Big Picture Ideas for Daily Rounds

  1. The goal is to get back to normal… don’t just say during rounds what we are doing for each problem, think about what else we need to do to make it better. You are a doctor now, and doctors have to come up with plans.
    1. Often a presentation will go like this: “Neuro: patient is sedated on 75mcg/hr of fentanyl and 15 mcg/kg/min of propofol since he is intubated; his RASS is -1 to +1 and his main barrier to extubation is his mental status, he gets agitated whenever we wean off the propofol but he’s too sleepy on the propofol to extubate” … and then the resident doesn’t say any more.
    2. What should follow is something like: “I think we should add precedex to manage the agitation without making him sleepier, and try to wean off the propofol… If we need to go up on the fentanyl, that’s ok. Maybe then we could extubate him tomorrow if he’s improved.” That is a plan.
  2. Change IV meds to PO meds if possible (cost, infection risk, and IV compatibility issues)
  3. Start feeding by mouth or by NG tube as soon as possible (maintains gut integrity to prevent sepsis and chronic inflammation, and helps maintain nutrition)
  4. Do what you can to prevent delirium
  5. Do what you can to facilitate extubation
  6. Maintain normoglycemia (hyperglycemia results in measurably worse outcomes)
  7. Do what you can to diurese patients of all the extra fluids we gave them (once hemodynamically stable)
  8. Minimize the infections we give them –
    1. Extubate ASAP
    2. Remove foley catheter ASAP
    3. Remove central line ASAP
    4. Remove arterial line ASAP
  9. Every day, evaluate why your patient is still in the ICU. Can we transfer them to a stepdown bed? Why not? What do we need to do in order to allow us to transfer them?
  10. Treat your patients as you would your own family.
  11. Seek out support if you are having trouble emotionally with the fact all these patients are very sick and dying. It is not an easy job that we do, but there are ways to make it better.