For the nursing student and new grad, time management can be one of the trickiest skills to learn. When I first started in the ICU, my preceptor kept having to refocus me as I felt like I was being pulled in two directions at once (two patients, two directions…on the floor I’m sure the tug-of-war is even more insane!). When you’re new, it can be difficult to manage your time effectively simply because you’re still learning what needs to be done and you lack a routine, which takes time to develop.
One of the first things I did which really helped was to keep a piece of paper with my bedside chart (yes, our unit does paper charting, isn’t that cute?). On this paper I would jot down quick lists of how I was going to cluster my interventions the NEXT time I went into the room…this kept me from going in every 5 minutes, but instead I got it down to every 30, sometimes every hour if the patient was stable enough. Of course, if you’ve got someone for whom you’re titrating neosynephrine every few minutes, that ain’t gonna work…but for general things this was super helpful and after a while it became so routine that I rarely have to use this approach.
My list might look something like this:
Print CVP waveform
Label IV lines
Hang new bag NS
Switch BP to other arm
I found that if I could do at least 5 things on each trip into the room, it drastically cut down on the “oh, one more thing” little trips that ate up so much of my time. Now, this may seem like “duh,” because it looks so obvious…but trust me…as a newbie this was something I had to actually make into a habit. Otherwise, I’d think of something that needed to be done and go do it right then, rather than thinking ahead about what ELSE I could do while I was in there. Once I got this habit down my work day flowed much more smoothly and I had time then to actually start thinking about my patients in a more global sense.
As far as developing routines go, my work day typically flows the same each day, but “situations” will always throw a kink into things. I would say the morning is much more predictable usually, and as the day progresses it’s a little more loosey-goosey. In general, let’s assume you’ve got Patient A who is super sick, on a vent and has titratable gtts, and Patient B who isn’t so bad off and will probably transfer out in the next day or so..the day pretty much looks like this:
0645-0715: Get report, greet both patients/families, super quick focused assessment (if they’re in for neuro, do a quick neuro check…if they’re in for respiratory, then check O2 sat, WOB, ask about SOB…if they’re post surgical, ask about pain, see if there’s pools of blood in the bed, look at the dressing…you get the idea). Ask each patient what I can bring them when I come back for their assessment…by asking what you can bring the patient THE NEXT TIME you come in, I find it cuts down on the waitressing aspect of the job.
0715-0730: Fill pockets (blunts to cap off unused IV lines & alcohol swabs…make sure I have at least three pens, a hemostat, scissors and my steth); Print EKG strips, take a quick look at labs, check to see if I need to replace K or Mg, write out my schedule of meds, lab draws, TODO items; Grab the warm blanket Patient B asked for earlier; he’s on sliding scale insulin and looks hungry, so I’ll get the glucometer and his tray unless my other patient needs me RIGHT NOW. Otherwise, I can take 3 minutes for a quick accu-check and meal delivery.
0730-0800: Assess sick Patient A first and TRY to chart it on the flowsheet. If she’s a typical ICU patient, then she has CVP and possibly A-Lines to level, waveforms to print, gtts to titrate, may need a turn and oral care if on vent…again, cluster cluster cluster! While I’m in the room for this first assessment, I’ll do a quick survey of what supplies are already in there, what supplies I need to bring THE NEXT TIME I go in. I’ll also update patient/family on the general plan and goals for the day, also find out if there is anything super important to them (maybe they want to nap later because they were up all night, or maybe they want to go outside to the patio, maybe their goal is to ambulate to the toilet for a proper BM…whatever it is, find out and see how you can work it into the day). Once I’ve completed my assessment, I’ll start making a “problem list”…if they’re doing pretty good and don’t have a lot of problems, then I’ll just start a list of things to bring up during rounds.
0800-0830: Assess Patient B and do the same things for them I did for Patient A…if your patients aren’t too terribly ill, this may go a bit quicker, but I try not to stress if it takes me until 0830 to fully assess and chart the flowsheet on both patients. Remember, I’ve peeked in at Patient B already and would know if he were in distress….but he’s sitting in the bedside chair watching the news, so he’s good. Depending on what meds he has, I may be able to administer them now thanks to the hour window available for med passes.
