Sunday, July 14, 2013

Don't waste my time! Physician Rounds.

Image from:

Physician rounds, ICU rounds, or multi-disciplinary rounds are very important in the care and treatment of mechanically ventilated patients. It is the only time (usually only once in a 24 hour period) that many specialties can share their concerns, ideas, and goals with the attending intensivist.  The attending physician is very busy, and  responsible for the over-site of many patients, so it is ideal to present your goals during rounds.

I have worked many places and still can't believe how RT's do not attend rounds or do not engage during rounds. These are usually the same RT's that complain that they do not have protocols or that ventilator management is by physician order only. 

"Its your own fault, your NOT allowed to manage the ventilator"

Wastes of Physicians Time
  1. Not being present during rounds. This looks bad for you, your supervisor, and department. It looks like you do not care, or do not have anything to provide. Additionally, it frustrates the physician when you have to page/call them so they can clarify an order which you missed due to your truancy.
  2. Do not let Nursing present the ventilator data. You are the respiratory therapist, why is the nurse reporting on the patient ventilator assessment? It is like you reporting on the patients bowel function.
  3. Do not simply state what are the current ventilator settings. Who cares (unless there was a huge deviation or change). The physician probably already knows the settings from the chart or electronic medical record. Also, who needs you just to recite ventilator settings, a nurse could do this.  
  4. Not being engaged. Yes, you showed up however, you need to express your plan or goals for the day on each patient your providing care to. You will notice this from your colleagues (pharmacy & physical therapy) they have no problem expressing concerns or presenting goals/plans to the attending physician. 
Making yourself a valuable resource

  1. Be prepared. Know what time rounds are and make sure you can attend them. If you have too much work outside of the ICU, ask your supervisor for help (they should know the importance of rounds). If they volunteer to participate in rounds for you, ask them to do your floor treatments instead. You are the one that needs to be present for both being seen as a resource and also rounds contribute to your learning. 
  2. Know the patient. Why is this patient on the ventilator today (which is different from why MV was initiated)?, What phase of MV are they in? Acute phase? Weaning phase? Are they performing spontaneous breathing trials (SBT')? Did they pass an SBT? Why did they fail a SBT?
  3. Know your protocols. Based on your protocols can you initiate anything before rounds.
  4. Take the initiative. If you have protocols do what you can before rounds, decrease FiO2, decrease PEEP, perform a medication assessment, perform a SBT, and provide the results during rounds. This makes you look like a rock star. 
  5. Know the specific goals for each patient. These should be based on your patient assessments and your protocols. Below (image 2) is example of what I created for my staff.
Image 2: RT Patient assessment for physician rounds.

This is an example of goal directed therapy, which was based on our protocols. The staff RT would use this form, assess the patient and see if the patient could progress. This form was also used for documentation, physician rounds, and shift reports. It provided a goal plan for each patient. 

6. Be a good wing-man. Sometimes at teaching institutions the pulmonary fellow, surgical fellow, or surgical resident will present to the attending.  Please, share the information with them 
in regards to assessment, plans, and goals. This will make them look good and you will have gained an ally.