Nursing Playbook (the Front Line)

Football players running
You are the Front line – without you no yards can be gained!

You are the front line. You are the team’s primary link to the patient. You do the heavy lifting. Without you there is no care!

  • You should meet with each hospitalist at the bedside from 9:15-11:00 AM every day.
    • Each patient presentation should take approximately 6-10 min.
    • (1-2 min) Discuss any patient events that occurred overnight using the SBAR format (see below)
    • (1-2 min) The hospitalist will then review pertinent changes over the past 24 hours with regards to laboratory findings and responses to therapy and then summarize the plan for the day. 
      • Ask any questions with regards to the plan. Be sure you understand the plan for the day.
    • (1-2 min) Then use the pneumonic TEMP to review key patient orders related to bedside nursing. This is information the physicians do not know and need to know. Your input is important and of high value
      • T – tubes IV lines, bladder catheter (are they needed, should they be changed
      • – Eating, exercise (activity, bed to chair, ambulating with assistance, need for PT), sleep and bowel movements
      • M – monitoring frequency  Vital signs Q4H or Q8H, when possible avoid during sleeping hours. Do the patient need telemetry? Does she require daily blood drawing?
      • P – Is the patients pain controlled? And finally does the patient understand the plan for the day? (teach back)

Here is an example of an ideal review of TEMP. Notice that a number of changes in the patients management are made during the discussion of TEMP.

All questions by the nurse should be answered during rounds (eliminates the need to page)

How should you report an unexpected event? Use SBAR (very brief and efficient)

  • Situation: What complication has occurred. Example: Mr. Jone’s developed chest pain overnight that was left substernal, sharp and radiated down his left arm.
  • Background: Describe underlying conditions, his original reason for hospitalization. Example: Mr. Jones was hospitalized for hyperglycemia and mild diabetic ketoacidosis. he has received 10 Liters of fluid over 24h.
  • Assessment: What do you think is going on. Example: Mr. Jones may have received excessive fluids. On exam I hear rales half way up both posterior lung fields, his heart rate is elevated at 120 and he has jugular venous distension. I suspect his chest pain is due to cardiac ischemia resulting from increased cardiac work because of CHF.
  • Recommendations:  What do you think should be done? Example: Should I order an EKG and ask the technician to draw cardiac enzymes? Do you want me to give him lasix? How about heparinizing him? We have been told that all patients with possible MI should also receive asparin and a beta-blocker. Do you want to order these?

When should you page the Hospitalists?

  • 7 AM-9:15 AM – page when there is a potential emergent issue. When a patient has worsened overnight. Specifically
    • Uncontrolled pain
    • Worsening vital signs
    • Critical lab values
    • Other worrisome clinical symptoms or signs (new onset chest pain, confusion etc)
    • Use the SBAR format when communicating these concerns.
    • Avoid pages for routine medication changes, diet etc. Wait to cover these during bedside rounds at 9:15 AM
    • Text the direct dial number for your phone, not the 5 digit extension (hospitalist wastes time calling the main number followed by the extension)