" I said that I know they've been doing CVP monitoring, but as far as I know Cordis is the name of a company. Is that shorthand for something up in ICU?

in ICU, cordis is just the term used for the large bore insertion sheath, through which a PA cath, or single, double or triple lumen cath may be inserted. you're right, it's a brand name but it's used generically, like Kleenex is for tissue

your report is fine except that I'd add the drips that the patient is on

[meandragonbrett]

I think mostly what we want to know are....

1) Name, dx, surgical procedure

2) Did they tolerate well

3) What drains are they going to have (so that we can be ready in the room when you arrive) Do they have chest tubes, NGT, is their belly going to be open and hooked to wall sxn?

I will get everything else I need to know from the CRNA.

[fiveofpeep]

estimated blood loss please :)

[meandragonbrett]

estimated blood loss please :)

Is that not generally something anesthesia tells you at your facility?

[grandmawrinkle]

We don't take report from the circulator where I come from, we get it from anesthesia directly (typically the CRNA that was there the whole case). To have the circulator call report as well seems redundant, especially when they aren't going to have nearly the amount of information that anesthesia is going to about what went on during the case. Sometimes the circulator will call and give us an ETA, but that's it.

Report from the OR I want:

surgery done, patient hx

VS, any abnormals

EBL and I&0, including what was given (blood, etc)

any drips infusing

last labs done in the OR (ABG, lytes, H/H, blood glucose)

abx given and times

last pain medication/dose, last anesthesia/sedative and whether it was reversed

if they know the plan of care (to extubate or not, etc.)

Any other stuff you can pretty much figure out from your own assessment when they get there.

[BridgetJones]

Yeah, I think it's a little redundant as well, but hey, I just work there. Thanks for the suggestions, they helped a lot!

[Hoozdo, ADN]

Another piece of valuable info is who is the MPOA and is the family

present waiting. Kindly point the direction of the waiting room if family

is present if you roll them up to the ICU.

Too much confusion hooking up pt and getting report from CRNA. We will

get the family when we are ready.

Thanks for asking. :redpinkhe

[fiveofpeep]

Is that not generally something anesthesia tells you at your facility?

at the hospital I did PACU in we got EBL all the time

at this hospital in SI we dont ever get EBL in report

[apocatastasis]

I like it simple. History of present illness, other pertinent history if you know it, procedure, any complications, drains, drips. If you don't have everything, no worries, MOST important is present illness, procedure, and complications, and anything else absolutely and/or immediately important to know.

Everything you tell me in report I'm going to see in my assessment and double check in the H+P, anesthesia notes, and perioperative notes anyway. Don't need you stressing yourself out about what to tell me or a long, drawn-out report about the shade of the patient's toenail polish, just tell me the most important things. :)

[TigerGalLE, BSN, RN]

Of course I want to know the patient's history and what surgical procedure has been done ect. But if you don't know much about the history at least tell me what they had done, what lines they have, where their a-line is, drains, and the I and Os during OR stay. Knowing what lines/drains they have helps me set up the room appropriately. Also I like to know their current vitals and HR/rhythm.

Thanks for asking