0830-0930: If Patient A has URGENT needs that the doc needs to address, I’ll call him as soon as I have all the data I need (lab values, etc.) Otherwise, it’s time for morning meds for Patient A, then meds for Patient B if I didn’t sneak them in already. As far as meds go, you have to use your judgement. Let’s say Patient A is in for septic shock and has scheduled antibiotics at 0900…that’s obviously going to take precedence over Patient B’s daily Pepcid tablet. Also, you’ll want to be sure to look at what antibiotics you have that are all due AT THE SAME TIME. It’s amazing how often this happens, and if you have the “Big Daddy” ones that hang for 60-120 minutes, this can be problematic. Sometimes you’ll have to check IV compatibility and see what you can Y-site in together…get those antibiotics in ON TIME, ya’ll! If I have a patient on a ton of IV meds and I notice when making my schedule that it’s going to be tricky to time them out, I will print out an “IV compatibility” report to see ahead of time what I can Y-site together. I put a copy by the bedside and a copy in my binder. Super helpful! One more thing I try to do early in the day is to label all my IV lines and pumps…we have pumps that scroll the name of the drug across the display…and honestly, sometimes I do not have time to wait the four seconds it takes for the name of the drug to scroll across…so I label the pumps, too. Having your IV lines labeled is SUPER IMPORTANT! Trace each bag to its pump then to the patient…make sure everything is what it’s supposed to be, and that nothing incompatible is running together. CLEARLY label each line…if there’s a “situation,” you want to know ASAP which line can be used to push epinephrine, for instance (and it’s not your insulin gtt line…so make labeling a part of your daily routine!)
0930-1000: Get ready for rounds! We have a list of items that we address in the same format each time…so I just go through the list and write out my notes. This takes a few minutes prep, but makes rounds go super fast. This is also where my problem list comes in handy. If my patient is in dire need of something, I obviously won’t wait until rounds to bring it up to the doc…but for less urgent things, I can get a handful of issues all handled at once. Super convenient. If I have time here, I’ll glue the EKG strips I printed out earlier into my binder along with any other waveforms. I’ll write my narrative notes if I didn’t do it earlier when I charted on the flowsheet. If I haven’t peaked at my patient’s H&P yet I will do it here…sometimes you find tidbits that got missed in report. MAYBE, just maybe I’ll go reheat my morning coffee.
1000-1400: Rounds (anywhere from1000-1200), maybe a morning break and at this point I’m basically on my schedule… q 2 turns and oral care, meds are scheduled out, lab draws are scheduled out. If I have to travel with my patient, I try to get that out of the way ASAP because it will seriously throw a kink into your day. I also try to take lunch by 1400…it is usually possible 🙂
1400-1700: By now the docs have rounded and you have orders. If I had stat orders that I saw earlier, I hopefully have done them by now. Otherwise, it takes a bit for the orders to get processed, but I usually have my charts back by now and can make sure everything has been entered correctly, see what I need to add to my TODO list, and see what will have to be passed along to my friends on the next shift. This is also the time when I do all my “extra fun paperwork”….IPOC/care plans, teaching checklist and such. If I have time, I take a more detailed look at my patient’s chart so I can see if anything else got missed in report….test results, past medical stuff, whatever.
1700-1845: I do my I/O totals at 1700, clear my pumps, empty Foley bag, empty drains, etc… I write my end-of-shift summaries, check any pending labs that need to be communicated in report and basically just start buttoning things up.
1845: It’s MAGIC TIME! Give report, clock out, go home, RELAX!
Of course, this is an example of a predictable day with patients who are basically cruising along…you can pretty much count on things kinking up your plan, whether it’s a transfer out, an admit from the ED, hemodynamic instability, a code, whatever…but in general this is how I try to organize my schedule, hopefully leaving enough wiggle room to account for the unexpected happening…because it will!
And that, ladies and gents, is all I got today. Be safe out there!