Interdisciplinary rounds start in the D6/4 report room behind the nursing station at 9am except for Wednesdays, when they start at 9:30. Please be on time! Representatives from nursing, case management, PT, OT, rehab, speech, swallow, clinical nutrition, social work and pharmacy are present. Each patient is discussed with regard to his therapy needs, medical progress, likely discharge disposition, earliest possible discharge date, and any barriers to discharge. The usual dispositions are home, acute rehab (in this or another facility), subacute rehab (at a skilled nursing facility), and inpatient hospice. To help standardize this process, please speak to the following:
- Plan for the day
- Plan for the stay
Work rounds follow immediately after multidisciplinary rounds. Presentations should follow the usual SOAP format (subjective, objective, assessment, and plan). An oral presentation guidance document we developed for the medical students on service with us is also pertinent to new residents; please review this (Appendix 4). Some key elements to report include:
Subjective: Does the patient report any worsening or new neurological symptoms such as headache, trouble swallowing, or worsened weakness?
Objective: How does today’s examination compare to yesterdays? Has the patient’s level of consciousness changed? Is their aphasia better or worse? What about their weakness?
A critical component of secondary stroke prevention is risk factor control. Each day, please present an update on the patient’s prevention regimen organized by risk factor:
- Hypertension: The range of recent blood pressures and the current drug regimen
- Diabetes: The range of recent glucose readings and the current drug regimen
- Dyslipidemia: Fasting lipid profile obtained during admission and current drug regimen
- Tobacco: Whether counseling has been provided and drug regimen (patch, varenicline)
- Obesity: Body mass index (BMI) and dietary and lifestyle counseling provided. Is the patient in the Stroke Prevention Exercise Program (S-PEP)?
Please also report results of the patient’s swallow evaluation (general diet, mechanical soft, etc.), antithrombotic status (aspirin, clopidogrel, Aggrenox, warfarin with most recent INR), and DVT prophylaxis (usually SQ dalteparin).
Regarding telemetry: If a telemetric alarm sounds, the nurse examines the rhythm and may (but may not) print a sample for review. Therefore, simply reviewing the previous night’s rhythm strips is not sufficient to detect important dysrhythmias that may have occurred. Please review the previous day’s alarms yourself on the electronic monitor.
Regarding the medication administration record (MAR): Nurses will appropriately hold blood pressure medications if the patient’s pressure is low at the scheduled time of medication administration, or administer PRN doses of anti-hypertensives if ordered. The physician is not always informed of this, however. It is therefore important to review the MAR yourself in order to ensure an accurate understanding not only of what medications the patient has ordered, but what he has actually received.