One of the most interesting things I came to learn when I was orientating in the ICU was the system of report. Now in the ED it was a little different.. “Are they breathing? Got a pulse? Great I’ll figure everything else out!” Okay that might be an over simplification of ED shift report, but in general it’s pretty quick and then you’re moving on. We would manage to get all of the info, but it was condensed.
The ICU is a different animal and you generally have that patient for a few more hours or days than the ED, there’s more consults involved and the subtle changes can be a big deal.
When I first went to the ICU I would give report off the top of my head, which generally went history, reason for visit, head to toe assessment, interventions and plan of care. Now it might have been my own communication impairment or possibly some sort of new ICU nurse hazing, but some nurses would stop me mid word and request information that I was getting to or in some cases already gave. That was a little annoying.
I came up with a plan to remedy that, and it worked out well. Behold the shift report sheet. Now you can come up with whatever works for you, but for me this little gem made life so much easier, especially for those patients you have for weeks to months. I generally write in pencil so I can update it each shift. It’s great for making a quick reference. I also found it helpful because I can put it between myself and the oncoming nurse so there is a flow, and yes, all the info is there.
When I am transferring a patient out, I make a copy for the nurse who is getting the patient, this way they have a quick reference as opposed to sorting though a 10 page printed out summery. icu-shiftreport-
It happens in the ICU and in the ED. The upset, angry, agitated, confused patient who manages to pull on every tube and line in an effort to gain freedom or control over their situation. It’s a terrible thing to witness. An elderly patient fighting so hard to free themselves from our hard work and interventions.
While restraints are one way to combat part of the physical issues it also complicates care and can essentially cause the patient more trauma, increased confusion and increased chances of developing PTSD.
Treating these patients, especially the geriatric population, is a bit like baking a cake, you need the right recipe.
A elderly woman in her 90’s was admitted to a tele floor for chest pain, ARF and UTI. While on the floor she had a witnessed cardiac arrest. ROSC was achieved within 15 minutes after 1 epi and CPR . The patient became alert before transfer to the ICU. She was agitated to say the least. She following some commands. She attempted to pull out her ETT several times, even when family attempted to redirect her. The patient turned out to be ureoseptic was put on a pressor, pain meds were given, but the agitation didn’t improve. Prior to admission to the hospital the patient had told her family she did not want to be on life support, but the patient’s medical proxy at the time of the incident could not make that decision. The patient was not on a sedation drip because the plan was to extubate in the morning. Push doses of fentanyl were given with little decrease in agitation.
As the night went on the daughter in law of the patient continued to try to calm the patient. She reviled that the patient was very hard of hearing and didn’t have her hearing aids in. The patient was able to write. She wrote clearly that she wanted the tube out of her mouth, “I want this out now”.
The patient was more calm when her care was explained to her via writing. She still required push doses of fentanyl for the rib pain she had as a result of the chest compressions as well as the pain from the ETT itself. She also received push doses of versed which reduced her anxiety and allowed her to rest.
What’s Causing the Behavior? PAD Check
Assess the patient, identify the cause of the behavior is essential. Look for simple fixes and causes, such as not having hearing aids in or not understanding the language spoken, and let us not forget about the intubated patient who is alert and did not want to be intubated because it was against this health care wishes!
Pain– Is the patient having pain? Are they intubated and sedated- what sedative is being utilized? Do they have adequate analgesia?
Agitation– How agitated are they? What’s their RASS score? What illness/injury are you treating? Was a medication started or removed around the time the agitation began? What is the environment like- noise and lighting levels?
Delirium– Assess level of delirium CAM-ICU score. Are they able to sleep, do they have hearing aids in or their glasses? Reorientate- Reorientate- Reorientate! Assess for early mobility. Are there family or loved ones visiting?– Educate them.
When I moved from the ED to ICU a coworker smirked devilishly and asked me how it felt to be a gardner. I’m sure my expression was inquisitive. His explanation of ICU nursing was that is correlated to gardening: water the plants to keep them alive until the season ended and they died. Perhaps some folks would think this is a cruel analogy, but it certainly has a true sentiment.
A significant population of the medical ICU are essentially residential patients of the ICU. They require so many interventions for cellular life, yet may never actually leave the intensive care unit. Caring for these patients requires the providers of their care to take a look inside their own definition of what life is and truly take stock of the bias that they may hold on the subject.
What life is to each of us is certainly diverse. For me, I have already made it known to my family and colleagues that if I cannot enjoy a margarita, the ability to taste the salt on the rim of that chilled glass, then please let met alone, and let me go in peace. My family and friends know my stance on my life, and luckily they have accepted my position, just as I have accepted my mother’s which clearly is that if I every put her on life support, when she finally passes she will absolutely haunt me for the rest of my natural life.
