The attendings, fellows, residents, PAs/ARNPs, and nurses all have particular expectations of you. Understanding these expectations is the key to a smooth, easy month. Better to know these things before the rotation starts.
Signout etiquette — Be on time; be efficient and to the point.
- Don’t be late for signout.
- Again: Do not be late for signout.
- During signout, you don’t have to give each patient’s backstory every day. Just what the plan is, changes made during the day, what the night/day team needs to follow up on. (New patients should be succinctly presented)
- Be efficient during signout. No long pauses, no looking stuff up on the computer.
- Do not answer the phone while giving or receiving signout. Make someone else in the room answer the phone and take a message.
- Pay attention during rounds. If you are on-call for your team, write down notes on the plan on each patient so you can present it at signout later. “It wasn’t my patient” shouldn’t be said during signout. Every patient on your team is your patient.
First thing after signout, you should see your patient. The thing that differentiates a skilled clinician from an unskilled one is not the ability to read data on the computer but rather to see your patient and know “is your patient sick or not sick”. You want to treat the patient, not the numbers… so the physical exam makes all the difference, and helps you to place the computer information in context.
In the morning, talk to the night nurses before they start signing out to the oncoming nurse or with the morning nurse about what happened overnight. However, do not interrupt their signout. (Interrupting them is a sure way to make nurses mad at you).
Don’t ask the nurses things that you can easily find in the computer (like the patient’s urine output) or ask them to tell you the patient’s drips (when you’re standing right in front of the pumps and could look it up yourself). This will make them even more angry than interrupting their signout.
Do ask them to help you read the pumps if you don’t know how yet. Do ask them if anything interesting happened overnight, and if there are any particular orders they need from us before rounds.
- During rounds, enter orders for each other.
- If you are presenting: you should not be entering orders.
- If you are not presenting: you should be paying attention and entering orders.
One of the challenges in the ICU is managing your list of to-dos. Some people like an information sheet on each patient, others only want a single sheet with all the to-dos in one place. Either works, fas long as it works for you. What likely won’t work is a task list in your head.
Maintaining your patient’s orders list:
Take responsibility for the orders entered on your patients and for cleaning them up each day. Unused and superfluous orders and PRNs should be discontinued.
- drips that are no longer needed (No longer on levophed? Hooray! Delete it!)
- unused electrolyte protocols
- PRNS that are not used or contraindicated, etc
Too many orders leads to people unsure of what is actually going on with patient and what they are actually using/getting. A million unused PRNs is fine for the floor but is not really appropriate for ICU patients unless they actually are using them. These are the sickest patients, and we need to know–and we want to control–exactly what the patient is getting.