ICU presentation

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fuegorama

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So I'm rounding out the last 2 months of med school with a crit care sub-I.
stupidstupidstupidstupid!!!!!

Actually I think it's great prep for internship and I dig it the most.

My trouble is my flailing presentations during rounds.
I am an "EM thinker" and have a pretty good mastery of the 2 minute spray. The depth and detail of these medicine folks is something I would like to emulate.

Does anyone have a favorite template/pattern they would like to share?

Thanks.
F

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So I'm rounding out the last 2 months of med school with a crit care sub-I.
stupidstupidstupidstupid!!!!!

Actually I think it's great prep for internship and I dig it the most.

My trouble is my flailing presentations during rounds.
I am an "EM thinker" and have a pretty good mastery of the 2 minute spray. The depth and detail of these medicine folks is something I would like to emulate.

Does anyone have a favorite template/pattern they would like to share?

Thanks.
F


In SICU we went by systems, which actually worked well for my EM thinking mind, because each organ system was a new quickie. So I did:

Events o/n (fever spike, acute psychosis, code, etc);
Neuro (including GCS & rest of exam, pain control, sedatives, any psych stuff); CV (tele,HR, BP/CV, exam etc, any of the relevant issues with meds/pressures); Pulm (vent settings or FiO2, IS performance, exam, last CXR/issues); Renal (fluid status I/Os; latest electrolytes); GI (diet w/ goal, nutritional status, boewl regimen/any issues with exam); Heme (any issues, DVT proph, latest cbc); ID (temps, last spike/last clx, any abx including day/total days and indication); Endo/Rheum/other categories (ie, ortho, etc) prn. I also became popular at rounds because I made a line list including ages as well so we could evaluate whether we still needed a site and also not let old lines just sit around and get infected.

Usually I would do these with goal directed plans in each organ system presentation (ie Neuro goal of weaning sedation to x), then sum up the patient's major issues and goals if there are a lot. At the end of our discussion I woud then recap the "to do" list by organ system. Liked it alot.
 
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In SICU we went by systems, which actually worked well for my EM thinking mind, because each organ system was a new quickie. So I did:

Events o/n (fever spike, acute psychosis, code, etc);
Neuro (including GCS & rest of exam, pain control, sedatives, any psych stuff); CV (tele,HR, BP/CV, exam etc, any of the relevant issues with meds/pressures); Pulm (vent settings or FiO2, IS performance, exam, last CXR/issues); Renal (fluid status I/Os; latest electrolytes); GI (diet w/ goal, nutritional status, boewl regimen/any issues with exam); Heme (any issues, DVT proph, latest cbc); ID (temps, last spike/last clx, any abx including day/total days and indication); Endo/Rheum/other categories (ie, ortho, etc) prn. I also became popular at rounds because I made a line list including ages as well so we could evaluate whether we still needed a site and also not let old lines just sit around and get infected.

Usually I would do these with goal directed plans in each organ system presentation (ie Neuro goal of weaning sedation to x), then sum up the patient's major issues and goals if there are a lot. At the end of our discussion I woud then recap the "to do" list by organ system. Liked it alot.

If you follow Hard24Get's advice above, you'll do great. This format is very similar to how our group runs rounds. Remember, even if there aren't any issues in a particular system, still mention it in rounds.

We've also included the line tracking and it is a help.

kg
 
Our attendings discourage us from presenting is a systems based format. I think it started with billing issues when resident's wrote their notes in a systems fomat.

For example, the problem is not "Pulmonary" but "Respiratory Failure"
 
Our attendings discourage us from presenting is a systems based format. I think it started with billing issues when resident's wrote their notes in a systems fomat.

For example, the problem is not "Pulmonary" but "Respiratory Failure"

This is an important issue as billing and quality control and assurance does depend on diagnoses not systems. Also, severity of illness, mortality rates can be misleadingly documented leading to confusion by coders. Some ICUs suffer from high mortality statistics related to diagnoses that are oversimplified like " community acquired pneumonia" rather than saying community acquiredpneumonia with septic shock and multi-organ failure....the more descriptive, the more accurate the statistics.

Personally, in presenting...a systems approach is good but the diagnosis germane to the system should be acknowledged both during the presentation and in the documentation. As tuna said...the problem isn't "Neuro-wise" or "Pulmonary-wise"
 
This is an important issue as billing and quality control and assurance does depend on diagnoses not systems. Also, severity of illness, mortality rates can be misleadingly documented leading to confusion by coders. Some ICUs suffer from high mortality statistics related to diagnoses that are oversimplified like " community acquired pneumonia" rather than saying community acquiredpneumonia with septic shock and multi-organ failure....the more descriptive, the more accurate the statistics.

Personally, in presenting...a systems approach is good but the diagnosis germane to the system should be acknowledged both during the presentation and in the documentation. As tuna said...the problem isn't "Neuro-wise" or "Pulmonary-wise"

Well, the way our electronic documentation works is that you make a bonified problem list within each organ system. So that Pulmonary may have 1. respiratory failure 2. ventilator-associated pneumonia. The end of the electronic note allows to you generate a problem list summary statement. I still think each system should be acknowledged and addressed because otherwise you end up realizing the person that mainly has "traumatic brain injury" also hasn't pooped in 2 weeks and is not on a bowel regimen.

Perhaps a compromise would be to start with the systems that have problems? Bigtuna, what does you attending want for systems without problems that are just being actively maintained, like GI or renal?
 
This is an important issue as billing and quality control and assurance does depend on diagnoses not systems. Also, severity of illness, mortality rates can be misleadingly documented leading to confusion by coders. Some ICUs suffer from high mortality statistics related to diagnoses that are oversimplified like " community acquired pneumonia" rather than saying community acquiredpneumonia with septic shock and multi-organ failure....the more descriptive, the more accurate the statistics.

Personally, in presenting...a systems approach is good but the diagnosis germane to the system should be acknowledged both during the presentation and in the documentation. As tuna said...the problem isn't "Neuro-wise" or "Pulmonary-wise"

All valid points from Eidolon6, no argument here.

As an attending, I want every system presented to me and we will address each one. It is up to me to place the appropriate terminology in my note to account for accurate coding and severity of illness scoring.

As a resident/fellow, it is up to you to gather all the data and put the "big picture" together the best you can, and present this to me with your plan. In order to do that, you need all the data for every system. It is very easy to get lost or overlook a small problem if you don't go systematically down some kind of organized systematic approach, every time.

It is up to your attendings to worry about coding/billing/severity of illness etc... If they want you to use certain phrases in order to help them and the coders, that is fine, but you shouldn't limit your presentation to a bunch of ICD-9 diagnoses. You'll learn nothing but secretarial work from this approach. If my residents don't use the proper terminology for our coders, I'll use it in my note, no big deal. I want to know they can gather the data, know how to evaluate it, and come up with a reasonable plan.

And like Eidolon6 mentioned....don't be a "wise-guy".

kg
 
Agree that it is nice to touch on all of the issues. In our hospital the SICU writes notes/does presentations by system. In MICU/CCU, the residents write notes in a problem based format. If you were to review a chart, most of the time you have no idea what is happening with a SICU patient but the problem based are much easier to review. This may be partly due to the characteristics of the residents writing the notes as well.

Nothing irritates me more than when a patient is in the unit for acute variceal bleed and the intern starts down the list "Neuro, CV, Pulm, ....".

At least touch on things in the order of importance.
 
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