In the past week I’ve had some interesting patient-nurse discussion and patient family-nurse discussions. In one of those conversations an ESRD, vented, liver CA, tube feed dependent, bed bound patient with multiple massive bed ulcers asked for hospice care. As a result the patient’s spouse asked for a psych consult. This patient knows that they will never walk again and that their body is failing. This patient has serious pain and prior to residing in the ICU for the past 3 months they were living in a nursing home, bed bound. This person had come to the decision that they wanted hospice care, yet they are being denied because of intermittent confusion related to intermittent elevated ammonia levels from liver cancer. The patient is a full code.
Another patient I’ve had has been intubated two weeks and cannot be weened form 100% FIO2. Proning didn’t help, and the addition of nitric oxide has only maintained a POX in the 80s. The patient had refused intubation for days, but eventually agreed when the high flow O2 they were on was no longer working. The patients body is failing. The patient is a full code. The family of the patient is loving, they adore the patient. They are hopeful for a recovery and they are strong on faith. When I’ve updated them on what has improved, stayed the same or what has worsened, I found that they weren’t getting the full picture. They expressed their confusion and frustration with not being informed on the patient’s current condition. How could they be confused if they are being updated daily?
They were confused because they were only receiving partial information.
The chest tube that was inserted after a biopsy was thought by them to be tool to thin the patients blood of clots from the patient’s lungs. They understood the ventilator kept her breathing, but didn’t understand that her inability to ween from 100% was serious and was not improving her health. The cardiac monitor numbers were not understood and the tachycardia was thought to be the pulse ox. The treatment for DVT and suspected PE was not well understood, nor was the fact that the patient was too unstable to take to CT. The constipation was thought to be an easy fix with a laxative, but not understood that the persistent hypoxia and hypotension was a bigger issue.
When families hear from residents, nurses, attending, consulting providers and have that information in little blurbs verses a conversation laying out the path and plan of care as well as the progression of the illness it becomes confusing.
Every family is different. Some might have a background that allows them to grasp the severity of what is actually going on, while others may not.
Perhaps we need to start assessing the family members and those charged with the decisions to see if they are truly understanding the whole picture. After we assess their reality and their needs we need to treat them just as we do with our patients and give them the information that we share with our medical staff. We need to explain to them what the current condition is. We need to explain and possibly re-expalin the risk and benefits of interventions. We need to update them on what has improved, worsened or stayed stable on a daily basis. If the patient is developing bedsores it is easy for the family who may not actually see the wounds to blame it on lack of care, but they may not understand that it also has to do with poor tissue perfusion or disease process.
Perhaps we should encourage more transparency in our care, even if we don’t know what is going on with the patient at the time.
One thing we should absolutely be doing is having family meetings with the provider team, social work and nursing early on. Yes, everyone is busy. Yes it is hard to coordinate a team to sit down and talk with a family, but it’s needed. One of the most repeated phrases I’ve heard from loved ones in the ICU is that they “didn’t know how bad it was”.
The patients we care for are often older and very sick, they are at the end of their season and wilting. Their loved ones are not ready to let go of the beautiful person they love. When the patient is intubated without a voice to say they are in pain, and they are sedated and appear sleeping they are essentially in a suspended state of affairs. They are also powerless. Sedated and sleeping does not mean free from suffering or improving in health.
While it is our job to heal and fix people to restore their health, often times we do not. It does not mean we are failing. We cannot stop the inevitable, death. We can only slow it.
If only I could count the number of times I got the stank eye when I brought a patient on a presser or two going through and IV up to the ICU from the ED. I get it. Central lines are way better for these types of meds, but I’m the nurse, not the Doc— Don’t shoot the messenger!
There’s been a lot of updates and publications on sepsis in the past year. With the roll out of CMS sepsis core measures starting in 2016 the clock is ticking on getting informed on not only what is expected for reimbursement but also to have a better working knowledge on what sepsis is and the the complexity of the disease. Bedside nurses and pre-hospital care providers are vital in the care of these patients. Being able to identify sepsis is the first step to treatment, but there is also lengthy close monitoring because these folks can change on a dime– one minute they are stable, the next minute they are circling the drain.
While it is important to get interventions done quickly for more than just the reimbursement reasons, it is imperative that bedside and pre-hospital field providers recognize when interventions are and aren’t working and be able to suggest/ advocate care and interventions in the best interest of the patient.
I’ve compiled a list of a few links that provide excellent resources, research and education regarding sepsis management from other FOAM/FOAN sites. As you are aware sepsis is an evolving species, so keeping up to date is a process.
Emcrit is an outstanding source for EM education. Scott Weingart has an amazing podcast and blog. Podcasts are put out on a regular basis. He’s the man who coined the phrase Upstairs Care Down Stairs. Check it out.
