If any patient is unstable upon your arrival in the morning, they take first priority. Assess the patient immediately and inform your senior resident. Pre- rounding can wait.
Gather vital signs, laboratory data, and imaging/ procedure results for each patient. Be aware that daily lab results may not be posted until 8:30 or 9am on the wards.
Interview and examine each patient at the bedside.
Inform your senior resident immediately if you are worried about any of your patients – if they are unstable, in distress, have new/worsening altered mental status or focal neurologic deficits, or otherwise just don’t look good.
Every attending has his/her own style of rounding. Traditional walking rounds tend to be popular, but others may prefer sit-down rounds to discuss details followed by faster fly-by rounds to visit with patients.
Be ready to provide a formal H&P for any new patients that weren’t staffed the previous day. SOAP format usually suffices for other patients.
Have the patient’s vital signs, daily labs, imaging/ procedure results, and current medication list handy.
Present your assessment and plan in a problem- based format for ward patients and systems-based format for ICU patients.
Strive to come up with a differential diagnosis for each problem. Consider the likelihood of each item on the differential and discuss methods to evaluate each (labs, imaging, procedures, etc).
Discuss strategies to treat each problem. Don’t be afraid to speak up and make suggestions – this is where a great amount of learning takes place!
As your team formulates a plan for each patient, write down a To Do list so you won’t forget things later on.
Discuss the plan with your patient and nursing staff. Open lines of communication are the key to excellent care.
If you didn’t order and call your consultants while rounding, do so immediately afterwards.
Complete your To Do list from rounds. This may include writing orders for laboratory tests, imaging, procedures, medication adjustments, and nursing requests.
Take a few minutes each day to re-assess each patient’s orders for the following:
Vitals: Are they stable enough to stop waking them up in the middle of the night for q4 hour vitals?
Medications: Do they have PRN medications for common complaints, ie. Pain, nausea?
Telemetry: Can they be taken off of telemetry?
Diet: Are their dietary restrictions appropriate for their current condition? Can they swallow safely? Do they need a Speech Path or Nutrition consult?
Activity: Can they come off of bedrest? Do they need a PT or OT evaluation?
Tubes/Lines: Can you remove any lines or tubes to reduce infection risk and improve mobility?
DVT Prophylaxis: Assess daily.
Discharge Planning: Assess discharge status and anticipate discharge needs daily.
At UIHC, routine labs are drawn by the nurses twice daily in the ICUs (4am and 4pm) and by phlebotomy once daily (5:30-9:30am) on the wards. Daily AM labs must be ordered the night before.
The IV team draws all labs at VAMC.
To add on labs to a previous draw in EPIC, you only need to select add on when ordering the lab. This will print to Specimen Control and the lab will be processed as long as they have a specimen in the appropriate tube. Call 63527 with questions about a sample.
To add on labs to a previous draw at the VA in CPRS, in the electronic order select Immediate Collect and place the time as N+1H. This will print to the lab and the order will be processed. Call 5500 to ensure that the order was placed properly and with any questions.
Electrolytes ⇒ PST tube
CBC ⇒ purple top tube
Coagulation ⇒ blue top tube
When a nurse tells you she/he drew a Rainbow, it means she/he drew every colored tube in case you wanted to add on additional labs later.
Urine labs can generally be added-on up to 24 hours after the specimen is received.
Gram stains from peritoneal and pleural fluid can be obtained by putting a fluid sample in a yellow top tube or sterile urine cup. The micro lab cannot perform gram stains on fluid from culture bottles.
At UIHC, ABGs are up to you outside of the ICUs. Nursing staff can call RT to draw the ABG after you try first.
At VAMC, ABGs are drawn by the IV team or RT.