Intensive Care Unit (ICU) Electronic Medical Record (EMR) and Rounding Efficiency for the Emergency Medicine (EM) Resident
INTRODUCTION
Months of Intensive Care Unit (ICU) rotations are required for United States (US) Emergency Medicine (EM) residents. As EM residents, we can feel out of place or less efficient than we are used to in this environment since we work primarily in a very different model and with a very different electronic medical record (EMR) setup. This post describes a common approach to effectively reviewing data on patients, and it specifically details how to set up and utilize the EMR for maximally efficient and efficacious patient care in the ICU. Specifics in this post are Epic-based, but some general concepts will apply to all ICU rounding. As boarding becomes more prevalent, and critically ill patients spend multiple shifts in the emergency department (ED), taking a similar approach in the ED is a wise strategy to prepare for shift-change.
Before we get started, remember that Epic is customizable at the individual user, departmental, and also institutional level. This means that the Epic at the institution of Brown Emergency Medicine may be different than another neighboring institution. Some hospital systems may pay for certain packages and not others, or have the EMR set up in different ways. This approach is based on a number of Epic setups that I have used across a few institutions. At the departmental level, there can also be big differences between different “contexts”. Make sure that you have selected the correct one for the service that you are on, and then customize it to your liking, or to the approach described in this post. Make sure you have the correct handoff pulled up, and know how this service uses the handoff/where they keep a living document.
DISCUSSION
Do it the same way:
ICU patients have large amounts of objective data to review a few times per day. To pre-round efficiently on patients, it is imperative that you are able to review this data quickly and without missing pieces. Being fast and thorough requires a systematic approach. You should almost always review patient data the same way every time. When you get busy or when you want to go fast, this is the only way to make sure you hit all the important data while being thorough. In fact, once you form these habits and tailor your EMR, this process should only take a few minutes per patient. It can be so fast that if there is a clinical change in a patient, you can fall back on this to holistically review all the objective data again to ensure you are not missing a part of the picture.
List view / Split Screen as Home Base:
When it’s time to review a patient’s data, click on their name from the list, and then pull up the horizontal split screen. Use the wrench to reorder the tabs in the order that you want to review the data; most people do something along the lines of the order in which data is presented during their rounds. For instance: default unchangeable tab (some type of “profile” or “index”), handoff (so you can quickly remember who you are reading about – this is like the one-liner during rounds, followed by the “subjective” or “24 hour events” that is usually presented in rounds), comprehensive flowsheet (this one tab alone probably has the lion’s share of the data in it, including all the vitals, infusions, and respiratory supports, although it may not be as visually effective as some of the more specific/targeted tabs), ins and outs (more visually pleasing way to see them than the flowsheet. I use our “overview” report here, and rearranged the boxes using “modify report” so that I/O is the first box, and then notes over the last 24hrs is the second box right below the condensed I/O. [I have a separate tab later on in my left to right flow for detailed I/O that shows me how many stools, how much ins were from meds, etc]), lab table (can click “8hrs” or “24hrs” to condense the timeframe), “fever” and/or “micro”, medication admin, and then some more specific tabs. Specific tabs I like, if available, are fever, glucose, blood, pain, coag, CHF, CIWA, detailed I/O.
For a number of tabs, for instance labs or medications, there may be a few options to choose from in your Epic. Figure out which one is the most effective; they will generally show similar data, but in different formats. Like I mentioned above regarding I/O, I actually have it listed in 3 different ways (comp flowsheet, which I find hard to follow, “overview” which is the simple table, and “ins and outs” which is a detailed table.) You can sometimes click blue hyperlinks to view the data in a different format (e.g. click “report”). If there is some objective data that you keep needing to access when pre-rounding, see if there is a tab that your Epic offers for it. For instance, you may want to add an ECMO tab if you are in a unit doing a lot of ECMO, or a blood tab in the trauma ICU. This information may be in your flowsheet too (depending on your Epic), although may be harder to find versus just having a tab dedicated to this data. Occasionally, and depending on how your Epic is set up, you may find data that you are needing regularly that isn’t available on your split/list view. If that is the case, integrate this into your workflow, but still try to do it the same way every time: enter the patient’s chart, navigate right to the thing you need (make it a tab within their chart), and then come right back to the list and continue working your way through the tabs from left to right in rounding order.
You may notice I didn’t mention imaging: this can be found in a few places and displayed in multiple ways, including sometimes in the “index” or “overview tab” which will often be forced as the first tab (and not customizable). Make sure this is part of your work flow one way or another, since it is a crucial piece of daily data to review. My favorite way to look at it is from the lab table, which allows you to click to either the images or the read, so you don’t have to leave your list view / horizontal split. This is also helpful because when presenting on rounds, we generally present imaging after labs (this is also where I find EKGs, echos, etc).