Life in the Fast Line– wow this is awesome! If you want to keep up on lit and you aren’t one for reading journals, this is for you. So what Chris Nixon does is fabulous. He and his crew sift though published papers and review them. The papers are relevant to practice today. The ECG (EKG for us Americans) Library is another great resource! Studying for boards check out the EXAMS tab!
The SGEM (skeptics guide to emergency medicine)- talk about turing EM on its head. The podcast and blog are great for that, and they have some interesting musical intros. So if you are looking for current practice, this is the place to come. Be advised some of the content may be beyond the archaic thinking of the dinosaurs you are working with.
Ever wonder how DKA should be treated? This is a good place to figure it out. The contributors to this blog do an outstanding job of bringing you up to date. They also host the REBEL Cast which is an excellent listen on your ride into work!
Brian Ericson has one of the most informative blogs and podcasts out there that is geared to nurses specifically! It’s like nursing information derived from the heavens. Yes finally! His content is strong of EBP and it’s relevant to the ED nurse. This isn’t the stuff you find on healthstream!
M&M has traditionally been a physician attended conference. It is an excellent way to review cases in a non punitive manner. The concept is to look at the events that transpired during a patients stay in order to improve care. Let’s face it we learn from all experiences, the good and the not so good. For whatever reason M&M hasn’t been something that has been open to the nursing ranks, and if you think about it that seems like a missed opportunity. Nurses are at the bedside delivering the care that is ordered. In the event that something occurred and the patient had a less than desirable outcome, this would be a great place to learn and ultimately improve our own practice.
As and ED nurse I can definitely recall getting a really sick patient working with our team to stabilize them and off to ICU they would go. We rarely would hear back about how the patient made out. If you’ve worked in a busy ED you know that there is very little time for follow up, but if we did have the time, imagine what we could learn.
Not long ago a patient came in with respiratory distress related to CHF. The patient had a long standing history of heart failure and an EF of about 20%. Hewas put on bipap and a nitro drip. His BP tanked while on the drip and he was given a fluid bolus. He eventually stabilized and was moved to a step-down room. A few weeks later his relative was in the ED and I found out he had died within a few days of his arrival.
Our facility has a policy for vasoactive drips, q 5 minute vitals until the patient is titrated. Unfortunately for whatever reason this patient wasn’t
monitored according to policy and the fluid bolus was given to correct the hypotension.
His death frustrated me. I did what I thought should be done. I spoke with the educator and an assistant director and suggested that the nurse who was caring for the patient review the policy. I’m not sure if that was ever done. I had suggested that the entire staff be reminded of the policy, because this was possibly something that could have been prevented.
M&M could be very helpful in nursing education. Perhaps this situation could have become something that changed a practice because it would essential provide a 360 view of this patient’s experience as well as a platform for improvements in a department.
As nursing professionals we can only improve if we know where we need to improve. Moving someone out of an ED or ICU isn’t the end of their care journey.
Just in time for the holidays a new crowd favorite, sepsis incentive payments. That’s right, brought to you by the folks at the Centers for Medicare & Medicaid Services (CMS). So here’s the list, be sure to check it twice, because not recognizing sepsis and meeting the bundles set by CMS can certainly lead to a poor patient outcome as well as an unpaid bill and lost revenue for your department and facility.
Sepsis identification can be a bit of a minefield, the symptoms could be sepsis and then again it might not be sepsis. This very discussion is something that I know all to well. As one of two nurses who helped develop a SIRS and Code Sepsis protocol in my shop, this was something that the physicians and nurses agonized over, but this is the criteria that CMS is utilizing, and yes this will make flu season interesting.
So here is the SIRS criteria— if you have two or more of the following with a known or suspected infection call Sepsis!
Temperature greater than 101.0 F or less than 96.8 F
Respiratory Rate greater than 20
Tachycardia, rate greater than 90
WBC count above 12,000 or less than 4,000 (this one is kind of hard unless they come in with labs and present them to you in triage) *If your patient from triage is on Neupogen there’s probably a reason why.. “Do you known what your last WBC count was?”
Additional signs include:
Altered mental status
Elevated lactate, greater than 2.0, at 4.0 you might be dealing with a the beast!
Hypotension SBP below 90
Hyperglycemia without history of diabetes
The sepsis time clock begins clicking the moment the patient is triaged for CMS reimbursement, but the patient’s sepsis timer started counting long before they came through your door.
The Bundles (tied to your reimbursement) TO BE COMPLETED WITHIN 3 HOURS:
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 ml/kg crystalloid for hypotension or lactate ≥4mmol/L
“Time of presentation” is defined as the time of triage in the emergency department or, if presenting from another care venue, from the earliest chart annotation consistent with all elements of severe sepsis or septic shock ascertained through chart review.
TO BE COMPLETED WITHIN 6 HOURS:
5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) ≥65 mm Hg
6) In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion and document findings according to Table 1.
