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Ok, here's just a quick thread on MY rounding technique.
First principle: Be flexible and tweak the system until it is efficient for YOU and YOUR setting. This requires proactivity and tinkering at first, but it pays off immensely once good habits are established. https://twitter.com/joydhughes/status/1355564260370374656
First principle: Be flexible and tweak the system until it is efficient for YOU and YOUR setting. This requires proactivity and tinkering at first, but it pays off immensely once good habits are established. https://twitter.com/joydhughes/status/1355564260370374656
First, get your EMR list organized properly. Sort by location, usually in descending order as most rounds are "gravity rounds."
(In some cases you'll round from sickest to most stable, but this ordered list will sequester ICU patients together, so that's helpful).
(In some cases you'll round from sickest to most stable, but this ordered list will sequester ICU patients together, so that's helpful).
Use print-preview to see if you like the layout. Maybe add space for notes, maybe tweak the margins to get it on one page. Once it's perfect, print.
You will gather data by categorical checklist to avoid missing anything:
Vitals
Ins and Outs (drains!)
Labs
-CBC
-Lytes
-Other
-Microbiology (stains, cultures, abx susceptibilities, final vs. __to date)
Path
Radiology/other tests
Meds
Notes
Vitals
Ins and Outs (drains!)
Labs
-CBC
-Lytes
-Other
-Microbiology (stains, cultures, abx susceptibilities, final vs. __to date)
Path
Radiology/other tests
Meds
Notes
Each of these categories is designated a region of your list. If you fold the list, they will be on a blank side. If you write on the front, just have a system where they are quick and obvious for you to glance at.
Make sure your EMR is set up with these categories in this order so you can flip through the tabs, or else see it all on the summary page.
When you open the chart for each patient, make sure you have the context. If it's the first day, you must account extra time for this step. Know their baseline health status, main hospital problem, procedures, complications, disposition.
Make sure a brief description is conspicuous for each patient on your list that will quickly remind you of who they are.
Gather data for each of the above categories and write it down.
Gather data for each of the above categories and write it down.
Vitals:
Shorthand is AFVSS if they are NORMAL.
If patient had tachycardia at 2 a.m., write that down. See if you can figure out why (nursing node regarding pain, etc.) or make a note to ask about it on rounds.
Note oxygen supplementation if relevant.
Include vent settings.
Shorthand is AFVSS if they are NORMAL.
If patient had tachycardia at 2 a.m., write that down. See if you can figure out why (nursing node regarding pain, etc.) or make a note to ask about it on rounds.
Note oxygen supplementation if relevant.
Include vent settings.
Ins and Outs:
What fluids are they on?
Fluid status for hospitalization and for past 24 hours.
UOP (EMRs will usually calculate ml/kg/hr now).
Record drain output for past 2 days (we will often pull based on consecutive day low output).
NG tube output.
Foley or no foley?
What fluids are they on?
Fluid status for hospitalization and for past 24 hours.
UOP (EMRs will usually calculate ml/kg/hr now).
Record drain output for past 2 days (we will often pull based on consecutive day low output).
NG tube output.
Foley or no foley?
Labs:
Big category. Learn the shorthand.
Circle abnormal labs. Write yesterday's value in parenthesis for reference (sometimes WBC of 18 is great news, sometimes bad news).
Check the micro! Know if it's day 2/5 NGTD versus NEGATIVE and FINAL.
Finger stick glucoses, too :)
Big category. Learn the shorthand.
Circle abnormal labs. Write yesterday's value in parenthesis for reference (sometimes WBC of 18 is great news, sometimes bad news).
Check the micro! Know if it's day 2/5 NGTD versus NEGATIVE and FINAL.
Finger stick glucoses, too :)
Path:
Often the reason people are in the hospital/on surgery services. Is there a frozen path report? How long has it been pending? If it's back, has consultant/attending discussed it with patient?
Often the reason people are in the hospital/on surgery services. Is there a frozen path report? How long has it been pending? If it's back, has consultant/attending discussed it with patient?
Radiology
Review all imaging and note abnormalities.
Review all other tests: ECHOs/ultrasounds/EKGs, etc.
Review all imaging and note abnormalities.
Review all other tests: ECHOs/ultrasounds/EKGs, etc.
Meds
Your mind should be thinking of some questions by this point. How much pain meds is the patient requiring? What's the antibiotic regimen and is that consistent with micro reports? Have you resumed anticoagulation? Note pertinent info.
Your mind should be thinking of some questions by this point. How much pain meds is the patient requiring? What's the antibiotic regimen and is that consistent with micro reports? Have you resumed anticoagulation? Note pertinent info.
Notes:
Read all nursing and consulting service notes. Know how they are doing with PT. Be aware of recommendations by other services. It's highly annoying to put through a consult and ignore the note. Don't miss the all important Social Work notes!
Read all nursing and consulting service notes. Know how they are doing with PT. Be aware of recommendations by other services. It's highly annoying to put through a consult and ignore the note. Don't miss the all important Social Work notes!
Ok, you have all the information you need for that patient. This process will get more and more efficient for you, and you should be able to get through each one in about 45 seconds, meaning you get your perfect list of 20 pts DONE in 15 minutes. Yes you can!
Now your list is arranged by geography, and you'll plan on gravity rounds. You may have an east/west wing with patients scattered on floors 6, 5, 4. Know that you'll zig zag from 6E to 6W and drop to 5W, shoot over to the special unit, back to 5E, then keep dropping to 4. Map it!
There are two types of attendings. One type wants to talk in transit and will hardly pause at the door before going in. The other will want to huddle at the door. Have the most important piece of info ready for the first type. Have the comprehensive picture ready for the second.
Go forth and conquer. I know you all can do it.
(And then you actually apply your clinical acumen and "round" on your patients. Happy to answer any questions about that process, but I figure y'all can take it from here).