Hopefully you are starting to get the overall approach here. The idea is that by moving from the furthest left tab on your horizontal sidebar across from left to right you are reviewing all the objective data you need to know, in the order you will be presenting it on rounds. Think about what data you always look at, what is important to review on your patients every morning, and what is expected to be presented on rounds, and arrange your row accordingly. Generally, the most universal data will be on the left, that way you will always click through those tabs on virtually everyone, but tabs like “glucose” might only be relevant on patients with labile glucose, and you might only check the “fever” tab when you want to see if culture data came back, or to quickly see what antibiotics were given last night. You should rarely have to leave the list view to click into a patient’s chart, which can slow you down dramatically and take you out of your systematic review process, resulting in things getting missed.
Once you have the tabs that you want in rounding-order, followed by your preferred specialized tabs, shorten their names. For instance, Comprehensive flowsheet, I just call “comp”. “Overview” is too vague for me, so I renamed it “I/O and recent notes”, and far to the right on my left-to-right flow I have “detailed I/O” which is what I renamed the more detailed table.
Orders and Notes:
From the split screen/list view, click on a patient’s row and certain buttons will appear on their highlighted row which directly link to areas that require you to leave the list view. To reiterate, ideally, the only reason to leave the list view should be to click one of these buttons. The buttons are “orders” and “notes”. Each one takes you directly to that section. This is the way to place orders during rounding, and how you can write notes when pre-rounding/rounding. It is also one of the ways to view notes when pre-rounding or throughout the day.
Your List:
Your list should have everything you need to clearly identify your patient (name, bed, age sex/gender, etc), may contain a few icons for “news”, and may contain the info you want on a printed list. Too many columns with too many words will make it cluttered and can be distracting or lead to confusion. I prefer a simple setup and like to leave the handoff columns for the handoff tab on the horizontal split, but I don’t print daily lists. I prefer my list to tell me who my patient is, who their nurse is, and give me some “news”. I like the icons that tell me if there is a new note that has been signed, if a new result has come back (and what level of panic), have a couple columns for vitals (e.g. last BP), and finally an icon for my sticky note. There are icons for consult notes (so I can see if another person has signed a note that I might be waiting on), and an icon for your own note (to know if you still need to sign one on that patient). The nice thing about the icons is that they don’t take up much room, and I don’t find they distract me like a lot of text would.
Some people take a different approach and add columns that are most helpful for printed list purposes: things like action plan, summary, overnight events, etc. essentially, their handoff. These are mostly pertinent for people that print a physical list and want this information on their paper, because in the EMR list view / horizontal split you will have a tab “handoff” which contains this information (see above).
The Sticky Note:
In the ED, it is common to have a note area that is not part of the patient’s chart that can be seen by the team and is used to present a very concise clinical summary, along with actionable to-dos (e.g. Hemoptysis, small volume, hx of same: [ ] CXR, [ ] CBC [ ] discuss with their pulm… or… ETOH WD [ ] reassess after phenobarb bolus [ ] floor vs ICU). This note is a very useful tool. I use it in the ICU too. Epic allows for “sticky notes” which are not part of the patient chart, and only you can view your own sticky. They serve as a quick way to jog your memory on a patient’s main active issues and what needs to happen. Add the “my sticky note” column to your patient list. Now an icon will show you if you have a sticky note, and if you hover, it will show you the text, and if you click, you can edit it, without having to leave the list view. I use this during rounds to jot personal to-dos and notes (usually team-based stuff will go in the handoff, which everyone can see). For instance, “[ ] A line” might go in the team based handoff too, but if it’s on a patient that another clinician is going to place the line in, I wouldn’t put it in my own sticky note, whereas “[ ] call pts sister back” might go in my own sticky, but doesn’t need to be on the whole team’s radar. A lot of people use pen/paper for this along with a printed paper list instead. This is an electronic alternative or adjunct to that system. But again, pick one way of doing it, and do it the same way every time so that things don’t get missed or forgotten. If you choose to use stickies, periodically hover over all your own stickies to read them like you would read your own paper list.
Five Take-Home Points:
Form the habit of reviewing the data the same way, on every patient, every morning/afternoon/evening. Build your EMR to reflect your order of operations and facilitate this process.
Almost everything needed to systematically review patients can be done from the list / split view when it is set up correctly.
In general, when performing this type of review, individual charts should only be entered for writing orders, writing notes, and little else (see point #2). When presenting during rounds you could move through these tabs. Orders and notes are a single click from the list / split view.
Use the list columns for basic demographics, to stay abreast of “news”, and for your sticky note.
Use your own personal sticky-note to keep track of to-dos and big picture summary
AUTHOR: Barret Zimmerman, MD is a fourth-year emergency medicine resident at Brown Emergency Medicine Residency.
FACULTY REVIEWER: Michelle Myles, MD is an attending physician and clinician educator at Brown Emergency Medicine.