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    ICU Bundle Checklist

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    Assessment & Plan (short)

    #ICU Bundle
    - Code Status:
    - ICU indication:
    - GI ppx:
    - DVT ppx:
    - Lines:
    - Tubes, Drains, Foley:
    - Last contact update:

    Educational

    #ICU Bundle

    Ventilator
    ? Spontaneous Awakening Trial (SAT)
    = turn off sedation
    ? Spontaneous Breathing Trial (SBT)
    = Place patient on Pressure Support 5/5
    - Perform SAT & SBT concurrently if able
    - Contraindications to SAT/SBT include FiO2 > 50%, PEEP > 8, O2 sat < 90%, pH < 7.30, SBP < 90 or MAP < 60, paralysis, intracranial pressure >15, concern for significant bleeding
    ? If ARDS: goal Vt 4-6 cc/kg of ideal body weight (calculated by height), plateau pressure < 30
    ? Head of bed at >30 degrees
    ? Oral care is ordered

    Sedation / Delirium
    ? Ask: Is patient delirious (CAM+)?
    ? Review med list for any deliriogenic medications and discontinue/change where possible
    ? Define RASS goal
    ? Record QTc daily, consider changing medications if QTc > 500

    Restraints
    ? Ask: Are restraints needed?
    ? Sign necessary restraint orders
    ? Discuss barriers to removing restraint orders

    Mobility
    ? Consult PT for early mobility
    - Contraindications include: deep sedation, paralysis

    Pressure Ulcers
    ? Ask: Are pressure ulcers present? Is a wound care consult needed?
    ? Discuss whether any changes are needed to ulcer management plan

    DVT prophylaxis
    ? Review patient’s current DVT prophylaxis orders and adjust if needed
    - Contraindications to LMWH DVT ppx include AKI (switch to UFH TID), clinically significant bleeding (hold pharmacologic), platelet count < 30K (hold pharmacologic)
    - Add sequential compression boots if holding pharmacologic prophylaxis

    GI / Nutrition
    ? Famotidine 20mg IV BID in intubated patients; Pantoprazole 20-40mg IV daily if history of GERD or GI bleed
    ? Review nutrition, consult nutrition if not already done. While awaiting nutrition input, start enteral nutrition:
    - In most patients, Osmolite 1.5 @10mL/hr, advance by 20mL Q6h to goal 50mL/hr
    - If renal failure and high K or phos: Nepro @ 10mL/hr, advance by 10mL Q6h to goal 40mL/hr
    - MVI with minerals daily
    - thiamine 100mg daily x3 days
    - folate 1mg daily x 3 days
    ? Ask: Is bowel regimen adequate? Make changes if necessary.
    ? Review glucose range over past 48h and insulin regimen, adjust regimen if needed.
    - Goal glucose range is 70-180

    Tubes / Lines / Drains
    ? List all tubes / lines / drains and discuss if any can be removed or should be changed

    Patient / Family Communication
    ? Discuss if patient has healthcare making capacity - if not, activate healthcare proxy
    ? Update families by phone
    - Suggest RN update at least daily
    - MD update Q3 days, with any significant clinical change, or per family request

    Disposition
    ? Discuss anticipated dispo, barriers to dispo

    Code Status
    ? Review current code status, discuss if goals of care are realistic with prognosis - if not, discuss with patient / family

    Abbreviations:
    SAT = Spontaneous Awakening Trial
    SBT = Spontaneous Breathing Trial
    CAM = Confusion Assessment Method
    RASS = Richmond Agitation and Sedation Scale

    Description

    Daily quality/safety checklist for patients in ICU; from BWH

    Organ systems
    • Pulmonology/Critical Care
    Medical field
    • Internal medicine
    Setting
    • Inpatient
    Author
    Patrick Sanger
    Page info

    Originally created: March 31, 2020 by Patrick Sanger

    [xyz-ips snippet="lastupdated"] [xyz-ips snippet="sectioneditor"] [post-views]

    Number of revisions: [xyz-ips snippet="numrevisions"]

    References
    [xyz-ips snippet="easyfootnote"]
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