7. Re-measure lactate if initial lactate elevated.
DOCUMENT REASSESSMENT OF VOLUME STATUS AND TISSUE PERFUSION WITH:
• Repeat focused exam (after initial fluid resuscitation) including vital signs, cardiopulmonary, capillary refill, pulse, and skin findings.
OR TWO OF THE FOLLOWING:
• Measure CVP
• Measure ScvO2
• Bedside cardiovascular ultrasound
• Dynamic assessment of fluid responsiveness with passive leg raise or fluid challenge
Of note, the 6-hour bundle has been updated; the 3-hour SSC bundle is not affected.
We are still woking out the kinks in our sepsis response. We have a cancer institute attached to our facility as well as a sea of nursing homes and assisted living facilities. Often enough the folks that roll through our doors are coming to us in less than ideal health and likely well into the sepsis spiral. This isn’t the time to play hot potato patient and park them out of the way because nobody wants the work! Sepsis is work. Sepsis work ups are a lot of work, especially if you are doing it by yourself. You need a team willing to work together to get-it-done! Every minute that goes by is a minute you never get back. Small delays add up at the patient’s expense both literally and figuratively speaking.
If you have a bias about a million dollar workup on a 90-year old aspiration pneumonia urosepsis repeat offender, then you have two choices: 1) leave the profession or 2) check your ego and bias at the ambulance bay and get to work, because it doesn’t matter what you think is a ridiculous treatment, this is someone’s loved one and if they are in your ED they deserve to be cared for according to their wishes and best practice.
While the majority of septic patients will be part of the elderly population you have to keep an eye out for the younger SIRS crowd. The potential for these folks to go bad is absolutely a good possibility especially if there are preexisting illnesses. Your walking SIRS patients deserve a good triage, and not the 2 minute get them in and out of your chair, because you think it’s a treat em’ and street em’ flu. Spend that extra minute to ask a few deeper questions and take a better look. That extra minute might mean the difference as to where you put them in your ED and how much monitoring they get before they crash.
A 34 year old female with a history of HIV comes in complaining of 3 days of fever and a non productive cough. Vitals on triage are T 103, P 115, BP 100/62, RR 20 and POX on room air is 97% She is compliant with her HIV meds and AOX3. She meets SIRS criteria because of her temperature and heart rate, we have a suspected infection. She’s not meeting septic criteria because she isn’t hypotensive, doesn’t show altered mental status or low pulse ox. She gets a set of labs, a chest X-ray that shows a right lower lobe pneumonia. She gets IV hydration 2 liters of NS. Unfortunately she’s not being closely monitored. Two hours later, it’s shift change and time for repeat vitals: BP 74/43, HR 110, POX 95%, T 99.1, RR 20. An additional 1 L NS bolus is given and a repeat lactate is drawn, the first lactate was 1.6, blood cultures are drawn. The patient’s vitals are checked every 15 minutes per policy. The SBP after bolus is 98, but doesn’t hold. The patient is moved to the more critical part of the ED and is admitted to ICU. The nurse that had originally received the patient had 7 additional patients before change of shift vitals were completed. The triage nurse didn’t call the sepsis alert because she didn’t feel that there was a site of infection, the patient wasn’t coughing at the time.
There are a few issues in this case that warranted sepsis re-education. One of the biggest obstacles though wasn’t clinical, it was peoples preconceived ideas of sick and not sick. There was a sense of false security that sepsis is a disease process of older people. News flash: Sepsis does not discriminate!
A few years ago I came across a podcast. It wasn’t just any podcast, it was EMCrit. The one and only Scott Weingart. For those of you who have never heard of EMCrit or Weingart I would encourage you to leave this site right now by clicking here, but please come back at some point.
During this podcast he talked about bringing upstairs care downstairs and the turf war between upstairs and downstairs. It really is an outstanding concept. In case you need a little clarification the upstairs care refers to the intensive care/ critical care areas, while the downstairs care is the emergency department. Take a listen to his words from episode 100.
That talk totally spoke to me as an ED/ER nurse. I’ve been in that uncomfortable state of limbo, when you know your patient needs interventions, but there isn’t a bed upstairs. Its the worst feeling. Weingart saw an opportunity, he did a fellowship in upstairs care and has evolved his practice. As nurses we really don’t have that opportunity. We can’t just go somewhere to learn some amazing skills set and bring that knowledge back to the ED, but I can only imagine the benefit it would bring to our patients if we did.
My plan for this blog and future podcast is to provide FOAM or FOANed to nurses in the hospital and pre hospital that focuses on emergency medicine and critical care. From my own experience I know that I did’t always get the type of continuing ed that I wanted in the workplace, but thankfully I came across some great podcasts and blogs that really gave me up to date information which I feel helped be become a better nurse.
I became a nurse to help people and learn, I didn’t become a nurse to just mindfully task nurse and check off assigned e learning!