Daily Orders
Daily orders are written on morning rounds in the Epic system by the resident/NP who is NOT presenting the given patient. After completion of rounds on the individual patient, the orders are to be pulled up on a computer and READ BACK OUT LOUD WITH THE PATIENT’S NURSE. Fellows should be listening to make sure nothing was missed or misinterpreted. In general, laboratory tests and X-ray examinations for the next day should be included in these orders. Guidelines are published for when to obtain labs and x-rays. Please note: not every patient needs daily labs and chest x-rays. Please personally inform the nursing staff of any STAT orders regardless of when the orders are written.
Troponin Testing/Revised Cardiac Risk Index
Verbal Orders
Verbal orders are a privilege and are intended for emergency situations only. ALL VERBAL ORDERS MUST BE SIGNED AS SOON AS POSSIBLE IN Epic. If verbal orders are not properly signed, this privilege will be revoked by the hospital.
Admission Orders
The SICU admission team writes or reviews all orders on patients excluding transplant immunosuppression, epidurals, chest tube, and drain orders. In general, the admitting surgical service will also write some admission orders in EPIC. Under the orders tab, these held orders can be found under the “Signed & Held” tab. The residents and fellows on the critical care team are responsible for knowing about all admission orders written by the admitting surgical team and should review them and discuss them prior to releasing them. Examine the orders thoroughly and make changes where necessary. If a plan discussed with the surgical service is changed by the SICU service, this should be discussed with the fellow and/or attending, and the surgical service should be notified of the change.THE CRITICAL CARE TEAM MUST REVIEW AND RELEASE ORDERS BEFORE THE NURSING STAFF WILL ACT ON THEM (DO NOT LEAVE ORDERS ON HOLD STATUS.
If admission orders are not present for the patient, the order set “CC SUR ICU Admission” should be utilized, DO NOT use a service-specific order set.
Restraint Orders
Restraints orders are to be filled out every morning on rounds for every patient requiring restraints. The state of Missouri levies heavy fines for any unit shown to be non-compliant with medical restraint guidelines. In order to maintain compliance with the state’s laws on restraints, Barnes-Jewish Hospital has a specific restraint policy that adheres to JCAHO standards. If a patient requires restraints, physician orders must be written within one hour of placing the restraints. The reason for placing restraints must be entered in the physician order entry system. If a patient requires restraints, this MUST be documented in the Epic section marked NV Restraint Face to Face and in a progress note specifying the reason for restraint usage. A statement such as “patient safety” does NOT suffice (prevention of specific device removal, does, though).
An example of an appropriate statement (for a patient on the ventilator) is “prevention of extubation which could result in hypoxia and/or respiratory insufficiency.” Another example (for a patient on pressors) is “to prevent patient from pulling out central line, which could result in hypotension since the central line is giving vasoactive medications needed to support blood pressure.” For upper extremity soft wrist restraints (ICU patient with invasive devices), an order must be written once when initiated; this order is sufficient for the duration of time the restraints remain on the patient. Any other type of restraints such as bed, chair, 4-point, etc., require daily written orders. If the restraints are discontinued at any time (e.g., improvement in mental status), the “ICU patient with invasive devices” order must be re-entered, but again will not require a daily order. If this is confusing seek out your fellow, attending, or clinical nurse specialist for clarification.
Radiology Tests/Imaging
Please note that special tests (MRI, CT, VIR procedures) must usually be arranged with the radiologist in addition to filling out the order in EPIC. Often the radiologist needs to be contacted so the studies can be prioritized with other studies needing to be done in the hospital. This communication with the radiology department will help facilitate examination completion in a timely manner and, hopefully, the results of the examination will be better communicated. Always consider the need for an anesthesiologist to travel with the patient for VIR procedures. The after hours number for CT is 758-6895 (emergency radiology).
Chest X-rays are prioritized as “critical,” “urgent,” “routine,” or “scheduled.”
“Critical” = An acute need for a film immediately, e.g. acute decompensation or suspected pneumothorax. For these patients, the radiology team will leave the ED to perform the study as soon as possible. This should be reserved for truly critical scans.
“Urgent” = An intervention has occurred (e.g. placement of a central line), a subacute change is occurring, or an earlier necessary film is inadequate; within 1-2 hours.
“Routine” = A film is necessary within the next 24 hours.